After completing an online course in PCIT (Parent Child Interaction Therapy), something just didn’t seem right to me.  This nagging feeling resurfaced when I watched a supplement to the training, on the topic of whether the model was culturally sensitive.  I watched as nearly every participant, PCIT practitioners and trainers, cited examples of families from non-Western cultures who struggled with the model.  Rationalizations were offered for why the model really is relevant across cultures, but the issue was largely avoided.  I believe that the reason that non-Western cultures may struggle with the model points to important flaws in this and other similar parenting models, and that considering these flaws may be important in how we treat families.

When parents seek treatment regarding their children, the presenting problem is very often some form of oppositionalism, and the stated goal is compliance.  On the surface, a model such as PCIT seems a perfect fit for this presentation.  The model does a good job of achieving compliance and cooperation with parental directives.  To generalize, in my own terms, PCIT largely uses methodology that emphasizes ego building/enhanced self-esteem (through parent child play), and basic behavioral manipulation.  That this is effective appears self-evident, and has basis in research.  At first glance, this seems like a perfect match between stated treatment goals and actual treatment outcomes.

There is, however, something missing.  While the immediate problem that parents often present with is mere compliance, there are often deeper, unstated, or even unknowing concerns and anxieties that accompany the presenting problem.  When a child refuses a parental directive, the child is refusing to conform to adult authority.  An often unstated anxiety that parents often carry relates to the ability of this child to cope with authority in his present and in his future.  Parents may fear that a defiant child will grow to become a defiant, angry, and unhappy adult.  Note, then, that the approach used by PCIT and other such models of ego building and manipulation does nothing to address this anxiety and issue.  While compliance may be achieved, the child has gained no skills in his ability to cope with authority.  While a home with less conflict and stronger individual egos will likely result in more cooperation with authority, the value and skill of complying with authority for its own sake is compromised.   The lack of engagement with families around this issue sends the subtle message that it just isn’t important, and the fact that the parent has abandoned the parental directive to the child, in favor of play and manipulation, sends the message that the parent is devaluing the importance of obeying authority.

Here we confront the cultural issue.  Western culture places tremendous value on individualism and non-conformity, while de-emphasizing and even demonizing authority.  The American hero is the creative genius who eschews convention, family, expectations, and authority.  As such, the notion that it is important for a child to learn to obey authority, as a value unto itself, is often ignored.  Defiance is a mere behavioral problem to be solved by ego building and manipulation, and the accompanying issue of authority is swept aside.  Other cultures, however, may place much more emphasis on this issue.  In the presentation I mentioned above, one story was told of an Asian father who stated that it was against his cultural values to play with children.  The panel clearly struggled with this.  While this is not how I parent, I can certainly appreciate the perspective.  Perhaps this family’s culture held that there should be firm boundaries between adults and children.  Play is for peers, but parents are to be revered and respected. 

As clinicians, we often fall into this same pattern, offering interventions to achieve compliance, while ignoring the parental anxiety related to obeying authority.  We can often find ourselves frustrated when parents don’t follow through on our suggested interventions, but we may be missing the fact that the underlying anxiety has not been addressed.  I would suggest that, when we offer behavioral interventions to manipulate behavior, parents may be thinking some variation of “yes, but I shouldn’t have to do that.  He should be able to listen to his parents/teachers, and if I go that route, am I not giving up on this important value?”  If parents are thinking some variation of this, it should not be surprising that they are less than enthusiastic about our suggested interventions.   Indeed, parents are often stuck on this idea, and struggle with accepting the oppositionalism of their child.  Engaging this thought and anxiety may go a long way toward helping parents get unstuck.   At the very least, we should be providing prodigious empathy for this parental concern, and validating the issue as important. 

At the end of the day, when dealing with oppositional children living in American culture, the PCIT model may be the most viable option for achieving a peaceful household.  Still, if we are to be effective in this or any other model, we need to be cognizant of what this model sacrifices, and what that sacrifice means to parents.  The Asian family I mentioned before may need to accept that raising a child in America is going to involve some sacrifice of their cultural values, but that will be made much easier by a therapist who validates, empathizes with, and respects the value itself.  When therapists treat models such as PCIT as ideal, they may be speaking a different language than parents who see it as a necessary evil that is far from ideal.