‘How is your parents’ relationship?’

Camilla Rosan is Head of Early Years Programme, Anna Freud Centre. First, Patrick asks her some questions.

What is the Anna Freud Centre's interest in inter-parental conflict?

The Anna Freud Centre has always had an interest in family wellbeing and believes that the co-parenting relationship, including parental conflict, is a critical but often overlooked part of this. Over the last five years, our expertise in mentalisation based therapy has strengthened and the Centre has focused on assessing and treating families where there is conflict between separated parents, often around the residency of and contact with their children. 

The parents seen by the Contact and Residence Disputes (CRD) project frequently have a history of litigation focused on the care of their children and current or historic allegations and counter-allegations against one another – usually around the abuse or neglect of their children. The children's own experience and needs are frequently obscured by the conflict between their parents, and their emotional, psychological and relational needs are adversely impacted. Often their relationship with one parent has broken down altogether as a result of them being involved with their parents' conflict. We receive referrals from parents directly, the Children and Family Court Advisory and Support Service, the Local Authority and directly from court. 

Recourses to support these families are incredibly scarce, partly because of a lack of evidence around what works and partly because the group is often considered hard to treat, with high levels of burnout among clinicians. 

The Anna Freud Centre has developed a model of 'therapeutic assessment' which we call 'Family Ties'. The model has three main components: a) improving both parents' capacity to mentalise their child and protect them from the parental conflict; b) gradually 'de-sensitising' the child to the non-resident parent, with the support and encouragement of the primary caregiver; and c) co-constructing with both parents a coherent 'narrative' around family events which is acceptable to them both (as well as the court, Local Authority or Children's Guardian where involved), which they can share with the child (Asen & Morris, 2016). 

More recently the CRD project has turned its attention to multi-family group work (see Asen & Scholz, 2010) in conjunction with, or sometimes as a more effective alternative to individual family work. Families stuck in entrenched patterns seem more able to recognise some of their difficulties when they are mirrored by families in the same predicament rather than described by professionals. They are sometimes more able to find new solutions in a context of mutual support and reduced stigma. The project has been inspired by work in the Netherlands by Justine van Lewick and her team, and their multi-family group model 'No Kids In The Middle' (van Lawick & Visser, 2018). The approach is well established in countries across Europe, and we are evaluating and adapting it to a UK context. 

The Centre has been provided funding by the Department for Work and Pensions (DWP) Reducing Parental Conflict 'Challenge Fund' for a 12-month project to train and supervise frontline staff in child and adolescent mental health services (CAMHS) and Local Authority settings to deliver specialist multi-family groups, and evaluate this intervention. As well as improving outcomes for children and young people, the project aims to increase professionals' confidence and improve access to support for families. We will also learn about the effectiveness of the intervention and facilitators and barriers to local support for a population that is often thought of as 'treatment resistant'. The Centre is also running, developing and evaluating this group work for families where the parents are involved with private family court proceedings. 

We aim to continue to develop and increase the evidence around effective treatment and to disseminate best practice to increase the provision for children caught between, and made the focus of, their separated parents' conflict. The Centre hopes to reach a stage where Local Authorities and the family courts are better informed about the treatment to recommend in these situations. We hope effective treatment will be more widely available and free at the point of access, so that these children can get the help they need as soon as they need it. 

What challenges have you faced in doing this work?

One of the big challenges we have is to successfully engage both parents, particularly the dads. We have been really focusing on how to improve this by co-producing our services and intervention delivery with dads, as well as mums. There is no one answer on how to do this well, but we have found that some simple changes can make a big difference – such as offering support in the evening or at weekends, and in locations that feel dad friendly (community centres, libraries, even supermarkets!). If we are to disrupt parental conflict, we need to promote empowering, positive role models for fathers.

Where are we with the evidence of impact on children of parental conflict?

Historically, parental conflict was only really considered pernicious to children if it was openly hostile and violent. However, thanks to the impressive work of academics such as Professor Gordon Harold and others, the evidence base has made great strides in recent years to illustrate that exposure to frequent, intense and poorly resolved conflict can harm children's developmental outcomes and impair their life chances.

It is important to say that a proportion of children whose parents exhibit inter-parental conflict go on to have a normal development, however a number of recent prospective studies strongly indicate that conflict can cast a long shadow. For example, there is an increased risk of adverse child outcomes, such as anxiety, depression, aggression, hostility, anti-social behaviour and criminality as well as deficits in academic attainment (Harold, 2016). There is also increased risk of impaired physical development such as obesity (e.g. Rhee et al., 2006). 

However, this body of research predominantly focuses on the impact to children over four years of age. As a psychologist working in the perinatal period and with families with children under five – I have to mention the gap in the evidence base around parental conflict interventions in the early years. What we do know is that becoming a parent is a critical risk period in the relationship, with increased conflict and a decline in satisfaction compared to couples with no children (Cowan & Cowan, 2000).

Based on the most recent national statistics collected on family breakdown, almost half of couples divorcing in 2015 had at least one child aged under 16 living in the family. Over a fifth of the children were under five and 64 per cent were under 11 (ONS, 2016). Also, around a fifth of children under one do not live with both biological parents, and this increases steadily with age, to over 40 per cent of 16-year-olds (DWP, 2016). 

These patterns are even more devastating to low income families, with over 50 per cent of low income families breaking down when they have children under five years of age. Clearly the early years are a risk period for new parents, but they are also an opportunity for early intervention – so I would like to see more research exploring what interventions work for whom, right from pregnancy.

How do we help parents recognise and act to change their behaviours? 

I think we need a system-wide change, where our society recognises the importance of reducing parental conflict as early in a child's life as possible. I think training and empowering the workforce is an important first step in this journey. Having a curious, competent and confident workforce of practitioners such as midwives, health visitors, and teachers who know more about inter-parental conflict and how it can impact children would mean they can ask parents about it. Simply asking, 'How are things going at home with your partner?' can go a long way. Then, once a problem is identified, we need evidence-based interventions to signpost families to. This is exactly what the DWP Reducing Parental Conflict agenda is changing. We are starting to deliver a range of interventions in the community that can actually help these families. I am a big advocate.

What is the role of psychologists?

I am a clinical psychologist by background. Certainly clinical psychologists, like many other practitioner psychologists are well placed to bring a systemic lens to this area of work by working with the whole system around the child, to avoid replication of splits and ensure good safeguarding of children. Psychologists are also well skilled in facilitating clinical supervision and reflective practice to work with this system to support clinicians in avoiding getting caught up with the conflict themselves.

Having said this, I think there is a huge gap in clinical psychology training related to couple or co-parenting-focused ways of working, and in my experience many psychologists feel very anxious about working in these ways. I think this is inadvertently reinforced in the NHS service structures, as couples support is not explicitly supported in most services. In the last year of my clinical psychology training, we had the opportunity to invite an external trainer, and we brought the wonderful Scott Woolley over from America to train us in emotionally focused therapy, which is an incredible evidence-based intervention for working with couple distress. It is still one of the most important clinical skills in my toolbox.

Another approach that I am not trained in (but would love to be) is behavioural couple therapy for depression and substance use, which again has a really fantastic evidence base, but you rarely see psychologists delivering it in the NHS. I really welcome how it has been rolled out in Improving Access to Psychological Therapies (IAPT) – I just wish there was more of it.

It is so important for psychologists and other practitioners to be up to date with the evidence in this area and deliver interventions based on evidence. There is emerging evidence that traditional family therapy approaches can be ineffective and, in some cases where children are caught in parental conflict, counterproductive (Warshak, 2010).

My last message to all the practitioner psychologists, no matter whether you work in CAMHS, IAPT, paediatrics or dementia, is to ask the people and families you work with, 'How are things with your partner?' or, 'How is your parents' relationship?'

Patrick Myers is Senior Ambassador for the Reducing Parental Conflict Programme, Department for Work & Pensions. Now, Camilla asks him the questions.

How did you come to be involved in this area of work and what is your role now?

I am an assistant director of children services in Dorset, which was one of 12 local authority areas that were interested in the trial work that led to the development of the full Reducing Parental Conflict programme. A relatively small amount of money was provided to each area to innovate in the relationship support space. At that time, it was reported that one in 10 children with parents living in the same household, were exposed to potentially damaging levels of conflict. The trials tested ways of engaging parents – in Dorset, investment in a post within a school cluster proved really valuable. 

However, all areas reported that there was not enough strategic leadership around reducing parental conflict, frontline practitioners were not confident in having conversations about the quality of relationships and there was also a paucity of interventions to deal with inter-parental conflict. So the findings of the trials known as Local Family Offers directly informed the development of the full programme. 

Working with the Early Intervention Foundation and Professor Gordon Harold and colleagues saw the publication of the research paper entitled What works to enhance inter-parental relationships and improve outcomes for children? Now seconded into the programme fulltime from Dorset Council, my role is to promote the evidence and work with national organisations to see how the evidence can influence the wider policy arena and become part of the family policy narrative. 

Why is the government interested in working with families to reduce parental conflict?

The overall ambition is to give every child the best start in life. We all know that parents play a critical role in giving children the experiences and skills they need to succeed. However, children who are exposed to parental conflict can suffer long-term harm. It can affect their early emotional and social development, their educational attainment and later employability – limiting their chances to lead fulfilling, happy lives. That's why we are working to reduce conflict between parents – whether they are together or separated. Sometimes separation can be the best option for a couple, but even then, continued co-operation and communication between parents is better for their children. The poor outcomes for children exposed to parental conflict can also lead to increased pressure on public services. 

What does the £39 million programme look like and how is it going?

One hundred and forty-nine local authority areas are engaged with the programme. For each of those, the offer of resource for strategic leadership support and practitioner training has been accepted. Practitioners receive both classroom and online training that shares the evidence base, helps with challenging conversations and offers practical tools to support action on the issue of conflict. This has now been tested and we are confident that the full breadth of practitioner training can be delivered through this mechanism. 

In 30 of the 149 local areas the programme is testing eight new parent interventions that focus on both parenting and the impact of conflict on children and parents. Parenting programmes that do not deal with conflict will not enable the necessary behaviour change to improve children's lives now and later. In addition, recognising the bi-directional relationship between conflict and alcohol, nine local authority areas have shared an Innovation Fund (jointly funded by the Department for Health and Social Care and DWP) to work with families where the parents are dependent on alcohol. The current phase of the programme lasts until March 2021 and as you would expect there is an extensive evaluation of all the programme strands. 

You mentioned the Innovation Fund for Children of Alcohol Dependent Parents, can you say some more on this?

The nine Innovation Fund projects are working in different ways, but the common feature is that they aim to work with the whole family and not just the parent in treatment. Like the Reducing Parental Conflict programme there is much investment in workforce development, stressing the quality of practitioner relationship with families as the route to better outcomes for those in treatment and their families. As well as seeking to increase the number of parents receiving treatment interventions, the projects are working purposefully with children individually and in groups. All nine areas have been able to create a remote model of service delivery responding to the likely increase in alcohol dependency during this time. 

How do you think psychologists can help, and how can they get involved with the national programme? 

I hope that many psychologists can see the connection between their work and the aims and objectives of the programme. The impact that parental conflict has on children's internalising and externalising behaviour as described by Gordon Harold mean that it should be of interest to a whole range of psychologists. Make contact with your local authority and see what opportunities are in your area, from training to the ability to refer onto the interventions that have been commissioned to support families to make their lives better.

Originally published online 24 August 2020

References

Asen, E. & Scholz, M. (2010). Multi-family therapy: Concepts and techniques. Routledge.

Asen, E. & Morris, E. (2020). High-conflict parenting post-separation: The making and breaking of family ties. Routledge.

Cowan, C.P. & Cowan, P.A. (2000). When partners become parents: The big life change for couples. Lawrence Erlbaum Associates Publishers.

DWP. (2016). Social justice outcomes framework: Family stability indicator. Department for Work and Pensions. 

Harold, G.T., Acquah, D., Sellers, R. et al. (2016). What works to enhance inter-parental relationships and improve outcomes for children. Department for Work and Pensions.

Rhee, K.E., Lumeng, J.C., Appugliese, D.P. et al. (2006). Parenting styles and overweight status in first grade. Pediatrics, 117, 2047-54.

van Lawick, J. & Visser, M. (2018). Action oriented and experiential work in the context of highconflict divorce. Context, 157, 14.

Warshak, R.A. (2010). Family bridges: Using insights from social science to reconnect parents and alienated children. Family Court Review, 48, 48-80.