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EmpoweringChildreninFamilies
ImpactedbySubstanceUse,
MentalIllness,andHIV/AIDS
Presentedby:
CarlaElia,Ph.D.
Allmaterialscopyright2014,CarlaElia,Ph.D.
Objectives
Describe the impact of maternal substance abuse,
mental illness, and HIV on childrens functioning.
List the core elements/Cognitive Behavioral Therapy
(CBT) skills of this Evidence-Based Intervention and
their application to the target population.
Identify helpful session topics aimed at supporting
families to cope with maternal substance use, mental
illness, and HIV on childrens functioning.
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Many Parallels
Comorbidity
HIV
Substance use
Mental illness
Similar challenges as other parents plus more
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Family Environment
Physical and mental impairment
Lack of supervision and limits
Limited or lack of modeling of adaptive
behaviors
Lack of motivation to model adaptive behaviors
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Family Environment
Lack of or limited affection and play
Lack of or limited recognition of childs
strengths and positive behaviors
Relationship and communication breakdown
Implicit family rules about expression of
thoughts and feelings
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Family Environment
Suspicion
Failure to foster social interactions
Social ostracism and stigma
Negligence
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Family Environment
Attachment
Bowlbys attachment theory: The parents ability to bond
with the child
Secure and insecure attachment
Secure parent-child attachment
Structure and stability
Consistent parenting
Needs and expectations are met
Predictability
Daily routines are respected
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Family Environment
Specific to Substance Abuse
Domestic violence
Expenditure of often limited household resources on
purchasing alcohol or other drugs
Frequent arrests, incarceration, and court dates
Time spent seeking out, manufacturing, and/or using
substances
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Family Environment
Specific to HIV
Fear of transmission can limit parent-child interactions
Stigma reduces parents disclosure to children
Limited child opportunity for social support
Anxiety regarding parents health
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Impact on
Child Functioning
Emotional problems
Substance use problems
Behavior problems
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Impact on
Child Functioning
Academic problems
Physical problems
Parentification
Low self-esteem and self-worth
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Impact on
Child Functioning
Self-blame
Embarrassment or shame
Estrangement from primary family and related support
Social isolation
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Impact on
Child Functioning
Early parent-child attachment impacts later style of
attachment
Avoidant
Anxious
Impact of insecure attachment
Mistrustful of others
Less willing to learn from adults
Difficulty understanding the emotions of others
Difficulty regulating their own emotions
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Impact on
Child Functioning
Impact of insecure attachment (contd)
Difficulty forming and maintaining relationships
Limited ability to feel remorse or empathy
Lack of social skills
Impaired social cognition
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Overview of TALK-LA
A family-centered intervention for HIV infected mothers
and their children
18-month randomized study conducted by a research
team at UCLA Center for Community Health
Many of the moms also suffered from substance abuse
and mental illness
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Intervention Trial
Recruited from 1/2005 10/2006
Eligibility criteria
Mother or female caregiver living with HIV
Caring for a child (6-20 years of age)
Children aware of caregiver diagnosis participated in
intervention
Mothers living with HIV (n = 339) (ages 21-69)
Child participants (n = 256) (age 12-20)
Los Angeles County
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Overview of TALK-LA
16 total sessions
Delivered in small weekly groups
Consisted of:
Child-alone sessions
Parent-alone sessions
Joint parent-child sessions
Opportunity to practice, internalize, and generalize
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The Intervention Model
Model integrates:
Cognitive behavioral theory (CBT)
Skills building and education
Family systems theory
Family roles, values and expectations
Attachment theory
Parent-child relationship
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Intervention Outcomes
81% of the moms attended at least 12 of the 16
sessions
Less family conflict reported as mothers attended more
sessions
Increased parental participation associated with less
sexual risk behaviors among adolescents
Children whose parents attended more sessions
reported less family conflict and more maternal bonding
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QUESTIONS?
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Why CBT Skills?
CBT is an evidence-based model for treatment of mood
disorders and substance abuse
CBT addresses underlying skills deficit
Moms need coping tools
Children need tools to cope with moms illness
Children need tools to promote resilience
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CBT Skills
Use of a Feeling Thermometer & Feel-Think-Do (F-T-D)
Framework
When we encounter a situation, we have:
A feeling about it (Feeling Thermometer rating & body reaction)
A thought about it (what we say to ourselves)
An impulse to do something about it (actions as a result of feelings & thoughts)
Typicall y a habit & not noticed
Goals:
Increase awareness of the F-T-D connection
Practice looking at life events within this conceptual framework
Gain control over feelings, thoughts, and actions
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CBT Skills
Think
Do
Feel
Feel-Think-Do
Framework
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CBT Skills
Feel
Feeling Thermometer rating
Physical or body reactions
(e.g., sweaty palms, a flushed face, trembling knees,
etc.)
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CBT Skills
Feeling Thermometer
Establishes a hierarchy of
comfortable vs. uncomfortable
events
Promotes awareness of
escalating discomfort by
linking our comfort level to
body reactions
Establishes a rate of optimal
performance (think & act)
Serves as a counseling tool
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CBT Skills
Feeling thermometer versus
labeling of emotions
Common language
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CBT Skills
Think
What we say to ourselves
Expectations & beliefs about people, places,
situations, things, or feelings
Reactions differ based on thoughts
Automatic & often distorted
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CBT Skills
Smart Thinking
Controls or counters self-defeating thoughts
Skills used to support smart thinking:
Positive self-talk
What we say to ourselves
Reframing
Re-describes the experience in positive terms
Changes the way in which the problem is
understood
Frames problems as opportunities to grow & learn
rather than as disasters
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CBT Skills
Do
Reactions to an event
Actions may include:
SMART problem-solving
Assertive behavior & communication
Relaxation
Challenge: Maintaining SMART actions in response to
high Feeling Thermometer & distorted thoughts
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CBT Skills
Short- & Long-term Goal Setting
Crucial to making behavior change ~ why?
Accomplishing vs. not accomplishing goals
Guidelines for goal setting:
Brief & specific
Clearly stated
Realistic (40-60 on Feeling Thermometer )
Clear end point
Stated in positive terms
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CBT Skills
Weekly goals: Short-term goal setting
Set goals at conclusion of each session
Relate to session activities
Review during next check-in
Praise success
Problem-solve/overcome barriers
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CBT Skills
Life goals: Long-term goal setting
Set goals/dreams for the future
Inspire commitment to therapy
Reference throughout therapy sessions
Provides purpose and meaning for life
Inspire emotional and physical well-being
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CBT Skills
Skill: SMART Problem-Solving
Slows down automatic decision making by
solving problems in a systematic manner
S = State the problem
M = Make a goal
A = Achieve a list of all possible actions
R = Reach a decision
T = Try it and review it
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CBT Skills
SMART Problem-Solving
Think before you act: Look at your choices
Based on decisional balancing model:
Often, people are in a state of conflict about situations
When undecided, if we argue for one side, person will
defend that side; if we argue towards the other side,
person will defend that side
SMART avoids this
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CBT Skills
Social Support Building
Types of social support
Emotional
Informational
Tangible
Sources of social support
Positive (+) versus negative (-) social support
Increase + support / Decrease - support
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CBT Skills
Assertive Behavior and Communication
Standing up for your needs while being respectful about the
needs of others
Verbal:
Use I statements (I would like this)
Say what you want respectfully
Pay attention to body language
Non-verbal: facial expressions, voice tone and volume, eye
contact, posture, gestures & interpersonal space
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CBT Skills
Stress management
Coping
Emotional regulation
Identifying and changing unhealthy patterns
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Benefit of Parallel Learning
Repetition
Practice
Modeling
Reinforcement
Morale
Motivation
Commitment
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Benefit of Parallel Learning
Life and smaller weekly goals
Opportunity for moms to focus on themselves versus
caring for others
Opportunity for kids to focus on themselves versus acting
as a parent
Model goal setting and following through for children
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Benefit of Parallel Learning
Life and smaller weekly goals
worry and hope for moms to watch children establish
life goals
worry for children to know moms have future aspirations
Creates opportunity for mutual support and modeling
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Benefit of Parallel Learning
Social support
mothers reliance on children as a source of support
mothers worry about children
childrens alienation by seeking support from others
Improves overall adjustment
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Benefit of Parallel Learning
Assertiveness
Learn how to be assertive with each other and others
Meeting needs leads to satisfaction & self-efficacy
mothers worry about children
childrens worry for mom
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Parallel Individual Session Topics
Healthy physical habits
Identify healthy physical habits
Identify and problem-solve/overcome barriers to
healthy physical routines
Choose a goal and implement
Benefit:
childrens worry for mom
parentification of children
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Unique Child Sessions
Coping with moms illness (HIV, substance abuse,
and/or mental illness)
What its like to live in a family affected by illness
Identify questions to ask mom regarding illness
Coping with disclosure
Identifying and coping with risky behaviors
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Parenting Sessions
Managing child behaviors
Ignoring, positive reinforcement, behavioral chart,
consequences, monitoring
Seeking social support related to parenting
parenting stress
Improves parent-child relationship
Enhances moms sense of self-efficacy and emotional well-
being
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Joint Parent-Child Sessions
Live physically healthy as a family:
Discuss pros & cons of being physically healthy
Identify unhealthy family patterns
Share individual goals related to physical health
How can family members support each other
in achieving goals?
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Joint Parent-Child Sessions
Establish a positive home environment:
Identify family strengths
Catch someone doing something good
Share life goals
How can family members support each other in
achieving goals?
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Joint Parent-Child Sessions
Communication
Opportunity for mom and child(ren) to share thoughts &
feelings about her illness
Mom to provide clarification and answers
Child(ren) to ask questions & share fears
Identify family rules & habits related to disclosure
Identify and problem-solve/overcome barriers to effective
communication
Moms practice listening receptively to children
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Parallel Individual Session Topics
Conflict resolution
Establish a hierarchy of likely conflicts using the
Feeling Thermometer
Identify recent parent-child conflicts
Learn & practice SMART conflict-resolution skills
Win-win situation
Role play
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Summary
Empowering mothers to serve as positive role models
for their children
Changes made on an individual level:
Improve mothers functioning
Establish healthy patterns that may be internalized &
practiced by children
Parenting skills used to enhance parent-child
relationship
Joint parent-child sessions improve parent-child
attachment
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QUESTIONS?
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Acknowledgements
This research is supported by the National Institute of
Mental Health
Grant #: MH-068194 (Rotheram-Borus)
Co-authors/Contributors:
Mary Jane Rotheram-Borus, Ph.D., Eric Rice, Ph.D., &
Patricia Lester, M.D. Center for Community Health,
University of California, Los Angeles
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Acknowledgements
Rotheram-Borus, M. J., Rice, E., Comulada, S., Best,
K., Elia, C., Peters, K., Li, L., Green, S., Valladares, E.
(2012). Intervention Outcomes Among HIV-Affected
Families Over 18 Months. AIDS and Behavior, 50, (4);
358-364.
Rotheram-Borus, M. J., Stein, J. A., & Rice, E.
(2014) "Intervening on conflict, parental bonds, and
sexual risk acts among adolescent children of mothers
living with HIV." Manuscript under review.
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CARLA ELIA, PH.D.
Consulting and Adult, Couples, and Adolescent Psychotherapy
http://www.drcarlaelia.com
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