Changes in Mindfulness Attitude after Parent–Child Interaction Therapy Skills Acquisition: Comparison of Mindfulness Attitude before and after the Parent–Child Interaction Therapy 40 Hours Basic Training

Abstract

I conducted this study to verify that the acquisition of PRIDE skills, an important skill for building good parent–child relationships in parent–child interaction therapy (PCIT), is associated with mindfulness attitude formation. PCIT, which was developed by Eyberg in 1974, is a behavioral therapy based on play therapy in which a therapist provides live coaching from a separate room while parents and children are playing in the same room to improve the parent–child relationship and children’s problem behaviors. The original and unique feature of my study is that I discussed PRIDE skills and mindfulness from the perspective that both are related to attentional control functions. The mindful attention awareness scale (MAAS) Japanese version was used as a measure of mindfulness. I compared the MAAS score of seven graduates who mastered PRIDE skills before and after 40 hours of PCIT International Prescribed Training Workshop, and as a control group, I compared the MAAS score of six non-training participants. As a result, the MAAS score had a significantly decreased tendency only in the PCIT group. It was suggested that mindfulness tendency may have increased in the PCIT group. PCIT may contribute to mindfulness attitude formation through improved attention and awareness. This study was approved and conducted by the Ethics Committee of the Faculty of Human Sciences, Kobe College. There are no conflicts of interest.

1. Introduction

I conducted this study to examine how the acquisition of skills for improving parent–child relationships (PRIDE skills) in PCIT: parent–child interaction therapy, promotes mindfulness attitude formation. This chapter presents the results of this study. Although studies on PCIT and mindfulness have existed to date, there are studies that argue against the two, as to whether PCIT or mindfulness techniques are more effective in improving caregivers’ mental stability and children’s problem behaviors (e.g., [1, 2]). I have not been able to find a study, at least at this time, that attempts to link PCIT and mindfulness in terms of “attentional functioning” by focusing on the similarities between the two functions, as my study does.

First, this is a unique perspective of this study. This study is only a comparative study with a very small sample. However, this study does indicate the possibility that the ability of skill users to observe and continuously verbalize their children’s behavior tends to enhance the mindfulness attitudes of the users.

In this chapter, I begin by providing an overview of PCIT and the “PRIDE skills” used in the first half of PCIT, child directed interaction (CDI), which is an important premise for this study to facilitate the reader’s understanding. PRIDE skills are a powerful tool for improving the relationship between caregivers and children and are one of the key components of this study. Therefore, I will first explain the skills and then provide a brief description of mindfulness. Next, I present the purpose, methods, results, and discussion of this study. This is because a basic understanding of PCIT and mindfulness is essential to the structure of this study.

Through this study, the reader will understand that the psychological functions embodied in the PRIDE skills of PCIT are related to mindful parenting attitudes. Furthermore, I believe that through this study, I was able to articulate the very abstract attitude of mindful parenting as a concrete behavior in the form of the PRIDE skills and provide a course of action that will help increase the practicability of mindful attitude formation for caregivers.

2. Outline of PCIT

2.1 What is PCIT?

Imagine a mother and her child happily playing together in a certain small playroom. The room is equipped with a one-way mirror, and a therapist in an adjacent observation room speaks to the mother wearing earphones, “Let’s praise the child, saying, ‘You built a wonderful castle’.” The mother repeats the therapist’s words and says to the child at her side, “You made a lovely castle.” The praised child smiles at the mother and concentrates on playing again, building more and more gorgeous castles. The mother’s face lights up as she sees her child smiling and concentrating on his play. The therapist says, “Mother, you did very well with your labeled praise!” and praises the mother for her efforts.

This is a typical scene at PCIT. A first-time observer would have no idea that this child has been diagnosed with ADHD and that just a few weeks ago, his mother was in trouble because of his terrible tantrums.

PCIT is a behavioral therapy based on play therapy in which a therapist provides live coaching from a separate room while parents and children are playing in the same room, as shown in Figure 1, to improve the parent–child relationship and children’s problem behaviors. PCIT was developed by Eyberg of the University of Florida in 1974. Findings that it is effective in reducing parental re-abuse rates to 20% [3] have increased the reputation of PCIT throughout the United States. After years of empirical research and refinement, PCIT has been reported to improve children’s problem behaviors, especially behavioral disorders such as externalizing aggressive behaviors [4], and meta-studies have also reported high efficacy [5]. Furthermore, it is ranked as a “well-established treatment” in the American Psychological Association’s evidence-based treatment guidelines [6]. Van der Kolk, a world authority on trauma, promotes the practice of PCIT at his trauma center, and Putnam, a leading dissociation researcher, has recommended PCIT in a lecture in Japan as effective in treating trauma and preventing abuse in children.

Figure 1.

PCIT role play in practice (therapist is skill coaching the parent role).

As shown in Figure 2, PCIT has an extremely high efficacy rate of d = 1.65 [7], indicating that it is outstandingly effective compared to medication, CBT, or other psychotherapies.

Figure 2.

Efficacy rates for each treatment. (Adapted from PCIT International Website: https://www.pcit.org/.)

PCIT is a behavioral therapy based on operant conditioning, but especially in the first half, it emphasizes the caregiver’s receptive involvement in child-initiated play and stabilizing the psychological state of the child and parents by strengthening attachment relationships. As shown in the photo at the beginning of this article, PCIT uses a method whereby the therapist provides live coaching from a separate room to parents wearing earphones through a one-way mirror (or through a computer screen when using the Internet) and gives specific, direct advice to parents on how to interact with their children. The therapist does not directly intervene with the child, but rather, the parent is asked to engage with the child using good skills, and the therapist supports the parent in a nested structure. This way of having the caregivers themselves develop the skills to observe the child and intervene specifically is what makes PCIT unique. In this study, I focused on the PRIDE skills, which are acquired in the first half of the CDI and used by parents on a regular basis throughout the therapy and which are considered to be the most important skills for forming parent–child attachment and improving the good relationship.

2.2 Structure of PCIT: CDI and PDI

PCIT consists of two steps. The first half is CDI, and the second half is PDI (parent-directed interaction). As mentioned above, in the first half of the CDI, caregivers receive 30 minutes of coaching in each session to learn PRIDE skills (see below) and promote receptive interactions in order to rebuild the parent–child relationship. Then, caregivers move into PDI, where they learn how to appropriately control the child, including effective time-outs for modifying the child’s behavior and how to give effective instructions. The extent of caregiver skill acquisition and improvement in the child’s problem behavior is confirmed through assessment with the ECBI (Eyberg child behavior inventory) and DPICS (dyadic parent–child interaction coding system). The caregiver receives feedback from the therapist on the results of the assessment, allowing the caregiver to monitor his or her own growth and changes in the child as the therapy progresses. Thus, PCIT is a highly structured and systematic treatment program with a standardized and detailed protocol and manual. However, what is interesting about PCIT is that the therapist intervenes only with the caregiver and not directly with the child. In other words, PCIT is a training program for caregivers to practically improve their own observation skills and responsiveness to their children through coaching.

2.3 Skills in CDI

The PCIT descriptions presented in this paper are based on the PCIT Protocol [8] and the Abbreviated Manual for Dyadic Parent–Child Interaction Coding System, Clinical Manual Fourth Edition [9].

The goal for caregivers to achieve in the CDI is to master the PRIDE skills (Do skills) (Table 1) and eliminate the AVOID skills (Do not skills) (Table 2). The PCIT sets clear criteria for skill acquisition, and once caregivers have met those criteria, he or she can move on to the next stage, PDI. In CDI, the caregiver enters the playroom each time with the child and follows the child’s lead in playing together. This time when the caregiver plays with the child using PRIDE skills and follows the child’s lead is named “special play time,” and the caregiver is given homework to practice the skills at home by conducting “special play time” with the child for 5 minutes each day. In the playroom, the caregiver wears earphones and receives instructions from the therapist, who observes the parent and child through a one-way mirror, about their interactions as appropriate. Prior to each coaching session, the therapist conducts a 5-minute coding session to determine which of the caregiver’s PRIDE skills are developing and which are weak and, based on the results, sets goals for each session and conducts coaching for approximately 30 minutes. The therapist also uses PRIDE skills throughout the therapy, talking to the caregiver, encouraging the caregiver, and consistently giving specific praise. In other words, PCIT cannot be successfully implemented unless the therapists themselves have mastered the PRIDE skills. The criteria for the mastery of PRIDE skills are discussed below.

PRIDE skills	Explanation and effects	Examples
P; Labeled Praise	Give children “Concrete praise” for positive behavior. Increase praised behavior and boost the child’s self-esteem.	“You picked a great color!”; “You take good care of your pen!”; “I’m glad you are playing quietly.”
R; Reflect	Repeat the child’s appropriate “words”. It allows the child to lead the conversation, shows that the parent is listening, and promotes the child’s ability to speak.	Child: “I made a big castle!”; Mother: “You made a big castle!”; (A cat is sleeping nearby.); Child: “Cute cat!”; Mother: “Cute cat taking a nap!”
I; Imitate	Imitate the appropriate “play or action” of the child. Imitate has the function of focusing the parent on what the child is doing, allowing the child to lead the play.	If a child draws a tree, the parent draws a tree as well.
D; Behavior Descriptions	Explain appropriate child behavior. Live coverage BD can let the child know that the parent is interested in and paying attention to the child. Child can maintain attention to his or her activities.	A child has picked up a red crayon and is drawing an apple.; Parent: “You have taken the red crayon and are drawing an apple.”
E; Enjoy	Enjoying special play time with the child. The parent can let the child know that he or she is enjoying time with the child.	Gentle body touch, laughter, and warm tone of voice to the child.

Table 1.

PRIDE skills.

Partially modified from Kuniyoshi [10].

Avoid skills	Explanation and effects	Examples
Command; Parent telling the child what he/she should or should not do.	CO takes the lead away from the child and causes him/her to lose the opportunity to make independent decisions.	⟨Indirect Command⟩; “Will you sit here?”; “I think you should paint this one red.”; ⟨Direct Command⟩; “Please sit here.”; “Paint this part red.”
Question; Asking the child to give an answer.	QU lets the parent lead the conversation. Many questions are commands and demand answers.	“Why does this cow cry?”; “Are you painting it red?”; “Do you want to play with trains next?”
Negative Talk; Expressions of disapproval toward the child.	It gives attention to inappropriate child behavior and lowers the child’s self-esteem.	“You did not do so good.”; “Your paint just blew out. Oh, My God.”; “You could have painted it better.”; “Oh, no! You’re going to paint that?”; “That’s why I warned you before!”

Table 2.

Avoid skills.

Partially modified from Kuniyoshi [10].

<About PRIDE Skills>

PRIDE skills are the five skills listed in Table 1 which are desirable skills for building parent–child relationships.

• P (Labeled Praise): Specific praise for appropriate “behavior” of the child. (Praise helps children build self-esteem and feel accepted. The child learns what behavior is appropriate and will repeat positive behaviors.)

• R (Reflect): The caregiver repeats the child’s appropriate utterances. (Reflect is a skill that allows the child to lead the conversation and promotes the child’s ability to speak by showing the child that the caregiver is listening properly).

• I (Imitate): This is the skill of imitating the child’s appropriate play (action). (Imitate allows the caregiver to focus on what the child is doing.)

• D (Behavior Descriptions): Describing the child’s appropriate behavior. The caregiver provides a “play-by-play” account of the child’s behavior as if the caregiver were an announcer (letting the child know that the caregiver is interested in and paying attention to the child). The child is able to maintain attention to his or her activities by having the caregiver’s attention.

• E (Enjoy): Enjoying special times with the child. The caregiver acts happy and natural, letting the child know that he or she is enjoying the time with the child. This includes gentle body touches, laughter, and a tone of voice that indicates the caregiver’s interest.

Thus, the five skills included in the PRIDE skills are those that make the child feel safe and secure in the sense that he or she is being watched and accepted with interest by the caregiver.

⟨Avoid Skills⟩

PRIDE skills are not the only skills in CDI. There are also another three skills, called “Avoid Skills,” that can keep children away from negative influences by minimizing the use of these skills by the caregiver. The “avoid skills” consist of “Question,” “Command,” and “Negative Talk” (Table 2).

In addition to PRIDE and Do not skills, CDI also uses “Selective Attention” and “Active Ignoring” skills that do not give attention to the child’s problem behavior, but since these skills are not directly addressed in this study, this paper will omit a description of these skills. In concluding my explanation of PCIT, I will discuss the standards for the mastery of PRIDE skills required of caregivers. This will be based on coding by DPICS. The caregiver uses each of the three verbal skills in the PRIDE skills, Labeled Praise, Reflection, and Behavior Description, at least 10 times in 5 minutes of play with the child and simultaneously uses the Do not skills no more than 3 times total in 5 minutes. In this study, the survey was conducted not with caregivers but with students attending a training workshop to become PCIT therapists. The reason for this will be explained later, but even in therapist training workshop, students are strongly expected to meet this mastery standard, and all participants in the PCIT therapist training workshop that I studied met this standard.

2.4 PCIT therapist training course and skill acquisition assessment

A prospective PCIT therapist must complete a 5-day, 40-hour training workshop in accordance with PCIT-International to accurately understand the principles, structure, and procedures of PCIT, as well as to acquire practical PRIDE skills. In this study, PRIDE skill acquisition was checked in the framework of DPICS skills coding for a 5-minute parent–child playtime video and a “mastery hour” of DPICS skills coding for a parent–child playtime role play. The mastery hour consisted of a 5-minute CDI role play in which the student played the parent and the trainer played the child, while another trainer and several students checked the skills of the student playing the parent based on DPICS. Thus, the mastery hour is a rigorous assessment of whether the student has met the mastery criteria. Participants in the parent role cannot complete the mastery hour exercise until they have fully met the prescribed PRIDE and Do not skills criteria in 5 minutes and must repeat the role play in the parent role until they reach the criteria. In this study, all trainees met these criteria, so all trainees were assigned to the mastery group.

2.5 Reasons for conducting this research with students in the training course

Since PCIT is a therapeutic technique for supporting caregivers, it is desirable that the study be conducted with caregivers who are actually receiving PCIT. However, even though PCIT is a short-term therapy, it often takes more than 20 sessions and about 6 months to complete. In addition, it is difficult to control the length of time because the time required for acquisition varies greatly from person to person, depending on the caregiver. Furthermore, at the facilities where I conduct PCIT, it is not possible to have many PCIT cases going on at the same time, and it is difficult to gather enough clients at the same time to actually study the effects of PCIT. For these reasons, it was decided to focus this study on participants in 40 hours training workshop, where several people can acquire skills under the same conditions in a short period of time.

3. About mindfulness

Mindfulness is a meditative state, so to speak, and according to Kabat-Zinn [11], mindfulness is defined as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.” In recent years, mindfulness has been gaining attention as an essential component of mental health in various psychotherapies, including cognitive therapy, dialectical cognitive-behavioral therapy, and stress reduction methods. In mindfulness, the greatest emphasis is placed on the attitude of simply observing thoughts that arise within oneself “as they are.” This is the process of “de-centering” through “awareness.” For example, when negative thoughts are repeated, a mindfulness attitude can be helpful in curbing the vicious cycle of ruminating, as described by Segal et al. [12]. According to Segal et al. [12], in cognitive-behavioral therapy, mindfulness attitude is a process of “de-centering” that separates and “distances” the self from thoughts and feelings, which is closely related to procedures that promote contextual change and have a preventive effect on depression relapse. Mindfulness is the Pali word “sati,” meaning “awareness,” and according to Gunaratana [13], this state is a subtle work of the mind, beyond words and logic, but experiential. When we recognize something, the moment just before we identify it is the state of awareness. At the same time, he also points out that “awareness” means to see things from a broader perspective.

Sumanasara [14] provides an understandable summary of the commentary on the meditative states in early Theravada Buddhism, in which he distinguishes two main categories of meditation: Samatha meditation and Vipassana meditation. According to Sumanasara, Samatha meditation is one in which the normal activity of the mind is suspended by focusing attention on an object, allowing the mind to unfold at a subtle level of activity. In Samatha meditation, by concentrating one’s attention on a specific object, thoughts and their associated desires and emotions are suppressed, attachment to the object disappears, and one feels the joy of becoming one with the object itself at that moment. However, as one progresses through the stages, the state of zen meditation becomes more abstract and difficult to recognize and verbally express through consciousness.

Vipassana meditation, on the other hand, is a meditation technique that aims to observe things as they are and is what is called mindfulness meditation. Vipassana meditation is a continuous process of “bringing awareness and attention” to oneself and all that surrounds oneself and becoming aware of phenomena that come and go in the mind while also acting on one’s own. A common exercise in mindfulness practice is to breathe in and out, keeping one’s attention on all bodily movements that accompany the breath, as well as on the changes in the external world. This process is expected to inhibit the hijacking of attention to one part of the object, such as thoughts or actions, and to increase awareness, observation, and awareness of multiple phenomena, which in turn creates a state of mindfulness. Vipassana meditation is also said to promote trait change, or long-term change, and in this sense, the acquisition of a mindfulness attitude is thought to bring about long-term positive change.

4. Objectives of this study

4.1 Commonalities between mindfulness and PRIDE skills

Summarizing the core functions of mindfulness from the above points, (1) improvement of observation of oneself and others and (2) acquisition of attention control skills can be identified. The focus of this study began with the idea that there may be similarities between the acquisition of PRIDE skills in PCIT and the process of mindfulness attitude formation. In other words, in order to implement the verbal skills of “Labeled Praise,” “Reflect,” and “Behavior Descriptions” of the PRIDE skills, the skill user is conscious of and observes the various words and actions of the child (target) in the “here and now.” Meanwhile, the skill user is required to switch his/her attention to himself/herself and immediately verbalize the skills. This is a very conscious internal process of verbalization. In other words, the skill user must continue to pay attention to multiple domains simultaneously, including the child’s expressive behavior in the “here and now” and his or her own internal state. Such continuous use of the PRIDE skills is thought to enhance the skill user’s ability to control attention and, as a result, contribute to the improvement of the observational function required for mindfulness. However, because PCIT uses the PRIDE skills in response to a child’s good behavior, some may think that the added value judgment of good behavior is different from a mindfulness attitude. In reality, however, in PCIT, the caregiver (skill user) is always coached to emit the PRIDE skills for every behavior of the child, regardless of the outcome of the child’s behavior (e.g., whether the child successfully piles blocks), except when the child is acting in a severely aggressive or destructive manner. As a result, in practical terms, the caregiver continually emits the PRIDE skills to the child at all times.

With the above as a research question, the present study will compare the changes in mindfulness scale scores of participants (skill users) before and after attending a 40-hour PCIT-International-approved PCIT Therapist Training Workshop (hereinafter referred to as “WS”) to determine the potential of PCIT skill acquisition for the formation of mindfulness attitudes. Although this is a modest study, it is hoped that it will serve as one exploratory study to demonstrate the potential of PCIT as a behavioral guide for mindful parenting.

4.2 The three PRIDE skills and the hypothesis of this study

We will discuss in more detail the three PCIT skills that are the basis for the study and that are presumed to be related to mindfulness. Since three of the PRIDE skills, (1) Labeled Praise, (2) Reflect, and (3) Behavior Description, are the three verbal skills that are the criteria for CDI acquisition, the present study will focus on these three skills. Again, (1) Labeled Praise is a technique in which the skill user identifies and praises the child’s specific behavior; (2) Reflect is a technique in which the skill user repeats the child’s utterance verbatim, without changing the meaning; and (3) Behavior Descriptions is a technique in which the skill user describes the child’s specific behavior in words, or in other words, a technique in which the skill user provides a live report of the situation.

In order to use the above three skills constantly, the skill user must be aware of the child’s specific behavior and speech and must always pay attention to what the child says and does. Not only that, the skill user must also be careful not to use the Do not skills at the same time. In other words, the skill user must consciously select the appropriate skill and instantly verbalize it to the child so that the skill user does not utter “Question,” “Command,” or “Negative Talk.” This is multitasking, and it occurred to me that this multiple and continuous attentional focus could produce the effects of attention control training and contribute to the improvement of observation and attention control skills, as referred to in mindfulness. In addition, mindfulness is not about concentrating on any one point but rather accepting and passing on internal and external stimuli that arise one after another. The state of mindfulness is created by not keeping awareness in one place but by quickly switching and dispersing attention to other areas to prevent “fixation” of awareness and to increase awareness with a broader perspective and distance. This process of mindfulness generation suggests that the use of the PRIDE skills is exactly in line with the mental state aimed for in Vipassana meditation, not Samatha meditation, and it is assumed that the use of the PRIDE skills has an element of mindfulness.

Approaching from the perspective of mindfulness meditation research, there have been many previous studies from the viewpoint that mindfulness meditation is involved in improving “attentional functions” [15]. Furthermore, Ogishima et al. [16] point out that attentional functions are categorized as subfunctions and that they may be associated with certain psychiatric disorders. Furthermore, Ogishima et al. [16] stated from their review of previous studies that it is unclear as to which attentional functions are associated with mindfulness meditation; however, they have consistently reported that there is an association between attentional functions and mindfulness. Ogishima et al. [16] categorized attentional functions into four subfunctions: “sustained attention,” “selective attention,” “executive attention,” and “attention switching,” and conducted a meta-analysis of the relationship between mindfulness meditation and attentional functions. The results showed that “sustained attention” had the greatest effect on mindfulness meditation. They also found that “executive function” had a moderate effect on mindfulness meditation, while “selective attention” and “attention switching” had a smaller effect on mindfulness meditation.

Next, we will consider the characteristics common to PRIDE skills in general for each of the four subfunctions of attention.

(1) “Sustained attention” is the continuous use of the attentional function, and in the PRIDE skills, the skill user’s sustained focus of attention on the child is relevant. (2) “Selective attention” refers to the selection of the target of attention and may include the skill user selecting PRIDE skills that match the child’s behavior and selectively suppressing the Do not skills. (3) “Executive attention” is an attentional function that sets a goal and regulates and inhibits one’s own thoughts and feelings toward achieving the goal. This may also be applicable in that the skill user appropriately controls his/her own attention toward achieving the skill acquisition standard and executes verbalization of the skill. (4) “Attention switching” refers to redirecting attention from one object to another. Skill users emit appropriate skills one after another according to the ever-changing behavior of the children, and this may be a series of attention switching in which they alternately redirect their attention to the children’s behavior and their own skills.

Thus, in PCIT, the skill user must constantly pay attention to the child while at the same time continuously redirecting attention to himself/herself and from there switch attention further to continue verbalizing his/her own skills. The purpose and hypothesis of this study is to investigate the possibility of improving mindfulness attitudes through the acquisition of PRIDE skills.

5. Method

5.1 Survey collaborators

For this study, I divided the participants into two groups: (1) the “PCIT skill acquisition group” (hereafter referred to as the “PCIT group”) and (2) a control group (non-attendee group). The “PCIT group” was recruited from students attending a 5-day, 40-hour training workshop for PCIT therapists, following the PCIT-International prescribed curriculum and protocol (the training workshop was led by the author, a certified PCIT trainer). The manuals used in the WS were the PCIT Protocol 2011 Japanese version ver.2.0 (2013) and the DPICS, fourth Edition, Japanese ver.1.01 (2014), both prescribed by PCIT-International. The WS included the prescribed 13 lectures, skills role play, demonstration practice, and skills check.

In recruiting research collaborators, (1) the “PCIT group” were those who agreed to cooperate in the research after explaining the research to the students prior to the start of the course. All seven graduate students who took the course were selected as research collaborators because they all passed the final mastery check of PRIDE skills (mean age: 36.14 years; SD: 15.64). The “control group” consisted of six graduate students who had not taken the course and who had voluntarily applied for the recruitment of research collaborators at the college and who agreed to cooperate in the research after prior explanation (mean age: 22.67 years; SD: 0.51). The higher mean age of the PCIT group was due to the inclusion of one older student.

5.2 Measurement scale

The mindful attention awareness scale (MAAS) was used in this study as a measure of mindfulness characteristics. This is a mindfulness scale developed by Brown & Ryan [17], which was translated into Japanese and standardized by Fujino et al. [18]. According to the explanation by Fujino et al. [18], the foundations of mindfulness are awareness and attention. Awareness is the accompanying awareness of external and internal stimuli to the mind and body, which serves as a direct bridge between us and the events and experiences that surround us. Attention, on the other hand, is the focus of awareness on a particular stimulus, which increases our sensitivity to that stimulus. However, while people perceive stimuli, they are unable to keep their attention on the stimuli and are said to be mindless [17, 19]. The MAAS was developed to focus on this “awareness” and “attention” and is a one-factor, six-point, 15-item mindfulness measurement scale. Fujino et al. [18] conducted a detailed examination of the factor structure, internal consistency, and construct validity and concluded that the Japanese version of the MAAS measures the same characteristics as the original version and can be used to measure the relationship between mindfulness and well-being for a wide age group.

In addition, MAAS has the following characteristics. (1) Because the MAAS targets the degree of awareness and attention of adults in general who have no experience with meditation, it employs expressions that are rooted in daily life. In other words, the questionnaire items regarding mindless state were used because mindless state is generally easier to understand than mindful state, which the respondents had no experience with. (2) The MAAS measures the degree of the qualities of awareness and attention themselves, since it excludes questions on patience, trust, acceptance, calmness, and well-being, which are thought to result from the qualities of awareness and attention. (3) The MAAS distinguishes awareness and attention from reflexive consciousness, which is meta-consciousness, and targets the quality of awareness associated with the stimuli themselves before such judgments and evaluations of the self. (4) MAAS is negatively correlated with mind wandering and captures the “distraction of attention” itself. (5) Although the MAAS does not include direct well-being-related questions, it was found to be negatively correlated with negative well-being-related characteristic and positively correlated with positive well-being-related characteristics. (6) MAAS measures mindfulness as a trait but is also related to mindfulness as a state and to emotional state scales related to well-being. (7) MAAS scores are higher with mindfulness psychotherapy and are also associated with increased well-being, which is facilitated by mindfulness psychotherapy.

From these characteristics, it is understood that the MAAS is a measurement scale focusing on attentional functions, and therefore, I have adopted the MAAS as an appropriate scale for measuring mindfulness tendency in this study. Fujino et al. are experts in mindfulness meditation, and in preparing the Japanese version, they paid particular attention to the presence or absence of awareness and attention and were careful to ensure that the translation was faithful to the intent of the original version. Back-translation of the Japanese version of MAAS has confirmed that there are no differences in the Japanese-English wording. In standardizing the MAAS, Fujino et al. reversed the MAAS in order to see the relationship with other scales, but since the MAAS is originally composed of items focusing on the mindless state, it is judged that lower scores indicate a higher tendency toward mindfulness. Therefore, for the purposes of this paper, a higher MAAS score means a lower mindfulness tendency.

5.3 Survey period

For the “PCIT group,” the survey was conducted over a longer period of time because the training course was divided into Part 1 and Part 2 instead of 5 consecutive days due to the graduate school curriculum (the WS was held in Part 1: July 13–15, 2019; Part 2: October 13–14 days). MAAS asked survey collaborators to conduct the survey before the start of the first session of WS and after the end of the last session. However, in order to maintain and improve their skills, the participants were required to practice PRIDE skills at least twice a week outside of the course days, at home for 5 minutes each time, targeting family members or videos of their children playing, and were asked to report their implementation to me immediately after each session via social networking. In addition, I asked all participants to report verbally on their skill practice during the interval period at the beginning of each course. In this way, I continued to reinforce the skills of the students. Three PRIDE skill-level checks were conducted on July 13, July 15, and October 14, and students were confirmed to be in satisfactory skill mastery status as of July 15 and October 14. The “control group” also performed two MAAS at the same interval as the PCIT group.

5.4 Method of implementation and ethical considerations

I explained to both the “PCIT group” and the “control group” the content of the survey and the ethical considerations before I began the study and had them sign a consent form. Subsequently, I administered the MAAS twice at the same interval to both groups at the beginning and end of the WS and obtained responses from all participants. This study was approved and conducted by the Ethics Committee of the Faculty of Human Sciences, Kobe College. There are no conflicts of interest. Survey participants were paid an honorarium after the second round of responses. The survey schedule is shown in Figure 3.

Figure 3.

Survey schedule. Note: The PCIT group was given the PRIDE skill check three times: immediately after the start of the WS, at the end of Part 1, and at the end of the WS. All participants reached mastery. Checks #1 and #3 were checked by coding on video, and a coding agreement rate of 70% or higher with the trainer each time was considered passing. Check #2 was conducted with a 5-minute role play by DPICS. A pass was determined when the skill use of the participant in the parent role reached the mastery criteria. The mastery criteria were the same as the normal PCIT criteria: Behavior Description, Labeled Praise, and Reflect each at least 10 times, and Question, Command, and Negative Talk no more than 3 times total.

6. Results and discussion

6.1 Results of the survey

First, the Wilcoxon-signed rank test was used to compare the first MAAS scores between the PCIT and control groups, and no significant difference was found in the initial values between the two groups. Next, a Wilcoxon-signed rank test was conducted to compare the first and second MAAS scores of each group, and it was found that only in the PCIT group, Z = –1.873; there was a significant decreasing trend in MAAS, albeit at the 10% level (Table 3, Figure 4). In the control group, there was no significant difference between the first and second MAAS scores. Although the MAAS scores were apparently lower in the control group, this was due to outliers, and statistically, there was no change in mindfulness tendency in the control group. Since lower MAAS scores are associated with a higher tendency toward mindfulness, the MAAS scores of participants who mastered PCIT skills were confirmed to have decreased, albeit significantly. Thus, the results suggest that PCIT skill acquisition may increase mindfulness tendency.

	MAAS #1			MAAS #2
	Mean	SD	Mean	SD	Z score	p
PCIT	50.57	13.7	47.29	12.6	−1.873	+
Control	48.17	15	43.33	11.3	−0.946	n.s.

Table 3.

Comparison of MAAS first and second scores.

+

p < 0.1.

Figure 4.

Comparison of MAAS scores between the first and second MAAS.

In this study, I conducted a comparative study of mindfulness scores among PCIT WS participants and found that students in the PCIT group showed an increased tendency toward mindfulness even after attending only 5 days, conducted over a period of only 3 months. For the caregivers who receive PCIT, the PCIT sessions are basically conducted for 1 hour each week for about 20 sessions, so they will be learning PCIT skills for an even longer period of time (about 6 months) than the students in the current study. Thus, a caregiver who continuously learns the skills for a longer period of time than the current student would have the experience to further train the “attention function” necessary to use the skill. It may be inferred from this result that caregivers, like the students, will have an increased attentional function and mindful attitude formation during the skill acquisition process. If caregivers can practice, learn, and use PRIDE skills on a daily basis, then PCIT can be said to provide a guide for caregivers to actually learn specific methodologies for “mindful parenting.”

6.2 Limitations of this study

As I stated in the objectives, there are four subfunctions of attention that are important for mindfulness: sustained attention, selective attention, executive attention, and attention switching. A person who is trying to learn PCIT skills, in order to use the skills, keeps selective and sustained attention on the child (sustained attention), discards the appropriate skills (selective attention), takes action with a goal (executive attention), and instantly switches skills one after another according to the child’s behavior (switching). If we may infer from this, we may assume that the attitude toward using PCIT skills is related to any of the attentional functions and that all of the attentional functions are essential to the improvement of PCIT skills. However, the present study could not clarify the mechanism of action of PCIT skills in relation to the subfunctions of attention and their effects on improving mindfulness attitudes. Although this was an exploratory study with a very small number of participants, this study may have opened the door for further research linking the effects of PCIT and mindfulness in the future. In order to further clarify these questions empirically in the future, it is necessary to increase the number of research collaborators and expand the scale of the study.

In addition, the research collaborators in this study were not actual child caregivers but rather graduate students who were studying to become PCIT therapists. In this regard, since the collaborators in this study had different motivations and backgrounds for learning PCIT than the caregivers, it is necessary to conduct a survey of caregivers during child-rearing in order to verify the actual “mindful parenting” effects of PCIT. These points are limitations of this study. However, when surveying PCIT caregivers, it takes time to conduct the cases themselves, and it is difficult to conduct a large number of cases at the same time; limitations exist due to the fact that PCIT is a psychotherapy. In order to conduct a large-scale study, it is necessary for multiple PCIT-implementing agencies to collaborate in planning, taking this into consideration. Research procedures would also benefit from an assessment of the personality of the skill users prior to skill acquisition. Qualitative studies such as interviews about mental processes in skill-use situations should be considered. In order to determine the direction of attention and the type of attention, it may be useful to confirm changes in the direction and duration of attention of skill users through the introduction of physiological devices such as an “eye tracker” that follows the viewpoint of the person using the skills. In mindfulness research, there are many studies using physiological measures such as EEG and fMRI during mindfulness. In the future, it will be necessary to construct more empirical research methods by physiologically measuring the state of mindfulness of skill users during PRIDE skill use.

Acknowledgments

This research was funded by a 2019 Kobe College of Human Sciences Educational Research Grant. I would also like to thank my research collaborators for their cooperation in this long-term study.