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. Author manuscript; available in PMC: 2024 Mar 1.
Published in final edited form as: Early Interv Psychiatry. 2022 Jun 17;17(3):244–251. doi: 10.1111/eip.13321

The School of Hard Talks: A telehealth parent training group for caregivers of adolescents and young adults

Emily R Kline 1,2,3,4, Heather Thibeau 1,3, A Simone Sanders 3, Beshaun J Davis 3,4, Alicia Fenley 5, Theresa McIntyre 6, Kelly English 6, Matcheri S Keshavan 3,4
PMCID: PMC10588675  NIHMSID: NIHMS1936786  PMID: 35715966

Abstract

Aim:

A large body of evidence demonstrates the importance of the family environment in the developmental trajectory of mental illness in young people. Caregiver communication skills training represents a potential model for influencing the outcomes of adolescents and young adults struggling with emerging mental health and behavioural difficulties. The aim of the current study is to describe the development of a telehealth group training intervention for caregivers of adolescents and young adults, and to report the results of a pilot feasibility-effectiveness study that took place in 2020–2021.

Methods:

The “School of Hard Talks” intervention consisted of 8 h of training in communication skills consistent with motivational interviewing techniques. All pilot study participants were assigned to receive the intervention. Outcomes of interest were family conflict, caregiver stress, caregiver self-efficacy and expressed emotion (EE). Participants were assessed three times: prior to the intervention, after the intervention and 12 weeks later.

Results:

A total of 62 participants enrolled in the study, of whom 49 completed the intervention. Large, significant improvements were observed over time in all four domains of interest. Qualitative feedback from parents was very positive and added context to quantitative observations.

Conclusions:

The School of Hard Talks was a feasible and effective intervention targeting both caregiver wellbeing as well as important mechanisms of risk for youth psychopathology, namely family conflict and EE. Further research involving a larger sample and a control condition are needed to confirm these findings.

Keywords: adolescent, caregivers, mental health, motivational interviewing, young adult

1 |. INTRODUCTION

Adolescence and young adulthood represent a critical window for early intervention with young people experiencing the onset of mental health and substance use challenges (Marín, 2016; McGorry & Mei, 2018). So-called “transition age youth” experience high rates of mental health problems (particularly mood and substance use disorders) and face the additional challenge of finding appropriate care due to provider shortages and administrative or cost barriers accessing mental health services (Cummings et al., 2013; Kieling et al., 2011). Many in this age group are reluctant to engage with treatment at all, citing reasons such as stigma, a preference for self-reliance and fear of psychiatric labelling and intervention (Gulliver et al., 2010; Salaheddin & Mason, 2016).

The emergence of major mental health problems in adolescence and young adulthood intersects developmentally with increasing autonomy, creating a dilemma for caregivers. Caregivers suffer from high levels of stress and burden and may be unsure of their role in detecting mental health problems, initiating treatment and participating in interventions (Angold et al., 1998; Houtrow & Okumura, 2011). Caregiver training strategies such as contingency management that are utilized with younger children are often not useful or developmentally appropriate for this population (Baumel et al., 2016). Relative to school-age children, adolescents and young adults may be more suspicious of adults’ efforts to control their behaviour and more interested in their peers’ approval than their parents’. However, a large body of evidence demonstrates the importance of the family environment in the developmental trajectory of mental illness (Caspi et al., 2004; Griffith et al., 2019; Izon et al., 2021; Roy et al., 2018). Environments characterized by high stress, conflict and criticism are associated with worse mental health outcomes for young people (Izon et al., 2018; Luebbe & Bell, 2014; Peris & Miklowitz, 2015; Schlosser et al., 2010). Therefore, there is a critical need for interventions that address family dynamics (especially parent-child relationships) for this age group across a wide range of diagnoses.

Caregiver communication skills training represents a potential model for influencing the outcomes of young people struggling with emerging mental health and substance use difficulties. In other words, caregivers may benefit from learning concrete strategies to de-escalate, affirm and promote autonomy when interacting with transition-age youth (Kline, 2020). Motivational interviewing (MI) is a communication style that emphasizes autonomous choice as well as curious exploration of a person’s ambivalence about change. MI is widely used by health professionals to increase the likelihood that patients will commit to healthy behaviour changes such as reducing substance use and adhering to prescribed regimens (Rollnick & Miller, 1995; Rollnick et al., 2008; Palacio et al., 2016; Engle, 2011; Foxcroft et al., 2016; Cushing et al., 2014). More recently, MI has been used by non-clinical professionals such as community health workers to address topics such as substance use reduction and blood pressure management (Schoenthaler et al., 2018; Sorsdahl et al., 2015). Caregivers of teens and young adults may find some MI strategies useful when communicating about important decisions.

The aim of the current study is to describe the development of a telehealth group parent training intervention based on MI communication skills and to report the results of a pilot feasibility-effectiveness study that took place in 2020–2021.

2 |. METHODS

2.1 |. Intervention development

The group telehealth intervention was developed in tandem with a one-to-one coaching intervention, described in Kline et al. (2021). Briefly, the developers attended multiple trainings in MI as well as community reinforcement and family training and mined these interventions for relevant themes. We also consulted with stakeholders including individuals with lived experience of mental illnesses and their parents; members of the MI network of trainers; and state mental administrators to gather information about training priorities, feasibility and structure.

The conflict between MI training integrity versus convenience and feasibility of the program for parents emerged early in this process. Although expert MI trainers advised that participants receiving less than 24 h of training were unlikely to obtain MI proficiency, we chose to limit the curriculum to 8 h based on feedback from family stakeholders. We did this mostly by focusing on core MI skills and leaving aside any focus on selective attention to change talk versus sustain talk. Additionally, we strove to create a culturally conscious intervention informed by diverse needs and perspectives while simultaneously embracing a process of cultural humility, that is, expecting the unexpected and remaining open to cultural perspectives that might challenge our model (Coard et al., 2004; Fisher-Borne et al., 2015). For example, we avoided language that indicated or implied that MI would be a correct or superior approach and emphasized MI as an “alternative” approach that might be worth trying if parents’ existing communication skills were not getting the desired results.

The author group reached consensus on a set of core learning objectives and chose and/or created learning activities that would satisfy those objectives. Instructional techniques utilized in the SOHT curriculum included use of a PowerPoint slide deck to explain concepts, journal and discussion prompts promoting self-reflection and disclosure and opportunities for real- and role-plays. Facilitators modelled an MI-consistent stance while running the groups by asking open-ended questions, practicing nonjudgment, using reflections and encouraging participants to decide for themselves which skills to try with their families. The themes and learning objectives of each 2 h modules are described in Table 1.

TABLE 1.

School of Hard Talks content and learning objectives.

Module and theme Learning objectives
Module one (2 h): The righting reflex • Build rapport within the group.
• Remind participants of the goals and structure of the course.
• Introduce concepts of MI and the MI spirit.
• Promote self-reflection about participants’ own experiences of feeling understood, confident, and in control.
• Demonstrate how MI is different than giving people advice.
Module two (2 h): Building understanding • Introduce the skills of open-ended questions and reflections.
• Practice using questions and reflections in conversation.
Module three (2 h): Hard talks • Review reflections and open-ended questions.
• Teach parents to ask permission before offering advice.
• Combine skills in a practice “hard talk”.
• Provide feedback to participants as they practice their skills.
Module four (2 h): Ready to launch • Consider when youth can take on more personal responsibility for healthy choices.
• Learn and practice control “handovers”.
• Learn and practice affirmations.
• Learn and practice confidence-boosting questions.
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Abbreviation: MI, motivational interviewing.

2.2 |. Procedures

All study procedures were reviewed and approved by the Beth Israel Deaconess Medical Center IRB and the Massachusetts Department of Mental Health IRB. Eligible participants were 18 years or older; able to speak and comprehend English; identified as a caregiver of an individual aged 14–24 with an identified mental health or behavioural concern and spent 20+ hours interacting with the young person per week. Caregivers of individuals with developmental disabilities impacting verbal communication were screened out.

Recruitment was initiated by dissemination of flyers to youth-serving mental health treatment settings in Massachusetts. Clinicians, parent partners, administrators in these settings were asked to share flyers with eligible caregivers. Potential participants were screened for eligibility over the phone. If deemed eligible, participants were assigned to the next upcoming group and completed assessments via REDCap (Harris et al., 2009). Research assistants also offered pre-group coaching on how to use the telehealth platform, StarLeaf. Participants joined the platform remotely via telehealth for all training sessions. Training consisted of 8 h of group-based MI training. After the group ended, participants were prompted via email to complete post-intervention and 12-week follow-up surveys via REDCap. Participants were reimbursed $25 per completed assessment (total of $75 over the course of study participation). They were not reimbursed for completion of the training sessions.

2.3 |. Measures

Feasibility metrics were the number of eligible individuals who contacted the study team; number of participants enrolled; number of hours participants attended; treatment satisfaction results; and percent of assessments completed.

Quantitative outcomes of interest were caregivers’ self-reported stress, conflict, expressed emotion (EE) and self-efficacy. These were assessed via validated self-report scales. Stress was assessed using Perceived Stress Scale (PSS), which has 10 items utilizing a 5-point Likert scale of “Neveh’ to “Very Often” (total score range, 0–40; Cohen et al., 1983; Roberti et al., 2006). Family conflict was assessed using conflict behaviour questionnaire (CBQ; Robin & Foster, 1989), which contains 20 true/false items (score range, 0–20). EE was assessed using the 20 item family questionnaire (FQ; Wiedemann et al., 2002), which consists of 20 Likert-scale items with responses ranging from “Never/Very Rarely” to “Very often” (score range, 20–80). Parenting self-efficacy was assessed using the 10-item parenting self-agency measure (PSAM; Dumka et al., 1996). The PSAM was slightly modified by the study team in that the 7-point Likert scale was replaced by a 0–100 rating, the average of which was used as the summary score across the 10 items (summary score range, 0–100). This modification was made due to conflicting reports in the literature about the preferred Likert-scale response options.

Within the post-intervention assessment, participants were also asked to respond to three open-ended questions via REDCap: What was most helpful about the training (asked at post-intervention assessment)? What would improve the training (asked at post-intervention assessment)? What changes have you noticed since participating in the intervention (asked at post-intervention and 12-week follow-up)?

2.4 |. Analyses

Participant enrolment and retention were analysed via descriptive analyses. Repeated measures ANOVA was used for quantitative outcomes. The ANOVA was conducted with three time points, examining the main effect of time on four variables of interest. Assumptions of sphericity were tested and Greenhouse–Geisser corrections were employed as indicated. Participants with any missing follow-up data were dropped from the repeated measures analysis sample. For the purpose of data visualization, the four quantitative outcomes measures were transformed to a 0–10 scale so that they could be presented within a single chart.

To analyse qualitative data, two authors (H. T., A. F.) reviewed participants’ written qualitative responses and conducted inductive thematic analyses (Braun & Clarke, 2006; Braun & Clarke, 2019). A third author (E. K.) provided input to resolve any discrepancies in coding and interpretation.

3 |. RESULTS

3.1 |. Enrolment and retention

A total of 62 participants enrolled in the study over the course of 9 months (April-December 2020). Groups took place from May 2020 to January 2021. See Figure 1 for a CONSORT flow diagram depicting enrollment and retention in the trial. Overall, 80% of participants who enrolled attended at least 5 h of group training and 59% attended all 8 h.

FIGURE 1.

FIGURE 1

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CONSORT flow diagram

3.2 |. Participants

Baseline data was available for 61 enrolled participants. The vast majority (93%) were women (mothers or grandmothers). About half (57%) were married or cohabiting with a partner or spouse. Participants identified their race as White (79%), Black (11%), multi-racial (8%) and Asian (2%). 10% identified as Hispanic/Latino. The average age was 52.84 (range, 34–77).

Participants cited a range of concerns about their children’s behaviour and mental health. The top behavioural concerns were defying rules (64%), substance use (41%) and difficulty with school-work (38%). Regarding psychiatric diagnosis, 20% reported that their child had no diagnosis and 80% reported one or more diagnoses. Diagnoses included anxiety disorders (49%), uni- and bi-polar mood disorders (47%), Attention Deficit Hyperactivity Disorder (33%) and post-traumatic stress disorder (10%). Nearly half (43%) reported that their child had at least one prior overnight admission to a psychiatric unit for treatment and nearly all (97%) reported that their child had received some form of therapy for mental health concerns.

3.3 |. Quantitative outcomes

A repeated measures ANOVA indicated significant and large effects on outcomes of interest (Table 2). Transformed mean scores at each assessment time point are presented in Figure 2. Participants’ scores on the PSS, PSAM and FQ changed substantially between pre- and post-intervention assessments, and then stabilized during the following 12 weeks. CBQ scores showed a different pattern, with changes occurring both between pre-post assessments and continuing to improve in the following 12 weeks.

TABLE 2.

Quantitative outcomes: Repeated measures ANOVA

Measure Df (time, error) F p η 2 d
Conflict behaviour questionnaire 2, 78 13.20 <.001 .25 1.15
Perceived stress scale 2, 78 13.15 <.001 .25 1.15
Parenting self-agency measure 1.60, 62.25a 10.70 <.001 .22 1.06
Family questionnaire 1.66, 64.60a 20.09 <.001 .34 1.44
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a

Due to violation of sphericity assumptions, Greenhouse–Geisser correction used and reported.

FIGURE 2.

FIGURE 2

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Quantitative outcomes

3.4 |. Qualitative results

Participants’ qualitative responses were analysed and organized thematically by three co-authors. Responses to queries about what participants liked about the intervention and suggestions for improvement are summarized in Table 3. With regard to intervention’s overall impact, the authors conceptualized five themes from participants’ written responses: changes in their communication style, increased self-awareness, improved relationships, improved parent mental health and improved child mental health. Changes in communication included listening more attentively, reflecting their child’s thoughts and feelings, asking open-ended questions and empowering their child to brainstorm their own solutions to problems. One parent remarked “I’ve become a much better listener and am able to show understanding and support without engaging in a disagreement”. Many parents also stated that the intervention helped them to become more aware of their typical reactions during charged parent–child conversations, providing them with tools to pause, reflect and proceed in a more skilled and effective manner. As an exemplar, one parent reported “I try to take a breath before reacting. I try to think about the reason for the behaviour rather than focus on the behaviour itself. I try to keep my eye on the goal.” Some parents wrote that the changes they made to their communication style had helped promote a closer parent–child relationship, with greater trust, respect and openness. Participants also noted improvements in both their own and their child’s mental health. For example: “my daughter feels validated and heard, which has decreased her acting out and outbursts.”

TABLE 3.

Qualitative feedback on training.

Prompt Identified theme (number of responses within this theme)
What has been the most helpful thing about this training? Content of the training:
• MI skills (22)
• Real/Role plays (12)
• Telehealth group structure (5)
• Facilitator MI demonstration of skills (2)
Empathy and/or effectiveness of the facilitators (5)
Camaraderie with other participants (5)
Personal growth or change (2)
What would improve the training? Changes to the structure or pacing of the groups (24)
On-going support or activities following the group-based training (11)
Change of telehealth platform (9)
No changes needed (7)
Developing supplemental materials for participants to reference (4)
Change some aspect of the content (1)
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Abbreviation: MI, motivational interviewing.

4 |. DISCUSSION

The “School of Hard Talks” training intervention was feasible to implement and subjectively useful to participants. Using telehealth as a medium for group parent training was an innovation born of necessity by the COVID-19 pandemic and was regarded as positive by most participants. Participants expressed gratitude that they could access the group remotely. Participants were also enthusiastic about the content of the training, which emphasized MI themes and skills and which was created with strong stakeholder input. Study retention through the duration of the 8 h intervention was strong. Although some participants dropped out before attending any intervention sessions, all who did at least some of the training attended 5 h or more. Most participants did not miss any sessions.

Although the lack of control group constitutes a limitation of this study, quantitative analyses offer preliminary evidence of significant effects on outcomes of interest. Effect sizes (reported as eta squared values in Table 2) indicating pre-post changes in all four quantitative domains (self-efficacy, stress, conflict and EE) were quite large and these changes were maintained at the 12-week follow-up assessment. Further, in three of the domains of interest (self-efficacy, EE and stress), scores dropped from pre- to post-intervention but then remained stable following the intervention period, suggesting that the intervention itself may have been responsible for these changes rather than the passage of time or random variation. Qualitative responses reflect and support the quantitative observations. Of course, without a control group for comparison, we cannot confidently attribute these changes to the intervention itself. Further study with a control comparator is needed. Additionally, although the author group and the stakeholder collaborators represented diverse cultural and racial perspectives, they were all residents of the United States Northeast, as were the pilot study participants; whether this intervention would work in other cultural contexts is not clear.

When designing this intervention, we endeavoured to find a parent training skillset that could be flexibly used across diagnostic categories, with the goal of avoiding diagnostic “silos” (McGorry et al., 2020). We targeted domains thought to be meaningful across a wide range of diagnostic presentations in adolescence and early adulthood (EE, family conflict) and recruited an intentionally broad and nonspecific cohort of caregivers. Caregivers reporting a range of diagnostic and behavioural concerns were highly engaged by this intervention, which they reported was relevant and practical for their concerns.

“Early intervention” in serious mental illness has received significant attention and financial investment over the past decade (McGorry et al., 2018). The goal of this approach is to offer treatment during early stages of mental illnesses so as to avert disability and improve long-term prognosis. These efforts have taken the form of attempts to define emergent or prodromal stages of schizophrenia and bi-polar disorder, as well as the development of specialized interventions or stand-alone clinics for such patients (Conroy et al., 2018). One unintended consequence, however, has been the proliferation of highly specialized treatment settings – for instance, clinics that treat only patients with attenuated psychosis symptoms. Overspecialization can complicate the process of finding appropriate care in a moment of escalating urgency for patients and families by introducing unnecessary stigma and requiring lengthy diagnostic assessments and elaborate referral networks (Ajnakina et al., 2019; Malhi et al., 2021). An alternative approach to early intervention is to offer transdiagnostic interventions that address a “pluripotent” stage of emerging psychiatric concern common in adolescence or early adulthood characterized by mood disturbance, cognitive difficulty and functional decline (McGorry, Hartmann, et al., 2018). Interventions offered at this stage might target common risk factors for further psychopathology development (caregiver EE and family conflict are two examples) that can be implemented by generalists rather than in specialty clinics. “The School of Hard Talks” represents this latter approach. Although the lack of diagnostic specificity could be considered a weakness of the study design, we regard this as a strength insofar as it enhances the feasibility and potential reach of this intervention.

The COVID-19 pandemic hastened two trends in mental health care: the acute shortage of high-quality, child and family focused mental health treatment (Auerbach & Miller, 2020; Marques et al., 2020); and the use of telehealth to improve the accessibility and convenience of care (Fernández-Álvarez & Fernández-Álvarez, 2021; Pfender, 2020; Reay et al., 2020; Zhou et al., 2020). Conducted at the height of the COVID-19 pandemic, this study aimed to test a novel telehealth group intervention targeting family communication dynamics rather than individual psychopathology. We found that the School of Hard Talks caregiver training program was attractive and relevant to parents’ concerns, that caregivers were enthusiastic about receiving assistance via group telehealth and that most were highly engaged and able to complete an 8 h intervention. Outcomes, measured both immediately following and 12 weeks after the intervention, suggest that the participation had significant and lasting impacts on domains of interest. MI skills training for caregivers of adolescents and young adults with mental health concerns represents a promising approach to reducing both caregiver distress and youth psychopathology development. Future research will include the use of a comparator group for stronger causal inference, the use of supplemental tools such as self-paced digital learning materials and more focused analysis of the intervention’s impact on diagnostic subgroups.

ACKNOWLEDGEMENTS

The authors wish to acknowledge the invaluable consultation provided by Angela Cooper, Linda Cutrell, Jonathan Delman, Kim Mueser and Shirley Yen.

Funding information

Massachusetts Department of Mental Health, Grant/Award Number: SCDMH821022085260000; National Institute of Mental Health, Grant/Award Number: K23MH118373

Footnotes

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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