Father Participation in Parent-Child Interaction Therapy: Predictors and Therapist Perspectives

ABSTRACT

Although engaging fathers effectively can bolster and sustain treatment outcomes, fathers participate in their children’s treatment at lower rates than mothers and have been left out of the literature on caregiver engagement. Because provider attitudes and behaviors shape the course of treatment, therapist perspectives on father attendance and engagement should be investigated. A mixed-method study design examined rates and predictors of father attendance in treatment and therapist perspectives on father engagement in Parent-Child Interaction Therapy (PCIT). Quantitative data were gathered through a survey distributed to PCIT therapists (n = 267) to identify the effects of: 1) therapist and caseload characteristics, 2) therapist confidence working with fathers, 3) therapist use of father engagement strategies, and 4) organizational practices for engaging fathers, on father attendance rates. Qualitative interviews with 23 therapists were thematically analyzed to expand upon therapist experiences engaging fathers. Therapists reported that on average, 60.97% of cases with a father available had regular session attendance by the father. Only frequency of therapist use of father engagement strategies predicted father attendance rate. Qualitative interviews expanded on the many barriers therapists face to engaging fathers and the variety of strategies they employ to engage fathers. Rates of father attendance in PCIT are higher than what has been previously reported in the literature but still show room for improvement. Despite barriers, therapists remain dedicated to developing solutions to elicit father engagement. Future research should evaluate whether therapist-reported engagement strategies effectively increase father participation and can be more widely disseminated.

Caregiver engagement in children’s mental health services has been identified as a crucial component of care (Haine-Schlagel & Walsh, 2015). Scholars have begun to identify specific strategies that engage caregivers in children’s mental health treatment in order to ensure that children access and benefit from care (Becker et al., 2018; Haine-Schlagel & Walsh, 2015). However, this research typically treats caregivers as an aggregate, failing to address different rates of engagement across female-identified (hereafter referred to as mothers) and male-identified caregivers (hereafter referred to as fathers), as well as differing family constellations (Panter-Brick et al., 2014). Historical inattention to father engagement in research and practice (Cabrera et al., 2018), reinforces preconceived gendered parenting roles and leaves mothers with the majority of treatment responsibilities. Therefore, it is critical to identify effective engagement strategies for fathers (Fabiano & Caserta, 2018).

Recent research highlights the impact fathers can have on their children’s development, including improved executive functioning and decreased risk of psychopathology (Barker et al., 2017; Cabrera et al., 2018; Lamb, 2010; Lucassen et al., 2015). Further, involving fathers in treatment has been shown to have positive impacts on children’s mental health treatment (Lundahl et al., 2008), and may lead to the sustainment of treatment gains (Bagner & Eyberg, 2003). A randomized control trial of a parenting intervention supporting parents of children ages 3 to 8 with conduct problems, with content aimed at engaging fathers, found that families participating in the father-engagement group reported fewer child behavior problems and less conflict between parents over parenting styles (Frank et al., 2015).

Even with these potential benefits of engaging fathers in treatment, fathers participate in their children’s treatment at lower rates than their female counterparts. A survey of 210 parenting intervention providers found that only 17.2% of providers reported that fathers often attend services (Tully et al., 2018). Interestingly, the most frequently reported strategy used by these practitioners to engage fathers was explaining to mothers the importance of engaging fathers (Tully et al., 2018). Even in their attempts to reach fathers, therapists seem to frequently rely on female caregivers as their loudspeaker. Defaulting to female caregivers as either a loudspeaker or as the sole caregiver participating in a child’s mental health treatment may be detrimental or ineffective in cases of maternal psychopathology, single-father families, and may exacerbate existing inequities in the division of familial labor (Lachance-Grzela & Bouchard, 2010; Yavorsky et al., 2015). Providers may also inadvertently reinforce gendered expectations of parenting and deny fathers the opportunity to hone their parenting skills.

Fatherhood and masculinity

It is critical in any discussion of fatherhood or maleness to recognize the multiplicity of ways male identity and fatherhood are performed and experienced. Fatherhood has shifted over time, adapting to economic and cultural changes (Cabrera et al., 2018; Teti et al., 2017), and will continue to evolve. It has been suggested that gender-role socialization and wider messaging about masculinity be considered when attempting to understand men’s reluctance to seek help or participate in mental health treatments (Jampel et al., 2020). Developers of parenting treatments and those who propose engagement strategies should also consider whether and how gender and fatherhood are being constructed through these interventions. Furthermore, if barriers to participation for fathers depend in part on gender-role socialization, such as a reluctance to consider feelings or acknowledge weakness, and gender roles are socioculturally unique, then engagement strategies must attend to multiple factors, including gender identity, culture, and context. It has been suggested that treatment should be adapted to address socioculturally specific patterns (Lau, 2006). Since fatherhood is conceptualized differently in different cultural groups, racial and ethnic identities of parents should be considered in attempts at engagement. Interventions that encourage fathers to consider their conceptions of masculinity have been incorporated into treatments that successfully improved parental involvement and parent-child relationships in fathers with problem drinking in Kenya (Giusto et al., 2020). These strategies may help ensure that interventions adapted to engage fathers do not ossify definitions of masculinity or familial gender roles, and instead approach masculinity and fatherhood flexibly.

Although not all families have a father, and many do not have both a father and mother, it is useful to consider how increased father engagement may impact mothers. Gender roles have shifted over the last century, however mothers still participate in the majority of childrearing tasks (Cabrera et al., 2018). While women are participating in the labor force at much higher rates, they are also responsible for the majority of household labor in addition to caregiving (Lachance-Grzela & Bouchard, 2010). Current father engagement strategies often rely on mothers by, for example, helping mothers identify barriers to father participation (Burn et al., 2019). Despite being well-intentioned, these strategies inadvertently contribute additional burden to mothers, who become responsible for wrangling both their child and partner. Effective father engagement must not increase demands on mothers, and should refrain from falling back on models that make mothers the primary protective adult.

Father engagement and service delivery

It has been suggested that both the design and delivery of children’s mental health services, and specifically parenting interventions, can impede the effective engagement of fathers (Panter-Brick et al., 2014). Pfitzner et al. (2015) summarize various factors impacting father engagement in services, including relational factors (e.g., provider attitudes and behaviors toward engaging fathers, trust between provider and father, delivery style, and rapport) and structural factors (e.g., format of intervention, program length), among others. Despite the identification of these specific factors, this same review cited as a primary limitation that most of the current literature relies on self-report by mothers. Additional research describing father and parent engagement strategies has suggested avoiding deficiency-based approaches to treatment (Fabiano, 2007), asking parents about their explanatory models regarding child behavior (Lau, 2006), and highlighting provider credentials and training when presenting information about a treatment to fathers (Tully et al., 2017). To further understand factors impacting father engagement, researchers have suggested that future studies evaluate how services are delivered and disaggregate caregiver data in order to evaluate different rates of and strategies for engaging mothers and fathers (Fabiano & Caserta, 2018; Panter-Brick et al., 2014). Delivery style is heavily impacted by the behaviors and approaches of practitioners, and researchers have also stressed the importance of evaluating the perspectives of service providers in order to better understand the provision of effective services in community settings (Nelson et al., 2006).

Current study

The current study investigated predictors of father participation in Parent-Child Interaction Therapy (PCIT), and practitioner perspectives on engaging fathers in this treatment. PCIT is a widely disseminated behavioral parenting program aimed at improving parent-child relationships and increasing parenting skills in order to treat behavioral and conduct problems in young children (Lieneman et al., 2017). PCIT engages parents in both didactic learning and in-vivo coaching (i.e., live feedback regarding use of parenting skills; Eyberg & Funderburk, 2011). Though research has shown that involving fathers in PCIT supports the maintenance of treatment gains (Bagner & Eyberg, 2003), limited research has identified if and how therapists engage fathers in care, and no rates of father participation in PCIT have been established. This is especially important to understand for the implementation of PCIT within community settings where clients often face multiple barriers to care, have lower resources, and present with clinical complexities (Quetsch et al., 2020). This study sought to fill this gap in the literature by conducting surveys and interviews with PCIT therapists to understand challenges and facilitators to engaging fathers within PCIT.

Methods

Participants

Survey participants were initially recruited via e-mail listservs for PCIT therapists. Therapists were eligible to participate if they had seen a PCIT client in the last 2 months. Of the 324 therapists who completed the survey, 267 met inclusion criteria for statistical analyses (were seeing children with fathers present in the child’s life, and reported valid father attendance rates). The majority were female (91.4%), non-Latinx White (75.6%), and Master’s level therapists (68.8%). They had an average of 8.88 (SD = 6.96) years of experience as therapists. Twenty-three therapists (87% female, 69.65% non-Latinx White) participated in qualitative interviews. Interviewees were selected by a mixed purposeful sampling strategy, in which purposeful random sampling was combined with criterion-i sampling to ensure that the providers worked in community settings (Palinkas et al., 2015; Patton, 2002). Therapists providing services in more than one language were oversampled to ensure adequate representation of therapists serving diverse clients. Participant characteristics are included in Table 1.

Table 1. Descriptive statistics of survey and interview samples.

	Survey Sample (n = 267)	Interview Sample (n = 23)
Variable (response)	Frequency (%) OR Mean (SD)	Frequency (%) OR Mean (SD)
Therapist Demographics & Professional Characteristics
Age	35.76 (8.54)	37.30 (6.68)
Gender
Female	244 (91.4%)	20 (87%)
Male	22 (8.2%)	3 (13.0%)
Non-binary/Genderqueer	1 (0.4%)	0 (0.0%)
Ethnicity
Non-Latinx White	201 (75.6%)	16 (69.6%)
Latinx/Hispanic	36 (13.5%)	7 (30%)
Other	29 (10.9%)	0 (0%)
Race	n = 261	n = 22
White	233 (85.4%)	22 (100%)
Black/African American	8 (3.1%)	0
Asian American/Pacific Islander	7 (2.7%)	0
American Indian/Alaska Native	2 (0.8%)	0
Multiracial/ Other	21 (8.1%)	0
Language of service provision
English only	211 (79.0%)	11 (47.8%)
Spanish	46 (17.2%)	9 (39.1%)
Other	10 (3.7%)	3 (13%)
Professional Discipline	n = 266
Clinical Psychology	96 (36.1%)	8 (34.8%)
Social Work	57 (21.4%)	5 (21.7%)
Counseling	52 (19.5%)	3 (13%)
Marriage Family Therapy	52 (19.5%)	5 (21.7%)
Other (e.g., School Psychology)	9 (3.4%)	2 (8.7%)
Highest Degree Obtained	n = 266
Master’s degree	183 (68.8%)	16 (69.6%)
Doctoral degree	75 (28.2%)	7 (30.4%)
Other	8 (3.0%)	0
Current Caseload Characteristics
PCIT Caseload, n = 266	6.06 (4.91)	6.26 (3.85)
PCIT cases where father is available	3.88 (3.39)	3.96 (2.75)
PCIT cases where father attends sessions regularly	2.23 (2.22)	2.43 (1.88)
% of caseload belonging to racial/ethnic minority	42.6% (33.5%)	58.9% (34.2%)

Procedures

The study received an exemption from the Institutional Review Board at the University of California, Santa Barbara. Participants were recruited through two PCIT listservs managed by training and certification organizations, PCIT International and the UC Davis PCIT Training Center. All participants who provided their e-mail address received a $20 gift card for completing the survey. Survey respondents indicated their willingness to partake in an hour-long interview, for which they would receive a $40 gift card. Interviews were conducted by four graduate student researchers with experience delivering PCIT.

Fifty-six percent of survey respondents indicated willingness to participate in an interview. Researchers conducted ten pilot interviews to refine the interview protocol. Respondents who indicated that they worked in a community setting were stratified by the language they provided services in and randomly selected using an online random sample generator to be invited for interviews. Forty-three participants received interview invitations via e-mail. As interviews were being conducted, the research team met weekly to discuss interview content and emerging themes (described in more detail below). Themes began to be redundant after 23 interviews, indicating that meaning saturation had been met, which generally occurs between 16–24 interviews (Hennink et al., 2017), and further recruitment ended.

Measures

Therapist characteristics

Demographic information (e.g., age, gender), professional background variables (e.g., degree), and caseload variables were collected through the Therapist Background Questionnaire (Brookman-Frazee et al., 2012).

Current rates of father attendance

Therapists were first asked how many PCIT cases they were currently seeing with a father (i.e. male caregiver) involved in the child’s life. This frequency was used to identify the denominator of families where there was potential for father engagement to begin with and to account for families that only had female caregivers (e.g., single-mother, families with two mothers) or families where a father was not available for caretaking (e.g., father deployed). Therapists were then asked how many PCIT cases they were currently seeing with a father attending sessions regularly. “Regularly” was not further defined for therapists, and was therefore left up to their discretion. Current rates of father attendance in sessions were calculated as percentages for each provider using the number of PCIT cases with a father involved in the child’s life as denominator and the number of PCIT cases where a father attended sessions regularly as the numerator.

Father Engagement Questionnaire

An abridged version of the Father Engagement Questionnaire (FEQ; Tully et al., 2018; Jiang et al., 2018) was used to capture therapist perspectives on father engagement and obtain quantitative measures of their use of father engagement strategies. The current study includes three scales from the original measure: (1) Frequency of Strategy Use, (2) Confidence in Working with Fathers, and (3) Organizational Practices for Father Engagement. Each of the three subscales used in the current study was associated with a higher likelihood of father attendance in the original study validating the measure (Jiang et al., 2018). A five-item scale was used to measure Frequency of Strategy Use, asking, “How often do you use the following strategies to engage fathers?” The use items were rated on a five-point scale from 1, Never to 5, Always. Mean scores resulted in the final Frequency of Strategy Use scale (α = 0.83). Confidence in Working with Fathers was measured using a ten-item scale which asked, “How confident do you feel with the following?” A five-point scale was used to evaluate the confidence items, from 1, Not at all confident to 5, Extremely confident. Mean scores produced the final Confidence scale (α = 0.90). Lastly, Organizational Practices for Father Engagement was measured using a four-item scale which asked if certain organization or agency practices were utilized to engage fathers, from 1, Never to 5, Always. Mean scores produced the final Organizational Practices scale (α = 0.69).

Semi-structured interview guides

Within the context of a longer interview about experiences delivering PCIT, therapists were asked a series of questions related to fathers engagement (e.g., “What experience do you have engaging fathers in PCIT?,” “How often do you engage fathers in PCIT?,” “How comfortable do you feel engaging fathers in PCIT?”). The interview followed a funnel approach, using follow-up questions to elicit further detail and examples after broad inquiries (Spradley, 1979). Interviews lasted approximately one hour.

Data analysis

Mixed-methods design

This study used a QUAN + QUAL approach. Quantitative and qualitative data given equal weighting in analyses. The quantitative data was used to ascertain rates of father attendance and predictors of father attendance. The qualitative data clarified, expanded on, and elucidated quantitative findings on father engagement through therapist narrative (Palinkas et al., 2011).

Quantitative data analysis

A multiple linear regression model was conducted using SPSS v. 27 to test the effects of various therapist and caseload characteristics on the dependent variable of rates of father attendance. Therapist predictors included gender (dummy coded with female/non-binary as the reference group), race/ethnicity (dummy coded with non-Latinx White as reference group), and years of practice. A race and ethnicity variable was aggregated into three groups 1) non-Latinx White, 2) Hispanic/Latinx, 3) Other (Black/African American; American Indian or Alaska Native; Asian American/Pacific Islander; Multiracial; Other). Although important information is lost when aggregating racial and ethnic identities, this recoding allowed the inclusion of race/ethnicity in the quantitative model given limited diversity in our sample. Therapist scores on the three FEQ subscales of Confidence, Frequency of Strategy Use, and Organizational Practices were also included as predictors in the model. The percentage of clients who were racial/ethnic minorities was also included in the model. Full descriptive statistics can be found in Table 1 while the results of the regression model are presented in Table 2.

Table 2. Multiple linear regression results predicting rates of father engagement in PCIT.

Variable (Response)	b	SE	Beta	t	p
Intercept	.185	.156		1.183	.238
Therapist Characteristics
Gender (Male)*	.038	.083	.028	.456	.649
Race/Ethnicity^+ (Latinx/Hispanic)	.076	.076	.070	.999	.319
Race/Ethnicity (Other Minority)	.027	.076	.022	.350	.727
Years in practice as therapist	.006	.003	.122	1.926	.055
Caseload Characteristics
Percentage of client caseload that is racial/ethnic minority	−.001	.001	−.097	−1.365	.173
FEQ Scales
Confidence	−.005	.047	−.008	−.116	.908
Frequency of Strategy Use	.080	.031	.174	2.589	.010
Organizational Practices	.041	.027	.104	1.559	.120

Note. FEQ = Father Engagement Questionnaire

* Reference group: Female or Non-binary/genderqueer

⁺Reference group: Race/Ethnicity: non-Latinx white

Qualitative data analysis

Interviews were transcribed and audited by undergraduate research assistants. A preliminary codebook was compiled consisting of a priori codes based on the interview guide. During an initial phase of coding, emergent codes were added to the codebook. The coding team, comprising undergraduate and graduate student researchers, met regularly throughout preliminary coding to review and refine codes, and resolve coding discrepancies. Once the team reached consensus about each code, a codebook was finalized. Members of the coding team then coded all 23 interviews, with 50% of them double coded by an advanced coder. Advanced coders met with members of the coding team regularly to review and resolve inconsistencies, with discrepancies resolved in meetings with the full research team. Coding by team consensus followed recommendations for conducting qualitative data analysis in implementation research (Aarons & Palinkas, 2007; Palinkas, 2014). Following coding, the authorship team conducted thematic analysis of co-occurring codes using NVivo v 12, with further textual analysis illuminating themes and subthemes (Braun & Clarke, 2006).

Results

Quantitative results

Descriptive statistics revealed that therapists had an average PCIT caseload of 6.06 clients (SD = 4.91). Of those cases, 3.88 (SD = 3.39) had a father involved in the child’s life and 2.23 cases (SD = 2.22) had fathers who were regularly attending PCIT sessions. The average rate of father involvement in the child’s life among PCIT cases was 69.59% (SD = 30.56%). The average rate of regular father attendance in all PCIT cases was 40.53% (SD = 31.1%) The average rate of regular father attendance in PCIT cases with an involved father was measured at 60.97% (SD = 36.99%). Mean scores on the FEQ scales show that therapists reported “sometimes” to “often” use of father engagement strategies by themselves (Frequency of Strategy Use: M = 3.35, SD = 0.81) and by their organizations (Organizational Practices: M = 3.63, SD = 0.93) with slightly higher scores on the latter. They reported being “somewhat” to “very” confident engaging fathers (Confidence: M = 3.65, SD = 0.57).

Overall, results of the multiple linear regression found that the model predicted father attendance (R² = .087, F(8, 256) = 3.06, p = .003). None of the therapist or client characteristics were predictive of differences in rates of father attendance. There was, however, one FEQ scale that predicted increased rates of regular father attendance. That is, therapists who reported higher scores on the Frequency of Strategy Use scale were more likely to have higher rates of father attendance in sessions [b = 0.174, t(267) = 2.59, p = .01]. The Confidence and Organizational Practices scales of the FEQ did not yield significant differences in rates of father attendance. Results of the multiple linear regression model are summarized in Table 2.

Qualitative results

Qualitative results triangulated and elaborated on quantitative findings, with two primary thematic categories identified: barriers to father engagement and father engagement strategies. The barriers therapists described converged with quantitative findings that fathers did not participate in treatment much of the time and expanded on perceived reasons for this lack of participation. Though therapist and client characteristics (e.g., therapist gender, race/ethnicity) were not predictive quantitatively, these characteristics did emerge as salient barriers in qualitative interviews. The strategies described qualitatively did not reflect items on the FEQ (for all items, see Supplemental Table 1), suggesting that therapists have developed many ad hoc strategies that might expand the current father engagement literature. Themes are described below and additional illustrative quotes are provided in Table 3.

Table 3. Themes and illustrative quotes.

Theme	Quote
Barriers to Father Engagement
Scheduling and availability	“most of the time they’re working one or two jobs, they’re getting home late.”
Family gender roles	“the family’s belief about gender roles and if it’s dad’s role to engage in things like the child therapy or if that’s one of mom’s duties. Families are really rigid in that, it can be hard to bring dads in”
Perceptions of child problem	“I think this dad had a lot resistance to participation in PCIT because he felt like it wasn’t really needed … ”
Mental health treatment stigma	“the biggest issue in getting fathers involved is the stigma behind mental health and counseling … a lot of dads will say ‘Okay, you can take them but I’m not going over there with you.’”
Treatment-specific aversions	“there are more dads who just like think the whole thing is really weird. Everything from sitting down and playing, to getting coached with a walkie-talkie, to ignoring a tantrum, you know, just all of it, it’s like ‘what are you guys doing.’ That’s a barrier”
Therapist identity	“it can be hard for parents in general, but particularly fathers, to receive directives from a young female therapist”
Father Engagement Strategies
Reaching out	“I will just call and introduce myself and say ‘hey I need you here. I really need you in the team.’”
Flexible scheduling	“trying to be flexible for them to come in in the evening”
Individual sessions	“I offered to meet with him individually or talk to him on the phone”
Incremental engagement	“When I have a dad that shows up that says ‘Look, you know, I just can’t be here every week’ I would say ‘Okay, can you give me this’ And I asked for a behavior observation, a first teach, and then if I can get one or two coaches, then bring them back in for a second teach … ”
Providing information	“I do a lot of front work in explaining why we’re even using play interventions, why is that so important for young kids, why are we using these techniques of play therapy and of child-directed interaction to address these really difficult behaviors that your child is having, so a lot of that is psycho-education.”
Stressing father’s important role	“I also try to emphasize how for male children, you are their model, I mean for girls too, but this is how he’s learning to be a man, that a man can be, that a grown-up, discipline doesn’t have to be scary, it can be calm but assertive, it can be loving and kind, it doesn’t have to always look like punishment. I try to emphasize that part of it, and then also when I’m working with dads and their daughters thinking about this relationship is so unique and important and why that is. So, I really try to be strength-based and emphasize dad why you’re so important
Connecting over shared characteristics	“it’s just not what we see in our culture, it’s just not how we were raised, so I have to just try to empathize with them, I am Hispanic as well … so it just takes a little bit more understanding where they’re coming from … ”

Barriers to father engagement

Therapists described many barriers to engaging fathers. They explained that scheduling and availability created challenges, such that “one big logistical barrier is that dads in general are less likely to be available during the work day.” Therapists explained that in their experience fathers often worked multiple jobs, “two or three jobs even, and then it’s just a time thing, it can be so hard to get them in.” This minimal availability was exacerbated by and likely contributed to familial gender roles. Therapists stated that “mom is almost always the go-between,” which they attributed to preexisting roles assigned to mothers and fathers in the family: “the roles are mom handles the kid stuff and dad isn’t really engaged.” One therapist stated “in my experience, fathers defer to mothers for caregiving, I think it’s a family issue and also largely a societal issue, an expectation that the mother will handle the kid’s behavior.” These differences in familial expectations about the roles and involvement of each parent resulted in differing perception of child problems, which therapists identified as a challenge in engaging fathers. As one therapist explained: “most of the time they aren’t the ones taking their children to meetings, parent-teacher conferences, they’re not part of that component. So then coming into therapy when they don’t really understand what the problem is … ”

Therapists explained that many of the fathers they had worked with, or attempted to work with, had negative preconceptions about mental health treatment and were “just kind of paranoid about therapy.” They recounted working with mothers who felt that “our son needs therapy and [the father] thinks this is for crazy people.” This mental health treatment stigma created “a lot of hesitancy in approaching mental health even for your own children.” Father’s beliefs about and discomfort with mental health treatment accompanied other treatment-specific aversions to particular components of therapy, which seem “weird to them.” Therapists identified giving praises, selective ignoring, and following the child’s lead as “really foreign for them.” Therapists stated that receiving in-vivo coaching was an element of treatment that was uncomfortable for many fathers. Though quantitative findings did not find that therapist characteristics predicted attendance, qualitative findings diverged from these findings in that participants frequently referenced how therapist’s identity contributed to difficulties with certain treatment components, such as receiving directives during coaching from a therapist. Therapists who identified as female reported that “it’s a lot harder to engage dads,” indicating that “for my colleagues who are older, and are male providers, the respect is automatically there when fathers come into treatment, and then even more so into PCIT.” Therapists described being young, female-identified, and not having a child as characteristics that they felt made it harder to engage fathers:

“one of the most difficult things for me is that I’m a woman […] I’m also white and so I think immediately - I don’t think we have any Caucasian clients in our clinic right now and so I think like, ‘A white woman who doesn’t look like she has children trying to teach me about parenting my kid?’ I think there’s a huge issue around that, and I think that goes for mothers and other caregivers also, but particularly for fathers in the community I work in … ”

Father engagement strategies

Although therapists recounted many barriers to engaging fathers in treatment, they also illuminated different strategies that they use to overcome these barriers, which elaborated on the quantitative finding that father-focused engagement strategies predict the rate of attendance. Therapists frequently described reaching out directly to fathers: “I try to reach out to them, introduce myself to them,” and “I called them – I called dad back directly.” Therapists additionally described flexible scheduling in order to accommodate limited availability. They described enacting this flexibility by both working evening hours and scheduling in advance: “sometimes I’ll set up an appointment with the other caregiver, if they know the father’s schedule, two weeks out to re-arrange it, to let them know ahead of time, and so there just goes – more planning goes into engaging fathers.” Therapists additionally recounted occasions of providing individual sessions to fathers, as in this example: “I remember working with a white American gay single father once and he needed […] more one on one time to vent, he was overwhelmed and very stressed so I added a few individual sessions throughout treatment, just to get to know him, to provide some safe space for him to become vulnerable and lower the defenses and I think that was beneficial.”

In addition to providing additional time, reaching out to fathers, and accommodating demanding work schedules, therapists described incremental engagement strategies, whereby they invited fathers to particular components of treatment, such as inviting them to attend just the intake, just a teach session, or to just observe part of a session in order to gradually elicit additional engagement and participation: “I’ve had dads just kind of sit in the coaching room with me and watch and listen so that they’re learning the skills. I’ve had dads come to, um, teach sessions at least, maybe if they can’t do the coaching, they at least come and get the information.” If fathers were unwilling or unable to fully commit, therapists described “having their fathers even come to one session.”

Therapists navigated preconceptions about mental health by providing information to fathers at the onset of treatment, including “[explaining] the process and how it works,” providing psychoeducation, and describing the utility of different therapy techniques. Therapists described doing more explaining and sharing rationale and even the scientific basis of PCIT in order to overcome barriers and hesitance found among fathers. It also seemed like this provision of knowledge allowed them to overcome treatment stigma: “we can sell PCIT as parenting skills, rather than therapy. And I think fathers, especially Latino fathers, are more likely to respond to tools that are being given to them so that they can support the child’s behavior, rather than therapy.” They frequently stressed the father’s important role in treatment and in their child’s life in order to galvanize interest and participation, explaining that “I really want them to feel that they’re an important part of this treatment.” Therapists felt that “telling them directly, ‘you’re an important part of your kid’s life, and we want you to be part of this,’ helps them feel not only welcome, but like, that they have an important and unique role.”

Although therapists identified demographic differences between themselves and fathers as a barrier to engagement and rapport-building, they also described ways in which they connected over shared characteristics (when available) to elicit engagement. One female-identified therapist stated: “I don’t use a lot of self-disclosure, but I think it’s really helpful to tell dads that I’m a parent as well.” Male-identified therapists described how that shared gender identity helped them engage fathers: “I think as a dad myself, it’s probably a little bit easier for me to connect with dads and for them to listen, especially given the very conservative and old school mentality of the region that I live in, it’s many times easier for a male caregiver to listen to another male. So I find it to be a little bit easier for me.” Therapists described using shared parenthood, gender-identity, and cultural background in order to connect with fathers.

Discussion

This study aimed to investigate therapist-reported rates of father participation in PCIT and to understand therapist experiences working with fathers through a mixed methods approach. Therapist quantitative reports indicated that fathers in families seen by this sample of therapists attend sessions at higher rates than what has been reported in previous studies. In a study of therapists in the United Kingdom, Scourfield et al. (2014) found 21% father participation in parenting courses, while a study of Australian therapists delivering parenting interventions for children with externalizing behaviors, found that only 17.2% of families with a father present in the home had a father attending sessions “often,” with 53.4% attending “sometimes” (Tully et al., 2018). In comparison to these numbers, 60.97% regular father attendance is remarkably high. Although therapists reported that in most cases with a father present in the child’s life, the majority attended sessions regularly, it is important to note that out of all PCIT cases only 40.53% included regular father attendance. Approximately 30% of PCIT cases involved families with no father in the child’s life at all, precluding any father attendance or participation, according to therapist reports. Higher rates of attendance in this study than in previous research on fathers may suggest that PCIT may be an ideal intervention through which to investigate father participation, particularly given multiple unique characteristics of the treatment. Previous calls to disaggregate caregiver data (Panter-Brick et al., 2014) and ensure that data is being collected from both caregivers (Fabiano & Caserta, 2018) may be addressed by PCIT, which routinely collects standardized measures from all involved caregivers. The multiple types of data gathered regularly (e.g., behavioral and parent-report) may offer further chances to investigate unique aspects of mother and father involvement, while similarities and differences in their reports can be assessed. The sessions outlined in the PCIT manual also specify how to include either single or multiple caregivers in each session, which may contribute to higher rates of two-parent engagement in PCIT than in other treatments (Eyberg & Funderburk, 2011).

It is also worth considering whether the framing of PCIT accords well with problem attributions more frequently found among fathers, since parental beliefs about problem etiology and expectancies for treatment are important areas to target to enhance engagement (Lau, 2006; Nock & Ferriter, 2005). The way mental health treatments are framed impacts men’s likelihood of participating in them (Jampel et al., 2020). Men exhibit less help-seeking behavior, and it has been suggested that the ego-centrality of a problem may impact their likelihood of seeking treatment (Addis & Mahalik, 2003). PCIT is framed as a treatment for child behaviors, and parents aren’t identified as the main target or patient. This may decrease the sense that the parent is lacking in some way. Fabiano (2007) pointed out that since fathers often have a higher sense of esteem in their parenting skills, deficiency-based interventions may be less enticing to them. Instead, it is recommended that interventions are presented as a way of enhancing skills. Because even the PCIT intake session instructs the therapist to “first, describe any notable parenting strengths,” Fabiano’s father-engagement suggestion is already, in a way, embedded in the protocol (Eyberg & Funderburk, 2011, p. 14). It is possible that these elements of the treatment may be particularly helpful for fathers. Niec et al. (2015) found that fathers demonstrated lower readiness for change than mothers before PCIT, indicating less interest in changing their parenting behaviors. The focus on parenting strengths and initial positive feedback may help corroborate this sense that parenting need not be changed, allowing fathers to become and remain engaged since it doesn’t demand dramatic changes initially.

Barriers to father engagement

Despite elements of PCIT that may contribute to the relatively high rates of father attendance reported by therapists in this study, therapists in this study described many barriers to engaging fathers that overlap with previous findings. Scheduling and availability have previously been identified as a major impediment, both in PCIT and parenting programs more broadly (Tully et al., 2017). Busy work schedules can also interfere with fathers’ adherence to crucial aspects of treatment such as homework completion, making it difficult to fully learn and implement new skills in the home setting (Chacko et al., 2009; Quetsch et al., 2020). Time, availability, and energy are especially finite for low-income and racial/ethnic minority families, who contend with additional stressors and structural barriers that compete for their attention, and ultimately lead to a higher likelihood of attrition (Lyon & Budd, 2010). One meta-analysis examining predictors of parent training efficacy found that family income was the only significant demographic predictor of treatment outcome (Reyno & McGrath, 2006). Father engagement among low-income families is, therefore, impacted by both professional obligations and the financial circumstances that often necessitate multiple jobs, which is reinforced by sociocultural gender norms of fathers being the “providers” (Salinas et al., 2011; Sicouri et al., 2018).

Therapist accounts of familial gender roles obstructing father engagement have also been found in previous research, in which therapists made similar observations, reporting that mothers are seen as de facto caregivers and expected to oversee their children’s treatment (Fabiano, 2007). Treatments themselves, which may be structured around mothers, often do not emphasize the importance of fathers and may strengthen these expectations. Fathers have reported feeling excluded and unimportant in treatment, which dissuaded them from attending (Cosson & Graham, 2012). Ossified familial gender roles do not reside entirely within fathers, however, and operate within familial structures; mothers’ beliefs about fatherhood have been found to moderate father involvement and perceptions of their parenting roles (McBride et al., 2005). Other barriers described by therapists in this study reflect previous findings; qualitative reports by therapists about discrepancies between parent perceptions of child problems echo findings that mothers and fathers perceive and report child problems differently (Grietens et al., 2004). It is possible that these differences in perception result from real differences in the ways children respond to their mothers and fathers; previous research has found greater levels of child compliance toward their fathers compared to their mothers (Calzada et al., 2004). Mental health stigma, as referenced by therapists in this study, has also been found to discourage help-seeking and lower participant retention (Golberstein et al., 2008).

Strategies to engage fathers

Many of the strategies described by providers in this study overlap with previous recommendations for engaging caregivers, while others do not. Becker et al. (2015) found that strategies such as promoting the accessibility of treatment and providing psychoeducation may lead to higher treatment attendance. These techniques echo strategies reported by therapists in this study who promoted accessibility for fathers by using flexible scheduling, and who described providing information to fathers that included psychoeducation and information about treatment. Motivational interviewing has also been recommended as a strategy for overcoming parental ambivalence and uncertainty about PCIT specifically, although it did not emerge thematically in the present study (N’zi et al., 2017).

While flexible scheduling and offering information are reflected in caregiver engagement research, many strategies described by therapists in this study do not fit into previous lists of caregiver engagement strategies. Two recent comprehensive literature reviews that aggregated engagement strategies did not include reaching out specifically to a caregiver, adding individual sessions, incremental engagement, stressing the father’s important role in treatment, or connecting over shared characteristics (Becker et al., 2018; Haine-Schlagel & Walsh, 2015). Peer pairing, which relies on shared characteristics such as culture or lived experience, has been identified as an engagement strategy, but it typically relies on commonalities between a client and lay health provider (Gustafson et al., 2018).

The absence of father-specific engagement strategies from the caregiver engagement literature is not surprising given the absence of male caregivers in this literature more generally (Panter-Brick et al., 2014). Some of the strategies described in this study may not have been classified as engagement strategies previously, such as adding individual sessions. However, within caregiver engagement frameworks, such as REACH, which includes strategies that enhance Relationship, Expectancy, Attendance, Clarity, and Homework, each of the strategies found in this study was used by therapists to improve engagement in one of these five domains (Becker et al., 2018). Adding individual sessions, for example, was used by therapist in an attempt to build rapport. Because most caregiver engagement literature defaults to maternal engagement or does not disaggregate parent data, strategies that work specifically to enhance father engagement may be inadvertently omitted.

While engagement strategies used by therapists in this study do not all accord with general caregiver engagement literature, they do reflect recommendations by researchers focusing on fathers. Fabiano (2007) suggests explicitly inviting fathers at intake, which involves reaching out specifically to fathers, as therapists in our study reported doing, and inviting small forms of participation rather than full commitment to a lengthy treatment as a way of initially overcoming fathers’ lower change readiness. This recommendation mirrors the incremental engagement strategy used by therapist in this study. Fabiano (2007) also recommends strategies that were not reported in this study, such as providing childcare, projecting an assumption of father engagement on families, and incorporating father-led activities into treatment. Some of the strategies proposed by Fabiano address barriers that therapists in this study recounted: in order to overcome different perspectives on child problem, Fabiano suggests focusing on functional impairment rather than specific symptoms. In order to reduce stigma, the article suggests reframing interventions as skills enhancers rather than treatment. Although individual therapists in our sample did recount reframing treatment, or implementing sports-related toys or metaphors for fathers, these strategies were described in individual instances and were not consistent or thematic, suggesting the need to more widely disseminate proposed solutions to engage fathers.

Treatments that have effectively engaged fathers may provide additional clues into what engagement strategies are most effective with male-identified caregivers. The Dad2K program, which modified SafeCare to increase participation for at-risk fathers, supplemented treatment with computer technology that included motivational content, sports themes, additional psychoeducational material, and male video actors. In a preliminary study, fathers rated the program favorably and demonstrated improved parenting skills (Self-Brown et al., 2015). A group Triple P that improved paternal parenting used additional father content to increase relevance to fathers, including explaining father contributions to child development and addressing issues frequently referenced by fathers (e.g., balancing work and home obligations, improving children’s social skills and competency, and coparenting; Frank et al., 2015). Another study compared a standard behavioral parent training group to COACHES, an enhanced BPT that incorporated sports activities and framed treatment as coaching children rather than training parents (Fabiano et al., 2009). In that study, both groups addressed barriers to father participation by including fathers in intake, ensuring accessibility through weekend scheduling and convenient locations, and offering child care. Both treatment groups resulted in improved child behaviors, but the COACHES group yielded higher attendance, homework completion, and enjoyment by fathers. Interestingly, fathers in both groups reported that they would participate in the group again, but those in the COACHES group were more likely to recommend the group to other fathers. Each of these treatments was effective in eliciting father participation and maintained high levels of father attendance at sessions. It is hard to disentangle the specific components of these approaches that are responsible for their effectiveness with fathers, and difficult to know whether the study’s aims and therapists’ purposeful invitation of fathers is primarily responsible for greater participation. In the current study, emphasizing the importance of father attendance at intake was the strategy therapists reported using most frequently, of both agency level and therapist level father engagement strategies (M = 3.97, SD 1.08). Reminding therapists that fathers should be invited to participate may be the single most important predictor of father attendance.

Engaging therapists to engage fathers

Though therapists reported on many engagement strategies for fathers, they may benefit from additional training and support in how to engage fathers. This support should start by reminding therapists that fathers can offer unique contributions and should be welcomed into treatment. Agency-wide supports and reminders could include signs in workspaces (e.g., “Have you talked to dad this week?”), conversations in supervision, or added questions in initial phone screens (“What is dad’s contact information? When is he available for a brief phone call?”). Training should also clearly delineate techniques for overcoming the many barriers that therapists describe facing, so that they have an arsenal of strategies available.

Trainings have been found to effectively increase therapist confidence and competence engaging fathers (Burn et al., 2019). It may be helpful for training to include challenging therapist cognitions about father involvement; for example, therapists in our study described their own gender identity as a possible barrier, as they felt that fathers were unlikely to take direction from a female. However, therapist identity was not found to predict father attendance in our quantitative results, and a study by Tully et al. (2017) of factors that fathers state impact their decision to participate in their child’s treatment found that having a male facilitator was ranked lowest among factors determining their participation. While it is possible that these expressed preferences do not translate into actual participation, it is important for therapists to understand which of their perceptions about father treatment hesitance are accurate, and which may be conjectures or their own uncertainties. Father reports indicate that the most important factors determining their participation in treatment are knowing that the facilitator is trained and understanding what is involved in the treatment (Tully et al., 2017). Therapists in our study may have been intuitively accommodating this second need by providing additional information to fathers, which included highlighting empirical evidence for PCIT. However, therapists did not report emphasizing their own training, with female-identified therapists focusing instead on demographic differences between themselves and male-identified caregivers that they felt detracted from their effectiveness at engaging fathers. It is possible that emphasizing one’s qualifications and training may actually be an underutilized father engagement strategy.

Other cognitions that may need to be challenged include deficit models of fatherhood, which see fathers as irrelevant to parenting or as characteristically neglectful or uninvolved (Panter-Brick et al., 2014). Therapists may have inadvertently internalized negative messages about fathers, their level of parental involvement, or their willingness to participate in treatment. Therapists who habitually work with mothers may default to inadvertently excluding fathers or may assume that the father is unavailable or uninterested. Assisting therapists in modifying their own preconceptions about fathers and father engagement may be a seminal first step.

Limitations & future directions

This study expands the literature on caregiver engagement, providing needed insight specific to engaging fathers. Additionally, it offers useful alternatives to recreating entire treatment models in order to engage fathers, such that engagement strategies can simply enhance treatments already known to work. However, it is limited in that it focuses on therapist reports of attendance rates and descriptions of father engagement. Although understanding how therapists perceive working with fathers is crucial in the effort to improve practice, therapists may have interpreted regular attendance and father availability differently. Additionally, the impacts of the engagement strategies identified in qualitative analysis are unknown. Future research will need to evaluate whether reported strategies actually lead to higher attendance and engagement rates among fathers.

This study was also limited in its use of attendance as a sole quantitative engagement measure. Regular attendance in treatment is an important element of engagement, but does not measure other dimensions of engagement, such as active participation in treatment sessions or homework between sessions (Haine-Schlagel & Walsh, 2015; Nock & Ferriter, 2005). Additionally, regular attendance was not specifically defined in the survey, and data on mother attendance was not gathered. Consequently, therapists may have had differing interpretations of “regular” attendance, and comparisons with attendance by mothers cannot be made. This study also looked specifically at PCIT, which is but one example of a treatment in which fathers can and should have an active role. It cannot be generalized to other treatments, although the study may provide clues into engagement strategies that may work across the board, which could enhance outcomes in treatment for children and their caregivers.

Finally, many of the therapists interviewed in this survey discussed heterosexual family arrangements. Although other family structures were referenced, themes related to single fathers or same sex couples did not emerge in the qualitative data. It will be important for future research to consider how father engagement operates in different family arrangements. It will also be important for research to continue to expand the definition of fatherhood, and to include genderfluid, nonbinary, and trans caregivers. Although the current study offers important insights into male-identified caregivers and fathers, it offers a limited perspective into how gender identity operates within families. The racial homogeneity of the qualitative sample should also be kept in mind when considering qualitative findings. Future studies will benefit from recruiting a more diverse sample, in order to understand how therapist racial identity may impact perspectives on or experiences with father engagement.

Despite these limitations, this study offers insight into ways therapists are already developing ad hoc engagement strategies to increase father participation in treatment. It suggests that despite limited research to date on father engagement, and limited trainings for community practitioners, therapists seem to recognize the importance of involving fathers in their children’s treatment. This study also highlights many barriers therapists perceive as impeding their efforts to engage fathers, and suggests opportunities for future research that can address barriers, both real and perceived. Evaluating the accuracy of therapists’ perceived barriers by comparing their perceptions to client and family data will illuminate where efforts to overcome these barriers should be targeted. Future studies should integrate the perspectives of fathers and therapists in order to potentially compare stakeholder perceptions. This study offers necessary insights into how therapists see their work and the fathers they do and do not work with, so that future research can continue to evaluate and improve the ways fathers are engaged in treatment.

Authors’ contributions

All authors contributed to the study conception and design. Interview preparation, collection of interviews, data collection, and qualitative data analysis were performed by all authors. Quantitative data analysis was conducted by JCG. Integration of qualitative and quantitative findings was performed by all authors. CCK, JCG, and MT drafted the manuscript. Funding acquisition was done by CCK and MLB. MLB provided comments on all versions of the manuscript. All authors read and approved the final manuscript.

Data availability of statement

The interviews generated and analyzed during the current study are not publicly available to protect the identities of participants, but are available from the corresponding author on reasonable request.

Ethics

This study was reviewed and determined exempt by the University of California, Santa Barbara Internal Review Board.

Acknowledgments

The authors would like to acknowledge the efforts of the undergraduate research assistants in the PADRES lab who contributed to data transcription and coding.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This study is funded by a University of California University of California Santa Barbara Academic Senate Grant awarded to MLB. Further, the time and effort to prepare this manuscript was supported by the National Institute of Health K01MH110608 awarded to MLB.