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Exploring the impact of involving fathers in the treatment of their children: 

A study using Interpretative Phenomenological Analysis (IPA) 

 

Anna Elisabeth Iversen, Barbara Hoff Esbjørn, Elisabeth Christensen & Nina Schultz Hansen 

 

 

Abstract. Although fathers have been shown to contribute uniquely to the development of 

psychopathology in children, they continue to be ignored in research and clinical work. 

Knowledge about the impact of involving fathers in their child’s treatment – for the child, 

couple and the family as a whole - is still sparse. The aim of this study was to explore parents’ 

experiences of having fathers involved in the treatment of their child. Parents, whose children 

had received cognitive behavioural therapy for an anxiety disorder, were interviewed about 

this topic. The participating parents had all been involved in the treatment of their child. 

Interpretative phenomenological analysis (IPA) was used to analyze the data in this study. 

Three higher order themes and 11 subthemes emerged from the six interview accounts. The 

three higher order themes were as follows: Strengthening the family system, empowerment of 

parents, and impact on partner relationship. Results indicated that parents’ experiences of the 

involvement of fathers to be beneficial not only on the child’s treatment but also on other 

aspects of family life. The parents reported that the family as a whole benefitted from the 

treatment and that the relationship between the parents was strengthened. A model was created 

to conceptualize these results.  

 

Keywords: childhood anxiety; family; father involvement; interpretative phenomenological 

analysis; treatment 

 

Please cite this article as: 

Iversen, A.E., Esbjørn, B.H., Christensen, E. & Hansen, N.S. (2012). Exploring the impact of 

involving fathers in the treatment of their children: A study using Interpretative 

Phenomenological Analysis (IPA). Qualitative Studies, 3(1): 22-39. 

 

Introduction 

‘Are we continuing to neglect fathers?’ is the title of an editorial by A. Vetere (2004). The answer 

to the question is that they may not be neglected, but that they continue to be underrepresented. 

The editorial therefore encourages more writing about fathers and their role in the family. 

Surveys among clinicians confirm the same trend in clinical practice – that fathers participate 

less in treatment of their children than mothers do (e.g. Lazar, Sagi & Fraser, 1991; Singh, 2003; 

Duhig, Phares & Birkeland, 2002). Furthermore our understanding of the parents’ experiences 

of involving fathers in the treatment of their children is very limited. However, as pointed out 

by Phares and colleagues (2006), it is not always clear whether this is due to the fathers refusing 

to participate, or if it is due to clinicians’ practice of not including fathers in treatment. A 

detailed understanding of the mothers’ and fathers’ experiences of having fathers participate in 

treatments of the children may guide clinicians when deciding if fathers should be invited to 

participate in their child’s treatment or not.  

 

A review of the clinical child and family research published between 1984 and 1991, found that 

fathers were also clearly underrepresented in child and family research that focused on clinical 

issues (Phares & Compas, 1992). In an update review 13 years later, they concluded that the 

situation had not changed much, and that fathers continue to be underrepresented in research 

on fathers and developmental psychopathology (Phares, Fields, Kamboukos & Lopez, 2005). 



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Zimmerman and colleagues reviewed five journals that focused on child and adolescent 

development and concluded that the same is true for the field of normal development, namely 

that fathers are clearly underrepresented (Zimmerman, Salem & Notaro, 2000). However, 

although fathers have been neglected in research on child psychopathology as well as in clinical 

practice, they do have a unique influence on children’s normal (e.g. Biller & Lopez-Kimptom, 

1997; Lamb, 1997; Pleck, 1997; Sarkadi, Kristiansson, Oberklaid & Bremberg, 2008) as well as 

abnormal development (e.g. Connell & Goodmann, 2002; Videon, 2005).  

 

Furthermore, reviews of father involvement in parent training of disruptive children have 

found that inclusion of fathers in treatment was associated with improved treatment outcome at 

follow-up (Bagner & Eyberg, 2003; Lundahl, Tollefson, Risser & Lovejoy, 2008). Treatment 

programmes involving fathers will have the advantage over treatments only involving mothers, 

that both parents receive training in parenting behaviours that will increase positive behaviour 

towards the child as opposed to programs involving only the mother, who must then explain 

the parenting principals to the father. These findings indicate the importance of investigating 

the unique contribution of father involvement further, and beyond the area of children with 

disruptive disorders. Whether these findings extend to children with internalizing disorders, 

e.g. anxiety disorders, is largely unexplored. Furthermore the positive effect of involving fathers 

may potentially rise as a result of two committed parents working together in treatment, 

irrespective of the gender of the parents; however, research has focussed mainly on 

heterosexual two-parent families, as these are more common and numerous questions 

regarding the role of fathers are yet unanswered. 

 

What is known is that fathers play an important role in the maintenance of childhood anxiety 

disorders. Fathers of anxious children have been found to exhibit more controlling and less 

autonomy granting behaviour than fathers of non-anxious children (Bögels, Bamelis & Bruggen, 

2008; Greco & Morris, 2002). As anxiety disorders are among the most common psychiatric 

disorders in childhood (Cartwright-Hatton, McNicol & Doubleday, 2006; Costello, Mustillo, 

Erkanli et al., 2003), studies of the value of including fathers in treatment of anxious children are 

also warranted. Evidence indicates that cognitive behavioural therapy (CBT) is an effective 

treatment, both when delivered to the child individually and when involving the parents of the 

child (Creswell & Cartwright-Hatton, 2007). Nevertheless, most of the studies involving parents 

in the treatment of the anxious child involve only the mother. In contrast to the literature on 

externalizing behaviour, fathers have in this line of research been largely neglected.  

 

When studying the role of fathers in relation to treatment, research has examined both direct 

and indirect effects. One indirect effect of the fathers’ role in relation to treatment is the personal 

characteristics of the father. One such factor is paternal anxiety, which has been found to make 

a unique contribution to treatment outcome, as elevated levels of paternal anxiety has been 

linked to poorer treatment outcome (Liber, van Widenfelt, Goedhart et al., 2008; Rapee, 2000). 

Moreover, paternal somatisation (Crawford & Manassis, 2001) and rejecting behaviours by 

fathers (Liber et al., 2008) have also been found to predict poorer treatment outcomes in anxious 

children. This is important, as it is widely known that anxious children are more likely to have 

anxious parents (Last, Hersen, Kazdin et al., 1991; Murray, Creswell & Cooper, 2009). In 

addition to dealing with their own anxiety, these fathers may also be affected in terms of how 

they help their own children overcome anxiety. As pointed out by Bögels & Phares (2008) 

fathers may play a different role compared to mothers, as fathers are often the ones who 

encourage the child to explore the external world, a behaviour that may be compromised if the 

father has anxiety himself (Bögels & Phares, 2008). Another way, in which the father may play 



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an indirect role on the children, is when the mother’s rearing behaviour is affected by the 

father’s emotional well-being and behaviours. In fact, Bögels and colleagues found that mothers 

are more negative towards their anxious children, if their partners suffer from anxiety. This 

may be due to the fact that paternal anxiety makes mothers more insecure as caregivers. The 

anxious fathers are also reported to be less supportive of their partners than non-anxious fathers 

in a control group (Bögels & Phares, 2008). This may in turn affect the mothers’ parenting 

ability, as mothers who feel supported by their partner show an improved interaction with their 

child (Bögels & Phares, 2008; Bögels & Brechman-Toussaint, 2006). McHale & Rasmussen (1998) 

also found that lack of partner support is a strong predictor for child anxiety in young children.  

 

Given the unique impact fathers have on the maintenance of children’s anxiety disorders as 

well as on treatment outcome, it is vital that fathers receive more attention in intervention 

efforts targeting internalizing disorders, and that the impact of mothers and fathers is not 

assumed to be equivalent. However, in many of the existing studies, fathers either are not 

involved, or paternal effects are not studied separately. Therefore, the impact of including 

fathers is to a large extent unexplored.  

 

The changing roles of fathers within families as well as changing notions of masculinity in the 

past few decades also underscore the importance of exploring the impact of involving fathers in 

the treatment of their children. Some argue that fatherhood and fathers’ role in the family is not 

as straightforward and unproblematic to define as it perhaps once was (e.g. Yarwood, 2011; 

Finn & Henwood, 2009). In recent years the concept of the “new father” has emerged, and the 

idea of the modern father as a caring, nurturing and emotionally involved co-parent involved in 

house work and child care has been an issue of some debate (Brandth & Kvande, 1998; Finn & 

Henwood, 2009; Yarwood, 2011). Although the concept of the traditional breadwinning, 

perhaps more distant, father continues to be a dominant construct, some studies point out that 

the role of the father within the family is indeed changing, as are fathering identities, towards a 

more actively involved, caring co-parent model (e.g. Finn & Henwood, 2009). The changing role 

of fathers also implies that the boundaries between mothers’ and fathers’ gendered roles in the 

family are becoming more diffuse, as fatherhood is beginning to include some traditionally 

maternal qualities (e.g. caring for children; Brandth & Kvande, 1998; Finn & Henwood, 2009; 

Yaewood, 2011). This move towards ‘new’, increasingly involved fathers, who share 

responsibilities with mothers clearly emphasizes the need for further investigating the impact of 

involving fathers in the treatment of their children. 

 

This study attempts to explore in detail parents’ experiences of involving fathers in the 

treatment of their children. In-depth interviews with parents of anxious children are carried out 

in order to provide insights into their perspectives on this topic. As pointed out by Richardson 

(1996), qualitative research is particularly appropriate in cases where the topic of study is 

characterized by complexity, ambiguity and lack of prior theory and research. This last point 

certainly applies for this topic, and is also the reason why a qualitative approach was chosen for 

this study.  

 

Method 

Methodology 

Interpretative phenomenological analysis (IPA; e.g. Smith, 1996; Smith, Jarman & Osborn, 1999; 

Smith & Osborn, 2003) was used to analyze the data in this study. IPA was developed for use in 

psychological research (Langdridge, 2004), and shares a number of similarities with grounded 

theory (Glaser & Strauss, 1967) in that they both put emphasis on the experience and meanings 



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of the participants (Langdrigde, 2004; 2007). However, IPA derives from the phenomenological 

tradition, and the focus of research is thus on investigating topics or objects as they are 

represented in and perceived by the participant. Thus, the method is concerned with the 

personal accounts and perceptions of a phenomenon. IPA does not attempt to create an 

objective account of an object or event (Smith & Osborn, 2003), but aims to explore the 

participant’s personal perception of a phenomenon. Another premise of IPA is that the research 

exercise is a dynamic process, as the researcher makes use of his own conceptions when trying 

to make sense of and interpret the other person’s accounts (Smith, Flowers & Osborn, 1997). 

Research questions in IPA projects are usually framed broadly and openly, and there is no 

attempt to test a predetermined hypothesis of the researcher. Instead ‘the aim is to explore, 

flexibly and in detail, an area of concern’ (Smith & Osborn, 2003, p. 53). As the focus in the 

present study was exploring parents’ perceptions, that is their phenomenological experience, of 

involving fathers in treatment, it was considered appropriate to make use of IPA.  

 

Participants and Recruitment 

The sample consisted of parents whose children had received cognitive behavioural therapy for 

an anxiety disorder. The participating parents had all been involved in the treatment of their 

child. Families, who had commenced and terminated treatment in the period January 2007 until 

April 2008, where both parents had attended the treatment, were invited to participate in the 

current study. An information letter was sent to them, in which the aim and procedures of the 

study were outlined. They were also informed that a decline of participation would have no 

effect on their future contact with the University Clinic, where they had received the treatment. 

The parents were instructed to return the consent form if they were interested in participating. 

The families were subsequently contacted by telephone in order to make an appointment for the 

interview. 

 

Ten families returned the consent form. In two of these cases it turned out to be impossible to 

find convenient times for the interviews. Thus, eight families ended up participating in the 

study, two of which took part in the piloting of the interview guide. The six remaining families 

constituted the sample for the current study. In one of these families, it was only the father who 

participated, as the parents were in the process of being separated. In another family, the child’s 

stepmother participated with the father, as she had lived with the child most of his life. In the 

remaining families, both parents took part in the interview. These were all cohabiting biological 

parents. Mothers and fathers had to take time off work in order to participate in the treatment. 

This was primarily paid for by themselves. Only one of the participants could take the required 

time off work without having to compensate. All participants were middle-class, caucasian 

Danes.  

 

The Intervention 

The treatment took place at a University Clinic, which provides treatment free of charge. All 

families had contacted the clinic on their own initiative and participated on a voluntary basis in 

the treatment. Participation of both parents was strongly encouraged, also in families where the 

parents were separated. All families received case formulation based cognitive behavioural 

therapy (CBT) following the standard procedure in this clinical setting. The treatment consisted 

of individual CBT sessions for the child in combination with parent sessions without 

participation of the child. The treatment started and ended with a family session where the 

child and the parents took part.  

 



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The child and parent sessions focused on minimizing anxious behaviour in the child. The 

parent sessions were also used to address family dynamics that were maintaining the anxious 

behaviour in the child, e.g. overcontrolling/intrusive behaviour of the parents. Parents were also 

encouraged to bring other topics to the sessions if they experienced these as relevant for the 

well being of the child, e.g. how to encourage the child to turn to both parents when distressed.  

 

Data Collection 

A semi-structured interview guide was created and consisted of a range of open ended 

questions about the parents’ experiences with having the father involved. The interview 

questions focused on the period before the treatment commenced, during treatment and after the 

treatment, at each time period focusing on the parents’ reflections about having the father 

involved, and what it would have been like without the father’s involvement. The interviews 

focused on positive and negative aspects of the fathers’ involvement. The interview guide was 

complemented with structured questions on demographic data and information about the 

practicalities involved in terms of both parents coming to treatment. The initial interview guide 

was tested on two families, and subsequently adjusted accordingly. The data from the two pilot 

interviews were not used in the subsequent analyses, because the questions differed somewhat 

from the main sample. 

 

The interview was administered to each set of parents at the same time. The duration of the 

interviews was between 23 and 55 minutes, with an average interview lasting 42 minutes. The 

shortest interview was with the parent who participated alone. All interviews were audio taped 

and transcribed verbatim. Audio records were deleted once the written records had been 

created. The confidentiality of the participants was secured by changing all names (person and 

places) in the written records. The written records were stored according to Danish regulations 

on storage of research data. 

 

The interviews were conducted by two experienced clinicians who had not been involved the 

treatment of the families who participated. Because both interviewers were female, great care 

was taken to communicate to the fathers a genuine interest in their contribution. The mothers 

were also encouraged to consider the father’s role in the treatment.  

 

Data analysis 

The analysis was carried out by the first three authors of the article. The coders had not been 

involved in the treatment or interviewing of the parents. IPA was used to analyze the data (e.g. 

Smith et al., 1999). The first step of the analysis involved a detailed reading and re-reading of 

the transcripts while initial thoughts and comments were recorded in writing on each 

individual transcript. In order to ensure trustworthiness regarding the findings, this process 

was carried out separately by the three coders. Subsequently the coders cross-checked their 

written comments with the two other coders. This triangulation of the analyses was employed 

in order to increase reliability and validity regarding the identified topics. Only topics on which 

the coders reached consensus were included in the following step. On the basis of this 

agreement, lists of comments were made for each transcript. The second step involved re-

reading the transcripts while extracting the salient topics. These were grouped thematically 

producing a list of themes for each transcript. This step was followed by a process of comparing 

themes across the different transcripts, attempting to make thematic connections between them. 

Subsequently these themes were clustered and higher order themes emerged, which reflected 

each cluster of subthemes. A master table was generated, listing higher order and subthemes. 



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Consensus agreement was used during all steps of the process in order to increase internal 

validity.  

 

Also, great care was taken by the coders to pay attention to positive and negative aspects in the 

parents’ accounts, in order to minimize the influence of possible biases and preconceptions held 

by the coders regarding the importance of the fathers’ involvement in the treatment. Positive 

aspects included all types of statements involving a positive evaluation of the topic in question, 

e.g. “This project would never have succeeded as well as it did had I not been there”. Whereas 

negative aspects involved all types of negative evaluations of the topic in question, e.g.” I was 

somewhat sceptical, because… well I am always sceptical about this type of treatment.” 

 

Findings 

Three higher order themes and eleven subthemes emerged from the six interview accounts. The 

three higher order themes were as follows: Strengthening the family system, empowerment of 

parents, and impact on partner relationship. Each of these themes includes a number of 

subthemes, which are listed in Table 1.  

 

Higher order themes 

 

Subthemes 

1. Strengthening the family system a. Improved father-child relationship. 
b. Increased sense of being united in the 

family. 

c. Preventing mothers from having 
responsibility for information transfer. 

d. Preventing isolation / detachment of 
the father. 

2. Empowerment of parents a. Unified as parents 
b. Increased parental competence 
c. Congruent views on child’s difficulties 
d. Supporting each other 

3. Impact on partner relationship a. Equality between parents 
b. Improved communication 
c. Improved understanding for each 

other 

Table 1. List of higher order and subthemes 

 

Strengthening the family system 

This super-ordinate theme emerged from the participants’ descriptions of a range of aspects, 

which they experienced as having a positive impact on the family system as a whole. Fathers as 

well as mothers described that the relationship between the father and the child improved. As 

one mother expressed it, ‘Father and son have found each other.’ The father added: ‘Yes, at that 

point I was forced to focus on his everyday life and I became more attentive to how he was 

communicating at home, and how he reacted. In that way I was... I was put in the position that I 

had to get involved in his everyday life... I had to pay more attention to various things. And 

that was a good thing, because I became more aware of what was going on in his everyday life, 

how he was doing, and whether it had been a good or a bad day.’  

 

Some parents reacted with surprise when told prior to treatment that both of them were 

expected to participate in the treatment of their child. As one father expressed it: ‘I thought it 



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was strange that we had to spend two people’s time on talking about myself or about us, 

because it was X [the child] that was the issue.’ And for some of the families it was difficult to 

find the time for both parents to participate in the treatment, which by some of the participants 

was perceived as a disadvantage: ‘...it takes two hours to get from where you are [work] until 

you’re back again, and that implies that he [the father] can’t leave the office early that day. That 

can be a disadvantage. I just don’t think we thought about it that way, because we were both 

ready to sacrifice a great deal in order to make this work.’ Although the families invested 

substantial time and energy in participating, there appeared to be a consensus that the time is 

well invested: ‘You experience that the more time you spend on your child, the more you get in 

return.’ 

 

Throughout the interviews, it also became clear that the parents not only experienced an 

improved relationship between the father and the anxious child, but that there was a secondary 

effect which went beyond their dyad: ‘I was positively surprised, and it turned out well. Today 

I get along better with my son than I’ve ever done before, also with my eldest son.’ 

 

The participants also described how the treatment contributed to a sense of family unity. In 

some of the families this feeling of unity was a product of the family being involved in a shared 

project: ‘I think that it kind of makes the family stronger that we’re all involved in it (...) because 

it is a shared task. If everybody is involved in it, then it is a shared task. If somebody is left out, 

then they wouldn’t quite feel like they were a part of the task.’ In other families the sense of 

unity developed because the father became more involved in the family and the family life than 

he was prior to treatment: ‘I think it has paid off that Dad has participated and has been so 

involved in what was going on, because before we got help and X was feeling that way, I felt 

that I pretty much was left on my own with it. But that was because Dad didn’t get a say 

regarding X. The fact that he has been able to participate here, I feel has brought together our 

family, because we have been united in the process.’ 

 

In some of the families there even appeared to be a development from dyads to a triad. The 

participants explained how they expected treatment without involvement of the father to 

strengthen the mother child dyad even more than was already the case, while the father-child 

relationship potentially would weaken. In general, the treatment seemed to contribute to a 

clarification of the father’s role in the family. One father expressed how he has become a part of 

the family after the treatment: ‘I’ve been given my family, I am in my family, I have kept my 

family... I have become a part of it, let me put it that way. That is probably the best thing... I’ve 

become a part of my family.’ 

 

Another subtheme which clearly emerged from the material was how parents experienced it as 

an advantage that both parents knew what the treatment was all about, and that they therefore 

were equally competent to deal with problems or conflict situations when they arise. 

Additionally, the participants experienced it as an advantage that one parent did not have the 

responsibility for making sure that the other parent was informed about the content of the 

sessions. One mother described how this scenario would put a bigger pressure on her as a 

mother, and give her more responsibility than the parent who was absent from the sessions. The 

fact that both parents participated, and therefore received the same information, also seemed to 

prevent disagreements about how to solve conflicts with the child. One participant described 

how treatment without involvement of the father could magnify conflicts between them as 

parents, as the father would not listen to her in the same way as he listened to the therapists, or 

that he would question her accounts of the sessions: ‘I liked the fact that we got the same 



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information about what to do, because if I had to communicate it all to you at home, I don’t 

think you would have listened in the same way (...) and we have also been able to discuss some 

of the things we disagreed on, and to have other people say “this is how it is”, because we have 

disagreed a lot along the way, especially before we came here, about how to deal with him.’ 

 

The participation of both parents was perceived as essential, especially in terms of preventing 

the father being detached or left out from the rest of the family. As one father described it: ‘Then 

mother and daughter would have had that in common. They would have had this thing 

together, and I would have been left out, and it would have been hard relating to X’s 

development. I guess. In terms of the father-daughter relationship, it would maybe have created 

a larger distance in the long term, and from a selfish point of view it would have been a sad 

experience to look at it all from the outside, or not being the one involved in the process and not 

having the full grasp of it.’  

 

Empowerment of parents 

This super-ordinate theme also emerged clearly from the interview accounts. Fathers and 

mothers seemed to agree that by participating in the child’s treatment, they obtained a new 

common ground, or platform from which to develop as parents. And by participating together, 

they went through a joint learning process as parents, where they started out at the same place, 

gained the same knowledge as well as same problem-solving tools. They also expressed that 

they experienced feeling more unified as parents, and that they after the treatment have become 

more interested in understanding each other. The parents also expressed that they feel more 

competent as parents, both in terms of how to cope with the child with the anxiety disorder, but 

also in terms of parenting in general. 

 

Another aspect, which they experienced as an advantage of participating together, is that they 

by the end of treatment had more congruent views on the child’s difficulties, and how to deal 

with them. When asked what it would have been like, had the father not been involved in the 

treatment, one mother explains: ‘Then I really think it would have been like “Oh no, now she is 

seeing ghosts again” if I was the only one who had seen the warning signs, that were... it would 

become a matter of conflict, really, whether or not he was about to go down that road again. 

Because we both have the same information we don’t have to discuss whether it’s true or not.’ 

 

There was also a consensus that being two in the process facilitated the parents’ support of each 

other, and that it put them at ease to know they are two to intervene with the child. This also 

enables more flexible problem solving, as both parents are trained to deal with potential 

difficulties. One parent described it as follows: ‘One advantage is that both of us have received 

information about how to deal with him differently at home, and that we’ve been able to help 

each other and to support each other in the new way of communicating with him.’ 

 

Impact on Partner Relationship 

Another aspect, which the participants drew attention to, is the fact that the participation of the 

father contributes to equality in the parents’ relationship. They experience the parenting task as 

more equally shared between them, and believe that the absence of the father in the treatment 

would reinforce the asymmetry between the parents, as the mother would continue to take a 

greater responsibility for the children’s anxiety. One of the mothers described it as follows: 

‘Now he is also a part of the family, now he participates in the decision making about the kids 

and all that. It used to be only me who took care of those things.’ The participants also 

experience that the participation of both parents has improved the communication between 



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them as partners, as well as in the family as a whole. They describe a more open dialogue as 

well as increased reflections about their parenting styles. The following citation from one of the 

mothers illustrates this point: ‘It [the therapy] has opened up for some dialogue between the 

father and I about this, or about the way we have organized our lives.’ This mother’s partner 

expressed that ‘the most important thing... was the participation itself, that we opened up for 

our thoughts about how we raise our children, and that we both need to raise them.’   

 

The participants also experience a better understanding of each other’s views on the child, as 

well as acceptance of their differences. They also describe having achieved more respect for 

each other’s views, in turn minimizing conflicts, for example about how to deal with the child. 

One father described it as follows: ‘In terms of ourselves, it gave us a good understanding of the 

ways in which we can understand things differently and interpret things differently and 

without really having thought about the other person (...) I think that it gave a good 

understanding of our differences, so you can say... not that it turned into couples therapy, but it 

was an eye opener in the sense that you take so much for granted and base it on your own 

perceptions or standpoint.’ 

 

Discussion 

Rationale for involving fathers 

Throughout the last couple of decades, a variety of paternal behaviours and personality 

characteristics have been shown to have an influence on the development of psychopathology 

in children, both as risk and protective factors (Bögels & Phares, 2008; Connell & Goodmann, 

2002; Lamb, 1997; Sarkadi et al., 2008). However, documented knowledge is still lacking about 

the effect of involving fathers in treatment of children with anxiety disorders. Most child and 

adolescent clinicians have experienced the benefits of involving both parents in children’s 

treatment. This study reiterates this practice. The results indicate that the parents experience 

that involving mothers as well as fathers in the treatment had an overall positive effect on the 

child. However, the benefits went beyond that, as the families also experienced positive effects 

on other aspects of family life. This is in accordance with findings from family systems 

literature, which highlights that the members of a family exert a continuous and reciprocal 

influence on each other (Cox & Paley, 1997; Hughes & Gullone, 2008). In an attempt to illustrate 

our findings, a model was created (see figure 1 below).  

 



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The figure illustrates how the parents expected the relationships between therapist, child, 

mother and father to be like, had the father not been involved in treatment, versus how they 

actually experienced these relationships, based on having the father involved. The model is 

hypothetical and should be investigated in further studies before firm conclusions can be drawn 

regarding its validity.  

 

In her discussion about why fathers are underrepresented in research on child and family 

functioning, Phares proposes several explanations for why fathers are neglected in treatment 

efforts. One of her explanations is that clinicians and researchers alike rely on theoretical 

frameworks which fail to take account of the fathers’ contribution to their children’s 

development. Other explanations put forward by Phares is the assumption that fathers are not 

involved in their children’s lives to the same extent as the mothers, or that fathers are unable or 

unwilling to participate in intervention efforts (Phares, 1996). However, the findings from this 

study indicate otherwise, namely that fathers are both able and willing to participate in the 

treatment of their child when they are encouraged to do so. This is corroborated by another 

study, where fathers’ attendance in their child’s treatment was found not to be related to work 

hours or family rolls but instead to the fathers’ relationship with their own fathers (Walters, 

Tasker, & Bichard, 2001).  

 

Studies of families where one of the members suffer from internalizing disorders report greater 

levels of family dysfunction than families with no disorders, including less confidence in 

problem solving and conflicts between parents regarding disagreement over child rearing 

(Hughes & Gullone, 2008). According to family systems theory, optimal functioning in families 

requires that the family members are able to access resources from the larger family (Cox & 

Paley, 1997). In treatment where only mothers and child are involved, they may not be able to 

access resources from the fathers, as he will represent the family’s function as it was prior to 

treatment. As families are held together by rules and relations that pull towards equilibrium in 

the families, changes in the system create new vulnerabilities. For the change to become 



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adaptive and stable, changes must occur at all levels of the family system. When fathers 

participate in the therapy, they may be empowered to enter the family in new ways at the 

different levels (father-child and spouse-relation) thereby increasing the likelihood that a new 

family structure may be created, applying more adaptive family rules and relations than prior 

to the treatment (Cox & Paley, 1997). This is in line with what was found in this study, as the 

participants see it as a necessity that the father takes part in treatment, as it enhances the quality 

of the father-child relationship as well as the father-mother relationship.  

 

Direct and indirect effects of involving fathers in treatment 

As suggested by Bögels & Phares (2008), fathers of anxious children may contribute to their 

child’s development in direct and indirect ways. The direct impact may occur in the domain of 

play activities, attachment and involvement in the child. The indirect influence may occur 

through the fathers’ impact on the mothers. When the father is supportive, the mother has more 

energy to care for her child. This is in line with the findings from the present study. When 

fathers were involved in treatment, they reported that they experienced a change in the father-

child relationship as well as in the relationship between the parents. Although we did not 

explicitly explore how this change in father-child relationships manifested itself, one could 

expect an improved relationship to involve more play and a greater involvement in the child’s 

everyday life. Moreover, the finding that the parents experienced the involvement of the fathers 

to create a common ground from which they could help the child is corroborated by research 

showing that similarities in rearing behaviour between parents is associated with lower 

parenting stress for mothers (Harvey, 2000).   

 

In prior research, fathers of anxiety-disordered children have been shown to be less supportive 

toward their partners (Bögels & Phares, 2008). This reiterates the necessity of enhancing also the 

relationship between mothers and fathers in order to enable them help their child overcome its 

difficulties. This finding may also explain why the mothers in the present study were so 

relieved by the achieved improvements in the partner relationship. Support from the partner 

has also been found to enhance the quality of the mother-child relationship (Bögels & 

Brechman-Toussaint, 2006),  whereas the lack of a common ground for parenting, with parents 

who put each other down in the presence of the child, are found to maintain child anxiety over 

time (Katz & Low, 2004).  

 

The inclusion of both parents also enables clinicians to address marital and coparenting issues 

that may affect the child’s anxiety. Coplin & Houts (1991) found that maritally distressed 

couples may have difficulty maintaining and generalizing skills learnt in parent training for 

oppositional child behaviour. According to Lee & Hunsley (2006), parenting interventions are 

strengthened when the coparental relationship is attended to. Coparenting is defined as the 

ways that parents work together in their roles as parents and includes the degree of support 

between the parents, the extent of childrearing disagreement, the division of childcare and 

household duties and responsibilities, as well as the alliance between the parents (Feinberg, 

2002). Lee & Hunsley are referring to psychological services in general, when they encourage 

more attention to coparenting. However, to the best of our knowledge, their hypothesis has not 

been studied in interventions with anxious children. A recent review of the family systems 

literature of families with internalizing disorders, reported that these families function poorly 

overall, but also specifically regarding marital relations, parenting styles and parental 

attachment (Hughes & Gullone, 2008). These findings stress the need for intervention at 

different levels in the family, including the marital relations and coparenting, if 

psychopathology is to be prevented. Based on the interviews from this study there is some 



 33 

indication that this also applies to families with anxious children, and that it was useful for the 

parents to address marital and coparenting issues.  

 

As pointed out by Bögels & Phares (2008), involvement of all fathers - anxious, divorced and 

those who find it hard to get off work - is necessary if we are to understand the true 

contribution of fathers on the development, maintenance and treatment of childhood anxiety.  

However, our results indicate that the way in which the fathers are involved in their child’s 

development may play an important role. Phares and colleagues also suggested that therapists 

may consider using mothers to convey information about the treatment to the fathers (Phares et. 

al., 2006). This suggestion is not supported by the findings in this study, which indicate that if 

mothers attend the sessions by themselves and are left to convey information about 

involvement of the father to him at home, this may increase the level of conflict between the 

parents. The mothers in the present study expressed great relief that they did not have to take 

on this mediating role, but instead could engage in a more equal partner relationship, as 

illustrated in figure 1. This is not surprising, when taking into account that mothers still have 

more overall responsibilities in terms of childcare compared to fathers (Craig, 2006; Leslie, 

Anderson & Branson, 1991; Renk et al., 2003).  

 

It is important to acknowledge that some, if not all, of the above mentioned effects of involving 

fathers in treatment of their children, may not be gender-specific. Some of these effects may 

arise as a result of two committed parents working together in treatment, irrespective of the 

gender of the parents. Thus, similar findings might have been found if the two parents 

constituted a gay or lesbian couple. In a recent review of studies comparing heterosexual two-

parent families with homosexual two-parent families and single-parent families on a number of 

parenting measures, Biblarz and Stacey (2010) found no evidence of gender-exclusive parenting 

abilities. Research indicates that the strengths and abilities typically associated with 

heterosexual two-parent families are found to the same degree in families headed by two 

women and presumably, although comparable research on this area has not yet been generated, 

in families headed by two men (Biblarz & Stacey, 2010).  

 

As this study only included families, who were heterosexual, conclusions cannot be drawn as to 

whether the findings also apply to homosexual two-parent families or other family 

constellations (e.g. intergenerational families). Further research would be required in order to 

establish whether the findings in this study are specific to involving fathers from heterosexual 

families in children’s treatment or if they can be generalized to other family forms.  

 

Limitations 

The findings from the current study need to be considered in light of the limited sample size, 

and the fact there is no follow-up data. In his book about qualitative research interviewing, 

Steinar Kvale suggests that one ought to interview as many persons as necessary in order to 

find out what you need to know (Kvale, 1997). We do not believe that the current topic of study 

has been exhausted with this small scale study. On the contrary, we urge further study of father 

involvement with larger sample sizes applying a quantitative design, or more heterogenic 

samples (e.g. other types of two-parent family involvement) using a qualitative design. In this 

study fathers and mothers primarily see advantages in involving fathers in treatment. However, 

the findings may have looked different, had we also included families in the study, where only 

one parent participated in the treatment. Also, it is not clear whether those parents who chose 

not to participate in this study had a different experience in terms of involving the father. Those 

who participated in this study all expressed an overall satisfaction with the treatment, and in 



 34 

general experienced a reduction in the child’s symptoms. It would strengthen the study 

significantly if parents who failed to experience a noticeable effect of the treatment took part in 

this study. Interviews with these families could help generate richer data about the effect of 

involving the father. Last, but not least, it would be ideal to also interview the children about 

their perceptions of having the father involved in the treatment. This was however beyond the 

scope of this study. Further research is needed before firm conclusions can be drawn on this 

topic, and before we know whether these findings can be generalized to this clinical group. 

 

It should be noted, however, that generalization is conceptualized rather differently within 

qualitative and quantitative research respectively. Within the field of qualitative research there 

is a growing tendency to emphasize the contextuality and heterogeneity of local knowledge 

over the universal generalization of results. Kvale (1997) mentions three goals of generalization 

within qualitative research: what is present, what is possible, and what could be. The study of what is 

present is the attempt to capture the typical and usual, whereas the study of what is possible 

highlights ends of the spectrum of possibility – e.g. to generalize what will be typical and usual 

in the future, but isn’t quite yet. Finally the study of what could be is the examination of 

situations thought to be ideal or exceptional. In this respect, research, besides describing the 

present and foreseeing the immediate future, can partake in reshaping/transforming the culture 

of a certain practice.  

 

Implications and future research 

Because of the limited sample size of this study, the implications for clinical practice are limited 

at this point. However, based on these parents’ accounts, there is some indication for 

encouraging fathers to take part in treatment alongside with the mother. For many clinicians 

who work with children, it is common sense to involve both parents in the intervention. 

However, our clinical practice also needs to be guided by evidence based practice. Another 

question to arise from this study is whether co-parenting should be addressed more 

systematically in clinical practice, which has been argued by Lee & Hunsley (2006). The parents 

who took part in this study experienced benefits in terms of coparenting, even though 

coparenting was not explicitly on the agenda in this treatment setting. On that basis it is 

relevant to reconsider whether coparenting should become a more explicit part of the treatment 

in this setting, as well as others. 

 

Further research is warranted, in order to test some of the hypotheses generated in this study as 

well as other areas of father involvement. A larger scale study would be especially useful, as a 

larger sample would strengthen the reliability of the data, and also increase the chances of 

including participants who were dissatisfied with the treatment, or whose children did not get 

better in spite of treatment. Another aspect which could shed more light on the effects of 

involving fathers is to investigate if there is an association between paternal involvement in 

therapy and direct effects on the child. Added benefits of father involvement, perhaps not 

surprisingly, have been found in other clinical groups (e.g. Bagner & Eyberg, 2003; Coplin & 

Houts, 1991; Webster-Stratton, 1985). One would expect the same to be true in families with 

anxious children. However, in addition to studying the obvious, whether there is a larger 

reduction in symptoms when the father is involved, it could be interesting to investigate if there 

are certain types of symptoms or behaviours that change when the father is involved in the 

treatment. 

 



 35 

The participants in this study were recruited from a clinic providing therapy for children with 

anxiety disorders. Evidently, the questions raised in this study are also worth studying in other 

clinical groups.   

 

Conclusion 

This study investigated parents’ perceptions of having fathers involved in the treatment of 

children with an anxiety disorder. Although the results are preliminary, they indicate that 

involving fathers had beneficial effects not only on the child’s treatment but also on the 

relationship between the parents. The parents reported that the family as a whole had 

benefitted from the treatment and that the relationships between the parents had become more 

equal, consequently making them better at supporting each other in helping the child overcome 

its difficulties.  

 

Acknowledgement 

We are very grateful to the parents who took the time to participate in this study. We also 

would like to express our gratitude to Helle Dittmann for interviewing the parents. 

 

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Authors 

Anna Elisabeth Iversen (corresponding author) is a clinical psychologist working at Child and 

Adolescent Psychiatric Centre Bispebjerg, Copenhagen. Email: 

Anna.Elisabeth.Iversen@regionh.dk. Barbara Hoff Esbjørn is an associate Professor at The 

Copenhagen Child Anxiety Project, University of Copenhagen, Department of Psychology. 

Elisabeth Christensen is a clinical psychologist working at a private clinic specialized in 

providing services for families with children with autism spectrum disorders. Nina Schultz 

Hansen is a master level psychology student at The University of Copenhagen and is currently 

attached to The Copenhagen Child Anxiety Project.