Trauma Focused Coping

Transcription

1 How to Implement Trauma Focused Coping A trauma focused cognitive behavioral treatment for youth A Partner with the National Child Traumatic Stress Network

2 How to Implement Trauma-Focused Coping What are key implementation strategies to successfully adopt a trauma specific cognitive behavioral treatment? Kelly Sullivan, Lisa Amaya-Jackson, Ernestine Briggs-King, Robert Murphy, Jessica Burroughs, Eric Vreeland, & Falesha Houston Center for Child & Family Health, Duke Evidence-based Practice Implementation Center Partners in the NCTSN Please note that this manual follows the outline and structure developed for the NCTSN s Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) Implementation Manual: Research & Practice Core and Child Sexual Abuse Task Force National Child Traumatic Stress Network (2004). How to Implement the Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Durham, NC and Los Angeles, Ca: National Center for Child Traumatic Stress. This project was funded in part by the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS) as part of the National Child Traumatic Stress Initiative. The views, policies, and opinions expressed are those of the authors and do not necessarily reflect those of SAMHSA or HHS. v. 3/11 1

3 Table of Contents Introduction... 3 Why Should Schools, Agencies & Clinicians Consider Implementing TFC?... 4 What is Trauma Focused Coping (TFC)?... 4 What Are the Components of TFC?... 4 Why Trauma Focused Coping?... 4 What Symptoms Does TFC Reduce?... 5 When Is TFC Not the First-Line Treatment of Choice?... 6 Targeting Stakeholders: Buy-In Within and Outside Schools and Agencies... 7 Implementing TFC: What does it take?... 7 Implementing TFC... 7 Information for Program Administrators... 9 Information for Implementing School Teams to Address: Information for Clinical Supervisors Information for Therapists and Counselors Conducting TFC Treatment Information for Families and Children Information for Community and Within-School Referral Sources Information for Third-Party Payors Timing of Implementation in Schools School Screening and Group Referrals Timing of TFC Groups Differences in Potential Group Co-facilitators by Ages of the Student Population Parent Consent, Contact, and Involvement Consideration and Support to Clinician and Counselor (Co-facilitator) Billing Guidance on Measures & Assessment Clinical Adaptation & Tailoring for Client Needs How to Obtain Clinical Skill Building Gaining and Sustaining Fidelity Addressing Fidelity Issues with Novice vs. Experienced Therapists Fidelity and Outcomes Service Needs in Addition to Treatment Additional Clinical Considerations Conclusion Appendices Organizational Readiness and Capacity Assessment Child and Adolescent Trauma Survey (CATS) Child s Exposure to Violence Form UCLA PTSD INDEX FOR DSM IV Child and Adolescent PTSD Checklist Trauma Focused Coping Fidelity Checklist & Coding Metric Sheet Child Trauma Toolkit for Educators Trauma Treatment Tools for The Traveling Therapist Additional School Resources Suggested Activities for Successful Groups in Schools Trauma-Focused Coping Fact Sheet

4 Introduction n a time when natural disasters, shocking violence exposure, and major accidents are commonplace, children and adolescents who experience these I extreme situations are left to deal with the emotional toll left behind. Symptoms of Posttraumatic Stress Disorder (PTSD) such as emotional numbing, irritability, and flashbacks can disrupt a child s life. Communities may wish to establish services for children who have encountered these types of experiences. Initiating a trauma program within the school system offers a safe and secure environment for a group treatment intervention. In addition to the clinical competence clinicians must be able to obtain to deliver any evidence-based treatment, clinicians and their agency must often deal with barriers and challenges to its implementation. Ironically, even the best clinical expertise in a given evidence-based treatment (EBT), such as TFC, will not positively impact the kids, if the necessary attention isn t paid to deal with the necessary steps for the EBT s successful implementation. School and mental health teams working together over the last decade, in thousands of communities across the country, have offered quality treatment to children who might not otherwise have accessed services. When attention is paid to both clinical and implementation strategies, providing TFC is very doable. This implementation manual was created to assist clinicians, teachers, and key stakeholders who wish to use TFC for traumatized children in their school systems. We hope it will assist you in adopting this evidence based practice in your community and offer guidance in overcoming barriers to implementation. 3

5 Why Trauma Focused Coping? Why Should Schools, Agencies & Clinicians Consider Implementing TFC? ecent disasters and community violence, school shootings in numerous states, R and other such episodes seen so often in the daily media, call upon the fields of education and mental health to develop a rapid-response trauma treatment protocol. The TFC protocol is applicable in school, clinic, and community mental health center settings for the treatment of single-incident traumas. It may also be useful as a primary treatment for traumatized children who are also challenged by multiple psychosocial stressors, since the structure of the protocol is flexible enough to be supplemented by adjunctive therapies such as family work or psychopharmacological interventions without losing its efficacy. Furthermore, the TFC protocol does not require family treatment and can be offered in a place the child or adolescent consistently attends (e.g., school) while in a format with which the child or adolescent is familiar (e.g. peer group). Finally, when the trauma itself is school-based, on site treatment of the children most affected can promote healing of the trauma throughout the school community. Here are some key bullets that can be considered part of an elevator speech which is a description of TFC that can be delivered to your stakeholders in just a few sentences: works for children who have experienced exposure to violence & trauma has been used successfully in schools, clinics, homes, & residential treatment facilities works in group format with minimal or no parent or caregiver participation is effective with children from diverse backgrounds works in treatment sessions What is Trauma Focused Coping (TFC)? rauma Focused Coping (TFC) is a protocol driven model of group cognitive T behavioral therapy for children and adolescents suffering from traumatic stress that stems from 1 or more single-incident traumas. (as opposed to longstanding chronic trauma such as ongoing child sexual abuse). This treatment program is successful in school settings for the reduction of PTSD symptoms, depression, anxiety, anger, and improved grief management. What Are the Components of TFC? T FC is a school-based intervention consisting of one individual assessment followed by 14 weekly group sessions with children and adolescents. Parents 4

6 receive an overview of the skills covered in each session and are encouraged to assist their children with using skills while at home. Each group session consists of the session goals, a review of the previous week, new information, practice with the therapist, and homework for the coming week. Table 1 gives a brief overview of the protocol. A more thorough description of each session can be found in the Trauma Focused Coping Manual. Table 1: Session by Session Summary of TFC Session Title Main Goal 0 Assessment Assessment 1 Overview & Psychoeducation Define objectives / Group rules 2 Anxiety Management Thoughts, feelings, behaviors 3 Anxiety Management & Cognitive PTSD / Traumatic reminders Training 4 Cognitive Training Behavioral coping 5a Anger Coping Anger coping 5b Grief Coping Grief management 6 Individual Pull-out Session Narrative exposure & construct stimulus hierarchy 7 Introduction to Narrative Exposure Introduce narrative exposure 8 Group Narrative Exposure Narrative exposure 9 Group Narrative Exposure Cognitive & affective processing 10 Cognitive & affect restructuring Schema modification 11 Worst Moment Exposure Exposure and in vivo exposure 12 Worst Moment Exposure Exposure & restructuring 13 Generalization Training & Relapse GT/RP Prevention 14 Graduation Graduation Ceremony 15 Booster Session Optional What Symptoms Does TFC Reduce? P TSD symptoms emanating from a single incident trauma can be severe and lead to problems in the home and school settings. The memories or reminders of the event can lead to avoidance behavior and negative emotions. Emotional numbing or physical reactions such as irritability may also result. TFC not only helps to reduce the PTSD symptoms, but it can also help improve anxiety, grief, and anger by teaching coping skills and cognitive restructuring. 5

7 When Is TFC Not the First-Line Treatment of Choice? any children in schools and/or clinical settings present with a trauma history. M Some of these children have significant symptoms and for many of those symptoms a trauma treatment is indicated. However, youth with significant disruptive behavior problems, suicidality, significant bereavement, psychosis, or substance abuse require other interventions before beginning a trauma focused treatment. Also, children who have experienced chronic sexual abuse or severe physical abuse should be treated individually or placed in homogenous (same trauma type) groups. Additionally these youth may have specific cognitions such as the belief that they are damaged, or have sexually reactive behaviors such as sexual risk-taking that may be better served in other trauma treatments such as Trauma-Focused CBT (Cohen, Mannarino, Deblinger, 2006). The TFC protocol does not target such behaviors and cognitions. However, TFC may be supplemented with these content specific needs, in individual treatment. 6

8 Implementing TFC Targeting Stakeholders: Buy-In Within and Outside Schools and Agencies S uccessfully implementing any evidence-based treatment in a school or agency requires the support of a variety of individuals and groups. Developing buy-in and commitment is an essential part of the implementation process. Along with the therapists and counselors who will be asked to provide the intervention, other key stakeholders in the implementing organizations that will directly affect how successfully TFC is implemented include administrative decision makers ( senior leaders ), clinical and administrative supervisors, direct service providers, administrative staff across the organization as well as parents and children being served. In implementing an evidencebased treatment in both an agency and a school, all the listed stakeholders in both organizations impact the success of it being delivered as intended. School counselors, teachers, principals, and even certain student groups require buy-in. Often this buy-in must also include the school superintendent. Many schools and community agencies that are linked with community systems and settings, consider their community partners to be key stakeholders in their success. These partners may provide referrals, as well as social, and fiscal, support. Community partners can include: Child Protective Services, police, pediatricians, and religious organizations. Implementing TFC: What does it take? he decision to adopt and implement TFC may mean simply that 1-2 clinicians are T going to treat some of their clients, or perhaps attempt to run a group in one of the schools in which they work. However, for any treatment, particularly a group model like TFC, to be successfully adopted in an agency and/or in a school in more than an anecdotal way, the organization and the practitioners must arrive at a readiness to conduct the organizational changes necessary to implement the new practice. Organizational readiness. Organizational readiness refers to how prepared an organization is to make the changes required at various organizational levels to successfully implement and sustain a new practice. Adopting and maintaining a new practice like TFC requires making a number of changes across an organization from intake to treatment completion. In fact, it may mean making changes prior to intake as outreach for appropriate referrals may be necessary. Organizational support by top management and senior leaders facilitates a make it happen approach. This commitment from senior leaders provides front line managers and staff with the support they need to provide the space, paperwork, planning, 7

9 supervision, access to technology and consultation, and other items necessary to implement the practice with fidelity. An organizational readiness assessment, developed by the National Child Traumatic Stress Network is enclosed in the Appendix. Please review this and more importantly, fill it out alongside the key program staff involved in planning implementation of TFC. (or any new practice). Prework and Pre-implementation training refers to what is usually a multi-step process in preparing agencies and schools for implementing a new practice such as TFC. Key recipients of training in TFC are therapists, supervisors and any co-facilitators of the groups such as school counselors. Others in an organization may also need to know about the new practice. In the case of implementing TFC in schools, principals, school boards, student services administrators, may have a stake in this new practice. When working with one school or several schools in a school district, providing some type of inservice on the impact of trauma on children followed by key points about what will be done to provide access to trauma treatment through the TFC group intervention will facilitate buy-in, recognition of need in the student population and ideas on how to help. Brochures or one page fact sheets, small team meetings, and notes in newsletters may serve as additional sources of information Enclosed in the Appendix is the NCTSN Child Trauma Toolkit for Educators which contains information sheets that can be used for many target audiences, including staff in the schools. In the case of implementing TFC in agencies, administrators, supervisors, receptionists, intake coordinators, insurers, consumers, referring agencies and many others may have a stake in TFC. Thinking through what level of knowledge about TFC is necessary for these Individuals. As therapists and supervisors become more familiar with the treatment, thoughts about how they can streamline key points to other staff should be considered and promoted by the agency leadership. Considerations about intake, outreach for referrals, brochures for client/parent engagement, may be examples of implementation strategies that need to be addressed. For therapists, two phases of training are provided if there is additional training requested beyond the treatment and implementation manuals: live training and ongoing expert consultation. For supervisors, additional consultation is also available (training in the TFC model is described later). Implementation refers to the act of putting into play the coordinated efforts of staff, clinicians, supervisors, and administrators working together in both the agency and the schools so that TFC is delivered effectively. From providing the treatment sessions and obtaining model-specific supervision, to documentation and billing practices, different staff and resources will play a variety of roles in fully installing a model program like TFC. Implementing TFC effectively also includes a plan for evaluating how the treatment is being used to ensure that facilitators/therapists are using TFC correctly. A recommended strategy for monitoring implementation is through the use of fidelity instruments. These tools allow 8

10 facilitators/therapists and supervisors to follow the course of each group or case to see which components are being implemented in a systematic and transparent manner. Fidelity instruments also track the course of implementation for the entire organization and yoke implementation to outcomes for individual children and groups. The TFC Fidelity Checklist is enclosed in the Appendix. It was designed to be used by trainers on consultation calls but may be used by supervisors, or, when neither of these are available, can be adapted for the use by the implementing clinician themself. Sustainability refers to having a plan in place to ensure that the agency will continue using TFC in a self-sustainable way after any training and consultation calls have ended without the support of expert consultants, ongoing training, or even supervisors who may leave to take other jobs. How can an organization sustain the practice of TFC after the support phase is over? This is a question to consider from the moment adoption begins. Information for Program Administrators T here are several important considerations that program administrators must take into account when considering the adpotion of TFC. These include: What organization-level adjustments will be required to support successful adoption and use of TFC by clinicians and counselors? Will TFC improve school outcomes and or organization performance? How much will it cost to achieve the desired improvements? Here are some key reasons to adopt and implement TFC: Many school children are not performing well due to trauma-specific distress. Outside of school, they may have a low likelihood to access services. Many policy-making entities and funders are adopting standards that favor the use of evidence-based practices such as cognitive behavioral treatment. There are increasing expectations that services must prove effective. Results that can be achieved with short-term intervention are cost-effective. Favorable experiences in a school based intervention may lead to seeking mental health services for other difficulties that may remain. Two key requirements for any new treatment implementation are: Organizational leadership that supports the use of evidence-based practices. This support leads to acceptance by clinicians. Training and ongoing supervision in the implementation of the model The cost of initial training depends on the type of training preferred and the number of staff to be trained. 9

11 The TFC manual, Trauma Focused Coping Manual: Treatment of Pediatric Post Traumatic Stress Disorder After Single-Incident Trauma (J.S. March and L. Amaya-Jackson) is available in two ways. It can be downloaded free of charge. Along with its accompanying appendixes (treatment outline for therapists and also for groups; handouts, stress thermometers, chapter outlines) It can be obtained as part of a replication kit from Sociometrics through Children s Emotional Disorders Effective Treatment Archive (CEDETA), funded by the National Institute of Mental Health., Programs in the collection were selected by a national advisory panel of leading scientists in the field of children s mental health disorders based on research evidence of program effectiveness. Kits include manual, User s guide, 1 year of Technical support and 2 continuing Education Credits. Training options include various intensities from beginning to advanced through the following options: Training option 1: 1 or 2 day overview workshop for $1250/day. If two trainers are used, it is an additional $1250/trainer/day. (Plus travel and supply costs) This workshop provides an overview of TFC, in which clinicians become familiar with the components of TFC, and receive some limited practice with specific interventions. Training option 2: 2 day workshop for $1250/day /trainer, plus $150/hour monthly consultations (Plus travel and supply costs) This workshop includes the same components as option 1, but also includes monthly telephone consultation of specific cases and allows for applications of skills learned. Training Option 3: 2 day workshop for $1250/day/trainer, plus monthly consultations (at above price) and a follow-up 2 day advanced training for $1250/day/trainer (plus travel and supply costs) This training allows for more comprehensive coverage of the components of the model, more opportunity to practice skills and interventions, the ability to apply skills to cases through the use of monthly consultations, and the ability to synthesize skills over time. Training Option 4: A Learning Collaborative Cost is around $200,000 (dependent on various factors) and is designed for groups of people This option intensely addresses all barriers to implementation and is a mechanism for us to monitor fidelity and coach clinicians individually in order to enhance their fidelity in an ongoing way. Upon completion, skills in all components, trainers who have been endorsed by the model developers will be able to say that the clinician has completed a case from start to finish, with fidelity. The Learning Collaborative includes: six days of in-person training with trainers endorsed by developers of the model that focuses on advanced clinical competence and addressing organizational barriers to implementation, 16 conference calls to further advance clinician skill and address barriers, one hour of monthly individual consultation time with each 10

12 participant and continuous quality improvement, and a standardized battery of pre and post psychological assessments. The National Center for Child Traumatic Stress (NCCTS) and the Duke Evidence-based Practice Implementation Center have been conducting Learning Collaboratives on the Adoption and Implementation of a number of evidence-based treatments. These are intended to help organizations gain the necessary clinical and implementation competence to embed evidence-based models into their practices. (For more information or to schedule a training, contact Lisa Amaya-Jackson, MD, MPH, at amaya001@mc.duke.edu. For more information on Learning Collaboratives, contact Jan Markiewicz at jan.markiewicz@duke.edu). Depending on how extensively an agency expects its therapists to change their current practices, agency-level adjustments may be required to implement TFC. As with learning any other new skill, adopting and adapting a new intervention will take time and energy. Program administrators should expect that therapists and their co-faciliators, such as guidance counselorswill need some time to gain these new skills. They may need extra supervision time and expert consultation time, and it may take more than sessions to implement the TFC model with individuals in the beginning. Administrative support in the early stages of this process often results in more efficient use of therapist/counselor time and greater therapist/counselor competence in using TFC later on. Information for Implementing School Teams to Address: he school team working with the trauma treatment clinician will need to address T a number of issues to not only support, but facilitate the students ability to meet as a group in their school community. Whether it is an elementary school, middle school, or high school that chooses to help its students by providing these groups-each one must have a team that works together. This school team must include 1) a designated senior leader the go to person for when decisions need to be made; 2) a designated counselor or school social worker who works with the trauma treatment clinician who handles logistics around space, time, group member identification, dealing with student questions, concerns that may come up during or between group sessions. 3) this same designated counselor may choose to be a co-facilitator of the group, working as a co-leader with the trauma treatment clinician. If not, they will still be indispensible to the therapist who is co-leading of the group. Critical information the school team needs to have written down and exchanged with their group clinician: Name, , phone number of senior leader designated as above Name, , phone number of counselor or school social worker Critical questions the school team needs to address and write down: What administrative support does the group leaders need in order to obtain the space and appropriate designated time to run the TFC groups. 11

13 To what extent are your school s staff committed to implement these trauma groups? What are the key challenges and barriers your school team will encounter in implementing TFC? What are some potential solutions to overcome these barriers? Use of the NCTSN Organization Readiness Assessment (in the Appendix) may be useful to the team, though some of the items require rewording to be considered from the schools perspective. The school team will need to work with the clinical leaders to plan and carry out the following to do items: Consider the best way to identify students in need. Identify 5-9 students who can participate in a group through one of two ways: Counselors work together and review potential candidates with clinician Utilize a trauma screening mechanism to administer school or select grades. Create and send a consent home for student s participation that must be signed and returned: For any screening survey done that identifies children in need For each student s participation in the TFC group Support Staff Collaboration to ensure communication with internal school staff and also with group leader. Plan for Teacher Sessions. These may be inservices that are planned to educate teachers to trauma impact and what an overview of TFC. It may also be necessary to meet with them as consideration is given to timing of when groups can be offered during class, lunch times, or afterschool. Plan for correspondence with Parents. This can vary with the characteristics of the school, the age of the students, and the parents wishes. Ideally the parents will attend a meeting to understand what the group is about and bring in consents and release of information. Parents contact info needs to be collected and designated school official and clinician s phone numbers and s made available to parents. If midgroup or followup group meetings are available to meet with the parents these should be set up at the front end. Space for the Group Sessions and materials needed Space for Individual Sessions and materials Schedule of group sessions, individual sessions, and preparatory contact necessary (between clinician/counselor or any other school personnel before each session (latter can be brief) Information for Clinical Supervisors onsidering the fact that therapists and school staff have implemented TFC in both C schools and in community clinics, there are many variations on clinical supervisors for these diverse professionals. School staff, including counselors, social workers, psychologists etc., may receive infrequent clinical supervision or administrative supervision only. Many therapists in agencies may have similar prospects for clinical supervision as well. Yet, all supervisors are critical to the successful implementation 12

14 of TFC or any evidence-based intervention because they are usually responsible for managing service delivery, providing training and supervision, and ensuring that staff meet programmatic and accountability expectations. As with other stakeholders, supervisors who see the value of TFC for children will support effective implementation. School student services supervisors and agency clinical supervisors should support the implementation of TFC because it works for the kinds of traumatized children and problems typically seen in schools and community agencies. Furthermore, the TFC manual provides facilitators/therapists a session-by-session outline and strategies that work. It is recommended that supervisors be trained in TFC and ideally have some opportunity to deliver it to traumatized children. Supervisors can make use of a variety of supervisory mechanisms, including regular supervision of individual or group cases and observation or recording of sessions, all of which will be aided with the use of the TFC fidelity checklist (see the Appendix) to help maintain treatment focus. Information for Therapists and Counselors Conducting TFC Treatment ndividuals who implement TFC may come from a variety of job titles, including I school guidance counselor, social worker, marriage and family therapist, professional counselor, and psychologist. As a result, those implementing TFC can actually have very different job responsibilities and a wide disparity in the time and capability needed to provide therapeutic services to children and adolescents. For example, high school guidance counselors are often charged with scheduling student coursework to meet graduation requirements and helping students with their postgraduation plans. School social workers also may be fully occupied with helping families meet basic student needs and school attendance requirements, while school psychologists may be spending most of their time on testing and evaluation. Therapists in community agencies not connected with schools, on the other hand, have much less access to children and adolescents in need of services. Due to the constraints and opportunities provided in both these worlds an ideal format to implement TFC is one in which a school student services staff person co-facilitates a TFC group with a community therapist. These various professionals, however, have the flexibility to implement TFC by themselves with individuals or in a group format and in schools or in community agencies. A key consideration for anyone interested in considering TFC is that this is a proven treatment with a manual that provides clear direction yet is not overly restrictive, thus allowing for flexibility and creativity. This fact may provide comfort to school student services staff who have had minimal time and may have less extensive training and experience in providing therapeutic services to their students. The time required to implement this kind of intervention must be weighed against other duties and responsibilities. For therapists, the availability of the TFC manual should not be viewed as a criticism of their current practice, but as a strategy to improve uptake of a new practice that is likely has some common elements of trauma therapy they may currently be utilizing. Therapists also must weigh other 13

15 competing responsibilities when considering implementing TFC, such as billing requirements. Information for Families and Children P arents need information about the treatment process and what they can expect. They also need to know what is expected of them and of their trauma-affected child or adolescent. It is important to communicate these key points about TFC and children: It is often successful in sessions in a group or individual format. Talking about the trauma, even though it may be hard, is an important ingredient in successful treatment. This will be done gradually. Parents will be given updates regarding the treatment process and are always encouraged to make contact with group leaders as they see fit. The Child Trauma Trauma Toolkit for Educators in the Appendix has a nice section on information about child trauma that may be helpful. Information for Community and Within-School Referral Sources hen implementing TFC, an organization will want to reach out to other agencies, W professionals, and potential clients/students and their parents or caregivers. When implementing TFC in schools it will be important to communicate to all school staff about appropriate referrals. Organizations implementing TFC should focus especially on communicating with those people who come into contact with families where trauma has occurred, and should explain that TFC has been shown to be effective and that it can augment other services currently being provided. The agency can provide a list of these agencies and individuals to be informed. Information for Third-Party Payors T hird-party payors support services that restore enrollees to effective functioning in a timely and cost-effective manner. Given these priorities, key points regarding TFC include: With TFC s structured, components-based approach, client improvement is trackable and time-limited. TFC generates highly observable results. TFC s effectiveness has been documented in children and adolescents who have experienced a variety of traumas, traumatic loss, and PTSD. 14

16 Timing of Implementation in Schools hen working with students, paying attention to the school calendar is important. W Getting a group(s) up and going requires planning ahead for screening, consenting, group time and coordinating the individual pull-out session (first narrative exposure) component of TFC. In addition to the weeks needed to run the groups, adequate time and preparation needs to be given to how children will be recruited into their groups (see below ). The best timing for recruitment is after the students have settled into the beginning of school, when teachers have started to know their students and are tuned in to those who may be struggling. At this time, teacher would be adequately prepared to fill out a teacher rating scale if asked to do so as part of the referral process into groups. Where school testing days and vacation fall may need to be attended to as group leaders consider what component the group might be addressing in relation to these breaks. It is advisable to NOT have just begun the Sessions on Narrative Exposure and the Trauma Narrative right before students go off for a break like December vacation or Spring Break. School Screening and Group Referrals he make up of the groups can occur in two ways: T 1) One is a two step process of referral and student requests. Guidance counselors, teachers, school nurses or social workers can make recommendations to the clinical teams that are running a group. Information being sent home to parents, coaches, or made available to students (posters, announcements) can result in students being referred and then available for assessment into whether TFC is an appropriate intervention for that student. Depending on the school population and school culture, the availability of a TFC group may remain more private (but not secret ) or well known. Educating those who are referring to the group will be important and this is where a trauma inservice can be timely, especially one that spells out the target and best candidates for making use of a TFC group. 2) The other option for obtaining the most appropriate group members is to do a screening. Screening has varied in schools and may include 1 or 2 grades being screened during a certain class or across certain class periods. Which measures to choose becomes paramount as time determines what can be done. Use of a PTSD screening measure like the CATS (the Child & Adolescent Trauma Survey) and if time is short, a depression and/or anxiety measure is preferable. Making sure a clinician is available and on site to assist the administration is important and address any questions or clinical concerns that may come up. Administering any of these measures will require parental consent. 15

17 Timing of TFC Groups he biggest challenge one may face is figuring out when to run the groups at a T school. Finding a time during the day may work out most easily in the elementary school grades. However, even in elementary school, like the older grades, teachers often are judged by their students performance on tests -- hence they may feel fearful of having students miss too much of class. Some schools hold groups in the class that abuts the lunch period; others choose to share the missed class across several classes. Middle school and high schoolers often require an afterschool meeting time. Timing of groups may be affected by sports practice times and when a classroom is available for a group to use. Differences in Potential Group Co-facilitators by Ages of the Student Population chool counselors or social workers often are considered as co-facilitators of the S groups. Having a co-facilitator is strongly recommended to allow for adequate adult therapeutic attention and observation of student reactions. Elementary school counselors often are asked to run social skills groups or grief groups, and may feel very comfortable in the co-facilitator role. High school counselors may be much more focused on college-prep and vocational testing than as mental health counselors and feel ill prepared and unwilling to co-facilitate a group in TFC. Counselors heavily associated with the Principal s office may be viewed as too closely aligned with him/her and may hinder group process and discussion by mistrusting student members, especially in the older grades. Parent Consent, Contact, and Involvement arental contact can sometimes be the most challenging aspect of providing an P intervention to youth. As in most therapy with youth, parental consent is required for treatment. For the same reason that schools may be the best venue to offer services to youth, it may also mean that having access to parents is doubly challenging. Work schedules, lack of transportation,and language barriers, all make it difficult for many parents to make it to the school. Furthermore, with the increased likelihood that youth participating in TFC are in foster care, locating the individual with the right to consent to treatment is an added barrier. Phone contact combined with sending home consents with the youth is one viable strategy. Alternatively, holding a parent group meeting that offers an overview of the treatment provides another option for obtaining treatment consent, while a mid-treatment and ending treatment group meeting can be additional options to promote parent communication. Lastly, utilizing /discussion blogs to provide occasional and useful information to parents is heartily recommended. 16

18 Consideration and Support to Clinician and Counselor (Cofacilitator) T FC assumes that the lead clinicians who begin to use it already have basic training and reasonable experience in child development, developmental psychopathology, and necessary skills around building a therapeutic alliance and group process. A master s level clinician is recommended for this trauma work, as this is likely the minimal level of training and experience in working with traumatized youth. When paired with the ins and outs of dealing with a youth group, particularly when they are being run in schools, requires the ability to navigate the school environment and time limitations within the context of doing clinical treatment. A co-facilitor may be another licensed therapist, a provisionally licensed or student therapist, or school counselor. Including a school social worker/psychologist/counselor makes the work in the school more seamless for the students and the group leaders. Being school personnel, they can assist a clinician who may be outside the school system or who is only involved to a minimum degree, understand what is going on in the environment students are dealing with on a day to day basis. Events or facts specific to the student or the school situation can be given to the lead clinician in a heads up fashion, handled by the counselor familiar with the issue, and then later debriefed so that it can be referred to when appropriate or serve as helpful background information if a simple reference is made about it. Having a counselor who works in the school being part of the group offers a connection for students who may need to continue to touch base after the group has ended. While it would be unfair to expect counselors to have extensive therapy skills, many have had experiences in running school groups such as grief groups or social skills groups, and bring unique experience to share with their clinician counterpart. They know and care about the students and can enhance relationship skills, help orient the group to the clinician and positively reinforce acceptance and good behavior in the group. Counselors in schools have varying roles and responsibilities. As a result, some of them will have more of a propensity for doing group work than others. Many high school counselors priority is to assist students with college and vocational prep including handling transcript and Scholastic Aptitude Testing (SATs). Several have told us that unlike their elementary school counterparts, they feel much less comfortable facilitating or co-facilitating groups. Nevertheless, with brief coaching of minutes before each session and debriefing afterwards, co facilitators can learn how they can contribute-especially around observation of affect and behaviors in the group and emphasis of key session objectives. Clinicians and their supervisor will need time and support to do this intensive work. Preparation for sessions takes time and skill acquisition can be time intensive for the first timers. Coordination with the schools and their co-facilitator (especially if they are school personnel ) takes time. Their agency as a whole must be capable of delivering an intervention that last sessions when provided in a group, or longer when provided to 17

19 an individual child or adolescent. Some components may require more time with some clients/students if they are to be effective. When administered in residential treatment settings where clients often have multiple traumas, this treatment has taken up to 24 sessions to administer. The treatment itself needs assurance of regular sessions; it requires space in the school setting that will allow students their privacy. The school must assure that students receive positive support from this experience and that it is without stigma. Supervisors as well as clinician providers need to know the model. If supervisors are not familiar with the approach, they will have difficulty assisting therapists in delivering it. Billing B illing for group therapy in an outpatient clinic setting is usually reimbursable, however barriers may exist such as a) lower reimbursement amounts than for individual therapy, b) the effect of variable attendance on financial estimates, and c) the cost of time for securing reimbursements and managing program. Billing for group services provided in a school setting is a bit trickier and requires the Principal to authorize clinical services on school property. Often, trauma-focused services delivered in schools are most easily accomplished when the school district, through Wellness Clinics or directly, contracts for services. This may or may not be done in partnership with community mental health or through grant funding. Regardless, what is allowed per service definition and billing requirements is important. Some school services may qualify for other service definitions such as being part of a community based service model. Billing a tauma treatment, including TFC is most straightforward when it is delivered as an individual outpatient visit and is reimbursable by Medicaid and other 3rd party payors when clinicians and clients meet eleigibility requirements.cvc (Crime Victims Compensation) is worth looking into for victims of crime with a police report. Agencies and treatment programs that wish to learn more about their state s CVC program should contact the US Department of Justice Office for Victims of Crime at Guidance on Measures & Assessment he use of measures, whether applied to a group or individual client, are used to T assist in a client s treatment planning to ensure that their needs have been identified and that the treatment they are being considered for is in their best interest. Using the same measure following treatment offers information to the clinician and client as to whether goals have been met in part or in full. TFC, being a trauma treatment requires clinicians to directly deal with the impact and consequence of trauma in the life of a child or adolescent. The research articles supporting its empiricism have utilized a longer list of measures than would necessarily be useful or feasible in the day-to-day work of a busy clinician and client. As a result we are recommending the domains we believe are important in assessing trauma and considering using TFC as part of the treatment plan. We have suggested measures that are readily available. (Feel free to choose others in those domains). Some of these that are free are 18

20 enclosed in the TFC Implementation Manual. We tried to reduce the number of measures suggested knowing that in a busy practice there may be other measures/assessments a clinician may also be using. Domain Trauma Stress Screen Trauma History PTSD diagnosis/symptoms Anxiety Depression General Behavior (optional but recommended) Suggested Measures Child & Adolescent Trauma Survey (CATS) (March et al.) Exposure to Violence Checklist (Amaya-Jackson et al.) First items (1-14) on UCLA PTSD Index for DSM IV (Pynoos et al.) UCLA PTSD Index for DSM IV (Pynoos et al.) Child & Adolescent PTSD Checklist (Amaya-Jackson et al.) Child PTSD Symptom Scale (Foa et al.) Multidimensional Anxiety Scale for Children (March) Revised Children s Manifest Anxiety Scale (Reynolds) Screen for Child Anxiety Related Emotional Disorders (SCARED): (Birmaher et al.) Children s Depression Inventory short or long form (Kovacs et al.) Mood & Feelings Questionaire (Costello et al.) Connors Teacher Rating Scale Strengths & Difficulties Questionaire (Goodman) Child Behavior Checklist (Achenbach) In considering children who should be in groups (particularly when they are being run in the school), these measures can be very helpful. Children or youth who are active and disruptive by either teacher report or the above measures are likely to not the best candidates for group work. Children with traumas and symptoms of post-traumatic stress and anxiety will likely show the highest level of response as will children with depression. When depression is due to significant loss & bereavement, additional or alternative treatment may be necessary. Children who are psychotic, with suicidality, or other severe risk-taking behaviors will need other treatments prior to being considered for TFC or other trauma treatment modalities. Clinical Adaptation & Tailoring for Client Needs rauma-focused Coping was created to be run in groups in schools. Group therapy T in clinics and residential treatment centers has also been done successfully. It was created with public health principles in mind that children who may not have access to services may best be served when they can be treated at school, in an efficient manner that also allows their peers to assist in the mediation of their traumatic stress. Keeping control of group dynamics is critical and is why two facilitators are recommended. There are a number of scenarios where clinicians may need to address clinical issues that require some logistical strategizing. 19

21 When a student requires more treatment than is feasible within the group setting, it may be due to the severity of the trauma (s) and intensity of their symptoms, Consideration as to whether a student should have co-occuring individual sessions (either 1-2 or many more) or follow up with individual work after the group is completed may be necessary. When used as an individual treatment, it is easy to extend the number of anxiety management sessions if a child is not ready for the trauma narrative. It is much harder when the child is a participant in a group. Having an individual pullout session and more than one group session that focuses on sharing the narrative allows a little leeway for an individual child to have extra time before he/she narrates. Certain traumas for certain youth may not be amenable to group work. For example, a student with sexual abuse trauma is not suitable to be placed in a group that is not made up of others with similar traumas and often gender grouping is critical. Sometimes a student who has had a single-incident trauma (such as a car accident or had a murder in their family) may also have been sexually abused. The clinician may be aware of this ahead of time or it may have not been disclosed until after the group has commenced. We have had students successfully complete their groups and then work on the more private aspects of their trauma in individual work. Of couse care has to be taken to make sure the appropriate connotation is made so that there is not positive reinforcement of secrecy and shame but rather the appropriate working through in a safe place with individual attention. How to Obtain Clinical Skill Building he TFC manual, along with this implementation manual, may well be all that is T needed for a clinician to begin using TFC successfully. This is most likely to happen with a clinician who has worked with children and youth and has had experience using cognitive behavioral therapy. Clinicians who have used CBT to treat anxiety, anger, and depressive disorders will see the generali CBT strategies in TFC, but those who have worked with traumatized youth will recognize the critcal aspects of a trauma focus. Therapists and their co-facilitators who have a trauma lens and understanding of key trauma concepts will most readily pick up TFC. For some clinicians, they will benefit from having 1-2 days of training that includes role plays, interactive expercies, and sample cases. Agency or individual consultation is available as well. Coaching has been cited by Fixsen et al (2004) as a critical factor in building implementation success. Coaching requires a clinician to actively apply his/her skills to a client who they are taking through the model. We have also found that coaching on a regular basis facilitates not only the ability to address fidelity but to also actively allow skillbuilding in clinicians above and beyond training on the model and on assessment. Because TFC shares many of the same components of other EBTs, coaching allows discussion of similarities and differences in the models. 20