THE IMPACT OF TF-CBT ON MENTAL HEALTH PROFESSIONALS

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1 THE IMPACT OF TF-CBT ON MENTAL HEALTH PROFESSIONALS DEB ANDERSON, PHD, MSW DIRECTOR OF CONNECTIONS PROJECT HARMONY CHILD ADVOCACY CENTER OMAHA, NE

2 EVIDENCE BASED PRACTICE Evidence may include Efficacy Randomized controlled trials Practical clinical trials Does the intervention consistently produce expected results under ideal circumstances? Effectiveness What benefits can be demonstrated in real world clinical settings?

3 WHY THE FOCUS ON EVIDENCE IN THERAPY? GOAL: TO IMPROVE QUALITY AND ACCESS OF MENTAL HEALTH TREATMENT U.S. VA MENTAL HEALTH STRATEGIC PLAN NATIONAL CHILD TRAUMATIC STRESS NETWORK AMERICAN PSYCHOLOGICAL ASSOCIATION AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY NATIONAL CHILDREN S ALLIANCE

4 TRAUMA TREATMENT PRINCIPALS CREATE CIRCLE OF SAFETY REDUCE PHYSIOLOGICAL REACTIVITY CREATE A NARRATIVE OF THE EXPERIENCE MAKE SENSE OF WHAT IT MEANS GRADUAL EXPOSURE TO DEFUSE TRAUMATIC TRIGGERS GENERALIZATION OF SKILLS TO EVERY DAY LIFE HEALING OF RELATIONSHIPS

5 TRAUMA FOCUSED COGNITIVE BEHAVIORAL THERAPY (TF-CBT) A conjoint child and parent psychotherapy; for children ages 3-16 who are experiencing emotional and behavioral difficulties due to traumatic life events. Incorporates trauma-sensitive interventions with cognitive behavioral, family, and humanistic principles and techniques. Children and parents learn new skills to process thoughts and feelings related to traumatic life events; manage and resolve distress; and enhance safety, growth, parenting skills, and family communication.

6 FOCUS OF TF-CBT TREATMENT Alleviate Symptoms of PTSD Distress around recall Avoidance Hyper-arousal Behavior Reenactment Alleviate misconceptions of distorted thoughts about the trauma Resolve behavioral problems that may have developed as a result of the trauma

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9 EFFECTIVENESS ADDRESSES AND RESOLVES PTSD DEPRESSION ANXIETY EXTERNALIZING BEHAVIORS INTERNALIZING BEHAVIORS SEXUALIZED BEHAVIORS FEELINGS OF SHAME AND MISTRUST PARENTAL COMPONENT INCREASES THE POSITIVE EFFECTS FOR CHILDREN BY REDUCING PARENTS OWN LEVELS OF DEPRESSION AND EMOTIONAL DISTRESS ABOUT THEIR CHILD S TRAUMA IMPROVES PARENTING PRACTICES AND SUPPORT OF CHILD

10 MOST EFFECTIVE WHEN IF ABUSE IS TRAUMA ALLEGATION IS CLEAR, HAS BEEN INVESTIGATED AND VALIDATED NON-OFFENDING PARENT (OR TRUSTED CAREGIVER) IS COOPERATIVE AND AVAILABLE CHILD HAS SYMPTOMS OF PTSD; POSSIBLY OTHERS SUCH AS ANXIETY, DEPRESSION, OR OPPOSITIONAL BEHAVIOR CHILD IS FREE OF PSYCHOTIC SYMPTOMS CHILD IS FREE OF ACTIVE SUICIDAL SYMPTOMS

11 TWO RESEARCH STUDIES JOURNAL OF EVIDENCE-INFORMED SOCIAL WORK (2015) DISSEMINATION OF TRAUMA-FOCUSED COGNITIVE BEHAVIORAL THERAPY WITH COMMUNITY PRACTITIONERS: FOCUS ON SELF-EFFICACY DISSEMINATION OF TRAUMA-FOCUSED COGNITIVE BEHAVIORAL THERAPY: A FOLLOW-UP STUDY OF PRACTITIONERS KNOWLEDGE AND IMPLEMENTATION

12 BACKGROUND OF PROJECT CAC DID NOT PROVIDE THERAPY; REFERRED TO COMMUNITY ALLOWED PARENTS TO SELECT PROVIDER CONCERNED ABOUT QUALITY OF SOME PROVIDERS BEGAN TRAINING THERAPISTS ABOUT CHILD SEXUAL ABUSE NCA ACCREDITATION STANDARDS RE: TRAUMA-INFORMED THERAPY NEEDED LINKAGE AGREEMENTS WITH PROVIDERS

13 TRAINING FOR COMPETENCE TRAINING FOR THERAPISTS UNEVEN TRAINING METHODS AND DELIVERY VARY CLIENT OUTCOMES IN THE FIELD OFTEN INFERIOR TO THOSE OBTAINED IN RANDOM CONTROLLED STUDIES CERTIFICATION, FIDELITY, AND SUPERVISORY ISSUES SUSTAINABILITY OF EBPS

14 WHAT OUR CAC DID SELECTED TF-CBT FOUND A MASTER TRAINER REQUIRED PARTICIPANTS TO COMPLETE AND SUBMIT PROOF OF ONLINE TRAINING GAVE PREFERENCE TO THOSE WHO COMPLETED 5-PART SERIES COORDINATED LOGISTICS PARTNERED WITH UNIVERSITY TO ASSESS SELF-EFFICACY

15 SELF-EFFICACY A PERSON S BELIEFS ABOUT HIS/HER CAPABILITIES TO SUCCEED IN SPECIFIC SITUATIONS.

16 RESILIENCY ABILITY TO ANTICIPATE, PREPARE FOR, RESPOND, AND RECOVER QUICKLY FROM CHANGE

17 SELF EFFICACY AND RESILIENCY INCIDENTALLY, WHILE WE WERE NOT RESEARCHING RESILIENCE AMONG MENTAL HEALTH PRACTITIONERS, WE WERE AWARE THAT A SENSE OF SELF-EFFICACY IS A PROTECTIVE FACTOR AGAINST SECONDARY TRAUMATIC STRESS AND BURN-OUT AND IT WAS IMPORTANT TO US TO KEEP OUR EXPERIENCED PRACTITIONERS WORKING.

18 RESEARCH QUESTION HOW CAN COMMUNITY CLINICIANS, WITHOUT A MANDATE FROM AN AGENCY, GOVERNMENTAL, OR HEALTH INSURANCE ENTITY, LEARN ABOUT AND BECOME COMPETENT TO PROVIDE BEST PRACTICES TO THEIR CLIENTELE?

19 THIS RESEARCH WAS INNOVATIVE FOCUSED ATTENTION ON TRAINEES PERCEPTIONS MEASURED SELF-EFFICACY SPECIFIC TO TF-CBT EXAMINED INDEPENDENT IMPLEMENTATION EFFORT ARE THEY USING TF-CBT? HYPOTHESIS: SELF-EFFICACY WILL INCREASE FROM BASIC TRAINING TO ADVANCED TRAINING.

20 DEMOGRAPHICS 60 PROFESSIONALS ATTENDED 33 COMPLETED FIRST SURVEY 31 COMPLETED SECOND LARGELY FEMALE AND CAUCASIAN MEAN AGE: YEARS OF MENTAL HEALTH EXPERIENCE 5 YEARS = MODE CREDENTIALS 7 PROVISIONAL, 7 LICENSED, 19 ADVANCED

21 METHOD ANNOUNCED RESEARCH AT BASIC TRAINING ED PRE-SURVEY AFTER BASIC TRAINING AND POST-SURVEY AFTER ADVANCED TRAINING (6 MO) UNIVERSITY RESEARCHER MANAGED IRB, LETTER OF PARTICIPATION, ETC. CAC COORDINATOR ANNOUNCED RESEARCH, FOLLOWED UP WITH SEVERAL INVITATIONS.

22 MEASURE OF SELF-EFFICACY 42 THERAPEUTIC TASKS GROUPED INTO 4 CATEGORIES: PROVIDING INFO ABOUT CHILD SEXUAL ABUSE PROMOTING CHILD S COPING PROMOTING PARENT INVOLVEMENT PROCESSING TRAUMA NARRATIVE IN JOINT SESSIONS 0 = I AM COMPLETELY SURE I CANNOT DO IT 100 = I AM COMPLETELY SURE I CAN DO IT

23 PROVIDING INFORMATION ABOUT CHILD SEXUAL ABUSE (5 ITEMS) CONSIDERING THE CHILD S AGE, DEVELOPMENTAL LEVEL, GENDER, CULTURE, AND UNIQUE CHARACTERISTICS, I CAN EFFECTIVELY HAVE A DISCUSSION ABOUT: ACCURATE INFORMATION ABOUT CHILD ABUSE AND TRAUMA WHO ABUSES CHILDREN AND/OR OTHER TRAUMATIC EVENTS THAT AFFECT CHILDREN HOW KIDS IN GENERAL FEEL WHEN THEY HAVE BEEN ABUSED

24 PROMOTING CHILD S COPING (20 ITEMS) CONSIDERING THE CHILD S AGE, DEVELOPMENTAL LEVEL, GENDER, CULTURE, AND UNIQUE CHARACTERISTICS, I CAN EFFECTIVELY INVOLVE THE CHILD AS I: TEACH CONTROLLED BREATHING: EXPLAIN THE RATIONALE, DEMONSTRATE PROPER BODY POSITIONING, DEMONSTRATE THE PROPER BREATHING TECHNIQUE, HELP CHILD GET A RELAXING WORD, AND HAVE THE CHILD DEMONSTRATE GIVE THE CHILD HOMEWORK TO PRACTICE CONTROLLED BREATHING

25 PROMOTING PARENT S INVOLVEMENT (11 ITEMS) CONSIDERING THE PARENT S/CAREGIVER S AGE, GENDER, CULTURE, AND UNIQUE CHARACTERISTICS, I CAN EFFECTIVELY: HAVE A DIALOGUE ABOUT SEX EDUCATION FOR THEIR CHILD AND THE PARENT S/CAREGIVER S PARTICIPATION IN THIS HAVE A DIALOGUE ABOUT THE INFORMATION THEIR CHILD NEEDS ABOUT SEXUAL ABUSE AND A SAFETY PLAN INFORM PARENT/CAREGIVER ABOUT THE CHILD S WORK ON EMOTIONS AND THE PARENT S PART TO HELP CHILD IDENTIFY EMOTIONS AT HOME AND PRAISE APPROPRIATE EXPRESSION OF EMOTIONS

26 PROCESSING THE TRAUMA NARRATIVE IN JOINT SESSIONS (6 ITEMS) IN PREPARING FOR AND CONDUCTING JOINT SESSIONS WITH CHILD AND PARENTS/CAREGIVERS, I CAN EFFECTIVELY: EXPLAIN ALL ASPECTS OF THE RATIONALE FOR HAVING JOINT SESSIONS THOROUGHLY PREPARE THE PARENT/CAREGIVER INDIVIDUALLY FOR HEARING AND APPROPRIATELY RESPONDING TO THE CHILD S TRAUMA NARRATIVE IN JOINT SESSIONS ENABLE THE CHILD TO BEGIN SHARING THE TRAUMA NARRATIVE AND HAVING A DIALOGUE ABOUT CONCERNS ABOUT THE NARRATIVE, BODY INTEGRITY, SAFETY PLANNING, AND RELATIONSHIPS

27 POST-SURVEY ADDED QUESTIONS DID YOU ACCESS TF-CBT BOOK? DID YOU READ IT? HOW MANY TIMES DID YOU VISIT THE TF-CBT ONLINE SITE? HOW MANY CONSULTATION SESSIONS DID YOU ATTEND?

28 OTHER FACTORS PARTICIPANTS WERE NOT GUARANTEED REFERRALS FROM CAC EXPECTED TO TAKE CAC REFERRALS IF THEY SIGNED LINKAGE AGREEMENTS COULD ACCEPT REFERRALS FROM OTHER SOURCES

29 IMPLEMENTATION MEASURED BY: # CHILD TRAUMA CASES TREATED WITH TF-CBT # CASES COMPLETING TF-CBT # CASES THAT INCLUDED CAREGIVER IN TREATMENT # TIMES PRACTITIONER USED UCLA PTSD REACTION INDEX TO ASSESS TRAUMA VALUE OF OVERALL CONSULTATION PROCESS GLOBAL MEASURE OF COMPETENCE IN TF-CBT LIKELIHOOD OF CONTINUED USE OF TF-CBT

30 RESULTS PURCHASE/ACCESS OF BOOK = 71% SLIGHTLY MORE THAN HALF READ ½ TO ALL REVISITS TO TF-CBT WEBSITE 42% VISITED 2 OR MORE TIMES TELEPHONE CONSULTATION CALLS 60% ATTENDED 5 CALLS 33% ATTENDED 6-13

31 SELF-EFFICACY INCREASED SIGNIFICANTLY FROM BASIC TO ADVANCED TRAINING EXPERIENCE MATTERED INVOLVING PARENTS (STAT SIGNIF) DOING PARENT-CHILD TRAUMA WORK (STAT SIGNIF) EDUCATION ABOUT CHILD SEXUAL ABUSE TEACHING CHILD COPING SKILLS TRAINING INVOLVEMENT WAS NOT ASSOCIATED WITH SELF- EFFICACY SCORES

32 OTHER RESULTS IMPLEMENTATION SCORES ASSOCIATED WITH NUMBER OF REFERRALS YET 7 PARTICIPANTS RECEIVED NO REFERRALS AND OVERALL REFERRAL RATE WAS LOW (~3) HIGH RATINGS FOR THE CONSULTATION SESSIONS HIGH RATINGS FOR CONTINUED USE OF TF-CBT

33 DISCUSSION PROJECT WAS SUCCESSFUL IN PROMOTING SELF-EFFICACY SCORES GAINS FROM BASIC TRAINING (85) TO ADVANCED (92) IS EXPERIENCE CENTRAL TO SELF-EFFICACY OR DOES THE REFERRAL PROCESS FAVOR SEASONED PROFESSIONALS? THOSE THAT IMPLEMENTED TF-CBT, RATED TRAINING AS POSITIVE AND VALUED CONSULTATION

34 LIMITATIONS RANDOMIZED AND CONTROL/COMPARISON GROUPS NOT USED VOLUNTARY PARTICIPANTS MAY BE MOTIVATED PRE AND POST-SURVEY MATCHING WOULD HAVE STRENGTHENED THE STUDY SELF-REPORT MEASURES HAVE LIMITATIONS LACK OF STRUCTURE/MANDATE RE: REFERRALS, ASSIGNMENT OF CASES, FIDELITY, PROGRESS, ETC.

35 RECOMMENDATIONS NEED STRUCTURE TO ASSURE REFERRALS ARE MADE TO ALL TRAINEES, MONITORED FOR FIDELITY, CLIENT OUTCOMES, ETC. COLLABORATION WITH RESEARCHERS COULD HELP WITH A STRUCTURE AND EVALUATION DESIGN TO FACILITATE CLINICIAN IMPLEMENTATION THIS EFFORT COULD LEAD TO FORMAL AND LARGER COLLABORATION IF MORE CONSUMERS AND PRACTITIONERS SUPPORT TF-CBT, NEED TO LOOK FOR WAYS TO IMPLEMENT AND SUSTAIN A LARGER EFFORT

36 DISSEMINATION OF TRAUMA- FOCUSED COGNITIVE BEHAVIORAL THERAPY: A FOLLOW-UP STUDY OF PRACTITIONERS KNOWLEDGE AND IMPLEMENTATION

37 RESEARCH QUESTION DID CLINICIANS GAIN KNOWLEDGE ABOUT THE COMPONENTS OF TF-CBT AND IMPLEMENT THE MODEL MONTHS AFTER TRAINING?

38 METHOD ORIGINAL SAMPLE N=51 + MORE RURAL COHORT OF TF-CBT TRAINED CLINICIANS N= 30 FINAL SAMPLE = 30 VIGNETTES THAT EVALUATE KNOWLEDGE ABOUT TF CLINICIANS EFFORTS AT ONGOING LEARNING OF TF USE OF MODEL AND ITS COMPONENTS DEMOGRAPHIC AND PERSONAL CHARACTERISTICS ONE TIME SURVEY MONKEY VOLUNTARY PARTICIPATION

39 STUDY WAS UNIQUE WE USED CLINICAL VIGNETTES WITH MULTIPLE CHOICE OPTIONS EACH VIGNETTE MATCHED ONE OF THE TF COMPONENTS (PRACTICE) WE ASKED ABOUT IMPLEMENTATION AND USE OF SELECTED COMPONENTS

40 CHARACTERISTICS OF PARTICIPANTS 90% FEMALE 97% CAUCASIAN 20% LICENSED OR PROVISIONALLY LICENSED 80% ADVANCED CREDENTIALS MEDIAN AGE = 42 YEARS OF PRACTICE EXPERIENCE = 12

41 IMPLEMENTATION QUESTIONS % REFERRALS APPROPRIATE FOR TF-CBT THAT CAME FOR THE FIRST APPOINTMENT % ATTENDING FIRST SESSION THAT DROPPED OUT BEFORE COMPLETING % OF CHILD-PARENT UNITS THAT INCLUDED SESSIONS WITH PARENT % OF CHILD-PARENT THAT INCLUDED CHILD S WORK ON TRAUMA NARRATIVE % OF CHILD-PARENT THAT INCLUDED PARENT WITNESSING CHILD S WORK ON TRAUMA NARRATIVE

42 RESULTS PARTICIPATION IN ONGOING LEARNING WAS LOW (4.93/10) KNOWLEDGE OF TF-CBT COMPONENTS AVERAGED 80% NO DIFFERENCE BETWEEN COHORTS NO DIFFERENCE BASED ON LICENSURE LEVELS AGE POSITIVELY RELATED TO HIGHER SCORE KNOWLEDGE SCORE POSITIVELY CORRELATED TO # OF REFERRALS RECEIVED

43 POSITIVE FINDINGS HIGH INTENTION TO USE THE MODEL 8.57/10 AVERAGE # OF REFERRALS FAIRLY HIGH = 11.5 LARGE NUMBER OF CASES SHOWED UP FOR INITIAL APPOINTMENT AND INCLUDED PARENT INVOLVEMENT (79%) THE MORE REFERRALS RECEIVED, THE MORE LIKELY CHILD TRAUMA NARRATIVE WORK OCCURRED

44 MORE POSITIVE FINDINGS HELPING PARENT AND CHILD WITH EMOTIONS DEVELOPING STRESS MANAGEMENT SKILLS TEACHING COGNITIVE CONNECTION PSYCHOEDUCATION ABOUT ABUSE

45 LESS POSITIVE FINDINGS USE OF UCLA PTSD REACTION INDEX WAS LOW WORK ON CHILD TRAUMA NARRATIVE WAS RELATIVELY LOW ONLY ABOUT 50% OF THERAPISTS INVOLVED PARENT IN SESSION WITNESSING TRAUMA NARRATIVE MODIFYING CHILD TRAUMA COGNITIONS WAS LOW

46 DISCUSSION OVERALL, RESULTS ARE STRONG IN VIEW OF THE COMPLEXITY OF CHILD/FAMILY S LIVES 80% AVE SCORE CAN BE VIEWED AS A RESPECTABLE GRADE MONTHS AFTER TRAINING. BUT WAS LOWER THAN SELF-EFFICACY SCORES (92%) ARE CLINICAL VIGNETTES THE APPROPRIATE MEASURE? DO THEY GET AT COMPETENCE? MAY BE SOME RESISTANCE TO EXPOSURE WORK WITH THE TRAUMA NARRATIVE LOCAL SMALL SCALE VOLUNTARY PROJECT CAN PRODUCE IMPLEMENTATION WITHOUT ORGANIZATIONAL MANDATE OR MONITORING

47 LIMITATIONS NO RANDOMIZATION OR CONTROL GROUPS # OF RESPONDENTS WHO STARTED BUT DID NOT COMPLETE SURVEY; SHOULD QUESTION ORDER BE CHANGED? BIAS IN SAMPLE OF COMPLETERS ARE THEY MORE KNOWLEDGEABLE OR CONFIDENT?

48 RECOMMENDATIONS GREATER STRUCTURE, AGENCY MANDATE, AND FINANCIAL SUPPORT MAY PRODUCE HIGHER RATES OF IMPLEMENTATION AND OPPORTUNITY TO MONITOR FIDELITY SEEK COLLABORATION FROM WIDE VARIETY OF PARTNERS REFERRALS, PROVIDERS, FUNDERS, ETC. MODIFY NEED FOR TRAUMA NARRATIVE CONSIDER CULTURAL MODIFICATIONS

49 POST SCRIPT WE WAITED 4 ½ YEARS TO OFFER TF-CBT TRAINING AGAIN WAS TOO LONG. NEW TRAINING MODEL DOES NOT REQUIRE 2 FACE-TO-FACE SESSIONS MAKES IT EASIER TO ATTEND ADDED CULTURAL ADAPTATIONS TO TRAINING ADDED TF-CBT OVERVIEW FOR REFERRALS, FUNDERS, AND OTHER STAKEHOLDERS

50 THANK YOU PROJECT HARMONY CHILD ADVOCACY CENTER Q ST OMAHA, NE