strategies for tf cbt supervisionoklahomatfcbt.org/wp-content/uploads/2015/04/supervi… ·  ·...

Strategies for TF‐CBT Supervision

Susan Schmidt, PhDElizabeth Risch, PhD

SPECIAL THANKS TO…

Laura Murray, PhDAssistant Professor, Department of International Health

Center for Refugee and Disaster ResponseJohns Hopkins Bloomberg School of Public Health

For Original Content Used in this Presentation

What are your questions about TF‐CBT supervision?

Supporting Agency TF‐CBT 

Implementation

Resource to Support Agency TF-CBT Uptake

TF-CBT Implementation Manualhttp://www.nctsnet.org/nctsn_assets/pdfs/

TF-CBT_Implementation_Manual.pdf

Successful Agency TF-CBT Uptake

Foster positive attitudes toward the TF-CBT model from leadership and direct service providers.

Create a plan for embedding ongoing TF-CBT related training and materials costs into the agency budget.Invest in therapy tools commonly used

in TF-CBT – books, handouts, toys, games, props.

Successful Agency TF-CBT Uptake

Create policies/procedures to support TF-CBT implementation:Create a culture of parent involvement in therapyCommitment to weekly TF-CBT sessionsEstablish standard TF-CBT billing codes

Successful Agency TF-CBT Uptake

Create policies/procedures to support TF-CBT implementation:

Case documentation templatesTrauma Narrative storage planManagement of subpoenas and other

requests for information

Successful Agency TF-CBT Uptake

Prepare and support supervisors: Have supervisors complete TF-CBT training

and consultation first.Allow for opportunities for continued model

use, if possible.Support supervisors’ participation in TF-CBT

continuing education

Successful Agency TF-CBT Uptake

Allow therapists time for:TrainingReadingSession preparationConsultation callsClinical supervisionContinuing education

Successful Agency TF-CBT Uptake

TF‐CBT Consultation RequirementsO Attendance at 12 one-hour teleconference calls, which

take place twice monthlyO Maintaining 1 to 2 active TF-CBT cases

O (estimated weekly time per case = 1 hr session, .5 hr session preparation and documentation)

O Completing a background information form at the beginning of each active TF-CBT case staffed through consultation

O (estimated completion time = .5 hr after first session)

O Completing weekly session updates through the TF-CBT session PRACTICE Components Tracking email survey

O (estimated weekly time = .25 hr)

Create a fidelity monitoring plan.

Successful Agency TF-CBT Uptake

Therapist outcomes Examples: Therapist satisfactionModel adherence Client retention

Client outcomes Examples: Session attendance Symptom changes Functional outcomes Client satisfaction

Metric Examples• Child/family TF-CBT treatment satisfaction ratings • CATS score changes across treatment (child & caregiver

reports)• Other child functioning outcomes• TF-CBT treatment entry rate and dropout rate• TF-CBT treatment length and session #s• Demographics of youth entering and participating in TF-CBT• Caregiver involvement in TF-CBT sessions• Agency retention rates of TF-CBT therapists• Job satisfaction ratings of TF-CBT therapists

Other metrics that may be of interest to families, clinicians, agency leadership?

Ideas to Increase and Maintain TF‐CBT Fidelity within your Agency

Supervision/Case Staffing: Regular case presentations using PRACTICE components as a guide For therapists in consultation, reviewing online session tracking

portal Recordings reviews or session observations Trauma stewardship check-ins PRACTICE components refreshers TF-CBT resource/chapter reviewsWebsite reviews – TF-CBT Web, CTG Web, TF-CBT Consult, CPT

Web, etc.

O http://shiny.ouhsc.edu/TfcbtPublic/Shiny/TherapistProgress/

O Can sort by agency and by therapist’s 4-character tag ID

O The tracking form identifies:O TF-CBT sessions scheduled/held for youth being

staffed through consultation and TF-CBT model components addressed during each session.

O A graph of the youth’s CATS assessment scores across administrations (youth and caregiver reports).

16

TF‐CBT ConsultationOnline Tracking Portal

17

Ideas to Increase and Maintain TF‐CBT Fidelity within your Agency

Recognition for completion of training milestonesCompletion of consultationAttendance at advanced trainingsCompletion of national TF-CBT certification

PRACTICE Component Tracking Board Small rewards for completion of TF-CBT

components or client graduations

Questions?

Clinical Supervision of TF‐CBT Therapists 

Recipe for Successful       TF‐CBT Supervision

Successful TF‐CBT Supervision

Know the model and components very well

Actively monitor supervisee fidelity to the TF-CBT model

Help supervisees learn to balance TF-CBT fidelity and flexibility

Remain up-to-date and share new and exciting TF-CBT research findings

Successful TF‐CBT Supervision

Give direct, honest and supportive feedback on supervisee TF-CBT implementation.

Watch supervisees for signs of secondary traumatic stress.

Successful TF‐CBT 

Supervision

Conduct effective supervision sessions: Model steps in TF-CBT by: Setting an agenda Giving supervisees time to share Providing opportunities for education and

practice

Successful TF‐CBT Supervision

Support Model LearningProvide time for:Web trainingsTF-CBT Web, CTG Web, TF-CBT Consult

Consult callsMinimum 12 calls in 6 months – 1 yrCase documentation for consult callsAdvanced TF-CBT training (4-6 months after

intro & then annual, if available)

Support Model LearningProvide time for:Session preparationAverage 20-30 min weekly per case for first few

cases.Advanced therapists need prep time, too.

TF-CBT case staffings in your on-site supervision

Support Model Use

Assign potential TF-CBT cases to therapist’s caseload in time with the Intro TF-CBT training. Therapists should have new cases ready

to start for consultation.

Support Model UseReview potential TF-CBT cases with therapist.

Conduct early trauma screen and, if positive, conduct PTSD assessment at beginning of case.

If child has trauma history + PTSD symptoms, TF-CBT is likely the best approach.

If therapist is hesitant to start TF-CBT, “Tell me why we shouldn’t use TF-CBT with this case.”

Work with therapist to plan out first sessions.

Support Model Adherence

At beginning of case, discuss plan for caregiver involvement. Help therapist be creative in reaching out to hesitant or missing caregivers.

Do a weekly check-in on TF-CBT case progress

Support Model Adherence

Use the PRACTICE Checklist or other fidelity monitoring form & review during each supervision session.

When progress through the PRACTICE components stalls, explore potential reasons and problem-solve in supervision.

Support Model Adherence

Remember - the tendency is for therapists to drift away from any evidence-based practice over time.

Acknowledge this and create a plan with the therapist for model fidelity.

Common Challenges in TF‐CBT 

Supervision

#1: Loses sight of the TF‐CBT Model Big Picture

Therapists may get bogged down in issues like:Parent’s complaints of child

misbehaviorSchool difficultiesRelationship difficulties

Remedy: Frame problems in the context of PTSD

Q’s for therapist:How is (problem) related to trauma &

PTSD?What skills has the client learned (or

needs to learn) to address (problem)? Is (problem) something that is better

addressed later in TF-CBT or upon completion of TF-CBT?

#2: Joining the chaos of traumatized families

COWS continually deter session plans

Remedy: Structure & PlanningQ’s for therapist: How is session structured? How is time

spent? What components of the model does the

family need to use to ‘corral the cows’? What are ways to model good boundaries

& use of coping skills in session?

#3: Uncertainty in readiness to progress to next component or even 

end treatment

May stay “stuck” in early phases of TF-CBT

May have difficulty recognizing “good enough” improvement

Remedy: Evaluate progress on treatment goals. 

Q’s for therapist:1. Is client managing ______ enough to proceed

to next component? What skill level does client need to move?

2. Compare initial functioning to now. Any change in client’s PTSD symptoms? Can client manage symptoms?

3. What is holding therapist back from moving into TN?

4. When will you and the family know treatment is done?

#4: Unfocused sessions & few engaging activities  

Therapist may have limited session prep time.Therapist discomfort may be hampering technique:

Examples of potential areas of discomfort: CBT modalityStructuring and directing sessions, Talking about traumaWorking with parentsWorking with children of certain age groups, Personal history of trauma

Remedy: Create a safe place for therapist to explore and share their 

challenges in this area. 

Discuss learning styles of family members.Brainstorm ideas for incorporating

structure and fun activities into sessions.

PRACTICE Component Supervision 

Ideas

TF‐CBT Supervision Includes:

O Reviews of PRACTICE component goals and tasks

O Active planning for subsequent sessionsO Reviews of relevant therapy resources & toolsO Discussion of caregiver involvementO Role plays and demonstrations to support

new skill developmentO Therapist self-care check-ins

Always check in on:O Session planning and activities/materials preparationO Adherence to PPRACTICE structureO Incorporation of caregivers into each sessionO Inclusion of gradual exposure elements into each

sessionO Use of interactive activities that give youth

opportunities for practice and teaching O Assignment and review of homeworkO Inclusion of fun and youth’s interests into sessions

ASSESSMENT AND ENGAGEMENT

Assist therapist in determining youth who may benefit from TF-CBT.

Review screening & assessment results. Discuss the relevant assessment feedback to share with

child/caregiver. Establish plan for symptom tracking and regularly review

outcomes in supervision.Discuss options for engaging reluctant or inconsistent

caregivers.

PSYCHOEDUCATION

Discuss psychoeducational topics needed for youth and caregiver(s)Brainstorm child, caregiver &

conjoint psychoed activitiesPlan for fun/novelty to ease

distress/avoidance.

PARENTINGDiscuss plan for engaging/supporting

caregivers. Regularly review therapist’s plan for

caregiver involvement in treatment.Potential role plays: EngagementTeach behavior management skills (e.g., active listening, labeled praise, behavior

charts, time out, logical/natural consequences, etc.)Good Boss/Bad Boss

PARENTING

Special topics Impact of therapist age, gender,

parental status on working with parentsEngaging the angry parentWorking with traumatized parentsFunctional Behavioral Analysis –

Trauma driven or parent reinforced behaviors?

RELAXATIONRole plays Teach stress response (fight, flight, freeze) to

children of different agesTeach specific relaxation skills (deep breathing,

muscle relaxation, visualization, etc.)

Special topics Working with the child/caregiver who thinks

relaxation is stupid or doesn’t workWhat to do when parents won’t practice with

their children

AFFECT REGULATION

Special topics Working with the emotionally disconnected

childWorking with the emotionally labile childWhat to do when parents are poor role models

for emotion regulation?What to do when parents won’t support their

child’s emotional development

COGNITIVE COPINGRole playsTeaching and reviewing problem-solving skills

(turtle steps, STOP technique, etc.)Teaching and reviewing the cognitive triangleHelping children change non-trauma related

cognitions with the triangleBasic Socratic questioning skills practice

COGNITIVE COPING

Special topics Teaching the cognitive triangle to:Oppositional youthYoung childrenCaregivers

Teaching caregivers to coach their child in the use of cognitive coping skills

TRAUMA NARRATIVERole playsIntroducing the Trauma Narrative to different

ages & to parentsUsing different metaphors/analogies/examples

to explain gradual exposureDeveloping the Trauma Narrative (building

narratives in multiple drafts)Managing child/caregiver avoidance (handling

the “I don’t knows/remembers”)

TRAUMA NARRATIVESpecial topicsHow to create strong introductions that set the

stage for exposure workDeveloping a plan for repeated gradual exposure

(developing the trauma narrative) Documentation, chart management &

confidentiality issues with trauma narrative workGradual exposure with caregiversIdeas for rolling with resistance

IN VIVO DESENSITIZATIONComponent Review

Review “Facing Down the Fears - I 35W Bridge Collapse” TF-CBT in vivo video onlinePracticing exposure hierarchy development

Discussion topicsWhen to use this techniqueHow to involve caregivers in in vivo work

COGNITIVE PROCESSING

Role playsUsing Socratic questioning with problematic

trauma-related cognitionsBest friend examplesUsing the cognitive triangle to shift problematic

trauma-related beliefs Using these skills with youth and with caregivers

COGNITIVE PROCESSING

Special topicsHow much movement should we expect when

processing problematic trauma-related cognitions?

How to balance psychoeducation with processing. When to give information during processing.

What to do when sticky cognitions won’t seem to budge.

CONJOINT PARENT‐CHILD SESSIONS

Special topicsWays to integrate conjoint parent-child work into

each session.When not to do conjoint work. Preparing children and caregivers for conjoint

trauma narrative review.

Role playsWhat to do when the discussion starts to get

heated.Managing the overwhelmed parent during the

conjoint session.

ENHANCING SAFETY AND SOCIAL SKILLS

Special topics When to teach about private parts and sexual behavior rules Calming the “freaked out” parent How to handle parents who don’t want to talk about sexual

issues Working with families impacted by domestic violence

Role plays Practicing No-Go-Tell Teaching Dr’s names for private parts Teaching the Sexual Behavior Rules

TREATMENT COMPLETION

Special topicsWhat is good-enough progress for treatment completion?When and how to transition from TF-CBT to a different

phase of treatment, if needed? How to model a healthy good-bye for the youth and

family?What parting messages does the therapist want to leave

with the youth and caregivers? Preparing the family for managing future stressors

Questions?

University of Oklahoma Health Sciences Center

Center on Child Abuse and Neglect

Susan-Schmidt@ouhsc.edu

Elizabeth-Risch@ouhsc.edu

(405) 271-8858

Contact Information