Child-Parent Psychotherapy Overview

PROGRAM DESCRIPTION

Child-Parent Psychotherapy (CPP) is an intervention model for children aged 0-5 who have experienced at least one traumatic event (e.g. maltreatment, the sudden or traumatic death of someone close, a serious accident, sexual abuse, exposure to domestic violence) and/or are experiencing mental health, attachment, and/or behavioral problems, including posttraumatic stress disorder (PTSD). The treatment is based in attachment theory but also integrates psychodynamic, developmental, trauma, social learning, and cognitive behavioral theories. Therapeutic sessions include the child and parent or primary caregiver. The primary goal of CPP is to support and strengthen the relationship between a child and his or her caregiver as a vehicle for restoring the child's sense of safety, attachment, and appropriate affect and improving the child's cognitive, behavioral, and social functioning. Treatment also focuses on contextual factors that may affect the caregiver-child relationship (e.g. cultural norms and socioeconomic and immigration-related stressors).

The type of trauma experienced and the child's age or developmental stage determine the structure of CPP sessions. For example, with infants, the child is present but treatment focuses on helping the parent to understand how the child's and parent's experience may affect the child's functioning and development. Toddlers and preschoolers are more active participants in treatment, which usually includes play as a vehicle for facilitating communication between the child and parent. Targets of the intervention include caregivers’ and children’s maladaptive representations of themselves and each other and interactions and behaviors that interfere with the child’s mental health. Caregiver and child are guided over the course of treatment to create a joint narrative of the traumatic event and to identify and address traumatic triggers that generate dysregulated behaviors and affect. When parents have a history of trauma that interferes with their responses to the child, the therapist helps the parent understand how this history can affect perceptions of and interactions with the child and helps the parent interact with the child in new, developmentally appropriate ways.

Staffing and Caseloads Treatment is generally conducted by a master’s or doctoral-level therapist or a supervised

trainee with at least two years of clinical experience.

Treatment involves weekly hour-long sessions.

Length of treatment varies depending on the complexity of the case. In published randomized control trials, the length of treatment was 1 year, with an average of 32.82 sessions across all the RCTs.

Caseloads vary depending on the complexity of the cases, whether the family is seen in home visits or in clinic, and the organizational structure of the agency. The CPP trainer generally speaks with the directors of agencies interested in CPP to think together about whether CPP fits their agency philosophy and organizational structure and to determine an appropriate caseload. Caseloads in the range of 10-12 are common.

EXPECTED OUTCOMES Based on findings from randomized controlled trials and CPP disseminations, improvement in the following domains is expected: Child Domains PTSD symptoms Comorbid diagnoses, including depression and anxiety General behavior problems including aggression, and attentional difficulties Capacity to regulate emotions Cognitive functioning Relational Domains Children’s perceptions of caregivers and themselves

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Children’s and caregivers’ attachment relationships Caregiver Domains Caregivers’ PTSD symptoms Caregivers’ general symptoms Caregivers’ empathy towards children Caregivers’ ability to interact in positive ways with children

EXTERNAL REVIEWS OF CPP

The following organizations have conducted independent reviews of the research on CPP, have listed CPP as an evidence-based practice, and have posted summaries on their websites. The Substance Abuse and Mental Health Services Administration’s (SAMHSA) National

Registry of Evidence-Based Programs and Practices (NREPP): http://nrepp.samhsa.gov/ViewIntervention.aspx?id=194

The California Evidence-Based Clearinghouse for Child Welfare: http://www.cebc4cw.org/program/child-parent-psychotherapy/

Oregon.gov Additions and Mental Health Approved Practices and Process: http://www.oregon.gov/OHA/mentalhealth/ebp/practices.shtml

(last updated 4/2012)

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Training in Child-Parent Psychotherapy Training in child-parent psychotherapy at the Child Trauma Research Program occurs through a number of different models. Below we describe the models and provide contact and cost information where appropriate. Currently all training models generally involve training agencies or agency teams. Except for training via clinician internships, we do not yet have a mechanism for training individual therapists.

Clinical Internships at the Child Trauma Research Program At CTRP, internships are available for psychology pre and post doctoral students, social

work interns, and UCSF psychiatry residents.

More information about the internship program can be found at http://childtrauma.ucsf.edu/training/internships.aspx and by contacting CTRP’s director of training Nancy Compton (nancy.compton@ucsf.edu)

National Child Traumatic Stress Network Learning Collaboratives

Child-parent psychotherapy is disseminated through the Learning Collaborative (LC) model of the National Child Traumatic Stress Network (NCTSN; nctsn.org).

Typically, LCs involve clinicians who are part of NCTSN member centers, but efforts are also made to accommodate clinicians from community agencies.

Agencies are selected through an application process that includes demonstrating organizational readiness to implement the practice.

Participating organizations assemble a team to participate in the LC that includes a senior leader, one or more supervisors, and clinicians. This approach helps the practice take root and grow in the agency.

Participating organizations agree to collect metrics and other outcome data.

Training involves three learning sessions held over the course of one year and telephone-based case consultation held twice a month for 1 1 /2 years. Learning sessions are hosted by centers participating in the LC, and take place at locations throughout the United States.

Cost: Training is provided free of charge. However, participants or their sponsoring agencies must pay for travel to the learning sessions.

More information about NCTSN Learning Collaboratives can be found at http://www.nctsnet.org/nccts/nav.do?pid=ctr_train_lc and by contacting Nick Tise (ntise@psych.duhs.duke.edu), the managing director of training and implementation at the NCTSN.

Child-Parent Psychotherapy Learning Communities A CPP Learning Community includes a group of agencies (usually from the same

geographic area) that have come together to learn the practice. Sites have the ability both to learn from one another as they develop their knowledge of the model and to pool resources to pay for training.

A learning community may be organized by CPP trainers, an agency, or an organizing body.

Learning communities typically include the components listed below in the section titled “standard CPP training components”.

Cost: Depends on the way the training is organized and should be arranged with the trainers (see general cost information below).

Child-Parent Psychotherapy Training for Individual Agencies Individual agencies can obtain training in CPP by contracting with CPP trainers.

The training will vary depending on the agency’s needs and experience but will typically include the components listed below under standard CPP training components.

Cost: Depends on the way the training is organized and should be organized with the trainers (see general cost information below).

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Standard CPP Training Components Training in CPP typically includes the following:

Demonstration that the agency is ready to learn and implement the practice o Agency staff have training in early childhood development or have consultation in

this area readily available to them. o Agency provides time and institutional support for reflective practice o Agency is able to assemble a team including administrators, supervisors, and

clinicians to learn the model

Agency staff read the manuals prior to participating in training.

Agency staff participate in a 1 ½ year training process that includes o Initial 3-day workshop o Two 2-day booster sessions (held six months apart, after the initial workshop) o Case consultation in person or via telephone (2 times a month for 1 ½ years) o All supervisors and clinicians participating in CPP training treat and receive

consultation on at least 2 CPP cases.

Standard CPP Training Costs Costs vary depending on the training model and the trainer. Daily rates for trainers vary from $2000-$3500 per day depending on trainer experience and time to travel to training site. Costs provided below are based on an estimate of one trainer for 30 people. For more people, we recommend an additional trainer, which would result in increased costs.

Initial 3-day workshop (3 days @ $2000-$3500 per day) $ 6000-10,500 Booster session #1 (2 days @ $2000-$3500 per day) $ 4000-7000 Booster session #2 (2 days @ $2000-$3500 per day) $ 4000-7000 2 groups for consultation calls (2X/month each group for 1 ½ years @ $150-350 each hour)* $10,800-$25,200 * For a group of 30, we recommend splitting the group into two calls, with each group having 36 calls over a 1 ½ year period. Cost for calls ranges from $150-$350 an hour depending on trainer experience, so cost for 72 calls would range from $10,800- 25,200 over the course of training)

Total Costs (Range) (not including cost of manual, travel for trainer, costs for phone calls) $24,800-$49,700 Total costs do not include indirect costs. When training is arranged through a University, indirect costs apply. For the University of California, San Francisco, the indirect rate ranges from 27.4-33% for trainings depending on whether work is being done on campus or off site. Total costs do not include costs of manuals. Below are the required and optional manuals and resources. Costs can be found on amazon.com

CPP TRAINING MATERIALS Required: Child Parent Psychotherapy Manual

Lieberman, A.F., & Van Horn, P. (2004). Don’t hit my mommy: A manual for child parent psychotherapy with young witnesses of family violence. Zero to Three Press: Washington, D.C.

Required: Book Describing Conceptual Framework, Intervention Modalities and Case Examples

Lieberman, A.F. & Van Horn, P. (2008). Psychotherapy with infants and young children: Repairing the effects of stress and trauma on early attachment. New York: The Guilford Press.

Optional: Adaptation of CPP for Traumatic Bereavement Lieberman, A.F., Compton, N.C., Van Horn, P., Ghosh Ippen, C. (2003). Losing a parent to death in the early years: Guidelines for the treatment of traumatic bereavement in infancy. Washington D.C.: Zero to Three Press.

FOR MORE INFORMATION Contact Chandra Ghosh Ippen, Ph.D. (415-206-5312) cpptraining@ucsf.edu