Implementing & Sustaining Effective Trauma-Mitigating Interventions

“Trauma Interventions in the Real World: Examples and Resources

Child Trauma Group MeetingZanvyl and Isabelle Krieger Fund

November 19, 2013

Trauma Matters• Trauma is gaining

recognition in the lay public for its impact on:– Short-term functioning

• Thinking• Behavior• Physiological response

– Longer term health (via ACES concept applied to today’s children & families)

Listening Carefully to Healing Neen• The public health paradox …– Trauma informed care is based on giving

alternatives to self-coping with trauma• TRUE

– Trauma informed care flips treatment upside down• MAYBE, but only if it was punitive confrontational

treatment– Trauma informed care complements consistent, responsive,

contingent responding by caregivers

• What trauma-informed services helped Neen?

Overview

• Fidelity• Common Elements and Factors• Implementation and Sustainability

Beyond Treatment Fidelity

• Strength of fidelity research base is over-estimated– In key studies, treatment adherence is in part

measured by caregiver satisfaction with the therapist and agreement that the therapist is working in ways that matter• surely this is correlated with how much improvement

there is in the case

3 Parts of Treatment Fidelity• Competence: The level of skill and judgment used in

implementing the procedure (Can they do it?)

• Adherence: Uses prescribed procedures (Are they doing it?)

• Differentiation: Do treatments differ on critical dimensions (Are the core elements delivered the way that this manual says)

• Schoenwald, et al., 2011• Berliner et al., (2013 ) Everyday competence and fidelity for EBP

organizations: Practical guide—2013.pdf

But Fidelity Costs A Lot: Fidelity Alternatives

• Self-reported Fidelity– Are they using the elements that they should be

using given the diagnoses?• Client-reported fidelity• Therapist behavior sampling

Fidelity Summary

Focusing so much on externally verified fidelity puts us on a track to frustration

Efficient Trauma-Focused EBPs: Focus on FLEXIBLE use of Building Blocks Not

Manuals

“It is improbable for any service array composed entirely of EBTs to serve all members of a diverse public mental health system.”

Southam-Gerow, et al. (in press).

How will I ever master all these Manualized

Evidence-Supported Treatments???

If only I could figure out the basic elements… I

could and mix and match as needed.

EBPs Matter But Not So Much with Youth Referred from Other Services

The Common Elements Approach• Using elements that are found across several evidence-

supported, effective manualized interventions

• “Clinicians ‘borrow’ strategies and techniques from known treatments, using their judgment and clinical theory to adapt the strategies to fit new contexts and problems” (Chorpita, Becker, & Daleiden, 2007, pp. 648-649)

• Actual treatment elements become units of analysis rather than the treatment manual

• Treatment elements are selected to match particular client characteristics

Common Elements as one Answer

LA Implementation of Common Elements: Outcomes for youth treated with MAP were strong, with effect sizes ranging from .59 to .80 on the Youth Outcome Questionnaire.

“These data support the notion that scaling up a mental health services approach in a system can be achieved through a strong and broad partnership among relevant stakeholders, can involve a train-the-trainer model, and can result in strong outcomes...”

Southam-Gerow, et al. (in press).

Weisz, J. R. et al. Arch Gen Psychiatry 2012;69:274-282.

Weisz et al. RCT Shows that Modular Approach to MH Treatment Works with Depressed, Anxious, or Conduct

Disordered Children

Can Differentiation Really Matter?

Follow the steps exactly

In the Beginning

Have the right ingredients; systematically apply within the model

Once you have Done it by the Book

Berliner et. al., CBT +

Toward Common Factors

• Engages client in meaningful work• Provides a logic to change effort• Generates hope• Measures progress

Common Factors

• Focuses on the client-therapist alliance– Listened to me; I felt heard, understood, respected– What we did and talked about were important to

me– I liked what we did today; the therapists approach

is a good fit for me– I hope we do the same kind of things next time;

overall the session was right for me

Common Therapeutic Factors of Trauma are Also Emerging

• Kathryn Collins, Chris Lane, and others are working on these as part of a NCTSN effort– They include common factors and elements used

in effective Trauma interventions

Continuous Assessment May Be Most Important of Common Factors

• RCT: Clinicians at 28 sites in 10 states completed assessments of youth (ages 11-18) functioning and symptoms every week. Dose response relationship—the more feedback passed on to the clinician the better the results. (Yet, feedback effect sizes were only .18, .24, and .27 for youth, clinicians, and caregivers, respectively.)

(Bickman et al, 2011)

Hawaii Looks at Practice & Outcomes

Monthly Treatment and Progress Summary form (MTPS) measures:– the service format and setting, – treatment targets, – clinical progress, – intervention strategies (e.g., exposure, logical

consequences, emotional processing), – and outcomes on a monthly basis.

Implementation• Active Learning Strategies

What Active Learning Helps Avoid…

Sustainability• Agency Readiness to Implement and

Implement and Implement

– Does it fit agency culture and funding

What We Also Want To Avoid…

EBPs: Treat to the Target and Match Organizational and Therapist Values

Competency-based Selection

www.ncwwi.org A Service of the Children’s Bureau, a Member of the T/TA Network

The better the fit between the requirements of the job and competencies of the job holder…

… the higher job performance and retention

will be.Select people for training who have the initial competency and a high likely to be longterm providers

Ongoing Consultation and Coaching

Purposes:• Teach effective practice• Ensure good judgment• Secure fidelity but prize competency• Increase staff satisfaction through support and

skill acquisition

Proposed EPB Sustainability Standards

• Training on how to do ongoing fidelity checking should be made available to subscribing organizations

• Train-the-trainer should be made available to local organizations by purveyors

• Use of local websites or MISs should be allowed vs. required use of ongoing provider/developer organizational websites

Partial ReferencesAarons, G.A., Hurlburt, M., & Horwitz, S. M. (2011). Advancing a conceptual model

of evidence-based practice implementation in public service sectors. Adm Policy Ment Health, 38: 4-23.

Aarons, G.A., Sommerfeld, D.H., Hecht, D.B., Silovsky, J.F., & Chaffin, M.J. (2009). The impact of evidence-based practice implementation and fidelity monitoring on staff turnover: Evidence for a protective effect. Jrnl of consulting and Clinical Psychology, 77(2), 270-280.

Barbee, A.P., Christensen, D., Antle, B., Wandersman, A., Cahn, K. (2011). Successful adoption and implementation of a comprehensive casework practice model in a public child welfare agency: Application of the Getting to Outcomes (GTO) model. Children and Youth Services Review, 33: 622-633.

Barth, R. P., Lee, B. R., Lindsey, M. A., Collins, K. S., Strieder, F., Chorpita, B. F., . . . Sparks, J. A. (2011). Evidence-Based Practice at a Crossroads: The Emergence of Common Elements and Factors. Research on Social Work Practice. doi: 10.1177/104973151140844

Bickman, L., Kelley, S. D., Breda, C., de Andrade, A. R., & Riemer, M. (2011). Effects of Routine Feedback to Clinicians on Mental Health Outcomes of Youths: Results of a Randomized Trial. Psychiatric Services, 62, 1423-1429.

Partial ReferencesDickinson, N.S., & Perry, R.E. (2002). Factors influencing the

retention of specially educated public child welfare workers. Evaluation Research in Child Welfare, 15(3/4), 89-103

Fixsen, D.L., Naoom, S.F., Blasé, K.A., Friedman, R.M., & Wallace, F. (2005). Implementation research: A syntnesis of the literature. Tampa: University of South Florida.

Fixsen, D.L., Blasé, K.A., Naoom, S.F., Wallace, F. (2009). Core implementation components. Research on Social Work Practice, 19(5), 531-540.

Glisson, C. Kukes, D., & Green, P. (2006). The effects of the ARC organizational intervention on caseworker turnover, climate, and culture in children’s service systems. Child Abuse & neglect, 30, 855-880.

Partial ReferencesSchoenwald, S. K., Garland, A. F., Southam-Gerow, M. A., Chorpita, B. F., & Chapman, J. E. (2011).

Adherence Measurement in Treatments for Disruptive Behavior Disorders: Pursuing Clear Vision Through Varied Lenses. [Article]. Clinical Psychology-Science and Practice, 18(4), 331-341. doi: 10.1111/j.1468-2850.2011.01264.x

Southam-Gerow, et al. (in press). MAPping Los Angeles County: Taking an evidence-informed model of mental health care to scale. Journal of Clinical Child and Adolescent Psychology.

Weisz, J. R., Chorpita, B. F., Palinkas, L. A., Schoenwald, S. K., Miranda, J., Bearman, S. K., . . . Res Network Youth, M. (2012). Testing Standard and Modular Designs for Psychotherapy Treating Depression, Anxiety, and Conduct Problems in Youth. [Article]. Archives of General Psychiatry, 69(3), 274-282. doi: 10.1001/archgenpsychiatry.2011.147

Weisz, J. R., Jensen-Doss, A., & Hawley, K. M. (2006). Evidence-based youth psychotherapies versus usual clinical care: A meta-analysis of direct comparisons. American Psychologist, 61, 671–689.

Weisz, J. R., Kuppens, S., & Eckshtain, D. (2011). Effects of psychotherapy with children and adolescents: Interim report of a meta-analysis. Unpublished manuscript, Harvard University, Cambridge, MA.

Zlotnik, J., DePanfilis, D., Daining, C., & Lane, M. (2005). Factors influencing the retention of child welfare staff: A systematic review of the research. Washington, DC: Institute for the Advancement of Social Work Research.