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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
(405) 271-8858
Contact Information
