Out of the Laboratories and Into the StreetsFuture Directions for PCIT in a Broad Range of Field Set

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Out of the Laboratories and Into the
StreetsFuture Directions for PCIT in a Broad
Range of Field Settings

• Mark Chaffin, Ph.D.
• University of Oklahoma Health Sciences Center

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Overview

• Why pick PCIT as a model for widespread
  implementation?
• What makes field settings different from research
  settings?
• Using technology to make it work
• Adaptation
• Thinking about a services research agenda

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Why Pick PCIT as a Model For Widespread
Implementation?

• Effective and Robust
• Across a range of children
• Across a range of problems
• Disruptive behavior disorders among young
  children
• Parent-to-child violence (physical child abuse)
• Parent-child relationship problems
• Adaptable across cultures
• Native-American adaptations
• Hispanic adaptations
• Effects durable over time, generalize across
  settings and across children in the family
• Ancillary benefits (e.g., parental depression)
• Teachable-learnable

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Kauffman Best Practices Project for Child Abuse
and Neglect
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National Child Traumatic Stress Network

• 50 centers nationally, funded by SAMHSA
• The mission of the NCTSN is to raise the standard
  of care and improve access to services for
  traumatized children, their families and
  communities throughout the United States
• PCIT is one of two major models selected for
  implementation

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Other Endorsements Moving PCIT Into Widespread
Implementation

• Office for Victims of Crime Guidelines
• APA Society of Clinical Child and Adolescent EBT
  Designation
• SAMHSA Model Programs List (in process)
• Washington State Institute for Public Policy List
  of Cost-Effective Models
• Federal Agencies Supporting Work
• NIH, CDC, SAMHSA

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Why Pick PCIT for Widespread Implementation?

• The questions is actually moot. Its been picked
  already
• The question now is HOW to implement PCIT in the
  growing number of field sites wanting to pick up
  the model

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What makes field settings different from research
settings?

• Academic Settings
• Doctoral and post-doctoral training programs
  lasting a year or more
• Graduate students and fellows
• Controlled and structured
• Long-term training and supervision by on-site
  faculty, usually with extensive PCIT experience
• Strong evidence-based culture
• Stable group of PCIT experts
• Relatively independent of system externalities
• Resource rich
• Climate promoting professional growth

• Field Settings
• Diverse field settings, often small
  community-based agencies
• Variety of staff backgrounds
• Less structured and controlled
• Usually no access to on-site expertise
• Evidence-based culture?
• Staff turnover?
• Very dependent on system externalities
• Resources?
• Climate? Burn-out?

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Reputation of Evidence-Based Treatments In Field
Settings?

• The Big Lies about evidence-based treatments
• Evidence-based practices are only developed with
  patients that one kind of problemour real-world
  clients have multiple problems
• FactPCIT (and most other EBTs) have been
  developed and tested with highly co-morbid and
  multi-problem populations
• Its therapist characteristics, not models that
  make treatment work
• FactSome PCIT therapists get better results than
  others, but so what? Both models and therapist
  factors matterwho ever claimed otherwise?
• Manuals are rigid and lock-step and dont
  anticipate inevitable case idiosyncrasies
• This is why you need to learn the theory and not
  just the manual. Getting competent with the
  model is the point, not being lock-step

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Reputation of Evidence-Based Treatments In Field
Settings?

• The Big Lies about evidence-based treatments
• Evidence-based practices are only developed for
  white middle-class populations and arent
  relevant for other groups
• Where have you been? Certainly not reading the
  PCIT research, thats for sure
• A common finding is that cultural adaptations to
  a treatment improve retention and engagement
  (which is good) more than they change
  outcomesmost EBT yield equivalent benefits
  across subgroups
• Culturally competent adaptations of PCIT are
  found to work welland retain the core elements
  of PCIT
• Besides, whats the alternativegiving minority
  populations untested and unsupported
  interventions? Isnt this just creating the care
  disparities we need to be working to eliminate?

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Making Implementation Work

• Consider organizational context
• Support for a sustainable PCIT program within an
  agency or practice
• You are setting up a program not training
  individual therapist(s)
• Minimum number of therapists
• Leadership commitment
• Funding base and reimbursement
• Organizational climate
• Is this a healthy organization or a burned out
  organization?
• Value placed on innovation and risk taking,
  versus value placed on conformity and CYA

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Making Implementation Work

• Consider organizational culture
• How we do things around here
• Behavioral skill focus
• Hard to get PCIT buy-in among staff committed to
  resolving underlying issues
• Level of therapist activity
• PCIT, like most EBT, require much higher level of
  therapist preparation and activitymay be very
  unfamiliar for go-with-the-flow or free-styling
  therapist cultures
• The poly-therapy culture
• A therapy for every problememerging evidence
  suggests that this reduces the effectiveness of
  parenting programs

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Making Implementation Work

• Consider externalities and practicalities
• Referral
• Referral flow established
• Practices/attitudes of child welfare system or
  court systems
• Acceptability of PCIT for referral systems
• Will it fit with the way service plans are
  drafted by CW and court?
• Transportation, especially where children are in
  foster care
• Funding (sufficient to support failed appointment
  costs)
• Setting up a structure for make-up sessions

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Making Implementation WorkBeyond the Train and
Hope Approach
From Joyce and Showers meta-analysis, 2002
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What Happens After Training?

• Hurlburt follow-up of TIY trainees
• Phone interview of trainees who, after training
  to criteria, returned to field practice settings
• Very few were implementing the model as designed
• A high percentage had dropped key elements of
  the modelsuch as behavioral rehearsal of
  parenting skills
• Our anecdotal experience at OUHSC is that
  significant drift from the PCIT model occurs
  despite strong commitment from field
  practitioners to do it right, and that this drift
  is not apparent in verbal consultation (the
  practitioner believes they have it right, and it
  sounds right in consultation)

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How Can Technology Help Us With Ongoing Coaching?

• Remote real-time (RRT) consultation
• Designed to approximate the usual PCIT co-therapy
  supervision approach
• Internet-based teleconferencing technology
• Allows consultant to
• Work directly with a PCIT trainee from anywhere
• View PCIT session in real-time
• Directly coach the PCIT therapist as the session
  is in process
• Take over coaching the parent to demonstrate
• Allows the PCIT therapist to
• Talk privately with consultant about session as
  it is in process
• Compare DPICS codings
• Receive feedback on coaching as it occurs

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What AboutDrift / Adaptation

• What is the difference between drift and
  adaptation?
• Drift is what you do, adaptation is what I do
• The dilemma
• Drift, where evaluated, usually results in poorer
  outcomes
• Adaptation, to some extent, often is necessary to
  make things work in some settings
• Adaptation, if done thoughtfully and well
  evaluated, can lead to growth, enrichment and
  development of a model
• We shouldnt tell field practitioners value
  innovation, value continuous quality improvement,
  but dont try it yourselfleave it to us
  academics

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The Drift / Adaptation Dilemma

• A proposed distinction
• Adaptation involves field practitioners in
  collaboration with model experts
• Perhaps additionally in collaboration with input
  from consumers
• Adaptation stays within the overall theory
  modelit doesnt mix-and-match ad hoc
• Adaptation is evaluated to see if it is achieving
  its intended goals

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Thinking About a PCIT Services Research Agenda

• Laboratory work will continue to be important
• But, it is time to begin moving much of our
  research focus into the services areafield based
• Questions not so much about can it work, but
  how do you make it work in diverse settings
• Questions about how PCIT will continue to evolve
  to suit field settings and improve field outcomes

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Evidence-Based Practice in the Field

• Broadly, Evidence-Based Practice (EBP) is not
  simply a group of Evidence-Based Treatments
  (EBT).
• It is a process for how treatments are developed,
  tested, adapted and how they evolve
• All treatments evolvethe question is about the
  form of natural selection that guides this
  evolution
• EBP is a form of natural selection based on
  rigorous outcome testing, rather than the usual
  ideology-based processes guiding treatment
  development and evolution

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A PCIT Evolution Agenda

• Partnerships between
• Those who develop the service model
• Those who evaluate outcomes
• Those who deliver PCIT in the field

Developers
Front-Line Practitioners
Outcome Researchers
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What Questions Can Partnerships Answer?

• How Do We Optimally and Efficiently Train and
  Implement PCIT?
• What Modifications Work and With Whom?
• Group models?
• Home-based?
• Cultural Adaptations?
• What Practices Can Improve Retention, Adherence
  to Homework, etc. in Field Settings?
• What Training Backgrounds Are Necessary to Do
  PCIT Well?
• What Happens When PCIT is Integrated Into Overall
  Service Packages (e.g., Family Preservation)?

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What Do We Need to Realize This?

• Consistent data, across sites
• Outcomes
• Fidelity and treatment content
• Data at multiple levels
• Organizational
• Individual Therapist
• Client
• Willingness of
• Researchers to accommodate less than laboratory
  levels of internal controls
• Practitioners to accommodate needs for
  consistency in data and practices (no
  free-styling practice)
• Willingness of policy makers and service delivery
  funders to support rigorous outcome evaluation
  and quality improvement effortsnot just funding
  units of service

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Implementing EBTTHE DREAM
IF YOU BUILD IT.
Thanks to Jim Emslie and Linda Anne Valle
THEY WILL COME
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Implementing EBTTHE REALITY
IF YOU BUILD IT.
Thanks to Jim Emslie and Linda Anne Valle
THEY WONT KNOW
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Implementing EBTTHE REALITY
IF YOU BUILD IT.
Thanks to Jim Emslie and Linda Anne Valle
THEY MAY LIKE THE ONE THEY BUILT BETTER
(even if it doesnt work.but, they may not know
this)
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Implementing EBTTHE REALITY
IF YOU BUILD IT.
Thanks to Jim Emslie and Linda Anne Valle
THEY WILL TRY TO COME, BUT THE MAP YOU SENT
WASNT WRITTEN IN THEIR LANGUAGE
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Implementing EBTTHE REALITY
IF YOU BUILD IT.
Thanks to Jim Emslie and Linda Anne Valle
THEY MAY WANT TO COME, BUT DONT HAVE THE TIME
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Implementing EBTTHE REALITY
IF YOU BUILD IT.
Thanks to Jim Emslie and Linda Anne Valle
THEY MAY WANT TO COME, BUT CANT AFFORD ADMISSION
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Implementing EBTTHE REALITY
IF YOU BUILD IT.
Thanks to Jim Emslie and Linda Anne Valle
THEY MAY WANT TO COME, BUT YOU DONT HAVE ROOM
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Implementing EBTTHE REALITY
IF YOU BUILD IT.
Thanks to Jim Emslie and Linda Anne Valle
THEY WILL TRY TO COME, BUT END UP NEXT DOOR
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Implementing EBTTHE REALITY
IF YOU BUILD IT.
Thanks to Jim Emslie and Linda Anne Valle
THEY WILL TRY TO COME, BUT YOU FORGOT TO BUILD A
GATE TO LET THEM IN
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Implementing EBTTHE REALITY
IF YOU BUILD IT.
Thanks to Jim Emslie and Linda Anne Valle
THEY WILL COME
THEN DECIDE TO REMODEL IT UNTIL IT NO LONGER
RESEMBLES WHAT YOU BUILT
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Implementing EBT
IF WE BUILD IT JOINTLY.
THEN WERE BOTH ALREADY HERE