Implications and Challenges in Intergrating EBPWithin a Domestic Violence Agency

Introductions

Laura Greenstone, Assistant Coordinator, LPC, Board Certified Art Therapist, Certified in TF-CBT, Certified Trauma Therapist in ITR, Disaster Response Crisis Counselor, Approved Counselor Supervisor

Janet Lee, Supervisor of Domestic Violence Support Groups, Field Instructor, Licensed Clinical Social Worker, Certified in EMDR

Cindi Westendorf, Program Coordinator, LPC, Board-Certified Art Therapist and Certified in TF-CBT, Disaster Response Crisis Counselor

Evidenced Based or Evidenced SupportedEvidenced Based :

● Treatment based on best practices.

● Scientific, medical based model of

research involving IRB approval.

● Well-designed ,randomized controlled

trials.

● Results include sizable, sustained

benefits to participants and/or society.

● Political, societal and monetary

influences.

Evidence Supported:

● Treatment based on best practices.

● Positive outcomes, but lacks body of research to validate findings such as; size of studies and use of control groups.

● May lack funding.

● Community based interventions.

● Allows for more flexibility and complexity of subjects.Encourages innovation.

Overview of 180 ServicesSafe HouseTransitional Housing24 Hour HotlinesCounselingYouth HelplineCreative Arts TherapyCourt Liaison ProgramPrevention and TrainingRape CareFamily Justice Center

Amanda’s Easel uses creative experiences to promote healing and growth.

Services offered at Amanda’s Easel:

● Art Therapy, Music Therapy and Play Therapy● Parent Counseling● Case Management● Educational and Recreational Support● Childcare during program

The Art Therapy Studio

The Music Therapy Studio

The Play Therapy Room

Creative Arts TherapiesMaster’s Degrees with National Credentials• Art Therapy• Dance/Movement Therapy• Drama Therapy• Music Therapy

Post Master’s Credentials• Psychodrama• Poetry/Bibliotherapy

NCCATA An alliance of membership associations dedicated to the advancement of

the creative arts therapies professions. NCCATA represents over 15,000

individual members of six creative arts therapies associations nationwide.

Creative Arts Therapists are human service professionals who use distinct

arts-based methods and creative processes for the purpose of ameliorating

disability, illness and optimizing health and wellness.

National Coalition of Creative Arts Therapy Associations

North American Drama Therapy Association

American Art Therapy Association

American Dance Therapy Association

National Association of Poetry Association

American Society for Group Psychotherapy and Psychodrama

American Music Therapy Association

www.nccata.org

The Why of The Work

• DV clients with significant trauma histories has increased.

• Working with disrupted attachment is difficult without first addressing trauma.

• Addressing client need i.e., Shorter term interventions and treatment for PTSD.

Core Principles of Treatment • Mental health treatment for the children AND their

non-offending parent.• Strengthening the relationship (attachment) between

the non-offending parent and the child. • Education about domestic violence and common

childhood reactions, which can help normalize experiences and decrease sense of isolation.

http://www.nctsn.org/

The Adverse Childhood Experiences Study (ACE Study) is a research study conducted by the American health maintenance organization Kaiser Permanente and the Centers for Disease Control and Prevention. Participants were recruited to the study between 1995 and 1997 and have been in long-term follow up for health outcomes.

Adverse Childhood Experiences (ACEs) are common. Almost two-thirds of study participants reported at least one ACE, and more than one in five reported three or more ACEs.

http://www.acestudy.org/index.html

Educating About The Importance of EBP Within Your Agency

● Multi-layered approach.

● Support from senior administration.

● Initiation from leadership.

● Clinician implementation.

● Evaluation and supervision of clinical work.

Evidenced Based and Supported Services at 180...

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

TF-CBT Definition

● Trauma Focused Cognitive Behavioral Therapy is a components based, empirically supported treatment for children and adolescents exposed to traumatic life experiences.

● Children and caregivers are both involved in learning skills to process the trauma, manage distressing thoughts, feelings and behaviors while enhancing safety, parenting skills and healthier communication.

Training and Certification

In order to be considered certified to use TF-CBT you must:

● Be a mental health professional with a masters degree or above in related field

● Complete the online TF-CBT Web

● Participate in live TF-CBT (two day) training

● Participate in follow up consultation 2x month for at least 6 months

● Complete 3 separate treatment cases with three children/caregivers

● Use of at least ONE standard instrument to assess treatment progress

● Taking and passing of the TF-CBT Therapist Certification Program Knowledge based Test

TF-CBT Certification Costs

● Training is obtained through the NCTSN TF-CBT Learning Collaborative, TF-CBT Train the Trainer Program, AACAP, APSAC, ISTSS, or other privately arranged trainings (NJ, NY, PA). https://tfcbt.org/

● Training through the NCTSN Learning Collaborative is at cost of travel ONLY.

● Private trainings can cost approximately $2000-3000/day per trainer plus expenses.

● Other trainings vary dependent on individual costs of privately arranged conferences. Estimated Cost $500 and up).

Eye Movement Desensitization and Reprocessing (EMDR)

● Eye Movement Desensitization and Reprocessing.

● Evidence-based psychotherapy for treating trauma including Posttraumatic Stress Disorder.

● EMDRIA (EMDR International Association) states:

http://www.emdria.org/

The model is designed to address the maladaptive encoding of and/or incomplete processing of traumatic or disturbing adverse life experiences.

EMDR Definition

EMDR Practice Goals

● Amelioration of presenting symptoms

● Decrease or elimination of distress from disturbing memories

● Improved view of self

● Resolution of present and future anticipated triggers.

• Licensed or certified in their profession for independent practice

• Minimum of two years experience in their field.

• Completed an EMDRIA approved training program in EMDR therapy.

• Conducted a minimum of fifty clinical sessions in using EMDR.

• Received twenty hours of consultation in EMDR by an approved consultant;

• Completed 12 hours of continuing education in EMDR every two years.

Estimated Cost = $1,200 and up

EMDR Certification

Instinctual Trauma Response (ITR)

The ITR Method - The Process“An Art Therapy Informed Approach”

Developed by Louis Tinnin, M.D. and Linda Gantt, Ph.D., ATR-BC

www.helpfortrauma.com

● Evaluate for Dissociative Disorders ● Trauma timeline including pre-verbal traumas● Graphic Narrative● Re-presentation● Parts Work/Externalized Dialogue

● Repeat for each traumatic event in sequence

The Graphic Narrative“Creating a Corpus Callosum Bypass” (Tinnin, 2010)

● Responsible for transmitting neural messages between the left and right hemispheres.

● Images created in the graphic narrative “...gives the nonverbal brain a “voice” (“the image comes first”), “re-presenting” it to both sides of the brain at the same time, bypassing the need to transmit material via the corpus callosum.” (Gantt, 2017)

Training Levels and Costs - ITR

Level 1 = Basic Accelerated Traumatology Course - online course with

experiential exercises - $499

Level 2 = Level 1 + Live Practicum course. Must pass parameters established to

prove you can administer the ITR method to a client proficiently - $499

Level 3 = Certified Trauma Therapist in the ITR method (CTT) = Level 2 + 6

months of consultation calls (12 calls) + Do your own trauma processing work +

3 CEs every two years - $299

Certification = $1300

Community Collaboration

● Child Advocacy Centers Multi-Disciplinary Team

● Other mental Health Providers for Peer Consultation

● Department of Children and Families

● Like-minded institutions such as; The Cares Institute, Academic Settings, Community Providers.

Setting the Stage

Supporting the delivery of EBP needs to include:

○ Organizational Support and Capacity

○ Clinical Competence

○ Family and Youth Engagement

Organizational Support and Capacity

Agency leadership must:

○ Educate staff about benefits of implementing practice.

○ Provides access to training and resources.

○ Identifies funders and other stakeholders.

○ Addresses cost and reimbursement factors.

○ Arranges consistent supervision and consultation.

○ Addresses implementation issues such as; monitoring fidelity, and training new clinicians,

○ Account for the collection of data.

Clinical Competence

● Clinical competence in delivering EBP is a critical component of effective adoption.

● Understanding of the effects of trauma on child development and family systems.

● Adequate staff/client ratio to deliver treatment with efficacy and to fidelity.

● Ability to sustain both training and supervision for certified professionals.

● Oversight of implementation plan.

Family and Youth Engagement

● Therapists and staff educate caregivers and youth provide psycho-education throughout participation.

● Provide rationale for any assessments administered.

● Engage caregivers and youth in all treatment planning, setting of goals and resources.

● Caregiver engagement in treatment needs to be routinely evaluated.

Funding Opportunities and Challenges: Public Monies

Evidenced based/supported services demonstrate clear impact such as, reducing recidivism, less lethal cases, improved outcomes, etc.

● Public monies (County, State, Federal) are the cornerstone of funding for programs, but require additional monies from other funders.

● Public dollars are substantial funding with clearly defined parameters.

● Public monies are less risk tolerant.

Funding Opportunities and Challenges: Private Monies

• Private dollars can be more flexible

○ Designated (Foundation grants)

○ Undesignated (Fundraising)

• Private monies can address specific community needs.

• Private dollars can support innovation.

The moral of the story: private and public partnership is the perfect marriage!

Outcomes & Pre and Post

Evaluation

Satisfaction Surveys - All

UCLA - TF-CBT

Trauma History Checklist - TF-CBT

Trauma Symptom Inventory - PALS

Parenting Stress Index - PALS

Dissociative Regression Scale - ITR

Trauma Recovery Scale – ITR

Implementation at 180

Case Vignette: TF-CBT

Components that address Trauma●Psychoeducation and Parenting

●Relaxation

●Affect Regulation

●Cognitive Coping

●Trauma Narrative

●In Vivo Exposure

●Conjoint Parent Child Sessions

●Enhancing Safety

No One Has Ever Asked

●Twelve year old Female (oldest of two girls)

●Extreme parentification due to Mothers depression/victimization

●Protective of family including abusive Father

●Withdrawn and isolated

●Took to the art and narrative work immediately

●Post evaluation described her gratefulness for being asked what happened

Case Vignette: EMDR

Case Vignette: ITR

The Graphic Narrative

● Startle

● Thwarted Intention

● Freeze

● Altered State

● Body Sensations

● Automatic Obedience

● Self Repair

5 Year Post Client Interview:

“Talking therapy never worked for me…(The art) helped me put the images out of my mind and out of my psyche…My brain was not repeating it anymore…The trauma felt over.”

Discussion: What shifts in funding are you witnessing?

Shifting to EBP within a DV agency requires a broader systemic change.

● How do you address this need? (Psycho-education AND clinical services for trauma treatment).

● Evidenced Based/Supported Services require qualified clinicians to administer services. How do you sustain the associated costs?

● Funding opportunities: billable mental health services within DV agencies? Benefits and challenges?

Thanks!

Contact us:

180 Turning Lives Around, Inc.732.264-4360

Cindiw@180nj.orgLaurag@180nj.orgJanetl@180nj.org