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Out of the Laboratories and Into the Streets—Future Directions for PCIT in a Broad Range of Field Settings. Mark Chaffin, Ph.D. University of Oklahoma Health Sciences Center. Overview. Why pick PCIT as a model for widespread implementation?

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Out of the Laboratories and Into the Streets—Future Directions for PCIT in a Broad Range of Field Settings

Mark Chaffin, Ph.D.

University of Oklahoma Health Sciences Center


Overview
Overview Directions for PCIT in a Broad Range of Field Settings

  • 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


Why pick pcit as a model for widespread implementation
Why Pick PCIT as a Model For Widespread Implementation? Directions for PCIT in a Broad Range of Field Settings

  • 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


Kauffman best practices project for child abuse and neglect
Kauffman Best Practices Project for Child Abuse and Neglect Directions for PCIT in a Broad Range of Field Settings


National child traumatic stress network
National Child Traumatic Stress Network Directions for PCIT in a Broad Range of Field Settings

  • 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


Other endorsements moving pcit into widespread implementation
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


Why pick pcit for widespread implementation
Why Pick PCIT for Widespread Implementation? 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


What makes field settings different from research settings

Academic Settings Implementation

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?

What makes field settings different from research settings?


Reputation of evidence based treatments in field settings
Reputation of Evidence-Based Treatments In Field Settings? Implementation

  • The “Big Lies” about evidence-based treatments

    • “Evidence-based practices are only developed with patients that one kind of problem—our real-world clients have multiple problems”

      • Fact—PCIT (and most other EBT’s) have been developed and tested with highly co-morbid and multi-problem populations

    • “Its therapist characteristics, not models that make treatment work”

      • Fact—Some PCIT therapists get better results than others, but so what? Both models and therapist factors matter—who ever claimed otherwise?

    • “Manuals are rigid and lock-step and don’t 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


Reputation of evidence based treatments in field settings1
Reputation of Evidence-Based Treatments In Field Settings? Implementation

  • The “Big Lies” about evidence-based treatments

    • “Evidence-based practices are only developed for white middle-class populations and aren’t relevant for other groups”

      • Where have you been? Certainly not reading the PCIT research, that’s for sure

      • A common finding is that cultural adaptations to a treatment improve retention and engagement (which is good) more than they change outcomes—most EBT yield equivalent benefits across subgroups

      • Culturally competent adaptations of PCIT are found to work well—and retain the core elements of PCIT

      • Besides, what’s the alternative—giving minority populations untested and unsupported interventions? Isn’t this just creating the care disparities we need to be working to eliminate?


Making implementation work
Making Implementation Work Implementation

  • 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


Making implementation work1
Making Implementation Work Implementation

  • 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 activity—may be very unfamiliar for go-with-the-flow or free-styling therapist cultures

    • The “poly-therapy” culture

      • A therapy for every problem—emerging evidence suggests that this reduces the effectiveness of parenting programs


Making implementation work2
Making Implementation Work Implementation

  • 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


Making implementation work beyond the train and hope approach
Making Implementation Work—Beyond the “Train and Hope” Approach

From Joyce and Showers meta-analysis, 2002


What happens after training
What Happens After Training? Approach

  • 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 model—such 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)


How can technology help us with ongoing coaching
How Can Technology Help Us With Ongoing Coaching? Approach

  • 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


What about drift adaptation
What About“Drift” / “Adaptation” Approach

  • 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 shouldn’t tell field practitioners— “value innovation, value continuous quality improvement, but don’t try it yourself—leave it to us academics”


The drift adaptation dilemma
The “Drift” / “Adaptation” Dilemma Approach

  • 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 model—it doesn’t mix-and-match ad hoc

    • Adaptation is evaluated to see if it is achieving its intended goals


Thinking about a pcit services research agenda
Thinking About a PCIT Services Research Agenda Approach

  • Laboratory work will continue to be important

  • But, it is time to begin moving much of our research focus into the services area—field 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


Evidence based practice in the field
Evidence-Based Practice in the Field Approach

  • 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 evolve—the 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


A pcit evolution agenda
A PCIT Evolution Agenda Approach

  • 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


What questions can partnerships answer
What Questions Can Partnerships Answer? Approach

  • 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)?


What do we need to realize this
What Do We Need to Realize This? Approach

  • 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 efforts—not just funding “units of service”


Implementing ebt the dream
Implementing EBT—THE DREAM Approach

IF YOU BUILD IT……….

Thanks to Jim Emslie and Linda Anne Valle

THEY WILL COME


Implementing ebt the reality
Implementing EBT—THE REALITY Approach

IF YOU BUILD IT……….

Thanks to Jim Emslie and Linda Anne Valle

THEY WON’T KNOW


Implementing ebt the reality1
Implementing EBT—THE REALITY Approach

IF YOU BUILD IT……….

Thanks to Jim Emslie and Linda Anne Valle

THEY MAY LIKE THE ONE THEY BUILT BETTER

(even if it doesn’t work….but, they may not know this)


Implementing ebt the reality2
Implementing EBT—THE REALITY Approach

IF YOU BUILD IT……….

Thanks to Jim Emslie and Linda Anne Valle

THEY WILL TRY TO COME, BUT THE MAP YOU SENT WASN’T WRITTEN IN THEIR LANGUAGE


Implementing ebt the reality3
Implementing EBT—THE REALITY Approach

IF YOU BUILD IT……….

Thanks to Jim Emslie and Linda Anne Valle

THEY MAY WANT TO COME, BUT DON’T HAVE THE TIME


Implementing ebt the reality4
Implementing EBT—THE REALITY Approach

IF YOU BUILD IT……….

Thanks to Jim Emslie and Linda Anne Valle

THEY MAY WANT TO COME, BUT CAN’T AFFORD ADMISSION


Implementing ebt the reality5
Implementing EBT—THE REALITY Approach

IF YOU BUILD IT……….

Thanks to Jim Emslie and Linda Anne Valle

THEY MAY WANT TO COME, BUT YOU DON’T HAVE ROOM


Implementing ebt the reality6
Implementing EBT—THE REALITY Approach

IF YOU BUILD IT……….

Thanks to Jim Emslie and Linda Anne Valle

THEY WILL TRY TO COME, BUT END UP NEXT DOOR


Implementing ebt the reality7
Implementing EBT—THE REALITY Approach

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


Implementing ebt the reality8
Implementing EBT—THE REALITY Approach

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


Implementing ebt
Implementing EBT Approach

IF WE BUILD IT JOINTLY…….

THEN WE’RE BOTH ALREADY HERE


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