Implementing PCIT in Field Agency Settings

1. Implementing PCIT in Field Agency Settings Mark Chaffin Beverly Funderburk University of Oklahoma Health Sciences Center

2. Plan • Review of PCIT • Lessons learned in implementation • Time for questions and discussion

3. PCIT? • Developed by Sheila Eyberg and colleagues at Univ. of Oregon and Univ. of Florida • Approximately 12-14 session dyadic, behavioral parent-training model originally designed as a treatment for disruptive behavior problems (ODD) among children 4-7years old • Key Feature—Live, direct coaching of parenting skills in interactions with child • Therapist coaches from behind one-way mirror • Parent wears wireless earphone (“bug in the ear”)

4. Time-Out Chair Video Camera Parent-Child Dyad Therapist Play Materials Table One-Way Mirror PCIT Set-Up Sound

5. Structure of PCIT • Two Phases • Child Direction Interaction (CDI)—teaches relationship enhancement skills, use of positive reinforcement, and ignoring minor misbehavior • Praise • Reflection • Imitation • Description • Enthusiasm • Avoid commands, criticisms, questioning, etc.

6. Structure of PCIT • Two Phases • Parent-Direction Interaction (PDI)—teaches discipline skills, minding • How to give specific instructions • Following step-by-step sequence for non-compliance • Consistency • Time-out and backups • Strategies for managing challenging situations (e.g., tantrum in grocery store)

7. PDI Discipline Skills Flow-Chart

8. PCIT Structure • Baseline assessment (including coding of parent-child interactions and behaviors) • Orientation and CDI Didactic • 3-4 CDI live-coached sessions. Weekly homework. • PDI Didactic • 5-6 PDI live-coached sessions. Weekly homework • All skills learned to criterion (may be extended somewhat if criteria are unmet) • Interactions re-checked each session and progress on behavior problems measured

9. Established Outcomes • Well-supported evidence-based model for disruptive behavior disorders in young children • Multiple outcome trials • Randomized trials • “Real-world” types of cases • Improvement in child externalizing behavior • Long-term maintenance of gain • Generalization from home to school setting • Generalization to untreated siblings in the same family • Improved parent-child relationship quality

10. Additional Applications Adapted as a Parent Treatment for physically abusive parents Randomized trial findings

11. Additional Populations and Adaptations • Adapted for children with FAS/FAE • Cultural variations • Puerto Rico • Hispanic (California) • Native American • Russia • Variations for older children (Oklahoma) • Adaptation to home-based services • Adaptation to group-based PCIT • PCIT mobile clinic for rural areas

12. Designations • Kauffman Foundation Best Practices • National Child Traumatic Stress Network • APA, Society on Clinical Child and Adolescent Psychology • Center for Evidence Based Practices • Children’s Bureau (ACYF) • SAMHSA Model Programs (in process) • OVC Guidelines Project • Washington State Institute for Public Policy (high cost-benefit)

13. So, Why Isn’t It More Widely Used? • Not new—been around for over 25 years • But • Training limited to academic research environments • Training usually follows a co-therapy training model (watch the master, do co-therapy with the master, the master watches you) • Limited access to trainers • Not marketed to front-line practitioners • As visibility has increased in recent years, demand for dissemination and implementation has skyrocketed

14. Implementing PCIT in Agency Settings • Our Current PCIT Implementation Projects Include: • CDC-funded trial for child welfare parents in field setting • SAMHSA/NCTSN project. Implementations in Utah, Washington, Alaska, and other states • NARCH (Native American Research Center for Health) implementation project • Multiple mental health agencies in Oklahoma • Fetal Alcohol Syndrome dissemination sites • Domestic violence shelter implementation sites

15. Implementation Issues • Forget “Train and Hope” – can’t rely on workshops alone. Ongoing directly observed practice with demonstration, feedback and consultation is important for good quality • PCIT implementation often requires an investment in infrastructure (equipment, rooms, etc.) • Scheduling equipment, rooms, etc. • Organizational issues—culture and climate • System externalities (e.g., PCIT requires both the parent and the child to be present, may be a problem for foster care populations) • Cost issues (e.g., more expensive to deliver than group-based parenting, cost of missed appointments greater than group models) • Problems with “mixing-and-matching” in therapy (e.g., poly-therapy). Drift. • Programs—not just individual therapists—need to be trained and developed

16. What Is Involved in PCIT Implementation? • Up-Front Site Commitment • Funding to develop infrastructure • Remodel for rooms with one-way mirrors • “Bug-in-the-ear” equipment • Video Cameras and audio equipment • Low end of around $5,000/room • Funding for staff training and supervision time (direct and opportunity costs) • Leadership commitment to develop and sustain a PCIT program, not just send therapists to a training workshop

17. What is Involved in PCIT Dissemination? • Commitment from Key Stakeholders • Will there be sufficient referrals to sustain a PCIT program? This may involve working not just with leadership (e.g., child welfare state office, school board) but also making sure the service will be utilized by the front-line (i.e., child welfare workers, teachers) • Commitment for necessary supports from the overall service system • Transportation for children and parents • Scheduling around school and work commitments • Avoiding so much therapy that adding PCIT and PCIT homework demands is too much • Where court-orders are involved, making sure these are written in a way that doesn’t conflict with PCIT (e.g., judges writing orders for “family therapy” then not accepting PCIT as fulfilling this order) • Payment mechanism in place sufficient to support the service

18. What is Involved in PCIT Implementation • Therapists • At least two, preferably more—a PCIT treatment team • Supervisor trained and committed to PCIT • Master’s degree or higher • Preferred individual therapist and key supervisor qualities • Knowledge and appreciation of behavioral theory • Personal dispositional innovativeness and willingness to try new things • Not a totally “mix-and-match” “free-styling” or “bag-of-tricks” therapist. Willing to stick with a protocol (this can be fixed with time) • Willing to practice in an open, visible way • High energy. Willing to work hard—PCIT requires more activity, planning and effort from the therapist. Therapist is “on” all the time • Collaborative—willing to share a case. PCIT therapists can switch off, work alone or together in combinations, pinch hit for each other, etc. This is not a “special, special intimate relationship with me and nobody else…..” kind of therapy.

19. What is Involved in PCIT Implementation? • Therapist Didactic Training • 40 hours of didactic • Typically done by a very experienced PCIT therapist(s) • Can be split up • Train CDI —> Do CDI • Train PDI —> Do PDI • Important to learn theory model as well as techniques • Includes direct observation of actual cases done by the trainer, role plays, etc. • Therapists trained to behavioral skill criterion for key PCIT skills

20. What is Involved in PCIT Implementation? • Post-Didactic Observation and Feedback • Our experience has been that even good trainees, with high enthusiasm, who did well in didactic training, met criteria and who sound like that have it, rarely actually have it in actual practice • We typically want direct observation of actual sessions for at least five (5) full completed cases • After this, periodic observation and consultation on difficult cases or protocol nuances. • Annual PCIT professional conference is available (which typically includes direct observation of established ‘masters’ at work)

21. Methods for Post-Didactic Observation and Feedback • The Classic PCIT Training Approach • Go be a grad student of postdoc somewhere and get trained • Go work somewhere and be a co-therapist with an established PCIT trainer • Have an established PCIT trainer visit your agency at least a full day every week for six months • Highly effective. Poor feasibility.

22. Methods for Post-Didactic Observation and Feedback • Substitutes for the Classic PCIT Training Approach • Traditional after-the-fact, second-hand, talk-about-what-you-did supervision • Very familiar to most practitioners • But, how people talk about what they did often poorly reflects what actually happened • Often does not correlate with outcomes • Traditional supervision, augmented with video tapes • How selected? • Can base feedback on actual observations • Delayed feedback • Can’t demonstrate a skill in session

23. Methods for Post-Didactic Observation and Feedback • Another option that we believe may be both feasible and preserve the advantages of the classic PCIT training approach • Using internet-based teleconferencing technology for live, real-time session observation and communication with the therapist. “Remote Real-Time” supervision (RRT).

24. Methods for Post-Didactic Observation and Feedback • Features of RRT supervision • The supervisor/expert can be located anywhere. Oklahoma City supervisors currently are observing live sessions in Salt Lake City, Seattle, Tulsa, Alaska, etc. • Supervisor sees and hears the parent/child dyad, also sees and hears the therapist. Therapist sees and hears the supervisor • Supervisor can talk privately to the therapist and vice versa during the session • Supervisor can take over coaching the parent during the session to demonstrate a skill • Can do this from your office (no video lab)

25. RRT Equipment • Clinic Site • High-speed internet connection (T1 or dedicated cable) • Teleconference equipment (sample on the right) • Room video camera and room audio wired into teleconferencing hardware • Bug-in-the-ear equipment on push-to-talk (so therapist can talk privately to supervisor, then push to talk to parent) • Supervisor Site • High-speed internet connection and teleconference equipment

26. Initial RRT Feasibility Testing • This a new use of a fairly mature technology, not a new technology. So, the quality of the sound, video, and the robustness of the technology have been very good • The actual performance of the system is very good • Therapist response has been good • Supervisor response has been enthusiastic—no traveling • Cost is significant (~$5,000 per site), but is not needed in perpetuity, so can be re-used sequentially at multiple sites • Some degree of on-site technical support for set up and initial troubleshooting is necessary