Merging In-Home Family Preservation
Services and Evidence-Based
Trauma Therapy
Mark R. Groner, MSSA, LISW-S
Carol Hoffstetter, MSW, LISW-S
Steven Fratantonio, MA, PCC
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Beech Brook, providing 165 years of
hope to children and families.
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Learning Objectives

Participants will learn basic concepts associated
with Family Preservation Services, Trauma-Focused
Cognitive Behavioral Thera[p (TF-CBT) and
Alternative to Families Cognitive Behavioral Therapy
(AF-CBT)

Participants will gain an understanding about how
TF-CBT and AF-CBT can be delivered effectively as
a component of Family Preservation Services.

Participants will learn the advantages and
challenges of implementing evidence-based
therapies in a home environment.
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A word about our history of being an
early adopter of trauma-informed care.
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Our approach has included:

Use of an internal Trauma-Informed Care
Team with ongoing self-study and
continuous performance improvement
activities.

Use of state and national learning
communities to advance understanding.

Development of internal trauma experts

Use of evidence-based trauma-informed
care practice models
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Why is a trauma-informed care approach so
essential?
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Let’s define “trauma,” “complex trauma,”
and “secondary traumatic stress.”
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What kinds of experiences result in
trauma? What aspects of child
development get derailed?
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Psychological Trauma Impacts the Brain
Part of Brain
Role
Amygdala (becomes Management of
over-reactive)
emotions
Impact
Emotional dysregulation
Hippocampus
(shrinks)
Memory and memory Impaired memory
consolidation
Broca (gets smaller
and deactivated)
Speech
Prefrontal Cortex
Executive functioning Impaired thinking,
judgment, and processing
Cortisol (gets overproduced)
Hormone (chemical
secreted by an
endocrine gland)
Norepinephrine (gets Neurochemical
released)
(chemical released
from a nerve cell)
Shuts down speech
Triggers amygdala
resulting in fight, flight,
freeze responses
Hypervigilence
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Definition of Trauma-Informed
Screening and Assessment
 Trauma-informed
screening: a brief,
focused inquiry, often in the form of a tool,
to determine whether or not an individual
has experienced specific traumatic events.
 Trauma
assessment: a more in-depth
exploration of the nature and severity of the
traumatic events, the sequelae of those
events, and current trauma-related
symptoms.
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Our general approaches to trauma
treatment
1. Provide and ensure safety.
2. Fix a broken system.
3. Maintain a positive and consistent therapeutic
relationship.
4. Tailor the therapy, taking into consideration client
realities.
5. Take gender and sociocultural issues into account.
6. Practice ethically, within sound standards of care,
and with appropriate boundaries to prevent
“counteractivation” (unwittingly becoming unduly
assertive or passive).
7. Take care of yourself and your team.
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Models of trauma treatment
Over 500 documented treatments
available for children and adolescents
(Kazdin, 2000).
NCTSN lists over 40 evidence informed
treatments that focus specifically on
trauma and new ones are constantly
being developed (NCTSN at
http://www.nctsn.org/resources/topics/treatments-that-work/promisingpractices
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Models of in-home family
intervention
Family Preservation Services
Intensive Home-Based Treatment
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Evidenced
Based Practices
TF-CBT AND AF-CBT
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What is TF-CBT?

Trauma Focused Cognitive Behavioral Therapy (TF-CBT)
A structured, evidence based model of therapy that addresses the unique
biopsychosocial needs of children with PTSD or other problems related to
traumatic life experiences

A hybrid treatment model that integrates:
Trauma sensitive interventions
principles
Attachment theory
Family Therapy
Humanistic Therapy
Cognitive-behavioral
Developmental Neurobiology
Empowerment Therapy
For Whom IS TF-CBT
Appropriate?
• Children with known trauma history- single or
multiple, any type
• Children with prominent trauma symptoms (PTSD,
depression, anxiety, with or without behavioral
problems)
• Children with severe behavior problems may need
additional or alternative interventions
• Parental/caretaker involvement is optimal
-However, PTSD improves even in the absence of caretaker
involvement
For Whom is TF-CBT Appropriate (cont’d)
Treatment settings: clinic, school, residential, home,
inpatient
Treatment length:
- 12-25 sessions
- Child and parent sessions
TF-CBT is appropriate for the following groups:
- Children in foster care
- Children with exposure to chronic trauma
- Children with PTSD or other trauma symptoms
- Children ages 3-17
- Children with PDD who function at higher level
- Children of different cultural groups
Treatment Research
• Studies have been conducted with children
exposed to sexual abuse, domestic violence,
traumatic, losses, and multiple traumas.
• Improved PTSD, depression, anxiety, shame
and behavior problems compared to clientcentered or nondirective therapy. PTSD
improved more with direct child treatment.
• Improved parental distress, parental PTSD,
parental support, and parental depression.
TF-CBT Components
PRACTICE
Psychoeducation and Parenting Skills
 Relaxation
 Affective Modulation
 Cognitive Processing
 Trauma Narrative
 In Vivo Desensitization
 Conjoint parent-child sessions
 Enhancing safety and social skills

Psycho Education
•
•
•
•
Teach, normalize and validate the symptoms and experiences of PTSD
Normalize the exposure to trauma
Help to decrease the self blame
Describe the TF-CBT components and structure
Parenting Skills
•
•
•
•
Educate the caregiver on Trauma and it’s impacts on
development/behaviors
Improve the relationship
Help the caregiver learn skills to manage difficult/inappropriate
behaviors
Help support the caregiver to support the child through the TF-CBT
model
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PRACTICE Skills (cont’d)
Relaxation/Stress Management
 Provide client skills to manage distress and lower the body’s alarm system
 Teach client difference between relaxation and distress tolerance
 Give client a tool box of skills
Breathing exercises
- Grounding techniques
Progressive muscles relaxation - Mindfulness activities
Thought stopping
- Guided imagery
Affect Modulation

Help clients identify feelings





All feelings are ok
Multiple/conflicting feelings are ok
Feeling intensity
Identify things to do when feeling sad, mad, anxious, etc.
Identify feelings associated with traumatic event
PRACTICE Skills (cont’d)
Cognitive Coping
•
•
•
•
•
Teach about the Cognitive Triangle
Help client access automatic thoughts
• Helpful or not helpful
Practice the skill of developing many ways to thing about a given situation
Practice the skill of being able to change thoughts, feelings, and behaviors
Positive self talk, challenge thinking errors
Trauma Narrative
•
•
•
Provide exposure to trauma-related memories while helping to identify unhelpful or
inaccurate cognitions that need to be processed
Help the child gain mastery over trauma reminders and reduce avoidance
Help put the traumatic exposure into context (other good things-future hopes)
-Break the narrative into chapters
-Use words, pictures, poems, drawings, and songs
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PRACTICE Skills (cont’d)
In-Vivo Exposure
•
•
•
Reduce avoidance that interferes with daily functioning
Separate harmless trauma reminders or triggers from fear
Gradual exposure, dealing with remaining avoidant behaviors
Conjoint Parent Child Sessions
•
•
•
Provide opportunity for support, praise and encouragement from caregiver
Sharing and praise for progress made
Trauma narrative sharing from child’s perspective
Enhancing Future Safety and
Development
•
•
•
Develop a plan to maintain safety
Teaching and reviewing safety skills for client and caregiver to use while no longer
in therapy
Personal safety spaces/boundaries
Alternatives for Families Cognitive
Behavioral Therapy (AFCBT)
A model focusing on working with families that experience frequent conflicts that
may result in excessive arguments or use of physical force or discipline.
Appropriate for use with families who are physically coercive, for child behavior
problems and trauma symptoms, family conflict, and caregiver verbal aggression,
emotional abuse, harsh or ineffective discipline, and child physical abuse
 Adopts a comprehensive approach to treatment targeting the contributors of the
angry and aggressive behaviors and the impact of these behavior's on a child’s
development and trauma /PTSD symptoms
 Must have a parent/caregiver willing to participate
 5-17 years of age
 The model is designed to help parents take responsibility for what has occurred
and learn new ways of problem solving, conflict resolution and parenting skills.
 Primary used in outpatient and in-home settings
 Has been used and reviewed with urban African American families but not
designed for any one ethic group.
 Aims to enhance individual competencies, caregiver-child relationships, and
family interactions.
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AF-CBT draws from:
Learning/behavioral theory
Cognitive Therapy
Victimology
Psychology of aggression
Family systems
Developmental
The Model broken into 3 phrases:
1) Engagement and Psychoeducation,
2) Individual Skill-Building, and
3) Family Applications.
Within each of these phases, clinicians use specific skills, roleplay exercises, performance feedback, home practice exercises,
handouts, and training examples on 15 specific topics designed
for the caregiver, child or both together.
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Outcomes of AFCBT
Kolko, 1966, Kolko et al., 2011, 2012, 2014
• Caregiver/child
verbal and physical
aggression
• Family conflict
• Recidivism
(caregiver)
• Child safety
• Child social
competence
• Parental
nurturing
• Family cohesion
Phase I: Engagement and
Psychoeducation

Topic 1: Orientation (Caregiver and Child)
◦ Description of the Model, discussion of other services, building rapport and
discussion of homework

Topic 2: Alliance Building and Engagement (Caregiver)
◦ Exploring coping skills, pros/cons of treatment participation, identify goals
 Topic 3: Learning about Family Experiences (Child)
◦ Feeling identification, gain child’s perspective on the incident, psycho
education on abuse, start to develop a plan for safety/alternative behaviors

Topic 4:Talking about Parenting and Psychoeducation
(Caregiver)
◦
◦
◦
◦
Review and process caregiver upbringing and exposure to abuse
Psycho education regarding effects of abuse and force
Explore the incident of abuse
Discuss and initiate a plan for alternative behaviors/safety
Phase II: Individual Skill-Building

Topic 5: Emotion Regulation (Caregiver)
◦ ABC model, Anger/Anxious- explore it and ways to control it, teach and practice
relaxation skills, develop a relaxation plan
 Topic 6: Emotion Regulation (Child)
◦ Same as caregiver session

Topic 7: Restructuring Thoughts (Caregiver)
◦ Review ABC model/triangle, explain role of cognitive coping, practice thought
restructuring, explore expectations of child’s behavior and begin to explain
clarification letter

Topic 8: Restructuring Thoughts (Child)
◦ Review ABC model/triangle, explain role of cognitive coping, positive self
statements, positive imagery, support child in making meaning of the abuse

Topic 9: Noticing Positive Behavior (Caregiver)
◦ Review ABC model, parenting styles/training, coaching skills, clarification letter
Phase II: Individual SkillBuilding
 Topic 10: Assertiveness and Social Skills (Child)
◦ Explore social skills and teach assertiveness skills

Topic 11: Techniques for Managing Behavior
(Caregiver)
◦ Effective discipline skills, active ignoring, positive reinforcement, clarification
letter

Topic 12: Imaginal Exposure – for PTSD (Child)
◦ Prepare child for clarification letter, self-regulation skills

Topic 13: Preparation for Clarification (Caregiver)
◦ Review caregiver progress with use of skills learned, begin to draft clarification
letter while highlighting specific content for caregiver
Phase III: Family Application

Topic 14: Verbalizing Healthy Communication (Caregiver
and Child)
◦ Identify and practice communication skills

Topic 15: Enhancing Safety through Clarification
(Caregiver and Child)
◦ Sharing of the clarification letter

Topic 16: Solving Family Problems (Caregiver and Child)
◦ Review model and steps of problem solving, process it’s utilization and continuation
after therapy is over

Topic 17: Graduation (Caregiver and Child)
◦ Review progress and routines, identify how to maintain progress on family plan
◦ Celebrate the successes.
Case
Presentation
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Case Presentation Details
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“Amber” 17yr. old, African American Female
Intensive in-home referral for Family Preservation Services
◦ BMO’s attempted SI, thoughts of harming her children
◦ Due to Amber’s defiance, argumentative and violent towards
BMO, and BMO’s in-effective parenting skills
◦ 2nd round of Family Preservation Services
Adjustment Disorder with Mixed Disturbance of Emotions and
Conduct
Lives with BMO, BMO’s boyfriend and half-sister
Amber has a history of neglect and loss from a young age

What treatment approaches would you
try?
 Think EBP!
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