Implementing PCIT in Field Agency Settings

Mark ChaffinBeverly FunderburkUniversity of Oklahoma Health Sciences Center

Plan

Review of PCIT Lessons learned in implementation Time for questions and discussion

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”)

Play Materials

Table

PCIT Set-Up

Time-Out ChairVideo Camera

Parent-Child

Dyad

Therapist

One-Way Mirror

Sound

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.

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)

PDI Discipline Skills Flow-Chart

Obey

ObeyDisobey

Labeled praise

Time- out (3 min)

Stays on

Command

Two choices

Return to task Obey Acknowledge

DisobeyTime-

out chair

Gets offWarning

1 per timeoutStays on Return to task Obey Acknowledge

Disobey Time- out chair

Gets off Time- out chair

Disobey

Labeled praise

Thank you for minding me right away

Thank you for minding . Now you don’t have to go to time out.

You have two choices: you can___ or go to time out

You didn’t choose to mind, so you have to sit in time out.

Stay on the chair until I say you can get off.

Stay there until I tell you to get off

Are you ready to __?

All right.

If you get off the chair again___(set backup)

Backup

You got off the chair, so __(say backup)

(Repeat for no more than 3 backups)

Wait ___seconds

O.k.

1999, The Alternatives for Families (AFF), CCAN, OUHSC

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

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

Additional Applications

Adapted as a Parent Treatment for physically abusive parents

Randomized trial findings

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

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)

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

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

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

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

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

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.

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

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)

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.

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

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).

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)

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

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