Disseminating TF‐CBT: A Mixed Methods Investigation of Clinician Perspectives and the Impact of Training Format and Formalized Problem‐Solving Approaches on Implementation Outcomes

Abstract

Background: Trauma Focused-Cognitive Behavioural Therapy (TF-CBT) has been established as an evidence-based treatment for youth with traumatic stress symptoms. The versatility of TF-CBT in conjunction with its established effectiveness has led to its widespread dissemination. However, dissemination efforts have not always translated into sustainability, which has prompted a more thorough investigation into those factors that impact implementation and encouraged the development of strategies that promote sustainability. Toward this end, the aims of this study were to: (1) determine which components of TF-CBT clinicians found the most difficult to implement; (2) explore clinicians' perceptions as to why these components were challenging; and (3) examine whether the use of formalized problem-solving approaches (FPSAs) or training format was associated with implementation outcomes. Methods: A mixed methods design was utilized to analyse survey data from mental health professionals (N = 85) who received TF-CBT training. Thematic analysis explored responses to questions concerning those TF-CBT components respondents found most difficult to implement, while bivariate analyses helped determine whether training format or the use of FPSAs was associated with training engagement, confidence in delivering TF-CBT, fidelity or sustainability. Results: Clinicians perceived the same three components of TF-CBT as most difficult regardless of the type of training they received, and provider, youth, caregiver, and organizational-related themes emerged from thematic analysis. Bivariate analyses indicated more extended training formats and the use of FPSAs were associated with greater implementation success. Conclusion: Findings suggest that perceived difficulty of TF-CBT components did not vary by training format, but more extended formats and the use of FPSAs were associated with more favourable implementation outcomes. Implementers should consider ways to utilize FPSAs within training programs, as well as focus on content identified by clinicians as difficult, as this may assist clinicians in developing skills and managing implementation barriers.

Conceptual Application of Trauma-Focused Cognitive Behavioral Therapy to Treat Victims of Bullying

“…Third, TF-CBT includes the gradual exposure intervention activity that is common to effective PTSD treatments, directly targets and challenges negative and distorted thoughts and beliefs about the world, and provides coping skills education and practice. TF-CBT helps children regulate emotions surrounding a highly distressing stressor and enhance safety to prevent revictimization (Ascienzo et al, 2020; Morina et al, 2016; National Institute for Health and Care Excellence, 2018). Regulating emotions is important because maladaptive coping strategies, such as disordered eating or substance use, can come from a perceived lack of adaptive coping options.…”

Client and counsellor experiences of abbreviated trauma-focused cognitive behavioural therapy for South African adolescents

“…You could see she just didn't want to engage anymore. (Counsellor E) Anxiety about approaching traumatic memories is common both among traumatised youth in TF-CBT treatment (Neelakantan et al, 2019) and among counsellors who are delivering exposurebased trauma interventions (Ascienzo et al, 2020). In an abbreviated model of TF-CBT, the reduced time frame for completing the trauma narrative component may further reduce acceptability and tolerability of this component.…”

“…Research also indicates that many counsellors have concerns about implementing evidence-based treatments in general, and exposure-based PTSD treatments specifically, resulting in low fidelity to treatment protocols and reduced treatment effectiveness (Ascienzo et al, 2020). For example, a study of standard-length TF-CBT implementation in the United States found that only 66% of counsellors reported being likely to use all the treatment components (Allen & Johnson, 2015).…”

Understanding therapists’ perceived determinants of trauma narrative use

“…Much like other exposure-based intervention components, TNs are rarely used in practice. Studies examining therapists' perspectives of TF-CBT found that TNs were rated as one of the most difficult TF-CBT components to implement and considered to be only appropriate for some children [17,18]. One study found that, although all evidence-based protocols for trauma include some element of exposure, only 14-22% of trauma-exposed youth received exposure during treatment [8].…”