On Staying the Course (of Treatment)
Before I joined the NCA staff, I served as director of a Children’s Advocacy Center, as well as the Director of Behavioral Health for the umbrella agency which was a primary care clinic. As part of my duties to manage the treatment of children suffering from traumatic stress symptoms, I frequently conducted chart audits, and one of the measures looked at the number of therapy sessions clients were receiving—an important measure to consider when looking at how effective a course of treatment is at achieving its goal of healing the client.
Our clinicians were trained in a variety of effective evidence-based treatments (EBTs): Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Child and Family Traumatic Stress Intervention (CFTSI), Theraplay, and Cognitive Behavioral Therapy (CBT). While they often provided treatment adhering to these tried-and-true models, sometimes they also offered clients within the same course of treatment an eclectic mix of models. As a clinician, even I was sometimes guilty. Why did we drift from the model for a session or two? Often it’s as simple as a crisis the child or family are experiencing or because I, as the clinician, was not adequately prepared for the session.
However, my chart audits continually reminded me that these deviations have a real cost. When clinicians at my CAC used an evidence-based model with fidelity, the average number of sessions delivered were significantly less, ranging from 5-14 sessions, than when the clients were receiving an eclectic mix. On the extreme end, one client received 56 sessions. The consequences for long, meandering courses of treatment that don’t stick to the evidence-based model are many. As an illustration of these consequences, I offer a tale of two clients.
The first child came to a clinician at the CAC after a forensic interview, and started a course of TF-CBT. But the sessions began to stray from the treatment model, due, seemingly, to issues related to the parents’ recent divorce and the child’s behavioral issues. With this particular child, elements of a variety of models were used which significantly increased the number of sessions, and did not result in a treatment model being completed. With the chaos in the family, and mother’s persistence about focusing on the behavioral issues, the clinician struggled with keeping the therapy on track. After 28 therapy sessions over a 9-month period, the child dropped out of therapy.
The second child, a 12-year-old, came in for a course of TF-CBT within three weeks of her forensic interview that substantiated her abuse. Owing to the client’s relationship to the abuser, and the family dynamics that ensued, this case was no less complicated than the first. However, in this case, the TF-CBT model was followed with fidelity, to include parallel sessions with the parents. 90-minute appointment slots were not always available so we had to be creative in terms of involving the parents in the process. The child and parents attended 11 sessions, and the child successfully discharged. Three months later, I checked in with the parents and the child continued to do well. The family reached out at different times due to other stressors, but the child did not return to regularly scheduled therapy. (That’s a good thing!) The child has since graduated high school, is in college and doing well the last time I heard.
As clinicians, it can be difficult to determine the best treatment model when children and families walk through our doors. Parents often are focusing on behavioral manifestations which may guide the direction of a session on that particular day. My suggestion to clinicians that I supervised was to choose an evidence-based model, and stick with it. I always took care to reassure parents that as treatment progressed, behaviors would likely improve.
Evidence shows treatment model fidelity leads to shorter treatment courses, as a recent study of TF-CBT in treating child traumatic stress demonstrated. This matters for a number of reasons. A shorter treatment course means that there’s a shorter window for financial, scheduling, and transportation problems that contribute to household stress and cause families and clients to drop out of treatment before achieving their goals. It also means that there’s less capacity—simply fewer appointment slots available—for therapists to take on new cases and help more children heal. (Why help one child when you can help three?) Long treatment courses can also contribute to a dependency on therapy with no resolution. For children, successfully discharging from therapy means they can go on leading a developmentally appropriate childhood. Finally, and most importantly, when a child’s treatment doesn’t follow the model, it can’t achieve the goals of the model—helping the child heal from his or her abuse.
Michelle Miller serves as Coordinator for Mental Health Projects at National Children’s Alliance. In her 24 years in the field, she has spent 15 years serving as a clinician. She has also served as director of the Butte Child Evaluation Center in Butte, Montana, where she provided both mental health services and forensic interviews for clients. She holds a Ph.D. in psychology and a master’s in social work.