Phase 1
Demographic Characteristics. Participants were predominantly female (n=60, 92.3%), master’s level (n=61, 93.8%), licensed therapists (n=34, 52.3%) with a mean age of 34.26 years (SD=10.62). The racial makeup of the sample included White (n=47, 72.3%), Black/African-American (n=11, 16.9%), Asian (n=4, 6.2%), American Indian or Alaska Native (n=1, 1.5%), Native Hawaiian or Other Pacific Islander (n=1, 1.5%), and other (n=6, 9.2%). The majority identified as non-Hispanic/Latinx (n=49, 75.4%). The plurality of participants were trained in TF-CBT the year prior to the present study (n=27, 41.5%); others were trained 7 years prior (n=2, 3.1%), 4 years prior (n=2, 3.1%), 3 years prior (n=6, 9.2%), 2 years prior (n=6, 9.2%) and in the year the study was conducted (2018; n=19, 29.2%). Three participants (4.7%) did not report when they were trained.
TN Intentions and Use. Therapists agreed with the statement that “I intend to” use TNs with the majority of patients who receive TF-CBT (M=4.22, SD= 1.03) on a 5-point scale. They also reported that they were likely to use TNs (M=5.94, SD=1.18) on a 7-point scale. However, 47.7% of therapists reported that they did not use TNs with patients receiving TF-CBT over the last 6 months[2]. Participants who completed qualitative interviews were more likely to report being likely to use TNs in the next six months, t(43.57)=-3.73, p=.001; no other differences were found between participants who did and did not complete qualitative interviews.
TPB Belief Elicitation. Beliefs are described below, along with the CFIR domains they reference (in italics). First, respondents were asked about the advantages of using TNs (i.e., beliefs underlying attitudes, also called behavioral beliefs). Many provided responses that CFIR would categorize as outer setting (which includes family characteristics), such as involving parents in a supportive role (Table 1). In addition, therapists identified positive intervention characteristics, such as the value of using TNs to help clients better understand their trauma and gain mastery over it. When asked to share the disadvantages of using TNs (which are also beliefs underlying attitudes), the majority of therapists reported that there were none. Those who did identify disadvantages noted concerns related to outer setting, including caregivers being unprepared, unhelpful, or unsupportive. Some therapists also identified concerns related to intervention characteristics, including that TNs would worsen the client’s symptoms.
When therapists were asked to state who would approve and disapprove of their TN use (to identify normative beliefs), they reported frequently that those who would approve included supervisors (who would be classified by CFIR as part of the inner setting), and caregivers and clients (who would be classified by CFIR as outer setting; Table 2). Several participants commented on the importance of agency-level support more broadly. The majority of participants reported that no one would disapprove of them using TNs. However, others reported that caregivers and/or clients might disapprove.
Table 2. Phase 1: Normative beliefs about using trauma narratives with majority of clients receiving TF-CBT and the CFIR domains
Those who are perceived to approve of the therapist using TN
|
|
N = 65
|
Count
|
%
|
CFIR Domain
|
Supervisor
|
30
|
46
|
IS
|
Caregiver
|
20
|
31
|
OS
|
Client
|
14
|
22
|
OS
|
Agency
|
10
|
15
|
IS
|
Those who are perceived to disapprove of the therapist using TN
|
|
N = 65
|
Count
|
%
|
|
No one
|
29
|
45
|
--
|
Caregiver
|
18
|
28
|
OS
|
Client
|
10
|
15
|
OS
|
Notes: Percentages may sum to more than 100% because participants could list multiple answers. All beliefs are inclusive to the “individuals involved” CFIR domain. We also mapped these beliefs on to other potential CFIR domains with which they are associated.
Abbreviations: Int = Intervention; IS = Inner Setting; OS = Outer Setting (includes Family Characteristics); Ind = Characteristics of Individuals; IP = Implementation Process
When self-efficacy beliefs were assessed with prompts about what would make it easier to use TNs, therapists stated that support from caregivers and consistent client attendance would make it easier (outer setting; Table 3). Participants also identified implementation process factors (e.g., training and supervision) as making it easier to use TNs. Topics identified as making TN use difficult largely involved client factors (e.g., client refusal, lack of caregiver support). A summary of the number of beliefs elicited for each prompt is shown in Table 4.
Table 4. Phase 1: Summary of TPB belief elicitation responses (N=65).
Question
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Total Beliefs
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Mean (SD) number of beliefs reported per person
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Number (%) of people who gave 3+ beliefs
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Advantages
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186
|
2.64 (1.71)
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30 (46.2)
|
Disadvantages
|
92
|
1.39 (0.75)
|
7 (10.8)
|
Easier
|
92
|
1.44 (0.69)
|
5 (7.7)
|
Difficult
|
115
|
1.78 (1.00)
|
12 (18.5)
|
Approve
|
131
|
2.06 (1.01)
|
22 (33.8)
|
Disapprove
|
75
|
1.23 (0.58)
|
2 (3.1)
|
Note: Total Beliefs column includes beliefs that are repeated across participants.
Phase 2: CFIR Qualitative Interviews
In addition to the a priori CFIR codes, statements were coded as a facilitator, a barrier, or both when participants indicated how a given statement affected their TN use. Table 5 includes example quotes for each code.
Table 5. Phase 2: Example quotes for each code.
Code
|
Example Quote
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Intervention Characteristics
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“I really like how structured it is. I think that’s very helpful, having the chapters and you know, but also having some freedom to let the kid choose, like okay which chapter are we going to work on today? That’s been helpful to have structure and then also flexibility.”
|
“[In] some cases the structure is very helpful for a kid to verbalize what they learn[ed] and how things are different … I’ve seen kids really proud of their narratives and they share with their parent and they’re able to have these “aha” moments.”
|
Modifications and Adaptations to TNs
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“I tend to do written narratives. I have clients who have done … more of rap narrative. [They were able to] talk about their trauma history [in a way] that they wouldn’t have been if we did a straight narrative like chapter one, chapter two, chapter three.”
|
“I had him dictate it to me because I knew he would really be finicky with grammar and spelling and all of that, and I think that would have held him up a bit.”
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Inner Setting
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“[Something that helps is … ] my supervisor and my coworkers being trained also. To have them to immediately bounce [ideas off of].”
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Outer Setting
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“I think that when you’re in a situation where the community you’re living in feels really unsafe, it’s hard to get that stuff under control.”
|
“I find that the kids that don’t have as many outside stressors happening can do their trauma narratives fairly quickly, whereas the kids that come in and they’re, you know, still going to court and going through that process… that makes it difficult too.”
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Family Characteristics
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“I think those cultural pieces sometimes can be really difficult. In certain communities when trauma occurs, you don’t talk about it, you bottle it up and it just goes unsaid…. I asked what happened next in terms of processing it, and she said, ‘Well everything just kind of went on like nothing happened, we didn’t talk about it and we just swept it under the rug as a family.’”
|
“It can be difficult when there’s really complex trauma histories … It’s [easier] when there’s a single episode or it’s a same type of abuse that they experience multiple times. But, when it’s physical, emotional, sexual, and neglect and a lot of it, the abuse that impacted them the most might actually be [happening] now.”
|
Characteristics of Individuals
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“The trauma narrative is honestly one of my favorite parts of TF-CBT cause it’s the culmination of all the work that we’ve already done. We’ve done all the gradual exposure and … they’ve learned all these skills so then being able to actually sit down and write it is really cool to hear… I feel like the gradual exposure has worked on me too and I’m desensitized to their trauma as well.”
|
“I remember feeling a little apprehensive beforehand. Is this going to go well? Is the parent going to react in a way that’s going to be helpful for the kid? I remember feeling excited that we were in this moment, but then also just apprehensive and a little bit nervous… And then afterward, feeling relieved and also…very hopeful, and having a sense of completion”
|
Implementation Process
|
“The second booster was really, really helpful for me after seeing clients for many months… I wish there was more work on processing the narratives and more explanations on the narrative because some of the people had different ideas of how long it should be or how thorough it should be or what it should look like. It was helpful in my call when the facilitator read some of their narratives of what they had done.”
|
Intervention Characteristics. Therapists generally perceived TF-CBT and TNs positively, often describing them as helpful and effective. There were mixed perspectives regarding whether TNs are sufficiently structured to allow the therapist to know next steps, or whether they are too vague to know exactly how and when to implement each component. Participants described a substantial amount of preparation involved when implementing TF-CBT, including TNs, but many said that it becomes easier with experience. Many therapists highlighted the difficulty of interruption of services as a result of non-attendance by the parent and/or child or other emergent life events. The amount of time required to meet with both the parent and child and to cover all necessary topics was also identified as a barrier. Therapists mentioned the importance of building rapport and a sense of safety with the client prior to beginning TNs and stated that this was made easier by the gradual nature of exposure to TN content. There were some concerns noted about the length of narratives and the feasibility of repeatedly reviewing long narratives given time constraints.
Modifications and Adaptations to TNs. Modifications to TNs were made to address issues of client comorbidity, literacy, attention span, or other life circumstances. Therapists used a variety of mediums for creating TNs, including drawing, rapping, creating PowerPoint presentations, using highlighters, and writing poems. Several participants adjusted the pace of TNs such that they only read parts of a long narrative in response to the child’s needs or due to session length. Therapists described various approaches of reading to the child, typing for the child, and getting rid of the TN at the end of treatment. The extent to which caregivers were involved in TNs was often adjusted depending on the child’s circumstances. In some cases, it was not feasible for a caregiver to be involved, and some therapists recruited other adults from the child’s life to hear the TN.
Inner Setting. Therapists described administrative issues as one of the most pervasive barriers affecting TN implementation. Common issues included lack of reimbursement for longer sessions and insufficient time to complete paperwork. Some therapists said that they typically conduct sessions in the community, which limits privacy for completing TNs. There were also concerns about clinic policies related to conducting TNs in the presence of an open legal investigation. Having supervisors and co-workers trained in TF-CBT was reported as a facilitator, whereas being the only trained therapist was a barrier. Several participants described agency expectations that TF-CBT would be used as a facilitator. Therapists working in school settings noted consistency in child attendance as a facilitator for TN completion. On the other hand, school-based therapists noted concerns about accessing parents, discontinuing therapy over the summer, and having students return to class dysregulated after completing TNs.
Outer Setting. One outer setting theme that emerged was a concern about using TNs to treat chronic trauma for clients living in communities with high rates of violence. Participants noted that in such cases, some avoidance may be protective. Participants also mentioned external factors, such as court or child protective services involvement, that may hinder the ability to use TNs and TF-CBT.
Family Characteristics. Several key themes emerged related to family factors affecting TN use. Therapists identified poor attendance and drop out as the most common barriers, whereas caregiver involvement and motivation were the most common facilitators. Logistics such as transportation and childcare were described as affecting attendance and consistent TN implementation. Furthermore, therapists mentioned cultural or family norms about the extent to which it is acceptable to speak about trauma and seek help to manage it. Therapists noted that client characteristics, such as developmental level or time since the trauma occurred also affected TN delivery. Participants reported that clients who were young at the time of the trauma had trouble remembering the event, which made completing the TN more challenging. Children who had recently experienced trauma were described by some therapists as not being emotionally ready to start a narrative or too symptomatic to successfully complete one. Therapists reported that it was easier to create TNs with children who were more interested in art and stories, whereas more verbal children sometimes had narratives that were too lengthy to repeatedly use.
Therapists reported that a single trauma was easier to treat compared to multiple or ongoing traumas. Poor attendance, drop out, and interruptions in treatment were described as often being the result of financial or housing instability, which led a shift to treatment focused on crisis management instead of on trauma. Children in foster care were described as the hardest to treat due to the lack of a consistent caregiver, as well as other sources of instability. Most therapists cited good rapport with clients and caregivers as facilitators for completing TNs. In general, stronger child-caregiver relationships were considered to result in more successful and smoother TNs, whereas children who had tense relationships with their caregivers were more difficult to treat.
Characteristics of Individuals. Therapist characteristics related to TN use largely included the emotional impact of using TNs. Many therapists reported experiencing or worrying about burnout and mitigating this risk by having the support of a team or having variety in the types of cases they treated. Several therapists also identified a process of desensitization whereby hearing TNs became easier over time. Therapists reported a wide range of emotions they experienced around TNs, including nervous, proud, fulfilled, sad, frustrated, intimidated, and relieved. Several therapists mentioned doubt and uncertainty when making decisions about how hard to push clients in sharing TNs.
Implementation Process. Initial training, booster training, and consultation calls were generally perceived positively. Several participants noted a desire for additional materials beyond the treatment manual to support implementation (e.g., slides, handouts), with some indicating that that need was met and others suggesting that more materials would have been useful. The booster training was identified as being critical to support TF-CBT and TN use. Overall, it was clear that participants felt that training alone was not sufficient, and that being able to implement TNs required support via consultation calls, additional training materials, and adequate time to prepare for sessions.
Post Hoc (Mixed Methods) Analysis. Therapists with high intentions and frequent TN use described using a wider array of mediums (e.g., songs, poems) to implement TNs than other groups. Although all groups described barriers and facilitators related to the inner setting, therapists with strong intentions and low TN use reported much more variability in their level of agency support for using TNs compared to other groups. This group also identified more themes related to uncertainty about clients’ readiness for doing TNs. Finally, the group with weaker intentions and moderate TN use did not mention booster sessions or consultation calls, whereas participants in the other groups described them as being integral to implementation success.
[2] Comparisons between participants trained in the past year (n=19, 29.2%) and in prior years indicated that they did not significantly differ in their likelihood of using TNs in the last 6 months, X2(1, N=61) = 3.42, p=.06