Frequently Asked Questions
1. My state is a county administered system. Can we apply as a county?
Yes, however it must be in collaboration with the State Office. This should be reflected in both the letter of interest as well as in the questionnaire. We want to ensure both local and state level participation for policy, funding, and sustainability reasons.
2. Will sites get any financial support?
The intervention including all learning components, organizational support, technical assistance, access to the web-based data management system and clinical consultations are provided at no cost to selected sites but no funds will be provided to sites.
3. My state requires us to go through a procurement process for working with contracted mental health providers. How will this work with the project timeframes?
We encourage jurisdictions to consider your particular statutory requirements and timeframes in your decision to apply as our start up activities will occur immediately upon award.
4. Page 2 says that “There will be approximately 20-40 participants in the child welfare and mental health groups.” Is that 20-40 CW participants and 20-40 MH participants? Or a total of 20-40 participants when CW and MH participants are added together?
20-40 each for a total of 40-80. We do want an equal number from each group as the training and activities are designed for that.
5. Can more than one provider agency participate?
More than one provider agency can participate but we are looking for a substantial number from the agency to commit to participate (not just 3-5). The leadership from each agency (CEO/ED and Clinical Director) will also need to be an active and ongoing member of the leadership team that has a series of learning and organizational capacity building activities associated with it.
6. Are child welfare and mental health supervisors required to participate?
Yes, the model is designed for supervisors to participate in the in-person training and also to provide ongoing supervision and feedback to their staff on the interventions. This will be in collaboration with our consulting team. In addition, we are requiring that mental health provider supervisors also utilize the CBT+ intervention with 3 clients and enter that data into the Toolkit. This is to ensure that supervisors have a strong working knowledge and skills in all facets of the clinical intervention.
7. Do the mental health providers receiving the CBT training and providing the CBT treatment need to be employees of our public mental health agency or can they be private providers with whom we work?
It depends on how the jurisdiction is structured in terms of who provides the clinical services. Some public MH agencies provide these services. Some states have contracts with private providers, or a combination. We are anticipating that both internal and private providers will be participating. The main distinction is that if it’s a private provider, it should not be an individual but rather an entire agency that commits most/all of their clinical staff to the training and consultation.
8. Page 9 says that applicants must select a provider; but on the Webinar you said that a provider may not need to be identified as part of the application. Could you clarify?
You will need to be thinking about and select a provider as soon as it’s awarded. Applicants don’t need to list the provider in the application if they have procurement rules/restrictions. You could though if you do not have a requirement to issue an RFP in order to select the provider. A latter cohort would definitely not need to have someone identified at the time of application.
9. We are wondering about the possibility of scaling up these models from the initial training cohorts. Do you think participating jurisdictions would be able (if they make the necessary time, resource and infrastructure investments) to develop local training capacity and deliver this to a broader segment of the workforce? Is there a possibility for a train-the-trainer module?
This is a big part of our conceptualization and long term plan. We hope to identify those “super users” via the consultation calls and provide the site a train-the-trainer/clinical consultant model to replicate going forward. We would be able to provide limited support to those folks but definitely want this to expand beyond the one site.
10. Are you able to share the organizational self-assessment in advance?
Unfortunately no, the selected site (Cohort 1) will be provided with a set of questions to respond to that will help us get a better sense of the landscape as it related to resources, relationships, structures, policies, etc.
11. A presenter indicated there was no cost for access and use of the Toolkit throughout the duration of this project (September 2018). Can you share what the cost would be after this time period?
The developer wants to keep costs low and has created a reasonable pricing structure for agencies. They would pay an annual subscription fee of $1000 for up to 50 users per agency and then $20/users after the first 50 registered users. This includes agency level reporting and supervisory features, periodic updates and improvements.
1. What is CBT+?
CBT+ is an efficient training method for 4 different interventions: CBT for anxiety, CBT for depression, Trauma-Focused CBT for trauma-specific distress, and Behavioral Parent Training. Providers learn how to do all 4 interventions during the in-person training and expert case consultation.
2. Why were the 4 interventions picked?
Anxiety, depression, PTSD, and behavior problems comprise the most common diagnoses/conditions for which children are referred to therapy in the public mental health system. It is estimated that up to 80% of children with a mental health problem could benefit by one or more of these interventions. All 4 interventions are based on a common theoretical framework, CBT and learning theory. Therefore, the training can cover the basic principles and skills that cross all 4 interventions during a common training program as well as teach the specific components that are unique to the individual interventions.
3. Are the 4 interventions in CBT+ evidence-based?
The Washington State Institute for Public Policy has conducted meta-analyses of mental health interventions for children. Some interventions are brand named, whereas others are generic. All 4 interventions in CBT+ can be found on the WSIPP Inventory as evidence-based or research-based. They are also identified as cost beneficial. The only exception is treatment for depressed young children for which there were insufficient studies.
The American Psychological Association’s website on effective practices for child therapy cites the benefits of each of the CBT+ components.
A recent update on evidence-based interventions (Southam-Gerow, M. A., & Prinstein, M. J. (2014). Evidence Base Updates: The Evolution of the Evaluation of Psychological Treatments for Children and Adolescents. Journal of Clinical Child and Adolescent Psychology, 43, 1-6. doi: 10.1080/15374416.2013.855128) explicitly argues for classifying families of interventions based on common underlying theories and common ingredients over simply classifying brand named programs.
Additional Resources on common elements and families of interventions:
Barth, R. P., Lee, B. R., Lindsey, M. A., Collins, K. S., Strieder, F., Chorpita, B. F., Sparks, J. A. (2012). Evidence-Based Practice at a Crossroads: The Timely Emergence of Common Elements and Common Factors. Research on Social Work Practice, 22, 108-119. doi: 10.1177/1049731511408440
Barth, R. P., & Liggett-Creel, K. (2014). Common components of parenting programs for children birth to eight years of age involved with child welfare services. Children and Youth Services Review, 40, 6-12.
Series of papers in a special issue of Journal of Clinical Child & Adolescent Psychology Volume 37, Issue 1, 2008
Eyberg, S. M., Nelson, M. M., & Boggs, S. R. Evidence-based psychosocial treatments for child and adolescent with disruptive behavior. 215-237.
David-Ferdon, C. & Kaslow, N. Evidence-Based psychosocial treatments for child and adolescent depression, 62-104.
Silverman, W., Ortiz, C., Viswesvaran, C. Burns, B.J., Kolko, D., Putnam, F., & Amaya-Jackson, L. Evidence-based psychosocial treatments for children and adolescents exposed to traumatic events. 156-183.
Silverman, W., Pina, A. & Viswesvaran, C. Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. 105-130.
4. Some websites do not list CBT+ at all—why is that?
Some websites (e.g., NREPP and CEBC4CW) only list treatments that are submitted by their specific developer. Because CBT and BPT have been under development for nearly 50 years by many developers all around the world, it has no “developer”, per se. Thus, it is not reviewable by these evidence-based practice websites. This does not mean that they have failed to meet the standards of these websites. Indeed, there are many other programs that have been derived from CBT and from basic BPT that are listed as highly effective. TF-CBT is the one component of CBT+ that is listed on every evidence-based practice that we have identified as relevant to the mental health needs of children and parents involved with child welfare services.
5. Why did the National Center choose generic over brand name versions of interventions?
The decision to choose generic interventions over brand names was based on feasibility and practicality in public mental health settings. Brand name versions often, but not always, have protocols and requirements that must be followed. In some cases they are controlled by proprietary entities. With generic interventions, organizations have more flexibility for sustainment because common supervision and QA methods can be applied across all 4 interventions and ongoing costs are minimized.
6. What about Trauma-Focused CBT, isn’t that a brand name?
Yes, CBT+ teaches the brand name version of TF-CBT, although the WSIPP meta-analysis finds that all CBT based versions of trauma-focused therapy are effective and cost beneficial. The reason for teaching TF-CBT is that it is a well-recognized intervention that is in demand and the developers are flexible about TF-CBT being delivered within the CBT+ learning framework.
7. Is there a protocol that providers must follow for the 4 interventions?
CBT+ teaches providers to select a clinical target based, at least in part, on results of a standardized measure. Once the clinical target is identified, the providers are instructed to follow the “flow” for the clinical target. The flow includes standard CBT elements such as psychoeducation, coping skills, addressing maladaptive cognitions and standard Behavioral Parent Training elements such as selective attention, rewards/consequences. For individual clinical conditions, there are the specific ingredients such as in vivo exposure for anxiety and behavioral activation for depression. The flow for TF-CBT follows the PRACTICE acronym. Ongoing clinical consultation and support for therapists will assist in selecting the most appropriate treatment target and how to move most effectively through the flow chart.
8. When is it OK to depart from the flow for one of the interventions?
Many children have more than one diagnosis and in most cases it is appropriate to select a target and stick with the flow until results are achieved. For example, TF-CBT will be effective for children who also have depression and mild to moderate behavior problems. There is preliminary evidence that young children’s depression or anxiety may be reduced through Behavioral Parent Training. In other cases, providers may use clinical judgment in the order, inclusion, and dosage of components. For example, it may be most useful to focus on behavioral activation first rather than attempting to initially to change depression-related (e.g., once the child is active, s/he may have more positive thoughts about self and the possibility of change). Another example is when a child has an internalizing condition such as depression or anxiety, but is also exhibiting behavior problems at home. The evidence-based interventions for depression and anxiety do not include parent components to address behavior problems. So it might be appropriate to do CBT for anxiety or depression with the child and BPT with the parent. The bi-weekly clinical consultation calls will help therapists make these determinations while maintaining fidelity to the model.
9. Have the developers of CBT+ and/or the center described for what age range of youth the model is appropriate?
Age 4 and up. TF-CBT and the BPT interventions have been tested with this basic age range. CBT for anxiety is evidence-based if delivered via the caregivers for the littlest kids down to 4.
10. We are very interested in the CBT+ quality assurance and fidelity measurement/improvement tools; these tools will be super key in ensuring long term effectiveness. Can you tell us any more about what those tools look like and how they function? Page 8 of the RFA says that inputting documentation into the toolkit will take an estimated 10-15 minutes on the 2-3 cases per clinician that are attended to the most closely during the 4 months of clinical consultation. When the therapist is using the toolkit on an ongoing basis (after the consultation with the CBT+ experts has finished), should they also anticipate 10-15 minutes of data entry per client?
The system is designed to be very user-friendly with many dropdowns so in reality entering case session data can take 2-3 minutes per session. The 10-15 minute timeframe refers to the additional administration and input of standardized clinical assessments that will be routinely administered.
11. We also note that the link on CBT+ (http://www.ncebpcw.org/cbt) mentions using the Toolkit to document competence; is the process to document competence on a certain number of early clients only? Or is there a process for measuring/improving fidelity on an ongoing basis? We ourselves don't know which would be most effective and efficient; we do know our providers will want to know as much as they can about ongoing QA/QI processes.
Following the rostering of the 3 clients, we would hope that clinicians and agencies find the tracking and reporting features so helpful that they will continue to use the Toolkit with other clients.
We are creating other fidelity measures that will be used in the clinical consultation calls and are exploring other innovative technologies to view and provide feedback similar to behavioral rehearsals.
Since building and sustaining organizational capacity is a large component of the model, we will be working with the leadership and implementation teams on ways the agencies can incorporate these processes into routine practices, tracking and reporting processes.