Frequently Asked Questions

Topics

• AF-CBT
• Clientele and Eligibility
• Session Structure and Setting
• Child Physical Abuse
• Relaxation Training
• Clarification
• Recording Sessions

About AF-CBT

What is AF-CBT?

Alternatives for Families: a Cognitive Behavioral Therapy (AF-CBT) is a trauma-informed, evidence-based treatment (EBT) designed to improve the relationship between children and caregivers in families involved in arguments, frequent conflict, physical force/discipline, child physical abuse, or child behavior problems.

How rigid is the AF-CBT model, or, how much could I change it in order to cater to my specific clientele?

The AF-CBT model is designed for clinicians to tailor each topic to the strengths and skill needs of the client. Clinicians are encouraged to come up with creative and developmentally appropriate activities to enhance engagement and skills. More often than not, clinicians and clients seem to feel that the framework of the AF-CBT model fits. In other words, we suggest covering each topic in order and not “bouncing around” from topic to topic. We do not suggest deviating too far from the basic structure laid out by the model.

Is AF-CBT well known by general providers?

Some states are further along than others in being able to train providers in AF-CBT. Although this is true, we are still trying to get the word out about these forms of therapy. Based on systematic reviews of available research and evaluation studies, several groups of experts and Federal agencies have highlighted AF-CBT as a model program or promising treatment practice, including the U.S. Office of Victims of Crime, the National Registry of Evidence-based Programs and Practices (NREPP), the National Child Traumatic Stress Network (NCTSN), the California Evidence Based Clearinghouse for Child Welfare, the U.S. Department of Health and Human Services’s Child Welfare Information Gateway, and the National Childrens’ Alliance.

I am interested in looking at the evidence base for AF-CBT. What studies have been conducted, and with what populations were they conducted?

A list of references can be found here.

Do you offer Continuing Education Units for completing AF-CBT training?

We have offered Continuing Education Units (CEUs) for mental health professionals in some of our AF-CBT training sessions, but AF-CBT is provided by a number of trainers from institutions around the United States. While we provide CEUs for our local training sessions held in Pittsburgh, different trainers handle these things in their own ways. However, for other training sessions, it’s best to check with the trainer for that session.

We do, however, offer free CEUs for completing our Overview and Fundamentals Course offered by the NCTSN. 

Clientele and Eligibility

Have AF-CBT clinicians worked with families who are court ordered to treatment?

Yes. We have several programs around the country who are implementing AF-CBT with clients who are mandated to treatment, either through the courts or through child protection services.  With caregivers who are mandated to treatment, we recommend spending more time on Phase I to find ways to engage caregivers in a meaningful way, even though this is not a service they may have sought out.  It may also be useful to contact the family’s worker or other professions who is involved in monitoring and managing the case in that systems (e.g., caseworker, probation officer, CASA, etc.) to provide an overview of the treatment and ways to effectively coordinate/communicate with one another.

If a child is abused sexually, is AF-CBT the best model to use?

If the primary referral reason for a child is sexual abuse and s/he meets criteria for PTSD, then Trauma-Focused CBT would be the preferred treatment. AF-CBT is not a treatment for child sexual abuse. If the primary referral reason is one that is listed in the AF-CBT eligibility screen and the child has a history of sexual abuse, then s/he  may be appropriate for AF-CBT. In these cases, it is helpful to determine whether the main goal is to address the coercive/conflictual family context or the child’s PTSD.  In some of these cases, there is a need to first stabilize the child's current environment before switching to TF-CBT to address the child’s trauma symptoms.

Is AF-CBT ideal for families with certain intellectual disabilities or mental health issues that could act as barriers to the treatment protocol?

Even though these factors can act as barriers to treatment, AF-CBT can be used with many families with intellectual/mental health disabilities. The therapist must learn to simplify the language and lower the complexity of therapy so that all parties are on the same level.

Should AF-CBT be used with families where a child is in foster care, placement, or living in any other location apart from the parents/caretakers?

Yes. Although these circumstances may be inconvenient, there are ways to have all members of a family involved in therapy as long as there is a chance that the family will be reunified. A workgroup of AF-CBT clinicians and supervisors has put together a supplement to the AF-CBT session guide that is specifically geared to help clinicians when working with non-biological caregivers.  It is available to trained clinicians through our website.

What factors would rule out this treatment?  For example, what about a family where physical abuse is fairly certain, but adamantly denied?  Or where there are other ongoing safety issues in the home?

The primary factors that would rule out using AF-CBT would be active drug and/or alcohol dependence or active psychotic symptoms. It would not be a first line treatment for children who have recently experienced sexual abuse. We would not include a parent who is actively perpetrating or has recently been a perpetrator of interpersonal violence with the parent involved in the treatment.

Session Structure and Setting

Does AF-CBT take place in only an office setting?

The setting of each session is up to you depending on your personal regulations and the best interests of the family.  AF-CBT has been conducted in diverse settings other than the office clinic, such as the home, residential programs, inpatient units, family support centers, or other community settings.

How can we keep the individual caregiver and child sessions separate when working in the home?

This can be a challenge, especially during home visits. You could suggest that the child watch a movie or play in a separate room while talking to the caregiver.  We sometimes have them wear headphones with loud music.  You could also work out an arrangement beforehand with the caregiver in order to have someone watch the child while you meet with him/her.  Obviously, when possible, try not to have the child present for a caregiver session. Other options include meeting with the caregiver while the child is at school and meeting with the child at school.

How can I tailor some activities more towards younger clients?

When working with younger clients, you could use drawing with crayons/markers, role plays, dolls, music, etc. You can be creative and use whatever you can according to your client’s abilities.  We also suggest using simpler language or terms, trying to use fewer overall words,. And allowing the child to practice or demonstrate how the content is used.

How is play incorporated into AF-CBT?

Clinicians are encouraged to develop play activities that further children’s skill development. For example, clinicians often play charades, create stories, and use puppets and dolls to help children expand their emotion vocabulary.

What are the challenges and benefits of conducting AF-CBT in a community mental health setting, as compared to other settings?

If the question is comparing treatment in a clinic to treatment in homes, then there are challenges and benefits to each. Most of them have to do with ensuring privacy and confidentiality.  The benefits to a clinical setting are less distractions, a controlled setting, and a better guarantee of soundproofing. The challenges are transportation, child care, and families not showing. The benefits to a home setting are that clients can apply the skills they are learning more easily during session, the clinician gains a better understanding of the family’s environment, and attendance is higher. The challenges are maintaining confidentiality when others are around, travel time for the clinician, and distractions in the home. In either setting, it is important to have routine supervision by a skilled practitioner and to be familiar with all mandated reporting and safety/crisis management options available to the family.

Child Physical Abuse

What is child physical abuse?

Although the actual definitions vary by state, most definitions agree that physical abuse occurs when a parent or caregiver commits an act that results in physical injury to a child or adolescent, such as red marks, cuts, welts, bruises, muscle sprains, or broken bones, even if the injury was unintentional (see NCTSN.org). Physical abuse can occur when physical punishment goes too far or a parent lashes out in anger. But even forms of physical punishment that do not result in physical injury have been considered physical abuse and are outlawed in some states.  Physical abuse may be a one-time event, but it may also reflect a pattern of repeated, deliberate acts. Physical abuse is often accompanied by other forms of child maltreatment, such as emotional abuse and neglect.

How widespread a problem is child physical abuse in the United States?

According to the National Child Abuse and Neglect Data System (NCANDS) Report from 2014, 17% of reports were for children who were victims of physical abuse. Of the 702,000 children reported for child abuse or neglect, this means that approximately 119,340 were physically abused.. The national estimate of children who received an investigation or alternative response was 3,248,000 in 2014.

Aside from the physical damage, what are the effects of physical abuse on children?

The impact of physical abuse on a child’s life can be immediate and far-reaching. It is especially devastating when a parent, the person a child depends on for protection and safety, becomes a danger. Many physically abused children become aggressive themselves or have other behavioral problems. They may do unto others what they’ve experienced themselves. Some children develop traumatic stress reactions. Some become anxious and depressed. Children who’ve been physically abused often have social problems. They don’t do very well at developing and maintaining friendships. They may have difficulties trusting authority figures. They may not feel good about themselves or see themselves as worthy. They may blame themselves for the abuse and feel that they must keep what goes on in their families a secret. Reactions vary depending on the age of the child, the kind of abuse, and how long it continues. In most studies, physically abused children have shown at least some types of psychological, social, and other problems, many of which may continue into adolescence and adulthood.

Can physical abuse affect development?

Research has shown that abuse and neglect may impair the healthy development of the brain. Chronic abuse can have significant and broad consequences. Physical, mental, and emotional development may all suffer (Widom, Kahn, Kaplow, Sepulveda-Kozakowski & Wilson, 2007).

What factors contribute to a child developing traumatic-stress reactions after physical abuse?

The greater the threat to life and to the body, the more likely the child is to develop the signs and symptoms of child traumatic stress. So the child who is more severely injured, the child who is terrified for his or her life, may be at greater risk of developing child traumatic stress reactions (English, et al, 2005). As with other forms of trauma, the child’s subjective perception of risk also matters. If a child perceives his life or body or self to be in great danger, he or she is more likely to develop traumatic stress reactions. Children who develop traumatic stress reactions after abuse also tend to blame themselves. They are the children who see themselves as so “bad” that they’ve caused their parent to “go out of control.” Or a child will say, “I must be a terrible person for Mommy to hate me so much.” We’re not sure if a child who blames him- or herself is more likely to develop traumatic stress reactions, or if feeling bad and guilty just go hand-in-hand with the traumatic stress reactions. But children who get angry and blame the caregiver seem less likely to suffer from traumatic stress responses.

Does every abused child react by becoming aggressive?

Aggression and “acting out” are very common but there are a wide range of reactions. Some children become numb. They don’t seem to care anymore if they are hit; they’ve lost the normal fight or flight reactions built-in to protect us from danger. These are the children we worry about most – those who no longer react with fear or try to run away. A child who’s become numb or stopped trying to resist or to fight back is more likely to get physically injured. These children may also fail to react to other dangers. These children may stop trying to make friends or succeed at school or plan for the future. They’ve simply given up.

Do some abused children become frightened rather than numb and withdrawn?

Some abused children become anxious and fearful rather than numb and withdrawn. This happens frequently when the abuse has no predictable pattern. A child who knows that daddy will come home every Saturday night drunk and try to hit him can at least anticipate what’s going to happen. He may even be able to prevent it from happening sometimes. He still has some control over his own life. A child who never knows when a caregiver will become physically violent, and never knows how far the caregiver will go, has no control. That child may become more anxious.

Can physical punishment that does not cause physical injury still cause psychological damage?

Punishment does not have to lead to physical injury to cause psychological problems. A number of studies have shown that children who are exposed to physical threats and aggressive acts by a caretaker may develop post-traumatic stress reactions and other psychological problems, such as aggressive behavior, depression, and anxiety (Knutson, DeGarmo, Koeppl & Reid, 2005).

Relaxation Training

Where can I get a relaxation training recording?

You can easily download these types of recordings via the internet or on YouTube.

Should the lights be lowered when doing relaxation training with a client?

Yes; the lights should be lowered, but never completely off. It may also help to situate the client in between you and the door.

Can relaxation training trigger flashbacks?

While we do not hear much about this sort of thing happening often with families in AF-CBT, this is possible with certain clients, especially when the clinician is not aware of the presence of certain traumatic experiences or their level of impact on anxiety, anger, or other emotional states. Of course, the skills these clients learn through relaxation training can aid them in dealing with the emotions that come along with their flashbacks. If this does happen, we suggest stopping the activity and leading the client through a more comfortable activity.

Would you ever have a parent and child together while doing relaxation training?

Relaxation training is usually done separately, unless you feel it would be valuable or beneficial to have both parent and child train together. It is typically difficult to do this when working with AF-CBT families, because they may have trouble relaxing around one another.

Clarification

Are there different clarification letters and can you explain how they might differ?

Each clarification is unique, addressing what the caregiver takes responsibility for, how the caregiver is going to keep the child or children safe, and what their plan is for the family’s future. We recommend that clinicians go through the clarification process with all participating caregivers, not just those involved in the child protection system. Caregivers have the opportunity to talk with their children about what they’re taking away from the therapy process, what change they’d like to see in themselves and the family, and their vision for how the family will function after therapy is completed.

Recording Sessions

When recording my therapy sessions to submit to you for feedback, do I use my own audio recording device when or will one be provided by you?

We ask that you use your own device. A digital voice recorder that can connect to a computer via USB cable is recommended. Your digital audio recorder should record audio in one of the following formats: WAV, WMV, MP3, or VOC.

It is not recommended that you record session audio on a smartphone or tablet due to these devices being connected to the internet, which poses a security risk to your data. The use of an iPad is not recommended, as it is not possible to upload files from an iPad without the purchase of third-party software.

Should I submit audio samples of sessions with the parent(s), the child, or both?

We encourage clinicians and supervisors to submit sessions that they would like feedback on. Sessions can be from any phase of treatment and with any participating clients and family members.

Do I need the family’s permission to submit audio samples to you?

Yes. You should always ask permission from the family to share audio from therapy sessions, and obtain a written, signed release from the family. It is recommended that you explain a few things about this process. We have provided a sample explanation below for your reference.

What is recorded and how the file is recorded

“I hope to record [audio or video] of our sessions on this [audio recorder or video camera]. I generally use recordings to help me to keep the facts straight so that I can accurately keep track of a session and write a report of your progress when the time comes to update others on your progress in treatment.”

Why the file is recorded, and who hears the recording

“My purpose in recording sessions here is to share the contents of the session with my supervisor and a consultant with whom I am working. I’m doing this in order to get their feedback and also to observe my own style as a therapist, so that I can assess if there are areas that I need to improve upon. In other words, these tapes are more about me than you and how well I am able to follow the protocol and teach you the skills necessary to complete the treatment. In doing so, I can better keep track of important things said that will help me to advocate for you when the time comes.”

What is done with the recordings

“I will destroy all of the tape recordings once I have had a chance to review them and definitely at the end of the treatment.”

What you are mandated to report

“I can keep what you say to me in confidence, with a few exceptions. I’m required by law to make a report to the authorities or help you make a report if you tell me something that might make me think that you might still be harming your child or someone else in your family, that your child or someone in your family is in danger of being harmed, or if your child tells me that they have either been hurt or fear they will be hurt by you or another family member in the household. We’re going to be learning a lot of new skills in our work together, so I don’t anticipate there to be any new incidents. But, just in case, I wanted to be sure you knew my role in keeping these sessions confidential.”