Monday, March 23, 2015

Trauma Systems Therapy: Good Idea, Wrong Model, Poor Implementation

New information about trauma and its effect on the brain has led the federal government and child welfare systems around the country to launch initiatives aimed at incorporating this knowledge into child welfare practice. In 2012, the District of Columbia won a $3.2 million five-year grant from the federal government to “make trauma-informed treatment the foundation of serving children and youth in the District's child welfare system.”1  This is a worthy goal. However, there are reasons for concern about the model chosen and the way the model was implemented.

The Child and Family Services Agency (CFSA) selected the Trauma Systems Therapy (TST) model, which it describes on its website as “an evidence-based approach shown to dramatically speed and improve healing of child victims of abuse and neglect without relying on medication, hospitalization or prolonged counseling.2 Unfortunately, this glowing account seems somewhat exaggerated. The California Evidence-based Clearinghouse on Child Welfare, the only clearinghouse of evidence-based practices in child welfare, reviewed TST but found that it “lacks the necessary research evidence to be given a scientific rating” as to whether it is supported by research or even promising.3

The lack of strong research evidence to support TST does not mean it is not a good choice as a model for CFSA; it simply raises the questions of whether the agency examined the research evidence before adopting TST and whether the agency was aware that it placed misleading language on its website. More concerning to anyone who has looked at this model is whether it is an appropriate choice for a child welfare agency.  

TST is a model of treatment for traumatized children and their families that was developed by Glenn Saxe and his team at Boston University Hospital and described in their 338-page manual, which CFSA bought and distributed to all of its social workers.4 Starting from page one, the manual makes clear that it is intended for mental health workers, stating, “If you are like most mental health clinicians in the United States, you work out of your office or a mental health clinic.” Later in the book, when the treatment is actually described, it becomes clear that true to its name, TST is a type of therapy, in which the clinician must see the family and the child at least weekly, and more like several times per week when the treatment starts.

TST is not appropriate for child welfare social workers because child welfare social workers are not therapists, are not trained to be therapists, and do not have the time to be therapists. No child welfare social worker has the time to spend about an hour with our clients at least once a week. Child welfare social workers are case managers. They have their hands full monitoring the children's well-being, making sure they get needed medical appointments, helping their parents secure the services they need to get their children back, preparing court reports and reams of required documentation, responding to crises, and dealing with constant audits, and more.  It is hard enough for social workers to squeeze in their required two visits a month, let alone see their clients four times a month as any serious therapist must do. Our clients need real therapists, as well as foster parents or birth parents (depending on where the child lives) who will work with the therapists and make their homes a healing environment for the children. Most of our clients receive their therapy from providers working with the Department of Mental Health, which has adopted several trauma-based therapeutic modalities.

So why did CFSA adopt TST? One reason may be that CFSA was already working with the Kansas-based consulting firm KVC, which has bought into TST bigtime. KVC has a long and tangled relationship with CFSA. KVC's Executive Vice President has also been CFSA's Deputy Director. Actually, she appears to have held both positions at the same time as a “shared executive” under a contract between CFSA and KVC.5  According to KVC's own website, their official's contractual position at CFSA "led to an additional contract for implementation of Trauma Systems Therapy (TST), a significant element of KVC's model.”6 The fact that a KVC employee used her contractual position at CFSA to promote another contract with her employer raises some concern about conflict of interest—and about whether CFSA made the best choice in adopting TST.

Even if we put aside all concerns about whether TST was an appropriate model for CFSA, the way it was implemented raises many questions. An extensive and elaborate training regimen began in May of 2013. All case-carrying social workers and supervisors were expected to read the manual and then participate in four 90-minute “webinars.” After completing the webinars, staff were required to participate in two full days of in-person training. After completing the training, staff were expected to observe or participate in twelve one-hour calls, called Trauma Team Meetings, in which they would learn to apply TST principles and tools to specific cases. Five cohorts of staff underwent this process, starting in May 2013 and finishing up in the summer of 2014. But staff had still not been told to use any of the forms or tools, which were still being modified for CFSA use.

A new set of trainings was rolled out in the fall of 2014. In October 2014, social workers, supervisors, and others were required to participate in a two-hour training which focused on a new trauma assessment tool that would be rolled out in December. In December 2014, all caseworkers and social workers were required to participate in an additional two-hour training. In this training, staff were presented with a new version of four different TST tools, which had been modified since we had received the earlier versions. But we were still not told to start using them. Moreover, we were told that it had been decided that not all clients would receive TST. According an email from  CFSA's Trauma Grant Specialist, CFSA began implementing its trauma assessment for new entries on December 1, 2014. That practice will be expanded to all youth in care starting on April 1. And by early summer, “trauma-informed practice will be fully implemented into case management and decision making.” I am intrigued by the fact that  “TST” was not mentioned in this email.

So over two years into the five-year grant period, and almost two years after the first cohort began its training, implementation of the TST model has barely begun. Moreover, it is not clear that the “trauma informed practice” that will be implemented will have much to do with the model in which we were trained. There is nothing wrong with taking two years to develop a trauma informed practice model that works for the child welfare system in the District of Columbia. But in that case, the District should not have started by training its staff in a model that had not yet been adapted for their use.

I have raised two sets of questions in this post. The first focuses on whether TST was an appropriate method to incorporate new information about trauma into child welfare practice. The second set of questions focuses on the implementation of TST. More than two years into the five-year-grant period,  staff have spent many hours in training. But aside from the new assessment, no changes to current practice have yet been incorporated. It remains to be seen whether CFSA's version of Trauma Systems Therapy bears much resemblance to the model that it originally adopted—and whether it will be the last straw for already-overwhelmed social workers.

  2. See
  3. Saxe, Glenn N., Ellis, B. Heidi, Kaplow, Julie B., Collaborative Treatment of Traumatized Children and Teens. New York: The Guilford Press, 2007.
  4. See
  5. See

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