PTSD Interrupted?, with Carrie Epstein

Season 5, Episode 2

“PTSD Interrupted?” with Carrie Epstein

[Intro music starts]

[Intro]

Teresa Huizar:
Hi, I’m Teresa Huizar, your host of One in Ten. In today’s episode, “PTSD Interrupted?”, I speak with Carrie Epstein, co-director of the Yale Center for Traumatic Stress and Recovery.

Over the past two decades or more, we’ve learned so much about the trauma experienced by children who’ve been abused. We know about their clinical symptoms. We know how these affect their functioning at home and at school. And we know about the lifelong impacts of leaving these trauma symptoms untreated. We’re grateful that not only child abuse professionals but your average citizen is now aware that victims of child abuse can develop PTSD at rates and severity to those of soldiers who’ve been to war.

But is that cycle of abuse, trauma symptoms, and PTSD development inevitable? Is it possible to interrupt that cycle in such a way that symptoms reduce and PTSD never develops in the first place? As you will find in our conversation, CFTSI—the Child and Family Traumatic Stress Intervention—is an evidence-based intervention that can do just that for some kids. I know you’ll be as interested as I am in this remarkable intervention.

Please take a listen.

[1:30] Teresa Huizar:
Carrie, welcome to One in Ten.

Carrie Epstein:
It’s a pleasure to be here. Thanks so much for inviting me to be here with you today.

[1:36] Teresa Huizar:
You know, you and I have had many conversations, but I don’t think that I’ve ever asked you, how did you come to this work originally?

Carrie Epstein:
It’s a bit of a journey, I would say. I’ll take us back to my first year of graduate school.

My internship was working as a clinician in one of the country’s first pediatric HIV/AIDS programs located in a hospital center in the Bronx. And it was about 35 years ago now, and the first case of pediatric AIDS was diagnosed in the Bronx not long before I arrived. And I have to say, back then I was very anxious about working with children and families impacted by trauma and traumatic grief.

But I wanted to be a clinician, and so I went to work. And it turned out to be a really incredible life-changing experience for me. I think, it was a moment in time, in a sense, when a different pandemic was just starting to impact our country and the world, HIV/AIDS. And the level of trauma and traumatic grief at the time was staggering.

And I worked with some incredible children and families at that time. Honestly, I would say that they were some of my greatest teachers. And they taught me how important it is clinically to listen, to really listen. And it was in this clinic that I not only learned about how essential the role of close observation is to our clinical work but also the ways in which children can remain alone.

But when the tragic and frightening nature of their circumstances interfere with clinicians themselves getting close enough to actually see and understand the burdens of the affected child. So I really learned that my getting up close and listening was in and of itself not only a fundamental clinical requirement but also a clinical source of relief for my patients, one that could be capitalized on to help them achieve as much mastery as they could and sort of help them distinguish between the facts and their terrifying fantasies. And I learned that making close observations and actually seeing children through the lens of the internal experience of their difficult realities also led to better outcomes.

So if you want to hear the rest of the story on at about a decade working in the Bronx, I took a position in an organization in New York City called Safe Horizon—an organization I know you know—one of the country’s largest victim assistance, victim advocacy organizations, to help develop their child trauma programs and help the organization adopt evidence-based treatments. Part of my work was to work closely with the organizations’ initially four—soon to be five—Child Advocacy Centers in terms of deepening the clinical services provided to children after recent disclosures. And then in 2001, while I was working at Safe Horizon, another important moment in the journey of my career occurred.

My office at Safe Horizon was located in lower Manhattan just a few, few blocks from the World Trade Center. And the September 11th terrorist attacks occurred and Safe Horizon became one of the leading responders to individuals and families and children impacted by the 9/11 terrorist attack. And I had the opportunity to be one of the directors and principal investigators for a multi-site study that focused on implementation of trauma-focused evidence-based treatments with children impacted by 9/11, including Trauma-Focused Cognitive Behavioral Therapy, TF-CBT. So it was a time in my career when I really began to learn a great deal of the impact of recent traumatic events on children and families.

Then in September 2001, the National Child Traumatic Stress Network—NCTSN—was formed, which has the goal, of course, of advancing a broad range of effective services interventions by creating trauma-informed evidence-based treatments to improve the standard of care. So I had the great opportunity of being the principal investigators for one of the original sites of the NCTSN based in New York City. And from there, my work just continued to focus on developing and implementing and evaluating best practices in evidence-based treatments for children and families impacted by trauma, including the development of the Child and Family Traumatic Stress Intervention, or CFTSI.

[5:42] Teresa Huizar:
So I want to pause here for a moment, Carrie, because I think many of our listeners, if not most of them, are going to be familiar with TF-CBT. And you know, it’s so interesting to see, you know, your own career of trajectory sort of parallel the development of NCTSN in some ways.

But what was it that really prompted the development of CFTSI? I think for folks who are not as familiar with that intervention, you know, we’ll give you an opportunity in a second to explain exactly what it is and what’s different about it. But I’m just curious about in all of that, what are the roots of it?

Carrie Epstein:
So, it’s a great question, and I think what I would say is that CFTSI grew out of more than three decades of really closely observing and learning about the phenomenon of trauma from children and families, impacted by abuse, by violence, and other traumatic events, as well as really decades of experience of responding to children and families immediately after the potentially traumatic event in the acute or peritraumatic phase of trauma response—meaning in the days and weeks after a traumatic event. And in addition, after years and years of collaborating with many colleagues who do respond to children in those moments, whether it’s child welfare colleagues, law enforcement colleagues, people in pediatric emergency departments, et cetera.

So we learned a great deal during that time. And then really sort of keeping in mind the clinical phenomena of trauma that we were seeing in this early phase of trauma response and realizing that there was no best practice or evidence-based treatment that had been developed for responding to children at that time, we moved toward thinking about how we might develop CFTSI.

[7:28] Teresa Huizar:
I think for people who are listening who are not clinicians, we’re going to need to unpack this a little bit—

Carrie Epstein:
Sure.

Teresa Huizar:
—because I think so many evidence-based interventions, first of all have some underlying principles that are somewhat similar, but there are also things about them that are unique and it’s helpful, I think, for people to understand that.

Tell me, what was the problem you were trying to solve through the development of CFTSI that other interventions had not solved?

Carrie Epstein:
I think you’re right that there are so many similarities between the different trauma-focused treatments and evidence-based practices for kids impacted by trauma. With CFTSI, we were looking at this window of opportunity soon after either a traumatic event or right after a disclosure of abuse, like in a Child Advocacy Center.

We know that in that moment there’s such a sense of loss of control about what happened to me, as the child, or to my child, on the part of the caregiver. There’s such chaos and dysregulation, so many needs that the family has in terms of case management needs and so many people interviewing them.

There’s such a sense of chaos and such a loss of control, both about the event that just happened and, now, the ensuing symptomatology. And there’s such a loss of control and things feeling so not predictable that the goal of CFTSI is really to address that sense of chaos and loss of control with predictability, and a way of helping regain a sense of control, mostly focused on symptoms.

[9:02] Teresa Huizar:
I think it’s such a helpful way to characterize it. If I think back on my own career even—I’m not a clinician, everybody who listens to One in Ten knows that [laughter], you do as well. So we have to talk in, you know, layman’s terms here.

Carrie Epstein:
Right.

Teresa Huizar:
But when I think about my own career, early in my career at a Children’s Advocacy Center, we often saw children who—and I think expected it probably because we had also had contact with adult survivors where often you were having disclosures relayed to you that were long after the fact. However, I think to your point, even though it might be long after the event occurred, the disclosure itself was like sort of setting a bomb off in your life, you know, in terms of the system response, what was going to suddenly happen, family response to that, what community response once people became aware.

Thinking about that critical period right after that’s happened, I think that was really revolutionary and, and truly important. And I know—you know, again, for our listeners, we’re not pitting these interventions against each other. All are important—

Carrie Epstein:
That’s right.

Teresa Huizar:
—and you are a master trainer of TF-CBT yourself, to this day.

Carrie Epstein:
That’s right.

Teresa Huizar:
So that’s—this is not, these are not competitive.

Carrie Epstein:
Not either/or.

Teresa Huizar:
These are complimentary. Yeah.

Carrie Epstein:
Right, right.

It’s interesting. Originally, CFTSI was developed specifically for implementation after recent traumatic event. And in about, I think it was 2005, and I was helping the five Child Advocacy Centers at Safe Horizon in New York City sort of develop their clinical work and responses to children impacted by abuse. It just became very clear to me that the Child and Family Traumatic Stress Intervention, CFTSI, would be a really good match for CACs, even though by the time a child discloses in the forensic interview, the abuses happened a long time ago. So we actually tried it out to see how it would go, and we just got the same identical outcomes by thinking of it as the window of opportunity to intervene right after the disclosure when, as you said, there’s a huge response on the part of the parents, a huge response on the part of the system.

Someone may be removed from the home, um, and the child’s symptoms be skyrocketed.

[11:26] Teresa Huizar:
I remember—and I can’t tell you the year. Boy, I’d have to really reflect on that. But I do remember the first time I heard about CFTSI. I was at a Hope Shining event for Safe Horizon. And Steven [Marans] was there, and I was there to talk about something else. And he and I got to talking about this, and then he presented about it. And I just thought to myself, “Oh my goodness.” I mean, it was like—I don’t even know what. The invention of fire [laughter]. I was just like this—

[Laughter]

To a lay person, this made so much sense to have something really tailored to intervening during that window.

Carrie Epstein:
Yes.

Teresa Huizar:
And I found the results even at that point—which it’s been some years—very exciting in terms of really reducing suffering of children very quickly.

It’s kind of interesting, Carrie, because when you first see these results, you’re sort of like, really? [Laughter]

Carrie Epstein:
Yep.

Teresa Huizar:
There’s been enough replication. We know: No, it’s not magic. It really does happen.

[12:25]
You know, can you talk a little bit about the intervention itself for people who don’t know much about it? The brief nature of it, you know.

Carrie Epstein:
Sure.

Teresa Huizar:
Generally what it is, so that they would understand how it might be different from other things they’ve seen or experienced.

Carrie Epstein:
Sure. CFTSI, or the Child and Family Traumatic Stress Intervention, is a brief five- to eight-session, evidence-based, trauma-focused mental health treatment.

And again, it’s the only evidence-based treatment model that’s developed specifically for implementation with children, adolescents, and their caregivers during this early phase of trauma response, right? Soon after the exposure of traumatic event or disclosure of abuse in a forensic setting like a CAC.

And so CFTSI has demonstrated effectiveness in reducing traumatic stress symptoms and reducing and interrupting PTSD and related disorders, including—to your point, Teresa—for children who have extensive trauma history prior to the most recent event or occurrence that precipitated their referral for CFTSI.

So, I’m one of the co-developers of CFTSI, along with Dr. Steven Marans, who you were just referencing. And what we really did was develop this model that’s meant to be implemented in this window of opportunity to intervene, to provide early intervention, regardless again of whether they have past traumas in their history.

So CFTSI as a treatment model really maps onto the, what we see, the clinical phenomena of traumatic reaction, what traumatic symptoms look like in this early phase of trauma response. And then based on a family strengthening approach, CFTSI works to increase communication between the child and caregiver about the child’s trauma symptoms by increasing support for children impacted by traumatic events.

And I can say a bit more about the goals of the model if that’d be helpful.

[14:19] Teresa Huizar:
Okay, we’ll get to that. But you’ve already said so much I want to unpack with you—

Carrie Epstein:
Yeah.

Teresa Huizar:
—for a moment. Because I think so many of the points that you made bear maybe exploring a little more or repeating.

One of those is that, well, I realize that you don’t characterize it as preventing PTSD. Anything that interrupts the onset of more concerning symptoms, I think can only be to the good. And I think that that is something that—you know, we’re used to sort of waiting until someone has almost a clinical level of trauma symptoms that are—you know, they probably would qualify for a diagnosis of PTSD before we intervene.

And I think that what this [CFTSI] allows is to get ahead of that where you can. And it’s not to say that that is the only thing that any child might ever need, but for a lot of kids it will be. And I think that that is wildly beneficial in and of itself in terms of alleviating suffering quickly.

And I just wonder, when you’re talking about the communication between kids and parents about their own trauma symptoms, can you talk about that? Because I remember again, one of the first times you talked to me about this, about how important it was to understand that what children report and what parents report may initially be different, and the implications of that coming to a better understanding and common understanding of what kids are experiencing.

And that was another eureka moment for this non-clinician. So can you talk a little bit about that?

Carrie Epstein:
So I almost want to unpack the few things that you raised myself.

Teresa Huizar:
Feel free. Go for it. [Laughter]

Carrie Epstein:
One thing that I was sort of thinking about is—this might be a really important opportunity to acknowledge the fact that for many people, including many clinicians, implementing a very brief model can seem counterintuitive. Right? Because it can be hard to imagine the extent of the impact that a brief model can have when the precipitating events can be so traumatically disregulating, the child’s so symptomatic, and the level, the degree of symptoms can be so high.

And I might also add that for anyone working in the Child Advocacy Center world, hearing about the horrors that too many children are confronted with when they’re exposed to violence and trauma can be especially unbearable if we feel helpless in providing relief or if we believe there’s no escape from their immediate suffering, or if we’re convinced that their futures are forever damaged or impaired.

And so I think it’s important to note that CFTSI not only reduces immediate suffering of traumatized children and families and reduces long-term damage to their development but it also identifies and ensures that they receive additional therapy or treatment help when indicated. So I think that was one piece that’s important to think about.

I think the other piece you’re asking about is the value of caregiver involvement and how that plays a role?

[17:16] Teresa Huizar:
That’s right. And also, the specific piece around the communication between kids—

Carrie Epstein:
Right.

Teresa Huizar:
—and caregivers around their trauma symptoms.

Carrie Epstein:
Sure. So I would say that CFTSI really capitalizes on key protective factors, and family and social support are some of the best predictors for good outcomes when it comes to intervening and doing trauma-focused work. And that’s why primary caregivers are central to CFTSI.

So CFTSI improves support through improving communication. The model really focuses on helping children, as you were saying, communicate about their reactions about their trauma symptoms and feelings more effectively and helps increase the caregiver’s awareness and understanding of their child’s experience. And in addition, then, CFTSI provides skills to help the children and family cope with and master reaction.

So I think, to your point, it’s important to think about why communication is so important for traumatized children. I think the answer is, is that when children are alone with and don’t have words to describe the kinds of trauma symptoms that they’re having, then their sort of symptomatic behavior is their only means of expressing what’s going on inside them, in a chaotic way. So they need recognition and understanding from the most important source of support in their lives, their caregivers.

And at the same time, caregivers are often unable to understand the connection between the traumatic event and their children’s symptoms and behavior. So we know that communication increases support. So really what we do in CFTSI is we work to replace the chaos and the dysregulation and the isolation that the child can be experiencing after trauma with a sort of a structured approach, with using language to describe their symptoms and an opportunity for recognition from, and then close connection with, their caregivers.

[19:18] Teresa Huizar:
I think one of the things that was impactful for me, were just seeing sort of the assessment differences between the way that kids describe their trauma symptom—the severity of it, really—and what parents knew and understood at the onset of treatment. So I think for, you know, probably anyone who’s worked in a Children’s Advocacy Center has had the somewhat similar experience in nonclinical settings too, which is: What the child says and what the parent may initially be aware of can often be very, very different.

And it’s not that the parent is downplaying. They may think that their child—let’s take nightmares, for example, or night terrors. They may think they’re having them once a week when in fact—

Carrie Epstein:
Right.

Teresa Huizar:
—once a week, the child is waking the parent up with them, but they may be continuously having them.

And so thinking about this difference between the level of suffering a child may have and the level of suffering their parent is even aware of—

Carrie Epstein:
That’s right.

Teresa Huizar:
—to be able to provide that support can be significantly different.

Carrie Epstein:
It’s really interesting, Teresa. So on the one hand, as you said, it may be that the parent is less aware of symptoms because the child is holding back from telling the parent for multiple reasons.

Like, “I’m worried that I’m going to burden my parent even more—

Teresa Huizar:
Hmm, hmm.

Carrie Epstein:
—after all of this.” Or, “I’m afraid I’m going to get in trouble even more.”

Teresa Huizar:
Hmm.

Carrie Epstein:
On the other hand, we also know that people impacted by traumatic experiences—actually, I would say adults and children alike—very often aren’t aware of their symptoms. They just feel rotten.

Teresa Huizar:
Yes.

Carrie Epstein:
And so they’re unaware of their symptoms. They’re not aware of them. They can’t put words to them. So they actually can’t communicate about them.

Teresa Huizar:
So interesting.

Carrie Epstein:
Right? So as you were describing, at the start of CFTSI treatment we also see a difference between what the child’s reporting with respect to their symptoms, as many people in the CAC world have seen, and what the parent’s reporting.

And the great news is, is that by the end of CFTSI, what we see is a significant decrease in this difference between what they’re reporting about the child’s level of trauma symptoms. And so we see this increased agreement in what they’re reporting as evidence of improved communication between the caregiver and child about the child’s trauma symptoms.

[21:40] Teresa Huizar:
In some ways what you are along the way training the caregiver to do is this sort of deep attention-paying, this deep observation and listening as well. Which children, you know, of course, respond to because they’re wanting a parent who’s engaged with them and is aware of what they’re experiencing.

Can you talk a little bit about, what is the benefit to caregivers for engaging?

You know, I think all evidence-based treatments have a caregiver component. Caregiver engagement is important. But what are you seeing as the—not only the benefits to kids, which are, I think, obvious; we’ve been talking about them—but to the caregiver themselves?

Carrie Epstein:
Yeah. And just to begin that piece of the conversation, you know, there are many times when caregivers actually are very wonderfully in tune with their children—

Teresa Huizar:
Mm-hmm.

Carrie Epstein:
—and actually may be more aware of some of the child’s symptoms than the child themselves. So as part of CFTSI, we ask the caregiver their understanding of their child’s symptoms. Separately ask the child their understanding of their own symptoms. And then we come together to kind of do a compare and contrast—not about who’s right or who’s wrong. But if the child’s having symptoms the parent’s not aware of, the child can then let the parent know about them. And to your point, if the parent has observed some symptoms that the child may be less aware of that they’re having—

Teresa Huizar:
Mm-hmm.

Carrie Epstein:
—the parent has the opportunity to let the child know how they’ve come to arrive at that understanding the child’s having those symptoms. And just being aware that their parent is paying attention can really be very, very helpful to the child.

The other thing that you asked was about what’s in it for the parent to participate? And I think there’s a few things.

One is that after a recent traumatic event or recent disclosure of abuse, as you all see in the CAC world, the parent, you know, can be walking in a fog, can be very overwhelmed, still trying to wrap their minds around that this happened in the first place. And there’s that, you know, cumulative experience of loss of control. “I can’t control what happened to my child. I didn’t even know it had happened. Now I’ve got my own symptoms, my child’s having symptoms.” Everything feels very, very out of control. And so by participating in CFTSI, we can sort of help the parent get sort of two feet on the ground again about returning to being able to be a parent, to feeling like that they can actually help their child by recognizing symptoms, recognizing trauma reminders that cause symptoms, and then strategies, coping strategies, behavioral interventions to help their child lower their symptoms and get relief from suffering.

The other piece that’s really important is the finding that CFTSI also reduces the parents’ own trauma symptoms. So the great news is that it hasn’t just been children who benefited from CFTSI. We know that CFTSI consistently demonstrates a significant decrease in the participating caregiver’s trauma symptoms. So in in a study, we found that 62% of caregivers just by participating in their child’s CFTSI treatment, experiencing clinically meaningful improvements in their own trauma symptoms.

And I think this is particularly significant for a few reasons. One, the parent gets relief themselves. Which is important. We also know that parent’s reactions can impact their child having symptoms and can impact their child’s recovery. Right? And we also know that parent relief from symptoms and suffering is a key predictor for the outcomes for their children following traumatic experiences.

So I think it really emphasizes the importance of caregiver engagement and involvement, um, in trauma-focused treatment in general.

[25:29] Teresa Huizar:
When you first started looking at that—the issue of, well, surprisingly, caregivers seem to be getting better right along with their kids—

Carrie Epstein:
Yeah.

Teresa Huizar:
—were you surprised?

Carrie Epstein:
I think I’m always surprised.

[Laughter]

You know, I think it’s, it’s just wonderful and powerful.

Teresa Huizar:
Yeah.

Carrie Epstein:
This was actually an area that meant a great deal to me—

Teresa Huizar:
Mmm. Mmm-hmm.

Carrie Epstein:
—as a clinician, as a trainer, as a co-developer, about what is happening for the parent. And so we decided to take a look. I think, as I said, I’m always surprised, but I was so pleased to see—and then not so surprised because CFTSI really does pay attention.

Um, and we purposefully, in the first session of CFTSI when we meet one-on-one with the parent, we ask about the parent’s own trauma history. So that we understand the context of what their experiences have been and what the child’s recent experiences may be bringing up for them, understandably. And we ask a parent, the parent’s own level of symptomatology, so that we can actually help, you know, mobilize that parent to be able to become aware of their own symptom and manage them so that they have, you know, the emotional bandwidth to support their children as well.

[26:39] Teresa Huizar:
In CACs often, I think, teams can feel sometimes frustrated with the parent that they don’t see as as supportive, for example, as they would like them to be. That sort of thing. And it seems to me that the missing component of that conversation may be the parent’s own trauma symptoms and trauma levels and what they’re dealing with over here.

And I think it’s just a wonderful, perhaps initially unexpected, side benefit that you have a parent who’s in a better emotional place to be able to help their child as their own symptoms are subsiding.

Carrie Epstein:
Yeah. You know, folks that work in CACs are such experts in those experiences of parents. There’s a whole range of ways parents can be reacting immediately after disclosure, right? It’s not only fully supportive. It could be the parent is not believing the child, blaming the child.

Teresa Huizar:
Mm-hmm.

Carrie Epstein:
And I think that in those circumstances, as people working in CACs, as clinicians working with children who are seen in CACs, we’re human beings and we can have our own initial response of sort of a, “How could you blame your child?” “How could you not believe your child?” And I think in those moments it can be so helpful to sort of pause and sort of scan ourselves with those reactions and then think about, wait, so what’s actually happening to the parent that got them to that place?

And one of the things we can think about is if sort of the, the central aspect of the traumatic experience, both for the child and for the caregiver, is sort of a loss of control. “I couldn’t control what happened to my child.” “I can’t control how I’m having all these reactions.” “I don’t know how to manage or control my child’s symptoms.” That it’s so difficult that in a sort of, in a way an attempt to reverse this feeling of loss of control, you know, people sort of unconsciously move toward behaviors and symptoms that are about reversing it.

So one way is to think, “Well, wait. It just couldn’t have happened,” or, you know, “Who can I blame for this? If I can find the person who’s responsible, I’ll feel more of in control.” “Oh, it must have been myself,” or “It must have been the child.” And so we can be aware that that might be what’s driving it. We can walk into the room with the parent in a different mindset and really appreciate that the parent’s been impacted by the trauma as well. And this may be one of their ways of expressing it.

[29:15] Teresa Huizar:
When you are approaching a caregiver about their child entering into treatment, how do you approach that conversation with them? I’m just curious about whether you find that they have the same initial skepticism that some, some other professionals do about “Really, a short-term treatment? What’s that going to do?” How do you approach that conversation?

Carrie Epstein:
I think that the way we initially approached the conversation is to first talk about with the parent about when kids go through difficult things, they very often have some issues or problems or challenges or reactions that are very understandable. And we start out by saying, “We want to check in with you and your child about how your child’s been doing since the recent event happened. And then we do a screening and assessment for trauma symptoms. These are symptoms that they’re reporting to the clinician. And so based on that, after they report some trauma symptoms to the clinician, the clinician can then, in that context, make a recommendation for a trauma-focused therapy. So given your child’s history or their recent experiences, it makes all the sense in the world they’re having the reactions they’re having. But just because it makes sense to have these reactions doesn’t mean it feels good. So here’s what I’m going to recommend, and one can actually, because CFTSI is a structured model, we can predict it. It’s really about helping to identify the reaction your child’s having and identify strategies to actually turn the volume down on those reactions, turn the volume down on the distress and suffering to help these symptoms go away.”

You think if one is presenting it in that way to families, we get less pushback about, “Really? A brief treatment?” The other thing we can also say is in the last session of CFTSI, you know, we do something called case disposition, but in the last session of CFTSI, we talk to the family about and what we might recommend as next steps. And in that moment, we can either be based on how the child’s presenting. They either don’t need more trauma-focused treatment—in fact, we find that 70 to 80% of kids who get CFTSI don’t need any other trauma-focused therapy because their symptoms have come down so far. And we can also talk about building on the work we’ve done in CFTSI and referring them on to a trauma-focused therapy, longer term trauma-focused therapy.

Teresa Huizar:
If they need that, yeah.

Carrie Epstein:
If they needed that. If it’s indicated.

[31:48] Teresa Huizar:
Yeah. I think it’s amazing that in that 70 to 80% of the time it isn’t.

Carrie Epstein:
Yeah.

Teresa Huizar:
You know, I think it’s a wonderful thing that kids can get what they need, and caregivers can get what they need, and they move on with their life with the skills that they’ve learned as a part of it.

Carrie Epstein:
Yeah.

Teresa Huizar:
Especially since, since kids often will be triggered again by something, I think we should, you know, expect that that’s a normal part of it. So giving them the skills to cope when something does come up, I think will be really important for them moving forward.

[32:17]
I’m wondering, you know, now a significant amount of research has been done that relates to CFTSI. Do you find that there’s a group of kids or a type of situation that relates to trauma for which it’s contraindicated for which it wouldn’t be helpful to make the referral?

Carrie Epstein:
I’m pausing to sort of think about your question and I’m, I’m, I’m not sure that there’d be just a group that I would say, “This group on the whole, we wouldn’t recommend CFTSI.” I think it would really be if there were specific circumstances, that would make it seem that CFTSI wasn’t the right match for a child or family.

One might be if the child is in a situation where there is no caregiver. Right now we actually haven’t yet—I’m saying “yet,”—thought about how to implement CFTSI in residential settings.

Teresa Huizar:
Interesting.

Carrie Epstein:
However, there are caregivers in residential settings, so I think that similar to TF-CBT, I think we could find ways where we could adapt the model for using the caregiver that’s around when the child is the most symptomatic and help can help the child identify their symptoms and bring them down.

We do CFTSI now with, you know, children living in foster homes because we engage the foster parent. So I think, I’d have to think about a group.

[33:42] Teresa Huizar:
You know, it’s—I’m glad you can’t think of one right away, because I think that what’s helpful of course to CACs is to feel—and other child abuse professionals—is to feel that, by and large, you know, an intervention if they are properly trained in it and adopt it, can be implemented with the broad range of kids and families that will come through their doors, knowing that there may be some individuals for whom it wouldn’t be appropriate. So I think that that’s helpful to know.

I’m also wondering, you know, occasionally, and it’s not specific to CFTSI, we get this question or this comment across any evidence-based treatment, I would say, where someone will say—and it’s not always a clinician. It’s usually being cited by an executive director about something their clinician has told them. “But now fill in the blank, evidence-based treatment, it’s not working for our kids.”

Carrie Epstein:
Mmm-hmm.

Teresa Huizar:
“It doesn’t work for our kids. We’re finding it’s not working for our kids.” I’m wondering what your advice is generally to that executive director who’s probably not a clinician. Right? So when they hear it, they come and report this to NCA. And I’m interested in your advice and then I’ll tell you what I do and [laughter] you can tell me if it’s all wrong.

[Laughter]

But I’m curious about, you know, what your advice is in that situation when someone’s like,
“No, my clinicians are just saying that’s not working for us. That doesn’t work for our kids.”

Carrie Epstein:
I think my starting point would be to listen, right? I mean, I’ve learned that from the kids I worked with way back in the eighties, that listening is a good place to start, to listening to what is it about the model that doesn’t work? You know, what is it that isn’t resonating with perhaps the children and families or what’s not resonating with the clinicians themselves?

You know, I think about if I’m just right now going to think about CFTSI, you know, again, CFTSI is a brief model, and many clinicians aren’t as experienced in doing brief work. They’re much more used to doing much longer-term work. And so brief treatment, one, it’s hard for people to believe that a brief model can be so effective.

And two, there’s a discomfort. There’s a feeling of, “Wait, I need time to engage. I need time to, you know, have the family warm up to me, develop relationship before I can even touch it.” Um, and so these are just some hypothesis, you know, sort of about what I might be listening for, about what is it about the model that either doesn’t resonate with the clinician or the clinician worries about, misunderstands about, or what’s not resonating for the families. And how do we think about maybe things that we could address? You know, about implementing a model with fidelity so that people get the same strong outcomes that we had, and fidelity with flexibility to sort of adjust and respond to the unique family and child that’s sitting in front of them.

Right. So that they have access to an effective trauma-focused therapy, but make it resonate with the family so that it’ll be more effective.

[37:03] Teresa Huizar:
There’s a reason you’re the clinician. I mean, Carrie—

[Cross-talk]

Carrie Epstein:
I would love to hear your response!

Teresa Huizar:
—that was so patient and lovely. [Laughter]

Carrie Epstein:
What’s your response?

Teresa Huizar:
Well, what I want to dig into is whether they are doing it with fidelity.

Carrie Epstein:
Right.

Teresa Huizar:
Yeah. Because I think … the way my own mind works. Again, we’re remembering that I’m a lay person, so give me a break here, Carrie.

Carrie Epstein:
I’m going to give you lot of a break.

Teresa Huizar:
[Laughter] But as a lay person, I think of this a little bit like medical things, right?

Carrie Epstein:
Yeah.

Teresa Huizar:
It is true that one could be following standard of practice care and for whatever reason, something might not work with a given patient, right?

Carrie Epstein:
Mm-hmm. Sure.

Teresa Huizar:
But in general, these things are studied, and so if I’m hearing, “Well, it doesn’t seem to be working with any,” I’m very suspicious about that.

Carrie Epstein:
Sure. Sure.

Teresa Huizar:
Because it just kind of raises a red flag for me that maybe we’ve deviated from the path and decided we don’t like module anymore, or maybe we’ve decided that there’s some other aspect we don’t want to do. Or maybe we went to a conference and heard about something that sounded very exciting that we decided to just pepper in, you know, and make it a gumbo. And so [laughter] I’m just like I’m kind of that end—

Carrie Epstein:
Cherry picking.

Teresa Huizar:
Exactly. I’m kind of on that end of, let’s unpack this a little bit in terms of: Are we still doing it the way we were trained to do it or or not? Because I do think that … I don’t know that I think we’ve talked enough, in the CAC movement anyway, which is the one I can speak to, about the ethics around providing care that we know that works and not experimenting on people like guinea pigs.

Carrie Epstein:
Mm-hmm.

Teresa Huizar:
You know, I think that there is an ethical responsibility we have—

Carrie Epstein:
Yeah.

Teresa Huizar:
—to do things that are evidence-based and to do them properly because kids can and will get better. And when I think people sort of view other alternatives as neutral. And I don’t know that we think enough about the fact that we can do active damage if we’re not careful.

Carrie Epstein:
Yeah.

Teresa Huizar:
You know, we can elongate someone’s suffering instead of shortening it or those kinds of things.

And so I just would like us to have more conversation, I think, in the movement about the fact that it’s not a matter of just personal preference or what you came out of graduate school thinking, you know, you were trained in or whatever. It’s also what is the science telling us is effective with these kids in reducing their suffering.

So that is my nonclinical explanation of why I don’t sound nearly as patient as you do when you say all of that. [Laughter]

Carrie Epstein:
I think if—again, not an either/or, I mean, I’m a big believer in increasing children and families access to trauma-focused treatments that we know. Because it’s about reducing suffering. And that every day that goes by that the child isn’t getting access to that trauma focused-treatment, they’re suffering from symptoms, and in fact, their symptoms may be getting worse. Their parents suffering from symptoms.

So I really agree with you, Teresa, that you know, there’s a real need to get these treatments to these kids. And so at any time when we’re sort of writing off these approaches, we need to think about whether for any reason we’re actually interfering with children getting access to the care that they deserve and that we ethically really need to provide.

[40:31] Teresa Huizar:
One of the reasons I wanted you to come on to One in Ten was because you guys recently published a study—I say “recently.” It’s now been some months. But you recently published a study where you really looked at a wide variety of factors to determine did CFTSI basically work with some populations better than others. And that was divided by a lot of demographic factors, gender, ethnicity, other types of things. I’m not even probably remembering them all.

Carrie Epstein:
Mm-hmm.

Teresa Huizar:
Can you just talk a little bit about the findings of that study? And one of the things that you brought up to me, and I want to be clear with our listeners about is, we are very sensitive to the issue that, evidence-based interventions were largely developed overall, not just CFTSI, but so many of them, by people who are white.

Carrie Epstein:
Mm-hmm.

Teresa Huizar:
And that we have to be sensitive to the legitimate issues that attend to that, and that our discussion of the study is not setting aside any legitimate questions and concerns around do things need cultural adaptations and applications. That’s not what we’re delving into here. We’re really talking about this in a somewhat different and certainly more respectful way.

Carrie Epstein:
Mm-hmm.

Teresa Huizar:
And so can you just talk a little bit about the study’s findings first, and then, if you would, address questions that have come up and that you’ve gotten around cultural applications?

Carrie Epstein:
Sure. So in the study that you’re referencing, it was of about 1,200 CFTSI cases seen in 13 different community-based clinical settings, including several CACs. So I think that’s important to know that this was really across the country in many settings. And in that study, we examined different factors associated with symptom reduction for children receiving CFTSI.

And the study revealed a significant reduction in the child’s trauma symptoms after completing CFTSI. And there was no statistically significant differences in symptom reduction based on several things: based on age, gender, ethnicity, or race. And in addition, there was no statistically significant differences in symptom reduction based on the level of the caregiver’s traumatic stress symptoms at the start of CFTSI treatment, the number of trauma types that the children had experienced prior to the most recent event that led to their referral for CFTSI, the child’s relationship with the perpetrator or, um, the nature of the traumatic event that led, that led to their referral.

So that was what we found in that study.

[43:12] Teresa Huizar:
I think one of the things that struck me about that exciting and long list is, CACs are addressing more and more trauma types these days. They’ve been used not just as a response to child sexual abuse or even other forms of maltreatment but responding to mass shootings and other kinds of trauma, natural disasters, those kinds of things. And it’s good to know that not even the trauma type, I mean you’re still seeing the same types of clinical results, which is wonderful.

Carrie Epstein:
Yeah, we really are. So, and you asked about the question about, you know, what the study demonstrated in terms of that, that we saw no significant difference across these groups.

And the piece about, you know, what’s behind that? And I’m happy to share some of my thoughts about. You know, why is CFTSI successful? Is CFTSI successful across age, gender, ethnicity, race? And I think one of the ways to that, that I think about it is that trauma impacts us and impacts brain and body functioning in similar ways, regardless of culture or what part of the world a person’s from.

And as clinicians, you know, one of our goals is to consider the common psychological and physical impacts of trauma. And with that in mind, think about, well, so what are our principles of intervention? How do we use our understanding of acute stress and trauma reaction, sort of as a roadmap for what we’re going to do clinically, our clinical strategy?

So in other words, how do we translate what we know about the phenomenon of trauma into effective, brief, trauma-focused treatment that has a goal of reducing trauma reactions and helping the child heal and begin to recover? Our goal is to sort of tap into the shared human experience of people impacted by trauma, and that can be the backbone of providing any intervention.

Right? So the clinical goals of CFTSI, each session of CFTSI, are meant to address that shared human experience of how trauma impacts us in similar ways. I would say that how the clinician achieves those goals may vary depending on the unique child and family that they’re working with. So to go back to what we were saying at the beginning of our conversation together, clinical works about listening and learning from families to find their sources of strength and support, and then weaving it into a treatment model that focuses on addressing trauma symptoms. Right?

And I think one of the best ways to learn about someone’s culture is by asking them about it, right? So like any good clinical treatment, the central task of CFTSI involves learning about a family’s background and the culture from which they’ve previously been able to derive strength and support.

We think we’re at our best in our clinical work when we remember that our best teachers are the people we work with. And this means learning about the cultural and religious beliefs and practices that have been central in their lives. And once we learn about those aspects of a family’s life, we’re in a stronger position to help them mobilize those practices and belief in support of recovery.

Right. So it’s a central part of CFTSI as the clinician is working with the child and caregiver to identify trauma symptoms that are impacting the child, and then identifying strategies to help lower those symptoms. You know, the clinician can ask about a family’s background and learn from the family what they have found that’s been helpful in the past in dealing with stressful situations. It’s often a wonderful opportunity to learn about a family’s culture and religious beliefs, as well as family adaptations that have been sources of support and strain. And so we found that learning about and identifying those resources, those cultural resources, have been really a way of helping families remobilize and capitalize on those sources of support and strength and recovery.

And so I think in many ways the study is really demonstrating that, that there’s a drop in the child’s trauma symptoms, um, because the central focus of CFTSI is on the common shared human experience of trauma.

[47:30] Teresa Huizar:
Thank you for sharing that. I think it’s an important piece of research that can, I think, help lots of clinicians and kids and families have more confidence even than ever in CFTSI. I’m just wondering sort of what’s next on the research horizon for you all. I know it’s, you know, research is never done, so what are you looking at these days?

Carrie Epstein:
Research is never done. I think there’s so many places we want to go next. And we, I think, would also be open if people have ideas about where they think they might really like to look at CFTSI and where to go next, we’d be very open. We just are finishing up a study that’s looking at CFTSI in the context of telehealth.

Teresa Huizar:
Mm.

Carrie Epstein:
And I think that—

Teresa Huizar:
Love it.

Carrie Epstein:
—this is a really important one, right? You know, after the pandemic we really had to sort of, for many of us—I know there’s certain states in this country that were already doing telehealth. For many of us, this was a real pivot that we really had to look at. And so during the pandemic, we were able to not only increase accessibility of CFTSI itself by adapting the model for implementation to the telehealth, but we took a look at the implementation. And the study really demonstrates really similar powerful outcomes in reducing not only the child’s trauma symptoms, but the caregiver’s trauma symptoms—the same outcomes whether they’re seen in person or virtually. That one I was really excited and possibly surprised at, and I think we’re really interested in continuing to look at that.

I think we’re also, in terms of next steps, also interested in looking at CFTSI with additional communities. Um, we are really starting to look at CFTSI with Native American communities. We’re interested in, you know, looking at CFTSI with younger children. So I think that we have some ideas and excited about where we’re going to go next.

[49:25] Teresa Huizar:
Well keep looking, because I can’t wait to hear more about all of those. And I think just the work is so needed, and we see kids who benefit from it every single day, which we’re delighted about. But anyway, when the publication comes out about telemental health and CFTSI, you’ve got to send it my way. I’m eager to read it.

And, um, I think it really reflects though a lot of the sort of, experience that many of our CACs have had that their family engagement was actually up and their clinical outcomes were as good with this and other evidence-based interventions delivered well in that way. So, which has to be a win for families where—

Carrie Epstein:
It is.

Teresa Huizar:
—things can be safely delivered in that way.

Carrie Epstein:
One other thing I might add, Teresa, is, thinking about CFTSI, you know, in the current context of mental health crisis that we find ourselves in.

Teresa Huizar:
Mm, mm.

Carrie Epstein:
The Surgeon General released recently two reports that indicate it’s a really hard time for children, adolescents in the United States. We’re seeing an increase of depression and anxiety and suicidal ideation, so there’s a greater demand for services. And at the same time, across the country, we’re experiencing a professional shortage of clinicians. We also know that during the pandemic we’ve seen about 30% of adolescents have had serious levels of PTSD, and that’s likely underestimated. So there’s an urgent need for not only early identification of children impacted by trauma but also the initiation of early interventions to support recovery.

And I think it’s important to point out that in addition to being an effective, early, brief treatment that lowers traumatic stress reactions, CFTSI also acts as very thorough assessment of children impacted by trauma and then provides an opportunity to determine if a child has need for longer-term treatment at the end when needed. And just to reiterate, you know, in the midst of this public mental health crisis, it’s important to keep in mind that approximately 70 to 80% of children who participate in CFTSI don’t need to be referred on for longer-term trauma-focused treatment. And so in this way it’s the brevity of CFTSI—the five to eight sessions—so the brevity and effectiveness can really help reduce the need for longer-term care and therefore really can help alleviate the long waitlists that characterize the current mental health crisis that I know so many CACs are facing as well. It increases accessibility and really allows programs to serve more children and families, which again is, is so significant in the midst of such an enormous child mental health crisis.

[52:03] Teresa Huizar:
Thank you for pointing that out. I know that the, you know, the primary reason to adopt, um, CFTSI isn’t to reduce waitlists, but it’s a wonderful knock-on effect—

Carrie Epstein:
That’s right.

Teresa Huizar:
—that it can shorten the wait that children and families have for treatment, and that’s critical when you are trying to reduce suffering overall. So thank you so much.

[Outro music starts]

Well, Carrie, goodness, an hour has flown by, and I could talk to you much longer, but I know you actually have kids you have to see clinically and teaching you have to do and other things. So one of these days you’ll have to come back and we’ll talk about all the things we didn’t get to today, but I truly, truly appreciate our partnership together. It has just been wonderful to work with you all, and I am a true believer in this intervention and look forward to our continued partnership.

Carrie Epstein:
Thank you, Teresa. And I just, in closing, I really want to say that, you know, I for one could not do the work I do without my colleagues, you know, who bring their ideas and their resources and their shared experience and their true dedication to the challenges we meet together every day. So, really just want to thank my co-developer of CFTSI, Dr. Steven Marans, and our entire team at the Yale Center for Traumatic Stress and Recovery. And also want to thank you not only for inviting me to be here with you today, but to thank you and your entire team at the NCA for not only the collaborative work we’ve had the opportunity to do together over many years, but really that invaluable partnership.

So thank you so much.

Teresa Huizar:
Truly our pleasure. Thanks again, Carrie.

[Outro]

[53:33] Teresa Huizar:
Thank you for listening to One in Ten. If you like this episode, please share it with a friend. And if you’re interested in CFTSI training or more information about it, please visit our website at www.nationalchildrensalliance.org.