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TF-CBT in Acute Settings

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pediatric_psydoc

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I am currently reading a book on TF-CBT for children. The authors define "short term" residential settings as 4-12 months. Can TF-CBT be used in more acute settings, such as when the patient is on the unit for 10-30 days? It seems like it would be difficult to employ in such a short period. If not TF-CBT, how should trauma be addressed when a patient is on a unit 10-30 days? Or is it best to focus solely on stabilization of the issue that brought them in, such as suicidality, self-injury, etc?


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WisNeuro

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You can definitely do TF-CBT in intensive settings with some efficacy. But, the real issue with inpatient/intensive settings (at least the ones I've seen/worked on), is that there is usually a lot more on board than trauma, mainly Axis II. So, in many cases, it ends up being a stabilizing stay rather than a transformative one. But, in relation to pretty clean PTSD, many of my old patients in PE work showed pretty drastic improvement by session 4-6, as long as they actually engaged with the exposures.
 
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MCParent

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You can definitely do TF-CBT in intensive settings with some efficacy. But, the real issue with inpatient/intensive settings (at least the ones I've seen/worked on), is that there is usually a lot more on board than trauma, mainly Axis II. So, in many cases, it ends up being a stabilizing stay rather than a transformative one. But, in relation to pretty clean PTSD, many of my old patients in PE work showed pretty drastic improvement by session 4-6, as long as they actually engaged with the exposures.
I've tended to find that reluctance to use PE in situations with more constraints (e.g., "oh no, patient is moving at the the end of the semester and it's already february, better not open that box...") is more about trainee fear of doing it than substantive concerns.
 
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WisNeuro

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I've tended to find that reluctance to use PE in situations with more constraints (e.g., "oh no, patient is moving at the the end of the semester and it's already february, better not open that box...") is more about trainee fear of doing it than substantive concerns.

Indeed, if you treat the patient like a fragile egg, they will also see themselves that way. If you acknowledge that the body and mind's natural response is recover and resilience, things go much better. I have never had a PTSD patient in PE have an adverse reaction from treatment. Granted, I don't do PE in the VA, but that's more due to Veteran's by and large refusing to engage in it because of myths they hear from others, and that I can cherry pick my therapy patients.
 
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Jake0006

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I am currently reading a book on TF-CBT for children. The authors define "short term" residential settings as 4-12 months. Can TF-CBT be used in more acute settings, such as when the patient is on the unit for 10-30 days? It seems like it would be difficult to employ in such a short period. If not TF-CBT, how should trauma be addressed when a patient is on a unit 10-30 days? Or is it best to focus solely on stabilization of the issue that brought them in, such as suicidality, self-injury, etc?

I'm guessing you're not a TF-CBT trained provider? As in, you did a 2 day training, with the follow-up consult calls? If you have done that, you can approach the trainer who did your consult calls and ask about the viability of instituting the TF-CBT model in such a short amount of time. 30 days would seem doable, depending on the trauma. TF-CBT is a 10 step model (A PRACTICE is the acronym for all the respective steps) built on exposure, and some traumas would be too intense to process in that fashion. Also, there should be the coordination with the family to share the trauma narrative (which can easily take 3 sessions to write or compose) for the in vivo exposure and conjoint sessions, the "I" and "C" of "A PRACTICE." I wouldn't think you could do it in less time that 10 sessions, whether you did that in 10 days or 30. Some clients won't be able to handle going that fast, or there are ongoing traumas and multiple traumas, you'll need at least 13 or 14 sessions to get through the model. If you don't do this, when you reassess using the CPSS, UCLA or the CATS, you'll notice that you don't have the decrease desired from the original assessment below clinically significant for PTSD (the A of A PRACTICE). I'm a certified TF-CBT provider, and while it's great that the musc.edu site for TF-CBT has spread the word some, and even let some practitioners whet their appetite for the approach, we've noticed in our community that there are many therapists that are using the info to poorly administer the treatment, and aren't trained in doing it. The assessment (pre and post) is the first to go! Convenient, because it would tell them how it's not working if they did it. We haven't noticed any therapists that can administer the model well without the training.
 

DD214_DOC

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Acute hospitalizations average about 7-10 days LOS, based upon what has been authorized by the insurance company. Criteria for approval of continued hospitalization beyond what was initially authorized (which can be as short as 5 days) is pretty strict and limited mainly to imminent risk of harm. If this has resolved, patients will be discharged.

Thus, I would not advise, attempt, or ever encourage starting a treatment protocol such as TF-CBT, as you're likely to be unable to complete it properly. Additional days will not be authorized simply because the patient is in the middle of therapy. The goal of acute hospitalizations really isn't treatment -- it's stabilization.
 
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AppsAintNoThang

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Acute hospitalizations average about 7-10 days LOS, based upon what has been authorized by the insurance company. Criteria for approval of continued hospitalization beyond what was initially authorized (which can be as short as 5 days) is pretty strict and limited mainly to imminent risk of harm. If this has resolved, patients will be discharged.

Thus, I would not advise, attempt, or ever encourage starting a treatment protocol such as TF-CBT, as you're likely to be unable to complete it properly. Additional days will not be authorized simply because the patient is in the middle of therapy. The goal of acute hospitalizations really isn't treatment -- it's stabilization.

LOS depends on the hospital and the insurance. It can range significantly depending on many factors. I regularly see patients in acute units for months as they stabilize and await placement.
 
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