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24 CW360 o Trauma-Informed Child Welfare Practice • Winter 2013PracticeTrauma-Informed PMTO: An Adaptation of theOregon Model of Parent Management TrainingLaura A. Rains, MSW, LCSW, and Marion S. Forgatch, Ph.D.Consistent effective parenting is a cornerstonefor children’s healthy adjustment undernormal circumstances; it is even moreessential for families facing adversities.Providing effective treatment to families inthe child welfare (CW) system who haveexperienced traumatic stress can promoterecovery from adversity and a return tohealthy balance. The Oregon model ofParent Management Training (PMTO)is an evidence-based program (EBP) thatincreases effective parenting, which in turnpromotes positive outcomes for childrenand parents (Forgatch & Patterson 2010).Recently PMTO has been tailored to addressthe needs of families in the CW system bystrengthening a focus on emotion regulationand adding mindfulness, thereby yielding atrauma-informed version of PMTO.Trauma and other adverse contexts canlead to emotional dysregulation. Parents mayreact with negative emotions, which in turncan interfere with effective parenting practices,and lead to negative outcomes for children andtheir families. Adversities such as transitions,unemployment, substance use, poverty,and discrimination can amplify caregivers’negative emotions and interfere with socialrelationships outside the family (DeGarmo &Forgatch, 1999; Patterson & Forgatch, 1990).Additionally, maltreated children in fostercare are burdened with challenges in socialemotionalcompetence (Pears, Fisher, Bruce,Kim, & Yoerger, 2010) and psychosocialdomains (Pears & Fisher, 2005).The intervention empowers parents toserve as change agents for their families.Intervention studies consistently find thateffective parenting mediates the harsh effectsof high-risk contexts on children’s adjustment.For example, a short-term longitudinal studyexamining recovery in the close aftermathof traumatic events identified parentingpractices as a key source of protection forchildren’s adjustment (Gewirtz, DeGarmo, &Medhanie, 2011). Findings from randomizedcontrolled intervention trials in samplesundergoing stressful family transitions haveshown that improved parenting practices yieldpositive outcomes for children and for theparents themselves (Forgatch & Patterson,2010; Patterson, Forgatch, & DeGarmo,2010).PMTO interventions decrease coerciveparenting and increase positive parenting(i.e., skill encouragement, problem solving,limit setting, positive involvement, andmonitoring). Improvements in parenting, inturn, buffer the effect of stressful contextson youngsters and promote healthyadjustment. More than four decades of carefulresearch with PMTO programs have shownbenefits for youngsters in terms of reducedinternalizing and externalizing behavior,deviant peer association, delinquency, policearrests, and increased academic functioningand positive peer relationships (Forgatch andPatterson, 2010). Several large-scale PMTOimplementations have been conductednationally and internationally. Adaptedversions of PMTO are being tested withdiverse populations, including English andnon-English speaking Latinos, militarypersonnel returning from the wars inAfghanistan and Iraq, Somali and Pakistanifamilies in Minnesota and in Norway, andfamilies in Mexico City.Originally, PMTO focused on parentinginterventions for child mental health issues. Inthe last decade, the intellectual contributionsof Dr. Abigail Gewirtz contributed totailoring PMTO programs to help familieswhose children have been removed for neglectand/or maltreatment. PMTO programs forCW include an intensive reunification projectin Kansas and in Detroit, Michigan. Parentslearn to integrate emotional regulation,mindfulness, communication, and problemsolving skills to improve relationships at homeand with adults in the community (e.g., othercaregivers, CW, judicial, school, employer).As parents become more effective, new doorsto healthy social environments open up forchildren and parents (Patterson et al., 2010).PMTO clinicians deliver the interventionin parent groups or individual family sessionsusing non-blaming, strength-based, activeteachingstrategies tailored to the specificneeds of families. To broaden the range ofemotional identification, practitioners usevideo and other media that elicit parents’descriptions of attributes of emotions inIntervention research must become standard practice to better understandthe role of parenting in children’s post-trauma recovery and therelationship between trauma-informed parent training and child welfare.terms of body posture, facial expression,and voice tone. To strengthen parent-childcommunication, families create an emotioncollage or play games designed to providepractice in managing common familychallenges. Clinicians engage families withtheatrics and humor, thus promoting acomfortable environment for differentiatingand expressing emotions.Families in the CW system need evidencebasedpractices to ensure enduring positiveoutcomes. Intervention research must becomestandard practice to better understand therole of parenting in children’s post-traumarecovery (Gewirtz, Forgatch, & Wieling,2008) and the relationship between traumainformedparent training and child welfare.The hardworking practitioners whose missionContinued on page 38
CW360 o Trauma-Informed Child Welfare Practice • Winter 2013 25Cultural Adaptations of Trauma Treatments in Indian CountryWynette Whitegoat, AB, and Richard van den Pohl, PhDThe National Native Children’s TraumaCenter at the University of Montana isfunded by SAMHSA as a Treatment andService Adaptation Center within theNational Child Traumatic Stress Network.Centers such as ours are charged withreplicating evidence-based trauma treatmentswhile adapting them to meet the needs oflocal communities. Our work has focused onproviding cognitive behavioral treatments,primarily Cognitive Behavioral Interventionfor Trauma in Schools, or CBITS (Jaycox,2004), in American Indian reservationschools. We also have worked to createtrauma-informed behavioral health, juvenilejustice, and child welfare systems. Indianand non-Indian staff members’ backgroundsinclude psychology, education, social work,counseling, early childhood, law enforcement,and the military.Inclusion of traditional Native culturalactivities in evidence based trauma treatmentshas produced strong appreciation for ourwork by some tribal partners. It also hasproduced great concerns from other tribalpartners largely due to sacredness of culturalactivities. The use of traditional healingwithin the Native communities we work withis seen to be the most reasonable option inregaining health and balance. Because cultureplays a critical role in facilitating healingamong Natives, it is seen as an essentialneed toward wellbeing. Although all tribesare different in culture and hold a variety ofperspectives and philosophies, the majoritydo share similar beliefs on the importance ofwellbeing. The psychological, social, physical,and spiritual dimensions are interconnectedand should be treated as one (LaFromboise,Trimble, & Mohatt, 1990). Ceremonies andother traditional practices bring comfort,hope, and rebalance to these four dimensionsfound within individual clients and theircommunity (McCabe, 2007). Not onlydoes traditional healing provide options forrestoration but also increases opportunities forcultural preservation, reinforcement of ethnic/tribal identity, and connection to culture andthe community (Hartmann & Gone, 2012;McCabe, 2007; Ranford, 1998).While adaptation of evidence-basedtreatments may seem incompatible withhigh fidelity replication, we have foundthat adaptations can enhance acceptability,sustainability and effectiveness of traumatreatments. Most tribal communities in theUnited States experience some distrust ofoutsiders (Yellow Horse Brave Heart, 2003),particularly child welfare workers. Whethera Tribe has experienced theft of deceasedgrandparents’ remains or whether “research”has been conducted that perpetuated racialstereotypes, there are good reasons for tribalmembers to be skeptical of outside expertswho offer simplistic solutions for complexproblems (Gone & Alcantara, 2007). Whilenot conducive to short-term change, we havedeveloped three developmental approaches thatseem to support long term relationships withTribes and tribal members. First, we only workin communities where we have been invited.Second, we consider that all data resultingfrom tribal partnerships are the property ofthe Tribe; the Tribe may or may not give uspermission to disseminate those data. Third, inaddition to protecting individual identity, wedo not disclose the identity of a Tribe unlessthe Tribe asks us to do so.We also have found it valuable to engagelocal community members in participatorydialog regarding their perceptions of thevalue of treating childhood trauma, whatthe outcomes of successful trauma treatmentWhile adaptation of evidence-based treatments may seem incompatiblewith high fidelity replication, we have found that adaptations can enhanceacceptability, sustainability and effectiveness of trauma treatments.should look like, and whether there alreadyare traditional support strategies that couldbe blended with the evidence-based traumatreatment. While some local adaptationshave been procedural (e.g., inviting studentsto draw a picture to supplement their oraltrauma narrative), we also have invited localcultural experts to contribute traditionallanguage and traditional healing strategiesduring group trauma treatment.In some communities, our early effortsto include traditional Native language andculture stimulated apprehensions among ourtribal partners. One set of concerns involvedthe proprietary nature of Native languageand culture. Closely linked were perceptionsthat researchers might exploit or otherwiseprofit from information shared by healers andElders, and because we do this work as partof our university employment, we cannotcompletely nullify this perception.To date, no Tribe has refused our requestto share results of trauma treatment. However,the extent to which we discuss traditionallanguage and culture follows one of threeprotocols. The protocol that is followedis determined by Tribal Council decisionwith recommendations from Elders. In thefirst case, traditional language and healingceremonies are made available to childrenand youth who choose them, but whetherand how that occurs is not disclosed inour dissemination. In the second case, wereport that a community volunteer withexpertise in language and culture participatedin the trauma treatment program, butthe intervention(s) he or she used are notrecorded, named or described. In the thirdcase, the traditional ceremony may be namedand may be described. In every case, weinform the Tribal Council of our findingsbefore disseminating elsewhere.Child welfare (CW) workers may beperceived as “outsiders,” for example, ifthey are employed by the Bureau of IndianAffairs, a federal agency. In recent years,BIA has employed Native workers whoalso are community members—a practiceconsistent with Indian self-determination.Alternatively, Tribes can provide their ownchild welfare services. Regardless of agencytype, CW workers face enormous challengesin child protection as the families they servefrequently are both neighbors and relatives.The adoption of Differential Response (DR)services has dramatically shifted the CWworker role from investigation only to a moreintegrated approach of family support servicescoupled with ensuring child safety. SuchContinued on page 38Practice
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