Black, Latino children do better with evidence-based therapy than talk therapy
When Rhaili Lowe was 10-years-old she was anxious, having trouble sleeping and concentrating, and wasn’t herself with her friends or family.
Rhaili was living with the memory of being molested by her father, and fear and confusion were weighing on her.
So her mother brought her to therapy in Manchester, where she talked and played games with a therapist for several months but didn’t improve. In fact, Rhaili, who is now 14, doesn’t remember the therapist actually spending much time even discussing why she was there.
“We played games. We colored and stuff, but while you’re coloring, you’re talking about your day. It wasn’t like ‘ let’s get back to why you’re here,’ ” she said. “It wasn’t really helping. It was more like, ‘How was your day? What did you do at school?’ ”
Stephanie Parnther says her daughter was actually getting worse.
But then the family moved to Hartford and, with Rhaili still suffering, Parnther brought her to the Village for Families & Children, where therapist Megan Bain used a comparatively new method called Trauma-Focused Cognitive Behavioral Therapy.
And it worked.
By the time her therapy ended, Rhaili said, she had more self-confidence and better self-esteem, even going on to win election last year as president of her school’s student council. Rhaili and her mother agreed to be interviewed for this story to spread the word about the effectiveness of the therapy Rhaili received, in the hopes it will help others.
“I felt like I had power over my body and myself,” she said. “I started to feel more self-confidence. I have anxiety still, but not as much as I had before.”
The therapeutic approach used with Rhaili, which is considered “evidence-based” because research shows its effectiveness, proceeds in a structured way that differs from what clinicians consider “treatment as usual.” It includes strategies for each therapy session, often with a projected timeframe, and requires regular assessments to evaluate whether a patient is improving. Often parents play an essential role in the process.
“I felt like I had power over my body and myself. I started to feel more self-confidence. I have anxiety still, but not as much as I had before.”
A recent study by the Child Health and Development Institute of Connecticut shows that such evidence-based treatments are significantly more effective than “treatment as usual,” or ordinary “talk therapy.” The study is based on an analysis of data from 46,729 children who were patients at behavioral health clinics in the state between 2013 and 2017.
Jeff Vanderploeg, president of CHDI, said he was very pleased that the study shows evidence-based practices clearly out-perform non-evidence based practices in a “real world setting.”
“If we want to invest in evidence-based practices, we should be sure that we get better outcomes than if we just let clinicians deliver what they want to deliver,” Vanderploeg said. “And the fact is, yeah, we are getting better outcomes than usual.”
Further, the disparity for black and Latino children, who don’t show as much improvement in traditional talk therapy as white children, was reduced or even eliminated when they were provided with an evidence-based therapy, the study showed.
“If we want to invest in evidence-based practices, we should be sure that we get better outcomes than if we just let clinicians deliver what they want to deliver. And the fact is, yeah, we are getting better outcomes than usual.”
Child Health and Development Institute of CT
Jason Lang, vice-president of CHDI, said, “that was not something we expected to see, in part because evidence-based therapies were not developed especially for children of color and they weren’t, as far as we know, adapted or modified in order to eliminate disparities.”
Lang said he thinks it possible that “treatment as usual,” which he said allows a lot more “variability and flexibility,” may result in therapists working differently with children of color, possibly “unconsciously or based on implicit bias.”
Vanderploeg called therapy-as-usual “kind of a black box. It’s driven primarily by the therapist by training and expertise and their preferences in treatment and we don’t really know the parameters of what’s going on.”
By contrast, Lang said, evidence-based therapies – called EBT’s — differ because therapists know what they are supposed to do during each session and the course of treatment is “pretty spelled out.”
“We don’t know [why],” Lang said, referring to the improved outcomes for minority children. “It may also be that some of the newer EBT’s have been developed with more diverse populations.”
Vanderploeg said the research results “really speak clearly to the importance of evidence-based practices and we need to explore ways we can scale up that work and sustain it.”
A detailed road map
There are many different kinds of evidenced-based therapies, but the CHDI study focused on Trauma-Focused Cognitive Behavioral Therapy and another type, called MATCH, which is used to treat anxiety, depression, trauma and conduct disorders. It is considered a form of cognitive behavioral therapy, which also is an evidenced-based treatment, albeit a less structured and more generic version.
At the state Department of Children and Families, Deputy Commissioner Michael Williams said the agency, which has been moving toward evidence-based practices for the past 10 or 15 years, now funds a mix of evidence-based and other therapies, with 50% to 60% of those in treatment receiving evidence-based treatments.
Nationally, it’s estimated that between 1% and 3% of children receive EBT, which CHDI says is related to the added time and cost to train staff. The CHDI report says that Connecticut has been a national leader in improving access to evidence-based treatments for children.
“We’re not exclusively doing evidence-based, but what we have come to appreciate is a good mix of those services that have some evidence behind them and those services we know are promising practices,” Williams said.
Other clinicians, while cautioning that it may not be effective for every child, agree about the beneficial aspects of EBT.
“What’s great about evidence-based treatment is it provides a guideline for the therapist,” said Elisabeth Cannata, a vice president with Wheeler Clinic. “They are targeting specific areas of need and it guides the therapist to be very targeted in their interventions, to really address it in a way that’s been demonstrated to be effective. It really helps the therapist to be more focused.”
Cannata likened it to someone needing heart surgery. “If you were seeking treatment for a cardiac condition,” Cannata said, “you would want to know that this has been researched before and that Dr. So and So has a good record.”
“It doesn’t mean that other treatments aren’t effective, but if you have a choice and you’re trying to build a system, choose things that have a proven track records. I see it as increasing the odds,” said Cannata. “It helps the therapist to be focused in their treatment, on why the client is coming into treatment, and what they want help with. How do we match an intervention to what they want help with? And then the treatment, because it’s a model with its own practice parameters, really helps therapists to be be focused.”
“Sometimes people worry it’s too cookbook-like,” said Cannata. “It’s not really cookbook-like. It’s more of a foundation that you build the therapy around … It provides the structure, but what the content is — the meat on the structure — is the individual factors that are unique to each family.”
Marcy Kane, vice-president of child services for Wellmore Behavioral Health, based in Waterbury, said that evidence-based practice “is like driving the car in an area you’re not familiar with but you have a very detailed road map to follow.” If you don’t know where you are and there’s no map, she added, not only will it take longer to get to your destination, but it’s also going to be “stressful and feel twice as chaotic.”
“I believe that the evidence-based practices really provide a detailed road map to help the practitioner move along in the treatment to get to the desired goals quicker,” Kane said.
“I believe that the evidence-based practices really provide a detailed road map to help the practitioner move along in the treatment to get to the desired goals quicker.”
Wellmore Behavioral Health
The periodic assessments that are part of an evidence-based treatment model, Kane said, also provide a “sense of hope and encouragement along the way,” as do mile-markers in a long race. “It really keeps you on the track much quicker,” she said.
She said that traditional therapies are generally more of a “fluid process.”
“Frequently, a therapist would just ask the family, ‘Hey, how is it going?’ and they might say, ‘This is going really well, but this isn’t going so well’,” she said, “but with evidence-based practices, we also incorporate data so that at those proverbial mile-makers in the race, we could say, ‘OK, well , on this assessment, you scored a ten the last time, which was a really high score’.”
She said Wellmore treats a lot of children with a history of exposure to traumatic events, including community violence and separation from family through loss, divorce, incarceration or the child welfare system. They may have trouble sleeping or concentrating or they may have intrusive thoughts that raise anxiety. Often, she said, children act out as a result of traumatic experiences.
The evidence-based treatments, she said, have enabled children to do “a lot more focused work on traumatic experience.”
A trauma narrative that leads to healing
For Rhaili and her mother, the difference in the effectiveness between traditional talk therapy and the trauma-focused cognitive behavioral therapy was huge.
As Megan Bain, Rhaili’s therapist explained it, the evidenced-based approach started with educating the child about sexual abuse in general.
“The first step is to learn about other people’s experiences,” Bain said. “She started to learn about statistics related to sexual abuse and domestic violence. You start talking about the general and then go the specifics related to the client’s experience. We knew she had a history of sexual abuse, she just wasn’t ready to call it that and we also knew that she had witnessed multiple episodes of domestic violence.”
“She really just wanted to forget what happened,” said Bain. “She wasn’t really able to connect that her feelings and experiences were related to trauma. I don’t know that she recognized what she had gone through as trauma at that time.”
Rhaili said this approach initially puzzled her.
“I thought it was stupid at first,” she said.”There were picture books with pictures of kids’ emotions and I’m like, why do I have to know about them? I know I’m annoyed, it’s an emotion, but in the end that helped me to figure out, to explain my emotions more. Before, I was like ‘Oh, I’m mad and I don’t know why. I’m just mad.'”
Learning about sexual abuse and domestic violence, Bain said, gave Rhaili “gradual exposure” and helped to prepare her to face her own trauma. The process included visiting particular geographic locations that made Rhaili anxious because her father frequented the area. The outings helped her to develop skills to cope with her emotions.
“The goal is not to eliminate the feeling altogether, but to help the child understand that they are in control of reducing it,” said Bain.
And it culminated with a “trauma narrative,” in which Rhaili, with Bain as scribe, recorded the traumatic experiences and exactly what happened.
“You start with creating a table of contents,” Bain said, and then the child talks about his or her worst experiences. “They talk about the biggest things to show that if they can conquer the worst case scenarios, then they are capable of handling the smaller situations that come up in life”
The process is structured and predictable, Bain said, which puts the child “in the driver’s seat” and “in control of their experiences.”
Parnther, who had been working with Bain separately, said she had feared the moment when Rhaili would write her narrative because she thought it might bring the trauma back in a way that would be damaging. But the opposite happened.
“That was the breaking point,” said Parnther. “I think it’s because when you have something bottled up, you can’t live. Letting it out actually healed her.”
Rhaili says now the process helped her “explain my emotions and what really happened and not just like shutting anything away.
“I told the hardcore story and I wasn’t not telling any details,” she said. “It felt good to get all that out.”
Stephanie said that for her the treatment has — in a sense — given her her daughter back.
“When you’re losing her, she shuts down,” Stephanie said. “It kind of stole her from her family emotionally and with her coming [to the Village] it actually gave her sense to live again.”
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