1. HSS – Helhetlig Støtte System
Cognitive Behavior Therapy ++
delivered to the Norwegian Directorate for Children, Youth
and Family Affairs, region North
Per Jostein Matre, MSW, child welfare expert
Cognitive Therapist and
National Supevisor in CBT
Authorized supervisor for social workers
Robert Jensen, BSW
Cognitive Therapist and
National Supevisor in CBT

2. Background
 In November 2010 the Norwegian Directorate for Children,
Youth and Family Affairs, region North decided a procurement
and called for offers to meet needs of systematizing and
improving the work carried out in all the institutions in the
northern region
 14 units all in all were included - (during the first year two
have been closed down), - at the moment there are 12 left
 The main goal was to systematize and improve ongoing
practice
 The implementation should be based on existing practice and
have a «bottom up» design, meaning that ongoing, existing
practice should be the base for change through teaching,
training and supervision

3. Requirements from region north
Methods:
By documenting existing practice and using data from the documentation, - develop and change
existing practice.
Practice:
Client data (level III) will be the basis for developing practice.
As the units lack a solid support system it is crucial first to focus on strengthening staff performance,
leader behavior and organizational procedures linked to problem-solving.
– Focus on results (Staff, leader and organizational level)
• What do the unit try to achieve with their existing practice?
• How do staff and leaders know they do a good job (quality wise)?
• The goals are that every unit establish own targets and quality criteria’s for their daily
practice.
– Using CBT (client level III)
Evaluation:
Shall be carried out using standardized assessment tools (level III) and be basis in documentation and
supervision for leaders and staff .
Assessment, feedback and evaluation (organization, staff and client level)

4. Main Goals
To systematize and improve
existing practice

5. Timeline – from the call for procurement to contracting
 Mid. of November 2010 - Region north send out the demands and
specifications to be met
 22.1.2012 Time limit to deliver a full detailed description of what,
when and by who
 30.3. 2011 Negotiations on contrakt terms
 28.4. 2011 Contracting
 22.5.2011 Starting point of the project

6. Our offer – related to different Goal levels – I - III
I. Organization and the leaders
Assess existing practice, competence and needs for supervision
Localy: Visit each unit, both the leaders alone and leaders together with a group of staff
Intervention; leader gathering setting up goals and following up performance
II. Staff
Staff assessment using New Goal Setting Questionnaire: (seven domains – well-being, support from leaders,
goal directedness, self – efficacy, specified goals etc.)
Quest – back, – on the internet
Local supervision
III. Client
Training in principles, theory and models in a module based Cognitive Behavior Therapy
– Training in both standardized and other assessment (ASEBA, SDQ, Global assessment, BYI etc.)
– Training in analyzing and conceptualization
– Training in goal setting and evaluating procedures based on Goal Atainment Scalling and weekly
based reports
– Training in specific interventions based upon different types of problems (e.g; anxiety, depression,
trauma etc)
– Establishing procedures for; monitoring operations, satisfaction with sercvice and evaluating client
satisfaction and client involvement
Core group gatherings
Local training and supervision

7. Implementing – HSS in region north
co – operation with who
A project carried out by Centre of Cognitive Practice – CCP (Asker – 20 km west of Oslo)
Per Jostein Matre Head of clinical services , cand. polit – MSW – clinical social work
Robert Jensen Manager , BSW – clinical social work
Partners
Kitty Dahl Psychol. PhD - Regional Centre for child and adolescent mental health (RBUP)
Hans Nordahl NTNU, Professor at psychological institute – clinical department
Eric Trupin University of Washington, USA
Professor & Vice Chair in the Department of Psychiatry & Behavioral Sciences
Director of the Division of Public Behavioral Health and Justice Policy
Arne Martin Nytrøen Considium, consultant in performance review (leaders)
Claes Linden Psychologist, specialist
Harald Stokkeland Consultant – leader support

8. Who is doing what – in the whole project?
Activity Per Robert Kitty Arne Harald Hans Eric Claes
Jostein Martin
Local X X
workshops
Core group X X X
workshops
Leader X X X
support
Performance X X X
reviews
Evaluation X X X X
Data X X X
collection
Support X
Project X
manager

9. Where are we working
In black; facilities /
centers for youth /
adolescent, age group
13 – 18
In red; facilities /
centers for children
and families, age
group 0 – 12

10. Timeline for implementation in Child Care Services in North of Norway
Evaluation Target First year Second year Third year
Instruments Group 2011(May) -2012(April) 2012(May) - 2013(April) 2013 (May) ->
O= Organization 2011 2012 2013
L= Leaders
S=Staff Spring Fall Spring Fall Spring Fall
C/Y/P/CWW/T= Children/ Youth/
Parents/ Child welfare workers/
Teachers
SVQ O/L/S May/August Results May/June Feedback May/June Results
(pre interventions) Feedback (short version) (short version) Feedback
Provided localy for staff once a year and to the leaders at the facility three times a year
GAS O/L/S May/June/ April/May April/May
august
Quest-back O/L/S June/August Results June/August Results June/August Results
Feedback Feedback Feedback
Satisifaction C/Y/P/ Once: End of the stay at the facility
measures CWW Given to the Youth, Parents and/other key people
EBPAS Staff September / April April/September
CTACS Staff September / January / April September / January / April
SDQ C/Y/P/T Twice: Start and end of the Youths stay at the facility
ASEBA C/Y/P/T Twice : Start and end of the Youths stay at the facility
(CBSL, YSR, TRF)
Specific C/Y/P At least twice: Early and end of the stay at the facility
Instruments for
problem areas

11. Organizing
Training and supervision directed to
different groups Regional workshops Local workshops
Leaders 8 full day performance review
workshops
4 full day leadersupport workshops
4 Core groups, aprox. 8 staff member per unit; 6 workshop for every group
25 – 30 %
Staff at the unit 13 full days of training
and supervision at
eache unit (total of 156
days + additional 12 +
12)
HSS-team meetings as regular as possible

12. Done at all units
Semi structured interview
Site Visit Questionnaire (SVQ)
Goal Attainment Scaling (GAS)
– 5 point scale from 0-4 (weak – strong practice)
– 21 domains
(e.g. organization, target (client) group, written practice / routines, procedures / assessment procedures,
analytical practice, working with goals, interventions, evaluating procedures, need for training and
supervision etc.)
• Two interviewers, both make notes and score
• Ca. 2 – 2 ½ hours with the leaders
• Ca. 3 hours with leaders and staff together
Internet based survey both for staff and leaders
Quest-back (put together based on 3 different instruments)
• 90 questions, around 35 minutes
• 15 domains, e.g.;
(1) Colleague support, (2) leader support, (3) own goal directed behavior, (4) self – efficacy, (5) optimism, (6)
engagement & commitment, (7) own practice
Self reports
CTACS: Cognitive Therapy Adherence & Competence Scale
• 21 questions
• Ca 10 min
EBPAS: The Evidence-Based Practice Attitude Scale
• 15 questions (own attitudes to evidence-based practice)
• 5 point Likert scale (0-4)
• 4 subscales and one total score
• Ca 10 min

13. Main findings – first year (2011)
Scoring each unit based on Site Visit Questionaire (SVQ)
Assessment Conceptualization Evaluation and Max / min
Virksomhet Analysis Goal setting Interventions Reporting Score
procedures procedures documentation
35 / 7
3 2 2 3 3 3 3 19
3 3 3 4 4 3 3 23
4 3 4 4 4 3 3 25
4 3 3 4 4 3 2 23
3 3 3 4 3 3 3 22
4 4 3 4 4 3 3 25
4 3 3 4 4 3 3 24
3 3 3 3 3 3 3 21
4 3 2 3 4 3 3 22
4 3 3 3 4 4 4 25
4 3 4 3 4 4 3 25
Ikke skåret
Ikke skåret

14. Implementing a blend of compatible
theories and working models

15. The plattforms
Cognitive Social Ecological
Behavior
Behavior cognitive Theory
analysis
Therapy theory
•Reinforcement
• Automatc thougths • PSE
• Generalization • Transition
• Assumptions • Resiprocal
and •System support
• Core beliefs model
maintenance
CBT
With children, adolescents
and families

16. Module based approach to CBT
Psychoeducation
module
Behavioral Cognitive Rational Performance /
Interventions Restructuring analysis Attainment
Module Module Module / Exposure Module
Assessment,
Self monitoring,
and evaluation Module Friedberg, R.D, McClure, J.M.
& Garcia, J.H (2009)

17. So, - what do we do, basics, the modules
and beyond ?

18. 1.
Assessment of
strengths and
challenges
6. 2.
Evaluation Analysis and
and re – conceptualiz -
conceptualiz - ing on four
ing levels
3.
5.
Setting goals
Skill training, for the stay
experiments, and the
exposure and specific
response treatment
prevention
4.
General and
specific
interventions Kuyken, Padesky, Dudley (2009); Friedberg & McClure
(2002); Friedberg, McClure & Garcia (2009); Stark (2010)

19. Assessment procedures
Global assessment
Descriptive
Functional
Longitudinal
Strengths and
Resources
Standardized ASEBA, SDQ
and specific Anxiety
assessment Depression
Trauma
Addiction
etc.
Re – assessment
Evaluation
re - conceptualization

20. Examples of Global assessment
GI Youth

21. Anamnestic Interview - AI
Sykehistorie, opplysninger om tidligere helseforhold og nåværende symptomer
innhentet fra ungdommen og/eller pårørende

22. Standardized assessments
www.sdqinfo.com/

23. ASEBA

24. Analysis and conceptualization
Level 1 Context
– increase the persons understanding of Others
connections between trigger – own Time
behavior and thoughts in the situation and Behaviour
how these two domains has impact on
emotions and bodily sensations
Emotions Thoughts
Trigger
Bodily
sensations

26. Level 2
– increase the persons understanding of
trigger – own behavior and thoughts and
how reduced negative emotions and bodily
sensations together with contextual
reactions maintain patterns

27. Escalation curve
Patterson 1987
Kan du rydde
Jeg sa du skulle
Opp etter deg
rydde, nå!
Toppen er nådd når det
gjelder følelser. ordbruk
og handlinger
Nedtrapping
Økt og økende intensitet
i følelse, ordbruk og Åhh – slutt
RYDD NÅ!!
handlinger med den gråtingen
Innhenting
Argumentering
irritert og opprørt
Utløser Lære å stoppe her
Utløser Bearbeiding
Rolig

28. A B C
(Activating event) (Belief) (Consequences)
Sitting down by the kitchen table, - Everything will fall apart Laying down at the sofa
Worrying about future events in a very I am a bad mother for my two daughters Reduced anxiety
negative way
I can`t make it Reduction of body sensation of heaviness
Nothing works

29. FULL - KONSEPTUALISERING
Level 4
Actuel situation Problem Strengths and resources
Strengths
and
resources
Level 3 Experiences Temperament,
Rules, values and goals
history biology, medicine;
Longitudinell both family
significant events social and economy
and individual
conceptualization
Triggers
AT – varme og kalde
kognisjoner.
Mellomliggende
Level 2 Level 1 antagelser (normer, regler,
mål og forventninger)
ABC – both triggers Connection between Kjerneantagelser
(globale fore-stillinger om
and Maintenance factors Descriptive conceptualization seg selv, andre, verden og tid)
dvs. Skjema
Functional
conceptualization
Behavior Emotions (0 til 10) Bodily
sensations (0 – 10)
Maintaining factors
Kuyken, Padesky and Doodley (2009); nnnn
Adapted by Per J Matre & Robert Jensen vers 11 2011

30. Goal setting
What can be
changed by
interventions
Behaviour
Context
Emotions Thoughts
Trigger
Bodily
sensations

31. Specifying goals in therapy – an example
Can you imagine
yourself together
with your two daugters
doing something
positive
What do you
actually see ?
How does it look in
Whe do you start doing like this, details? Do you get a
what is yuor time frame? clear imagery of it?
When you see this what
more do you see?
Goal setting
procedure
- working with
visualized goals in
Is it realistic?
therapy
What can you do
to make it more realistic? Do you see your own
Who, besides yourself can performance and effeort
help, so that it becomes ? Do you get a clear
more realistic? What imagery of it? Do you
obstacles are there, act as your own
Can you handle supportive helper?
them with own
Is it actual and
strengths
attainable to you?
Can you see details
of how to make
it more achievable
for you? Who can help
you besides your –
self?

32. Ines plan part I

33. Ines plan part II – evaluation

34. Interventions
 Skill training
 Skill training
 Behavior experiments
 Skill training & changing thoughts
 Exposure
 changing behavior and thoughts
 Response prevention
 changing behavior and thoughts
 Tasks between sessions
 Skills, changing behavior and thoughts
 Parental involvement
 changing behavior, thoughts and interactions

35. Example - Ines behavior experiment

36. Evaluation and reconceptualizing
Global assessment
Descriptive
Functional
Longitudinell
Strengths and
Resources
Standardized Anxiety
and specific Depression
assessment Trauma
Addiction
etc.
Re – assessment
Evaluation
re - conceptualization

37. This is our plan
Evaluation Target First year Second year Third year
Instruments Group 2011(May) -2012(April) 2012(May) - 2013(April) 2013 (May) ->
O= Organization 2011 2012 2013
L= Leaders
S=Staff Spring Fall Spring Fall Spring Fall
C/Y/P/CWW/T= Children/ Youth/
Parents/ Child welfare workers/
Teachers
SVQ O/L/S May/August Results May/June Feedback May/June Results
(pre interventions) Feedback (short version) (short version) Feedback
Provided localy for staff once a year and to the leaders at the facility three times a year
GAS O/L/S May/June/ April/May April/May
august
Quest-back O/L/S June/August Results June/August Results June/August Results
Feedback Feedback Feedback
Satisifaction C/Y/P/ Once: End of the stay at the facility
measures CWW Given to the Youth, Parents and/other key people
EBPAS Staff September / April April/September
CTACS Staff September / January / April September / January / April
SDQ C/Y/P/T Twice: Start and end of the Youths stay at the facility
ASEBA C/Y/P/T Twice : Start and end of the Youths stay at the facility
(CBSL, YSR, TRF)
Specific C/Y/P At least twice: Early and end of the stay at the facility
Instruments for
problem areas

38. What have we done - May 2011 - September 2012
Spring 2011 Fall 2011 Spring 2012 Fall 2012 Remains
SVQ, GAS X X 2013
Quest-back X X 2013
EBPAS X X X 2013
CTACS X X2 X2 2013
SDQ X X X 2013
ASEBA X X X 2013
(CBSL, YSR, TRF)
Specific X 2013
Assessment
instruments for
problem areas
Specific X 2013
interventions for
anxiety, depression,
trauma, addiction
cd etc
Satisifaction X 2013
measures
Result review and X X X 2013
feedback
Leader support X 2013