Research

A pilot study of this intervention was conducted in 2010 in South Florida involving two agencies that served adolescents who were in the process of transitioning from foster care to independent living. A total of 31 participants between the ages of 12 and 23 completed both an intake questionnaire and an exit questionnaire. Youth who participated in the program reported higher rates of talking to a trained counselor about sex and sexual health and using contraception at last sexual encounter after the program ended.

In 2015, The Policy & Research Group (PRG) received a grant from the Office of Adolescent Health Teen Pregnancy Prevention Program to evaluate the effectiveness of PS-R using a randomized controlled trial. The study takes place in five states with over 100 masters-level clinicians in various therapeutic settings that serve youth ages 14-19 who have experienced trauma. The study will be finished in 2019, and results will be posted when the analysis is complete.

Study Analysis and Outcomes (Download Now)

In 2016, PRG received a grant from the Family and Youth Services Bureau (FYSB) to evaluate the effectiveness of e-PS-R, the blended learning version of PS-R which involves eight on-line sessions and four facilitator meetings. This study takes place in two states with juvenile justice involved youth ages 14-19. This study will be finished in 2020, and results will be posted when the analysis is complete.

e-PS-R Intervention Package 2022

Practice Self-Regulation™️ has nine core components that make up a foundation for long-term health and well-being. The content of each component (what is taught) is listed below, followed by a description of the intervention’s pedagogy (how the content should be taught) and implementation guidance (the learning environment in which the program should be taught).

Practice Self-Regulation™️ is Trauma-Informed: Acknowledging and understanding the impact of adverse childhood experiences (trauma) on current behavior.

Affect Regulation: Introducing, teaching, and supporting each participant’s practice of affect regulation (thoughts, feelings, physiological reactions, behavior, and outcomes). Facilitate understanding and exploration of affect regulation’s relationship to, and influence on sexual decision-making.

T.O.P.* Workbook for Sexual Health: Youth generally complete the workbook on their own time. If they need support they may work on it during sessions in collaboration with the facilitator. The workbook contains self-directed activities that help simplify complex concepts related to trauma. This helps youth more easily understand and apply effective coping strategies for self-regulation and optimal sexual decision-making. The workbook provides a clearly defined and structured way of guiding youth through the therapeutic process.

Multi-Sensory Activities: Neuroscience indicates that multi-sensory activities enhance brain processing and executive functioning (working memory, analysis and synthesis, organizational skills, internal speech, emotional and behavioral regulation). Each session includes at least one multi-sensory activity such as guided imagery or other mindfulness practices. Other activities enhance self-awareness through drawing and/or writing, such as creating a personal shield for self-protection or a self-portrait of the person they want to be.

Positive Youth Development: Research indicates that focusing on strength and resources promotes therapeutic change. It also indicates that people are more likely to be successful working towards a goal (sexual health) rather than trying to avoid something negative (pregnancy, STI’s, harm to self or others). This represents contrast between approach and avoidance focused interventions.

Self-Efficacy (autonomy): Motivational Interviewing is used as the foundational philosophical approach to promote life-long optimal sexual decision-making. This involves helping youth to understand influences on their sexual decision-making, addressing discord, ambivalence, and increasing motivation to practice optimal sexual decision-making.

Personal Values: Youth identify personal values and refer to them throughout the process in order to move towards alignment between their stated values and behavior.

Uniform Session Structure: Creating and maintaining a safe, stable, and supportive environment is a foundation of trauma-informed care. Predictability is an element of stability and identifying clear expectations for change influences successful outcomes in psychotherapy. Using a uniform session structure streamlines the therapeutic process and reduces stress for both therapists and participants. After the first introductory session the following nine involve:

• Checking-in and facilitating a decision dialogue
• Monitoring progress in the workbook
• Sex education and multi-sensory activities
• Obtaining client feedback through Wrap Up questions

Future Orientation: Research indicates that future orientation is a predictive factor for positive youth development and youth violence prevention.

There are five pedagogical approaches that should be used when delivering PS-R.

Individual Sessions: Supporting youth healing from trauma requires safe and supportive confidential communication to promote health and well-being. It is imperative that all communication meets Health Insurance Portability and Accountability Act (HIPAA) requirements ensuring data privacy and security provisions for safeguarding mental health information.

Motivational Interviewing: This is a collaborative conversation style for strengthening a person’s own motivation and commitment to change (Miller & Rollnick, 2013). It provides the foundation for optimally engaging participants and communicating most effectively. All facilitators are expected to demonstrate competence in this philosophical approach.

Role Model: Children learn what they live. When facilitators model health, well-being, self-care, and warm, nonjudgmental, empathic, and genuine communication young people are more likely to mirror such behavior.

Affect Regulation: A trauma-informed approach for adolescent sexual health is predicated on affect regulation. Affect regulation has five core components: thoughts (cognition), feelings (affect), physiological reactions, behavior, and outcomes. The first three are internal processes people learn to mindfully observe as they experience external stimuli (arousal [not necessarily sexual]). These three internal elements influence decision-making that in turn influences behavior and outcomes. While cognition and behavior play a part in all therapy this approach is not limited to a general cognitive behavioral therapy approach (CBT). This model is in keeping with tenets put forth for trauma-informed interventions promoted through the National Child Traumatic Stress Network (NCTSN).

Skill Practice: People are most likely to remember what they directly experience and practice. Neuroscience indicates that humans thrive in settings that provide a variety of stimulating, engaging, and increasingly challenging experiences with enough repetition to solidify desired outcomes (Steinberg, 2014, van der Kolk, 2014). Opportunities to practice personal ideas for change allows for mistakes and poor judgment to be self-corrected with support and encouragement (Steinberg, 2014, van der Kolk, 2014).

Population: PS-R is designed for youth aged 12 and above. Unless a 10 or 11-year-old is highly motivated and has the intellectual capacity to comprehend all elements of the intervention, it is not recommended for anyone under the age of 12. It should never be facilitated with anyone under age 10.

Facilitation Setting: PS-R should be facilitated in private and confidential individual therapy sessions by professionals trained in the model. It is not recommended for group or family therapy, as highly sensitive topics related to trauma may be unsafe to address outside of individual meetings.

Program Duration: PS-R is composed of ten structured, individual therapy sessions intended to promote optimal sexual decision-making. PS-R is intended to be delivered in one-hour sessions over 10 consecutive weeks (one session each week); however, it may take longer depending on a youth’s mental health needs and scheduling (for example, vacations or missed appointments).

Timing of intervention: Each therapist determines in collaboration with each youth, when the intervention is introduced, facilitated, and ended within each youth’s treatment plan. Implementation of the intervention during therapy sessions can be suspended for short periods of time when indicated by the youth’s mental health needs. Any time a youth decompensates and is unable to focus on the intervention, session plan activity is suspended until the youth has returned to baseline and can competently participate again. This may occur for a short duration within a single session, or may require suspension of one or more sessions.

Session activities a participant chooses: Youth are always invited to work in therapy in a way that best meets their needs within the range of choices between the workbook, multi-sensory activities, and sex education. It doesn’t matter whether a youth does the workbook on their own time, individually during therapy sessions, or in collaboration with the facilitator during therapy sessions.

Additionally, youth may, or may not participate in multi-sensory activities during sessions. If they are not interested during a specific session, they are welcome to do so at a later time. It doesn’t matter if they want to do an activity not designated in a specific Session Plan. Facilitators are encouraged to facilitate the activity a youth wants to do and wait to proceed to the next Session Plan. They may also choose to repeat any of the activities whenever they want to.

Intensity of focus on chosen activity: While youth have choices among activities, collaboration between the therapist and participant indicate the level of depth in which each one is addressed. Youth should never be required, pressured, or coerced into participation.

Number of activities: Youth makes this decision based on their personal interest and motivation.

Theory of Change:
The theory of change for this intervention integrates the latest research on adolescent development and brain processing that reflects the neuroscience of decision-making and behavior (Jensen & Nutt, 2015; Steinberg, 2104; van der Kolk, 2014). While the goal is to prevent pregnancy, infection, disease, and harm to self and/or others, the means for accomplishing such a goal involves three interactive components. While a participant’s knowledge about safe sex practices increases, so does their knowledge about the impact of trauma on sexual decision-making through both the T.O.P Workbook for Sexual Health (Schladale, 2015) and multi-sensory activities created to enhance memory retention and optimal decision-making.

Exploring the impact of trauma helps participants recognize harmful behavior patterns and consider motivation to change such risky sexual behaviors. In addition to knowledge, the intervention addresses impulsivity and skills to improve affect regulation. The combination of self-awareness, skills, and motivation for change results in increased self-efficacy to both negotiate and practice safe sex. The program should result in an increase in harm-free sex, condom use, a decrease in number of sexual partners, and ultimately reduce the chance of the youth getting pregnant or impregnating a partner before age 20.

The T.O.P.* Workbook for Sexual Health Facilitator’s Manual includes theoretical underpinnings for the intervention. They include theories of attachment, human ecology, family systems, and social learning.
Attachment: Attachment is an instinctual biological bond that a child has with significant caregivers. Human capacity for self-regulation develops through attachment. Secure infant attachment occurs when attuned caregivers meet a child’s needs. A child learns trust through this process, which produces chemical changes in the brain that influence self-regulation. When secure attachment is threatened, significant chemical changes occur in an infant’s brain. When caregivers are not consistently predictable, or responsive, infants can fail to develop a capacity to self soothe. (Bowlby, 1988; Siegel, 1999; Applegate & Shapiro, 2005).

As youth experience secure relational connections, their belief system about relationships can change. Throughout the intervention, facilitators model benevolent connection, provide psychoeducation, support youth’s exploration of attachment, and provide mentoring. When healing occurs, relationship patterns are positively changed.

Human Ecology: The narrative approach of this workbook utilizes a life course perspective based on theories of human and family ecology. Ecology is simply the relationship between a person and the various elements of their environment (Bronfenbrenner, 1979). In this case, a youth’s ecology is made up of their living environment, neighbors, school, church, and broader community. Addressing challenges participants face in their day to day lives enhances potential for them to develop and practice self-awareness focused on learning to take good care of themselves.

Family Systems: Research recognizes that the behavior of a youth receiving services may reflect the pain of an over-stressed family system (Saunders, Berliner, & Hanson, 2004; Thornton, Craft, Dahlberg, Lynch & Baer, 2002; Kagan & Schlosberg, 1989). Systems theory provides a relational way of viewing behavior. It emphasizes reciprocity, relationships, context, and patterns (Becvar & Becvar, 1988).

Integrating underlying assumptions of systems theory (Hoffman, 1981) is central to this intervention. Maintaining a belief that the whole is greater than the sum of its parts illustrates the importance of engaging youth in the setting in which they live. This philosophy embraces an assumption that many people working together have a greater opportunity for success than a few working in isolation. It also illuminates the phenomenon that adults actively influence similar emotional states in children (Stein & Kendall, 2004). While negative parent-child experiences hinder development and brain functioning, positive therapeutic interactions can facilitate restorative processes that promote stress reduction, memory retention, maturation, health and well-being. Such interaction has a ripple effect in which all participants can embrace a commitment for sexual health.

Social Learning: This explains how behavior is learned and maintained (Bandura, 1985). It occurs through observation of others in the context of relationships or obtained symbolically through media presentation. Witnessing violence increases childhood vulnerabilities (Groves, 2002; Dodge, Pettit & Bates, 1997). When children are raised in an environment that glorifies violence and/or models the use of violence as an acceptable way of meeting needs, they may choose to sustain relationships in a similar manner. Youth are often unable to understand complex elements of violence and abuse; hence they perpetuate it without clearly understanding the impact on self and others.
Above all else, we know that life experiences influence brain development and trauma can cause significant impairment. Helping young people who have experienced trauma, including those in foster care and out of home placement, make sense of the impact of adverse childhood experiences (ACEs) on their relationships and sexual decision-making can influence motivation for sexual health and well-being.

Practice Self-Regulation™️ for Sexual Health is designed to be facilitated in 10 individual sessions with a facilitator specifically trained in the model. Due to the sensitive nature of trauma it should not be facilitated in group or family therapy.  The model has nine core components promoting long-term health and well-being. While flexibility is built into the model, the following adaptation guidelines can help organizations and facilitators promote optimal effectiveness across a variety of settings.

Core component 1: Trauma-informed
Adaptation: PS-R can be facilitated in a wide variety of settings as long as the environment lends itself to a safe and supportive environment.

Rationale and guidance: The Substance Abuse and Mental Health Services Administration of the United States federal government has designated key elements and key principles of trauma-informed services (SAMHSA, 2014). As long as these elements and principles are adhered to, the intervention can be facilitated indoors or outdoors in any setting that provides private and confidential space for communication and facilitation of multi-sensory activities. The ACE Score Calculator (adapted: Finkelhor, et. al., 2015) provides a foundation for identifying the adverse childhood experiences (ACEs) of individual participants.

Core component 2: Positive youth development
Adaptation: Identifying, affirming, and promoting individual strengths.

Rationale and guidance: Both Motivational Interviewing and positive youth development have been shown to provide the most direct and effective approach to change. When facilitators interact with participants in warm, nonjudgmental, empathic and genuine ways, youth are most likely to consider positive change in their lives (Duncan, Miller, Wampold, & Hubble, 2009).

Core component 3: Uniform session structure
Adaptation: Streamline session process and content.

Rationale and guidance: Predictability is a potentially calming and stress reducing experience for the human brain that can lower stress hormones. When people can expect a familiar and generally positive experience and realize such an event, the brain, mind, and body can focus better, more effectively retain information, and improve executive functioning. When facilitators follow the uniform structure of each session, behavior becomes predictably habituated, and participants are more likely to feel calm, competent, and confident in addressing therapeutic challenges that promote potential for positive change. Two empirically predictive questions anchor the beginning and wrap up each session.

Core component 4: Self-efficacy (autonomy)

Adaptation: Allow and support youth in making their own decisions

Rationale and guidance:  Neuroscience indicates that young people thrive in trauma-informed settings that respond to their needs with flexibility and allow for mistakes and poor judgment to be self-corrected with adult support and encouragement.  Even when participants are not making optimal decisions, it is imperative that facilitators communicate respect and consideration for their choices. Directing, dictating, and expecting to youth to do what facilitators tell them to do goes against the entire foundation of the model.

Core component 5: Personal values
Adaptation: Facilitating the Motivational Interviewing Personal Values Card Sort.

Rationale and guidance: This simple and straightforward values card sort is provided free of charge to download and use in a wide range of settings. It is an efficient tool for organizing and thinking about personal values and exploring what is most important to participants. It is highly recommended as a foundation for exploring life experiences and creating a vision for becoming the person a participant wants to be.

Core component 6: Affect regulation
Adaptation: Introducing, teaching, and supporting the practice of self-regulation can be done in a wide variety of ways that reflect the neuroscience of trauma and decision-making.

Rationale and guidance: Affect regulation is the central unifying element of the model. Effective programs are sequenced, active, focused, stimulating, scaffolded (demanding, but not so much that they overwhelm capability) and sustained through practice (Saunders, Berliner & Hanson, 2004; Steinberg, 2014). Intervention should involve activities to improve executive functioning (working memory, analysis and synthesis, organizational skills, internal speech, emotional and behavioral regulation); require intense concentration; mindfulness practice; exercise; and strategies to boost self-control and the ability to delay gratification (Steinberg, 2014).

Core component 7: T.O.P.* Workbook for Sexual Health
Adaptation: Reading the workbook and processing it in session.

Rationale and guidance: The workbook, a clearly defined and structured framework for healing trauma, is meant to be read and processed in sequence as each chapter builds on previous information and establishes a purposeful flow. Skipping over sections or chapters is not recommended. Participants who are motivated to complete the workbook often read it and answer questions semi-autonomously on their own. Those who are ambivalent may focus on some parts and not on others, or may read the workbook and not answer some, or all of the questions in writing. Others may want to read the workbook in session with the facilitator’s support and assistance. Participants should be nonjudgmentally supported no matter how they go through it even if they are unwilling to read it at all.

Core component 8: Multi-sensory activities
Adaptation: Facilitating specifically focused activities.

Rationale and guidance: Multi-sensory activities reflect the neuroscientific integration of cognitive and affective processing that enhance memory retention and behavioral change. They promote understanding of key concepts, memory retention, and help participants reduce impulsivity, learn to negotiate, and practice harm free and protected sex. PS-R activities were specifically chosen for each session in order to build on the affiliated chapter topics and sexual health information. Activities designated for the intervention are highly recommended. 

Core component  9: Future orientation
Adaptation: Creating a vision for success.

Rationale and guidance: Future orientation is considered a protective factor for everyone, and especially for youth with adverse childhood experiences (ACEs). Envisioning a goal, identifying a plan and writing it down, and creating a vision for a positive future are all known to enhance potential for successful outcomes. While mindfulness activities help to ground participants in the here and now, future oriented activities can provide motivation for long-term change. Combining both maximizes neuroprocessing to enhance understanding, promote effective memory retention, reduce impulsivity, negotiate, and practice harm-free and protected sex.

Here are details about the randomized controlled trials for both PS-R, funded by the Office of Adolescent Health (OAH) and e-PS-R, the Family and Youth Services Bureau (FYSB) through the federal department of Health and Human Services (HHS).
Target Populations:
In order to be eligible to participate in the studies, youth needed to meet the following criteria:
Aged 14-19
Receiving outpatient counseling services at one of the study’s implementation sites (OAH), or involved in Juvenile Justice (FYSB)
Deemed appropriate for the study by agency staff with regards to physical and mental health
Not previously used either of the T.O.P.* Workbooks
No previous participation in the PS-R program

Settings:
The PS-R, OAH study was facilitated with over 100 masters-level licensed clinicians in New Mexico, Michigan, Maine, Louisiana, and California.

The e-PS-R, FYSB study was facilitated by non-clinically trained study coordinators in rural New Mexico and West Virginia.

Length:
Practice Self-Regulation™ is composed of 10 structured 55-minute individual therapy sessions. For the study, therapists had 18 weeks to deliver the 10 PS-R sessions. The intervention was intended to be conducted weekly.
e-PS-R (electronic blended learning) is composed of 8 on-line sessions and four 45-minute helper meetings. Study coordinators had 12 weeks to complete the intervention on a weekly basis.

Program Overview, Background, and Implementation Information: (openly available to anyone on the PS-R website)

• • Evidence of Program’s Effectiveness
  • Core Components
  • Logic Model and Theory
  • Implementation Guidance
  • Guidance on Allowable Adaptations
  • Resources and Support

Those who purchase the PS-R intervention will receive the following materials:

Intervention Package: (materials for purchase)  All elements of the intervention have passed the federal Medical Accuracy Review Board.

• • • 10 PS-R Session Plans: 10 laminated session plans and 10 Sex Ed fact sheets and 2 flow charts for designated multi-sensory activities.  Each session plan has detailed information on everything needed to successfully facilitate every element of each session.
    • Sex Ed Fact Sheets: These include medically accurate anatomy charts, puberty information sheet, sexual identity information sheet, risks for pregnancy and disease, and contraception description sheets.
    • T.O.P.* Workbook for Sexual Health: Each intervention package includes 1 workbook for a facilitator.  Additional workbooks are purchased for each participating youth as they are confidential and cannot be shared, copied, or reissued.
    • Desktop Resources for Facilitators: An electronic folder containing 13 OAH approved resources.  These include the ACE Score Calculator; tip sheets for trauma-informed, safe and supportive environments; federally authorized medically accurate websites for additional information and resources; Motivational Interviewing Values Card Sort; Expert Tips for Resilience cards; and electronic copies of laminated flowcharts if youth want their own copies.
    • PS-R Logo Bag: This includes all of the material listed above with hard copies of the Motivational Interviewing Values Card Sort and Expert Tips for Resilience cards, plus one box of markers, a package of 15 miniature tubs of Play-Doh,™ and a pad of drawing paper.

• Fidelity Monitoring Templates:

• • • PS-R Participant Feedback Questionnaire
    • PS-R Attendance Tracking Form
    • PS-R Fidelity Monitoring Tool: Therapist Self-Report 
    • PS-R Fidelity Monitoring Tool: Observer Report 

Those who purchase e-PS-R will receive the following materials:

Intervention Package: (materials for purchase)  All elements of the intervention have passed the Federal Medical Accuracy Review Board.

• • • Access to the online T.O.P.* Workbook for Sexual Health.  This consists of 8 online sessions with videos and resources for participants.
    • 4 PS-R Meeting Plans:  4 laminated meeting plans and 2 flow charts for designated multi-sensory activities.  Each meeting plan has detailed information on everything needed to successfully facilitate every element of each meeting.
    • Sex Ed Fact Sheets: These include medically accurate anatomy charts, puberty information sheet, sexual identity information sheet, risks for pregnancy and disease, and contraception description sheets.
    • T.O.P.* Workbook for Sexual Health: Each intervention package includes access to the website for a facilitator.  Access to the website is purchased for each participating youth as all activity is confidential and cannot be shared without the youth’s designated permission.
    • Desktop Resources for Facilitators: An electronic folder containing 6 FYSB approved resources.  These include the ACE Score Calculator; tip sheets for trauma-informed, safe and supportive environments; federally authorized medically accurate websites for additional information and resources; Motivational Interviewing Values Card Sort; Expert Tips for Resilience cards; and electronic copies of laminated flowcharts if youth want their own copies.
    • PS-R Logo Bag: This includes all of the material listed above with hard copies of the Motivational Interviewing Values Card Sort and Expert Tips for Resilience cards, plus one box of markers, a package of 15 miniature tubs of Play-Doh™, and a pad of drawing paper.

• Fidelity Monitoring Templates:

• • • PS-R Participant Feedback Questionnaire
    • PS-R Attendance Tracking Form
    • PS-R Fidelity Monitoring Tool: Therapist Self-Report 
    • PS-R Fidelity Monitoring Tool: Observer Report

Professionals interested in being trained to implement any of the PS-R interventions must attend a training with a PS-R certified trainer. PS-R training takes place over three and a half days with an introduction to Motivational Interviewing, an overview of the neuroscience of trauma, and in-depth practice of facilitation of each session.  The course ends with fidelity monitoring on the last morning. At the training, attendees receive all materials needed to facilitate the intervention listed in the PS-R package section above. Trainers may purchase additional training materials before or after being trained.

Continuing education credits (CEUs) may be purchased for training participants if arrangements are made ahead of time.  This usually takes approximately 3 month’s prior to training in order to complete all requirements. Whether, or not CEUs are offered, all training participants receive a certification of completion.

Most PS-R facilitators are qualified mental health professionals (QMHPs).  If a training participant is not clinically trained they are required to provide written documentation clarifying a formal consultation and supervision arrangement with a licensed QMHP.

Post training support is always available to answer questions and address any fidelity monitoring assistance.  Session plan video summaries are provided for each trainer. All trainers have direct phone numbers and e-mail addresses for ongoing PS-R support and assistance.

Training of Trainers is available on a contract basis. Contracting information and costs are provided in the “Costs” section of this website. An annual licensing fee of $4,000.00 is required for individuals and agencies providing training independently of the Practice Self-Regulation™ organization. These legal agreements are facilitated, and maintained in collaboration between PS-R staff and designated agency representatives.

Qualifications to become a PS-R trainer:

• Preference is given to licensed QMHPs with Master’s degrees in a recognized discipline for mental health counselling who are in good standing with their state’s board of licensing professionals
• A Master’s or Bachelor’s degree in an allied health related field such as social work, mental health counseling, public health, or sexual health with documented experience and written documentation clarifying a formal consultation and supervision arrangement with a licensed QMHP in good standing with their state’s board of licensing professionals

Please contact Joann Schladale at schladale@me.com if you are interested in becoming a PS-R trainer.

PS-R Participant Feedback Questionnaire 

These are paper and digital forms that participants complete at designated time periods throughout the study.  They track participant knowledge and memory retention across the full study timeframe.

Download Here

PS-R Attendance Tracking Form 

These are paper and digital forms that facilitators use to track participant attendance.  They track the number of session each youth participates in.

PS-R Fidelity Monitoring Tool: Therapist Self-Report 

This is a paper form that is completed by therapists at the end of each PS-R intervention session. It tracks administrative data, the number of activities completed at each session, and why activities were not completed. 

Download Here

PS-R SH (Sexual Health) Monitoring Tool: Therapist Self-Report

Download Here

PS-R Fidelity Monitoring Tool: Observer Report 

These are paper and digital forms for session observers to assess both fidelity monitoring and facilitator competence for continuous quality improvement.

Download Here