Trauma Affect Regulation: Guide for Education and Therapy for Adults (TARGET)

Scientific Rating:
3
Promising Research Evidence
See scale of 1-5
Child Welfare System Relevance Level:
Medium
See descriptions of 3 levels

About This Program

The information in this program outline is provided by the program representative and edited by the CEBC staff. Trauma Affect Regulation: Guide for Education and Therapy for Adults (TARGET) has been rated by the CEBC in the area of: Trauma Treatment (Adult).

Target Population: Adults with posttraumatic stress disorder (PTSD)

Brief Description

TARGET is an educational and therapeutic intervention designed to prevent and treat traumatic stress disorders (including PTSD, severe anxiety disorders, depression, and dissociative disorders), co-occurring addictive, personality, or psychotic disorders, and adjustment disorders related to other types of stressors.

TARGET teaches a seven-step sequence of skills, the FREEDOM Steps, designed to enable participants to recognize, understand, and gain control of stress reactions by enhancing their strengths/abilities for mental focusing, mindfulness, emotion regulation, executive function, and interpersonal engagement/interaction.

TARGET provides a systematic approach to processing traumatic and other critical memories that does not require memory processing

TARGET provides a manualized protocol for brief (4-session), time-limited (10-14 sessions), and extended (26+ sessions) individual, group, or couple/family education and therapy. TARGET can be delivered in community, outpatient, inpatient, residential treatment, shelter, workplace, correctional, or healthcare settings.

TARGET has been adapted to be gender-specific, culturally responsive, and attuned to the unique needs of adults who have experienced (or are currently experiencing) childhood trauma, sexual trauma, domestic violence, community violence, traumatic losses, disaster trauma, medical trauma, racism-related trauma, sexual identity-related trauma, or military trauma.

TARGET for Adolescents is highlighted in the Trauma Treatment (Child & Adolescent) topic area on the CEBC as well.

Program Goals:

The goals of Trauma Affect Regulation: Guide for Education and Therapy (TARGET) for Adults are:

  • Reduction in severe PTSD symptoms and remission from diagnostic PTSD
  • Enhanced capacities for emotion regulation and stress/anxiety management
  • Reduction in biopsychosocially impairing stress reactions
  • Reduction in severe anxiety, depression, guilt, and shame
  • Reduction in persistent complicated bereavement
  • Reduction in severe problems with anger and aggression
  • Reduction in severe problems with psychoform and somatoform dissociation
  • Increased ability to maintain sobriety in recovery from addictive disorders
  • Reduction in non-suicidal self-injury
  • Increased self-efficacy and dispositional hope/optimism

Essential Components

The essential components of Trauma Affect Regulation: Guide for Education and Therapy (TARGET) for Adults include:

  • A unique sequential set of stress management skills—FREEDOM steps:
    • Focus – Pay attention to your body signals, clear your mind, and focus on one thought that reflects what you truly value.
    • Recognize triggers – Know your stress Triggers and teach your brain to distinguish between a real threat and a reminder.
    • Emotion self-check – Identify ALARM/REACTIVE Emotions (fear, anger, sadness) and balance them with MAIN Emotions (calmness and confidence).
    • Evaluate thoughts – Learn to evaluate the ALARM thoughts and find within them the MAIN Thoughts that represent what you believe in.
    • Define goals – Restore hope by tapping into goals that express your true values and dreams rather than quick fixes.
    • Options – Regain personal control by making choices that reflect who you are and what you want most in your life.
    • Make a contribution – Recognize how you make the world a better place when you are in control of your brain’s stress ALARM.
  • Group therapy conducted by Bachelors, Masters or Doctoral-level facilitators (a single facilitator or co-facilitators) that may be time-limited (10-14 sessions), brief (4 sessions), or extended (26+ sessions)
  • Individual therapy conducted by Masters or Doctoral-level clinicians that may be brief (4 sessions), time-limited (10-14 sessions), or extended (26+ sessions)
  • Couple therapy conducted by Masters or Doctoral-level clinicians (single therapist or co-therapy team) that may be brief (4 sessions), time-limited (10-14 sessions), or extended (26+ sessions)

Adult Services

Trauma Affect Regulation: Guide for Education and Therapy for Adults (TARGET) directly provides services to adults (regardless of whether they are parents or caregivers) and addresses the following:

  • Problems with PTSD, anxiety, depression, guilt, shame, dissociation, conflict and detachment in intimate relationships, isolation and insufficient social support, addictions, work/workplace stress, psychosomatic symptoms, and nonsuicidal self-harm
Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: TARGET individual or group therapy with adults with severe addictions or mental illness provides education for family and support system members, and conjoint therapy sessions with family/support persons when clinically indicated.

Delivery Settings

This program is typically conducted in a(n):

  • Birth Family Home
  • Community Agency
  • Foster/Kinship Care
  • Homeless Shelter
  • Hospital
  • Jail
  • Outpatient Clinic
  • Prison or pre-release center
  • Residential Care Facility
  • School
  • Domestic Violence Shelter

Homework

Trauma Affect Regulation: Guide for Education and Therapy for Adults (TARGET) includes a homework component:

Personal Practice Exercises have been designed in a manualized form for participants to use at home. Using these exercises, participants practice and record the use of the FREEDOM steps.

Languages

Trauma Affect Regulation: Guide for Education and Therapy for Adults (TARGET) has materials available in languages other than English:

Dutch, Spanish

For information on which materials are available in these languages, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

A project coordinator and dedicated training space within the host agency to work with Advanced Trauma Solutions on the implementation process, and clinical staff to lead groups or conduct individual treatment.

Minimum Provider Qualifications

Master’s or Doctoral level required for individual couple versions of TARGET. Bachelor’s level or higher required for group TARGET.

Education and Training Resources

There is a manual that describes how to implement this program, and there is training available for this program.

Training Contact:
Training is obtained:

Advanced Trauma Solutions, Inc., is the only licensed provider for the TARGET model. Training is conducted on-site for agencies in the United States and Canada, and either on-site or at the ATS Training Center in Connecticut for agencies internationally.

Number of days/hours:
  • Introductory: 3-5 days
  • Advanced: 3-5 days
  • Train-the-Trainer: Custom based on agency goals
  • On-going consultation: approximately 75 hours per facilitator per year

Implementation Information

Since Trauma Affect Regulation: Guide for Education and Therapy for Adults (TARGET) is rated on the Scientific Rating Scale, information was requested from the program representative on available pre-implementation assessments, implementation tools, and/or fidelity measures.

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Pre-Implementation Materials

There are pre-implementation materials to measure organizational or provider readiness for Trauma Affect Regulation: Guide for Education and Therapy for Adults (TARGET) as listed below:

There are written documents describing the scope of services and an organizational assessment of readiness for trauma-informed care. These form the basis for pre-implementation project planning. Descriptions of these materials may be obtained by request to www.advancedtrauma.com.

Formal Support for Implementation

There is formal support available for implementation of Trauma Affect Regulation: Guide for Education and Therapy for Adults (TARGET) as listed below:

Advanced Trauma Solutions, Inc., provides a comprehensive approach to implementing the TARGET curriculum. A two-hour web-based video introductory course describing TARGET is available for agencies and clinicians/facilitators who are preparing for the in-person TARGET training curriculum.

An intensive training and rigorous quality assurance program includes fidelity monitoring, direct feedback, and group consultation that leads to therapist certification. Training includes a series of components designed to guide clinical staff through an intensive learning process that prepares them to implement TARGET concepts and skills in group, individual, and family settings.

Fidelity Measures

There are fidelity measures for Trauma Affect Regulation: Guide for Education and Therapy for Adults (TARGET) as listed below:

The TARGET fidelity measure is a behaviorally specific rating scale that identifies each key component of TARGET (session by session) with specific descriptive anchors to facilitate accurate ratings by independent observers. The checklist has 56 discrete items keyed to engagement, session structure, and each of the concepts/skills in each sessions of the curriculum; comment sections address therapeutic and working alliance. It is recommended that each TARGET session is videotaped, submitted for fidelity review, and rated on competence and adherence to the model using the above checklist. Independent fidelity monitors review session recordings, rate each one based on this tool, and provide a written report to the therapist. Supportive direct feedback is provided through individual coaching and group consultation.

When taping is not feasible, fidelity is monitored by completion of skills worksheets with clients and review of the worksheets by TARGET staff.

A train-the-trainer program provides sites with the capacity to develop and sustain internal TARGET trainers (with ongoing fidelity monitoring of training and consultation and certification/re-certification of trainers).

Implementation Guides or Manuals

There are implementation guides or manuals for Trauma Affect Regulation: Guide for Education and Therapy for Adults (TARGET) as listed below:

TARGET has a curriculum that includes detailed manuals, client handouts, visual aids, posters, and other educational tools to support the rollout of the program.

Research on How to Implement the Program

Research has not been conducted on how to implement Trauma Affect Regulation: Guide for Education and Therapy for Adults (TARGET).

Relevant Published, Peer-Reviewed Research

This program is rated a "3 - Promising Research Evidence" on the Scientific Rating Scale based on the published, peer-reviewed research available. The practice must have at least one study utilizing some form of control (e.g., untreated group, placebo group, matched wait list study) establishing the practice's benefit over the placebo, or found it to be comparable to or better than an appropriate comparison practice. Please see the Scientific Rating Scale for more information.

Child Welfare Outcome: Child/Family Well-Being

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Frisman, L., Ford, J., Lin, H-J., Mallon, S., & Chang, R. (2008). Outcomes of trauma treatment using the TARGET model. Journal of Groups in Addiction & Recovery, 3(3-4), 285-303.

Type of Study: Randomized controlled trial
Number of Participants: 213

Population:

  • Age — Mean=38 years
  • Race/Ethnicity — 120 White, 52 Black/African American, 22 Hispanic/Latino and 19 Other
  • Gender — 130 Females and 83 Males
  • Status — Participants were individuals with full or partial posttraumatic stress disorder (PTSD).

Location/Institution: 3 locations in Connecticut: Rushford Center, Inc., in Middletown; The Connection, Inc., in Middletown; Morris Foundation, in Waterbury

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study compared Trauma Affect Regulation Guide for Education and Therapy (TARGET) to trauma-sensitive usual care (TSU) with participants in three adult outpatient clinics with full or partial PTSD. Measures utilized include the Global Appraisal of Individual Needs (GAIN) and Post-Traumatic Cognitions Inventory (PTCI). Results indicate that TARGET was superior to TSU in maintaining sobriety self-efficacy, although there were no significant differences between the groups on any other measures. Ethnic differences emerged, with White TARGET participants reporting more improvement than non-White participants on posttraumatic cognitions, and fewer non-White men reported relapses in TSU than in TARGET. Limitations include possible interviewer bias, the very low total dose of TARGET treatment received by the TARGET group, alternations in the randomization procedures during the study, and contamination of the comparison group treatment with TARGET principles and techniques.

Length of postintervention follow-up: 6 and 12 months.

Ford, J. D., Steinberg, K.L., & Zhang, W. (2011). A randomized clinical trial comparing affect regulation and social problem-solving psychotherapies for mothers with victimization-related PTSD. Journal of Behavior Therapy, 42(4), 560-578.

Type of Study: Randomized controlled trial
Number of Participants: 146

Population:

  • Age — 18-45 years
  • Race/Ethnicity — 40% African American, 18% Latina, 41% White not Hispanic, and 1% Other
  • Gender — 100% Female
  • Status — Participants were mothers or primary caregivers for a child 5 years old or younger with current full or partial PTSD and past exposure to victimization or incarceration.

Location/Institution: Hartford, Connecticut

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study compared a trauma affect regulation guide for education and therapy (currently called Trauma Affect Regulation: Guide for Education and Therapy for Adults (TARGET)) to present-centered therapy (PCT) and wait-list (WL) conditions on ethnoracial minority mothers with post traumatic stress disorder (PTSD). Subjects were randomly assigned to one of the 3 groups. Measures utilized include the Traumatic Events Screening Inventory (TESI), Clinician Administered PTSD Scale (CAPS), Structured Clinical Interview for DSM-IV (SCID-P), Post-Traumatic Cognitions Inventory (PTCI), Interpretation of PTSD Symptoms Inventory (IPSI), Trauma Memory Questionnaire (TMQ), Generalized Expectancies for Negative Mood Regulation (NMR), Coping Orientation to Problems Experienced (COPE), Inventory of Interpersonal Problems–Short Form (IIP-32), State-Trait Anxiety Inventory, State Version (STAI-S), Beck Depression Inventory (BDI), Trauma-Related Guilt Inventory (TRGI), Parenting Stress Index-Short Form (PSI), and the Relationship Scales Questionnaire (RSQ). Results indicated that TARGET achieved statistically and clinically significant improvement on PTSD and affect regulation measures compared to WL, with more consistent and sustained (over a 6-month follow-up period) evidence of improvement than PCT. Limitations include possible interviewer bias at posttest, missing data due to attrition, and study was underpowered to detect the to-be-expected small differences between two active therapies.

Length of postintervention follow-up: 3 and 6 months.

Ford, J. D., Chang, R., Levine, J., & Zhang, W. (2012). Randomized clinical trial comparing affect regulation and supportive group therapies for victimization-related PTSD with incarcerated women. Behavior Therapy, 44, 262-276.

Type of Study: Randomized controlled trial
Number of Participants: 72

Population:

  • Age — 23-57 years
  • Race/Ethnicity — 60% White and 40% Women of color
  • Gender — 100% Female
  • Status — Participants were incarcerated women with full or partial posttraumatic stress disorder (PTSD).

Location/Institution: Hartford, Connecticut

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study compared Trauma Affect Regulation: Guide for Education and Therapy (TARGET) to supportive group therapy (SGT) with incarcerated women with full or partial posttraumatic stress disorder (PTSD). Groups of 10-12 subjects were randomly assigned to either TARGET or SGT. Measures utilized include the Traumatic Events Screening Inventory (TESI), Clinician Administered PTSD Scale (CAPS), the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM), the Trauma Symptom Inventory (TSI), the Generalized Expectancies for Negative Mood Regulation (NMR), the Hope Scale, the Heartland Forgiveness Scale (FS), the Expectancy of Therapeutic Outcome (ETO), and the Working Alliance Inventory–Brief (WAI-B). Results indicate that both interventions achieved significant reductions in PTSD and associated symptom severity and increased self-efficacy. TARGET was more effective than SGT in increasing sense of forgiveness toward others who have caused harm in the past. Limitations include possible interviewer bias, study was underpowered to detect the to-be-expected small differences between two active therapies, and sample size.

Length of postintervention follow-up: None.

References

Courtois , C. A., & Ford,  J. D. (2013). Treating complex trauma: A sequenced relationship-based approach. New York: Guilford.

Ford, J. D., Fallot, R., & Harris, M. (2009). Chapter 20: Group therapy. In C. Courtois & J. D. Ford (Eds.), Treating complex traumatic stress disorders: An evidence-based guide (pp. 415-440). New York: Guilford.

Ford, J. D., & Saltzman, W. (2009). Chapter 19: Family therapy. In C. Courtois & J. D. Ford (Eds.), Treating complex traumatic stress disorders: An evidence-based guide (pp. 391-414). New York: Guilford.

Contact Information

Name: Julian Ford
Agency/Affiliation: University of Connecticut Health Center
Department: Dept. of Psychiatry
Website: www.advancedtrauma.com/Services.html
Email:
Phone: (860) 679-8778

Date Research Evidence Last Reviewed by CEBC: June 2017

Date Program Content Last Reviewed by Program Staff: February 2017

Date Program Originally Loaded onto CEBC: June 2013