The Origins and Practice of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

Trauma, simply put, is an abstract concept referring to the enduring adverse impact of extremely stressful events. It is multiple and chronic exposure to developmentally adverse interpersonal events such as chronic maltreatment, neglect, abandonment/loss, physical/sexual assault, emotional abuse, and witnessing violence/death. Historically, the early formulations of the psychoanalytic theory of psychopathology were cast in a traumatic mold. Freud’s initial therapeutic efforts to resolve trauma led to memories of “childhood traumata” which Freud believed to essentially be experiences of sexual abuse prior to the age of 8. Freud concurrently noted the effects of traumata as the choice of hysteria or obsessional symptoms, influencing personality organization and function. He believed that trauma could be uncovered or reconstructed. In distinguishing between the cause and consequence of trauma, Freud described both the quantitative factor if the etiology of trauma and the defensive repression of the traumatic experience.

Some negative emotional impacts of trauma include attachment issues, lack of trust, lack of ability to soothe/be soothed, resistance to authority, hyper vigilance, inattention, sleep difficulty, self-harm, and a lack of empathy or over-involvement in the distress of others. Traumatic situations are generally overwhelming for an individual and inhibit their ability to cope. A person’s core developmental competencies: affective, behavioral, cognitive, somatic, relational, and self-care are often negatively impacted. Trauma may have adverse effects on our neurophysiological makeup as well as our psychosocial functioning.

It is well documented that one of the impacts of prolonged exposure to trauma is a decrease in cognitive ability. The brain stem to the frontal cortex is often negatively impacted. One area of particular importance is the association between frontal lobe deficits and trauma. In general, frontal lobe deficits refer to compromised abilities to inhibit impulsivity or aggression or to redirect attention from repetitive behavior. Multi-disciplinary health and development studies have illustrated the factors most closely correlated with trauma were associated with general criminal offending, a scope of mental health problems, academic failure, economic resource deficits, and early onset anti-social behavior. These individuals often do not develop properly and lose their ability to “play” as children as well as form/sustain healthy relationships, become much sexualized, and adapt externalizing behaviors such as aggression as well as phobias, and symptoms of PTSD. (anxiety, depression, flashbacks, hyperarousal…etc.) Most research conducted on the impacts of childhood exposure to trauma focuses on the range of psychological and behavioral impacts including but not limited to depression, anxiety, trauma symptoms, increased aggression levels, anti-social behaviors, lower social competence, temperament issues, low self-esteem, dysregulated mood, loneliness and increased likelihood of substance abuse. These children are also at higher risk for school difficulties such as peer conflict or impaired cognitive functioning. Teenage pregnancy, truancy, suicide attempts, and delinquency are also listed as impacts. Long-term physical impacts have rarely been documented, but one study done indicated that children who have experienced some form of trauma are found to have significantly higher heart rates than other children even post-event.

Trauma treatment needs a focus. Mental health practitioners are faced with many problems and several possible interventions for trauma. If not careful, a clinician can run the risk of choosing a treatment approach that can become as fragmented as the traumatized client’s internalized world. There are many trauma-focused mental health interventions for youth that integrate elements of cognitive treatment. Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) was developed by Esther Deblinger, PhD, in collaboration with Drs. Judith Cohen and Anthony Mannarino. It is an empirically supported treatment model that has been evaluated and refined over the past 18 years to help children overcome trauma related to abuse, violence and grief. This treatment approach has been recognized by the federal government’s Substance Abuse and Mental Health Services Administration as a model program due to the extensive outcome data supporting its effectiveness. (Cares institute) While TF-CBT was primarily developed for addressing the needs of children who have suffered sexual abuse, the model has been adapted for use with children who have suffered a variety of traumatic experiences, such as physical abuse, exposure to domestic violence and traumatic grief.

The TF-CBT method of therapy is highly structured and it contains both parent and child interventions within subsequent 90 minute weekly sessions. TF-CBT is a short-term treatment that lasts approximately 12-20 sessions. During these sessions, a trained mental health practitioner gradually moves the client through 8 components at his/her own pace. (Lorain County Board of Mental Health) These 8 components are as follows: parenting skills/psychoeducation, relaxation techniques, affective expression and regulation, cognitive coping, the development and processing of a trauma narrative, gradual exposure, conjoint parent/child sessions, and safety review and future development. These components together are summarized by the acronym PRACTICE. TF-CBT is an evidenced based treatment that is currently being adapted and implemented both within the USA and internationally.

During the first treatment component: Psychoeducation, it is important to begin educating the family about the TF-CBT approach starting from the first familial contact. Parents are often understandably worried about their child who has experienced a traumatic event and concerned about what this will mean for their child’s long-term prognosis. Providing this information can help the family out tremendously by filling in the gaps and sending a message of hope. Following the initial assessment, the clinician should provide the child’s diagnostic information as well as introduce the TF-CBT model treatment plan. The therapist should then provide information regarding the impact of trauma on children and family members, the nature of PTSD or other diagnosis and symptoms that the child is exhibiting, as well as information to help normalize the family’s current situation. The Parenting component involves the parents receiving parallel sessions along with the child, which also address the PRACTICE elements. The also receive additional interventions to optimize parenting skills as they sometimes change following a child’s exposure to a traumatic event.

The Relaxation section of the process should be individualized for each child and their parent. These skills are specifically aimed towards reversing any physiological changes resulting from their traumatic experience as well as to help children achieve mastery over their stressors. Both the children and parents are allowed to choose from an array of different methods to self-soothe when they are feeling physically or psychologically stressed, ultimately providing a sense of control which they were deprived of during their original traumatic experiences. These skills may include deep breathing, progressive muscle relaxation, blowing bubbles, yoga/meditation, mindfulness, listening to music, sports, knitting, singing, or incorporating humor. The therapist’s job is to work with the family to create several options that will be realistic for the child to use in various settings such as school, home, or on the playground. The children will then practice these techniques and report back during sessions for fine-tuning and continued practice.

The Affective Modulation skills are tailored in a similar way to fit each family. Severely traumatized children are affectively constricted resulting from the event. The therapist may then initially work with the child to expand their range of affective expression by engaging in an assortment of games themed around feelings. This is generally followed by work with both the parent and child to develop individualized affective modulation skills by identifying the child’s difficult areas. The therapist will then assist the children and parents with strengthening these skills and add them to their “toolbox” so to speak, encouraging them to practice these skills in between sessions.

It is also necessary for the children and parents to gain Cognitive Coping skills or to recognize the connections among their thoughts, feelings, and behaviors relating to everyday situations. In this process, the therapist will encourage the children and parents to identify thoughts related to upsetting events, determine the feelings/behaviors they have associated with those thoughts, and then evaluate whether or not these thoughts are accurate or helpful to them. The children and parents can also be encouraged to generate alternative thoughts for each of the situations and then to explore the feelings and behaviors associated with those thoughts and whether or not they prove themselves to be more prosocial/soothing than the original thoughts. This activity provides children and parents with the understanding that they have control over their own thoughts and consequently, over their feelings as well, thus adding another tool to the toolbox which they can use to soothe themselves while experiencing trauma reminders.

Upon completion of the skill-building components of TF-CBT, the therapist proceeds to more trauma-specific components, beginning with The Trauma Narrative and Cognitive Processing of Traumatic Experiences. In this section, the child develops a trauma narrative using a medium of their choice from writing, dictation, art, poem, song, dance, or creation of a book. Creation of this trauma narrative helps the child to overcome avoidance of traumatic memories, identify their cognitive distortions through their telling of the story in their own words, and contextualize their traumatic experience into the larger framework of their life by telling the story in context with time frames. The narrative should include thoughts, feelings, body sensations, and the worst moments of the traumatic experience. This helps them to recognize that they are more than merely a victim of trauma. With the child’s permission, this narrative is then shared with the parent during their separate sessions. Once the child completes their narrative, the therapist assists them in cognitively processing any cognitive distortions associated with their negative affective states. Ideally, this cognitive processing will use the techniques which the child mastered earlier during the cognitive coping components, learning to change their thoughts.

The In Vivo Mastery of Trauma Reminders involves developing a graduated exposure program for children who have developed generalized avoidance of unavoidable social cues/situations, leading to functional impairment. This manner gradually exposes the child to that of which they are fearful, ultimately helping the overcome their anxiety and improve their quality of life. This section follows the same general principles as other graduated exposure programs as well.

The Conjoint Child-Parent Sessions are an important focus of the TF-CBT model for families as it allows for the parent to participate in treatment. TF- CBT has been provided solely for children, but evidence shows that the children experience greater benefits when their parents participate as well. During these joint sessions, the communication shifts from children speaking directly about their traumatic experiences with the therapist, to sharing this information with the parent while the therapist moves into the background. Children will typically share their trauma narrative with their parent who has previously heard it from therapist. The child and their parent then build on their ability to communicate openly about other aspects of the traumatic experience by asking each other questions that they may have been too uncomfortable to ask previously, allowing parents to provide reassurance/praise to their children for discussing their ongoing fears and cognitive distortions with appropriate guidance and modeling from therapist. These sessions often enhance the parent’s role as a reliable source for trauma-related information through enjoyable joint activities as well.

Finally, Enhancing Safety and Future Developmental Trajectory assists the traumatized child with honing additional skills in order for them to remain safe in the future. The final sessions leading up to termination involve the implementation of safety skills tailored to each family’s particular situation. They are then typically practiced during the last few parent-child sessions. The children and parents are then encouraged to apply the skills learned during TF-CBT treatment to other difficult situations they may encounter, not only applying to traumatic circumstances, after termination of therapy.

It is important to note however, that this type of treatment is not optimal for everyone. It is not ideal for children whose primary issues are not trauma-related. (e.g., children with significant conduct problems present before the trauma or children and adolescents with runaway behavior, suicidal and cutting behaviors. It is critical for these children to determine whether or not their trauma symptoms are primary. And if not, then what other mental health problems should take precedence in their treatment. If there are co-occurring issues, it is important to provide conjoint treatment for the co-existing condition so that the TF-CBT therapist can focus solely on the trauma-specific treatment without being constantly sidetracked by co-morbidity problems. A thorough TF-CBT assessment is needed to determine whether or not a child/individual is exhibiting specific trauma symptoms, and if not, then TF-CBT would not be appropriate. In these cases, the individual should be referred for an alternative evidence supported treatment model.

The entirety of tests and studies conducted have supported the efficacy of this model for improving PTSD, depression, and other emotional/behavioral difficulties in children from 3-17 years of age. Two effectiveness studies have demonstrated the promise of TF-CBT in treating Childhood Traumatic Grief as well. The results of a pilot study are very promising in suggesting the usefulness of this approach for the treatment of PTSD and other trauma related symptoms in abused children and adults in resolving past child abuse trauma. In addition, all 4 children as well as their caregivers reported that they had learned skills to cope with current situations when their PTSD symptoms had been re-triggered. This method of practice has been used following the 2001 terrorist attacks in New York City as well as to provide treatment to individuals affected by Hurricane Katrina. Each stated in the United States is continuing to attempt to collect various types of data with regard to adoption and implementation of the TF-CBT model of treatment.

In recent years, as many organizations across the world have been moving more in the direction of providing Trauma Informed Care, they have been pushing the use of TF-CBT and attempting to train all clinical staff on it. A manualized TF-CBT program which was developed and piloted in 2004 studying 4 children in New Zealand between the ages of 9 and 14, comprised psychosocial strengthening, coping skills training, gradual exposure using creative media, and special issues relevant to trauma and abuse. Until recently, Cognitive Behavioral Therapy treatment for childhood anxiety/trauma was considered to be the gold standard. Psychodynamic Psychotherapy was also among the most popular forms of treatment applied to address a wide range of symptoms associated with trauma. Given current up to date findings, practice guidelines recommend a variation of CBT and psychotherapy, incorporating trauma-focused components for treating the specific problems of traumatized and abused children. The efficacy for this treatment is well-known; primarily in children who have experienced multiple traumas.
The hallmark of TF-CBT also referred to as the aspect that sets it apart from other, more traditional therapies is the gradual exposure in the trauma processing approach, linked to the idea of creating a trauma narrative. TF-CBT is unique from other therapies in several ways such as the many therapeutic components of TF-CBT from emotional regulation skills to direct discussion of the traumatic event, and even the incorporation of a trauma narrative to help the child to progress through their treatment more efficiently. It also provides more flexibility than other common treatments.

TF-CBT treatment is evidenced-based rather than strengths based but like with most methods, variations can be made to accommodate a strengths perspective. An example of this practical application would be in learning relaxation techniques; the child may be a very talented reader, in which case the therapist may incorporate reading as a relaxation strategy for the child. Similarly when creating his/her trauma narrative, the therapist can encourage the child to select a medium/method of implementation most fitting to them such as art or interpretive dance. TF-CBT as a whole can be applied to build upon the child’s strengths and mastery.
TF-CBT is often used to help children recover from sexual abuse by encouraging them to speak freely about their trauma. The recent Penn State sex abuse scandal further exemplifies a case in which the use of TF-CBT would be appropriate, as the abuse is presumably over for those victims and they are currently safe. An article from Social Work Today explains that by describing the details of what occurred before, during, and after the traumatic event and how the victim’s feelings are connected to it, the child is better able to “face” their trauma, allowing them to more effectively work through it, showing signs of improvement within 12-16 weeks of treatment. When an individual experiences trauma in their life, it can bring about symptoms of Post-Traumatic Stress Disorder (PTSD), depression, anxiety, and overall behaviors that are disruptive to daily functioning. In children, these can cause flashbacks of the traumatic event, sleep disturbance, and avoidance. These issues need to be addressed so that the individual/child does not continue to believe that the event was their own fault, that they did something to perpetuate the situation, or in the most severe cases, begin to live their lives avoiding people, places, and things that remind them of this traumatic event, leading to complete isolation. TF-CBT suggests that being open and communicative through exposure is highly effective in helping children to overcome these feelings of helplessness, anger, and so forth.

Some people believe that once a child/individual has experienced sexual abuse or a trauma of that magnitude, they will never recover from it and are doomed to never again enjoy life the way they once did before the event or events. Through research and implementation of therapy; specifically TF-CBT, it has been proven that by being committed to slowly walking through their past traumatic experience(s), a child/individual can develop the ability to accept what happened and move forward. I believe that it is essential to offer children/individuals a chance to recover from trauma; especially that of sexual abuse, in a healthy and constructive way such as attending therapy, and the techniques explained through TF-CBT seem to offer that through gradual exposure to the trauma and overcoming it in a series of steps.

TF-CBT confirms that mental health practitioners across the world are in a position to help traumatized children by being thoroughly trained in implementing TF-CBT interventions. Furthermore, the use of TF-CBT interventions may also help traumatized youth in reducing their symptoms of depression, anxiety, and problematic behaviors. It is strongly suggested that TF-CBT is more effective than attention control, standard community care, and other waitlist control conditions at reducing these symptoms.

Based on the fact that the majority of traumatized children who receive TF-CBT continue to demonstrate symptom relief post-treatment and increase their coping skills as a result of the treatment elements has shown the long-term effectiveness of TF-CBT for resolving anxiety, depression, and other trauma-related symptomology. Research findings continue to support the effectiveness of a TF-CBT treatment model for maltreated and/or traumatized children over comparable intervention models. The positive treatment outcomes of current studies demonstrate not only the effectiveness of the TF-CBT approach but also that the treatment gains are clinically significant for children and their families representing a range of multiple abuse histories, cultural backgrounds, and various caregiver arrangements. In addition to being used to treat victims of Hurricane Katrina and the 2001 Terrorist Attack, TF-CBT was also used in Sri Lanka, Indonesia and Thailand following with 2004 Tsunami. The National Institute of Mental Health is also in the process of funding adaptation of TF-CBT for HIV affected sexually abused children in Zambia. It has since been used in the aftermath of the Sandy Hook Shooting, The Boston Bombing and the earthquakes in Nepal. It has proven to be a great success in assisting the victims ,their families, and the communities at large cope with the with undeniably high levels of stress the accompany disaster and terrorism.

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is one of the most widely used and effective interventions for children and youth who have experienced some type of trauma. This method is based on Humanistic, Cognitive-Behavioral, and Family Theory Evaluation of TF-CBT over a period of time including several randomized controlled trials, effectiveness studies, and ongoing studies have demonstrated that this method of therapy is helpful for children, youth and adults who have experienced sexual abuse, domestic violence, traumatic grief, terrorism, disasters and multiple traumas.

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