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TRAUMA-FOCUSED COGNITIVE BEHAVIORAL THERAPY TRAINING AND SUPERVISION

Trauma-Focused CBT: What is It?

Trauma-focused CBT, also sometimes called TF-CBT, is a form of cognitive behavioral therapy specifically adapted for children who have experienced trauma, and who are having significant emotional and/or behavioral problems related to these  traumatic life events.  Children who have experienced traumatic events may have a few or many post-traumatic stress disorder (PTSD) symptoms, and meet the criteria for full-blown PTSD.  Thus, the experience of a trauma does not necessarily lead to PTSD, and might in fact result in other emotional or behavioral symptoms, such as disruptive behaviors, depression, or anxiety due to trauma.

Symptoms of child traumatic stress include but are not limited to:

• Repeated, upsetting memories of the traumatic event

• Flashbacks, reliving the experience

• Very upset by sights, sounds, or smells that trigger the memory of the traumatic event

• Avoiding places or people that are reminders of the event

• Being easily startled

• Showing very little emotion, seeming “numb” regarding the event

• Nightmares

• Difficulty sleeping

• Difficulty concentrating

• Lack of interest in usual activities or personal relationships the child once enjoyed

How Was Trauma-Focused CBT Developed?

TF-CBT is a hybrid treatment model that incorporates a number of trauma-sensitive intervention components, based on cognitive, behavioral, humanistic, and family-ecological conceptual foundations.   This TF-CBT training course teaches therapists how to individualize TF-CBT techniques to children and their contextual circumstances.  In all instances, this requires establishing and maintaining therapeutic relationship with child and parent, psycho-education about childhood trauma and PTSD, individualizing relaxation skills taught to the child and parent, adapting skills related to affective modulation to the child, family, and culture, and building the child's cognitive coping skills by connecting the child's thoughts, feelings, and behaviors related to the trauma.

Although TF-CBT was designed to treat trauma symptoms and full-blown PTSD in children who have experienced a trauma, TF-CBT has also been shown to:

• Improve child externalizing behavior problems (including sexual behavior problems if related to trauma)

• Improving parenting skills and parental support of the child, and reducing parental distress

• Enhancing parent-child communication, attachment, and ability to maintain safety Improving child's adaptive functioning

• Reducing shame and embarrassment related to the traumatic experiences

• Children will benefit most from TF-CBT if a parent or caregiver participates with them in the treatment.  However, even when children do not have a consistent caregiver, they can still benefit from TF-CBT.  TF-CBT studies in children and youth have shown that the intervention can yield improvements for periods up to two years after treatment.

Importantly, more than most types of CBT, TF-CBT was designed to be used with some flexibility, based on the individual's situation. Skilled TF-CBT clinicians may change the order of skills being taught, but all appropriate components  are generally used during the course of the training.  Therapeutic elements of TF-CBT can be easily remembered, based on the "PRACTICE" acronym.

Trauma Focused Cognitive Behavioral Therapy:

The PRACTICE acronym

• Psychoeducation and Parenting skills

• Relaxation

• Affective Expression and Regulation

• Cognitive Coping

• Trauma Narrative Development and Processing

• In Vivo Gradual Exposure

• Conjoint Parent - Child Sessions

• Enhancing Safety and Future Development

TF-CBT therapists work with both the parent and the child.  Therapeutic components taught to parents are: 1) Effective parenting skills, 2) Increasing parental support of the child, 3) Stress management skills „for caregivers, 4) Reducing inappropriate parenting practices, 5) Reducing parental trauma-related emotional distress, and 6) Improving personal safety skills, and 7) Enhancing parents' ability to manage trauma reminders and future stressors.

Several psychoeducational components of TF-CBT are taught to both the parent and child intervention, including 1) Teaching parent and child about sexual abuse and PTSD and typical „reactions of victims, 2) Teaching parent and child about healthy sexuality, and 3) Educating parent on child behavior management skills.

Child-specific components include:

• Relaxation, often done using relaxation tapes or scripts.  This may also include practicing deep breathing/Belly Breathing, Listening to music, and progressive Muscle Relaxation

• Affective Regulation.  This component includes "Feelings identification" intended as a relatively non-stressful way for children to begin talking about their feelings with the therapist.  By sharing common everyday feelings with each other, the therapist is able to gauge the child's  verbal and emotional ability to accurately identify and express a range of different feelings.  The child gets to know a little about the therapist, sees that the therapist has had "bad" feelings, and that the therapist  "good" as well as open about sharing these feelings with the child.

• Trauma Narrative.  One unique component of TF-CBT is the trauma narrative.  The goal of working with the child's trauma narrative is to "unpair" the thoughts, reminders, or discussions of the traumatic event from the child's overwhelming negative emotions such as terror, horror, extreme helplessness, or rage.  Over the course of several sessions, the child is encouraged  „to describe more and more details of what happened before, during and after the traumatic event, as well as the child's thoughts and feelings during these times.

• In Vivo Exposure (Facing Your Fears).  In vivo exposure is used to desensitize the child to “trauma cue” or “trigger”.  This is done at child’s pace and only after teaching them other components such as relaxation and cognitive coping. Another means of helping the child face his/her fears includes “gradual exposure” to triggers (ex. scene of the crime).  This may be especially important for children who need to continue to be around where the abuse took place (school, a room in their house etc)

• Cognitive Coping Strategies.  After the trauma narrative is complete, the child and therapist directly explore and correct any cognitive errors (inaccurate or unhelpful thoughts).  One way to do this is to re -read the child's trauma narrative book in the session, focusing during the session on all of the thoughts the child has been able to express.  As each thought is verbalized in the book, the therapist and child examine whether the thought was accurate and helpful.  Alternative thoughts are identified that can replace unhelpful or inaccurate thoughts.

CONJOINT SESSIONS

Both the parent and child are prepared for conjoint sessions ahead of time.  The therapist shares the trauma narrative with the parent ahead of time, and the parent is taught about appropriate responses, including questions or challenges to incorrect cognitions.  Then during the conjoint session the child reads the trauma narrative aloud, and at the end, the parent and therapist praise the child for bravery.  Likewise, the child is also prepared ahead of time.  With the therapist, the child asks questions (prepared ahead of time by the therapist after reviewing these issues with the parent).   During the conjoint session the therapist serves to facilitate communications between parent and child directly, only intervening if there are difficult (inaccurate or unhelpful) cognitions that the other one does not challenge and correct.

The REACH Institute works with a number of national TF-CBT experts  to provide state-of-art training courses to teach therapists in its use through proven strategies, including distance learning methods such as webinars, and web-based self-paced training programs, and face-to-face training followed by ongoing phone conference calls for up to one year.  For more details, see our page on Psychotherapy Training Courses. Alternatively, for additional details about how to register for this program, go to the "About Us" webpage, and contact the REACH Institute's Executive Director, Lisa Hunter Romanelli, PhD