Question 1

What is trauma-focused CBT and how does it work?

Judith Cohen · Accepted Answer

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an evidence-based psychotherapy for children ages 3-17 with significant trauma-related mental health problems and their parents or primary caregivers. The TF-CBT model is resiliency-focused and works through multiple mechanisms including building coping skills, mastering trauma-related fear/anxiety, and enhancing parental/caregiver support.

TF-CBT consists of nine components, summarized by the acronym “PRACTICE” which are implemented in three phases. The Skills Building or Stabilization Phase includes Psychoeducation, Parenting Skills, Relaxation Skills, Affective Modulation Skills, and Cognitive Processing Skills components. The Trauma Narration and Processing Phase consists of the Trauma Narration and Processing component, and the Consolidation Phase includes In Vivo Mastery, Conjoint Child-Parent Sessions; and Enhancing Safety components. Gradual Exposure (GE) is also included throughout the TF-CBT model to help children and their parents/caregivers gain increasing mastery over trauma reminders and memories.

Therapists provide TF-CBT at least once weekly for approximately 12-20 sessions that are typically 45-60 minutes in length. These are primarily individual sessions divided between the youth and parent, respectively, with several parent-child sessions also included.

More information about the TF-CBT model and how it works is available at our web-based training course, TF-CBTWeb2.0 (https://tfcbt2.musc.edu ) or in our treatment book, Treatment Trauma and Traumatic Grief in Children and Adolescents (www.guilford.com/p/cohen )

Question 2

In the school setting: What are the most important strategies/tips for teachers to know on how to form/implement a trauma-informed classroom?

Anthony Mannarino · Accepted Answer

Teachers can be a very important partner in helping school-based counselors or community-based therapists to effectively implement TF-CBT. The most important strategies for teachers to know in this regard are described in the National Child Traumatic Stress Network’s (NCTSN) material on how to develop trauma-informed schools. These materials are available at:  https://www.nctsn.org/sites/default/files/resources//creating_supporting_sustaining_trauma_informed_schools_a_systems_framework.pdf

Additionally, it is helpful for teachers to understand that in some instances children who present with behavioral problems in the classroom may actually be demonstrating traumatic stress reactions because of trauma reminders in the school.

Question 3

I have read that trauma narration and cognitive processing of trauma is an aspect of TF-CBT; how is a child taken through this process safely and effectively?

Esther Deblinger · Accepted Answer

During the initial TF-CBT Skills Building/Stabilization Phase, the child and parent/caregiver receive and practice a variety of coping skills in combination with Gradual Exposure (GE). This prepares the child for engaging in the second TF-CBT phase, Trauma Narration and Processing, during which the child gradually describes increasing details about their personal trauma experiences (“speaking the unspeakable”) and cognitively processes these experiences (“making new meaning”). When the therapist has effectively implemented GE throughout the initial TF-CBT treatment phase, the child and parent/caregiver already understand the benefit of addressing trauma-related topics, confronting trauma-related fear instead of using avoidance strategies, and using skills such as relaxation, affective modulation and changing thoughts to cope with negative trauma-related feelings, thoughts, behaviors or interactions .

Engaging the child in more direct discussion about their own trauma experiences (trauma narration) is thus a natural progression in the GE process. The therapist uses understanding of the individual child to tailor specific strategies (e.g., using a timeline, life narrative, creating a book, writing a poem, rap song, creating a series of pictures, etc.) for encouraging the child to engage in the trauma narration process. This is an interactive process with the therapist that typically occurs over the course of several sessions. The therapist often works with the child to create an outline of the material the child plans to include in their trauma narration at the start of the process (e.g., “Table of Contents” for a book), and through interactive, supportive listening and asking non-directive questions, helps the child to include increasing details (e.g., about thoughts, feelings, body sensations) and to transcribe the child’s oral descriptions into a written account.

Gradual exposure occurs through the child and therapist together reviewing the material the child described at subsequent sessions. During this process, the child often spontaneously corrects inaccurate or unhelpful trauma-related cognitions (thoughts/beliefs) that have been causing negative feelings or behaviors. If maladaptive cognitions remain, the therapist assists the child in making new and more helpful meaning of these, using cognitive processing strategies gained in the Skills Based components.

It is important to clarify that the Trauma Narration and Processing work occurs only during sessions with the therapist; between sessions the child practices the initial PRAC skills but does not continue to work on Trauma Narration and Processing at home. With the child’s knowledge and agreement, during individual parent/caregiver sessions, the therapist shares the child’s trauma narration with the parent/caregiver and helps the parent/caregiver to process this material. Although trauma narration can be challenging for therapists and for children, a large proportion of children who have participated in TF-CBT have said that this was the best and most helpful part of TF-CBT.

Question 4

How to help with the self-blame of a parent who thinks that it's their fault that their child was sexually abused (by someone else)?

Judith Cohen · Accepted Answer

Since keeping their children safe is something that most parents expect themselves to do, self-blame is common for non-offending parents whose children have experienced trauma. Cognitive processing is a critical component for such parents. The first step in cognitive processing is validation, i.e., that the belief makes some sense (i.e., a parent expecting that they will keep their child safe is not unreasonable), and that anyone telling themselves that it is their fault this happened to their child would have negative feelings (e.g., sad, self-anger, shame, guilt, etc.). Also, therapists can normalize self-blame in the sense that this is very common among many parents whose children have been sexually victimized.  However, it is also important to critically examine the logic of the thought “It is my fault that my child was sexually abused by (other person)” Several potential techniques may be useful, including Progressive Logical Questioning, Responsibility Pie, and Best Friend Role Play. These are all described in more detail in TF-CBTWeb2.0 (https://tfcbt2.musc.edu ) and Treating Trauma and Traumatic Grief in Children and Adolescents, 2nd Edition, (www.guilford.com/p/cohen )

It may be helpful to explore some of the following issues in order to establish the degree to which the parent can claim “fault” or “blame” for their child’s sexual abuse:

1)	Did you knowingly arrange for your child to be sexually abused by the perpetrator (e.g., in exchange for money, drugs, etc.), i.e. was the parent trafficking the child? This would be rare, but if so,  it is in part the parent’s fault, but it is also the perpetrator’s fault for actually perpetrating the abuse (use the responsibility pie; explore mitigating factors such as substance dependence, mental health issues, etc.)

2)	Did you know that the offender was sexually abusing your child and allow it to go on anyway? (This is also very uncommon.) If so, the parent failed to protect but the actual abuse was the perpetrator’s fault (use the responsibility pie)

3)	Did your child tell you about the abuse and you refused to believe them? If so, what were the reasons the parent didn’t believe the child? Did these reasons make sense?

4)	If none of 1-3 are true (this is most parents): 
How did you respond when you found out about the abuse? (e.g., correct “didn’t respond perfectly” cognitions—no one knows what to do or say)
How could you have known about it before you found out? (e.g. correct  “should have known” cognitions—how could you have known?)

The following NCTSN information sheets may be helpful:
Why Don’t They Tell: https://www.nctsn.org/resources/why-they-dont-tell-teens-and-sexual-assault-disclosure  
Coping with the Shock of Intrafamilial Abuse: https://www.nctsn.org/resources/coping-shock-intrafamilial-sexual-abuse-information-parents-and-caregivers

Question 5

Are neurological changes a part of childhood trauma? In the case of ADHD/ADD, how do you differentiate if symptoms are a result of trauma or pre-existing ADHD?

Anthony Mannarino · Accepted Answer

Childhood trauma is associated with a variety of neurobiological changes. Promising new research documents that TF-CBT can reverse some of these changes in children and adolescents. For children who have a long history of trauma exposure (e.g., parental physical abuse and exposure to parental intimate partner violence since 3 years old) presenting with ADHD symptoms at age 6, it can be particularly difficult to differentiate whether these symptoms are primarily related to the child’s trauma or related to another primary disorder such as ADHD, because neither the child’s symptoms nor the history can provide clarity in this regard. (However, if the symptoms started around the time of the trauma exposure, it makes it more likely that they are trauma-related as opposed to ADHD.)

In some  situations providing a course of TF-CBT or another evidence-based trauma-focused therapy may clarify the diagnosis. Specifically, if the child’s symptoms significantly improve with this treatment, the symptoms are likely trauma-related, and such a treatment course would alleviate the need for medication management. Alternatively, after several weeks of attempting trauma-focused treatment, the therapist may be able to clarify that the child needs a stimulant trial to be able to benefit from the therapy.

Question 6

Do children need to be able to verbalize their trauma for this treatment? What if they have an unclear memory of the trauma or the trauma was pre-verbal?

Esther Deblinger · Accepted Answer

Yes. For TF-CBT the child must have at least one remembered trauma experience and must be able to verbalize this trauma exposure. Another evidence-based trauma-focused treatment such as Child Parent Psychotherapy may be effective for young children (0-6 years old) who do not remember their trauma or for whom the trauma was pre-verbal.

Question 7

How can I become certified in TF-CBT if I don't live in the US?

Judith Cohen · Accepted Answer

At this time National TF-CBT Therapist Certification is only available for therapists in the U.S. and Canada. Efforts are currently underway to develop parallel TF-CBT national therapist certification programs in other countries.

Question 8

Do you have resources available to assist in delivering TF-CBT via telehealth?

Anthony Mannarino · Accepted Answer

Yes, many resources are available to assist therapists in delivering TF-CBT via telehealth, including a three-hour webinar that describes general telehealth implementation considerations as well as suggestions about how to deliver each TF-CBT component via telehealth; a 2-hour NCTSN webinar on using Sesame Street videos and other resources for implementing TF-CBT via telehealth for young children; and a variety of other resources. These are available at https://www.tfcbt-telehealth-resources

Question 9

Many therapists report reluctance to using exposure and cognitive processing approaches to trauma due to client distress and high drop-out rates. Do you have advice/an opinion on this? Is the trauma narrative component of TF-CBT necessary for clients to get better?

Esther Deblinger · Accepted Answer

Some proportion of children, particularly those whose pre-treatment scores of trauma-related symptoms are in the mild to moderate range, may improve significantly when they receive the initial TF-CBT Skills/Stabilization Phase so that they will not need to continue with the rest of TF-CBT treatment. Therapists should assess the child at pre-treatment using a standardized instrument that evaluates trauma symptoms (e.g., the Child PTSD Symptom Scale for DSM-5), and then reassess the child after the child completes the PRAC skills (Skills/Stabilization Phase). If the score is in the normal range and the child and parent prefer to end treatment at that point, it is reasonable to do so.

However, if the child continues to have symptoms, it is important for the therapist to continue treatment. It is also important to note that Gradual Exposure is used throughout TF-CBT, including during the Skills/Stabilization phase, and that therapists who are reluctant to talk about trauma-specific topics may be avoidant of appropriately providing GE during the first TF-CBT phase, which may contribute to children’s difficulty with successful engagement or completion in Trauma Narration and Processing. Often the therapist’s personal avoidance contributes substantially to delaying or preventing the child from moving forward to this phase of treatment. It is important for such therapists to explore their own trauma avoidance and whether providing trauma-focused treatment is a good fit for them.

Question 10

How does TF-CBT compare to EMDR for trauma in children? What is your opinion on using EMDR with children?

Judith Cohen · Accepted Answer

A relatively small (n=40) randomized controlled trial comparing TF-CBT to Eye Movement Desensitization and Reprocessing (EMDR) for children ages 8-17 years old  in the Netherlands demonstrated that both treatments were equally effective  in improving PTSD symptoms. Additionally, TF-CBT was as efficient as EMDR in decreasing children’s PTSD symptoms (both treatments did so in about 8 treatment sessions). However, TF-CBT was significantly more effective than EMDR for improving children’s co-occurring depressive or ADHD symptoms in this study. These findings suggest that either TF-CBT or EMDR is an effective treatment for 8-17 year old children who present with PTSD symptoms, but for those who have other comorbid symptoms, TF-CBT may be more effective.

Question 11

Is it okay to treat a child's trauma related to witnessing domestic violence if they continue to live in the DV situation?

Anthony Mannarino · Accepted Answer

In situations where the trauma is ongoing, the first consideration is assuring the child’s safety. Given DV dynamics (misuse of power and control) and the relationship between the child and DV offending parent/stepparent with whom the child and abused parent continue to live, attempting to “keep a secret” about the child’s participation in trauma treatment would pose a potential risk to the child’s and non-offending parent’s safety. In this situation, therapists should not start trauma-focused treatment such as TF-CBT without informing both parents  living in the home (i.e.,  DV victim and offender) about the treatment being offered (i.e., it is trauma-focused therapy related to the child’s exposure to DV). If the perpetrating parent does not agree to the child participating in the treatment, the non-offending parent (direct victim of the DV) may then choose between remaining in the ongoing DV situation without allowing the child to receive trauma treatment; or leaving and seeking treatment for the child. Interestingly, several families in which the mother continued to live with a DV perpetrating spouse agreed to participate in TF-CBT during a community-based randomized controlled treatment study for this population, and children receiving TF-CBT experienced significantly greater positive outcomes with regard to their PTSD and anxiety symptoms than those who received supportive counseling. Additionally, children in the TF-CBT group had significantly fewer serious adverse (unsafe) events, suggesting that their non-offending parents learned how to keep them safe.

If the DV offender living in the home is not in a caregiving relationship with the child (e.g., mother’s paramour who has few or no direct interactions with the child), and clinical judgment indicates that the child’s and non-offending parent’s safety are not at risk by providing trauma-focused therapy, the clinician may make the decision to provide such treatment.

Question 12

If adolescents present with self-harm and running away (esp in foster care), would you advocate the use of DBT for stabilization before commencing trauma exposure?

Esther Deblinger · Accepted Answer

Suicide is a serious problem that merits careful assessment. Acute suicidality should be differentiated from repetitive non-suicidal self-injury. Youth who are actively suicidal due to Major Depressive Disorder often require hospitalization followed by evidence-based treatment for this disorder rather than DBT. Adolescents who present with serious and/or persistent non-suicidal self-injury likely would benefit from Dialectical Behavioral Therapy (DBT) prior to receiving trauma-focused therapy such as TF-CBT. Running away is a different problem from self-injury, and often is part of a complex trauma presentation. In this case, TF-CBT applications for complex trauma would be appropriate.

Question 13

Are children reluctant to see therapists for trauma?

Judith Cohen · Accepted Answer

Like adults, children often avoid talking about their trauma experiences because these experiences are scary, painful, and embarrassing to talk about with a stranger. It is natural for children to avoid what they fear, but learning to face fears is the most effective way of mastering and overcoming them. Therapists can effectively engage children in TF-CBT by implementing the model in flexible and creative ways, using strategies that incorporate the child’s own interests and strengths, and making therapy fun.

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