Trauma Focused Cognitive-Behavior Therapy
Cognitive behavioral therapy (CBT) is based on the theory that upsetting emotions (e.g., anxiety) are associated with physiological symptoms (e.g., racing heart), negative thoughts (e.g., “Everyone will laugh at me when I give my presentation”), and problematic behavior (e.g., not going to school to avoid doing the presentation). For children and adults exposed to trauma, the physiological, cognitive, and behavioral responses are often reactions to thinking and feeling they are in danger. During a traumatic experience, the danger is real. Problems arise when the person perceives they are still in danger, even when it is over and they are safe. This can happen when they are triggered, which means something reminds them of the trauma. Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT; Cohen, Deblinger, & Mannarino, 2017) incorporates CBT principles with a trauma perspective. TF-CBT uses a PRACTICE acronym to describe the treatment components:
- Psychoeducation about trauma and parenting strategies
- Relaxation training in portable techniques that children and caregivers can use anywhere when feeling anxious
- Affect identification to help children and caregivers label and identify emotions and teach them the connection between emotions, thoughts, and behaviors
- Cognitive processing to systematically identify and challenge negative or distorted thoughts that may be lead to emotional and behavioral problems
- Trauma narration to helps children learn to manage reactions to trauma reminders (e.g., smells, sights, sounds) without the feared consequences
- In vivo exposure to people and places that have been avoided
- Conjoint caregiver-child sessions to discuss the trauma and other family stressors
- Enhancing safety to prepare for situations that might put children at risk
When the traumatic event is associated with a death, the trauma work is followed by grief work. CBT techniques learned during PRACTICE are applied to promote coping with grief. Children and caregivers address any feelings about the deceased and current and future relationships, with the goal of increasing social connections. Additional activities enable the child to make meaning of the death. Joint child-parent time helps the caregiver practice communicating with the child about the deceased and plan together for upcoming challenging events like holidays and anniversaries.
What Happens in TF-CBT Sessions
TF-CBT is designed to be a short-term therapy, typically completed in 6-9 months (16-24 sessions). Children and caregivers meet separately with the same therapist for the psychoeducation, skill-building, parenting, and exposure components of treatment. Then, children and caregivers meet together for family work. Sessions include: planning the agenda for session, home practice review, focus on specific PRACTICE component, and home practice assignment.
Parents/caregivers are vital partners in a child’s TF-CBT work. They are taught the same coping skills because they may be experiencing their own stress, and they play an important role in coaching their child to use their new skills.
victim of traumatic grief
Matthew’s father went to work one morning and never came back. A New York policeman, he had run into the World Trade Center on September 11, 2001, and died as the buildings collapsed on top of him.
Matthew’s life collapsed, too, under the weight of that awful morning. Just 6 and extremely close to his father, he began crying and expressing anger with alarming frequency. He stopped reading.
Matthew and his mother were assigned to work with Michelle, a therapist trained in Trauma-Focused Cognitive-Behavioral Therapy for Grief. She taught them skills to handle anger and anxiety. The crying and yelling started to subside.
Part of the therapy was helping Matthew write a book about his father and how he died. He then was scheduled to share the narrative with his mother. When Matthew began to share it, he began to cry and crawled under his mother’s chair. Matthew’s mother responded by reaching out to hold him. He allowed her to soothe him and together, they practice a relaxation skill taught by Michelle. Michelle then encouraged Matthew and his mother to read the book together while she held him.
When they finished, Matthew told the therapist that “sometimes it is just someone’s time to go, and then they die.” He was beginning to make meaning of the tragedy.
Next, Michelle worked with Matthew to create a memory box, filled with mementos of his father. When the box was completed, Matthew took it home and opened it when he wanted to think or talk about his father. Only weeks after shutting down at mention of his father, Matthew started to learn that traumatic recollections can be delicately redirected into memories more warm and therapeutic.
When applied astutely and gently, cognitive behavioral therapy works to help children speak more openly and learn how to heal.
victim of traumatic grief
Carlos loved gymnastics. Tumbling and flipping were his favorites. But when he was sexually abused by his coach, it was his 7-year-old life that got turned upside down.
He is having nightmares, wetting his bed, having tantrums, and afraid of gymnastics altogether. His supportive mother is torn between trying to give him time and helping him realize that life does go on. She read about how helpful Cognitive Behavioral Therapy can be and spoke to our intake coordinator about that intervention. But we can’t see him yet, because of our waiting list. His school is pressuring her to address his behavior. If we don’t see Carlos and his mother soon, she will have to seek other – most likely less effective — care or give up.
If we don’t intervene, Carlos will almost certainly face social and emotional problems in adolescence and adulthood. He is at significant risk for dropping out of school, succeeding in workplace and family life.
A moment of abuse can last a lifetime.
family needed multi-cultural therapy
Emilia, age 7, was sexually abused by her 21-year-old cousin. She comes from a Hispanic family with a history of abuse. She urgently needs to get off the PARTNERS waiting list to receive two types of interventions: short-term to handle the trauma, and long-term to separate from her familys history and create her own life direction.
With most of Emilia’s key family members knowing only Spanish, other therapy has been ineffective. She needs top-caliber intervention that is culturally-sensitive.
“I came to PARTNERS to be involved in my daughter’s therapy with my husband, but I wasn’t sure whether there would be a Spanish-speaking therapist for us who would also speak English to Emilia,” her mother recalled. “PARTNERS gave my family exactly what we needed, and even more: a multicultural understanding of our Nicaraguan background. After 6 months this allowed Emilia to feel normal again.”
Emilia learned that the abuse wasn’t her fault, and grew unashamed to speak openly with her parents. The whole family became involved — her three sisters even came to celebrate her graduation from therapy.
“Gracias por existir PARTNERS! Quedémonos socios para combatir el silencio del abuso de nuestras comunidades.”
Translated: “Thank you for existing, PARTNERS! Let’s remain partners to combat the silence of abuse in our communities together.”
Outcome / Research Results
More than 20 randomized clinical trials have demonstrated the efficacy of TF-CBT compared to other forms of therapy in the reduction of PTSD, depression, and behavior problems in children who have experienced sexual abuse, domestic violence, natural disasters, terrorism, and other forms of trauma. At Child HELP Partnership, we want to ensure that our families have the same rates of improvement as those families who participated in the randomized trials.
The chart below presents our own outcomes at each stage of therapy at Child HELP Partnership.
Percentage of Children with Mental Health Problems at Each Stage of PARTNERS Therapy
No Data Found
As the chart shows, the percentages of children with PTSD, depression, and conduct problems decrease significantly over the course of therapy. Additionally, each phase of TF-CBT is important for recovery. By reducing rates of PTSD, depression, and conduct problems, we are not only easing the current pain of the children served, but preventing the need for long-term, expensive mental health care.