While Trauma Focused Cognitive Behavior Therapy is targeted at treating children and adolescents exposed to trauma, I have found that many of my adult clients also benefit from this framework. Because of childhood trauma, they too are struggling with emotional and behavioral dysregulation issues, difficulty trusting others, trauma related shame and social skills deficits.
Facts about TF-CBT
- Works for children who have experienced any trauma, including multiple traumas.
- Is effective with children from diverse backgrounds.
- Works in as few as 12 treatment sessions.
- Has been used successfully in clinics, schools, homes, foster care, residential treatment facilities, and inpatient settings.
- Works even if there is no parent or caregiver to participate in treatment.
Traumatic stress reactions can be more than simply symptoms of PTSD and often present as difficulties with
- Affect regulation / emotional dysregulation
- Relationships /Interpersonal effectiveness
- Attention and consciousness /impulsivity
- Systems of meaning
Deficits in these areas can significantly impact development and adaptive functioning over the lifespan.
There are multiple components of TF-CBT
- Psychoeducation to teach the person about the trauma in general in order to stigmatize and begin to explore unhelpful cognition related to the trauma. (If the trauma was a natural disaster, for example, the education may focus on the likelihood of experiencing that again, and creating a safety plan.)
- Parenting skills to aid the parent in helping the child identify and modulate emotional reactions and behaviors.
- Relaxation and stress management skills to assist all parties in effective affect regulation
- Affect expression and modulation to help all parties understand the difference between thoughts and feelings.
- Cognitive coping and processing to illustrating the relationships among thoughts, feelings and behaviors.
- Trauma narration to help the client connect with thoughts and feelings related to the trauma, and (eventually), identify and address unhelpful thoughts
- In-vivo mastery of trauma reminders to reduce hypervigilence
- Conjoint parent-child sessions to improve communication between parent and child and enhance parent's ability to support the child in recovery.
TF-CBT has been shown to produce reductions in:
- Intrusive and upsetting memories
- Emotional numbing
- Behavior problems
- Sexualized behaviors
- Trauma-related shame
- Interpersonal distrust
- Social skills deficits
When children are traumatized, they may:
- Be confused
- Not completely understand what has happened
- Blame themselves
- Hold on to myths because they've been misled and deliberately given incorrect information.
- One of the best ways to help is to provide accurate information.
There are a variety of types of trauma.
The Adverse Childhood Experiences (ACE) study identified 10 common ACEs, but there are many more including, but not limited to: ACEs include:
- Physical abuse/neglect
- Sexual abuse
- Emotional abuse/neglect
- Mother treated violently
- Substance misuse within household
- Household mental illness
- Parental separation/divorce
- Incarcerated household member
Other types of trauma include
- Death of a parent or sibling
- Hurricane/Tornado/ Natural Disaster
After the client is provided with psychoeducation and rapport has been established, the therapist moves on to feelings identification, stress management and cognitive coping to ensure the child and caregivers have the tools needed prior to beginning the trauma narrative.
Feelings identification helps therapist judge child’s ability to identify and articulate feelings; teaches the child how to rate the intensity of the emotion and how to express feelings appropriately in different situations. Some children may have difficulty initially identifying and/or discussing their own feelings. Therapists can try discussing the feelings of other children or characters from books or stories. During this time it is usually appropriate to introduce the difference between thoughts and feelings, because many children describe thoughts when asked to identify feelings. For example, “How do you feel about being here?” “I want to go home.”
The next step is to introduce Cognitive Coping which will help participants recognize and understand the difference between accurate and inaccurate and helpful and unhelpful cognitions. They will also continue to work on recognizing the distinction and relation among feelings, thoughts, and behavior; generating alternative thoughts that are more accurate or more helpful; and attempting to change their feelings and behavior by thinking differently.
All of this work culminates into the trauma narrative. The purpose of the trauma narrative is to help to control intrusive and upsetting trauma-related imagery, reduce avoidance of cues, situations, and feelings associated with trauma exposure, identify unhelpful cognitions about traumatic events, help the child recognize, anticipate, and prepare for reminders of the trauma, and break apart thoughts, reminders, or discussions of the trauma from overwhelming negative emotions. Once the narrative is created, the client and therapist read through the trauma narrative several times, identifying thoughts and feelings, and correcting cognitive distortions and errors. After several “exposures” the child will typically experience progressively less extreme emotional reactions and physiological reactivity.
It is important to help the child create a positive and optimistic ending to the narrative. Encourage them to include in the narrative ways in which they are different now from when the traumatic events happened and when therapy began; what they have learned from going through the trauma and creating the narrative and advice they might give to other children who have experienced similar types of trauma.
The creation of the trauma narrative is both an end in itself, helping the child tell the story with reduced anxiety and healthier cognitions, and a starting point for the exploration of how the child thinks and feels about the trauma and its impact.
For more information on how to do Trauma Focused Cognitive Behavior Therapy, you can participate in our live webinar Tuesday 4/4/2017 and Thursday 4/6/2017 (sign up here https://www.allceus.com/member/cart/index/index?c=30) or you can subscribe to our youtube channel (https://youtube.com/allceuseducation )to be notified when the video is released, or you can subscribe to counselor toolbox podcast on your favorite podcast app to be notified when the podcast is released.