Trauma Focused CBT Part 1 Treating Trauma and Traumatic Grief in Children & Adolescents
~ Define Trauma Focused CBT
~ Explore the components of Trauma Focused CBT and their intended functions
~ Explore ways to use TF-CBT with adult clients
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.
Facts About Trauma
~ TF-CBT is intended for children with a trauma history whose primary symptoms or behavioral reactions are related to the trauma.
~ Traumatic stress reactions can be more than simply symptoms of PTSD and often present as difficulties with
~ Affect regulation
~ Attention and consciousness
~ Systems of meaning.
~ These effects can also interfere with adaptive functioning
Components of TF-CBT
~ Parenting skills
~ Relaxation and stress management skills
~ Affect expression and modulation
~ Cognitive coping and processing are enhanced by illustrating the relationships among thoughts, feelings and behaviors.
~ Trauma narration
~ In-vivo mastery of trauma reminders
~ Conjoint parent-child sessions
Effects of TF-CBT
~ Reduction in:
~ Intrusive and upsetting memories
~ Emotional numbing
~ Behavior problems
~ Sexualized behaviors
~ Trauma-related shame
~ Interpersonal distrust
~ Social skills deficits
~ Primary issue is defiant or conduct disordered
~ Child is suicidal or homicidal
~ Child is severely depressed
~ Child is actively abusing substances
~ When children remain in high-risk situations with a continuing possibility of harm, such as many cases of physical abuse or exposure to domestic violence, some aspects of TF-CBT may not be appropriate. For example, attempting to desensitize children to trauma memories is contraindicated when real danger is present.
~ Potential barriers and obstacles may include the following: The parent caregiver…
~ Does not agree that the trauma occurred
~ Agrees that the trauma occurred but believes that it has not affected the child significantly or that addressing it directly will make matters worse.
~ Is overwhelmed or highly distressed by his or her own emotional reactions and is not available or able to attend to the child’s experience.
~ Is suspicious, distrustful, or does not believe in the value of therapy.
~ Is facing many concrete problems such as housing, that consume a great deal of energy.
~ Is not willing or prepared to change parenting practices even though this may be important for treatment to succeed.
Interventions to Strengthen Parental Alliance
~ Specific strategies that can be undertaken include:
~ Perseverance in establishing a therapeutic alliance
~ Exploring past negative interactions with social service agencies or therapy
~ Exploring the parent/caretaker’s potential concerns that may make them feel as if they are not being understood, accepted, believed, listened to, or respected
~ Exploring/helping to overcome barriers to participating in treatment
~ Emphasizing the centrality of the caregiver’s role in the child’s recovery
~ Using parent sessions to reduce parent/caregiver distress and guide them through structured activities that empower them in interactions with the child
~ Delaying joint sessions until the parent/caregiver can offer the child support
~ Educate about how therapy works
~ Instilling optimism about the child’s potential for recovery
Information about Trauma
~ 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.
~ Psychoeducation helps to
~ Clarify inappropriate information children may have obtained directly from the perpetrator or on their own
~ Identify safety issues.
~ Provide another way to target faulty or maladaptive beliefs by helping to normalize thoughts and feelings about the traumatic experience(s).
~ Get the child to start talking about the specific trauma(s) that he or she has experienced in a less anxiety-provoking way by talking, in general about the type of trauma
Types of Trauma
~ 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
~ Death of a parent or sibling
~ Hurricane/Tornado/ Natural Disaster
~ Psychoeducation typically involves:
~ Specific information about the traumatic events the child has experienced
~ Body awareness/sex education in cases of physical or sexual maltreatment
~ Risk reduction skills to decrease the risk of future traumatization.
~ Information needs to be tailored to fit the child's particular experiences and level of knowledge.
~ Provide caregivers with handout materials to reinforce the information discussed in-session.
~ Encourage caregivers to discuss information at home
~ Begin by getting a sense of what children by using a question-and-answer game format in which a child gets points for answering questions correctly.
~ Correct and add developmentally appropriate information to the child's answers.
~ Some sample questions might include:
~ What is [type of trauma]?
~ How often do things like this happen?
~ Why does this [type of trauma] happen?
~ Meet the child and family where they are by presenting information in a way in which they can relate it to their own belief system.
~ Assess general beliefs about the trauma
~ Focus on the events THEY perceive as traumatic
~ Tailor the psychoeducational information so the family can be more receptive to it.
~ General views of mental health and mental health treatment should be assessed and addressed.
~ Provide a rationale and overview of the treatment model.
~ Educate parents about the trauma.
~ Talk about:
~ The child's trauma-related symptoms
~ How early treatment helps prevent long-term problems
~ The importance of talking directly about the trauma to help children cope with their experiences.
~ Reassure parents that children will first be taught skills to help them cope with their discomfort and that talking about the trauma will be done slowly, with a great deal of support and discussion.
~ Help the caregiver understand their role in the child's treatment, since this treatment model emphasizes working together as a team.
~ Parent input, questions, and suggestions are welcome
Stress Management Techniques
~ Controlled Breathing
~ Helps slow heart rate
~ Triggers “rest and digest”
~ Thought Stopping
~ Verbally (saying “go away” to the thought) or distracting oneself from an unpleasant thought.
~ Replace an unwanted thought with a pleasant one. (Identify ahead of time)
~ Teaches that thoughts—even unexpected, intrusive ones—can be controlled.
~ Keep a log of when the technique is used, what they were thinking about, and how effective thought stopping was.
Stress Management Techniques
~ Relaxation Training
~ Persons of Asian and Hispanic origin tend express stress responses in more somatic (i.e., physical) terms
~ When deciding how to present relaxation techniques, be creative.
~ Have the child help you to integrate elements into the technique to make it more relevant to them.
~ Have the child identify methods that he/she uses to relax (drawing, listening to music, walking…)
~ Be sensitive to children’s wishes if they do not wish to close their eyes or lie down
~ Parents can often also benefit from relaxation training
~ Helps therapist judge child’s ability to identify and articulate feelings
~ Teaches the child how to rate the intensity of the emotion
~ Teaches how to express feelings appropriately in different situations
~ Some children may have difficulty initially identifying and/or discussing their own feelings.
~ Try discussing the feelings of other children or characters from books or stories
~ Help children identify how they experiences emotions if they seem detached from the experience.
~ Introduce the difference between thoughts and feelings.
~ Many children describe thoughts when asked to identify feelings
~ How would you feel? I would want to run away.
Parent Sessions During Feelings Identification
~ Normalize that some children may be seemingly in constant distress or detached from the trauma
~ Share with the parents activities you do with the child
~ Let them know what specific difficulties (if any) their child is having
~ Encourage the parent to praise the child for appropriate management of difficult emotions (successive approximations)
~ If parents have difficulty identifying emotions, provide them with examples… “How do you feel when…”
~ If parents are overcome with their own emotions
~ Validate their feelings
~ Explain how children need to see parents can handle talking about the trauma
~ TF-CBT can be an effective intervention for children or adolescents whose primary presenting issue is trauma-related emotional or behavioral dysregulation
~ TF-CBT is not appropriate for clients who are actively suicidal, severely depressed or currently abusing substances.
~ TF-CBT starts with psychoeducation, then teaches stress management and coping skills to aid in the management of distressing feelings.
~ Psychoeducation helps to clarify inappropriate information children may have
~ Feelings identification helps participants start effectively labeling and communicating their feelings