120 -Trauma Focused Cognitive Behavioral Therapy Part 1
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Trauma Focused CBT  Part 1  Treating Trauma and Traumatic Grief in Children & Adolescents
Objectives
~    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
~    Relationships
~    Attention and consciousness
~    Somatization
~    Self-perception
~    Systems of meaning.
~    These effects can also interfere with adaptive functioning
Components of TF-CBT
~    Psychoeducation
~    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
~    Avoidance
~    Emotional numbing
~    Hyperarousal
~    Depression
~    Anxiety
~    Behavior problems
~    Sexualized behaviors
~    Trauma-related shame
~    Interpersonal distrust
~    Social skills deficits
Inappropriate Populations
~    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.

Challenges
~    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
~    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
~    Bullying
~    Death of a parent or sibling
~    Hurricane/Tornado/ Natural Disaster
~    Fire

~    https://www.samhsa.gov/capt/practicing-effective-prevention/prevention-behavioral-health/adverse-childhood-experiences

~    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?

Cultural Considerations
~    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.
~    Demystify
~    Destigmatize/normalize

Parent Sessions
~    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

Feelings Identification
~    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

Summary
~    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

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