Trauma focused cognitive behavioral therapy
Specialtypsychology

Trauma focused cognitive behavioral therapy (TF-CBT) is an evidence-based psychotherapy or counselling that aims at addressing the needs of children and adolescents with post traumatic stress disorder (PTSD) and other difficulties related to traumatic life events.[1] This treatment was developed and proposed by Drs. Anthony Mannarino, Judith Cohen, and Esther Deblinger in 2006.[2] The goal of TF-CBT is to provide psychoeducation to both the child and non-offending caregivers, then help them identify, cope, and re-regulate maladaptive emotions, thoughts, and behaviors.[3] Research has shown TF-CBT to be effective in treating childhood PTSD and with children who have experienced or witnessed traumatic events, including but not limited to physical or sexual victimization, child maltreatment, domestic violence, community violence, accidents, natural disasters, and war.[4][5][6][7] More recently, TF-CBT has been applied to and found effective in treating complex posttraumatic stress disorder.[8]

Description

TF-CBT is a treatment model that incorporates various trauma-sensitive intervention components.[9] It aims at individualizing TF-CBT techniques to children and their circumstances while maintaining therapeutic relationship with both the child and parent.[10] TF-CBT treatment can be used with children and adolescents who have experienced traumatic life events. It is a short-term treatment (typically 12-16 sessions) that combines trauma-sensitive interventions with cognitive behavioral therapy strategies.[11] It can also be used as part of a larger treatment plan for children with other difficulties.[12] TF-CBT includes individual sessions for both the child and the parents, as well as parent-child joint sessions.

Major treatment phases and components

Major components of TF-CBT include psycho-education about childhood trauma and individualizing relaxation skills. There are 3 treatment phases (stabilization, trauma narration and processing, and integration and consolidation). These phases include 8 different components throughout these sessions, denoted by the ‘PRACTICE’ acronym seen below.[2] The provider will facilitate 4-5 sessions each phase, while the PRACTICE components are delivered in sequential order.[2]

  • Psychoeducation and Parenting skills
  • Relaxation
  • Affective Expression and Regulation
  • Cognitive Coping
  • Trauma Narrative Development and Processing
  • In Vivo Gradual Exposure
  • Conjoint Parent-Child sessions
  • Enhancing Safety and Future Development

Phase 1: Stabilization

Psychoeducation and parenting skills. Information about trauma responses and reminders are given, normalized, and validated. Caregivers are also given strategies to respond to these trauma responses.[2] Education on trauma reminders (e.g., the cues, people places etc associated with the trauma event) helps explain to children and caregivers how PTSD symptoms are maintained.[2] An additional goal of many psychoeducation sessions is to explain the role of the brain in PTSD symptomatology. Generally, the amygdala, or the "fear center" of the brain, is hyper-responsive, and the prefrontal cortex, which is involved in processing, decision making, and down-regulation, is less active, or even reduced in volume.[13] Usually, the prefrontal cortex will work to process the signals sent through the amygdala, assisting in regulated responding to stressful events. These connections have been found to be reduced in patients with PTSD, further explaining the heightened levels of fear responding to trauma reminders.[13] This information can be broken down in several "child-friendly" methods (e.g., the hand model of the brain[14]) and efficiently leads into the second module of TF-CBT: relaxation.

Relaxation. The child and caregiver are education on skills that inform relaxation in order to cope with their stress responses.[2] Some examples of techniques taught are progressive muscle relaxation, paced breathing, or guided visualization.[15]

Affective Expression and Regulation. This component assists the child in becoming more comfortable or knowledgeable regarding the expression of feelings and thoughts, so that they may practice and develop skills in order to manage their stress response.[15] The caregivers are educated on these skills and encouraged to practice using the emotion-language taught in session when trauma reminders are brought up at home.[2][15]

Cognitive Coping. This component helps both the child and caregiver recognize maladaptive thoughts, feelings, and behaviors and replace them with more accurate responses.[2] This section can be more challenging for clients, particuarly younger children.[16] The cognitive triangle (thoughts, feelings, and behaviors) is used to exemplify how our cognitive, emotional, and behavioral processes interact.[15] Children are guided through the identification of negative everyday thoughts (e.g., I sit alone at lunch because no one likes me), and these skills are then adapted to the negative thoughts surrounding the traumatic event (e.g., "this happened to me because I am a bad kid").[15]

Phase 2: Trauma Narration and Processing

Trauma Narrative Development and Processing. This is an interactive process that allows the child to address specific details about their experience with trauma. A written summary is developed through a creative medium, which serves as a tool to process these reactions. This content is then shared with the caregiver, in order to give the opportunity for the caregiver to also process these cognitions.[2]

Phase 3: Integration and Consolidation

In Vivo Gradual Exposure. This is the only optional component within TF-CBT. The caregiver and child develop a fear hierarchy and develop strategies to face each fear. The caregiver is crucial in this session, as they must give consistent encouragement and persistence for the child to use their relaxation and TF-CBT skills.[2]

Conjoint Parent-Child Sessions. Direct communication is encouraged between child and caregiver to continue open communication about the trauma experience, and other important issues before treatment concludes.[2]

Enhancing Safety and Future Development. Practical strategies are developed that assist in enhancing the child’s sense of safety and trust.[2]

Treatment Sessions

Unless, it is a conjoint parent-child session, each session is about 1 hour, and the therapist spends 30 minutes with the child and 30 minutes with the parent.[2] In the conjoint parent-child sessions, the therapist meets with the caregiver alone for 5–10 minutes, then the child alone for 5–10 minutes, then both caregiver and child together for 40–50 minutes.[2]

Child-specific sessions

During the child therapy sessions, the therapist focuses on relaxation training such as deep breathing and muscle relaxation skills, emotion regulation (identifying feelings), a trauma narrative and processing (discussing the overwhelming events and associated feelings), as well as cognitive coping strategies (identifying and replacing negative thoughts).[17]

Parent-specific sessions

Parents or primary caregivers are considered as the central therapeutic agents for improvement in TF-CBT.[5] During the parent sessions, the therapist discusses the appropriateness of the treatment and safety plans with the parents and encourages positive parenting skills to maximize effective parenting.[18] These sessions are important in helping the caregiver use and model specific coping skills for their own psychopathology for their child to show how they can manage their own symptoms.[19]

Parent-child conjoint sessions

During the conjoint sessions, the therapist shares the trauma narratives and challenges to incorrect/negative thoughts as a means to encourage and facilitate parent-child communication. The therapist would only intervene when inaccurate cognitions were not addressed.[1]

Group sessions

Group TF-CBT is an alternative to individual TF-CBT that reduces individual therapist hours and provides relief after disasters or in areas with limited resources.[20] Similar to individual TF-CBT, group TF-CBT involves both child and caregiver and utilizes the ‘PRACTICE’ elements, typically delivered through 12 structured sessions that target the reduction of distress and feelings of shame.[20]

Evaluation of effectiveness

Randomized clinical trials examining the efficacy of TF-CBT have found it to be an effective treatment plan for a variety of disorders in both children and adolescents.[21][22] TF-CBT has been proven to effectively reduce symptoms of PTSD, depression, anxiety, externalizing behaviors, sexualized behaviors, and feelings of shame in traumatized children.[23] TF-CBT has been shown to improve positive parenting skills and support of the child through the enhancement of parent-child communication.[12] A study examining the combinatorial effect of TF-CBT with sertraline has found that there were only minimal benefits associated with adding sertraline to the treatment, providing evidence for an initial trial of TF-CBT before medication.[24] Evidence has also shown that TF-CBT is more successful than control groups despite whether it is delivered in a group format or individually.[25]

While TF-CBT has been shown to just as effective as Eye movement desensitization and reprocessing (EMDR) for the treatment of chronic post-traumatic stress disorder (PTSD) in adults, the results were tentative given low numbers in the studies, high drop out rates, and high risk of experimenter bias.[26]

There are some controversies that exist about the effectiveness of CBT for treating trauma. About 50% of patients involved in efficacy studies still have their trauma related symptoms at the end of treatment.[27] CBT is currently being researched for its effectiveness on therapy compared to other types of therapeutic interventions. Most of these studies have been conducted in outpatient research clinics.[28]

Methods of access

Therapist

TF-CBT can be delivered by a variety of mental health professionals ranging from clinical social workers, counselors to psychologists and psychiatrists.[29] Qualified therapists are required to be rostered or nationally certified in TF-CBT. Part of the training for this treatment includes an online TF-CBT certified training course.[30] Additional criteria are required in order for a clinician to be rostered or nationally certified.[31] It is recommended that the practitioner not only complete the online training course, but also attend a multi-day in-person training, and receive continuing supervision for 6–9 months from TF-CBT supervisor or consultant, while also practicing with families who have experienced trauma.[32]

Implementation and adaptations

Since its development in the 1980s, TF-CBT has been used by therapists in many countries such as Australia, Cambodia, Canada, China, Denmark, Germany, Japan, the Netherlands, Norway, Pakistan, Sweden, United States, and Zambia.[33] In some US states, implementation has been done in collaboration with the Substance Abuse and Mental Health Services Administration National Child Traumatic Stress Network.[32] It has also been used with children in the foster care system, with those who have suffered from traumatic life events, including the 9-11 terrorist attacks, and those who experienced Hurricane Katrina.[34]

TF-CBT has also been adapted to different cultures, including Latino populations. The treatment manual book has been translated into a variety of languages, such as Dutch, German, Japanese, Korean, and Mandarin.[35] Because TF-CBT can be implemented by local lay counselors, it makes it a feasible mental health resource option in low and middle income countries, or in areas with low-resources.[36]

In the wake of the COVID-19 pandemic there was a shift from in-person to remote delivery of psychotherapy. Because of the increase in demand for trauma-focused treatment in trauma-affected areas, practitioners have been able to facilitate TF-CBT virtually.[37] Virtual TF-CBT therapy is more cost effective and has increased access to psychotherapy.[37]

Many children are exposed to multiple events, or chronic trauma.[38] These persistent experiences of traumatization impact a child's ability to form primary attachments, which may lead to an array of difficulties and is often referred to as "complex trauma."[38] Complex trauma has sometimes been viewed as more difficult to treat, as its characterized by heightened levels of affective dysregulation, difficulties with attachment security, dissociation, and a fragmented sense of self.[8][38] More recent research has identified TF-CBT as an effective approach for treating children with complex postraumatic stress, one article finding that those with complex PTSD showed a greater reduction in their symptoms following treatment than those who had non-complex PTSD.[8] In the United States, the concept of complex trauma is recognized, but it is not considered a distinct diagnosis based off of the text revised version of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5-TR).[39] Countries other than the United States who use the International Classification of Diseases (ICD) have recently recognized complex PTSD (CPTSD) as its own disorder in the ICD-11 revised edition.[40] The benefits of its inclusion in the ICD-11 are that it may lend to more individualized treatments that better address the nature of the trauma, as well as contribute to the research pool surrounding stress-related disorders.[40] Some listed challenges, especially in light of its consideration to be added to the DSM-5, were that complex trauma may function better as a purely dimensional disorder, which is not reflective of the current diagnostic system, and that there is not enough identified psychometric properties to warrent its inclusion.[41]

References

  1. 1 2 Cohen, Judith A. (2006). Treating trauma and traumatic grief in children and adolescents ([Online-Ausg.]. ed.). New York: The Guilford Press. ISBN 978-1593853082.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Cohen, Judith A.; Mannarino, Anthony P. (July 2015). "Trauma-focused Cognitive Behavior Therapy for Traumatized Children and Families". Child and Adolescent Psychiatric Clinics of North America. 24 (3): 557–570. doi:10.1016/j.chc.2015.02.005. PMC 4476061. PMID 26092739.
  3. ↑ Kar, Nilamadhab (April 2011). "Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a review". Neuropsychiatric Disease and Treatment. 7: 167–181. doi:10.2147/ndt.s10389. ISSN 1176-6328. PMC 3083990. PMID 21552319.
  4. ↑ Cohen, J. A.; Mannarino, A. P.; Perel, J. M.; Staron, V. (2007). "A pilot randomized controlled trial of combined trauma-focused CBT and sertraline for childhood PTSD symptoms". Journal of the American Academy of Child & Adolescent Psychiatry. 46 (7): 811–819. doi:10.1097/chi.0b013e3180547105. PMID 17581445.
  5. 1 2 COHEN, J. A.; MANNARINO, A. P.; BERLINER, L.; DEBLINGER, E. (1 November 2000). "Trauma-Focused Cognitive Behavioral Therapy for Children and Adolescents: An Empirical Update". Journal of Interpersonal Violence. 15 (11): 1202–1223. doi:10.1177/088626000015011007. S2CID 16067137.
  6. ↑ Ford, J. D.; Russo, E. (2006). "Trauma-focused, present-centered, emotional self-regulation approach to integrated treatment for posttraumatic stress and addiction: trauma adaptive recovery group education and therapy (TARGET)". American Journal of Psychotherapy. 60 (4): 335–355. doi:10.1176/appi.psychotherapy.2006.60.4.335. PMID 17340945.
  7. ↑ de Arellano, Michael A. Ramirez; Lyman, D. Russell; Jobe-Shields, Lisa; George, Preethy; Dougherty, Richard H.; Daniels, Allen S.; Ghose, Sushmita Shoma; Huang, Larke; Delphin-Rittmon, Miriam E. (May 2014). "Trauma-Focused Cognitive-Behavioral Therapy for Children and Adolescents: Assessing the Evidence". Psychiatric Services. 65 (5): 591–602. doi:10.1176/appi.ps.201300255. ISSN 1075-2730. PMC 4396183. PMID 24638076.
  8. 1 2 3 Jensen, Tine K.; Braathu, Nora; Birkeland, Marianne Skogbrott; Ormhaug, Silje Mørup; Skar, Ane-Marthe Solheim (2022-12-19). "Complex PTSD and treatment outcomes in TF-CBT for youth: a naturalistic study". European Journal of Psychotraumatology. 13 (2). doi:10.1080/20008066.2022.2114630. ISSN 2000-8066. PMC 9518270. PMID 36186162.
  9. ↑ COHEN, JUDITH A.; MANNARINO, ANTHONY P.; KNUDSEN, KRAIG (October 2004). "Treating Childhood Traumatic Grief: A Pilot Study". Journal of the American Academy of Child & Adolescent Psychiatry. 43 (10): 1225–1233. doi:10.1097/01.chi.0000135620.15522.38. PMID 15381889.
  10. ↑ COHEN, JUDITH A.; MANNARINO, ANTHONY P.; STARON, VIRGINIA R. (December 2006). "A Pilot Study of Modified Cognitive-Behavioral Therapy for Childhood Traumatic Grief (CBT-CTG)". Journal of the American Academy of Child & Adolescent Psychiatry. 45 (12): 1465–1473. doi:10.1097/01.chi.0000237705.43260.2c. PMID 17135992. S2CID 42041010.
  11. ↑ Cohen, JA; Mannarino, AP; Iyengar, S (Jan 2011). "Community treatment of posttraumatic stress disorder for children exposed to intimate partner violence: a randomized controlled trial". Archives of Pediatrics & Adolescent Medicine. 165 (1): 16–21. doi:10.1001/archpediatrics.2010.247. PMID 21199975.
  12. 1 2 Cohen, JA; Mannarino, AP; Knudsen, K (Feb 2005). "Treating sexually abused children: 1 year follow-up of a randomized controlled trial". Child Abuse & Neglect. 29 (2): 135–45. doi:10.1016/j.chiabu.2004.12.005. PMID 15734179.
  13. 1 2 Sherin, Jonathan E.; Nemeroff, Charles B. (2011-09-30). "Post-traumatic stress disorder: the neurobiological impact of psychological trauma". Dialogues in Clinical Neuroscience. 13 (3): 263–278. doi:10.31887/DCNS.2011.13.2/jsherin. ISSN 1958-5969. PMC 3182008. PMID 22034143.
  14. ↑ Dr. Dan Siegel's Hand Model of the Brain, retrieved 2023-10-20
  15. 1 2 3 4 5 Brown, Elissa J.; Cohen, Judith A.; Mannarino, Anthony P. (2020-12-01). "Trauma-Focused Cognitive-Behavioral Therapy: The role of caregivers". Journal of Affective Disorders. 277: 39–45. doi:10.1016/j.jad.2020.07.123. ISSN 0165-0327. PMID 32791391. S2CID 221121563.
  16. ↑ Pollio, Elisabeth; Deblinger, Esther (2017-12-15). "Trauma-focused cognitive behavioural therapy for young children: clinical considerations". European Journal of Psychotraumatology. 8 (sup7). doi:10.1080/20008198.2018.1433929. ISSN 2000-8066. PMC 5965038. PMID 29844883.
  17. ↑ "Trauma-Focused CBT Training". Retrieved 20 April 2014.
  18. ↑ Cohen, Judith A.; Mannarino, Anthony P. (November 2008). "Trauma-Focused Cognitive Behavioural Therapy for Children and Parents". Child and Adolescent Mental Health. 13 (4): 158–162. doi:10.1111/j.1475-3588.2008.00502.x. PMID 32847188.
  19. ↑ Martin, Christina Gamache; Everett, Yoel; Skowron, Elizabeth A.; Zalewski, Maureen (September 2019). "The Role of Caregiver Psychopathology in the Treatment of Childhood Trauma with Trauma-Focused Cognitive Behavioral Therapy: A Systematic Review". Clinical Child and Family Psychology Review. 22 (3): 273–289. doi:10.1007/s10567-019-00290-4. ISSN 1096-4037. PMC 8075046. PMID 30796672.
  20. 1 2 Deblinger, Esther; Pollio, Elisabeth; Dorsey, Shannon (2015-12-23). "Applying Trauma-Focused Cognitive–Behavioral Therapy in Group Format". Child Maltreatment. 21 (1): 59–73. doi:10.1177/1077559515620668. ISSN 1077-5595. PMID 26701151. S2CID 206666505.
  21. ↑ Cohen, JA; Deblinger, E; Mannarino, AP; Steer, RA (Apr 2004). "A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms". Journal of the American Academy of Child and Adolescent Psychiatry. 43 (4): 393–402. doi:10.1097/00004583-200404000-00005. PMC 1201422. PMID 15187799.
  22. ↑ Cohen, JA; Berliner, L; Mannarino, A (Apr 2010). "Trauma focused CBT for children with co-occurring trauma and behavior problems". Child Abuse & Neglect. 34 (4): 215–24. doi:10.1016/j.chiabu.2009.12.003. PMID 20304489.
  23. ↑ Seidler, GH; Wagner, FE (Nov 2006). "Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study". Psychological Medicine. 36 (11): 1515–22. doi:10.1017/S0033291706007963. PMID 16740177. S2CID 39751799.
  24. ↑ Cohen, JA; Mannarino, AP; Perel, JM; Staron, V (Jul 2007). "A pilot randomized controlled trial of combined trauma-focused CBT and sertraline for childhood PTSD symptoms". Journal of the American Academy of Child and Adolescent Psychiatry. 46 (7): 811–9. doi:10.1097/chi.0b013e3180547105. PMID 17581445.
  25. ↑ Thomas, Fiona C.; Puente-Duran, Sofia; Mutschler, Christina; Monson, Candice M. (May 2022). "Trauma-focused cognitive behavioral therapy for children and youth in low and middle-income countries: A systematic review". Child and Adolescent Mental Health. 27 (2): 146–160. doi:10.1111/camh.12435. ISSN 1475-357X. PMID 33216426. S2CID 227079848.
  26. ↑ Bisson J, Roberts NP, Andrew M, Cooper R, Lewis C (2013). "Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults". Cochrane Database of Systematic Reviews. 12 (12): CD003388. doi:10.1002/14651858.CD003388.pub4. PMID 24338345
  27. ↑ Silva, Hernán (March 2009). "Cognitive Behavioral Therapies for Trauma (2nd Edition) Edited by Victoria M. Follette and Joseph I. Ruzek. New York: The Guilford Press, 2006. 472 pp". Depression and Anxiety. 26 (3): 301–302. doi:10.1002/da.20323. ISSN 1091-4269.
  28. ↑ Silva, Hernán (March 2009). "Cognitive Behavioral Therapies for Trauma (2nd Edition) Edited by Victoria M. Follette and Joseph I. Ruzek. New York: The Guilford Press, 2006. 472 pp". Depression and Anxiety. 26 (3): 301–302. doi:10.1002/da.20323. ISSN 1091-4269.
  29. ↑ "What is Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)?". Retrieved 20 April 2014.
  30. ↑ "TF-CBT Web: A web-based learning course for trauma focused cognitive behavioral therapy". Retrieved 20 April 2014.
  31. ↑ "TF-CBT.org Certification Criteria". 26 March 2021.
  32. 1 2 Lang, Jason M.; Ford, Julian D.; Fitzgerald, Monica M. (2010). "An algorithm for determining use of trauma-focused cognitive–behavioral therapy". Psychotherapy: Theory, Research, Practice, Training. 47 (4): 554–569. doi:10.1037/a0021184. ISSN 1939-1536. PMID 21198243.
  33. ↑ "Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)". Retrieved 20 April 2014.
  34. ↑ Dorsey, S (2012). "Trauma-focused CBT for youth in foster care: Preliminary findings from a randomized controlled trial". In Presented at the San Diego Conference on Child and Family Maltreatment San Diego.
  35. ↑ "Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)". Retrieved 20 April 2014.
  36. ↑ Thomas, Fiona C.; Puente-Duran, Sofia; Mutschler, Christina; Monson, Candice M. (2020-11-20). "Trauma-focused cognitive behavioral therapy for children and youth in low and middle-income countries: A systematic review". Child and Adolescent Mental Health. 27 (2): 146–160. doi:10.1111/camh.12435. ISSN 1475-357X. PMID 33216426. S2CID 227079848.
  37. 1 2 Jones, Chelsea; Miguel-Cruz, Antonio; Smith-MacDonald, Lorraine; Cruikshank, Emily; Baghoori, Delaram; Kaur Chohan, Avneet; Laidlaw, Alexa; White, Allison; Cao, Bo; Agyapong, Vincent; Burback, Lisa (2020-09-21). "Virtual Trauma-Focused Therapy for Military Members, Veterans, and Public Safety Personnel With Posttraumatic Stress Injury: Systematic Scoping Review". JMIR mHealth and uHealth. 8 (9): e22079. doi:10.2196/22079. ISSN 2291-5222. PMC 7536597. PMID 32955456.
  38. 1 2 3 Cohen, Judith A.; Mannarino, Anthony P.; Kliethermes, Matthew; Murray, Laura A. (2012). "Trauma-focused CBT for youth with complex trauma". Child Abuse & Neglect. 36 (6): 528–541. doi:10.1016/j.chiabu.2012.03.007. PMC 3721141. PMID 22749612.
  39. ↑ "VA.gov | Veterans Affairs". www.ptsd.va.gov. Retrieved 2023-11-25.
  40. 1 2 Nestgaard Rød, Åshild; Schmidt, Casper (2021-01-01). "Complex PTSD: what is the clinical utility of the diagnosis?". European Journal of Psychotraumatology. 12 (1). doi:10.1080/20008198.2021.2002028. ISSN 2000-8066. PMC 8667899. PMID 34912502.
  41. ↑ Resick, Patricia A.; Bovin, Michelle J.; Calloway, Amber L.; Dick, Alexandra M.; King, Matthew W.; Mitchell, Karen S.; Suvak, Michael K.; Wells, Stephanie Y.; Stirman, Shannon Wiltsey; Wolf, Erika J. (2012). "A critical evaluation of the complex PTSD literature: Implications for DSM-5". Journal of Traumatic Stress. 25 (3): 241–251. doi:10.1002/jts.21699. ISSN 0894-9867. PMID 22729974.

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