Trauma-Focused Cognitive Behavioral Therapy

Trauma affects people of all ages, demographics, and lifestyle circumstances. Trauma can range in severity, but trauma, by definition, includes experiencing or witnessing any life-threatening event.

Some common traumas include: 

• Physical assault or abuse
• Emotional abuse
• Sexual abuse
• Natural disasters like earthquakes, wildfires, or hurricanes
• Severe neglect
• Medical diagnoses
• The death of a caretaker or close loved one
• Bullying

Single-event traumas refer to a specific event with a defined beginning, middle, and end. For instance, a severe car accident constitutes a single-event trauma. Complex trauma refers to compounded traumatic events, such as chronic childhood neglect or recurrent episodes of violence.

Although the child might not always be able to verbalize their feelings, trauma can affect children profoundly.

Well-known effects of trauma include:²

• Difficulties with attachment to caregivers and other attachment figures.
• Physical symptoms (stomachaches, headaches, nausea, muscle tension).
• Hypersensitivity to touch, sound, or certain sights.
• Apathy and detachment towards usual interests or relationships.
• Problems in school.
• Inability to remember the trauma or feeling like the memories are fuzzy and scattered.
• Sleep problems (night disturbances, flashbacks, nightmares, not wanting to sleep alone).
• Hypervigilance and increased anxiety in social settings.
• Dissociation symptoms (zoning or spacing out often).
• Regressing age-appropriate behavior.
• Excess self-blame and guilt.
• Depression symptoms.
• Substance use.
• Disordered eating.
• Desire to hurt oneself or others.
• Rapid and ongoing mood swings.

Some symptoms are apparent, whereas others are more covert and difficult to understand. For instance, older children may believe they must present as strong and unaffected to protect their families. As a result, they might appear seemingly unaffected by the trauma when they’re struggling immensely. Similarly, Very young children lack the specific language to describe symptoms or emotions.

Across all populations, trauma is notoriously challenging to treat. Let’s review some of the common barriers affecting children.

Ongoing crises: Complex trauma can compound itself, meaning that traumas continue to unravel without a defined beginning or end. Ongoing crises may be prominent in settings lacking a consistent home life or stable caregivers.

Attachment ruptures: Children may find it hard to trust any adult, including therapists, after encountering a trauma. Subsequently, they may attend therapy but refuse to talk or open up.

Limited accessibility to treatment: Some children may lack the financial or physical ability to attend therapy. Likewise, caretakers may not acknowledge the importance of seeking treatment after experiencing a trauma. 

Shame and fear: Children may be hesitant to talk about their trauma due to intensified feelings of shame or guilt. They may fear retaliation from the abuser or worry about other consequences like the family getting split up.

TF-CBT (trauma-focused cognitive behavioral therapy) is an evidence-based psychotherapy model focused on helping youth and their families with trauma-related symptoms. This therapy focuses on changing negative thoughts and replacing them with more realistic thoughts and how to implement healthier coping strategies to manage their distress. In addition, it can help family systems come together to improve communication and strengthen their collective response to the trauma.

TF-CBT can be highly effective in treating PTSD and other related trauma impacts. Additionally, it can help with a range of cognitive and behavioral problems.³

TF-CBT is a manualized approach, meaning that trained clinicians follow a specific curriculum. As a result, children have the opportunity to speak about their traumas freely while gaining insight and tools for how to cope with their stress response. 

TF-CBT is a relatively new therapy developed collaboratively by Drs. Judith Cohen, Anthony Mannarino, and Esther Deblinger. They speak of their work in the 2006 manual, Treating Trauma and Traumatic Grief in Children and Adolescents.⁷ 

That said, the interventions are not necessarily new. Many of them have been described in earlier literature. Similarly, CBT practitioners have utilized similar approaches in their work since Dr. Aaron Beck pioneered the theory in the 1960s.⁸

TF-CBT is a conjoint parent-child treatment. Sessions typically last around an hour, with the child and parent seeing the therapist separately for 30 minutes each. Later in the treatment, the parent and child will see the therapist completely together.

Successful therapy entails building meaningful rapport between the therapist and all participants. Because trauma can erode trust, this process may take time. Children need to feel like they will be safe and supported during their treatment. 

The main components of TF-CBT can be summarized by the acronym PRACTICE.⁹

P: Psychoeducation and Parenting Skills

The therapist will spend time teaching both parent and child about trauma and its related impact. They will review common statistics, symptoms, and fears. They might also teach about common coping strategies, the fight, flight, or freeze response, and other strategies about dysregulation. 

The goal is to help clients understand (and prepare to cope with) different triggers that may arise. This phase also focuses on empowering caretakers to support their children.  

R: Relaxation Techniques

Learning how to relax is an integral part of trauma healing. First, the therapist may spend some time reviewing relaxation techniques the client already uses and enjoys.

Moreover, the therapist will teach various relaxation strategies like deep breathing, visual imagery, and progressive muscle relaxation. Some therapists will show clients various online tools they can use to meditate or relax. Clients can use these skills both in and out of the session.

A: Affective Expression and Regulation

In this phase, the therapist focuses on attunement to support the client in identifying and sharing current emotions. They may also use skills in modeling and healthy communication. 

It’s essential to learn how to self-soothe when feeling overwhelmed or triggered by trauma-related material. Self-soothing activities may include positive affirmations, pleasant activities, and reaching out for support.

C: Cognitive Coping and Processing

This is the heart of CBT. First, the therapist will educate the child and parent on the relationship between thoughts, feelings, and behaviors. Then, they will demonstrate how some of the cognitive distortions (faulty thought patterns) impact healthy coping.

As the child becomes more aware of their cognitive distortions, they start recognizing patterns they want to change. Subsequently, they might start feeling more confident in practicing new coping skills. 

T: Trauma Narration and Processing

This part includes discussing, reviewing, and desensitizing oneself from traumatic events. Trauma processing may consist of any combination of verbal, written, or creative expression.

During this stage, the therapist integrates gradual exposure activities. This means that they take time to slowly accustom the child to share about the trauma while checking in to make sure they feel safe and comfortable. The child decides which events they want to include. Furthermore, they can also include positive events in their trauma narrative.

Within the processing, the therapist will take note of ongoing themes and cognitive distortions. Some familiar distortions include assuming that:

• You are unlovable
• People will always hurt or abandon you
• Vulnerability is bad or stupid
• You will never be happy or successful
• Bad things will continue happening
• The world is unsafe 

I: In Vivo Exposure

In vivo exposure refers to gradually exposing the child to specific stimuli or perceived threats. For example, this stage might include slowly habituating them to louder noises if the child fears people shouting. Such exposure may be real or imagined through guided imagery.

The goal is to learn how to tolerate situations that feel uncomfortable by practicing self-regulation skills. This phase entails developing a desensitization plan. Therapists may also engage support people outside of therapy to help the child.

C: Conjoint Parent/Child Sessions

This therapy emphasizes parent-child interaction and support. The caregiver does not need to be biologically related to the child. For example, therapists may work with foster parents, other relatives, group home staff, or teachers. 

Ideally, the child and caregiver come together to strengthen communication and create moments for bonding. While sharing trauma may be appropriate, the conjoint sessions do not need to entail the complete narrative.

E: Enhancing Personal Safety and Future Growth

This last phase focuses on educating children on specific safety and awareness skills about healthy relationships, sexuality, and self-esteem. Finally, therapists will teach families how to prepare and cope with future triggers should they arise.

Empirical data shows TF-CBT as a highly effective treatment model for youth. Such findings consistently highlight how TF-CBT can reduce PTSD, depression, and behavioral symptoms in children who have experienced trauma. 

TF-CBT has been proven to specifically help with:⁵

• Experiencing fewer intrusive thoughts and avoidance behaviors.
• Increased ability to withstand and cope with traumatic reminders.
• Decreased PTSD symptoms (depression, anxiety, dissociation, behavior problems).
• Increased sense of interpersonal trust and social competence.
• Increased awareness of personal safety.
• Increased ability to manage future trauma triggers.

Similarly, parents appear to yield similar benefits. Research shows that parents tend to report reduced rates of depression and PTSD. They tend to indicate having a better understanding of their child’s situation, and they rate themselves as more capable of supporting their children.

Because TF-CBT can temporarily worsen trauma symptoms, clients must demonstrate some ability to practice distress tolerance skills.

Therefore, TF-CBT is inappropriate for children or adolescents experiencing actively severe suicidal ideation, psychosis, or self-harm behaviors. It is also not appropriate for people actively under the influence or struggling with a substance use disorder.

These populations will typically benefit from a more structured, supervised approach. In some cases, they may require a higher level of care offered in a hospital-based or inpatient setting. After achieving stabilization, TF-CBT may be an appropriate approach.

TF-CBT is a short-term treatment. Most clients finish treatment within 12-16 weeks, although some may need up to 25 sessions. Therapists usually meet with their clients once per week for about an hour. 

Some children will need additional services after achieving substantial trauma resolution. Such services may include long-term therapy, psychiatric medication, or case management.

It’s important to provide a healthy termination for clients. In many cases, this goodbye can help clients recognize and process feelings about abandonment and rejection. The therapist will aim to frame termination as an achievement- they may use transitional objects to highlight the ongoing continuation of support.¹⁰

TF-CBT is identified as an appropriate model for children ages 3-18 exposed to trauma. The child’s caregivers are also encouraged to participate, and their involvement can improve treatment outcomes.⁴ The parents or caregivers cannot be the ones who participated in the abuse (i.e., this treatment would not be recommended if the parent sexually or physically assaulted the child). 

In addition to trauma exposure, appropriate therapy candidates:⁵

• Experience PTSD.
• Demonstrate heightened feelings of shame, depression, or anxiety.
• Exhibit behavioral problems that are not age-appropriate.

Qualified clinicians will conduct a thorough assessment before initiating treatment. This assessment will typically include a diagnostic screening for PTSD, depression, and anxiety.

Yes, adults can also benefit from TF-CBT. While most TF-CBT manuals focus on treating children, CBT for trauma is nothing new. In fact, many therapists use the following techniques in supporting their adult clients:

• In vivo exposure
• Understanding cognitive distortions
• Changing negative self-talk
• Relaxation training

Idaho Youth Ranch works with young adults up to age 24. 

TF-CBT is a branch of CBT, a standard psychotherapy model used with numerous populations and presenting problems. CBT specialists tend to focus only on cognitive and behavioral interventions. They may adhere to a specific approach that entails only those techniques.

However, TF-CBT combines interventions from several other theories, including:⁶

• Family therapy, which identifies interaction patterns between family members.
• Attachment theory, which helps to strengthen the connection within the parent-child relationship.
• Neurobiology, which offers awareness on how the brain changes and develops in response to trauma.