Trauma-Focused Cognitive Behavioral Therapy

Understanding Childhood Trauma

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 is a single-event trauma. Complex trauma refers to compounded traumatic events. Such as chronic childhood neglect or recurrent episodes of violence. 

Children can't always verbalize their feelings, but trauma can affect them profoundly. 

Well-known effects of trauma include:

• 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 clear, whereas others are more covert and difficult to understand. Older children may believe they must present as strong to protect their families. As a result, they might appear seemingly unaffected by the trauma. Despite struggling immensely. Similarly, very young children lack the specific language to describe symptoms or emotions. 

Challenges of Treating Trauma in Children

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. This means that traumas continue to unravel without a defined beginning or end. Ongoing crises may be frequent in environments where there's no stable home life or consistent caregivers. 

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

Limited accessibility to treatment: Some children may not have the financial or physical ability to attend therapy. 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 feelings of shame or guilt. They may fear retaliation from the abuser. Or worry about other consequences like the family getting split up. 

What is TF-CBT?

TF-CBT is trauma-focused cognitive behavioral therapy. It's a proven model focused on helping youth and their families with trauma. This therapy emphasizes replacing negative thoughts with more realistic ones. And adopting healthier coping strategies to manage distress. It can help families improve communication and strengthen their collective response to 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.

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

TF-CBT History

TF-CBT is a new therapy developed by Drs. Judith Cohen, Anthony Mannarino, and Esther Deblinger. Their work is mentioned in Treating Trauma and Traumatic Grief in Children and Adolescents.

These interventions are not new. Many of them have been described in earlier literature. Similarly, CBT practitioners have used similar approaches since Dr. Aaron Beck pioneered the theory in the 1960s.

How Does TF-CBT Work?

TF-CBT is a conjoint parent-child treatment. Sessions typically last around an hour. The child and parent see the therapist separately for 30 minutes each, and then they see the therapist 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 are summarized by the acronym PRACTICE.

P: Psychoeducation and Parenting Skills 

The therapist will spend time teaching both parent and child about trauma. They'll talk about 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 

• other strategies for dysregulation  

The goal is to help clients understand (and prepare to cope with) different triggers that may come up. 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. The therapist may spend some time reviewing relaxation techniques you use and find helpful. 

Moreover, the therapist will teach various relaxation strategies, such as 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 expressing current emotions. They may also use skills in modeling and healthy communication.  

It’s essential to learn how to self-soothe. Especially 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. The therapist will teach the child and parent about the connection between thoughts, feelings, and behaviors. Then, they will show how some cognitive distortions, such as faulty thought patterns, impact healthy coping. 

The child will become more aware of their cognitive distortions, start recognizing patterns they want to change, and might feel 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 sharing about the trauma while checking in to make sure they feel safe and comfortable. The child decides which events 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 to perceived threats. This stage might involve getting the child used to loud noises if they fear 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 and 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. Therapists may work with foster parents, other relatives, group home staff, or teachers.  

Ideally, the child and caregiver come together to strengthen communication. They create moments for bonding. Sharing trauma may be suitable. But the conjoint sessions don't have to include the entire narrative. 

E: Enhancing Personal Safety and Future Growth 

This last phase focuses on educating children on specific safety and awareness skills. These include healthy relationships, sexuality, and self-esteem. Therapists will instruct families on how to prepare and cope with future triggers. 

What Are the Benefits of TF-CBT?

Empirical data shows TF-CBT as a highly effective treatment model for youth. TF-CBT can decrease PTSD, depression, and behavioral symptoms in children who 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 often report a better understanding of their child’s situation. And they feel more capable of supporting them.  

What Are the Limitations of TF-CBT?

TF-CBT can temporarily worsen trauma symptoms. That's why clients must show some ability to practice distress tolerance skills. 

TF-CBT is inappropriate for some children or adolescents. These include kids experiencing 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 need a higher level of care offered in a hospital-based or inpatient setting. After achieving stabilization, TF-CBT may be an appropriate approach. 

How Long Does It Take for TF-CBT to Work?

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 extra services after achieving much trauma resolution. Such services may include long-term therapy, psychiatric medication, or case management. 

It’s important to provide clients with a healthy termination. Goodbyes 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.

Who Is a Good Candidate for TF-CBT?

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. Their involvement can improve treatment outcomes. The parents or caregivers cannot be the ones who participated in the abuse. This treatment would not be recommended if the parent sexually or physically assaulted the child.  

In addition to trauma exposure, appropriate therapy candidates:

• 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. 

Can TF-CBT Be Applied to Adults?

Yes, adults can also benefit from TF-CBT. While most TF-CBT manuals focus on treating children, CBT for trauma is nothing new. 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.  

What Is the Difference between CBT and TF-CBT?

TTF-CBT is a branch of CBT. It's a standard psychotherapy model used with many 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 identifies interaction patterns between family members. 

• Attachment theory helps to strengthen the connection within the parent-child relationship. 

• Neurobiology offers awareness on how the brain changes and develops in response to trauma. 

TF-CBT is a widely-known trauma treatment appropriate for children, adolescents, and their caregivers. It is a brief therapy. Many clients begin experiencing immediate relief after just a few sessions. 

While trauma may be unavoidable, recovery is possible. It is crucial to seek professional support if you suspect your child might be struggling with trauma symptoms. Even if you are unsure, seeking a consultation can still be beneficial.  

To learn more about TF-CBT for you or a loved one, contact us today to schedule a consultation.