1. Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT)1
Michael A. de Arellano, Ph.D.
National Crime Victims Research and Treatment Center
Medical University of South Carolina
Dee Norton Lowcountry Children’s Center
Charleston, SC
1 Judy Cohen, Anthony Mannarino, & Esther Deblinger, 2006

2. A Learning Resource for TF-CBT
Web-based learning
Learn at own pace
Concise explanations
Video demonstrations
Clinical scripts
Cultural considerations
Clinical Challenges
Resources
Links
10 hours of CE
Free of charge
Access at:

4. Other resources www.musc.edu/ctg www.musc.edu/tf-cbt-consult

5. Consequences of Abuse Acute distress almost universal
Overall, abused kids report more problems than nonabused children
PTSD, depression, aggression/sexual behavior problems
Impact can be long lasting
Childhood trauma is risk factor for adult problems
Impact varies; most recover over time with/without tx
DOES EVERYONE WHO IS ABUSED NEED TREATMENT?
HOW ABOUT IF THERE IS AN ABSENCE OF ACUTE SYMPTOMS, DO THEY STILL NEED TREATMENT?
RE: LAST BULLET: WHAT DO YOU THINK ABOUT THAT?

6. Affective Trauma Symptoms
Fear
Sadness
Anger
Anxiety
Affective Dysregulation

7. Behavioral Trauma Symptoms
Avoidance
Modeling maladaptive behaviors
Sexualized behaviors
Violent behaviors
Bullying
Substance Abuse
Self-Injury

8. Cognitive Trauma Symptoms
Irrational Beliefs
Distrust
Causation of trauma
Distorted Self-Image
Loss/Betrayal of Social Contract
Accurate, but unhelpful, cognitions

9. Typical Trauma-Related Problems
Posttraumatic Stress Disorder
Acute Stress Disorder
Depression
GAD
Specific Phobias
Other anxiety
Other internalizing difficulties
Secondary Enuresis or Encopresis
Delinquency/aggression
Other externalizing

10. Typical Trauma-Related Problems
ADHD
Substance Use/Abuse
Dissociation
Social skills deficits
Academic delays
Sexual difficulties
Poor self-esteem
Stigmatization
Trust issues
Cognitive distortions
WHAT DOES A TYPICAL TRAUMA EXPOSED KID LOOK LIKE?

11. Selecting Treatment Components
Relaxation training, cognitive coping skills
Trauma Narrative
Coping Skills, Relaxation training, exposure
Cognitive therapy, Coping Skills Training, Behavioral activation
Psychoeducation
Behavior Management
Anger Management, Coping skills, Behavior Management
Anxiety/hyper-arousal
Reexperiencing
Avoidance/Dissociation
Depression
Sexual Concerns
Sexual Acting Out
Anger/Acting out

12. Evidence-Based Treatments
Defined in child abuse services as:
“…competent and high-fidelity implementation of practices that have been demonstrated safe and effective, usually in randomized controlled trials (RCTs)…” (Chaffin & Friedrich, 2004)
Expert review of child abuse and neglect field services suggest that treatments are not based on any clear evidence (Kauffman Best Practices Project, 2004; Saunders et al., 2004)

13. Evidence-Based Practices
Movement towards identifying EBPs for maltreated children and families
U.S. Office for Victims of Crime (OVC, 2001)
Reviewed 24 treatment protocols
One treatment was “well-supported and efficacious”
Kauffman Foundation of St. Louis
Identified small number of under-disseminated EBPs for abused children and their families
Empirical support, soundness of theory, general clincial acdeptance, size of literature, tx’s potential for benefits and harm

14. Identified as Best Practices for in Child Abuse Treatments
Trauma Focused Cognitive Behavioral Therapy (TF-CBT)
Judith Cohen and Tony Mannarino
Abuse Focused Cognitive Behavioral Therapy (AF-CBT)
David Kolko
Parent Child Interaction Therapy (PCIT)
Sheila Eyberg, M. Chaffin

15. What Are Evidence-Based Treatments for Traumatized Children?
What They Are Not:
Rigid
Lockstep
Inflexible…

17. What is TF-CBT? A hybrid treatment model that integrates:
Trauma sensitive interventions
Cognitive-behavioral principles
Attachment theory
Developmental Neurobiology
Family Therapy
Empowerment Therapy
Humanistic Therapy

18. Treatment Research
Trauma-Focused CBT is the most rigorously tested treatment for traumatized children
6 randomized trials
Improved PTSD, depression, anxiety, shame and behavior problems compared to supportive treatments
PTSD improved more with direct child treatment
Improved parental distress, parental support, and parental depression compared to supportive treatment

19. Difficulties Addressed by TF-CBT
CRAFTS
Cognitive Problems
Relationship Problems
Affective Problems
Family Problems
Traumatic Behavior Problems
Somatic Problems

20. Respectful of Cultural Values Adaptable and Flexible Family Focused
Core Values of TF-CBT
CRAFTS
Components-Based
Respectful of Cultural Values
Adaptable and Flexible
Family Focused
Therapeutic Relationship is Central
Self-Efficacy is emphasized

21. Cultural Sensitivity and Competence
Essential to understand family’s values related to religion, ethnicity, and culture
Previous treatment outcome studies (Cohen & Mannarino; Deblinger et al.) - successful treatment for diverse ethnic and racial populations
Child Maltreatment article (Cohen et al., 2001)

22. Child and Parent Components
Individual sessions for both child and parent
Parent sessions - generally parallel child sessions
Same therapist for both child and parent

23. Is TF-CBT the Right Treatment
What is the diagnosis?
Is the diagnosis and/or symptomatology related to the trauma?
Can TF-CBT interventions be integrated with other treatment strategies which address non-trauma problems?

24. Contraindications for TF-CBT
Dangerous behaviors (e.g, suicidality; severe aggression
Unsafe environment (e.g, trauma is ongoing or there is high risk for reoccurence)
Unstable placement

25. TF-CBT Components PRACTICE Psychoeducation and Parenting Skills
Relaxation
Affective Modulation
Cognitive Processing
Trauma Narrative
In Vivo Desensitization
Conjoint parent-child sessions
Enhancing safety and social skills

26. TF-CBT Sessions Flow Sessions 1-4 5-8 9-12
Entire Process is Gradual Exposure
Baseline
Assessment
Sessions
Psychoeducation Trauma Narrative Conjoint Parent
Parenting Skills Development and Child Sessions
Processing
Relaxation Enhancing
In-vivo Gradual Safety and
Affective Exposure Future
Expression and Development
Regulation
Cognitive Coping

27. Psychoeducation Goals:
Normalize child and parent reactions to severe stress
Provide information about psychological and physiological reactions to stress
Instill hope for child and family recovery
Educate family about the benefits and need for early treatment

28. Parenting Skills Parents as central therapeutic agent for change
Establish parent as the person the child turns to for help in times of trouble
Address behavior problems that may be caused or worsened by trauma exposure.
Prioritize concerning behaviors such as sexualized or aggressive behaviors.
Flexibility to include different parenting strategies (PCIT).

29. Treatment of Parents Research
Evidence that treating parent is important:
Deblinger et al. (1996): Treating parents resulted in decreased behavioral and depressive symptoms in child
Cohen and Mannarino (1996): Parents’ emotional reaction to trauma was the strongest predictor of treatment outcome (other than treatment type)
Cohen and Mannarino (1997): At the 12 month follow-up, parental support was significantly related to decreased symptoms in child

30. Relaxation Reduce physiologic manifestations of stress and PTSD
Explain body responses to stress
Shallow breath, muscle tension, headaches
Focused breathing/mindfulness/meditation
Progressive Muscle Relaxation
Physical Activity
Identify what is relaxing for the child and parent.

31. Learn to apply coping skills to effectively manage affect
Affective Modulation
Feeling Identification
Accurately identify and express a range of different feelings
Board games (e.g., Emotional Bingo)
Feeling brainstorm
Color My Life or person
Learn to apply coping skills to effectively manage affect

32. Cognitive Processing
Help children and parents understand the cognitive triad: connections between thoughts, feelings and behaviors, as they relate to everyday events
Help children distinguish between thoughts, feelings, and behaviors
Help children and parents view events in more accurate and helpful ways
Encourage parents to assist children in cognitive processing of upsetting situations, and to use this in their own everyday lives for affective modulation

33. Doing - Thinking - Feeling Interaction
Trigger
Feeling
Doing
Thinking

34. Direct Discussion of Traumatic Events
Reasons we avoid this with children:
Child discomfort or Parent discomfort
Therapist discomfort
Legal issues
Reasons to directly discuss traumatic events:
Gain mastery over trauma reminders
Resolve avoidance symptoms
Correction of distorted cognitions
Model adaptive coping
Identify and prepare for trauma/loss reminders
Contextualize traumatic experiences into life

35. Cognitive Processing of the Traumatic Experience
Develop optimal understanding of the trauma within the context of the child’s life
Common negative distortions
Self-blame
Overestimating danger
Changed world view

36. Conjoint Sessions: Sharing the Trauma Narrative with the Parent
Parent may not know details of what happened
Avoidance
Legal issues
Explore what parent knows about the traumatic event
Share with parent what child has said in therapy

37. In-Vivo Mastery of Trauma Reminders
Resolve generalized avoidant behaviors
Gradually help the child get used to the feared situation
Identify the feared situation
Design the in vivo desensitization plan
Praise and reinforce in vivo work
Therapist MUST have confidence that this will work or it won’t

38. Enhancing Safety Skills
Typically done in conjoint parent-child sessions, but may also be done individually
Develop a safety plan which is responsive to the child’s and family’s circumstances and the child’s realistic abilities
Practice these skills outside of therapy also
For sexually abused children, include education about healthy sexuality
For children exposed to DV, PA, CV, may include education about bullying, conflict resolution, etc.

40. Resources
Cohen, Mannarino, & Deblinger (2006). Treating Trauma and Traumatic Grief in Children and Adolescents Sage Publications.
Cohen, Mannarino & Deblinger (2012). Trauma-Focused CBT for Children and Adolescents: Treatment Applications. Guilford Press: New York, NY.
Deblinger, E. & Heflin, A.H. (1996). Treating sexually abused children and their nonoffending parents. Sage Publications: Thousand Oaks, CA.

41. For More Information about Training
Developers: Judy Cohen, MD, Alleghany General Hospital, Anthony Mannarino, PhD, Alleghany General Hospital, or Esther Deblinger, PhD, CARES Institute, UMDNJ-School of Osteopathic Mediciine.
Website:

42. Michael A. de Arellano, Ph.D. dearelma@musc.edu