TF-CBT: Past, Present, and Future Anthony P. Mannarino, Ph.D. Director, Center for Traumatic Stress in Children and Adolescents Allegheny General Hospital Professor of Psychiatry Drexel University College of Medicine Pittsburgh, PA © 2011 Anthony P. Mannarino

Research TF-CBT has the greatest amount of empirical support of any treatment for children and families exposed to traumatic life events.

TF-CBT Randomized Clinical Trials 10 RCTs 7 RCTs have been completed by the Cohen, Deblinger, and Mannarino team One RCT in the Democratic Republic of Congo for sex trafficked girls and child soldiers One RCT in Norway by Tine Jensen and her group King et al. RCT

TF-CBT Dismantling Study Funded by NIMH Investigators: Esther Deblinger, Ph.D. Melissa Runyon, Ph.D. Robert Steer, EdD. UMDNJ-SOM Stratford, New Jersey Anthony Mannarino, Ph.D., Judith Cohen, M.D. Allegheny General Hospital Pittsburgh, Pa

Study Design Examining the impact of the trauma narrative component and length of tx Children 4-11 years of age with a recent history of CSA randomly assigned to –8 sessions with trauma narrative –8 sessions with NO narrative –16 sessions with trauma narrative –16 sessions with NO narrative

Post-Treatment Results Children and parents across all treatment conditions showed significant post-treatment improvements No significant post-treatment differences across conditions with respect to –Child reported levels of body safety skills, depression, shame, internalizing symptoms, and hypervigilence PTSD symptoms –Parent depression

Post-Treatment Results (cont’d) TN conditions were most effective for: - Sexual abuse-related fear - Anxiety - Parental distress No TN conditions were most effective for: -Externalizing behavior problems -Parenting practices

Conclusions Study replicates benefits of TF-CBT for children (4-11 years of age) Study documents the effectiveness of an abbreviated TF-CBT format (8 sessions) TF-CBT leads to trauma recovery across all conditions (with or without written narratives) Psychoeducation & skill building sessions involve more than anticipated opportunities for gradual exposure and processing

Clinical Implications Study documents children overcome fear/ anxiety and parents overcome abuse-related distress more efficiently when written narrative and processing is incorporated (i.e. 8 sessions with trauma narrative) In TN conditions, children often report TN is most helpful part of therapy Narratives may assist in the uncovering and processing of idiosyncratic dysfunctional beliefs HOWEVER……. Do not spend too few or too many sessions on TN and processing Parenting skills focus maybe more critical than TN focus for children with externalized behavior problems

TF-CBT for Children Experiencing Domestic Violence Funded by NIMH Investigators Cohen & Mannarino AGH Conducted at Women’s Center and Shelter of Pittsburgh (WCS) CRAFT Project: Children Recover After Family Trauma

Rationale for CRAFT Project More than 20% of children in the U.S. experience DV Diverse MH problems, including externalized behaviors, educational problems, relationship problems…also, Internalized problems: PTSD, anxiety, depression Few studies have focused on children’s internalized problems following DV

Rationale for CRAFT Project In addition, many children continue to have contact with perpetrators Mothers don’t leave, return to perpetrator, establish relationship with new perpetrator Children want to or must visit perpetrator (e.g., if parent or parent figure) Many families will not come to MH clinic for services or attend long-term treatment (CPP) Need to evaluate community-based, brief treatment for children with ongoing contact with perpetrator

Design Brief (8 session) TF-CBT vs. Child Centered Therapy (TAU at WCS) provided by child therapists at WCS Children ages 7-14 years, of mothers experiencing DV who sought any services at WCS between Recruitment, assessment, treatment provided at WCS

DV Study Results TF-CBT more significantly more effective than CCT for: - PTSD symptoms (total PTSD; PTSD avoidance; PTSD hyperarousal) - Anxiety

Clinical Findings Remission of PTSD diagnosis: CCT: 18 to 10 (44% remission) TF-CBT: 32 to 8 (75% remission) Serious Adverse Events during treatments (treatment completers): CCT: 10/32 TF-CBT: 2/43 Z=2.9, p<0.005

Discussion Focus on safety and improving ability to distinguish between real danger vs. generalized cues as well as ongoing contact with perpetrator  most PTSD improvement in hyperarousal rather than re-experiencing or avoidance Given the brief treatment and ongoing contact with perpetrators, differences in two active treatments were modest—e.g., scores at post-treatment were not significantly different between the groups on several instruments

Conclusions Brief adapted version of TF-CBT is reasonably effective for treating DV-related PTSD and anxiety symptoms in community setting TF-CBT can be effectively adapted, accepted and disseminated to a community DV setting.

Child and Adolescent Trauma Treatment Services (CATS) Project CATS Project: TF-CBT used following 9-11 terrorist attacks in NYC demonstrated significantly greater improvement in PTSD among > 500 children receiving TF-CBT than those receiving usual treatment.

TF-CBT for Foster Children TF-CBT tested in IL compared to Systems of Care treatment as usual (SOC TAU) TF-CBT was significantly better than SOC TAU in improving children’s : Behavioral and emotional problems (CANS) PTSD symptoms (UCLA PTSD RI) Less running away Less placement disruption

Dissemination TF-CBTWeb - Over 100,000 learners have registered for course - A little under 50% have completed the course CTGWeb TF-CBTConsult Current NIMH research project comparing web-based learning with live clinical training and consultation

TF-CBT Train-the-Trainer Program 45 trainers who have been trained in three different cohorts over the past five years Several approved national trainers at MUSC To a large extent, these trainers have been able to meet the need for TF-CBT trainings on a regional, national, and international basis.

TF-CBT Train-the-Supervisor Program Two cohorts of about 35 supervisors from around the country Major goal of the TTS Program is local sustainability of TF-CBT within a specific organization. Program consists of 15 months of conference calls; distribution of supervisory materials

National Child Traumatic Stress Network (NCTSN) Consortium of programs funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) to increase the quality and access to care for traumatized children and their families Our Center for Traumatic Stress in Children and Adolescents has been a Treatment Development Center in the NCTSN since its inception in 2001

NCTSN Learning Collaboratives NCTSN has sponsored three national TF-CBT Learning Collaboratives and several regional TF-CBT Learning Collaboratives Other states (Delaware; Washington; Connecticut; South Carolina; North Carolina), based on the NCTSN model, have sponsored their own state-wide TF-CBT Learning Collaboratives

National Child Traumatic Stress Network (NCTSN) TF-CBT Implementers Site for clinicians, supervisors, and administrators who have participated in NCTSN- sponsored national and regional Learning Collaboratives

Translations Our book has been translated into Dutch, German, Korean, Japanese and Chinese.

New TF-CBT Book To be published in 2012 Applications of Trauma-Focused Cognitive-Behavioral Therapy for Children and Adolescents Chapters on play interventions; children with developmental disabilities; residential settings; applications for Latino-Americans and American Indians; schools; children in foster care; complex trauma

National and International Dissemination Projects 23 states have sponsored/are sponsoring TF-CBT dissemination projects, including Nevada, Utah, Washington, Connecticut, Delaware, Arkansas, New York, Illinois, South Carolina, California, and North Carolina. International dissemination projects in Norway, Germany, the Netherlands, Japan, Sweden, Cambodia and Zambia

TF-CBT Therapist Certification Program WHAT WILL BE THE REQUUIREMENTS? 1.Therapist state licensure 2.Completion of TF-CBTWeb 3.Completion of live 2-day clinical training 4.At least 6 months of consultation calls (a total of 12 calls 5.Or, in place of 3 & 4, participation in an approved TF- CBT state, regional, or national learning collaborative led by an approved TF-CBT national trainer.

TF-CBT Therapist Certification Program (cont’d) 6.Completion of TF-CBT with at least five families 7.Attestation of the use of objective instruments(s) to measure treatment outcome 8.Passing a TF-CBT knowledge-based test 9.Certification will be for five years

Special Thanks Ben Saunders, Dan Smith and our wonderful colleagues at the Medical University of South Carolina Therapists around the world from whom we have learned so much and who have helped us make TF-CBT a much better treatment model. Guilford Press National Child Traumatic Stress Network Esther and Judy All of the children and families who have demonstrated extraordinary courage in the face of trauma and who have inspired us to do better work

Bruised, Not Broken Stuck in the darkness and full of fear You wake in the morning and the sun appears I thought it was over, I thought he had won But I learned the battle had just begun In all the silence these words were spoken: Bruised, not broken. I can rebuild what’s been taken down, Can plant my feet on solid ground. Peace of mind is what I’ve found Things have stopped, things have changed But one thing still remains From the noise these words were woken Bruised, not broken by Alyssa, 11 years old, after TF-CBT