What Is Trauma-Focused CBT?

Just as a child can experience depression and anxiety, childhood trauma can also occur. Sometimes, symptoms may even develop into full-fledged post-traumatic stress disorder (PTSD) in children, which is diagnosed when an individual suffers from marked distress and impairment following exposure to a traumatic event. Fortunately, though, there are many treatment options available to treat trauma-related distress, such as trauma-focused CBT. A modified version of cognitive-behavioral therapy, trauma-focused CBT can prevent the long-term effects of childhood trauma.

What Is Trauma-Focused CBT?

Trauma-focused CBT (TF-CBT) is a type of trauma therapy for children, in that it addresses emotional and behavioral problems presumed to arise in response to a traumatic event that occurred. This therapy modality focuses not just on the child but also on the family, in that the child's parents or caregivers are often heavily involved in the treatment of the child who experienced trauma. In this therapy approach, children are taught a variety of skills to help them cope with their trauma and are gradually exposed to trauma-related cues. Thus, trauma-focused CBT is a structured intervention that is family-oriented, trauma-focused, and skills-based [*].

How Is TF-CBT Different From Traditional CBT?

Before delving into how trauma-focused CBT works, it is worth noting, first and foremost, that it is distinct from traditional CBT for kids. Although all cognitive-behavioral approaches operate under one main assumption - which is that maladaptive thoughts are the primary contributor to emotional problems - in traditional CBT for teens and kids alike, the chief aim is to alter these maladaptive thoughts so that emotional distress will be alleviated.Problematic behaviors are targeted as well, which explains the inclusion of a behavioral component in CBT. Finally, traditional CBT addresses a wide array of psychological problems. For example, CBT for PTSD may be offered as treatment for youth with trauma. There is also CBT for anxiety, which is given to children who struggle with anxiety as the main problem. Thus, unlike trauma-focused CBT, it is not indicated solely for one overarching mental health issue.

Meanwhile, trauma-focused CBT strives to regulate several domains that were specifically affected by trauma. These domains include affect, behavior, biology, cognition or perception, and social or school functioning [*]. Moreover, as mentioned earlier, this therapy modality is structured and skills-based. In its protocol, there are several steps and procedures that the child and their accompanying caregiver must undergo before the entire therapeutic process can come to a close. Thus, although trauma-focused CBT is considered a cognitive-behavioral approach, it still shows several distinctions from traditional CBT.

When Is TF-CBT Used?

Among the cognitive-behavioral approaches available, trauma-focused CBT is one of the standard psychotherapies that are specifically indicated for trauma. Therefore, it is best suited for youth who have been exposed to trauma or who have PTSD. Note, though, that it is not required for clients of TF-CBT to be diagnosed with PTSD [*].

To add to that, children and adolescents may benefit the most from TF-CBT if the traumatic event they have experienced is one that they remember. For trauma-focused CBT to be effective, they should also exhibit symptoms that are clearly a response to their trauma [*].

How Effective Is TF-CBT?

So how effective is trauma-focused CBT? With youth who display problematic behaviors - such as running away from home, for example - TF-CBT proves to be more effective than therapy as usual [*]. With regard to PTSD and other comorbid conditions such as depression and anxiety, clients from clinical populations who are treated with TF-CBT have also been found to show considerable improvements. Such treatment gains are all the more bolstered when trauma-focused CBT includes the parent or caregiver in the child's treatment [*].

What Happens During a TF-CBT Session?

In TF-CBT, structure and a positive therapeutic relationship are key for it to work. At the very start of treatment, the therapist lays the groundwork for a relationship that makes the client feel safe. This is crucial because these individuals have been exposed to a kind of trauma that threatened their safety.

As for trauma-focused CBT being a structured intervention, there are three main phases: the initial stabilization phase, the trauma-processing phase, and the final integration phase.

Phase 1 of TF-CBT: Initial Stabilization

Apart from building rapport with the child, the goal of the therapist in the first phase of trauma-focused CBT is to teach the client coping skills [*]. There are six components in the initial stabilization phase. First, the therapist strives to enhance safety. This is accomplished through the therapeutic relationship and the development of a safety plan. This component is followed by psychoeducation, wherein both the youth and their caregiver are taught about the impact of trauma and trauma triggers. In the psychoeducation component, hope for healing is also instilled in the client.

The third component focuses on teaching the caregiver parenting skills that could contribute to establishing a relationship with the youth that is characterized by trust, respect, and understanding. The initial stabilization phase continues with the therapist helping the client learn relaxation skills. Finally, the first phase of TF-CBT ends with the youth being taught additional skills, such as emotion regulation and cognitive coping skills.

Phase 2 of TF-CBT: Trauma Processing

In the second phase of trauma-focused CBT, the goal is for the client to gain understanding of their experiences [*]. There are two components: trauma narrative and processing, followed by in vivo mastery of trauma reminders. First, the therapist collaborates with the client in developing a trauma narrative. The objective of the trauma narrative and processing component is to facilitate self-understanding in the youth, as well as understanding of their relationships and their past. Moreover, by developing a narrative, the client may reconceptualize the events that have transpired in their life in a more positive way.

The second component, in vivo mastery of trauma reminders, aims for the youth to develop mastery of regulating their emotions and behaviors in relation to their trauma. In vivo mastery also requires the client to revisit their trauma and its associated reminders.

Phase 3 of TF-CBT: Final Integration

The last phase is called the final integration phase, wherein the objective is for the client to be able to incorporate what they have learned in trauma-focused CBT in real life [*]. Specifically, the youth is encouraged to engage in a conversation about their trauma with their caregiver, just as they did with their therapist. Such conversations occur in what is called conjoint youth-parent sessions. Furthermore, to ensure that the child's transition from communicating with the therapist to communicating with the caregiver flows seamlessly, the therapist continues cultivating a supportive environment for the client.

How Long Does TF-CBT Take?

Usually, trauma-focused CBT lasts for about 8-16 sessions, divided equally among the treatment phases. However, given that there are three phases to trauma-focused CBT, each with corresponding components or substages, the duration of treatment may extend to 25 sessions, sometimes even up to 30 sessions [*].

Are There Any Risks of TF-CBT?

As with all psychological interventions, there are also risks in trauma-focused CBT. Specifically, because healthy caregiver involvement is one of the keys to the effectiveness of TF-CBT, the client might not fare well if their caregiver does not participate in accordance with the learnings and skills gained in therapy. For example, if the caregiver has a tendency to blame the child for their trauma, this can result in worse outcomes. Another example of counterproductive caregiver participation is avoiding the child's problems. This may lead to the youth developing more problematic acting-out behaviors, as well as more severe negative affect [*].

What to Look for in a Trauma-Focused Cognitive-Behavioral Therapist

To ensure that trauma-focused CBT is ultimately effective, the therapist providing the intervention should be competent and knowledgeable about TF-CBT. Thus, if you are looking for a trauma-focused cognitive-behavioral therapist, you might want to look for the following qualities [*]:

• Establishes a relationship characterized by trust: Trauma-focused CBT will not work if the therapist cannot establish trust in the relationship. In addition, trust is necessary so that the client feels safe and comfortable enough in expressing their thoughts, feelings, and experiences. The therapist therefore must be skilled in building rapport and establishing trust.
• Advocates for their client: From the very beginning of TF-CBT, the trauma-focused cognitive-behavioral therapist must be a champion for the youth seeking their services. This entails enhancing safety, establishing a positive therapeutic relationship, and developing resiliency in the client.
• Encourages a safe space: To develop a safe environment for the youth with trauma-related symptoms, the ideal therapist should be able to provide a space that encourages the client to be more expressive about their own perspectives and decisions. Moreover, the ideal therapist should make strong efforts to engage caregivers in the TF-CBT sessions and even include other community members who are considered safe by the child.

What Role Do Parents or Caregivers Play in TF-CBT?

As mentioned earlier, it is not just the child or adolescent exhibiting trauma-related symptoms who participates in trauma-focused CBT; parents or caregivers are also involved in the youth's healing and recovery. The extent to which caregiver involvement is crucial is evidenced by the practice of the therapist spending an equal amount of time with the parent or caregiver. Thus, in many of the TF-CBT sessions, 30 minutes are spent with the child, and 30 minutes are spent with the caregiver [*].

The goal of trauma-focused CBT in terms of involving the caregiver is to help them deepen their understanding of the youth's trauma-related problems. In addition, trauma-focused CBT aims to provide the caregiver with the same skills taught to the child so that the caregiver can effectively guide their child in employing these coping skills.

In sum, parents or caregivers play an integral role in TF-CBT by providing a well-informed understanding of trauma-related problems for improved communication with their child and by supplementing the child's application of learned coping skills.

The Bottom Line

Trauma-focused CBT is a variant of cognitive-behavioral therapy that is mainly devoted to addressing trauma-related problems in individuals. Literature to date has shown that it is an effective intervention, especially when the child's parent or caregiver is involved. Thus, if you are a parent whose child is experiencing symptoms of trauma, it might benefit you and your child to look for a competent therapist who specializes in trauma-focused CBT. For therapists, treatment sessions may be enhanced by the use of CBT worksheets, as well as trauma worksheets.

References:

1. Cohen JA, Berliner L, and Mannarino A. Trauma focused CBT for children with co-occurring trauma and behavior problems. April 2010.
2. Cohen JA and Mannarino AP. Trauma-focused cognitive behavior therapy for traumatized children and families. 2016.
3. Cohen JA, Mannarino AP, Kliethermes M, and others. Trauma-focused CBT for youth with complex trauma. 30 June 2012.
4. Yasinski C, Hayes AM, Ready B, and others. In-session caregiver behavior predicts symptom change in youth receiving trauma-focused cognitive behavioral therapy (TF-CBT). 2016.