Trauma-Focused CBT
By Lynn Mollick
On Sunday, July 22 Esther Deblinger addressed NJ-ACT on Trauma-Focused CBT (TF-CBT) for Children, Adolescents and their Parents, an empirically-supported treatment. Dr. Deblinger developed TF-CBT in collaboration with Drs. Judith Cohen and Anthony Mannarino for children with a history of sexual abuse, but research has extended its use to other childhood traumas. TF-CBT involves individual child and parent sessions as well as conjoint sessions to both practice skills and process the trauma(s) experienced. Dr. Deblinger uses the acronym PRACTICE to describe TF-CBT’s 8 components:
P = Psychoeducation and parenting Skills. Give parents and children facts about common reactions to trauma. Discussing trauma openly but in general during the initial sessions constitutes gradual exposure. Discussing trauma in the abstract helps prepare children for later, more personal and focused trauma-related discussion and processing. Actively encourage children to ask questions.
Show concern for parents’ well-being and compliment their strengths. Offer empathy during early sessions when parents are most upset, and wait until a therapeutic bond has developed before challenging dysfunctional beliefs.
Explain the rationale for TF-CBT. If previous treatment has been unsuccessful, describe how TF-CBT will be different from previous treatment. This provides hope and helps prevent premature termination. Remind parents that their actions contribute to their child’s perception of themselves, others and the world. Encourage parents to show affection and give praise to help children remember that they are special.
Emphasize parents’ modeling healthy coping rather than over-emotionality. Keep a light tone, be positive, and encourage parents to do likewise. Parents’ response to the trauma shapes the child’s response.
R = Relaxation. Teach relaxation of the body and the mind -- progressive muscle relaxation, imagery techniques, meditation, and/or mindfulness.
A = Affect regulation. Acknowledge feelings about the trauma and explain that talking about these feelings will gradually diminish their intensity. Teach parents and children to identify multiple feelings in themselves and others.
C = Cognitive coping. Help children learn about the relationships between thoughts, feelings and behaviors. Identify functional and dysfunctional beliefs. Later after a trauma narrative is developed this will help children to identify and challenge dysfunctional developing beliefs. Use Socratic questioning, gather evidence, and correct mistaken conclusions.
T = Trauma narrative development and processing. This component may begin with reading children’s picture books about trauma with patients. Process details of the trauma by asking children to use therapy time to write their own narrative about their experience. The narrative can be a book, a play or even a song about their experience. Accepting feelings and processing emotion is the goal. Eventually children develop a narrative about the trauma that does not leave them feeling ashamed, damaged, frightened, or out of control.
Trauma processing is stressful, so at the beginning of treatment predict that children might become resistant during this phase. Talk about the child’s courage, and keep your tone playful and gentle. When children resist treatment, offer two therapy activities and let them choose between the two. Always begin with less distressing aspects of the trauma, and end every session with something they enjoy.
I = In vivo gradual exposure to thoughts, images, and feelings during sessions, and real life situations that trigger PTSD symptoms. This component is particularly important for school refusal, sleep refusal and other avoidant behaviors that interfere with daily functioning.
C = Conjoint parent-child sessions that involve practicing skills may occur anytime during treatment, but trauma-focused conjoint sessions occur in the latter phases of treatment. Once parents have processed their own trauma reactions and are emotionally prepared, the children share their art project and/or the trauma narrative they developed, if clinically appropriate. The parents’ treatment has prepared them to respond with love and acceptance instead of doubt, blame, or distress.
E = Enhance safety and future development. Ninety percent of all sexual abuse is committed by someone the child knows. Treatment gives parents correct information. Therapist modeling and role playing helps children develop body safety skills and encourages open parent-child communication about personal safety that can continue long after therapy has ends.
Evaluate the impact of treatment by asking children what they have learned and what they would say to another child who has had the same experience.
Throughout her presentation, Dr. Deblinger emphasized two points:
1) Therapy should not avoid discussing the trauma.
2) Therapy should be humorous and fun.
A free, 10-hour introductory training course in TF-CBT is available online at
www.musc.edu/tfcbt
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