Trauma Focused Cognitive Behavioral Therapy

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Trauma FocusedCognitive Behavioral Therapy

• Margaret Comford, LCSW, LSCSW
• MIDWEST TRAUMA TREATMENT CENTER

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Trauma Impact

• Severe distress almost universal
• Unresolved childhood trauma may lead to adult
  mental health problems
• Trauma impact may be long lasting
• Trauma impact varies most children recover over
  time

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Therapeutic Themes for Traumatized Children

• Anger
• Depression
• Anxiety
• Hopelessness
• Difficulty with affect regulation
• Low self esteem

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Diagnoses

• PTSD
• Depression
• Adjustment disorders
• Anxiety disorders

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Complex PTSD

• Affective dysregulation
• Interpersonal problems
• Self esteem issues
• Self injurious behaviors

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Difficulties Addressed by TF-CBT

• CRAFTS
• Cognitive Problems
• Relationship Problems
• Affective Problems
• Family Problems
• Traumatic Behavior Problems
• Somatic Problems

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TF-CBT Research

• 10 randomized trials, all but one with sexually
  abused children
• Outcomes include improved PTSD, depression and
  behavior problems compared to nondirective
  treatment
• Improve parental distress, parental support, and
  parental depression compared with nondirective,
  supportive treatment

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Treatment of Parents

• Evidence to support treating parents
• Deblinger, 1996 showed decreased behaviors and
  depressive symptoms in child
• Cohen Mannarino, 1996 parents emotional
  reaction to trauma was the strongest predictor of
  positive treatment outcomes
• Cohen Mannarino, 1997 12 month follow-up
  showed decreased symptoms in children when
  parents had support

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Common Parental Concerns in Child Traumatization

• Over-protectiveness
• PTSD Symptoms
• Over-permissiveness
• Inappropriate child blame
• Inappropriate self blame guilt

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What is TF-CBT

• A hybrid treatment model that integrates trauma
  sensitive interventions with cognitive behavioral
  strategies.

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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

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What is manualized treatment?

• It is not the treatment but guidelines to
  implement it
• Allows joint establishment of treatment goals
• Uses developmentally appropriate therapeutic
  interventions
• Therapeutic relationship is key
• Therapist creativity judgment important

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Cognitive Behavioral Interventions

• Direct discussion of traumatic event
• Cognitive exploration and reframing
• Psychoeducation
• Feelings identification
• Self calming skills
• Joint parent/child sessions

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Outline of Treatment

• Individual sessions for both child and
  parent/caregiver
• Parent sessions usually follow the same focus
  as the childs
• Child and parent assigned to the same therapist

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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

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Psychoeducation

• GOALS
• Normalize childs and parents response to the
  traumatic event
• Identify and reinforce accurate cognitions about
  the traumatic event
• Educate regarding expected responses and diagnosis

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Feelings Identificationand Expression

• GOAL
• To assist children and their parents in
  accurately identifying their feelings
• Includes feelings related and not related to the
  traumatic experience
• Should be started in the first session with the
  child

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Stress Management Techniques

• GOAL
• To reduce the physiological manifestation of
  stress and PTSD

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Cognitive Coping

• GOAL
• To practice the skill of focusing on the positive
  instead of the negative aspects of any given
  situation
• Learn the relationship between thoughts, feelings
  and behaviors

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Creating the Trauma Narrative

• GOAL
• Gradual desensitizing the child to their
  thoughts, feelings and reminders of the trauma
• Learn to recognize, anticipate and prepare for
  traumatic reminders
• Contextualize traumatic event

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Discuss or not to discuss

• Reasons we choose not to discuss
• Child discomfort
• Parent discomfort
• Therapist discomfort
• Reasons we choose to discuss
• Desensitization
• Address avoidance symptoms
• Correct inaccurate or unhelpful cognitions
• Model adaptive coping
• Prepare for traumatic reminders

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Sharing Narrative with Parent

• Therapist should remember
• Parents may not know details of what happened
• Ask what was your reaction?
• Discuss issues of confidentiality and any
  developmental concerns

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Cognitive Processing

• GOAL
• Educate parents and children about the cognitive
  triangle connection between thoughts, feelings
  and behaviors.

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Cognitive Reframing

• GOAL
• To decrease negative behavioral and
  psychobiological effects through developing
  appropriate cognitions about the traumatic event

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Behavior Management

• GOAL
• Establish rapport and confidence in ability
• Create safety for the child

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Joint Parent-Child Sessions

• GOAL
• Share information about childs experience
• Correct parents cognitive distortions
• Correct childs cognitive distortions
• Encourage parent-child communication
• Prepare for future traumatic reminders
• Model appropriate responses
• Safety planning
• Healthy sexuality information

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Resources

• TFCBTWeb http//tfcbt.musc.edu
• Nctsnet.org
• BOOK

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CONTACT INFORMATION

• Margaret Comford, LSCSW, LCSW
• Midwest Trauma Treatment Center, LLC
• 400 East Red Bridge Road
• Suite 212
• KCMO 64131
• 816-589-4636
• margaret_at_treatingtrauma.com
• www.treatingtrauma.com