INTRODUCTION TO TRAUMA-FOCUSED COGNITIVE BEHAVIORAL THERAPY Elizabeth Feldman, PhD University of Washington School of Medicine

The origins of TFCBT  Developed for treating sexually abused children  Viewed working with parents as an integral part of treatment Esther Deblinger, Ph.D. Center for Children’s Support University of Medicine and Dentistry of New Jersey & Judith Cohen, M.D., and Anthony Mannarino, Ph.D. Center for Traumatic Stress in Children and Adolescents Alleghany General Hospital

Understanding PTSD  What is Post Traumatic Stress Disorder? 1) Traumatic Event 2) Avoidance 3) Re-experiencing 4) Hyperarousal 5) Interference with daily functioning

Example case:  Age  Gender  Race/Ethnicity  Home life environment  School history  Outline of traumatic events  Current environmental supports  Other existing health-related diagnoses

Complex PTSD Ongoing, chronic exposure to traumatic events. No one, isolated trauma. Symptoms can be wide-ranging, but should still meet criteria for PTSD.

Common themes of PTSD  Loss of trust in self & others  Self-blame  Shame & Guilt  Anger  Relationship difficulties  Behavior problems  School failure  Difficulty managing affect  Hopelessness  Depression

Common Caregiver Themes  Inappropriate self-blame and guilt  Inappropriate child blame  Overprotectiveness  Overpermissiveness  Post Traumatic Stress Disorder/symptoms  Anger, aggression  Hopelessness, worry, depression

Example case:  Age  Gender  Race/Ethnicity  Home life environment  School history  Outline of traumatic events  Current environmental supports  Other existing health-related diagnoses

Choosing TFCBT RCTs demonstrating efficacy/effectiveness of TFCBT for:  Ages 3-18  Boys / Girls  Multiple racial/ethnic backgrounds  Varying socio-economic status  Single or multiple trauma history  Placement with biological parents or child welfare  Children with behavior problems

TFCBT is not for:  Clients with extreme therapy-resistant behavior  Clients with active suicidal behavior  Clients with severe cognitive disabilities

TFCBT – A Practice!  Assessment!  P sychoeducation and Parenting Strategies  R elaxation  A ffective expression and regulation  C ognitive coping  T rauma narrative and processing  I n vivo exposure  C onjoint parent child sessions  E nhancing personal safety and future growth

Trauma-focused Cognitive Behavioral Therapy Child’s Treatment Coping Skills Training: Emotional Expression Cognitive Coping Relaxation Gradual Exposure & Processing Education: Child Sexual Abuse Healthy Sexuality Personal Safety Caregiver’s Treatment Coping Skills Training: Emotional Expression Cognitive Coping Relaxation Gradual Exposure & Processing Education (like child sessions) Behavior Management Joint Sessions Coping Skills Exercises Gradual Exposure & Processing Education Regarding Sexuality and Sexual Abuse Personal Safety Skills Family Sessions From Deblinger & Heflin (1996)

Assessment Goal: Identify trauma history and presence of trauma-related symptoms. 1) Trauma History 2) Internalizing 3) Externalizing 4) Avoidance 5) Re-experiencing 6) Hyperarousal 7) Interference with daily functioning

Psychoeducation Goal: Normalize symptoms, validate experience and reactions, instill hope for recovery. 1) What is trauma? 2) What is PTSD? 3) What is TFCBT?

Parenting Goal: Support caregivers to reduce their own stress/anxiety, improve the child-adult relationship, help the caregiver support the child’s recovery. 1) Praise 2) Rewards 3) Active Ignoring 4) Time Out Specific for kids with PTSD:  Confidence in limit-setting  Not reinforcing avoidance  Coping coaching

Relaxation Goal: Create “tool box” that the client can use in his/her own environment to manage symptoms. Relaxation is not just progressive muscle relaxation and deep breathing…  What do you do to relax?  Relaxation vs. Distress Tolerance

Affective Regulation Goal: Normalize multiple conflicting feelings, teach varying levels of feelings, teach vocabulary for talking about traumatic events competently.  Feelings Education (what are emotions?)  Connecting feelings to traumatic or difficult events  Feelings thermometers  Learning self-soothing techniques

Cognitive Coping Goal:  Essential to help clients/families evaluate the ways in which trauma changed their thinking and correct distorted thoughts.  Make sure clients don’t define themselves by their traumatic experiences. Cognitive Processing occurs before and after the Trauma Narrative. First teach the skill, then use it.

Cognitive Coping The heart of TFCBT: GOALS:  Clarify the difference between thoughts, feelings, and behaviors.  Demonstrate how thoughts, feelings, and behaviors affect each other. thoughts behavior feelings

Trauma Narrative Goal: “To gradually expose client to thoughts, memories, and other innocuous reminders of the abusive experience until they can tolerate those memories without significant emotional distress and no longer need to avoid them.” (Deblinger & Heflin, 1996, p. 71)  Comes from Anxiety Framework  Un-pairing of harmless stimuli with learned anxiety response.

Trauma Narrative Should include: 1) Before the trauma 2) Components of the trauma (chapters) with specific details, thoughts, feelings, and associated memories 3) The “worst” part 4) “What I learned” or “What I would tell other kids” 5) The future

Cognitive Processing of the TN: Goal: Identify latent or overt cognitive distortions or unhelpful beliefs and challenge them with the client.  Revisit the cognitive triangle, add consequences  Use Socratic questioning  Never “tell” the clients to change their beliefs

Common Trauma-Related Thoughts/Feelings  Guilt  Shame / Disgust  Self-Blame  Hopelessness  Fearfulness  Worthlessness  Lack of control  Depression

In-Vivo Exposure Goal: Unpair feared stimuli (triggers) from the learned response of anxiety/fear. Examples:  The dark  Streets  Men Use general and specific fear ladders, set up homework and practice activities with reward systems.

Enhancing Safety Goal: Prepare for the future  Learn to recognize signs/symptoms that indicate the need for a return to treatment  Create usable, meaningful safety plans  Plan for using coping skills  Consider environmental supports

Conjoint Sessions Goal: 1) Increased exposure / opportunity for mastery 2) Increase child & caregiver communication 3) Support asking and answering questions  Essential to prepare adequately  (individual with CG and with client before joint session)  Invite prepared questions, comments, feedback  Celebrate success!

Summary  Assessment!  P sychoeducation and Parenting Strategies  R elaxation  A ffective expression and regulation  C ognitive coping  T rauma narrative and processing  I n vivo exposure  C onjoint parent child sessions  E nhancing personal safety and future growth TFCBT – it works!

Thank You!