Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT)1 Michael A. de Arellano, Ph.D. National Crime Victims Research and Treatment Center Medical University of South Carolina Dee Norton Lowcountry Children’s Center Charleston, SC 1 Judy Cohen, Anthony Mannarino, & Esther Deblinger, 2006

A Learning Resource for TF-CBT Web-based learning Learn at own pace Concise explanations Video demonstrations Clinical scripts Cultural considerations Clinical Challenges Resources Links 10 hours of CE Free of charge Access at: www.musc.edu/tfcbt

Other resources www.musc.edu/ctg www.musc.edu/tf-cbt-consult www.musc.edu/cpt

Consequences of Abuse Acute distress almost universal Overall, abused kids report more problems than nonabused children PTSD, depression, aggression/sexual behavior problems Impact can be long lasting Childhood trauma is risk factor for adult problems Impact varies; most recover over time with/without tx DOES EVERYONE WHO IS ABUSED NEED TREATMENT? HOW ABOUT IF THERE IS AN ABSENCE OF ACUTE SYMPTOMS, DO THEY STILL NEED TREATMENT? RE: LAST BULLET: WHAT DO YOU THINK ABOUT THAT?

Affective Trauma Symptoms Fear Sadness Anger Anxiety Affective Dysregulation

Behavioral Trauma Symptoms Avoidance Modeling maladaptive behaviors Sexualized behaviors Violent behaviors Bullying Substance Abuse Self-Injury

Cognitive Trauma Symptoms Irrational Beliefs Distrust Causation of trauma Distorted Self-Image Loss/Betrayal of Social Contract Accurate, but unhelpful, cognitions

Typical Trauma-Related Problems Posttraumatic Stress Disorder Acute Stress Disorder Depression GAD Specific Phobias Other anxiety Other internalizing difficulties Secondary Enuresis or Encopresis Delinquency/aggression Other externalizing

Typical Trauma-Related Problems ADHD Substance Use/Abuse Dissociation Social skills deficits Academic delays Sexual difficulties Poor self-esteem Stigmatization Trust issues Cognitive distortions WHAT DOES A TYPICAL TRAUMA EXPOSED KID LOOK LIKE?

Selecting Treatment Components Relaxation training, cognitive coping skills Trauma Narrative Coping Skills, Relaxation training, exposure Cognitive therapy, Coping Skills Training, Behavioral activation Psychoeducation Behavior Management Anger Management, Coping skills, Behavior Management Anxiety/hyper-arousal Reexperiencing Avoidance/Dissociation Depression Sexual Concerns Sexual Acting Out Anger/Acting out

Evidence-Based Treatments Defined in child abuse services as: “…competent and high-fidelity implementation of practices that have been demonstrated safe and effective, usually in randomized controlled trials (RCTs)…” (Chaffin & Friedrich, 2004) Expert review of child abuse and neglect field services suggest that treatments are not based on any clear evidence (Kauffman Best Practices Project, 2004; Saunders et al., 2004)

Evidence-Based Practices Movement towards identifying EBPs for maltreated children and families U.S. Office for Victims of Crime (OVC, 2001) Reviewed 24 treatment protocols One treatment was “well-supported and efficacious” Kauffman Foundation of St. Louis Identified small number of under-disseminated EBPs for abused children and their families Empirical support, soundness of theory, general clincial acdeptance, size of literature, tx’s potential for benefits and harm

Identified as Best Practices for in Child Abuse Treatments Trauma Focused Cognitive Behavioral Therapy (TF-CBT) Judith Cohen and Tony Mannarino Abuse Focused Cognitive Behavioral Therapy (AF-CBT) David Kolko Parent Child Interaction Therapy (PCIT) Sheila Eyberg, M. Chaffin

What Are Evidence-Based Treatments for Traumatized Children? What They Are Not: Rigid Lockstep Inflexible…

What is TF-CBT? A hybrid treatment model that integrates: Trauma sensitive interventions Cognitive-behavioral principles Attachment theory Developmental Neurobiology Family Therapy Empowerment Therapy Humanistic Therapy

Treatment Research Trauma-Focused CBT is the most rigorously tested treatment for traumatized children 6 randomized trials Improved PTSD, depression, anxiety, shame and behavior problems compared to supportive treatments PTSD improved more with direct child treatment Improved parental distress, parental support, and parental depression compared to supportive treatment

Difficulties Addressed by TF-CBT CRAFTS Cognitive Problems Relationship Problems Affective Problems Family Problems Traumatic Behavior Problems Somatic Problems

Respectful of Cultural Values Adaptable and Flexible Family Focused 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

Cultural Sensitivity and Competence Essential to understand family’s values related to religion, ethnicity, and culture Previous treatment outcome studies (Cohen & Mannarino; Deblinger et al.) - successful treatment for diverse ethnic and racial populations Child Maltreatment article (Cohen et al., 2001)

Child and Parent Components Individual sessions for both child and parent Parent sessions - generally parallel child sessions Same therapist for both child and parent

Is TF-CBT the Right Treatment What is the diagnosis? Is the diagnosis and/or symptomatology related to the trauma? Can TF-CBT interventions be integrated with other treatment strategies which address non-trauma problems?

Contraindications for TF-CBT Dangerous behaviors (e.g, suicidality; severe aggression Unsafe environment (e.g, trauma is ongoing or there is high risk for reoccurence) Unstable placement

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

TF-CBT Sessions Flow Sessions 1-4 5-8 9-12 Entire Process is Gradual Exposure Baseline Assessment Sessions 1-4 5-8 9-12 Psychoeducation Trauma Narrative Conjoint Parent Parenting Skills Development and Child Sessions Processing Relaxation Enhancing In-vivo Gradual Safety and Affective Exposure Future Expression and Development Regulation Cognitive Coping

Psychoeducation Goals: Normalize child and parent reactions to severe stress Provide information about psychological and physiological reactions to stress Instill hope for child and family recovery Educate family about the benefits and need for early treatment

Parenting Skills Parents as central therapeutic agent for change Establish parent as the person the child turns to for help in times of trouble Address behavior problems that may be caused or worsened by trauma exposure. Prioritize concerning behaviors such as sexualized or aggressive behaviors. Flexibility to include different parenting strategies (PCIT).

Treatment of Parents Research Evidence that treating parent is important: Deblinger et al. (1996): Treating parents resulted in decreased behavioral and depressive symptoms in child Cohen and Mannarino (1996): Parents’ emotional reaction to trauma was the strongest predictor of treatment outcome (other than treatment type) Cohen and Mannarino (1997): At the 12 month follow-up, parental support was significantly related to decreased symptoms in child

Relaxation Reduce physiologic manifestations of stress and PTSD Explain body responses to stress Shallow breath, muscle tension, headaches Focused breathing/mindfulness/meditation Progressive Muscle Relaxation Physical Activity Identify what is relaxing for the child and parent.

Learn to apply coping skills to effectively manage affect Affective Modulation Feeling Identification Accurately identify and express a range of different feelings Board games (e.g., Emotional Bingo) Feeling brainstorm Color My Life or person Learn to apply coping skills to effectively manage affect

Cognitive Processing Help children and parents understand the cognitive triad: connections between thoughts, feelings and behaviors, as they relate to everyday events Help children distinguish between thoughts, feelings, and behaviors Help children and parents view events in more accurate and helpful ways Encourage parents to assist children in cognitive processing of upsetting situations, and to use this in their own everyday lives for affective modulation

Doing - Thinking - Feeling Interaction Trigger Feeling Doing Thinking

Direct Discussion of Traumatic Events Reasons we avoid this with children: Child discomfort or Parent discomfort Therapist discomfort Legal issues Reasons to directly discuss traumatic events: Gain mastery over trauma reminders Resolve avoidance symptoms Correction of distorted cognitions Model adaptive coping Identify and prepare for trauma/loss reminders Contextualize traumatic experiences into life

Cognitive Processing of the Traumatic Experience Develop optimal understanding of the trauma within the context of the child’s life Common negative distortions Self-blame Overestimating danger Changed world view

Conjoint Sessions: Sharing the Trauma Narrative with the Parent Parent may not know details of what happened Avoidance Legal issues Explore what parent knows about the traumatic event Share with parent what child has said in therapy

In-Vivo Mastery of Trauma Reminders Resolve generalized avoidant behaviors Gradually help the child get used to the feared situation Identify the feared situation Design the in vivo desensitization plan Praise and reinforce in vivo work Therapist MUST have confidence that this will work or it won’t

Enhancing Safety Skills Typically done in conjoint parent-child sessions, but may also be done individually Develop a safety plan which is responsive to the child’s and family’s circumstances and the child’s realistic abilities Practice these skills outside of therapy also For sexually abused children, include education about healthy sexuality For children exposed to DV, PA, CV, may include education about bullying, conflict resolution, etc.

Resources Cohen, Mannarino, & Deblinger (2006). Treating Trauma and Traumatic Grief in Children and Adolescents Sage Publications. Cohen, Mannarino & Deblinger (2012). Trauma-Focused CBT for Children and Adolescents: Treatment Applications. Guilford Press: New York, NY. Deblinger, E. & Heflin, A.H. (1996). Treating sexually abused children and their nonoffending parents. Sage Publications: Thousand Oaks, CA.

For More Information about Training Developers: Judy Cohen, MD, Alleghany General Hospital, Anthony Mannarino, PhD, Alleghany General Hospital, or Esther Deblinger, PhD, CARES Institute, UMDNJ-School of Osteopathic Mediciine. Email: jcohen1@wpahs.org amannari@wpahs.org deblines@umdnj.edu Website: www.pittsburghchildtrauma.org www.musc.edu/tfcbt

Michael A. de Arellano, Ph.D. dearelma@musc.edu