(TF-CBT) Trauma-Focused Cognitive Behavioral Therapy

Typically, one-third of the total treatment is devoted to each phase of treatment.

Stabilization

The stabilization and skill-building phase begins with a focus on psychoeducation about the dynamics, prevalence, impact, and treatment of the experienced trauma, working toward developing skills to manage trauma reminders.

Trauma Narrative

The details of the child’s traumatic memories are gradually introduced, discussed and written about over the course of this middle phase of treatment. We use techniques such as storyboarding, cartoon strips, or poster boards, to allow for verbal and non-verbal expression.

Consolidation

The final phase of treatment then focuses on the integration and consolidation of what has been learned, with an emphasis on enhancing direct parent–child trauma-related communication, safety skills development, and the mastery of new behaviors and emotional responses.

Sessions are structured by the therapist to introduce interventions that are relevant to the particular stage of treatment. For example, during the Stabilization Phase of therapy, a child session may begin with a review of coping skills that the child was encouraged to practice between sessions; continue with a new skill component; then provide role play and practice of that skill; ending with a discussion with child and parent about what the child is encouraged to practice during the coming week. This is a planned progression towards the next stage of therapy.

PRACTICE

Since TF-CBT is a skills and strengths-based model, its components typically need to be practiced by the child and parent in order to be effective. We use the acronym PRACTICE to remind the child and family of the core TF-CBT components and the value of practicing them for the duration of treatment and beyond. A good deal of the therapy work associated with TF-CBT will occur between sessions, when parents and children are asked to practice certain skills at home. In the following list, the components of PRACTICE are arranged in relation to the phase of treatment:

P Psychoeducation and Parenting skills
R Relaxation
A Affective modulation
C Cognitive coping
T Trauma narration and processing
I In vivo mastery of trauma reminders
C Conjoint child–parent sessions
E Enhancing future safety and development

Although there is considerable gradual exposure in the earlier TF-CBT components, developing the trauma narrative is more intensive and extensive. One of the goals of creating the trauma narrative is to unlink thoughts, reminders, or discussions of the traumatic event from overwhelming negative emotions such as terror, horror, extreme helplessness, avoidance, anger, anxiety, shame, or rage. Over the course of several sessions, the child is encouraged to describe more and more details of what happened before, during, and after the traumatic event and the thoughts and feelings during these times. As the child is sharing his/her story in some type of format, the therapist is responding with validation, support, encouragement, and gentle questions. These components can allow the child to successfully integrate the trauma experience and its meaning into a larger optimal self-concept.

Parents are often traumatized themselves by the child’s traumatic experience. For example, if there was a trauma event, such as a house fire, the parent also experienced the trauma and may have their own stress symptoms. The TF-CBT components are typically provided separately to children and parents in individual sessions, with conjoint child–parent session time focused on practicing skills, and later on, toward the end of therapy, providing opportunities for open communication about the trauma experienced.

Including parents in therapy provides such parents with skill-building components that may help them cope better. From their own healing they are better equipped to model positive change and encourage their children in practicing effective coping skills. However, if a parent is having significant impairment with their own mental health issues, their own individual therapy may be advised.

The most immediate and influential environment for most children is that of their families. Parents can have an important impact on whether, to what degree, and how quickly children recover from trauma-related problems. They can also influence whether children’s improvements are temporary or whether these gains are sustained long after the end of treatment. We view parents as an important source of support and reinforcement for children’s progress both during treatment and subsequently.