Trauma focused cognitive behavioral therapy

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Trauma focused cognitive behavioral therapy
Specialty Psychology

Trauma focused cognitive behavioral therapy (TF-CBT) is an evidence-based therapeutic approach that aims at addressing the needs of individuals with post traumatic stress disorder (PTSD) and other difficulties related to traumatic life events. [1] This treatment was developed and proposed by Drs. Anthony Mannarino, Judith Cohen, and Esther Deblinger in the 1990's. [2] [3] The goal of TF-CBT is to provide psychoeducation to both the victim and non-offending caregivers, then help them identify, cope, and re-regulate maladaptive emotions, thoughts, and behaviors. [4] Research has shown TF-CBT to be effective in treating childhood PTSD and with children who have experienced or witnessed traumatic events, including but not limited to physical or sexual victimization, child maltreatment, domestic violence, community violence, accidents, natural disasters, and war. [5] [6] [7] [8] While originally studied as a treatment for children and adolescents, its use has more recently expanded to include adult patients. [9] Additionally, TF-CBT has been applied to and found effective in treating complex posttraumatic stress disorder (cPTSD). [10]

Contents

Description

TF-CBT is a treatment model that incorporates various trauma-sensitive intervention components. [11] It aims at individualizing TF-CBT techniques to the patient and their circumstances while maintaining a therapeutic relationship with both the patient and parent. [12] TF-CBT treatment can be used with children and adolescents who have experienced traumatic life events. It is a short-term treatment (typically 12-16 sessions) that combines trauma-sensitive interventions with cognitive behavioral therapy strategies. [13] It can also be used as part of a larger treatment plan for children with other difficulties. [14] TF-CBT includes individual sessions for both the child and the parents, as well as parent-child joint sessions.

Major treatment phases and components

Major components of TF-CBT include psycho-education about childhood trauma and individualizing relaxation skills. There are 3 treatment phases (stabilization, trauma narration and processing, and integration and consolidation). These phases include 8 different components throughout these sessions, denoted by the ‘PRACTICE’ acronym seen below. [2] The provider will facilitate 4-5 sessions each phase, while the PRACTICE components are delivered in sequential order. [2]

Phase 1: Stabilization

Psychoeducation and parenting skills. The child and caregiver are taught about trauma responses and coping mechanisms. Validating their emotions about their trauma responses is crucial. Caregivers are also provided with strategies to assist their child in responding to trauma responses. [2] Education on trauma reminders (e.g., the cues, people, places etc. associated with the trauma event) helps explain to children and caregivers how PTSD symptoms are maintained. [2] An additional goal of many psychoeducation sessions is to explain the role of the brain in PTSD symptomatology. Generally, the amygdala, or the "fear center" of the brain, is hyper-responsive, and the prefrontal cortex, which is involved in processing, decision making, and down-regulation, is less active, or even reduced in volume. [15] Usually, the prefrontal cortex will work to process the signals sent through the amygdala, assisting in regulated responding to stressful events. These connections have been found to be reduced in patients with PTSD, further explaining the heightened levels of fear responding to trauma reminders. [15] This information can be broken down in several "child-friendly" methods (e.g., the hand model of the brain [16] ) and efficiently leads into the second module of TF-CBT: relaxation.

Relaxation. The child and caregiver are educated on skills that inform relaxation in order to cope with their stress responses. [2] Some examples of techniques taught are progressive muscle relaxation, paced breathing, or guided visualization. [17]

Affective Expression and Regulation. This component assists the child in becoming more comfortable or knowledgeable regarding the expression of feelings and thoughts, so that they may practice and develop skills in order to manage their stress response. [17] The caregivers are educated on these skills and encouraged to practice using the emotion-language taught in session when trauma reminders are brought up at home. [2] [17]

Cognitive Coping. This component helps both the child and caregiver recognize maladaptive thoughts, feelings, and behaviors and replace them with more accurate responses. [2] This section can be more challenging for clients, particularly younger children. [18] The cognitive triangle (thoughts, feelings, and behaviors) is used to exemplify how our cognitive, emotional, and behavioral processes interact. [17] Children are guided through the identification of negative everyday thoughts (e.g., I sit alone at lunch because no one likes me), and these skills are then adapted to the negative thoughts surrounding the traumatic event (e.g., "this happened to me because I am a bad kid"). [17]

Phase 2: Trauma Narration and Processing

Trauma Narrative Development and Processing. This is an interactive process that allows the child to address specific details about their experience with trauma. A written summary is developed through a creative medium, which serves as a tool to process these reactions. This content is then shared with the caregiver, in order to give the opportunity for the caregiver to also process these cognitions. [2]

Phase 3: Integration and Consolidation

In Vivo Gradual Exposure. This is the only optional component within TF-CBT. The caregiver and child develop a fear hierarchy and develop strategies to face each fear. The caregiver is crucial in this session, as they must give consistent encouragement and persistence for the child to use their relaxation and TF-CBT skills. [2]

Conjoint Parent-Child Sessions. Direct communication is encouraged between child and caregiver to continue open communication about the trauma experience, and other important issues before treatment concludes. [2]

Enhancing Safety and Future Development. Practical strategies are developed that assist in enhancing the child’s sense of safety and trust. [2]

Treatment Sessions

Unless it is a conjoint parent-child session, each session is about 1 hour, and the therapist spends 30 minutes with the child and 30 minutes with the parent. [2] In the conjoint parent-child sessions, the therapist meets with the caregiver alone for 5–10 minutes, then the child alone for 5–10 minutes, then both caregiver and child together for 40–50 minutes. [2]

Child-specific sessions

During the child therapy sessions, the therapist focuses on relaxation training such as deep breathing and muscle relaxation skills, emotion regulation (identifying feelings), a trauma narrative and processing (discussing the overwhelming events and associated feelings), as well as cognitive coping strategies (identifying and replacing negative thoughts). [19]

Parent-specific sessions

Parents or primary caregivers are considered as the central therapeutic agents for improvement in TF-CBT. [6] During the parent sessions, the therapist discusses the appropriateness of the treatment and safety plans with the parents and encourages positive parenting skills to maximize effective parenting. [20] These sessions are important in helping the caregiver use and model specific coping skills for their own psychopathology for their child to show how they can manage their own symptoms. [21]

Parent-child conjoint sessions

During the conjoint sessions, the therapist shares the trauma narratives and challenges to incorrect/negative thoughts as a means to encourage and facilitate parent-child communication. The therapist would only intervene when inaccurate cognitions were not addressed. [1]

Group sessions

Group TF-CBT is an alternative to individual TF-CBT that reduces individual therapist hours and provides relief after disasters or in areas with limited resources. [22] Similar to individual TF-CBT, group TF-CBT involves both child and caregiver and utilizes the ‘PRACTICE’ elements, typically delivered through 12 structured sessions that target the reduction of distress and feelings of shame. [22]

Evaluation of effectiveness

TF-CBT is considered the gold standard for treating PTSD and related symptoms in children and adolescents exposed to trauma. [23] A meta analysis that examined 28 randomized control trials concluded that TF-CBT was an effective treatment and supported international guidelines that recommended its use as first-line treatment. [24] Randomized clinical trials examining the efficacy of TF-CBT have found it to be an effective treatment plan for a variety of disorders in both children and adolescents. [25] [26] TF-CBT has been proven to effectively reduce symptoms of PTSD, depression, anxiety, externalizing behaviors, sexualized behaviors, and feelings of shame in children who have experienced trauma. [27] TF-CBT has been shown to improve positive parenting skills and support of the child through the enhancement of parent-child communication. [14]

A study examining the combinatorial effect of TF-CBT with sertraline has found that there were only minimal benefits associated with adding sertraline to the treatment, providing evidence for an initial trial of TF-CBT before medication. [28] Evidence has also shown that TF-CBT is more successful than control groups despite whether it is delivered in a group format or individually. [29] CBT is currently being researched for its effectiveness on therapy compared to other types of therapeutic interventions. Most of these studies have been conducted in outpatient research clinics. [30]

While TF-CBT has been shown to be just as effective as Eye movement desensitization and reprocessing (EMDR) for the treatment of chronic post-traumatic stress disorder (PTSD) in adults, the results were tentative given low numbers in the studies, high drop out rates, and high risk of experimenter bias. [31]

Methods of access

Therapist

TF-CBT can be delivered by a variety of mental health professionals ranging from clinical social workers, counselors to psychologists and psychiatrists. [32] Qualified therapists are required to be rostered or nationally certified in TF-CBT. Part of the training for this treatment includes an online TF-CBT certified training course. [33] Additional criteria are required in order for a clinician to be rostered or nationally certified. [34] It is recommended that the practitioner not only complete the online training course, but also attend a multi-day in-person training, and receive continuing supervision for 6–9 months from TF-CBT supervisor or consultant, while also practicing with families who have experienced trauma. [35]

Implementation and adaptations

Since its development in the 1980s, TF-CBT has been used by therapists in many countries such as Australia, Cambodia, Canada, China, Denmark, Germany, Japan, the Netherlands, Norway, Pakistan, Sweden, United States, and Zambia. [36] In some US states, implementation has been done in collaboration with the Substance Abuse and Mental Health Services Administration National Child Traumatic Stress Network. [35] It has also been used with children in the foster care system, with those who have suffered from traumatic life events, including the 9-11 terrorist attacks, and those who experienced Hurricane Katrina. [37]

TF-CBT has also been adapted to different cultures, including Latino populations. The treatment manual book has been translated into a variety of languages, such as Dutch, German, Japanese, Korean, and Mandarin. [38] Because TF-CBT can be implemented by local lay counselors, it makes it a feasible mental health resource option in low and middle income countries, or in areas with low-resources. [39]

In the wake of the COVID-19 pandemic there was a shift from in-person to remote delivery of psychotherapy. Because of the increase in demand for trauma-focused treatment in trauma-affected areas, practitioners have been able to facilitate TF-CBT virtually. [40] Virtual TF-CBT therapy is more cost effective and has increased access to psychotherapy. [40]

Many children are exposed to multiple events, or chronic trauma. [41] These persistent experiences of traumatization impact a child's ability to form primary attachments, which may lead to an array of difficulties and is often referred to as "complex trauma." [41] Complex trauma has sometimes been viewed as more difficult to treat, as its characterized by heightened levels of affective dysregulation, difficulties with attachment security, dissociation, and a fragmented sense of self. [10] [41] More recent research has identified TF-CBT as an effective approach for treating children with complex posttraumatic stress, one article finding that those with complex PTSD showed a greater reduction in their symptoms following treatment than those who had non-complex PTSD. [10] In the United States, the concept of complex trauma is recognized, but it is not considered a distinct diagnosis based on the text revised version of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5-TR). [42] Countries other than the United States who use the International Classification of Diseases (ICD) have recently recognized complex PTSD (CPTSD) as its own disorder in the ICD-11 revised edition. [43] The benefits of its inclusion in the ICD-11 are that it may lend to more individualized treatments that better address the nature of the trauma, as well as contribute to the research pool surrounding stress-related disorders. [43] Some listed challenges, especially in light of its consideration to be added to the DSM-5, were that complex trauma may function better as a purely dimensional disorder, which is not reflective of the current diagnostic system, and that there is not enough identified psychometric properties to warrant its inclusion. [44]

Related Research Articles

<span class="mw-page-title-main">Cognitive behavioral therapy</span> Type of therapy to improve mental health

Cognitive behavioral therapy (CBT) is a form of psychotherapy that aims to reduce symptoms of various mental health conditions, primarily depression, PTSD and anxiety disorders. Cognitive behavioral therapy focuses on challenging and changing cognitive distortions and their associated behaviors to improve emotional regulation and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include many issues and the treatment of many mental health and other conditions, including anxiety, substance use disorders, marital problems, ADHD, and eating disorders. CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event and can include triggers such as misophonia. Young children are less likely to show distress, but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

<span class="mw-page-title-main">Dialectical behavior therapy</span> Psychotherapy for emotional dysregulation

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders and interpersonal conflicts. Evidence suggests that DBT can be useful in treating mood disorders and suicidal ideation as well as for changing behavioral patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies and ultimately balance and synthesize them—comparable to the philosophical dialectical process of thesis and antithesis, followed by synthesis.

<span class="mw-page-title-main">Physical abuse</span> Medical condition

Physical abuse is any intentional act causing injury or trauma to another person or animal by way of bodily contact. In most cases, children are the victims of physical abuse, but adults can also be victims, as in cases of domestic violence or workplace aggression. Alternative terms sometimes used include physical assault or physical violence, and may also include sexual abuse. Physical abuse may involve more than one abuser, and more than one victim.

Psychological trauma is an emotional response caused by severe distressing events that are outside the normal range of human experiences. It must be understood by the affected person as directly threatening the affected person or their loved ones generally with death, severe bodily injury, or sexual violence; indirect exposure, such as from watching television news, may be extremely distressing and can produce an involuntary and possibly overwhelming physiological stress response, but does not produce trauma per se. Examples of distressing events include violence, rape, or a terrorist attack.

Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy that is a recommended treatment for post-traumatic stress disorder (PTSD), but remains controversial within the psychological community. It was devised by Francine Shapiro in 1987 and originally designed to alleviate the distress associated with traumatic memories such as PTSD.

<span class="mw-page-title-main">Complex post-traumatic stress disorder</span> Psychological disorder

Complex post-traumatic stress disorder is a stress-related mental and behavioral disorder generally occurring in response to complex traumas.

Interpersonal psychotherapy (IPT) is a brief, attachment-focused psychotherapy that centers on resolving interpersonal problems and achieving symptomatic recovery. IPT is an empirically supported treatment (EST) that follows a highly structured and time-limited approach. Interpersonal therapy is intended to be completed within 12–16 weeks. IPT is based on the principle that relationships and life events impact mood and vice versa. The treatment was developed by Gerald Klerman and Myrna Weissman in order to treat major depression in the 1970s and has since been adapted for other mental disorders. IPT is an empirically validated intervention for depressive disorders and is more effective when used in combination with psychiatric medications.

Childhood trauma is often described as serious adverse childhood experiences. Children may go through a range of experiences that classify as psychological trauma; these might include neglect, abandonment, sexual abuse, emotional abuse, and physical abuse. They may also witness abuse of a sibling or parent, or have a mentally ill parent. These events can have profound psychological, physiological, and sociological impacts leading to lasting negative effects on health and well-being. These events may include antisocial behaviors, attention deficit hyperactivity disorder (ADHD), and sleep disturbances. Additionally, children whose mothers have experienced traumatic or stressful events during pregnancy have an increased risk of mental health disorders and other neurodevelopmental disorders.

Prolonged exposure therapy (PE) is a form of behavior therapy and cognitive behavioral therapy designed to treat post-traumatic stress disorder. It is characterized by two main treatment procedures – imaginal and in vivo exposures. Imaginal exposure is repeated 'on-purpose' retelling of the trauma memory. In vivo exposure is gradually confronting situations, places, and things that are reminders of the trauma or feel dangerous. Additional procedures include processing of the trauma memory and breathing retraining.

Trauma Systems Therapy (TST) is a mental health treatment model for children and adolescents who have been exposed to trauma, defined as experiencing, witnessing, or confronting "an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others". TST focuses on the child's emotional and behavioral needs as well as the environments where the child lives (home, school, community). The treatment model includes four components (skill-based psychotherapy, home and community-based care, advocacy, and psychopharmacology) that are fully described in a published manual. A clinical trial showed that TST is effective in improving the mental health and well-being of children who have been traumatized. TST has also been successfully replicated.

Cognitive behavioral therapy for insomnia (CBT-I) is a therapy technique for treating insomnia without medications. CBT-I aims to improve sleep habits and behaviors by identifying and changing thoughts and behaviors that prevent a person from sleeping well.

Cognitive processing therapy (CPT) is a manualized therapy used by clinicians to help people recover from posttraumatic stress disorder (PTSD) and related conditions. It includes elements of cognitive behavioral therapy (CBT) treatments, one of the most widely used evidence-based therapies. A typical 12-session run of CPT has proven effective in treating PTSD across a variety of populations, including combat veterans, sexual assault victims, and refugees. CPT can be provided in individual and group treatment formats and is considered one of the most effective treatments for PTSD.

PTSD or post-traumatic stress disorder, is a psychiatric disorder characterised by intrusive thoughts and memories, dreams or flashbacks of the event; avoidance of people, places and activities that remind the individual of the event; ongoing negative beliefs about oneself or the world, mood changes and persistent feelings of anger, guilt or fear; alterations in arousal such as increased irritability, angry outbursts, being hypervigilant, or having difficulty with concentration and sleep.

Transgenerational trauma is the psychological and physiological effects that the trauma experienced by people has on subsequent generations in that group. The primary mode of transmission is the shared family environment of the infant causing psychological, behavioral and social changes in the individual.

Internet interventions for post-traumatic stress have grown in popularity due to the limits that many patients face in their ability to seek therapy to treat their symptoms. These limits include lack of resources and residing in small towns or in the countryside. These patients may find it difficult to seek treatment because they do not have geographical access to treatment, and this can also limit the time they have to seek help. Additionally, those who live in rural areas may experience more stigma related to mental health issues. Internet interventions can increase the possibility that those who suffer from PTSD can seek help by eliminating these barriers to treatment.

<span class="mw-page-title-main">Internet-based treatments for trauma survivors</span>

Internet-based treatments for trauma survivors is a growing class of online treatments that allow for an individual who has experienced trauma to seek and receive treatment without needing to attend psychotherapy in person. The progressive movement to online resources and the need for more accessible mental health services has given rise to the creation of online-based interventions aimed to help those who have experienced traumatic events. Cognitive behavioral therapy (CBT) has shown to be particularly effective in the treatment of trauma-related disorders and adapting CBT to an online format has been shown to be as effective as in-person CBT in the treatment of trauma. Due to its positive outcomes, CBT-based internet treatment options for trauma survivors has been an expanding field in both research and clinical settings.

Sexual trauma therapy is medical and psychological interventions provided to survivors of sexual violence aiming to treat their physical injuries and cope with mental trauma caused by the event. Examples of sexual violence include any acts of unwanted sexual actions like sexual harassment, groping, rape, and circulation of sexual content without consent.

Being exposed to traumatic events such as war, violence, disasters, loss, injury or illness can cause trauma. Additionally, the most common diagnostic instruments such as the ICD-11 and the DSM-5 expand on this definition of trauma to include perceived threat to death, injury, or sexual violence to self or a loved one. Even after the situation has passed, the experience can bring up a sense of vulnerability, hopelessness, anger and fear.

Imagery Rescripting is an experiential therapeutic technique that uses imagery and imagination to intervene in traumatic memories. The process is guided by a therapist who works with the client to define ways to work with particular traumatic memories, images, or nightmares.

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