INTRODUCTION TO
TRAUMA-FOCUSED COGNITIVE
BEHAVIORAL THERAPY
Elizabeth Feldman, PhD
University of Washington
School of Medicine
The origins of TFCBT
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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
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What is Post Traumatic Stress Disorder?
Traumatic Event
Avoidance
Re-experiencing
Hyperarousal
Interference with daily
functioning
Example case:
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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
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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
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Inappropriate self-blame and guilt
Inappropriate child blame
Overprotectiveness
Overpermissiveness
Post Traumatic Stress Disorder/symptoms
Anger, aggression
Hopelessness, worry, depression
Example case:
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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:
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Clients with extreme therapy-resistant behavior
Clients with active suicidal behavior
Clients with severe cognitive disabilities
TFCBT – A Practice!
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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
Caregiver’s Treatment
Coping Skills Training:
Emotional Expression
Cognitive Coping
Relaxation
Gradual Exposure & Processing
Gradual Exposure & Processing
Education:
Child Sexual Abuse
Healthy Sexuality
Personal Safety
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)
TF-CBT Sessions Flow
Entire process is gradual exposure
Baseline
assessment
1/3
1/3
Sessions 1 - 4
Sessions 5 - 8
 Psychoeducation
/Parenting Skills
 Trauma Narrative
Development and
Processing
 Relaxation
 Affective
Expression and
Regulation
 Cognitive Coping
 In vivo Gradual
Exposure
1/3
Sessions 9 - 12
 Conjoint Parent
Child Sessions
 Enhancing
Safety and
Future
Development
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)
2)
3)
What is trauma?
What is PTSD?
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)
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Praise
Rewards
Active Ignoring
Time Out
Specific for kids with PTSD:
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Confidence in limit-setting
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Not reinforcing avoidance
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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…
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What do you do to relax?
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Relaxation vs. Distress Tolerance
Affective Regulation
Goal: Normalize multiple conflicting feelings, teach
varying levels of feelings, teach vocabulary for
talking about traumatic events competently.
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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)
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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.
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Revisit the cognitive triangle, add consequences
Use Socratic questioning
Never “tell” the clients to change their beliefs
Common Trauma-Related
Thoughts/Feelings
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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
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Essential to prepare adequately
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(individual with CG and with client before joint session)
Invite prepared questions, comments, feedback
Celebrate success!
Summary
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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!