TF-CBT: Past, Present, and Future
Anthony P. Mannarino, Ph.D.
Director, Center for Traumatic Stress in
Children and Adolescents
Allegheny General Hospital
Professor of Psychiatry
Drexel University College of Medicine
Pittsburgh, PA
© 2011 Anthony P. Mannarino
Research
TF-CBT has the greatest amount of
empirical support of any treatment for
children and families exposed to
traumatic life events.
TF-CBT Randomized Clinical Trials
• 10 RCTs
• 7 RCTs have been completed by the Cohen, Deblinger,
and Mannarino team
• One RCT in the Democratic Republic of Congo for sex
trafficked girls and child soldiers
• One RCT in Norway by Tine Jensen and her group
• King et al. RCT
TF-CBT Dismantling Study
Funded by NIMH
Investigators:
• Esther Deblinger, Ph.D.
• Melissa Runyon, Ph.D.
• Robert Steer, EdD.
UMDNJ-SOM
Stratford, New Jersey
• Anthony Mannarino, Ph.D.,
• Judith Cohen, M.D.
Allegheny General Hospital
Pittsburgh, Pa
Study Design
• Examining the impact of the trauma narrative
component and length of tx
• Children 4-11 years of age with a recent history of CSA
randomly assigned to
– 8 sessions with trauma narrative
– 8 sessions with NO narrative
– 16 sessions with trauma narrative
– 16 sessions with NO narrative
Post-Treatment Results
• Children and parents across all treatment conditions showed
significant post-treatment improvements
• No significant post-treatment differences across conditions
with respect to
– Child reported levels of body safety skills, depression,
shame, internalizing symptoms, and hypervigilence PTSD
symptoms
– Parent depression
Post-Treatment Results (cont’d)
TN conditions were most effective for:
- Sexual abuse-related fear
- Anxiety
- Parental distress
No TN conditions were most effective for:
- Externalizing behavior problems
- Parenting practices
Conclusions
• Study replicates benefits of TF-CBT for children (4-11 years
of age)
• Study documents the effectiveness of an abbreviated TF-CBT
format (8 sessions)
• TF-CBT leads to trauma recovery across all conditions (with
or without written narratives)
• Psychoeducation & skill building sessions involve more than
anticipated opportunities for gradual exposure and processing
Clinical Implications
• Study documents children overcome fear/ anxiety and parents
overcome abuse-related distress more efficiently when written
narrative and processing is incorporated (i.e. 8 sessions with
trauma narrative)
• In TN conditions, children often report TN is most helpful part
of therapy
• Narratives may assist in the uncovering and processing of
idiosyncratic dysfunctional beliefs
HOWEVER…….
• Do not spend too few or too many sessions on TN and
processing
• Parenting skills focus maybe more critical than TN focus for
children with externalized behavior problems
TF-CBT for Children Experiencing
Domestic Violence
• Funded by NIMH
• Investigators Cohen & Mannarino AGH
• Conducted at Women’s Center and Shelter of
Pittsburgh (WCS)
• CRAFT Project: Children Recover After Family
Trauma
Rationale for CRAFT Project
• More than 20% of children in the U.S. experience DV
• Diverse MH problems, including externalized
behaviors, educational problems, relationship
problems…also,
• Internalized problems: PTSD, anxiety, depression
• Few studies have focused on children’s internalized
problems following DV
Rationale for CRAFT Project
• In addition, many children continue to have contact
with perpetrators
• Mothers don’t leave, return to perpetrator, establish
relationship with new perpetrator
• Children want to or must visit perpetrator (e.g., if parent
or parent figure)
• Many families will not come to MH clinic for services
or attend long-term treatment (CPP)
• Need to evaluate community-based, brief treatment for
children with ongoing contact with perpetrator
Design
• Brief (8 session) TF-CBT vs. Child Centered Therapy
(TAU at WCS) provided by child therapists at WCS
• Children ages 7-14 years, of mothers experiencing DV
who sought any services at WCS between 2004-2009
• Recruitment, assessment, treatment provided at WCS
DV Study Results
• TF-CBT more significantly more effective than CCT
for:
- PTSD symptoms (total PTSD; PTSD avoidance;
PTSD hyperarousal)
- Anxiety
Clinical Findings
• Remission of PTSD diagnosis:
CCT: 18 to 10 (44% remission)
TF-CBT: 32 to 8 (75% remission)
• Serious Adverse Events during treatments (treatment
completers):
CCT: 10/32
TF-CBT: 2/43
Z=2.9, p<0.005
Discussion
• Focus on safety and improving ability to distinguish between
real danger vs. generalized cues as well as ongoing contact
with perpetrator most PTSD improvement in hyperarousal
rather than re-experiencing or avoidance
• Given the brief treatment and ongoing contact with
perpetrators, differences in two active treatments were
modest—e.g., scores at post-treatment were not significantly
different between the groups on several instruments
Conclusions
• Brief adapted version of TF-CBT is reasonably
effective for treating DV-related PTSD and anxiety
symptoms in community setting
• TF-CBT can be effectively adapted, accepted and
disseminated to a community DV setting.
Child and Adolescent Trauma Treatment Services
(CATS) Project
• CATS Project: TF-CBT used following 9-11
terrorist attacks in NYC demonstrated
significantly greater improvement in PTSD
among > 500 children receiving TF-CBT than
those receiving usual treatment.
TF-CBT for Foster Children
• TF-CBT tested in IL compared to Systems of Care
treatment as usual (SOC TAU)
• TF-CBT was significantly better than SOC TAU in
improving children’s :
• Behavioral and emotional problems (CANS)
• PTSD symptoms (UCLA PTSD RI)
• Less running away
• Less placement disruption
Dissemination
• TF-CBTWeb
- Over 100,000 learners have registered for course
•
- A little under 50% have completed the course
• CTGWeb
• TF-CBTConsult
• Current NIMH research project comparing web-based
learning with live clinical training and consultation
TF-CBT Train-the-Trainer Program
• 45 trainers who have been trained in three different
cohorts over the past five years
• Several approved national trainers at MUSC
• To a large extent, these trainers have been able to meet
the need for TF-CBT trainings on a regional, national,
and international basis.
TF-CBT Train-the-Supervisor Program
• Two cohorts of about 35 supervisors from around the
country
• Major goal of the TTS Program is local sustainability of
TF-CBT within a specific organization.
• Program consists of 15 months of conference calls;
distribution of supervisory materials
National Child Traumatic Stress Network
(NCTSN)
• Consortium of programs funded by the Substance
Abuse and Mental Health Services Administration
(SAMHSA) to increase the quality and access to care
for traumatized children and their families
• Our Center for Traumatic Stress in Children and
Adolescents has been a Treatment Development
Center in the NCTSN since its inception in 2001
NCTSN Learning Collaboratives
• NCTSN has sponsored three national TF-CBT Learning
Collaboratives and several regional TF-CBT Learning
Collaboratives
• Other states (Delaware; Washington; Connecticut;
South Carolina; North Carolina), based on the NCTSN
model, have sponsored their own state-wide TF-CBT
Learning Collaboratives
National Child Traumatic Stress
Network (NCTSN)
• www.nctsn.org
• TF-CBT Implementers Site for clinicians, supervisors,
and administrators who have participated in NCTSNsponsored national and regional Learning
Collaboratives
Translations
Our book has been translated into
Dutch, German, Korean, Japanese and
Chinese.
New TF-CBT Book
• To be published in 2012
• Applications of Trauma-Focused Cognitive-Behavioral
Therapy for Children and Adolescents
• Chapters on play interventions; children with
developmental disabilities; residential settings;
applications for Latino-Americans and American
Indians; schools; children in foster care; complex
trauma
National and International
Dissemination Projects
• 23 states have sponsored/are sponsoring TF-CBT
dissemination projects, including Nevada, Utah,
Washington, Connecticut, Delaware, Arkansas, New
York, Illinois, South Carolina, California, and North
Carolina.
• International dissemination projects in Norway,
Germany, the Netherlands, Japan, Sweden,
Cambodia and Zambia
TF-CBT Therapist
Certification Program
• WHAT WILL BE THE REQUUIREMENTS?
1.
2.
3.
4.
Therapist state licensure
Completion of TF-CBTWeb
Completion of live 2-day clinical training
At least 6 months of consultation calls (a total of 12
calls
5. Or, in place of 3 & 4, participation in an approved TFCBT state, regional, or national learning collaborative
led by an approved TF-CBT national trainer.
TF-CBT Therapist
Certification Program (cont’d)
6. Completion of TF-CBT with at least five families
7. Attestation of the use of objective instruments(s) to
measure treatment outcome
8. Passing a TF-CBT knowledge-based test
9. Certification will be for five years
Special Thanks
• Ben Saunders, Dan Smith and our wonderful colleagues
at the Medical University of South Carolina
• Therapists around the world from whom we have
learned so much and who have helped us make TF-CBT
a much better treatment model.
• Guilford Press
• National Child Traumatic Stress Network
• Esther and Judy
• All of the children and families who have
demonstrated extraordinary courage in the face of
trauma and who have inspired us to do better work
Bruised, Not Broken
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Stuck in the darkness and full of fear
You wake in the morning and the sun appears
I thought it was over, I thought he had won
But I learned the battle had just begun
In all the silence these words were spoken:
Bruised, not broken.
I can rebuild what’s been taken down,
Can plant my feet on solid ground.
Peace of mind is what I’ve found
Things have stopped, things have changed
But one thing still remains
From the noise these words were woken
Bruised, not broken
by Alyssa , 11 years old, after TF-CBT