Trauma focused cognitive behavioral therapy

Psychoeducation and parenting skills. Information about trauma responses and reminders are given, normalized, and validated. Caregivers are also given strategies to respond to these 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.[13] 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.[13] This information can be broken down in several "child-friendly" methods (e.g., the hand model of the brain[14]) and efficiently leads into the second module of TF-CBT: relaxation.

Relaxation. The child is given skills that inform relaxation in order to cope with their stress responses. The caregivers are then educated on the child’s techniques.[2]

Affective Expression and Regulation. This component assists the child in becoming more comfortable with the expression of feelings and thoughts, so that they may practice and develop skills in order to manage their stress response. The caregivers are educated on these skills.[2]

Cognitive Coping. This component helps both the child and caregiver recognize maladaptive thoughts, feelings, and behaviors and replace them with more accurate responses.[2]

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]

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]

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).[15]

Parents or primary caregivers are considered as the central therapeutic agents for improvement in TF-CBT.[5] 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.[16] 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.[17]

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 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.[18] 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.[18]

TF-CBT can be delivered by a variety of mental health professionals ranging from clinical social workers, counselors to psychologists and psychiatrists.[27] 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.[28] Additional criteria are required in order for a clinician to be rostered or nationally certified.[29] 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.[30]

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.[31] In some US states, implementation has been done in collaboration with the Substance Abuse and Mental Health Services Administration National Child Traumatic Stress Network.[30] 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.[32]

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.[33] 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.[34]

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.[35] Virtual TF-CBT therapy is more cost effective and has increased access to psychotherapy.[35]

Many children are exposed to multiple events, or chronic trauma.[36] 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."[36] 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.[8][36] More recent research has identified TF-CBT as an effective approach for treating children with complex postraumatic 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.[8]