May/June 2012 Issue

Trauma-Focused Cognitive-Behavioral Therapy — Hope for Abused Children
By Lindsey Getz
Social Work Today
Vol. 12 No. 3 P. 22

With effective treatment, children can recover from sexual abuse and other traumas. In TF-CBT, one key to recovery is encouraging children to open up and talk freely about their trauma.

In the recent Penn State child sexual abuse scandal, former assistant coach Jerry Sandusky allegedly sexually assaulted or had inappropriate contact with underage boys on or near the university’s campus. The fact that officials allegedly continually concealed information about these incidents reflects the secretive manner in which child sexual abuse matters are often handled. It is common for people to react to such incidents by wanting to sweep them under the rug or pretend they never happened.

But trauma-focused cognitive-behavioral therapy (TF-CBT) is a model that encourages the very opposite. Central to this therapy is the importance of walking through the trauma via gradual exposure as a means for the child to come to terms with what happened—and move on.

“One of the most toxic but common results of a trauma like sexual abuse is for children to think it was their fault or they did something to perpetuate the situation,” says Kay Connors, MSW, LCSW-C, program director of the Center for Infant Study and Family-Informed Trauma Treatment Center in the department of psychiatry at the University of Maryland School of Medicine. “The child may believe there is something inherently wrong with them. That’s where being open and communicative through the application of gradual exposure [to the trauma] can be highly effective in helping children to overcome these feelings.”

Lucy Berliner, MSW, director of the Harborview Center for Sexual Assault and Traumatic Stress in Seattle, agrees: “The Penn State scenario is the perfect example. The kids made choices not to tell people or even to take certain gifts or privileges, so it’s understandable how in a posttrauma state they would decide it was their fault. It’s not a simple process to help children to start reevaluating their own beliefs and coming to an understanding that it wasn’t their fault. That’s where TF-CBT comes into play.”

Facing Trauma
TF-CBT is a unique form of cognitive-behavioral therapy that has been specially adapted for children who have experienced trauma. The Kauffman Best Practices Report has recognized TF-CBT as an evidence-based treatment for sexually abused children. Now, it is also considered a best practice for treating children who have experienced other trauma, including other types of child abuse or witnessing domestic violence.

After a trauma, children may experience symptoms of posttraumatic stress disorder (PTSD) or other emotional or behavioral symptoms, such as depression, anxiety, or disruptive behaviors. Some symptoms of child traumatic stress include repeated upsetting memories of the incident, flashbacks, avoiding people or places that are reminders of the event, being easily startled, having nightmares, and difficulty sleeping. But research indicates that within 12 to 16 sessions of TF-CBT, most children will show significant improvement (Cohen, Deblinger, Mannarino, & Steer, 2004; Deblinger, Mannarino, Cohen, Runyon, & Steer, 2011).

Many clinicians claim that TF-CBT has been the most effective treatment they’ve utilized in working with young trauma patients. “TF-CBT has the most research support of any treatment for children and families exposed to traumatic life events,” says Anthony Mannarino, PhD, a professor and vice chair of the department of psychiatry at Allegheny General Hospital in Pittsburgh who codeveloped TF-CBT with Esther Deblinger, PhD, and Judith Cohen, MD.

Evidence-Based Treatment
The evolution toward evidence-based therapies is not unique to the trauma field. “Regardless of who is paying for therapy services—the government or the insurance companies—there has been a stronger push in support of treatments that are proven to work. TF-CBT falls square in that category,” Berliner says.

“TF-CBT has the biggest evidence base for effectiveness in posttrauma situations,” Connors adds. “However, this can pose a challenge for social workers who are dealing with people who are currently in traumatic situations. Social workers are often dealing with families where the trauma is still happening, and there are safety concerns such as ongoing domestic violence. In order for TF-CBT to be most effective, children’s safety needs to be fully addressed and the trauma needs to be behind them. For instance, if you’re looking at the kids from Penn State who are currently safe and the abuse is presumably over, then TF-CBT can be highly effective for them.”

What Differentiates TF-CBT
One aspect that makes TF-CBT unique is its utilization of therapeutic components, says Monit Cheung, PhD, MSW, LCSW, MA, a professor of social work at the Graduate College of Social Work at the University of Houston in Texas. “TF-CBT is composed of some essential components, including education about childhood trauma and PTSD; emotion education and emotion regulation skills; relaxation and stress management; connecting thoughts, feelings, and behaviors which are related to the trauma; direct discussion or sharing of the traumatic event; safety skills training education about interpersonal relationships; and coping skills of future trauma,” Cheung explains. “In the case where children are involved, the parent treatment components also include education of parenting skills such as suggesting behavioral management strategies to handle distress.”

TF-CBT is also unique for incorporating a trauma narrative. As the child progresses through treatment, he or she is encouraged to describe more and more details of what happened before, during, and after the traumatic event as well as his or her feelings about what happened.

“One thing that is key about TF-CBT is that it is based on proven treatments for anxiety problems which all have exposure as their central element,” Berliner says. “It’s facing up to the thing you’re afraid of. In the case of TF-CBT, it’s memories. The child may avoid thinking about what happened to them or become very upset if reminded. But avoidance is the way to keep a problem going. If you compare it to a fear of flying—no one is going to get over that fear by avoiding planes. But that’s probably the hardest part of TF-CBT for clinicians. Many clinicians have a belief that asking kids to talk about a trauma is going to be traumatizing, so they avoid it. Many clinicians are not comfortable with trauma-based therapies.”

Support for Therapists
This lack of comfort is one of the biggest barriers to using TF-CBT, Mannarino says. “Therapists don’t like to talk to kids about these very difficult situations,” he notes. “They don’t want to stir up the bad stuff. But the truth is that these kids are carrying the memories with them every day, and TF-CBT will help them to come to terms with what happened and realize it’s not a part of who they are. When kids are traumatized, they often believe it’s part of who they are, but it’s our job to show them it’s just something bad that happened to them.”

However, to successfully implement this therapy to benefit the child, this barrier needs to be overcome. “Hearing a child’s story about a trauma can be difficult and painful,” Mannarino says. “Vicarious traumatization for therapists is always a concern. When training therapists in TF-CBT, we always emphasize that it’s good for them to have support systems and peer consultation as they work through these difficult cases so that they can be supported as well. With full-time clinicians, we would recommend that they make sure their caseload has some variety. You don’t want every case to be dealing with trauma or it simply becomes too much.”

Caregiver Involvement
TF-CBT also recognizes the importance of caregiver support in the child’s recovery process. Young clients and their (nonoffending) parents or caregivers participate separately in therapy and then attend joint sessions. This component works on stress management, parenting, and communication skills and allows the child to be better supported outside therapy sessions.

While this is another aspect that makes TF-CBT unique, it also can be a barrier to successful treatment. “Most child therapists go into the business because they want to work with children, and this is a model where about half of the therapy time is dedicated to work with the parents,” Mannarino says. “Parents are viewed as critical in the child’s life, so we’re doing a lot of psychoeducation with them. We involve them every step of the way. That may be something that’s uncomfortable for child therapists who aren’t used to working with adults.”

Berliner says in training future TF-CBT therapists, this is definitely a focus. “Most child therapists are used to working with the child alone, but in this model, the parent is actively involved,” she says. “The parent learns everything about the child. They learn to be present and to hear the child talking about the trauma and how it affected them. They’re also helped to learn specific parenting skills. While it’s been found very effective to have the parents’ support, it’s not always easy for therapists to initially accept this model. Training would help make them more comfortable.”

Mannarino also points out that research has indicated it doesn’t matter if the caregiver is the mother or father—or even another caregiver such as a foster parent. TF-CBT is most effective with some sort of caretaker involved. “There are certainly situations where the parent is not present or not involved, but the treatment can still be effective with any caregiver in the child’s life participating,” he says. “However, in some cases, no matter what the therapist’s efforts are, we can’t get a caregiver involved. Even in those circumstances, we have data that shows PTSD still improves. So the absence of a caregiver should not be a reason to avoid this treatment.”

Incorporating the Model
While TF-CBT can be effective in many cases, it isn’t always indicated. “First and foremost, there needs to be a verifiable trauma,” Mannarino says. “If a child has had a preverbal trauma as an infant, for example, and they don’t remember anything about it, then TF-CBT wouldn’t be appropriate.”

It’s also inappropriate for youth who are actively suicidal. “They need to get control over what’s going on with them before walking down the trauma road,” Mannarino says, adding that any trauma therapy would not be recommended for a suicidal child. “With that being said, there are kids who have suicidal thoughts but are not actively suicidal, and those kids could benefit from TF-CBT, as it could help them with some emotional regulation.”

Although the recommended age range for TF-CBT is 3 to 18 years old, some argue it may not be as effective with preschoolers. “While the research base says a lower limit of 3 years old, I think there has to be some highly specialized conditions for TF-CBT to really work with preschoolers because it’s a cognitive framework,” Connors says. “You have to tweak it to make it appropriate for them.”

For social workers interested in training, an online Web-based course called TF-CBT Web (http://tfcbt.musc.edu) goes through the nuts and bolts of the therapy with a lot of scripted information as well as some expert weigh-in via live streaming video. The course is free, and Mannarino says the registration rate has never dropped, indicating consistent interest in this therapy model. Participants can expect role playing for almost every component of the model.

In classroom learning, the training is also skill oriented. “They’re practicing screening measures to ask kids about trauma, practicing teaching skills, and practicing to work with parents,” Berliner explains.

Mannarino says if there was one key point he would want social workers to realize about TF-CBT, it’s the therapy’s effectiveness. “This is the kind of message we want to give the families that have kids with a traumatic event in their history,” he says. “Families may be incredibly worried that their child won’t recover from sexual abuse or some other trauma, but the research shows that the child will get better. And their chances of recovery are even better through this trauma treatment model.”

Regarding the Penn State situation, Mannarino says he’s been incredibly disappointed by the media coverage. While it was a terrible event, he says the negative focus on the victims’ recovery potential is sending the wrong message.
“The media has clearly suggested that these kids are hopelessly victimized and will never be able to recover, and that’s simply not true,” he says. “The message should be that victims can overcome trauma. It was a horrible occurrence, but these kids can get past it and be good citizens in our society and lead good, fulfilling lives. With the right kind of help, these kids can recover.”

— Lindsey Getz is a Royersford, PA-based freelance writer and a frequent contributor to Social Work Today.

References
Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A multisite, randomized controlled trial for children with sexual-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43(4), 393-402.

Deblinger, E., Mannarino, A. P., Cohen, J. A., Runyon, M. K., & Steer, R. A. (2011). Trauma-focused cognitive behavioral therapy for children: Impact of the trauma narrative and treatment length. Depression and Anxiety, 28(1), 67-75.