Clinician's Corner: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

Anthony P. Mannarino, PhD, & Judith A. Cohen, MD

Although TF-CBT is highly effective at improving youth posttraumatic stress disorder (PTSD) symptoms and diagnosis, a PTSD diagnosis is not required in order to receive this treatment. TF-CBT also effectively addresses many other trauma impacts, including depressive, anxiety, cognitive and behavioral problems. Additionally, TF-CBT improves the participating parent’s or caregiver’s personal distress about the child’s traumatic experience, parenting skills, and supportive interactions with the child.  

The United States federal government’s Substance Abuse and Mental Health Services Administration has recognized TF-CBT as a Model Program due to the extensive outcome data from RCTs that support its effectiveness in improving a variety of problems. While TF-CBT was originally developed to address the needs of children who experienced sexual abuse, over the past 15 years it has been used and studied for many other populations of traumatized youth. Research now documents that TF-CBT is effective for diverse, multiple and complex trauma experiences, for youth of different developmental levels, and across different cultures.

Over the past five to seven years, there have been increasing efforts to apply TF-CBT to children and adolescents who present with complex trauma. In the RCTs conducted by the TF-CBT developers, participants typically have had multiple traumas (3-4 on average) and disruption in many areas, including PTSD, affective, cognitive, behavioral, and interpersonal domains. Additionally, most of these youth had experienced interpersonal violence often in their family of origin. There has also been significant dissemination of the TF-CBT model to clinical settings where youth would likely present with complex trauma including residential treatment settings, group homes, state hospitals, and foster care.  

Based on these research and dissemination projects, there are many things that we have learned in regard to how to apply the TF-CBT model with youth with complex trauma. First, (and this is no surprise), treatment is longer. In our research studies, TF-CBT has been successfully implemented in 8-16 sessions.  With youth with complex trauma, the length of treatment is 16-25 sessions and occasionally somewhat longer. Also, for youth with more straightforward trauma presentations, TF-CBT treatment is often divided into thirds; one-third for the stabilization phase, one-third for the trauma narration and processing,  and one-third for integration and closure. With youth with complex trauma, the proportions change as we suggest one-half of the treatment for stabilization, one-quarter for the trauma narration and processing, and one-quarter for integration and closure. This greater focus on stabilization skills reflects the fact that most youth with complex trauma have more challenges with affective and behavioral regulation.  Indeed these youth could receive as many as 12-14 sessions in which they are learning effective coping and other self-regulation skills. It should be noted that despite the above changes in the proportionality of the different phases of TF-CBT that parental/caregiver involvement/skill building and gradual exposure occur throughout treatment, regardless of whether a youth has a more straightforward or complex trauma presentation.

There are other potential clinical adjustments in the implementation of TF-CBT with youth with complex trauma. Although a focus on safety may be the final component in the TF-CBT model, it is typically the first component to be implemented with youth with complex trauma. Safety and trust with the therapist and safety planning related to possible ongoing violence in the youth’s environment are essential first steps in trauma treatment with this population. Also, because affective and behavioral dysregulation are more common in youth with complex trauma, we suggest focusing on relaxation and other coping strategies prior to introducing psychoeducation as the latter may be perceived as threatening and overwhelming.  

Another clinical adjustment relates to the common belief that many youth with complex trauma presentations have unique underlying trauma themes that deeply affect who they are, how they relate to others, and how they perceive the world. Examples of such themes might be “I am damaged,” “the people who are supposed to love you hurt you,” “I can never trust anyone,” “I am worthless so no one will ever want me,” etc. Situations or people that trigger these themes may serve as trauma reminders for youth with complex trauma. Also, we suggest that therapists assist youth during the trauma narration and processing in understanding how the multiple traumas in their lives have reinforced these underlying trauma themes. It is worth adding that a timeline and/or life narrative may be more appropriate for this group than a trauma narrative. For more information in regard to how TF-CBT is implemented with youth with complex trauma presentations, please see either the Cohen, Mannarino, Kliethermes, and Murray article (2012) or the chapters on residential treatment or adolescents with complex trauma in our most recent TF-CBT book (Cohen, Mannarino, & Deblinger, 2012).  

The treatment manual for TF-CBT is Treating Trauma and Traumatic Grief in Children and Adolescents by Cohen, Mannarino, and Deblinger (2006). It is published by Guilford or easily found at the ISTSS bookstore.  TF-CBT trainings and follow-up consultation are conducted nationally and internationally by the developers and certified TF-CBT trainers. A listing of upcoming trainings can be found at www.musc.edu/tfcbt which is the website for TF-CBTWeb, our web-based course. The latter is free and provides 10 continuing education credits. To date, over 200,000 clinicians around the world have registered for TF-CBTWeb and over one-half have actually completed the course.  

About the Authors

Anthony P. Mannarino, PhD, and Judith A. Cohen, MD, along with Esther Deblinger, PhD, are the developers of TF-CBT. Dr. Mannarino is the Vice Chair of the Department of Psychiatry and Director of the Center for Traumatic Stress in Children and Adolescents (CTSCA), Allegheny General Hospital, Allegheny Health Network, and Professor of Psychiatry at the Drexel University College of Medicine. Dr. Cohen is the Medical Director of the CTSCA and also Professor of Psychiatry at Drexel University.  

References

Cohen, J.A., Mannarino, A.P., & Deblinger, E.  (2006). Treating trauma and traumatic grief in children and adolescents.  New York:  Guilford.

Cohen, J.A., Mannarino, A.P., & Deblinger, E.  (2012). (Eds.)  Trauma-Focused CBT for children and adolescents:  Treatment applications.  New York:  Guilford.

Cohen, J.A., Mannarino, A.P., Kliethermes, M.. & Murray, L.A.  ( 2012).  Trauma-focused CBT for youth with complex trauma.  Child Abuse & Neglect, 36, 528-541.