Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a psychotherapy for children ages 3-18 who have experienced trauma. It is short-term, structured therapy, provided in 8-25 sessions, each session lasting 60 to 90 minutes. Sessions are divided equally between child and parent. 30 years of research on TF-CBT has shown it to be highly effective in treating posttraumatic stress disorder in children.
Central Concepts of Trauma-Focused CBT
An offshoot of CBT, Trauma Focused-CBT techniques help children modify negative, unhelpful thoughts, emotions and behaviors that result from traumatic experiences. All materials use age-appropriate language, skills building and examples. An essential part of Trauma Focused-CBT is providing equal time to the parent. Trauma Focused-CBT includes psychoeducation for the parent while teaching new skills, including effective parenting, stress-management, and communication. It is important to note that only a non-offending parent can be part of the treatment.1
Trauma Focused-CBT has a narrative component that is critical to its success. The child creates a story, which is first shared with the therapist. The therapist uses careful interventions to help the child build tolerance. Finally, the child shares the story with the parent, allowing the parent to completely understand the child’s perspective. This provides the parent with an opportunity to use the skills she/he learned during conjoint therapy.
TF-CBT uses a structured, three phase format with components presented in a sequential order, skills practice is part of the intervention.
Practical components of TF-CBT include:2
- Psychoeducation about child trauma and trauma reminders
- Parenting component including teaching parenting skills
- Relaxation skills individualized to youth and parent
- Affective modulation skills tailored to child, family and culture
- Cognitive coping: connecting thoughts, feelings and behaviors
- Trauma narrative and processing
- In vivo mastery of trauma reminders
- Conjoint child-parent sessions
- Enhancing safety and future developmental trajectory
- Processing traumatic grief
What Can TF-CBT Help With?
Over time, TF-CBT has moved beyond just treating childhood sexual abuse for which it was developed. TF-CBT has been refined into an evidenced-based, manualized treatment tested on traumatic bereavement, posttraumatic stress disorder, depression, anxiety and behavioral problems. The high success rate of TF-CBT to heal childhood trauma is great enough to encourage further research for other problems. There are some important parameters—TF-CBT is only beneficial if the child has at least one remembered trauma along with prominent PTSD symptoms, although a PTSD diagnosis is not necessary.1
TF-CBT treatment can alleviate many symptoms and improve mental health for both child and parent.
TF-CBT treatment targets feelings and issues like:
- Guilt
- Shame
- Feeling powerless
- Depression
- Anxiety
- Behavioral outbursts
- PTSD symptoms including sleeplessness, agitation, flashbacks, nightmares, anger, poor concentration, hypervigilance, emotional numbness, low self-worth
- Somatic responses like bed wetting, stomachaches, headaches, night terrors, tantrums, self-harm
- Triggers that create excessive emotional, physical, or behavioral responses
- Substance abuse
Since there is a parental focus to treatment, TF-CBT can improve overall family relations. It can change family dynamics by adding effective communication skills, situational awareness, emotional regulation, and stress management. Parental guilt can be alleviated, and a sense of safety and trust can be rebuilt. This can help prevent further trauma, create healing and promote overall resiliency.
TF-CBT Treatment Phases
A child must be thoroughly evaluated by a qualified professional before beginning trauma focused therapy. The therapist will speak with the child and parent, as well as other caregivers if there are any. Interviews with the child’s teacher and other important people like pastors, babysitters, school counselors, CPS case workers, and the child’s pediatrician may be useful. The therapist wants to have a complete understanding of the trauma complexity. The therapist will assess the trauma impact in the domains of affect (emotions), behaviors, cognition (thoughts), biological, social interactions and the child’s own perceptions.
There are three phases of TF-CBT treatment: (1) stabilization, (2) trauma narration and processing, and (3) integration and consolidation. It is imperative that TF-CBT interventions maintain fidelity with the model in order to be effective.3
Stabilization Phase
During this phase, the therapist uses psychoeducation to provide information about common trauma responses and helps relate trauma reactions to the child’s own experiences.
Here are some techniques related to the stabilization phase:
- Validation: letting the child know what he/she is feeling is normal.
- “Bad things” vs. “Bad kid”: helping parent and child understand “bad things” happen, and they don’t mean the child is “bad.”
- Provides hope for the future: helping child and parent accept that the child’s experience does not define the child.
- Identifying trauma reminders: working with the parent and child to ascertain the smells, sights, touch, sounds, places, and memories that are cues that initiate the fear response.
- Optional: For sexual abuse victims, teaching accurate names for private parts of the body and providing insights on appropriate safety and boundaries3
During this phase, the patient learns many skills, including:
Parenting Skills
This phase also includes training parenting skills to focus on strategies for responding to the child’s behaviors, such as:
- Therapist provides instructions, practice and role playing.
- Learning effective “time in” and “time out” practice.
- Using effective praise = instead of general praises like “good job”, praise is focused on a very specific behavior.
- Learn to attend to positive behaviors, not just negative ones, and then positively reinforce them while ignoring unwanted behaviors.
To be effective, only one unwanted behavior is targeted at a time.3
Relaxation Skills
Relaxation skills are also taught. Childhood trauma changes the neurobiology of the brain so attention must be paid to finding calming relief. The therapist will provide instruction on deep breathing, progressive muscle relaxation, and visualization. Children will be encouraged to find relaxation in activities they enjoy. The therapist meets with the parent and teaches the parent the relaxation skills that the child identifies as most helpful so they can practice relaxation together.3
Affect Modulation Skills
Additionally, during this stage patients will learn affect modulation skills. Trauma often sets up a child to create safety mechanisms such as pushing away emotions, feeling numb, or denying any negative feelings. The therapist must help the child regain access to emotions and learn how to effectively manage them. A variety of strategies are presented, including problem solving, seeking social support, positive distractions, pleasant experiences, mindfulness, and anger management. Parents are also taught similar strategies and they are practiced with role playing in session. Parents learn how to tolerate their child’s negative emotions and to become skillful at initiating support for the child.3
Cognitive Processing Skills
This component helps the child and parent to understand the relationship between thoughts, emotions and behaviors, just like in CBT. Then the child and parent learn how to replace negative thoughts with thoughts that are helpful and more accurate. The therapist does not focus on the trauma experience with the child but works around it by focusing on other aspects of life. Parents are taught the CBT model and start working with negative thoughts related to everyday events. Later, parents can work with the therapist on thoughts related to shame and guilt.3
Trauma Narrative & Processing
Trauma narrative and processing is when the therapist and child engage in a careful story telling wherein the child describes the difficult details of the trauma experience. The focus is on the child describing the feelings, thoughts, and body sensations that occurred during the trauma episode. By speaking out loud about the “horrible” event, the child learns mastery over frightening memories. The therapist helps the child use the previously learned CBT strategies to replace negative thoughts.
The child can create a story book, writing or drawing the narrative of the trauma. The processing takes place for several sessions at a pace that the child can tolerate. The parent meets with the therapist in parallel sessions in which the parent hears the trauma story and learns what it was like for the child. Using CBT, the parent also learns mastery over his/her thoughts, emotions and behaviors.3
Integration & Consolidation
In certain situations, children need to experience real life in order to manage their ongoing fears and avoidance. This component is optional.
For example, a child who was sexually abused in her bed may need to learn to tolerate sleeping alone in her room. The therapist, child and parent create a hierarchy of fear inducing scenarios and rate them from 1 to 10 (least to most). The child starts with the least fearful and moves through them all. This is a small step approach to learning tolerance. It can take several weeks and incorporates all the relaxation skills the child has learned. The parent must be fully invested and consistent in helping with the in vivo plan.3 This can also occur in conjoint child-parent sessions: During this phase of treatment the parent and child are brought together for several sessions.3
This is the complete PRACTICE model for TF-CBT. It is proven to be effective and superior to other therapeutic interventions with resolving trauma and trauma related problems with children ages 3 to 21.1,2
Trauma-Focused CBT Example
The following is an example of a child exposed to domestic violence (related to me by a colleague)
Sam was six when his mother’s boyfriend’s abuse escalated. One Saturday morning the boyfriend attacked Sam’s mom with a kitchen knife. Though she was only slightly injured, the trauma ran deep. The boyfriend was arrested and incarcerated and was no longer a threat, but Sam refused to go to school and when he did go, he was angry and aggressive toward other children. One day, Sam’s teacher called and said Sam was being expelled because he tried to use his pencil to stab the student next to him during an argument.
Sam’s mother, Michelle, sought help at a child trauma treatment program where my colleague was a certified TF-CBT therapist with years of experience. The therapist completed a thorough assessment of Sam and together with Michelle, they made a treatment plan. Over the next 16 sessions, Sam and Michelle worked through the TF-CBT PRACTICE model with the therapist.
In the beginning, Sam’s behavior got worse, not better. The therapist explained to Michelle that this is common. The therapist had been teaching Michelle effective parenting skills; however, Michelle wasn’t using them consistently. With help, support and encouragement from the therapist and lots of role playing, Michelle put in the work and started to see positive changes in Sam’s behavior. He was soon back in school.
Sam worked with the therapist on creating a picture book that illustrated Sam’s terrifying experiences. Each page was a frightening scene depicting yelling, or violence. Slowly, Sam uncovered his fears, and was able to talk about them. During the process, the therapist helped Sam change his thinking from, “I was a bad kid, and it was all my fault that mom got hurt,” to “It was the boyfriend who hurt my mom. I was just a little kid in a bad situation. It made me scared and sad that I couldn’t help her.”
When Sam was ready, Michelle and Sam met with the therapist so Michelle could see and hear Sam’s story. Michelle cried as she learned what the trauma was like in a child’s mind. It helped motivate her to read some parenting books suggested by the therapist and to commit herself to consistent, thoughtful parenting while modeling appropriate behavior for Sam.
In the last few conjoint sessions, Sam and Michelle laughed and cried, hugged and argued, but Michelle set firm boundaries and reinforced positive behaviors. By the end of the sessions, they had made a safety plan for home and school. Sam and Michelle had both changed. They healed some wounds and learned to relax. They still faced struggles, but both of them had gained tools and strategies, and were feeling the beginnings of trust and safety. Michelle continued on with her own therapy in my care. We focused on resolving her trauma using EMDR therapy.
Note: My colleague reminded me how important it is to monitor and support the parent while she/he is learning new skills. If the parent is not using a skill correctly and consistently, the child’s behavior will likely escalate in response (out of confusion, distrust, or emotional dysregulation). The therapist must be skillful and intuitive enough to work with both the parent and child at the same time. It’s a highwire act during which the therapist does not want to lose focus or balance.
How to Find a TF-CBT Therapist
Finding a qualified TF-CBT therapist should be somewhat easy. If you are looking for the most qualified TF-CBT therapist, first try the TF-CBT Therapist Certification Program website. Certified therapists have gone through rigorous training and supervision to become proficient in the use of TF-CBT and should keep to the fidelity of the model. Other therapists may have some knowledge and very little training, which may be a detriment to treatment. It is important to remember that there are many therapists who take short courses in TF-CBT but have not completed certification. They may or may not be qualified to work with complex trauma in children.
Do not be afraid to ask therapists about their education, training, certifications, experience and their personal treatment philosophy. It is important to have the right fit so that treatment goals can be accomplished within a safe, honest, trustworthy environment in as short a time frame as possible.
How Much Does TF-CBT Cost?
Clients can choose a private pay therapist and pay an hourly rate set by the therapist. The national average rate is $60 to $120 per 45-50-minute session. There is substantial price variability when you pay out of pocket because there are no set rates. Sessions can cost between $20 to $300 per session. Location, type of practice, experience, training, education and reputation all play a part in the cost of therapy. Open discussion about payments will take place either in the initial telephone screening or at the first session.
Generally, insurance companies that provide mental or behavioral health care benefits will pay for TF-CBT therapy. Some insurance plans may have an annual deductible that must be met first, and a copay at time of service. This information will be available from the insurance company, so it is important to contact them first. Be aware that insurers often have limitations on the number of sessions available in a given year.
What to Ask Before Starting TF-CBT
Some questions to ask your therapist before beginning TF-CBT therapy include:
- Are you certified in TF-CBT? Tell me about your training and experience with TF-CBT therapy.
- Have you treated children with trauma symptoms similar to my child’s and was it effective?
- Will we need 90-minute sessions as opposed to 60 minutes? Do all sessions include me?
- Can you estimate the number of sessions that may be needed?
- How will I know that my child and I can safely engage in TF-CBT?
- What if TF-CBT doesn’t work for my child, then what?
- How will we know when the therapy is complete?
What to Expect at Your First Appointment
Hopefully, the therapist has all the necessary forms easily available online so they can be completed and brought to the first meeting. The therapist will review the parent’s concerns, questions, and discuss treatment goals. All financial information, policies and consents will also be explained and signed by the parent or guardian.
The therapist will provide brief information about TF-CBT, including how it works, the treatment process, and potential outcomes. Often therapists will send the parent home with some reading material so she/he can have a more in depth understanding of TF-CBT and their role in treatment. Finally, the therapist will discuss all the safety factors involved in TF-CBT treatment and outline some of the challenges that will be faced. The first phase will begin after the comprehensive evaluation of the child is complete.
Is TF-CBT Effective?
The TF-CBT Therapist Certification Program website has an extensive list of studies from 1996 to the present. There are at least 21 randomized control trials that indicate the efficacy and superior outcomes using TF-CBT for childhood PTSD and related conditions.4
According to Pennsylvania State University’s Evidence-based Prevention and Intervention Support center (EPIS) these are the common research outcomes:5
- Children receiving TF-CBT show decreases in PTSD symptoms, behavior problems (including sexualized behavior), anxiety, and depression. There is also evidence of improved social adjustment and ability to respond effectively to potentially unsafe situations.
- Caregivers show improved parenting skills, increased support to the child, and reduced levels of depression and trauma-related distress.
- Studies show excellent maintenance of treatment gains up to two years after treatment ends
History of Trauma-Focused Cognitive Behavioral Therapy
According to Dr. Judith Cohen, “At least one trauma is reported by two-thirds of American children and adolescents (hereafter referred to as “children”); 33% of children experience multiple traumas before reaching adulthood.”3 Childhood trauma is a serious social and health crisis in America. Dr. Cohen and her colleagues chose to address it by creating an effective treatment.
TF-CBT is the result of the work of three childhood trauma experts, Dr. Judith Cohen, Dr. Esther Deblinger, and Dr. Anthony Mannarino. Dr. Cohen is a Child and Adolescent Psychiatrist and Professor at Drexel University College of Medicine where she established a center for childhood trauma. Dr. Deblinger works as a Clinical Psychologist and Professor of Psychiatry at Rowan University School of Osteopathic Medicine and has been widely published. As a Clinical Psychologist, Dr. Mannarino heads the Center for Traumatic Stress in Children and Adolescents and is a Professor at Drexel University College of Medicine. All three are recognized leaders in the field of child and adolescent sexual abuse and trauma.
TF-CBT is a modified version of Cognitive Behavior Therapy (CBT), an evidenced-based intervention that targets negative thinking. TF-CBT was introduced in the 1990’s and was initially directed at young children who experienced sexual abuse. However, research from 1996 to the present indicates that TF-CBT is effective for various emotional and behavioral difficulties related to one or more trauma events, including PTSD, depression, anxiety and bereavement.
According to the National Child Traumatic Stress Network, TF-CBT research has shown that it is appropriate and beneficial to various types of cultural groups. It has been tested in rural, suburban and urban settings, schools and treatment centers, and with military families. In 21 randomized controlled trials TF-CBT provided superior relief of symptoms than comparison therapies.4
