Trauma-Focused Cognitive Behavioural Therapy (TF-CBT)

Childhood trauma can result from abuse, natural disasters, violence, or bullying, just to name a few. These can impede a child’s development and lead to difficulties in adulthood. Children affected by trauma might find it challenging to regulate emotions, have cognitive and behavioural concerns, and are at higher risk of mental illness. With trauma often inflicting interpersonal challenges, children might also have an inaccurate view of self, impacting their hope and perception of their capabilities when planning their futures. How do these symptoms and challenges impact a child's daily life? They might use maladaptive coping mechanisms like smoking, drugs, or alcohol. They could also experience intense isolation leading to a lack of engagement in social activities or absenteeism in school. The overall effects of childhood trauma can increase their risk of addiction, depression, suicide, and career obstacles if left untreated.

Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) is an empirical treatment model specifically designed to address childhood trauma. It invites non-offending caregivers and children to engage in a low-cost, short-term treatment plan ranging from 12-24 sessions where compassion, holism, and understanding are the foundation for therapeutic success. The treatment plan is broken up into three guided phases and uses the acronym PRACTICE to outline the steps in each phase. We will explore the steps of TF-CBT in detail below.  

 Phase One – Stabilization 

Psychoeducation 

This step involves the counsellor providing information on trauma to reduce the stigma and validate the client's experiences. For example, exploring how trauma impacts the mind and body. Cognitive behavioural strategies such as self-talk or reframing help improve their view of self, which can reduce negative self-talk, catastrophic thinking, and intrusive thoughts.  

Relaxation

Before engaging in the trauma narrative and processing phase, it is imperative to regulate stress levels that can be elevated through a dysregulated hypothalamic-pituitary-adrenal (HPA) axis in the brain. This could include grounding techniques, deep breathing exercises, or building strategies using topics that spark the child's interest. Consider your child’s favourite superhero, toy, or paint colours to motivate and help them share their story. 

Affect Modulation Skills

Trauma can often make children feel they do not have a voice or safe space to express their emotions. In this step, the counsellor gently encourages them to share their emotions and demonstrates the safety and benefits of open expression. For example, the counsellor might encourage the child to express when they are angry, uncomfortable, or sad. To tailor this step to build on a child’s creative ability, they could draw their emotions to help express what is difficult for them to articulate verbally.

Cognitive Processing 

The cognitive triangle is introduced in this step to help the child and caregiver understand the influence their behaviours, thoughts, and emotions have on one another.

For more information on the cognitive triangle, visit our blog on Cognitive Behavioural Theory using this link: Cognitive Behavioural Theory.

Phase Two – Trauma Narrative and Processing 

Trauma Narrative and Processing

At this stage, the child has learned the skills to stay within the window of tolerance and gradually begins exploring their trauma. The counsellor will pay close attention to the pace and intensity of emotions that arise in this stage, returning to the stabilization stage when necessary. Once the experiences have been shared, the counsellor meets with the caregiver to discuss essential information the child expressed. This is to help the caregiver gain a deeper understanding of the child's traumatic experiences, thoughts, and beliefs while aiding in their own guilt and shame.

To learn more about the window of tolerance, visit an article produced by Psychology Today using this link: Window of Tolerance.

Phase Three – Integration and Consolidation   

In-Vivo Exposure

In-vivo exposure is a step that can be useful for children who experience avoidance or fear caused by the trauma that is hindering their quality of life. This step is only used for children within the window of tolerance. The caregivers play an essential role in this step as they can assist the child in gradually exposing themselves to a fearful or anxiety-provoking situation. For example, walking alone might begin with the caregiver, then progress to walking alone down the street, leading to walking alone around the block. The counsellor and caregiver would carefully monitor the child’s level of distress, and if it were too much, they would not proceed with the activity. 

Conjoint Caregiver and Child Sessions

The conjoint caregiver and child sessions provide the opportunity to strengthen the relationship that might have been strained by the trauma. Working through guilt, anger, or shame is essential to strengthen the bond. This step also provides the opportunity to discuss topics appropriate for the child's age, such as bullying, decision-making, school, or friendships. The goal is to practice productive communication techniques and develop trust and respect that can bring harmony to the relationship. 

Enhancing Safety and Future Considerations

The final step is a proactive endeavour to discuss strategies that can be used beyond the therapeutic environment. For example, developing a safety plan and reaffirming strategies to ground and self-regulate in times of distress. Making the plan collectively with the caregiver and the child can ensure the child feels validated and supported, as they are both responsible for engaging in the plan.

It is important to note that these steps and phases are not linear. If a child needs to revisit a previous step due to overstimulation or exposure, the counsellor will guide them back before proceeding to the next step to ensure no harm is endured.

TF-CBT has proven to be effective in enhancing self-esteem, autonomy, and safety impaired through childhood trauma. Improving the effects of childhood trauma enhances the outlook for the overall well-being of future generations. It also helps boost productivity and wellness in the Guelph community. 

If you or someone you know has experienced trauma, please reach out here to book a FREE telephone consultation. We have many team members who practice TF-CBT, as well as other evidence based trauma treatments.

References

Ascienzo, S., Sprang, G., & Eslinger, J. (2020). Disseminating TF‐CBT: A mixed methods investigation of clinician perspectives and the impact of training format and formalized problem‐solving approaches on implementation outcomes. Journal of Evaluation in Clinical Practice, 26(6), 1657–1668. https://doi.org/10.1111/jep.13351

Cohen, J. A., & Mannarino, A. P. (2015). Trauma-focused cognitive behavior therapy for traumatized children and families. Child and Adolescent Psychiatric Clinics of North America, 24(3), 557–570. https://doi.org/10.1016/j.chc.2015.02.005

Erford, B. T. (2020). 45 techniques every counsellor should know (3rd ed.). Pearson.

Psychology Today. (n.d.). Trauma-focused cognitive behavioural theory. Retrieved June 8, 2023, from https://www.psychologytoday.com/ca/therapy-types/trauma-focused-cognitive-behavior-therapy

The National Child Traumatic Stress Network. (n.d.). Effects. Retrieved June 7, 2023, from https://www.nctsn.org/what-is-child-trauma/trauma-types/complex-trauma/effects

The National Child Traumatic Stress Network. (n.d.). Trauma types. Retrieved June 7, 2023, from https://www.nctsn.org/what-is-child-trauma/trauma-types