TF-CBT Basics

1. TF-CBT Basics Presented By: Lorien Holman, LPC-S, CEO

2. TF-CBT The History • TF- CBT was developed by Drs. Anthony Mannarino PhD, Judith Cohen MD, and Esther Deblinger MD. • TF-CBT is an evidence-based treatment that has been evaluated and refined during the past 25 years • Was developed to treat children and adolescents who were sexually abused and has now been expanded to treat impacts of trauma as well such as affective (e.g., depressive, anxiety), cognitive and behavioral problems, and improving the participating caregiver’s personal distress about the child’s traumatic experience, effective parenting skills, and supportive interactions with the child. • Is now recognized by SAMSHA as a Model Program due to extensive research efforts to include 21 randomized controlled trials which have been conducted in the U.S., Europe and Africa, comparing TF-CBT to other active treatments and have documented TFCBT is superior for improving children’s trauma symptoms and responses. • TF-CBT is a structured, short-term treatment model that effectively improves a range of trauma-related outcomes in 8-25 sessions with the child/adolescent and caregiver.

3. Overview:Core Concepts • Assessments • Engagement • Psychoeducation • Parenting • Relaxation • Affective Modulation • Cognitive Coping • Trauma Narrative • Cognitive Processing • In-Vivo Exposure • Family Sessions • Enhancing Safety

4. Assessments • Identify the history of trauma • Identify PTSD symptoms • Establish a baseline • Observe client and family during assessment process (clinical observations) • Assessment Tools: • CATS- Child and Adolescent Trauma Screen • the only trauma screen paid for by Medicaid • TESI-Traumatic Events Screening Inventory • TSCYC- Trauma screen checklist for young children • TSCC- Trauma Screen Checklist for Children • BRIEF-C- Behavior Rating Inventory of Executive Function • ASQ-Ages and Stages Questionnaire • Child Sexual Behavior Inventory • Child PTSD Symptom Scale

5. Methods of assessment for Children • Standardized measures • Telling the story • Reading a book • “A Terrible thing Happened” • “The Right Touch” • “I said No” • Interview with caregiver • Getting their perspective on the event, child’s symptoms and behaviors • Assessing context by exploring environment, development, and social protective factors • Clinical observations

6. ADHD Understanding PTSD and Similar Diagnoses

8. Engagement • Getting parental and client involvement • Setting the foundation and expectations for treatment • Establish goals of treatment • This should be done collaboratively • Sometime can be split between parent session and child session • Reduce resistance as much as possible

9. Engagement • Refer back to assessment results and problems that have been identified by family and/or client • Explore and link the child and caregivers goals and explore PACEs with family, as well as progress and successes made as treatment progresses • Explore rewards or incentives that can be used to increase motivation

10. Psychoeducation • Teach, normalize, and validate symptoms of PTSD • Normalize the trauma exposure • Statistics • Groups • Reduce or eliminate self blame • Outline TF-CBT process and how it helps • Components and structure • Clarify the importance of consistent efforts in treatment

11. PsychoEducation • Books • Taking Action: Support for Families with Children with Problematic Behaviors By: Jane F. Silovsky, Ph. D • Games • Youtube • https://www.youtube.com/watch?v=uJCWysVuxcs&t=13s (young children sexual abuse) • Worksheets or Workbook (it’s free! https://tfcbt.org/wp-content/uploads/2014/07/Your-Very-Own-TF-CBT-Workbook-Final.pdf) • Fun and Creative activities

12. Working with Parent or Caregiver • Understand family system and relationships within it • Learn skills to manage difficult or inappropriate behaviors • Skills covered should include: • Appropriate and timeliness of praise and rewards • One on One or Special Time • Understanding selective attention and ignoring • Power struggles • Consequences

13. Parenting Tools • Worksheets • https://depts.washington.edu/hcsats/PDF/TF-%20CBT/pages/7%20Trauma%20Focused%20CBT/General%20Questions%20for%20Psychoeducation.pdf • Role playing • Especially helpful when working in the Trauma Narrative • Modeling • Observing parent child interactions and practicing skills as well as coaching • Independent reading

14. Relaxation • Skills that the child can use in any setting • Feelings First Aid Kit or a “Toolbox” • Use activities the child already enjoys (drawing, music, reading, watching youtube) https://www.youtube.com/watch?v=_kYKoc7Cm7E&t=80s • Yoga, mindfulness, guided imagery, controlled breathing • Can be used when working with the trauma narrative • Differentiate between relaxation and distress tolerance skills • Know when to use each

15. Affective Modulation • Develop feeling language and be able to label feelings • Begin to understand feelings and normalize multiple, uncomfortable or competing feelings • https://www.youtube.com/watch?v=tNsTy-j_sQs (anxiety and depression) • Cognitive Triangle – Thoughts, feelings, behavior • TF-CBT Triangle of Life app available from Allegheny Health Network IOS Based • Understand intensity of feelings- In the workbook there is a thermometer • Explore feelings related to trauma • Learn Emotion Regulation Skills

16. Cognitive Coping • Cognitive triangle • Explore automatic thoughts that may be causing distress • Distress can be caused from both traumatic reminders and non traumatic experiences • Explore ways to understand our feelings and ways to change them and out behavior by becoming more aware of and changing unhelpful thoughts • Thoughts, feelings, behavior games • Don’t Go Bananas

17. Cognitive processing • Identify unhelpful and inaccurate thoughts • Explore with both the caregiver/client ways that the traumatic event may have changed their view of themselves, the world, their family, and their future • Explore helpful and more accurate ways to think about trauma exposure and replace old thoughts with new ones • “Damaged goods” more positive view “It’s not my fault”

18. Bottom-Up Interventions What is it? Working with the body/going through the body to change the brain • Sensory awareness or exposure techniques • Give me 5 • Close your eyes and touch and describe objects • Introspective Awareness • Yoga • Diaphragmatic breathing • Exercise • Progressive Relaxation • Exercise

19. Top-Down Interventions What is it? It’s working with trauma using cognitions to affect the body • Cognitive Restructuring/reappraisal • Acceptance and Commitment cognitive exercise • Transcendental Meditation • Focus Meditations • Empty Chair Technique • Assertiveness training • Talk therapy

20. Horizontal Interventions What is it? It’s going across hemispheres of the brain • Processing across modalities • Cross hemispheric processing • Art Therapy • Sensory Integration

21. Trauma Narrative What is it? • Telling the story of the trauma experience and should be done for each experience • Use media that the child likes, clay, paint, crayons, pencils • Comic Strips • Collage • Doll house • Puppet show

22. Trauma Narrative Cont. • Provide exposure to trauma related memories • Explore unhelpful and inaccurate cognitions that need to be processed • Identify thoughts related to altered world view of self, related to trauma exposure or context of trauma • Put traumatic exposure into context (there are good things, future hopes and dreams)

23. In- Vivo Exposure • Learn how to differentiate between trauma reminders or fear response triggers (fear of spiders) • Identify triggers and explore causation- (use a fear ladder) • In session practice of distress tolerance skills during progressive exposure (as needed) • Create support with caregivers and client through use of praise and rewards • Exploring previous coping skills • Helps to reduce the avoidant responses that interfere with daily functioning

24. Family Sessions • Family sessions should happen regularly to provide support, praise and encouragement from their trusted adults • Learn what the child has done so far • Allows trusted adult to hear the child’s perspective • Provides a higher level of exposure with trusted adult • Provide space for parent to ask questions and process feelings about traumatic event as well as provide a place to role play showing support, praise and encouragement (parent only session)

25. Building Safety • Develop safety plan with both the child and family • Builds structure for family which in turns supports client after treatment • May go back to a video they liked • Usually toward the end of treatment however can be done anywhere • Include self harm or suicidal thoughts safety plan • Identify risk factors, triggers, “red flag warnings” • Explore appropriate boundaries with others

26. References • Tfcbt.org • https://www.nctsn.org/resources/it-adhd-or-child-traumatic-stress-guide-clinicians • Youtube • Feldman and Dorsey UW 2010 • Nueroscience for Clinicians Jennifer SweetonPh.D M. S., M.A.