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Introduction to Trauma-focused cognitive Behavioral therapy. Elizabeth Feldman, PhD University of Washington School of Medicine. The origins of TFCBT. Developed for treating sexually abused children Viewed working with parents as an integral part of treatment Esther Deblinger , Ph.D.

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introduction to trauma focused cognitive behavioral therapy

Introduction to Trauma-focused cognitive Behavioral therapy

Elizabeth Feldman, PhD

University of Washington

School of Medicine

the origins of tfcbt
The origins of TFCBT
  • Developed for treating sexually abused children
  • Viewed working with parents as an integral part of treatment

Esther Deblinger, Ph.D.

Center for Children’s Support

University of Medicine and Dentistry of New Jersey

&

Judith Cohen, M.D., and Anthony Mannarino, Ph.D.

Center for Traumatic Stress in Children and Adolescents

Alleghany General Hospital

understanding ptsd
Understanding PTSD
  • What is Post Traumatic Stress Disorder?
  • Traumatic Event
  • Avoidance
  • Re-experiencing
  • Hyperarousal
  • Interference with daily functioning
example case
Example case:
  • Age
  • Gender
  • Race/Ethnicity
  • Home life environment
  • School history
  • Outline of traumatic events
  • Current environmental supports
  • Other existing health-related diagnoses
complex ptsd
Complex PTSD

Ongoing, chronic exposure to traumatic events.

No one, isolated trauma.

Symptoms can be wide-ranging, but should still meet criteria for PTSD.

common themes of ptsd
Common themes of PTSD
  • Loss of trust in self & others
  • Self-blame
  • Shame & Guilt
  • Anger
  • Relationship difficulties
  • Behavior problems
  • School failure
  • Difficulty managing affect
  • Hopelessness
  • Depression
common caregiver themes
Common Caregiver Themes
  • Inappropriate self-blame and guilt
  • Inappropriate child blame
  • Overprotectiveness
  • Overpermissiveness
  • Post Traumatic Stress Disorder/symptoms
  • Anger, aggression
  • Hopelessness, worry, depression
example case8
Example case:
  • Age
  • Gender
  • Race/Ethnicity
  • Home life environment
  • School history
  • Outline of traumatic events
  • Current environmental supports
  • Other existing health-related diagnoses
choosing tfcbt
Choosing TFCBT

RCTs demonstrating efficacy/effectiveness of TFCBT for:

  • Ages 3-18
  • Boys / Girls
  • Multiple racial/ethnic backgrounds
  • Varying socio-economic status
  • Single or multiple trauma history
  • Placement with biological parents or child welfare
  • Children with behavior problems
tfcbt is not for
TFCBT is not for:
  • Clients with extreme therapy-resistant behavior
  • Clients with active suicidal behavior
  • Clients with severe cognitive disabilities
tfcbt a practice
TFCBT – A Practice!
  • Assessment!
  • P sychoeducation and Parenting Strategies
  • R elaxation
  • A ffective expression and regulation
  • C ognitive coping
  • T rauma narrative and processing
  • I n vivo exposure
  • C onjoint parent child sessions
  • E nhancing personal safety and future growth
trauma focused cognitive behavioral therapy
Trauma-focused Cognitive Behavioral Therapy

Child’s Treatment

Coping Skills Training:

Emotional Expression

Cognitive Coping

Relaxation

Gradual Exposure & Processing

Education:

Child Sexual Abuse

Healthy Sexuality

Personal Safety

Caregiver’s Treatment

Coping Skills Training:

Emotional Expression

Cognitive Coping

Relaxation

Gradual Exposure & Processing

Education (like child sessions)

Behavior Management

Joint Sessions

Coping Skills Exercises

Gradual Exposure & Processing

Education Regarding Sexuality

and Sexual Abuse

Personal Safety Skills

Family Sessions

From Deblinger & Heflin (1996)

assessment
Assessment

Goal: Identify trauma history and presence of trauma-related symptoms.

1) Trauma History

2) Internalizing

3) Externalizing

4) Avoidance

5) Re-experiencing

6) Hyperarousal

7) Interference with daily functioning

psychoeducation
Psychoeducation

Goal: Normalize symptoms, validate experience and reactions, instill hope for recovery.

  • What is trauma?
  • What is PTSD?
  • What is TFCBT?
parenting
Parenting

Goal: Support caregivers to reduce their own stress/anxiety, improve the child-adult relationship, help the caregiver support the child’s recovery.

  • Praise
  • Rewards
  • Active Ignoring
  • Time Out

Specific for kids with PTSD:

  • Confidence in limit-setting
  • Not reinforcing avoidance
  • Coping coaching
relaxation
Relaxation

Goal: Create “tool box” that the client can use in his/her own environment to manage symptoms.

Relaxation is not just progressive muscle relaxation and deep breathing…

  • What do you do to relax?
  • Relaxation vs. Distress Tolerance
affective regulation
Affective Regulation

Goal: Normalize multiple conflicting feelings, teach varying levels of feelings, teach vocabulary for talking about traumatic events competently.

  • Feelings Education (what are emotions?)
  • Connecting feelings to traumatic or difficult events
  • Feelings thermometers
  • Learning self-soothing techniques
cognitive coping
Cognitive Coping

Goal:

  • Essential to help clients/families evaluate the ways in which trauma changed their thinking and correct distorted thoughts.
  • Make sure clients don’t define themselves by their traumatic experiences.

Cognitive Processing occurs before and after the Trauma Narrative.

First teach the skill, then use it.

cognitive coping the heart of tfcbt
Cognitive CopingThe heart of TFCBT:

GOALS:

  • Clarify the difference between thoughts, feelings, and behaviors.
  • Demonstrate how thoughts, feelings, and behaviors affect each other.

thoughts

behavior feelings

trauma narrative
Trauma Narrative

Goal:

“To gradually expose client to thoughts, memories, and other innocuous reminders of the abusive experience until they can tolerate those memories without significant emotional distress and no longer need to avoid them.” (Deblinger & Heflin, 1996, p. 71)

  • Comes from Anxiety Framework
  • Un-pairing of harmless stimuli with learned anxiety response.
trauma narrative22
Trauma Narrative

Should include:

  • Before the trauma
  • Components of the trauma (chapters) with specific details, thoughts, feelings, and associated memories
  • The “worst” part
  • “What I learned” or “What I would tell other kids”
  • The future
cognitive processing of the tn
Cognitive Processing of the TN:

Goal: Identify latent or overt cognitive distortions or unhelpful beliefs and challenge them with the client.

  • Revisit the cognitive triangle, add consequences
  • Use Socratic questioning
  • Never “tell” the clients to change their beliefs
common trauma related thoughts feelings
Common Trauma-Related Thoughts/Feelings
  • Guilt
  • Shame / Disgust
  • Self-Blame
  • Hopelessness
  • Fearfulness
  • Worthlessness
  • Lack of control
  • Depression
in vivo exposure
In-Vivo Exposure

Goal: Unpair feared stimuli (triggers) from the learned response of anxiety/fear.

Examples:

  • The dark
  • Streets
  • Men

Use general and specific fear ladders, set up homework and practice activities with reward systems.

enhancing safety
Enhancing Safety

Goal: Prepare for the future

  • Learn to recognize signs/symptoms that indicate the need for a return to treatment
  • Create usable, meaningful safety plans
  • Plan for using coping skills
  • Consider environmental supports
conjoint sessions
Conjoint Sessions

Goal:

  • Increased exposure / opportunity for mastery
  • Increase child & caregiver communication
  • Support asking and answering questions
  • Essential to prepare adequately
    • (individual with CG and with client before joint session)
  • Invite prepared questions, comments, feedback
  • Celebrate success!
summary
Summary
  • Assessment!
  • P sychoeducation and Parenting Strategies
  • R elaxation
  • A ffective expression and regulation
  • C ognitive coping
  • T rauma narrative and processing
  • I n vivo exposure
  • C onjoint parent child sessions
  • E nhancing personal safety and future growth

TFCBT – it works!