TFCBT Resource Material

Treating Trauma and Traumatic Grief in Children and Adolescents

This is considered the most recent, gold standard treatment manual for Trauma-Focused Cognitive-Behavior Therapy. This web course was built following the principles outlined here, but the book contains much more detailed information and provides nuance that is difficult to convey in an online format.

Available at Amazon and Barnes and Noble

Treating trauma

Child Sexual Abuse: A Primer for Treating Children, Adolescents, and Their Nonoffending Parents

This volume applies the principles of TF-CBT specifically to the child sexual abuse population and highlights issues and clinical dynamics unique to this group.

Available at Amazon and Barnes and Noble

Child sexual abuse

Resources by Module

Foundations of TF-CBT

Psychoeducation

What is Child Sexual Abuse?

Child sexual abuse can be really confusing. Sometimes, kids aren’t even sure whether or not they've been abused. Child sexual abuse is when an adult or someone older than you touches or rubs your private parts. Sometimes the older person asks the child to touch their private parts. He or she may make you do these things by being mean and hurting you. He may pretend it's just a game and give you money or a toy. They can be someone you know, like your relative or a close family friend. Or, they could be a complete stranger or someone you hardly know. Sexual abuse is always wrong, and it's always the adult's fault.

Who is Sexually Abused?

Unfortunately, sexual abuse happens to a lot of kids. It happens to boys and girls of all different ages. It doesn't matter whether you're rich or poor—sexual abuse can happen to lots of different kids. The important thing to remember is that being sexually abused is not your fault; it's not about what you look like or anything that you did. It's always the adult's fault.

Who Sexually Abuses Children?

It's hard to understand why anyone would sexually abuse kids. There are lots of reasons—some adults have sexual feelings for children, which most people don't have. Some offenders choose to sexually abuse a child even though they know that it's wrong. Some sexual offenders even use tricks or make kids scared so that they can get what they want. Most sex offenders are men, but sometimes women sexually abuse kids, too. You can't tell offenders by the way they look or act or dress. Even though there are some people who sexually abuse kids, there are MANY more people who only touch kids with ok touches.

How Do Kids Feel When They’ve Been Abused?

The emotions kids have when they are sexually abused can be very hard to understand. Sometimes, the sexual touching feels good, and you may even like or love the person who did this to you. It's ok to have lots of different feelings about the abuse. Some kids feel really mad at the person or afraid of him. Some kids even feel guilty about what happened. Sometimes these feelings can affect how kids behave. Like maybe you're feeling scared about the abuse and you don't want to sleep alone or you just don't like to be alone. Some kids feel mad a lot and they get into lots of fights. Some kids feel real sad and just want to cry all the time. It really helps to talk about all of these feelings.

Why Don’t Children Always Tell About Abuse?

Sometimes it's hard for other people to understand why kids don't tell about being abused. And you know what? There are lots of reasons why kids might not tell. Sometimes, the person who did the abuse tells the child that it's 'a secret,' and that they shouldn't tell anybody. Sometimes the person makes threats and says things like 'if you tell anyone, I'll hurt you, or I'll hurt your mom.' The person who hurt you may even tell you that if you tell, no one will believe you. Sometimes, kids don't tell because they're ashamed or embarrassed or afraid that they'll get in trouble.

Physical Abuse

Parents sometimes do things that hurt kids. For instance, some parents say things that hurt kids, such as calling them a mean name. Some parents do things that hurt, such as hitting or pushing. Most parents don't do this because they're bad or mean. Most of the time they do this because they're trying to teach kids something or are trying to keep kids from hurting themselves. However, this isn't the right way for parents to teach. Some kids may believe that they're responsible when their parents hurt them, but that’s not true. All kids misbehave sometimes and do things that their parents don't like. You're no different from other kids. It's important to remember that no matter what you do or say, you're not responsible for your parents' or any other adult’s behavior. You're only responsible for yourself and how you decide to behave.

Witnessed Violence

Sometimes kids blame themselves when their parents fight and argue. It's really important for you to know that it’s not a kid’s fault when grown ups disagree. Your parents [or other caregivers] should never hit each other, even when they're really mad. People who live together disagree about lots of things, and it's 'ok' to be angry. But, there are better ways to handle things than hitting and yelling at each other. It's your parents' (or appropriate adults') job to find better ways to handle things when they're feeling mad at each other. Just remember, it's ok to be mad, but it's not ok to hurt someone."

Getting Parents On Board

It's really important for us to provide your child with correct information about healthy sexuality. We want to give her information so that he/she can feel good about his/her body and positive about sexuality.

If the child's been sexually abused, you can say "Unfortunately, she's been given some incorrect information because of her sexual abuse."

For non sexually abused kids: "A lot of kids have incorrect information about sex and their bodies, and this can be very confusing."

You may worry about putting ideas into his/her head, but kids know a lot more than we think!

If the child's been sexually abused, you can say "Unfortunately, even though it's hard to think about, the sexual abuse has made your child aware of, and probably confused about, sex."

You may also be worried that if we talk about sex, we're kind of giving her permission to go out and have sex. What's important to understand is that your child is going to be curious about sex and us talking to her about it isn't going to increase the likelihood that she'll be sexually active. Also, we're not going to just give her facts about sex. We're going to work together to be sure that we give your child correct information AND also share your family's values about sexuality.

Child Sexual Abuse (CSA) Fact Sheet

Parenting

Providing psychoeducation to parent

We have already talked about how children often react to traumatic events with anxiety and distress. Other common reactions are disruptive behavior, aggression, anger, or having trouble following rules. Fortunately, several effective strategies are available for parents to use to deal with these types of behavior.

Teaching parents how to use praise

Praise is a valuable tool parents can use to increase their child's desirable behavior. Most children respond well to praise or positive attention, which is why it is important to know how and when to use praise effectively.

The first thing to remember is the difference between labeled and unlabeled praise. "You're a great kid!" and "Good!" are sometimes helpful, but they are unlabeled and it can be unclear to the child what you liked about their behavior. This is why it is better to use labeled praises instead of unlabeled praises. A labeled praise is specific and it tells the child what you are praising. An example of a labeled praise is: "I like how you took out the garbage the first time I asked." This example is clear in terms of what the parent was praising—the parent liked that the child took out the garbage, and especially appreciated that the child did not need to be told more than once to do so. It is also important to praise desirable behavior as soon as possible after it happens. The more immediate the reward, the more the child will be affected by it.

One of the most important rules is to be consistent. Children's behavior is most difficult to manage when they have unpredictable rewards and consequences for their behavior. This does not mean that you must praise a behavior each and every time it happens. But, when possible, it helps to keep consistency at a high level.

This may seem unusual at first, but one of the hardest things for parents is to avoid criticizing their child while praising them. Let's use the example of the child taking out the garbage. If that same child usually does not take out the garbage the first time the parent asks, the parent might have been tempted to say instead: "I like how you took out the garbage the first time I asked. Why can't you do that every time?" The problem with this praise is that it will not reward the child's good behavior as effectively as in the example above.

Last, but not least, it is important to avoid sounding robotic when praising your child. An enthusiastic praise can go a long way toward rewarding your child's desirable behavior.

Teaching parents how to use active ignoring

Children often will do something undesirable in order to get attention from parents, even if it is negative attention. It is easy and common for parents to attend and respond more often to undesirable behavior than to their child's desirable behavior. By doing this, they may be rewarding their child's undesirable behavior without realizing it. For this reason, it is important to use praise for desirable behavior and active ignoring for undesirable behavior. By active ignoring, I mean that you avoid reacting to the child's behavior in any way, positive or negative. You are not fully ignoring the behavior if you make eye contact with the child or react to the child's behavior in a way that shows emotion through language or facial expressions. When you remove all forms of attention, positive or negative, the child will learn that they will have to engage in other behaviors in order to get your attention. Very importantly, NEVER ignore dangerous or unsafe behavior. You should only use active ignoring to decrease undesirable, non-dangerous behavior.

Teaching parents how to use timeout

Another strategy that is effective in decreasing undesirable behavior is 'timeout.' You've probably heard about timeout before, and you may have even tried it with your children. But, timeout is a bit more complicated than most people think, and unless you were taught how to use it by someone with lots of skills and experience, we may need a refresher on the effective use of timeout. The primary goal of timeout is to remove a child temporarily from a reinforcing environment or situation in order to decrease an undesirable behavior. Timeout should not be done in a crowded room. It should be done in a quiet, un-stimulating room, and should last only a few minutes. Some experts recommend that it should last, at most, for one minute for every year of the child's age (e.g., a 6-year-old child would get a 6-minute timeout). Other experts consider a 3-minute timeout to be long enough for most children aged 7 years or younger.

Teaching parents other contingency management strategies

A behavior chart is another useful tool to manage children's behavior. You can arrange it so that you specifically pick behaviors that you would like to see more often. Always try to frame goals in a positive way. For example, instead of setting a goal to "stop being mean to your brother when he wants to play with you," the goal can be framed more positively, such as "sharing toys with your brother." A goal can be set for this, say, 3 times per week or more, and stickers can be used each day to document whether or not the child shared his toys with his brother on that day. At the end of the week, the stickers are added up, and if the goal is met, the reward is earned. Parents can be creative with the types of behavior that they pick for behavior charts, but it is most helpful to:

  • a. be consistent
  • b. frame goals positively
  • c. set short-term goals (use one day or one week rather than one month)
  • d. follow through with rewards

If the reward at the end of the week is ice cream, be prepared and avoid postponing the reward. The behavior chart is most likely to be effective if parents follow through consistently and predictably.

Relaxation

Explain rationale for controlled breathing

Today we're going to be learning a way to help ourselves calm down and control our nervous and upset feelings. I'm going to show you a special way of controlling the way you breathe that can really help you calm down and feel better. When you learn to control your breathing, you'll find that it's much easier to control your emotions and calm down. It's also something you can do anytime and anywhere. When you get good at it, we'll have you show your parent how to do it, too.

Demonstrate proper body positioning

OK, let's get in a comfortable position. Can you sit like I am? Now, put one of your hands here, right above your belly button, and the other up here on your chest.

Demonstrate proper breathing technique

Now, let's concentrate on our breathing. When we breathe in, the hand on our tummy should move up, and when we breathe out it should move down. The hand on our chest should stay still and not move the whole time. This means we are breathing correctly... Okay, now that you're getting the hang of it, let's try to breathe more slowly when we breathe out than when we breathe in. I'll count while we practice, and let's see if I can count higher when we're breathing out than when we're breathing in.

Introduce relaxing word

Now that we've learned the helpful, calming way to breathe, let's try to add a way to keep our thoughts and minds calm as we're breathing. You keep breathing like you are, but each time you breathe out, I want you to say the word 'Calm' to yourself. I want you to try to concentrate on the word calm. If you have other thoughts pop into your head besides 'calm,' try to picture them floating away with your breath as you exhale.

Explaining the rationale for PMR

Sometimes we all feel a little on edge, or nervous. When we have those feelings, our bodies can sometimes get tense or tight. This is an uncomfortable feeling - sometimes it even hurts to be tense. To help get rid of those tense feelings, we're going to figure out a way to help you learn to relax your body. This will help you feel looser and calmer.

Sample instruction for young children/full body relaxation

Have you ever seen spaghetti noodles before they are cooked? What do they look like? Right, they are very stiff and not relaxed at all. How about spaghetti after it's cooked, what is that like? Right, bendy and twisty. Well, that's what I'd like us to do. First, we'll pretend to be uncooked spaghetti and be very tense and standing up very straight. And then we'll be cooked, loose and relaxed spaghetti. Good! OK now...Let's see you do it. Uncooked spaghetti (pause a few seconds)... Cooked spaghetti.

Sample instruction for older children/progressive muscle group relaxation

OK now that you are comfortable, I'd like you to listen carefully. I am going to be making you aware of certain feelings of tension in your body and then showing you how to reduce those tensions. Watch the movements I make and then make them yourself. First, point your toes back up toward your head. Feel the tension that occurs in your feet, ankles, and lower legs. Pay close attention to the feelings of tightness and tension. And now relax your feet, let them return to their normal position. Feel the difference in your feet, ankles, and lower legs; where it was tense just a moment ago, there is now a feeling of relaxation. Now straighten your right leg and lift it off the chair. Feel the tension on the top of your leg and also in your stomach. Pay attention to that feeling of tension. And now let go, let your leg relax and return to the chair, and note the difference between the relaxation you now feel and the tension that was there before.

This same basic instruction is then given for each major muscle group moving up the body, such as arms/biceps, stomach, shoulders, neck, face, and eyes/forehead.

Affect Identification & Regulation

Explain rationale for feelings identification

Today we are going to learn ways to help talk about feelings. We all experience lots of types of feelings. For many children who have experienced abuse, some feelings may feel very strong and may be difficult to cope with at times. Learning how to talk about these feelings can help you talk to others about these feelings and can help you learn to cope with them better.

Then we are going to talk a little about how we know we are having these feelings and how we know others are having these feelings. This will help make it easier to talk about feelings in therapy and with others.

Have the child identify as many feelings as possible

The first thing we are going to do is to come up with a list of feelings, just so that we both know the different names we use for different feelings. OK, let's see how many feelings we can come up with. Name as many feelings as you can and I will write them all down in the next one/two/three minutes.

[Child names feelings and the therapist records them in a list.]

Great job! You came up with (number) different feelings! Now let's talk a little about each feeling you named. The first feelings on your list were 'happy'. Tell me how you know when you are happy or when others know you are happy.

Prompt for physical indicators such as smiles, eyes squint, laughter, etc.

Great! Now let's talk about the next feeling on your list: 'sad'. How do you know when you are feeling sad or when others are feeling sad?

Prompt for physical indicators such as crying, redness in face, tears, sobbing, etc.

Great! Now let's try the next one: 'mad'. Tell me how you know when you are mad or when others are mad.

Prompt for frowns, feeling tense, yelling, heart beating fast, redness in face, etc.

"Good, now let's try 'scared'. Tell me how you know when you are feeling scared."

Prompt for a frightened look, heart beating rapidly, shaking, cold clammy hands, sweating, shortness of breath, screaming, crying, etc.

Go through all feelings on the list. If children have a hard time coming up with physical indicators, therapists can model naming physical indicators they notice when they are having the feeling being discussed.

Teach the child how to rate the intensity level of an emotion

You did a great job naming and describing all of those feelings. Now we are going to talk a little about rating how strong we feel emotions. Sometimes we have very strong feelings and sometimes they are not so strong. For example, sometimes we feel a little angry and other times we feel very, very angry. We are going to figure out a way to talk about how strong the emotion we are feeling is. We call it a SUDS rating. We rate feelings from '0' to '10,' with '0' being not feeling the emotion at all and with '10' being feeling the strongest possible feeling we have ever had in our life. For example, for feeling scared, a '0' means not having absolutely any feelings of being scared at all; on the other hand, a '10' would mean feeling the most scared you have ever felt in your life.

[It is important to establish the anchors on the scale as being the absolute extremes to reduce the tendency to rate one side of the scale or the other.]

Now, let's practice. You told me about that time when the dog was chasing after you and barking and you really thought the dog was going to bite you. You said that you were very scared. Using the SUDS scale from 0 to 10, how would you rate how scared you were?

[If the child says 'a 10,' emphasize that this means that this is the most scared he has ever been. Other examples of when the child has reported being scared can be used as comparisons to achieve some variability on the ratings.]

Now let's talk about how you felt when you were in the waiting room before today's session. You said you were scared because you did not know what we were going to talk about. Use the SUDS scale, how scared were you."

[Help the child to give the situation a realistic rating, comparing it to other situations that were more or less scary to the child. Continue this procedure for other feelings, including angry and sad, which are more likely to be elicited in traumatic situations.]

Teach the child how to express feelings appropriately in various situations

Therapist: "Let's talk a little about the ways that we express emotions and the most helpful ways to express emotions. Let's think of a situation that made you feel scared."

Child: "When I saw someone on TV who looked like my uncle" (who sexually abused the child).

Therapist: What did you do?

Child: I went to my room and cried.

Therapist: Did you tell anyone how you were feeling?

Child: No, I just went to my room and cried by myself.

Therapist: Did crying by yourself make you feel better?

Child: Yes, but I was still scared and I had bad dreams about him that night.

Therapist: Sometimes crying can make you feel better, but there are other things that you can do to make you feel better. Talking to someone else (friends, parents, siblings) about it can sometimes make you feel better. Writing about it, drawing about it, or some other form of art can sometimes make you feel better. There are lots of ways to express your feelings that can help to make you feel better than just holding them in.

Cognitive Coping

Introducing Thought-Feeling Difference

We have spent some time already talking about different types of feelings, the way that different feelings make our bodies feel, and the way we act when we feel certain things.

[Provide some relevant, child-specific examples from the Affect Identification and Regulation module.]

Well, feelings are not only related to our bodily sensations, but also to the thoughts that we think in our head. If a person gets a good grade on a test, they may feel proud or happy. Some thoughts that can go with proud and happy feelings are 'Good for me!' or 'I am really good in this subject,’ and ‘I can't wait to tell my parents about it.' These thoughts are different from the way your body feels, and the big smile that is on your face, but thoughts and feelings are related to one another. Can you think of another feeling? When would someone feel that way? What kinds of thoughts would a person have in that kind of situation?"

Reviewing Thought-Feeling Difference (if needed)

What do you remember about the difference between thoughts and feelings?

If the child gives a clear, accurate answer, you can say:

"Great! I'm glad you remembered the difference between thoughts and feelings. Today, let's talk a little bit more about where thoughts come from, and how they go along with what we feel and how we behave."

If the child has difficulty providing an answer, introduce the following scenario:

"Let's see if we can refresh your memory a little. Suppose that a friend of mine did not say hello to me at school in the morning. I say to myself. "What a snob!" and I get really mad. What was I feeling? What was a thought I was having?"

Prompt the child again for remembering the difference between thoughts and feelings. If the child is still having difficulty, consider using the script for introducing the thought-feeling difference.

Outline the "Cognitive Triangle"

"OK, take a look at this triangle I'm drawing here. At one corner I'm writing 'Thoughts'. At this corner, I'm writing 'Feelings'. And here at the last corner, I'm writing 'Behaviors' (or 'Actions'). Do you see how they are all connected on the triangle? That is because in our real lives, our thoughts, feelings, and behaviors are all related to one another. And today I'm going to show you how."

[Use example to explain how thoughts affect behavior.]

OK, let me show you what I mean about how thoughts, feelings, and behaviors are related. I want to imagine this situation. You walk into the cafeteria and see two of your friends. As soon as they see you, they start laughing really hard. OK, that's the situation. Now, tell me what your thoughts would be if that happened.

Typically, the child will give a response that indicates some sense that the friends are laughing at him/her. However, if the child gives a more positive response, that's fine—just go with the response that the child gives you, as long as it is a thought, as opposed to a feeling. Correct any feeling statements the child makes by saying, for example, "Sad? OK, sad is how you would feel (point to feeling point of triangle), but can you tell me what you would be thinking?" If the child remains stuck on feelings, you can suggest a thought: "Right, you really would feel sad. Sometimes when people in this situation have sad feelings, they might be thinking 'My friends are laughing at me.'" Once the thought is identified, write it on the diagram next to the feeling point of the triangle.

OK, you would think 'Why are they laughing at me? Do I look stupid?' That's a thought. Now (trace along line to feeling) ... what kind of feeling would you have if you thought 'Why are they laughing at me?'

Write down the feeling named next to the feeling point of the triangle.

"Good that's a feeling that you might have if you thought that your friends were laughing at you. Now I want you to tell me what you would do if you felt that way?" (Point to 'Behavior' corner of the triangle.)

Write down the behavior next to the feeling point of the triangle.

"Now, let's imagine the same situation of walking into the cafeteria and your friends are laughing really hard. Can you think of another thought that you might think? Maybe a thought that was less negative?"

Write down the new thought either next to the original thought in a different color ink, or on a new piece of paper with the cognitive triangle drawn on it. You should feel comfortable prompting the child with a more helpful cognition, if necessary. You can do this by asking questions like: Can you think of any other possible thing that these friends might be laughing at other than you? Is it possible that someone told a really funny joke right before you walked in? Once the child has identified a thought, continue on with the Feelings and Behavior corners of the triangle as above.

"OK, let's review. We took the same situation, but wound up with very different feelings and behaviors, just by changing the way you think about the situation. Sometimes it can be very difficult to find a different, more accurate, or more helpful way of thinking, but it's definitely worth it to try. I wonder if we can come up with some other examples of when you can try this in your everyday life, and see if we can make a difference."

Generate scenarios and have child identify thoughts, feelings, and likely behaviors

"Can you think of a time recently when you got upset about something? Maybe a time when you were embarrassed, or scared, or angry?"

You should feel comfortable suggesting any problem situations that you are aware of. Try to start with more minor examples first. The goal is not to "fix" all the child's unhelpful thinking right away, but to show him or her how to alter it. Once the child generates a situation, proceed on a new cognitive triangle diagram as above.

Help child generate more accurate or helpful thoughts

"What other thoughts can you come up with about what happened? Is there another way to think about what happened? How would that different thought make you feel?"

Sometimes a child will provide another obviously inaccurate thought when prompted to generate something new. When that happens, it's useful to try to get the child to examine the thoughts in terms of their accuracy. Don't bother trying to dispute things that really are true (e.g., if a child says, "I failed the science test and that means I'm stupid," it's pointless to try to dispute the fact that the child failed the test). Instead, use progressive logical questions (also called the Socratic method) to examine the accuracy of the thought and help the child come to a different conclusion. For example:

Therapist: "What makes you think someone is smart?"

Child: "They get good grades and don't fail tests."

Therapist: "What else would tell you someone is smart?"

Child: (shrugs, rolls eyes)

Therapist: "Well, they might solve problems well. Or, maybe they are good at reading and writing. Do those things make you smart?"

Child: "I guess."

Therapist: "That's interesting. Because, you know, you did fail this test, but I bet you've gotten good grades at other times before. And your mom told me you are big help at solving problems, like when she can't figure out the computer. And I know from what we've done together that you're good at reading and writing."

Child: "So? I still failed the test!"

Therapist: "Yes, but based on the definition we have of what it means to be smart, it sounds like we agree that you aren't stupid at all. In fact, you're pretty smart! So, you can't have failed the test because you aren't smart. What could be another reason you failed the test?"

This technique is sometimes difficult to do well and requires you to think well on your feet. It's a good idea, to the extent that it's possible, to be prepared for the kinds of unhelpful or inaccurate thoughts the child might generate. Don't be afraid to take your time to think before challenging a child's cognitions.

Discuss how to apply this skill to real life

"Also, when you find yourself getting upset next time, try to ask yourself, 'What is it that I am thinking about this situation?' Then try to ask yourself if that thought is accurate, or if it is helpful to you. If not, try to think of a different way of thinking about the situation. This can change the way you feel and act in a situation that could otherwise be upsetting."

"Now, this is not a simple thing to do because you can't just say, 'Presto! Now I think different', and have all your problems disappear. It's something you have to work at and learn to do. When do you think you might try this in your everyday life?"

Trauma Narration & Processing I

After deciding on the format for the narrative and creating a “Table of Contents,” begin completing the chapters. We recommend saving the very last chapter, which looks toward the future and may talk about what’s been learned in treatment, until the very end.

Ask-Listen-Repeat-Write Down

Which part of the book/narrative would you like to work on today? Looking over the table of contents we developed, it looks like you could work on Chapter 2, Chapter 4, or Chapter 5. Where would you like to start?

Okay, Chapter 4 is about how your mom found out that your uncle was abusing you.

(Ask) Tell me about what happened that day.

(Listen) You may need to encourage the child to elaborate if he gives a short answer, or you may need to encourage the child to slow down if she gives a very long one.

(Repeat) So, you said you were texting with your best friend and telling her what happened, and then your friend’s mother took her phone away because she wasn't supposed to text at dinner, and your friend’s mom saw what you were texting about. Then your friend’s mom called your mom. Is that about right?

(Write Down) Okay, let’s write that down. Either you or the child can do the writing, depending on factors like age, willingness to write, etc.

Next the Ask-Listen-Repeat-Write Down cycle is repeated until the section of the narrative is complete

(Ask) Ok, so, what happened next? …

Elaborating the narrative with thoughts and feelings, if necessary

OK, you did a great job of telling me what happened when your mom found out about your uncle touched your private parts. I’m wondering a little bit about what that might have been like for you, about the thoughts and feelings you were having at that time. Let's read through what you have written again, and I may ask you about that.

Then, as the narrative is reviewed, you can repeat the Ask-Listen-Repeat-Write Down sequence as it pertains to the thoughts and feelings the child experienced during the events of the chapter.

You said your mom started yelling when she was on the phone and then came into the room where you were doing your homework.

(Ask) What did you think was going on? How did you feel about the way she was acting?

(Listen) You may need to encourage the child to elaborate some. You can do this with minimal encouragement, like just saying “Mm-hmm?” or “And then?”


(Repeat) So you thought “what is the matter with mom!?” and you were feeling a little bit nervous. Right?

(Write Down) Okay, let’s add that into the story. We can write it down right here.

Next, repeat the Ask-Listen-Repeat-Write Down sequence as needed to complete the section of the narrative.

(Ask) Okay, so when your mom started yelling her questions at you about your uncle, what kinds of thoughts and feelings did you have then? …

Trauma Narration & Processing II

Introducing the Best Friend Role Play

There’s part of your narrative that I wanted to talk about a little bit more. You did a great job talking about what it felt like when your uncle touched your private parts. And you said that a thought going through your head when that happened was “I am gross and disgusting.” Tell me a little bit about that thought…

I see. Let’s try something. I’d like you to imagine that your best friend came to you and told you that her uncle touched her private parts, and that because of that abuse she thought she was “gross and disgusting.” How do you think you would react to that? …

Let’s see what would happen. I’m going to pretend to be your best friend, and you get to be you, and we’re going to have that conversation. You just need to react to me as if I were really your best friend. Say to me exactly what you’d say to her, and I will say what I think she might say to you. Okay?

It’s interesting that you would challenge your best friend to think differently about herself differently after being abused by her uncle. Is that something you think can apply to you, too?

Other Cognitive Processing/Socratic Strategies

Ask about evidence:
  • How do you know that’s what your classmates are thinking? Has anyone ever said that to you?
  • Of all the people you consider to be your friends, about how many would you say have said something like that to you?
Seek clarification:
  • Tell me more about why you feel or think that way.
  • When you say “unlikeable,” what do you mean?
  • You’ve said you’ll never trust someone again. Explain that to me some more.
Ask about assumptions:
  • What do you think that reason this trauma happened might be?
  • Why do you think some kids experience physical assault and some don’t?
  • You seem convinced that something better or less awful would have happened if you had acted differently in this situation. Tell me more about that. How can you know?
Help analyze the implications of unhelpful beliefs:
  • So, if you believe that you will never be able to trust someone again, how do you think that might affect you as you get a little older?
  • Have you thought about what it might mean if you go through the rest of your life thinking that no place is safe/ that no one will like you/that you’ll never have a family? What are some of the positives about thinking that? Are there any negative aspects to thinking that way?

In Vivo Mastery

Creating a hierarchy

It sounds as though you’re still having some problems using the bathroom on your own, particularly at school. Let’s talk about that to help me understand what’s going on, and to help us figure out a way to help make that better.

Are there times or places when you can use the bathroom without being nervous or afraid? Tell me about those.

What kinds of things make you the most nervous about using the bathroom? Is it better at home? Where is it worst? What about when other people are there – does that make it better or worse for you?

When do your nervous feelings start – like, when you think about having to use the bathroom, when you are walking to the bathroom, when you get in the bathroom, or what?

Okay, keeping that stuff in mind, let’s try to put things in some kind of order, going from most scary to pretty much totally not scary. I think this is what you said was the most scary situation for you – being in the bathroom with the lights off away from home, like at school.

Here’s what you said was the least scary – standing in the doorway of your bathroom at home.

Let’s put the rest of what we talked in order.

Using “10 seconds more”

When you are trying out a situation on your list, it’s going to make you nervous or scared. That’s on purpose – if the situation isn’t a little bit scary for you, we should probably move up the list to an item that’s higher on the scale. So what do you think you should do when you feel scared? (Some kind of review of the coping strategies that have been used during PRAC would be appropriate – relaxation, deep breathing, imagery, etc) Great – I want to teach you one more thing that can be really helpful.

The first thing I want is to try something. Let’s count 10 seconds (for younger kids, it’s okay to do 5 seconds). Did that seem like a long time? It went by pretty fast, right?

If you are trying one of these exercises and you decide that you are just too nervous to stay any longer, ask yourself to stay for 10 more seconds. It’s just a little bit more time, and like we just proved here today, it goes by really fast. So, after you decide that you just can’t stay one second more, try to hold out for 10 more seconds.

(Be sure to include the caregiver in this instruction, as well. Caregivers can be great resources for encouraging kids to cope with their anxiety in In Vivo exercises)

Conjoint Sessions

Starting the session

We’re here today to listen to Anita share her trauma narrative with us. She’s been working really hard on this, and she’s done a really good job telling her story. I’m really excited to have her share it with you. But first, I want to go over how we’re going to do this. When I ask her to start, Anita is going to read us her trauma narrative. We’re going to pay attention and listen quietly, without interrupting. Anita, if you want or need to take a break, that’s okay. Or if you want some help with something, just let me know. But I know from watching you practice that you’re ready to do this. When Anita is done, it’ll be our turn to share our reactions with Anita. Then, after that, we’ll see if anyone has any questions or things that they want to talk about. Does anyone have any questions before we get started? Okay, Anita, go ahead and share your story with us.

What if you need to interrupt due to problem caregiver behavior?

In general, conversations about inappropriate caregiver reactions, such as being overly emotional or expressing doubt or skepticism about the narrative, should take place out of the child’s hearing.

Okay, I’m going to ask Anita to stop for a moment. Anita, you’re doing a great job! But there are some things I need to speak to your grandmother about. Grandma, would you mind stepping out of the room with me so we can chat briefly? Anita, we’ll be back soon.

How to resume the narrative

Okay, Anita. Thank you for being patient while I spoke to your grandma. Would you like to start over from the beginning of the narrative, or just pick up where you left off? We’re ready and excited to hear the rest of your story!

Enhancing Safety

Correct Names of Body Parts

Your body is very special. It belongs to you. You have all kinds of different parts of your body—some parts of your body don't need clothes all the time, but other parts need clothes most of the time, even when you go swimming. These are your private parts. What do you call your private parts?

Then proceed to correct naming of body parts—can use diagrams and/or drawings to facilitate.

Healthy Sexuality/Body Awareness

Your body is very special and, it's ok to have sexual feelings. When you become an adult, you can enjoy having sex with someone who you love. That will be a very special thing. Sex with someone you care about is a positive, loving thing.

OK and Not OK Touches

Sometimes people have to touch your private parts for a good reason. For example, a doctor or nurse may touch your private parts during a checkup. Sometimes your parents may need to touch your private parts to put medicine on you if you're hurt or sick. NOBODY should touch your private parts for other reasons, even if it is someone you know and love. If you feel funny, strange, or uncomfortable about the way someone's touching you, you can tell that person, "NO!" Also, make sure you tell an adult about what happened, like a parent, or relative or teacher or friend—someone who you trust. Keep telling until someone listens to you!

Just to review—what are the 3 things you should do if someone tries to touch your private parts? You should:

  1. Say "No."
  2. Get away from the person.
  3. Tell a grownup you trust about what happened.
  4. Tell another grown-up if the first one doesn’t do something.

Remember, if someone tries to touch you, it is not your fault. Never be too afraid to tell what happened.

Identify a safety plan for potentially dangerous situations

"It's important for you to have a plan about what to do if you're feeling afraid or scared that something bad is about to happen. First, can you name some adults that make you feel safe?"

If child's having difficulty, can say: "How about your neighbor or teacher at school?"

"If something bad was happening or if you were worried or feeling unsafe, these are the people you should tell."

If age appropriate, help child write down phone numbers and find a safe place to keep this list.

"What about safe places you could go if something was happening at home? Can you go to your next door neighbor's? You can also dial '911' if there was an emergency—remember, it's important for you to feel safe and to be able to talk to any adult to help you."

Frequently asked Questions Concerning the Use of TF-CBT

This section presents answers to some of the most common questions therapists have about the use and delivery of TF-CBT.

1. Can TF-CBT really be used with very young pre-school children?

Yes. Several studies, including three randomized controlled trials, have included very young children, ages 3-5 years, and found significant benefits. Information from randomized clinical trials and clinical anecdotal reports by clinicians using TF-CBT indicate that abused and traumatized children as young as 3 years of age can benefit from TF-CBT. Obviously, the way one does TF-CBT with a 4 year old is different from doing it with a 14 year old. As with all treatments for youth children, adaptations for a young child's developmental capabilities have to be made. However, very young children can learn and work through all of the TF-CBT treatment components. For example, they can understand that they are not the only child to have experienced a similar set of traumatic events. They can learn relaxation and calming skills. They can learn to identify and distinguish thoughts and feelings, and understand the relationships between thoughts, feelings and behaviors. And they can construct a trauma narrative using techniques such as pictures, drawings, dictated narratives, and other approaches.



2. Can TF-CBT be used with children from diverse ethnic, racial, or cultural backgrounds?

Yes. TF-CBT has been found to be effective with children of diverse ethnic, racial and cultural backgrounds. Within the U.S. TF-CBT has been found effective with children from African American, Latino/Hispanic, Native American, and Asian American backgrounds. It has been used effectively with Spanish-speaking new immigrants. TF-CBT is being used successfully in many other countries, including those as diverse as Zambia, Tanzania, South Africa, Congo, Germany, Norway, Sweden, Pakistan, the Netherlands, China, Singapore, Japan, and Cambodia. Randomized controlled trials have demonstrated the effectiveness of TF-CBT in countries outside the U.S. The National Child Traumatic Stress Network has rated TF-CBT as being and excellent treatment to use with children from different cultural, ethnic or racial backgrounds. The TF-CBT model respects and recognizes the multiplicity of cultural values and the centrality of the family in designing treatment plans and implementing TF-CBT components.


3. Can TF-CBT be used with children who have a suspected, but not a definitive history of abuse or trauma?

TF-CBT is intended for use with children who have a confirmed history of at least one identified potentially traumatic event that has resulted in trauma-related symptoms. If there are serious questions about the validity of a child's history of trauma or abuse, TF-CBT should not be used until there is reasonable confidence that the child has experienced trauma. TF-CBT is not likely to help children who do not have a known abuse or trauma experience that can be directly approached in treatment. Every treatment component of TF-CBT engages children and caregivers in activities that require some level of acknowledgement of and gradual exposure to the traumatic experience. Therefore, if the abuse or trauma history is questionable, these treatment techniques cannot be done.

Cases not substantiated.

There may be situations where a child does describe abusive or traumatic events and has posttraumatic stress symptoms, but for technical, procedural, policy or legal reasons, the case is not substantiated, founded, or indicated by a social service or law enforcement agency. In those cases if a systematic clinical assessment results in a reasonable clinical opinion that the child did experience trauma in the past and has resulting symptoms, TF-CBT may be used even if child welfare or law enforcement authorities do not substantiate the case.

4. Can TF-CBT be used with children or youth who do not acknowledge or say they do not remember whether or not they have been abused or experienced a traumatic event?

There are situations when it is definitively known that a child did experience abuse or other traumatic incident at an age where they should remember it, but the child does not acknowledge it or says he or she does not remember it. Every treatment component of TF-CBT engages children and caregivers in activities that require some level of discussion of the traumatic experience. Therefore, for TF-CBT to be effective, the child will need to acknowledge the abuse or trauma, at least to some degree. A key clinical challenge is understanding why the child is avoiding acknowledging the abuse or trauma and helping them do so in a supportive and therapeutic manner.

However, a small number of children never acknowledge the experiences, even after good work has been done to reduce avoidance. It is not feasible to provide trauma-focused treatment for children who are completely unable or unwilling to talk about past traumatic events. An obvious clinical challenge is to differentiate these children from those children who will be able to eventually acknowledge these experiences, however reluctantly, and work through them in therapy.

Reasons children may not acknowledge abuse or trauma.

Avoidance.

Avoidance is primary symptom cluster of posttraumatic stress disorder (PTSD). Children often will avoid talking about or even acknowledging traumatic events in order to avoid the reexperiencing and hyperarousal symptoms that accompany those memories. They sometimes develop a hard pattern of avoidance that is difficult to discern from genuine denial.
  • Is the abuse or trauma documented in records from prior services (e.g., mental health, children's advocacy center, forensic evaluator, child protective services, or law enforcement)? If so, avoidance is the likely cause of the lack of acknowledgement.
  • Traumas such as natural disasters, medical procedure trauma, animal attacks, or motor vehicle accidents usually can be reliably reported by the parent. However, the child still may not acknowledge any trauma history. Even though the parent can "prove" that the child experienced these traumatic events, if the child does not acknowledge that they occurred, it will be very hard for you to assess the presence of trauma-related symptoms in such children. Therapists may develop hypotheses about possible processes that may be occurring in these children that lead them to deny that these events occurred (e.g., forgetting; avoidance; traumatic brain injury; dissociation) and should attempt to determine which explanation seems to best fit with the child's clinical presentation.

Dissociation. By definition dissociation is an episodic, not a continuous state. If dissociation were the explanation for the child's denial of the traumatic experience(s) during the assessment, the child would at other times (i.e., when not dissociating) be able to acknowledge that the trauma did occur. If there are no times when the child acknowledges the trauma, it is unlikely that dissociation is the explanation.

5. Should TF-CBT be used with children who do not report significant symptoms related to their past exposure to potentially traumatic events?

TF-CBT should be provided only to children who have clinically significant mental health problems and impairment in functioning related to a history of abuse or other potentially traumatic events. Eligible children will have some symptoms of posttraumatic stress disorder (PTSD), but do not need to meet full diagnostic criteria for PTSD. In addition to PTSD symptoms, traumatized children often exhibit symptoms of depression, anxiety, fear, shame, guilt, self-blame or externalizing behavior problems. However, if a child does not have clinically significant symptoms related to past abuse or traumatic events, TF-CBT should not be used. Rather, another evidence-based treatment that is specifically designed for the symptoms they do have should be used.


It should be noted that making the decision as to whether a not a child has trauma symptoms can be challenging. Many children initially deny they have symptoms and may score in the normal range on standardized measure of posttraumatic stress symptoms. Clinicians should be aware that a presentation such as this may be due to avoidance behavior on the part of the child. Children may refuse to acknowledge that they are experiencing distress regarding their trauma experiences in an effort to avoid talking about it because it is highly distressing for them. These children actually may have severe trauma symptoms.

When children describe absolutely no problems after significant incidents that cause traumatic stress in most children, score 0 or exceedingly low on self-report measures of PTSD, or refuse to discuss their trauma experiences, clinicians must discern if the child is in fact highly resilient and any trauma symptoms are truly resolved or the are simply reluctant to talk about the past events and their thoughts and feelings about them. Avoidance and fear of consequences are common reasons for children not acknowledging trauma symptoms.

6. Can TF-CBT be used in cases where parents do not believe the child about the abuse or are unsupportive of them?

Even in cases of disbelief or poor support, it is important to remember that in most situations, parents are the most important people to children and are key to their recovery. Therefore, a goal of therapy is to engage parents, even disbelieving parents, in the process and build their ability to support the child. The most common reason that parents do not believe the child about abuse allegations is that the alleged abuser is someone the parent loves and depends on for emotional and possibly financial support. In these cases the alleged abusers often are family members, romantic partners of the disbelieving parents or other persons parents may genuinely doubt could ever harm the child. Because believing their children were abused by trusted persons would have significant psychological and instrumental consequences, parents often will look for other Answers for children's allegations that will allow parents to continue to hold onto both their children and the alleged abusers. These family situations present considerable challenges to doing TF-CBT. However, often family engagement and other techniques can be used to engage the parent and achieve an adequate level of support to do TF-CBT. If a parent remains unsupportive despite all efforts to engagement, another more supportive caregiver may need to be located.

7. Can TF-CBT be used for children who do not have a parent or long term caregiver available to participate in treatment?

Yes. The best outcomes are most likely to be achieved when both a child and his or her supportive parent or caregiver participate in TF-CBT together. Whenever possible, caregivers should be included in TF-CBT treatment. However, TF-CBT can be used successfully with children without caregivers and with children whose caregivers are unavailable or unwilling to participate in treatment despite all efforts to engage them.

One exception is for children with significant behavior problems. For treatment to be effective, parents or primary caregivers must be included in treatment. Parent or caregivers involvement and engagement is necessary to developing and implementing effective strategies to change children's behavioral difficulties.

8. Can TF-CBT be used with children who live in chaotic and sometimes violent home settings?

Before trauma treatment can begin, a certain level of safety for the child needs to be established in the home. If the child is at risk of harm, social services should be notified and trauma treatment should wait for an acceptable level of safety. If the family situation is so chaotic, dangerous or even violent that these problems prevent the child or parent from being able to attend to the child's trauma-focused treatment, the family should be provided services to address these more pressing needs before offering trauma-focused treatment to the child. If you only offer TF-CBT to such a family, they would likely fail to follow through with this treatment recommendation because it would not be addressing the family's most urgent needs.

However, some homes are chaotic and unpredictable but do not rise to the level of threatening the child's safety. In those cases, TF-CBT, particularly the parental components, can be used to help bring more stability to the home. If the child and parent are able to focus on the child's needs and complete the therapy procedures, TF-CBT can be beneficial even in unstable and unpredictable homes.

9. Can TF-CBT be used with children who live in foster care or kinship care?

Yes. Living in a stable home with permanent parents or caregivers is not required for a child to benefit from TF-CBT. TF-CBT has been found to be effective with children living in foster care, kinship care, homeless shelters, and other alternative living situations.

TF-CBT typically takes 12-20 sessions to complete. If it is likely that the child's current placement will be disrupted before treatment can be completed, the TF-CBT skills-based components (PRAC) can be provided during this time. These skills often will be helpful in managing the stress associated with the transition from one placement to the next.

However, the trauma narrative should not be started if the child cannot complete it before the living situation is changed.

Choosing a caregiver to involve in treatment can be difficult when children have unstable or changing living situations. The basic principle to follow is, caregivers who are likely to be with the child the longest should be involved in treatment.

For some children, more than one set of caregivers may be involved in treatment over time as their living situation changes. For example if a child is currently in foster care, but the treatment plan is for the child to return to the care of the biological parents relatively soon. In those cases, involving both foster and biological parents at the proper times may be necessary.




10. Can TF-CBT be used with children or youth who live in institutional settings, such as residential treatment centers, group homes, or juvenile justice facilities who often have histories of multiple traumatic experiences and complicated clinical presentations?

Yes. TF-CBT has been implemented successfully in institutional settings. Children residing in residential treatment centers, group homes, juvenile justice facilities and other institutional settings frequently have experienced traumatic events and have clinically significant symptoms of PTSD and other trauma-related problems. Therefore, TF-CBT is indicated in these cases. The biggest challenge in using TF-CBT in institutional settings is that there may not be a parent or caregiver readily available to participate in treatment or parental or caregiver involvement will be limited due to distance or institutional policies. If a parent or caregiver cannot travel to the facility, they often can participate electronically by telephone or video conferencing. For children with no available supportive caregiver, direct care staff may be used in that role in treatment.

11. Should TF-CBT be used for children with severe behavioral problems?

Abused and traumatized children often have behavior problems that are part of the expression of trauma symptoms. Because of this finding, TF-CBT includes components for teaching caregivers effective behavioral management techniques. Under most circumstances, TF-CBT can successfully address both traumatic stress symptoms and difficult behavioral problems, especially if those problems primarily developed during or after the traumatic experiences. Research studies evaluating TF-CBT with children and adolescents repeatedly have demonstrated significant behavioral improvements in response to treatment.

However, there are some case circumstances in which children or youth behavior problems are so severe and disruptive that more intensive behavior management therapy or even a restrictive environment is indicated. Situations such as repeated violence against others, daily substance abuse, hurting animals, fire setting, serious criminal behavior, or dangerous behavior may warrant such therapy. Often in cases of severe behavior problems, neither the child nor the caregiver can focus on trauma treatment because of ongoing disruption due to severe behavioral difficulties. Treatment may be interrupted by day program or in-patient stays, repeated school suspensions, or even incarceration. In these situations, the general principle is that the problematic behavior should be approached first, directly managed, and brought under control prior to beginning TF-CBT.

12. Can TF-CBT be used with children with developmental delays?

It depends on the nature and severity of the delay. Children with severe communication disorders or those who are so cognitively delayed that it is difficult for them to communicate or process basic thinking are not good candidates for interactive talk therapies, including TF-CBT.

If the child has a more common mild to moderate intellectual delay that causes them to function with the abilities of a much younger child, at least functioning at an age 3-4 years level, then TF-CBT often can be used. The same adaptations you would make for a very young child with limited cognitive, abstraction, and communication abilities can be applied with cognitively delayed children.

13. Should TF-CBT be used when children are receiving other mental health interventions?

In some situations you can provide TF-CBT to children who are receiving concurrent mental health interventions for problems unrelated to trauma. Some questions to consider are:

  • Are there significant theoretical or practical differences between the other intervention and TF-CBT that will lead to confusion for the family if they receive both treatments concurrently? Will the family have to choose which therapist or provider to listen to if conflicts arise?
  • Is the time required to attend and participate in multiple programs or interventions so prohibitive that it is likely to negatively affect treatment attendance or adherence and reduce the effectiveness of all interventions?
  • Are the other problems so severe and/or chronic that the child should not start trauma-focused treatment now?

If the answer to any of these questions is "Yes," providing TF-CBT concurrently with the other treatment may be problematic. An example where a concurrent intervention may work is in-home, wrap-around, behavioral management services that typically provide behaviorally-based interventions that are trauma-informed and consistent with TF-CBT parenting principles. Another is medication management. On the other hand, non-directive play therapy may not be a comfortable match with TF-CBT.