Elsevier

Child Abuse & Neglect

Practical Strategies

Trauma-focused CBT for youth who experience ongoing traumas

Abstract

Many youth experience ongoing trauma exposure, such as domestic or community violence. Clinicians often ask whether evidence-based treatments containing exposure components to reduce learned fear responses to historical trauma are appropriate for these youth. Essentially the question is, if youth are desensitized to their trauma experiences, will this in some way impair their responding to current or ongoing trauma? The paper addresses practical strategies for implementing one evidence-based treatment, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for youth with ongoing traumas. Collaboration with local therapists and families participating in TF-CBT community and international programs elucidated effective strategies for applying TF-CBT with these youth. These strategies included: (1) enhancing safety early in treatment; (2) effectively engaging parents who experience personal ongoing trauma; and (3) during the trauma narrative and processing component focusing on (a) increasing parental awareness and acceptance of the extent of the youths' ongoing trauma experiences; (b) addressing youths' maladaptive cognitions about ongoing traumas; and (c) helping youth differentiate between real danger and generalized trauma reminders. Case examples illustrate how to use these strategies in diverse clinical situations. Through these strategies TF-CBT clinicians can effectively improve outcomes for youth experiencing ongoing traumas.

Introduction

A number of evidence-based treatments are now available to treat children who experience trauma (www.nctsn.org). This paper focuses on one such manualized, evidence-based treatment for maltreatment-related traumatic stress responses, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT, Cohen, Mannarino, & Deblinger, 2006; www.musc.edu/tfcbt). TF-CBT includes components to enhance youth resiliency-based coping skills, actively includes parents or caregivers in treatment, and develops trauma narratives and cognitively processes the youth's personal trauma experiences. Many neurobiological systems change in response to child trauma experiences (Cohen et al., 2002, DeBellis et al., 1999) and are often manifested as problems with sleep, concentration, irritable outbursts, or somatic symptoms. Current knowledge is lacking about the impact of treatment on these biological-based vulnerabilities, or the interaction of therapy and repeated trauma on reversing these changes. For past traumas, relaxation, affective modulation and in vivo strategies are typically implemented to address biological-based hyperarousal symptoms (e.g., physiological reactivity to trauma cues, hypervigilance or over-attention to environmental threat detection, etc.). Parental support contributes significantly to success. Youth experiencing ongoing trauma may not be able to successfully apply coping strategies until they are able to differentiate between historical danger, realistic present danger, and over-generalized trauma reminders. The process of creating a trauma narrative is often critical to providing youth with the ability to make these distinctions. Trauma-focused treatments such as TF-CBT impart skills useful for coping with ongoing trauma, including awareness of and increased ease with coping with ongoing trauma reminders and recognizing traumatic responses. This may prove important to professionals in providing continuity of care, as well as reporting re-abuse that occurs in these youth.

Therapists often provide TF-CBT to children who have experienced past traumas such as child abuse or neglect, traumatic losses, or multiple previous traumas. However, many children experience ongoing traumas. Various forms of violence may be new or newly detected after TF-CBT treatment initiation. Typical types of ongoing traumas are domestic, community and school violence. For example, maltreated youth are at increased risk for high school bullying victimization (e.g., Mohapatra et al., 2010), which may include sexual harassment and physical attack, as well as the more common psychological abuse (verbal abuse, rumor-spreading, ostracizing, etc.). These potentially traumatic events are similar to child maltreatment in some ways (e.g., all tend to be chronic, all may have multiple perpetrators), and may re-surface prior posttraumatic stress responses. However domestic, community or school violence differ from child maltreatment in that no formal system exists to protect children from the former types of traumas. As a result, they rarely if ever result in legal child protective action or prosecution. Thus, beyond any protection families themselves can provide, few if any, external forces prevent these traumas from continuing. In a recent study of youth receiving treatment for Posttraumatic Stress Disorder (PTSD) symptoms related to their mothers' domestic violence, more than half of their mothers acknowledged that their youth continued to have ongoing contact with the perpetrators; youth themselves reported more frequent contact with the perpetrators, with 40% acknowledged repeated trauma exposure during treatment (Cohen, Mannarino, & Iyengar, 2011). Clearly, ongoing risk to the youth remains. Despite mandated reporting requirements and child protective services, child abuse may also reoccur during therapy. Two international studies of HIV affected sexually abused youth indicated that more than half of these youth lived with families where there were domestic violence perpetrators, and almost half (48%) had ongoing contact with their sexual abuse perpetrator (Murray et al., 2010, Murray et al., submitted for publication-a). This level of risk to the youth is problematic for their healthful development and severely challenges resilience processes (e.g., Cicchetti, Rogosch, Sturge-Apple, & Toth, 2010).

Mental health therapists often ask whether evidence-based, trauma-focused treatments such as TF-CBT are appropriate and helpful for youth who experience ongoing traumas. In particular, therapists are concerned about using the exposure-based components (e.g., gradual exposure, trauma narration and cognitive processing of traumatic experiences), which are typically used to gain mastery over memories and reminders about past traumatic experiences. Therapists question how youth can benefit from these exposure-based interventions that are supposed to "de-sensitize" youth to their past traumatic memories and experiences, if they are simultaneously experiencing repeated traumas in real life and thus being repeatedly re-sensitized to the same types of traumas. How exactly is TF-CBT used for these youth and is there any evidence that it works for these youth?

We have been conducting a series of TF-CBT treatment studies in the US and Zambia for children who were exposed to ongoing traumas including domestic violence (US) and multiple traumas related to domestic violence and HIV/sexual abuse (Zambia). Collaborative efforts between the authors, community/local therapists, and family members have helped us to develop practical strategies for implementing TF-CBT for these youth. The purpose of this paper is to share the practical strategies learned from these efforts, and to address the above concerns of therapists who are trying to help youth who are exposed to ongoing traumatic experiences. Youth experiencing ongoing traumas often have little time to reflect upon these experiences before the next trauma occurs. It is exceedingly difficult to see oneself and one's situation clearly while still being immersed within that situation. It is, therefore, important to help these youth to develop coherent narratives or self-stories with adaptive cognitions and contextualization even in the context of ongoing traumas. TF-CBT is an intervention designed to achieve these goals, and additional attention is needed when ongoing trauma is detected.

Section snippets

TF-CBT application for past traumas

In order to most clearly describe how these strategies are different, we briefly describe a case example, to illlustrate how TF-CBT is typically implemented for a youth who experienced past traumas. TF-CBT components and their typical application for past traumas are listed in Fig. 1.

Case example: Maya, a 12-year-old girl, experienced sexual abuse from approximately 5 to 9 years old by her biological father who is now incarcerated. Maya presented to treatment initiated by her foster mother's

Differences between past and ongoing traumas: Key issues for TF-CBT adaptation

There are three key issues to be recognized for TF-CBT use where there is risk for ongoing trauma to the youth. The first difference between past and ongoing traumas is the degree to which youth, their parents and therapists can realistically count on the youth's ongoing safety. As evident in the above case example, Maya initially did not believe she was safe from future abuse; however, her therapist could realistically address these maladaptive cognitions because Maya's current environment was

Collaborative projects implementing TF-CBT for ongoing traumas

The strategies described here were developed through collaboration with families (youth and parents), community therapists and other professionals providing services to these families in two settings. The Children Recover after Family Trauma (CRAFT) Project was conducted from 2004 to 2009 to evaluate the effectiveness of TF-CBT compared to usual child treatment in a community domestic violence center, the Women's Center and Shelter of Greater Pittsburgh (WCS) (Cohen et al., 2011). The project

TF-CBT strategy #1: enhancing safety early in treatment

From the start of both of the above projects, addressing safety early in treatment was identified as a priority for youth experiencing ongoing traumas by several stakeholders. The first application was to move the enhancing safety component to the start of treatment as depicted in Fig. 2. Therapists begin to implement this component at the outset of treatment by assessing children's immediate risk for repeated trauma exposure. This can be a daunting and sensitive task. For example, in the CRAFT

TF-CBT strategy #2: Enhancing parental engagement

As with any effective trauma treatment model, engagement is a critical part of TF-CBT (Cohen et al., 2006, pp. 35–43) since betrayal of trust is a core issue for traumatized individuals that successful therapy must address. Parents who have remained with abusive partners, have repeatedly returned to these partners, or who have gotten into repeated abusive relationships often believe that in these situations, there is more danger in leaving the perpetrator than in remaining. Therapists can

TF-CBT strategy #3: Optimally focusing the trauma narration and processing

Typical goals of the trauma narrative and cognitive processing include: (1) desensitizing youth to feared memories of past traumatic experiences and thus mastering phobic avoidance of these memories; (2) identifying and addressing maladaptive cognitions related to past traumas; (3) contextualizing past trauma into one's entire life experiences; and (4) preparing the parent to directly support the youth related to past traumatic experiences. Ongoing traumatic experiences provide new

Summary

Through collaboration with local community organizations, therapists, and family members, TF-CBT developers and trainers have developed practical strategies for applying this evidence-based trauma treatment for youth who continue to experience ongoing traumas and their non-offending parents. These strategies include: (1) focusing early and as needed on an ongoing basis during therapy on enhancing safety for youth and parent that is appropriate to the youth's developmental, emotional, and

Acknowledgments

We thank the Women's Center and Shelter of Greater Pittsburgh, The University of Lusaka and the counselors who participated in these projects. Most importantly we thank the families and children who participated in these projects for their assistance, courage and inspiration.

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