Trauma-Focused Cognitive Behavioral Therapy: Life After Freud

Trauma Focused Cognitive Behavioral Therapy (TF-CBT): How Far We've Come From Freud

How do we deal with trauma?

We all encounter trauma of one kind or another, but we are generally adept at coping with our mini-traumas.

The real challenge is learning how to address and heal from the truly traumatic experiences in life: sexual assault, witnessing extreme violence, living with domestic violence, combat experiences, etc.

Our ideas about what trauma is, how it affects us, and how to most effectively address it have come a long way from our early understanding, and there are now multiple options for treating trauma and helping those suffering from trauma to live their best lives.

 

Before you start reading this article, I recommend you to download these 3 Positive CBT exercises for free. With these exercises, you will not just be able to understand positive CBT on a theoretical level, but you’ll also have the tools to apply it in your work with clients or students.

You can download the PDF for free on this page: https://bit.ly/2VmfP5r

 

Understanding Trauma: Freud’s Psychoanalysis and More

Conceptualizations of trauma have changed quite a bit over time, as have the methods and approaches for treating it.

The word “trauma” comes from the Greek term for penetration or wounding, an indication of how serious the effects of trauma can be (Valent, 2003). Trauma was generally not at all well-understood, or even seriously considered as a psychological injury, until Freud’s psychoanalysis in the late 1800s.

Freud was one of the first to take a deeper dive into trauma, especially sexual trauma experienced by women when they were young. To Freud, early sexual abuse was often the cause of women’s troubles. Instead of blaming hysteria and other symptoms of trauma (as he saw them) on divine retribution or harassment from evil entities, Freud popularized the idea that trauma could cause lasting psychological issues like avoidance, repression, and neuroticism (Valent, 2003).

However, it is clear today that many of Freud’s theories fall short when reviewing the evidence. Trauma is not always sexual, and symptoms are frequently unrelated to sexual dysfunctions.

For example, psychoanalysis was applied heavily during the aftermath of World Wars I and II, helping “shell shocked” veterans who were suffering from what we now understand as Post-Traumatic Stress Disorder or PTSD (APsaA, 2018). Much of what we have learned about trauma and common responses to it comes from the work of psychoanalysts and researchers of trauma and psychoanalysis.

In addition to psychoanalysis, there are other, more modern ways of understanding and treating trauma. Cognitive Behavioral Therapy (or CBT) has made great strides in treating those suffering from the effects of severe trauma, and many clinicians have had great success with positive trauma therapy as well.

One approach that was developed specifically for young people suffering after a traumatic experience is Trauma-Focused Cognitive Behavioral Therapy. It does not have the long and illustrious history that psychoanalysis has, but it does enjoy the support of several efficacy studies and clinical trials.

Read on to learn more about this treatment for trauma in children and adolescents.

What is Trauma-Focused Cognitive Behavioral Therapy?

Trauma-Focused Cognitive Behavioral Therapy, or TF-CBT, is an evidence-based treatment program intended to help children and their families deal with the aftermath of a traumatic experience (Good Therapy, 2017).

General Cognitive Behavioral Therapy (CBT) offers effective methods for treating trauma-related disorders and promoting healing, but TF-CBT offers expanded methods, incorporates techniques from family therapy, and uses an extremely trauma-sensitive approach. TF-CBT is also relatively short-term, lasting no more than 16 sessions for most clients.

The Trauma-Focused Cognitive Behavioral Therapy approach is applied in a safe and stable environment to encourage clients to share their feelings and aims to help those who have experienced trauma learn how to manage difficult emotions in a healthier way. The therapist will prioritize skill-building for both the child and the parents, and assign homework for families to practice these skills (Good Therapy, 2017).

The 8 PRACTICE Components of TF-CBT

Trauma-Focused Cognitive Behavioral Therapy is administered in eight components comprising three distinct phases.

In addition to these eight components, there is another, complementary component for parents of the child in therapy. The parenting component consists of an individual parents-only session for each of the eight PRACTICE components. These sessions will help parents build their parenting skills and enhance child-parent interactions through techniques such as praise, effective attention, and contingency reinforcement schedules (Cohen, n.d.). These sessions are intended to help parents connect their child’s behavioral problems to the trauma they have experienced, a vital step towards appropriately addressing the issues and promoting healing.

TF-CBT begins with the stabilization phase.

Phase One – Stabilization

In phase one, the therapist will walk the clients through the Trauma-Focused Cognitive Behavioral Therapy approach, provide psycho-education about trauma and healing, and help them develop the skills they will need to promote meaningful healing and development.

P – Psycho-education

The first phase will begin with an important first step – learning about trauma. The parents and the child will all receive information on trauma and the common reactions to traumatic experiences. The therapist will go over Post-Traumatic Stress Disorder (PTSD) and common behavioral problems with the clients and ensure the child and parents that their reactions are normal and understandable and that their feelings are valid.

Finally, this component is wrapped up by encouraging the parents and the child that there is hope for recovery. The therapist will acknowledge that although it may be a long road and much effort may be required, it is possible to live a happy and healthy life once again.

R – Relaxation Skills

components of Trauma-Focused Cognitive Behavioral Therapy

The second component is relaxation skills. These are intended to help the child reverse the physiological arousal effects of the trauma they have suffered, although relaxation skills can also be taught to parents in the parenting session.

Relaxation skills and techniques that may be taught include:

  • Focused breathing
  • Mindfulness
  • Progressive muscle relaxation
  • Exercise
  • Yoga
  • Songs
  • Dance
  • Blowing bubbles
  • Reading
  • Prayer
  • Other fun/relaxing activities

 

These can be used at any time, but children will likely find them especially useful when trauma reminders pop up (triggers that bring up memories of the trauma).

A – Affective Regulation Skills

Similar to the relaxation skills component, this component is included to help the child learn some helpful strategies for identifying, modulating, and regulating any upsetting affective states that may arise, especially those that are a result of the trauma experience.

There are many affect regulation skills and techniques that can be covered in this component, including:

  • Problem-solving
  • Anger management
  • Present focus
  • Obtaining social support
  • Positive distraction activities
  • Using skills in relation to trauma reminders

 

C – Cognitive Processing Skills

The final component of phase one is the cognitive processing skills component. Like the previous two components, the intent is to help the child build the skills necessary for coping with their stress and achieving meaningful healing from their trauma.

Cognitive processing skills help the child to:

  • Recognize the connections between their thoughts, feelings, and behaviors.
  • Replace their harmful or unhelpful thoughts with more accurate or more helpful ones.

 

To identify which thoughts are harmful or unhelpful, the child may ask themselves two questions about a particular thought:

  1. Is it accurate?
  2. Is it helpful / Does it make me feel better?

 

If the answer to either question is “No,” the thought will likely be flagged for potential removal and replaced with a more accurate and/or more positive thought.

These skills are generally put to the test during the next phase when the child is constructing their trauma narrative.

Phase Two – Trauma Narrative

T – Trauma Narration and Processing

Trauma Narrative Trauma Focused Cognitive Behavioral Therapytrauma therapy

In this phase, the therapist will walk the child through creating a trauma narrative.

The trauma narrative is the child’s telling of the story of their traumatic experience(s). They are often quite difficult to begin, as the emotions engendered by the original trauma can come flooding back as the sufferer recalls the details of the event(s), but it will get easier as the process goes on.

The child may find it helpful to begin by focusing on the facts – the who, what, when, and where of the experience. Next, they can add the thoughts and feelings that arose during the experience. Once they are comfortable listing or describing their thoughts and feelings during the experience, they can move on to the most difficult or disturbing moments of their trauma. This will be difficult, but it is necessary to put together a comprehensive narrative of the trauma.

Finally, the child should take what they have produced so far and wrap it all up and create a seamless narrative, with the option of adding a final paragraph about how they feel now, what they have learned, and if they have grown from the experience.

As the child is working on their narrative, the therapist should keep the parent(s) updated in the individual parent sessions. Once the trauma narrative is finalized, the child can share the complete narrative with his or her parents.

Phase Three – Integration / Consolidation

In phase three, the aim is to consolidate the lessons learned, continue to build skills and improve connections, and prepare the family for future success.

I – In Vivo Mastery of Trauma Reminders

Trauma reminders are stimuli the child may experience in his or her everyday life that can bring up intense, painful, and debilitating memories of the trauma suffered. It is also possible for these reminders to skip the memories entirely and send the child straight into the physiological arousal that thinking about the trauma could provoke (causing the child to hyperventilate without knowing exactly why, for example).

The in vivo mastery component involves helping the child overcome their avoidance of generalized reminders and work towards mastering more specific reminders. The therapist will develop a hierarchy of reminders and work with the child to gradually master feared stimuli, working from least feared to most feared.

This component can start in the stabilization phase, but will take several weeks to complete.

C – Conjoint Child-Parent Sessions

During TF-CBT, the joint parent-child sessions are key opportunities for the therapist to help families reconnect and plan for continued healing and growth.

It is in these sessions that the child can share their trauma narrative with their parents, and work together on improving their communication both about the trauma and in general. These sessions may also help families address healthy sexuality and develop a family safety plan for potential future threats or crises (things like bullying, drugs, and domestic violence).

Once the parents and child are communicating in a more healthy and productive way, and once the child has worked through their trauma narrative and gained the skills necessary to cope with their trauma responses, the therapist can help the family move on to the final component.

E – Enhancing Safety

This component is all about taking the positive skills and insights gained through therapy and applying it to family life going forward. It is imperative that families come up with plans to deal with the stressors and trauma reminders that will undoubtedly arise in the future.

Families can come up with safety plans for specific situations and continue to work on valuable skills, like problem-solving, refusing drugs, and general social skills (Cohen, n.d.)

Treating PTSD & Traumatic Experiences: Trauma-Focused CBT Training

Treating PTSD & Traumatic Experiences Trauma focused cbt

If Trauma-Focused Cognitive Behavioral Therapy has piqued your interest, there are some great resources out there to help you learn more about implementing this type of therapy in your own practice.

The Trauma-Focused Cognitive Behavioral Therapy website (https://tfcbt.org) provides information on how to get certified in TF-CBT. There are eight steps that must be taken to achieve certification:

  1. Master’s degree or above in a mental health discipline.
  2. Professional licensure in your home state.
  3. Completion of the TF-CBTWeb training.
  4. Participation in a live TF-CBT training (two days) conducted by a treatment developer or an approved national trainer.
    OR
    Live training in the context of an approved national, regional, or state TF-CBT Learning Collaborative of at least six months duration in which one of the treatment developers or a graduate of our TF-CBT Train-the-Trainer (TTT) Program has been a lead faculty member.
  5. Participation in a follow-up consultation or supervision on a twice-monthly basis for at least six months or a once-monthly basis for at least twelve months. The candidate must participate in at least nine out of the twelve consultation or supervisory sessions. This consultation must be provided by one of the treatment developers or a graduate from our TTT program. Supervision may be provided by one of the treatment developers, a graduate of our TTT program, or a graduate of our TF-CBT Train-the-Supervisor (TTS) Program.
    OR
    Active participation in at least ¾ of the required cluster/consultation calls in the context of an approved TF-CBT Learning Collaborative.
  6. Completion of three separate TF-CBT treatment cases with three children of adolescents with at least two of the cases including the active participation of caretakers or another designated third party.
  7. Use of at least one standardized instrument to assess TF-CBT treatment progress with each of the above cases.
  8. Taking and passing TF-CBT Therapist Certification Program Knowledge-Based Test.

 

You can register for the test, contact TF-CBT page staff, and learn more about training at this link.

7 TF-CBT Workbooks & Worksheets

There are many different Trauma-Focused Cognitive Behavioral Therapy worksheets that you might find helpful for yourself or your clients, as well as a few comprehensive workbooks that walk the client through each aspect of treatment.

If your client is a child between the ages of six and fourteen, this workbook from TF-CBT experts Hendricks, Cohen, Mannarino, and Deblinger is a great resource. It includes information about TF-CBT treatment, trauma experiences and responses, and worksheets, exercises, and other activities that can complement a treatment plan.

If your client is a teenage girl who has suffered from sexual abuse, this workbook from Lulie Munson and Karen Riskin may be perfect for her. This self-help/complement to therapy is highly rated by therapists and provides an excellent guide for girls who are struggling.

A great resource for adults struggling with trauma is the PTSD Workbook from Mary Beth Williams and Soili Poijula. It’s not specific to TF-CBT, but there is a lot of overlap between TF-CBT techniques and discussions of PTSD causes, symptoms, and suggestions for healing. The workbook will guide the reader through interventions, activities, and exercises that can help those suffering from trauma to not only cope, but thrive.

If you’re more interested in one-off activities and exercises than comprehensive workbooks, there are many worksheets and handouts that you may find helpful. A few of the most popular and engaging worksheets are described below.

What is Trauma?

This handout is a great first step toward helping you or your client understand what trauma is, how it happens, and how it can affect your moods, thoughts, and feelings.

At the top of the handout is a quick definition of trauma:

“A powerful emotional response to a distressing event, such as war, an accident, the unexpected loss of a loved one, or abuse. Trauma can continue to cause both emotional and physical symptoms for many years after the event has concluded.”

A few of the biggest risk factors for trauma are listed next, including:

  • The traumatic experience was unexpected.
  • The trauma occurred during childhood.
  • The victim has experienced past traumas.
  • Feeling of helplessness during the experience.
  • The experience happened repeatedly, or over a prolonged period of time.
  • The victim is dealing with other major stressors, unrelated to the trauma.

 

The handout also includes some of the most common symptoms of trauma, although it also assures the reader that every experience with trauma is unique. Sufferers of trauma frequently experience:

  • Avoidance of trauma reminders, including memories
  • Exaggerated startle responses
  • Irritability, anger, and other negative emotions
  • Flashbacks to the traumatic event
  • Distressing dreams and other sleep problems
  • Self-blame regarding the traumatic event

 

Finally, the handout describes some of the most effective treatment methods for those struggling with trauma:

  1. Cognitive Behavioral Therapy: a common and well-supported treatment for trauma disorders.
  2. Exposure Therapy: a therapy in which the patient is exposed to reminders of their trauma in a gradual and safe way.
  3. Medication: can be used to treat many symptoms of trauma, including anxiety, depression, and insomnia.
  4. Other Treatments: Narrative Exposure Therapy, Eye Movement Desensitization and Reprocessing (EMDR), and group therapy have all been found to be effective in treating trauma as well.

 

To view this information for yourself or print it out for your clients, click here.

Thinking Mistakes

This handout lists some of the biggest “thinking mistakes” we make, also known as cognitive distortions. There are many distortions in our thinking that can creep up on us (see our piece on these distortions here), but these nine are the most common:

  1. Black and White Thinking: You tend to think of things in extremes – either you’re perfect or you’re a total failure.
  2. “Yes But” Thinking: You tend to ignore the positives in your life and focus only on the negatives.
  3. Mind Reading: You act as if you are able to tell what other people are thinking without checking with them first.
  4. Telling the Future: You act as if you can predict the future and know that something will turn out badly.
  5. Emotional Reasoning: You decide how things “really” are on the basis of how you feel.
  6. Labeling: You attach negative labels to yourself and call yourself names.
  7. Should Statements: You try to motivate yourself by thinking “I should do this” and “I shouldn’t do that.”
  8. Overgeneralizing: You make a conclusion about something on the basis of one or two things.
  9. Catastrophizing: You exaggerate the likelihood that something bad will happen, or you exaggerate how bad it would be if it really did happen.

To see examples for each distortion or print this handout for yourself or your clients, click here.

CBT Thought Record

This worksheet is an excellent tool for identifying cognitive distortions. Our automatic, negative thoughts are often related to a distortion that we may or may not realize we have. Completing this exercise can help you to figure out where you are making inaccurate assumptions or jumping to false conclusions.

The worksheet opens with space to describe the situation in which the negative automatic thought arose. The instructions are to identify where you were and what you were doing, as well as any other pertinent contextual information.

Next, you are instructed to rate the strength of the emotion or feeling the situation evoked on a scale from 0% (weakest) to 100% (strongest).

The third component of the worksheet directs you to write down the negative automatic thought, including any images or feelings that accompanied the thought.

After you have identified the thought, the worksheet instructs you to note the evidence, both for the accuracy of the thought and against the accuracy of the thought. This is a classic mechanism used in many situations and can help you to make an informed decision about the accuracy of your thoughts.

Next, you have an opportunity to create an alternative thought that can replace the automatic negative thought. Using the evidence for and against the initial thought, you can come up with a thought that is more accurate.

Finally, you are instructed to rate the strength of the emotion or feeling once again. The hope is that the intensity of the feeling has decreased due to the evidence-based evaluation of its accuracy.

This worksheet will be available for download soon.

Overcoming Avoidance: Facing Your Fears

overcoming avoidance trauma focused cbt

Getting over the tendency to avoid situations, people, places, and even thoughts that remind the client of the trauma is a very important step in overcoming trauma and growing from the experience.

This worksheet from Carol Vivyan can help the client identify their avoidant tendencies and come up with a plan to reduce their avoidant behavior.

First, the worksheet includes space for the client to write down anything that he or she fears and actively avoids, including situations; people; places; tv, radio, or internet sources; and thoughts, along with a distress rating on a scale from 0 (least feared or distressing) to 10 (most feared or distressing).

Next, the client is instructed to rewrite the list, only this time including the most feared or distressing item at the top of the list and the least feared or distressing item at the bottom of the list.

Once the list is organized, the worksheet directs the client to think about the least feared or distressing item and come up with ideas for how to start facing it. It may help to break it down into smaller steps. The client should write down what comes to mind, including any smaller steps they have decided on, along with any coping strategies they may use while facing this fear.

A table is included for the client to use in this step, with three columns:

  1. Feared situation
  2. Steps I need to take to face the feared situation
  3. Coping strategies I can use during the feared situation

 

Once the client has successfully completed this step for her or his least feared situation, the client should continue on for each item on the list. The process should begin with the least feared situation, then the second least feared situation, all the way up to the most feared situation.

To see this worksheet, click here.

A Take Home Message

In this piece, we discussed what trauma is, how it can affect us, and how it can be effectively addressed, especially in young people.

I hope you found this piece interesting and informative. If you are struggling with the effects of trauma right now, remember that most individuals who suffer from a traumatic experience go on to shed the debilitating symptoms and lead happy and healthy lives. There is hope!

Have you tried Trauma-Focused Cognitive Behavioral Therapy before, as a practitioner or a patient? What did you think of the treatment? Do you think we’re on the right track when it comes to treating trauma? Let us know your thoughts in the comments section below.

Thanks for reading!

  • APsaA. (2018). Psychoanalytic theory & approaches. American Psychoanalytic Association. Retrieved from http://www.apsa.org/content/psychoanalytic-theory-approaches
  • Cohen, J. A. (n.d.). Trauma-focused CBT for children and adolescents. Pittsburg State University. [Slideshow Presentation]. Retrieved from http://protectchildren.psu.edu/sites/network/files/Cohen.pdf
  • www.getselfhelp.co.uk
  • Good Therapy. (2017). Trauma-focused Cognitive Behavioral Therapy. Good Therapy. Retrieved from https://www.goodtherapy.org/learn-about-therapy/types/trauma-focused-cognitive-behavioral-therapy
  • www.psychologytools.com
  • www.therapistaid.com
  • Valent, P. (2003, August 30). Trauma and psychoanalysis. Deakin University Lecture. Retrieved from http://www.paulvalent.com/publication/trauma-and-psychoanalysis-talk-deakin-universitytrauma-and-psychoanalysis-talk-deakin-university/

About the Author

Courtney Ackerman is a graduate of the positive organizational psychology and evaluation program at Claremont Graduate University. She is currently working as a researcher for the State of California and her professional interests include survey research, well-being in the workplace, and compassion. When she’s not gleefully crafting survey reminders, she loves spending time with her dogs, visiting wine country, and curling up in front of the fireplace with a good book or video game.

Comments

  1. Danita Courtney

    Very informative and helpful. Based on what I’ve read, I’ve been working on Phases 1 and 3 for over 30 years. And finally feel able to talk about “what really” happened. I’m to the point where I am willing to share the details, the narrative with others in order to rid myself of my history. I have a new life and feel like that past belongs to a different person. I’d like to put that person to rest. Give her a proper send off in writing. And say good bye to that wounded soul. This is such good work. Live improving and saving work. Thank you.

    Reply
  2. Steven Foster

    I think you for trying to help people but I myself suffer and my psychiatrist asked me to look into this website I don’t think it helped me very much because I have these feelings without knowing why and it’s gotten to the point where I completely avoid anything and everyone and yes I do have preconceived notions of how things could be but let’s be honest people can add and subtract and you know if a situation is going in One Direction what the consequences could be if something else was to be put on top of it so by avoiding people I’m avoiding conflict by avoiding conflict I’m avoiding police officers by avoiding police officers I am avoiding judges by avoiding judges I’m avoiding jail sentences so I should stay home

    Reply
  3. Paula

    Thank you! I have only recently been introduced to the concept of TF-CBT, and found this article while looking for more information. It’s by far the most helpful introduction and explanation, and the links to specific tools are so valuable. Your work here is excellent and very much appreciated.

    Reply
  4. Eric L. Wilkins

    This article is simply amazing! I was recently attracted to attending a TF-CBT 2 day training. I discovered this article trying to introduce myself to an overview. Even after going only a third of the way in I knew I’d stumbled into a true treasure. Thank you Ms. Ackerman & Positive Psychology Program.

    Reply

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