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Trauma-Focused Cognitive Behavioral Therapy:

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Mannarino, A. P., & Cohen, J. A. (2017, September). Trauma-Focused Cognitive Behavioral Therapy:  What is it, how good is it, and why families need it. [Web article]. Retrieved from: http://www.societyforpsychotherapy.org/trauma-focused-cognitive-behavioral-therapy

Dr. Anthony P. Mannarino

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) was developed by Drs. Anthony Mannarino, Judith Cohen and Esther Deblinger. TF-CBT is an evidence-based treatment that has been evaluated and refined during the past 25 years to help children and adolescents recover after exposure to traumatic life events.  TF-CBT is both a phase-based and components-based intervention.  The initial focus is on stabilization skills followed by trauma narration and processing.  The final components address integration and closure.  In total, there have been 20 randomized clinical trials (RCTs) supporting the efficacy of the model.  TF-CBT is a structured, short-term treatment that effectively improves a range of trauma-related outcomes in 8-25 sessions with the child/adolescent client and caregiver. Although TF-CBT is highly effective at improving youth posttraumatic stress disorder (PTSD) symptoms and diagnosis, a PTSD diagnosis is not required in order to receive this treatment. TF-CBT also effectively addresses many other trauma impacts, including depressive and anxiety symptoms, shame, and behavioral difficulties, including sexual behavior problems.  Additionally, TF-CBT improves the participating parent’s or caregiver’s personal distress about the child’s traumatic experience, parenting skills, and supportive interactions with the child as well as reducing the caregiver’s depressive symptoms (Mannarino & Cohen, 2014).

Dr. Judith Cohen

TF-CBT has been studied around the world.  In Europe, there have been RCTs in Norway and Germany which have reported results entirely consistent with those found by the TF-CBT developers (Jensen et al., 2014; Goldbeck, Muche, Sachser, Tutus, & Rosner, 2016).  Moreover, in the German study, results demonstrated that youth with complex trauma symptoms responded as well to TF-CBT as youth without complex trauma (Sachser, Keller, & Goldbeck, 2016).  TF-CBT has also been investigated in low resource countries, especially in Africa.  In one innovative study, Murray and her colleagues (Murray et al., 2015) trained non-mental health professionals to implement TF-CBT in Zambia with youth ages 5-18 who had experienced many types of trauma.  TF-CBT was significantly superior to treatment as usual (TAU) in reducing trauma and stress-related symptoms when provided by these lay counselors.

Children exposed to traumatic events are at risk not only for short-term psychological difficulties but also long-term negative sequelae.  In this regard, the landmark study by Felitti and his colleagues (Felitti et al., 1998) demonstrated that adverse child experiences (ACEs) were significantly correlated with health risks including alcoholism, drug abuse, obesity, depression, and suicide attempts during adulthood.  Accordingly, it is critical that children exposed to trauma and other ACEs receive appropriate evidence-based trauma treatment to help optimize their developmental trajectory.

There are a number of developments that have facilitated the wide dissemination of TF-CBT.  Most notably, there is TF-CBTWeb (www.musc.edu/tfcbt), our web-based course, created by Saunders and Smith at the Medical University of South Carolina.  Over 300,000 learners have accessed TF-CBTWeb over the past decade, with over one-half completing the course.  (Saunders, Personal Communication, 2017).  This number includes therapists from every state and numerous countries around the world.  Additionally, we have developed the TF-CBT Train-the-Trainer (TTT) Program.  Currently, there are approximately 70 approved TF-CBT trainers.  Over the past decade, our trainers have provided in-person TF-CBT trainings that have been attended by a conservative estimate of over 50,000 clinicians.  There is also the TF-CBT Train-the-Supervisor (TTS) Program the goal of which is to build the sustainability of TF-CBT in individual organizations. This goal is based on the idea that it is more likely that supervisors would remain at a given agency than frontline therapists.  To date, nearly 80 TF-CBT supervisors have completed our TTS Program and the great majority of these individuals have remained at their original organization, thus contributing to TF-CBT sustainability.

Although TF-CBT is a highly efficacious child trauma treatment and has been widely disseminated around the world, how do we know that therapists are implementing the model effectively and with fidelity?  First, we start by maintaining frequent contact with TF-CBT trainers and supervisors to insure that training, consultation, and supervision are being provided based on the latest TF-CBT research and the evolution of the model.  For example, typically TF-CBT is implemented in 12-16 therapy sessions but the length of treatment can be extended for youth with complex trauma.  Also, with youth with complex trauma, there is a greater need to address safety and trust issues at the outset of TF-CBT  as well as “core trauma themes” being the central focus of the trauma narration and processing component (Cohen, Mannarino, Kliethermes, & Murray, 2012).  These types of modifications are communicated frequently to TF-CBT trainers and supervisors so that trainees are receiving the most up-to-date education about the model.

We have also created the National TF-CBT Therapist Certification Program to assure that clinicians have some demonstrated competency in the TF-CBT model.  To qualify for therapist certification, clinicians must be licensed in a  mental health discipline in their home state, have completed TF-CBTWeb, have participated in an in-person TF-CBT training and follow-up consultation calls, are using an objective measure to assess pre-post treatment outcomes, and have completed the model with at least three families.  After clinicians are deemed eligible based on these criteria, they are able to take the TF-CBT Knowledge-Based Exam which provides candidates with clinical vignettes to which they answer questions based on their understanding of TF-CBT.  After passing the exam, clinicians are listed on our certification website (https://tfcbt.org).  To date, there are approximately 2100 nationally certified TF-CBT therapists whose contact information and geographic location are provided.  Parents, referral sources, and others are now able to find certified TF-CBT therapists simply by accessing the certification website.  Ultimately this is the real goal of our certification program; to make it easier to find competent, well-trained TF-CBT therapists so that children and families exposed to traumatic life events can obtain high quality, evidence-based trauma treatment.

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References

Cohen, J.A., Mannarino, A.P., Kliethermes, M., & Murray, L.A. (2012). Trauma-focused CBT for youth with complex trauma. Child Abuse & Neglect, 36, 528-541.

Felitti, V. J., Anda, R. F., Nordenberg D., Williamson D. F., Spitz A. M., Edwards V., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood
experiences (ACE) study. American Journal of Preventive
Medicine, 14, 254-258.

Goldbeck, L. Muche, R., Sachser, C., Tutus, D., & Rosner, R. (2016). Effectiveness of Trauma-Focused Cognitive Behavioral Therapy for children and adolescents:  A randomized controlled trial in eight German mental health clinics.  Psychotherapy and Psychosomatics, 85, 159-170.

Jensen, T.K., Holt, T., Ormhaug, S.M., Egeland, K., Granly, L., Hoass, L.C., et al. (2014).  A randomized effectiveness study comparing Trauma-Focused Cognitive Behavioral Therapy with therapy as usual for youth. Journal of Clinical Child & Adolescent Psychology, 43, 356-369.

Mannarino, A.P. & Cohen, J.A.  (2014). Clinician’s Corner:  Trauma-Focused Cognitive Behavioral Therapy (TF-CBT).  Traumatic Stress Points, October Issue.

Murray, L.A., Skavenski, K., Kane, J.C., Mayeya, J., Dorsey, S., Cohen, J.A., et al. (2015). Effectiveness of Trauma-Focused Cognitive Behavioral Therapy among trauma-affected children in Lusaka, Zambia:  A randomized clinical trial.
JAMA Pediatrics, 169, 761-769.

Sachser, C., Keller, F., & Goldbeck, L. (2016). Complex PTSD as proposed for ICD-11:  Validation of a new disorder in children and adolescents and their response to Trauma-Focused Cognitive Behavior Therapy, Journal of Child Psychology and Psychiatry, 58, 160-168.

Saunders, B. Personal Communication, May 17, 2107.

Further Reading

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