Spotlight on Trauma-Focused Cognitive Behavioral Therapy: A Road to Healing

A daughter hugging her mother.

JR (not his real name) was very bitter when he came to the emergency shelter at Family Connection, Inc., in Birmingham, AL. He’d clashed with his mom and her boyfriend and experienced physical abuse. He didn’t want a relationship with his mom anymore and suffered from low self-esteem. He thought his mom had chosen the boyfriend over him, and he felt no one would ever choose him.

To help JR come to terms with the things he’d gone through, clinical staff at Family Connection used a popular evidence-based practice called Trauma-Focused Cognitive Behavioral Therapy. TF-CBT, as it’s called, helps youth see how post-traumatic stress manifests itself in their thoughts, emotions and behaviors. The therapy’s goal is to provide an outlet for youth to find what works for them—what soothes them and lets them heal emotionally.

In JR’s case, “We worked through all those feelings, and got Mom involved in counseling too,” says Residential Program Director Brandi Horton. “She ultimately ended up breaking up with the boyfriend and making changes for herself too once she saw how her behaviors were affecting her son.”

In the end, TF-CBT enabled JR to return home. His relationship with his mom blossomed, and he became more involved in school, Horton says.

A Roadmap to Change

TF-CBT is typically delivered in 12 to 16 therapy sessions. Therapist and youth can work one-on-one, in joint sessions with a parent or caregiver, or in a group setting. The therapy includes the following steps:

Assess trauma. The therapist looks into the youth’s history of traumatic exposure, post-traumatic stress disorder symptoms, and behavior.

“It’s so important in the first day or two to meet with youth as often as possible, gather information about what issues are present, and how their behaviors and beliefs are related to the traumatic experience,” Horton says.

Define goals. The therapist and youth make a plan for how they will measure progress over time and how they will know the young person is better.

“People”--both youth and therapists—“need to have a sense of success,” says Rosemary Creeden, associate director of trauma services at FrontLine Service, a community-based organization offering services to help people overcome trauma and end homelessness in Cleveland, OH.

‘Normalize’ symptoms to reduce self-blame. The therapist enables the young person to draw a dotted line between past experiences and the actions they take every day, so they won’t just think they are “bad” people.

“A lot of kids are not seeing the connections—that they are acting out in school because they were abused by their uncle, for example,” says Jennifer Mettrick, director of implementation services who has trained youth- and family-serving professionals on TF-CBT through the University of Maryland Institute for Innovation & Implementation. “We help them see that the root is something that happened to them, not that there’s something defective about them.”

Involve caregivers, if possible. Parents and caregivers often naturally block out family trauma and minimize it because they don’t want to think about it, as JR’s mom had likely done. But it's critical to train adults invested in young people’s recovery on how to react when young people show symptoms of trauma, says Creeden. And involving them in the process allows them to see what it means for young people to get better. That can help the adults heal, too.

Teach coping methods. The therapist introduces young people to practices they can use every day, such as relaxation and mindfulness techniques. In this stage, young people learn to think about their trauma differently and tell a different story about what it means in the context of their lives. Young people also learn that they don’t need to disclose what happened to everyone they meet. Therapists can also help youth find creative outlets that work for them—such as dance, art and music—to stop intrusive thoughts from overpowering them, says Creeden.

Getting Certified

Allegheny Health Network and the Rowan University School of Medicine Child Abuse Research Education Service Institute are the purveyors of TF-CBT training. Certification is open to professionals who hold a master’s degree and licensure for psychology or social work in their state. Getting certified takes three steps:

  1. Training. Staff complete a free online course to familiarize themselves with the language and content of the treatment, and then they attend a two-day training.
  2. Practice. For 6 to 12 months, trainees take on at least three cases where it is appropriate to use TF-CBT, two of which must involve the caregiver as well, and trainees participate in regular consultation calls with a certified TF-CBT train-the-trainer graduate as well as his or her supervisor.
  3. Testing. Lastly, trainees register to take a two-hour online exam.

The two-day training can cost from $100 to $300 per person if done at regional and national conferences, or around $3,000 to have a TF-CBT trainer come to an agency and provide training. The exam costs $125 per person. To lower costs, FrontLine shared the expense of onsite training with several other agencies.

If your agency can afford it, you might want to consider training non-clinical staff as well as clinicians, so that your organization can consistently apply the underlying philosophy of TF-CBT to all interactions with youth, Horton says.  

“A youth might be really aggravated one day and have a lot of behavior issues,” Horton says. “Having the TF-CBT training allows both certified and non-certified staff to look past that, consider the reasons, and find the patience to teach them and try to help them,” Horton says.

Learn more

Read about strategies for incorporating art and other creative activities as an alternative to talk therapy in helping youth overcome traumatic stress.

Download this TF-CBT Practice Checklist (PDF, 36.6KB) for a list of strategies for identifying appropriate TF-CBT cases and using the practice.

Read the National Child Traumatic Stress Network's detailed TF-CBT implementation guide (PDF, 426KB) for more detail.

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