25 Trauma-Focused Cognitive Behavioral Therapy

25 Trauma-Focused Cognitive
Behavioral Therapy
An Evidence-Based Approach for Helping Children Overcome the
Impact of Child Abuse and Trauma
Melissa K. Runyon, Elizabeth Risch, and

Esther Deblinger
Introduction
Exposure to one or more potentially traumatic events (PTEs) in childhood
is an unfortunately common experience, with nearly 60 percent of children in the
United States reporting at least one form of victimization (e.g., sexual abuse,
physical assault) in a one-year time period. Some children are quite resilient,
experiencing minimal or only acute difficulties and recovering naturally over
time, whereas others may suffer episodic and/or chronic psychosocial difficulties
across the life-span (Bryant, Salmon, Sinclair, & Davidson, 2007; Cloitre et al.,
2009; Kendall-Tackett, Williams, & Finkelhor, 1993). Early effective evidence-
based interventions may help to disrupt the potentially lifelong negative effects of
childhood trauma. Four evidence-based therapy models identified under the child
trauma section of the California Clearinghouse of Evidence-based Programs for
Child Welfare (CEBC) website have either met the requirements for the Supported
by Research Evidence category (i.e., Child-Parent Psychotherapy – Lieberman,
Van Horn, & Ghosh Ippen, 2005) or have met the more rigorous requirements for
the Well-Supported by Research Evidence category (i.e., eye movement desensi-
tization and reprocessing – Shapiro, 2001; prolonged exposure for adolescents –
Foa, Chrestman, & Gilboa-Schechtman, 2008; and trauma-focused cognitive
behavioral therapy (TF-CBT) – Cohen, Deblinger, Mannarino, & Steer, 2004,
2016). According to Morina, Koerssen, and Pollet (2016), TF-CBT (Cohen,
Mannarino, & Deblinger, 2016; Deblinger, Cohen, Mannarino, Runyon, &
Heflin, 2015) has more research support demonstrating the model’s effectiveness
for helping children overcome the impact of trauma than any other treatment
available with more than 20 randomized trials being completed to date (Cohen,
Mannarino, & Deblinger, 2016). Given the strong record of empirical support for
TF-CBT, the present chapter includes a summary of supporting research; a review
of predictors, moderators, and mediators associated with treatment outcomes;
a clinical description of the model; and a case study illustrating the practical
implementation of TF-CBT.
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526 Post-Traumatic Stress Disorder
Importance of Evidence-Based Therapies to Help Children

Overcome Trauma
According to a meta-analysis, approximately 16 percent of youth develop
PTSD after exposure to a traumatic event (Alisic et al., 2014). The current
Diagnostic and Statistical Manual of Mental Disorders (DSM-5) delineates PTSD
as encompassed in four symptom clusters, namely re-experiencing, avoidance,
negative cognitions and mood, and hyperarousal (American Psychological
Association, 2013). Re-experiencing of the trauma involves overwhelming emo-
tional and/or physiological distress in relation to memories or reminders of the event.
In response to this overwhelming distress, youth may seek to avoid reminders of the
traumatic event, as well as their own thoughts and feelings related to the event.
Avoidance is a common maintenance factor in fear-related disorders (Foa &
Rothbaum, 1998; Pineles, Mostoufi, Ready, Street, Griffin et al., 2011). Further,
avoidance limits a youth’s intentional processing and meaning making of their
experiences and may increasingly undermine their developmental trajectory.
The negative cognitions and mood symptoms account for the development of
inaccurate and/or unhealthy beliefs about the world, the self, and others. For youth
who experience interpersonal traumas, overgeneralized and negative beliefs about
relationships, others, and one’s self can develop, such as believing people cannot be
trusted or that one is a bad kid. Youth are more likely to experience increased
negatively valenced emotions and may have difficulty experiencing positive emo-
tions. The final symptoms cluster, hyperarousal, includes a number of behavioral
symptoms (i.e., sleep and concentration difficulties) arising from an overactive,
easily stimulated sympathetic nervous system.
Youth may exhibit a continuum of PTSD symptoms ranging from post-traumatic
stress symptoms (PTS) that do not meet full PTSD criteria to more complex trauma
reactions. Other youth may exhibit symptoms of anxiety, depression, disruptive
behavior, or substance use disorders after trauma exposure. Complex trauma
describes a core set of impairments resulting from traumatic experiences occurring
in an interpersonal context, repeatedly, and typically over a prolonged period of time
(e.g., incest or witnessing chronic domestic violence in the home). The domains
impacted in complex trauma are emotional and behavioral dysregulation, relation-
ships and attachment, dissociation, cognition and thinking, and self-concept.
Complex trauma has not been established as a formal diagnosis in the DSM-5, and
there is continued debate and research on the unique symptom profile (Kliethermes,
Schacht, & Drewry, 2014). However, the ICD recognizes the diagnosis of complex
trauma, and the findings of a national survey of agencies in the National Child
Traumatic Stress Network suggest that 78 percent of youth receiving mental health
treatment in the community have a complex trauma history (Spinazzola et al., 2005).
Thus, further understanding of unique difficulties and treatment needs of youth
experiencing complex trauma will have implications for trauma-focused treatment.
PTS reactions may be chronic if left untreated, resulting in both mental and
physical health impairments in adulthood. The Adverse Childhood Experiences
(ACEs) study (Felitti et al., 1998) has demonstrated a longitudinal relationship
Trauma-Focused Cognitive Behavioral Therapy 527
between childhood adversity (e.g., abuse, separation from caregivers) and chronic
mental and physical health conditions. A higher number of ACEs increases the
likelihood an individual will suffer from diseases, such as chronic obstructive
pulmonary disorder, cardiac disease, cancer, depression, and alcoholism and sub-
stance use in later life (Felitti et al., 1998). The societal financial costs of child
maltreatment are substantial, with the lifetime financial burden for new fatal and
nonfatal child maltreatment cases in 2008 being an estimated $124 billion in the
United States (Xiangming, Brown, Florencea, & Mercya, 2012).
Increased awareness of the prevalence of trauma and acknowledgment of the
impact on individual and societal functioning has resulted in a movement toward the
development of trauma-informed systems (e.g., child-serving systems, including
social services, public education, and health care) that offer support to and address
the needs of children who experience trauma. This allows for individuals interacting
with children to view their emotional and behavioral presentation through a trauma-
informed lens leading to a better conceptualization and understanding of their
presenting problems. One of the treatment approaches frequently embedded in
these trauma-informed systems is TF-CBT, a model that has earned the Substance
Abuse and Mental Health Administration’s (SAMHSA) highest rating for empirical
support and has been widely disseminated, both nationally and internationally.
TF-CBT Practice Components

TF-CBT is a short-term (12–16 ninety-minute sessions) cognitive beha-
vioral therapy model that also incorporates concepts from attachment, humanistic,
and family systems theory. The treatment approach incorporates psycho-education,
skill building, and trauma narration and processing. Within a given session, the
therapist may spend varying amounts of time with the child, the caregiver(s), and the
whole family to best accomplish the treatment goals. TF-CBT has been applied
across many settings (residential, outpatient, home based), with single, multiple, and
complex trauma types, and in diverse populations (Cohen, Mannarino, & Deblinger,
2016).
The essential components of TF-CBT are represented by the acronym
PRACTICE: Psycho-education and parenting (P), Relaxation (R), Affect regulation
(A), Cognitive coping (C), Trauma narration and processing (T), In vivo mastery (I),
Conjoint sessions (C), and Enhancing safety and future development (E).
The inclusion of various treatment components in therapy sequentially follows the
acronym, with appropriate clinical caveats. For example, when safety risks are
present, the “Enhancing safety” component including the development of a safety
plan, is moved to the start of treatment. Similarly, the “Parenting” component is often
a focus throughout the entire course of treatment, and “Conjoint” sessions may be
initiated early in treatment to provide caregivers with opportunities to practice the
parenting skills with their children while the therapist observes. In general, there is
flexibility and overlap of components within and across individual treatment
sessions.
Treatment is provided in three phases, stabilization (PRAC), trauma narrative and

processing (T), and consolidation (ICE). The explicit and intentional focus on the
youth’s trauma is initiated in the assessment and included in each component of TF-
CBT. Progress through the components of TF-CBT is facilitated by the inclusion of
gradual exposure to the traumatic memories in each session. In this way, most youth
increasingly become less avoidant of initiating the trauma narration process as the
treatment progresses.
In the first phase of treatment, psycho-education initiates the treatment process by
providing information that promotes a healthy understanding of the youth’s trau-
matic experiences. When secrecy and isolation are associated with childhood trau-
matic experiences, such as in the case of sexual abuse and other interpersonal
violence, youth often develop feelings of self-blame, guilt, shame, and a sense of
being different from peers. Thus, families are taught general facts about the traumas
experienced (e.g., how common is domestic violence), traumatic stress responses
(e.g., PTS symptoms, how a child feels after family fighting), and the process of
recovery (e.g., treatment description, time frame). Through the process of psycho-
education, the young person is exposed to the discussion of the experienced trau-
matic events in general terms. Further, conjoint activities facilitate discussions about
trauma in a safe and supportive environment to increase comfort in discussing the
topic.
As mentioned earlier, the parenting component is often a consistent focus over the
course of treatment sessions. Broadly, goals within the parenting component are
fostering a trauma-informed perspective and parenting style and are providing
developmentally appropriate behavior management strategies. It is essential that
parenting work be provided in a manner that is supportive and collaborative with
the caregivers. Caregivers participate in a parallel process of TF-CBT, learning
PRAC skills to cope with their own emotional reactions to their children’s trauma,
so they can serve as good coping models and reinforce their children’s use of
effective coping skills through praise and positive reinforcement. Later this parallel
learning also helps caregivers cope with their own emotional reactions to the
trauma(s) and when clinically appropriate it prepares them to respond in
a positive, supportive manner when children share their trauma narratives with the
caregiver.
Relaxation provides a skill to manage distress in both the youth’s and the caregiver’s
daily lives (related to trauma memories and everyday stressors) and within session to
manage distress during gradual exposure. Families are taught the physiological
impacts of stress and trauma, including the fight-flight-freeze response. Specific
relaxation techniques taught may vary and include focused breathing, progressive
muscle relaxation, imagery, and naturally relaxing activities. An important focus is
aiding families to identify trauma reminders and use relaxation to reduce distress.
Thus, relaxation techniques are taught early in treatment and practiced regularly both
at home and in the sessions.
In the affect regulation component, families learn to identify and communicate
their feelings and develop methods for managing distress. Youth often lack aware-
ness and language for their internal states; thus, this is taught in sessions and
practiced with support of caregivers in the home environment. Often a version of

a “Feel Better Plan” or coping skills toolbox is developed with a family to encourage
use of healthy coping techniques (e.g., diaphragmatic breathing, mindfulness, guided
imagery, assertive expression of emotions) or activities when a child is experiencing
high levels of distress.
Teaching the connections between thoughts, feelings, and behaviors is central in
the cognitive coping component. Families learn and practice applying cognitive
theory to their day-to-day lives, as well as how trauma may impact one’s thinking.
Cognitive coping skills, such as catching and challenging cognitive distortions and
positive self-talk may be taught for managing day-to-day stress. Teaching youth to
identify and challenge daily unhelpful thoughts is a precursor for the cognitive
processing of trauma-related thoughts and beliefs, which is encouraged only after
youth have completed their trauma narrative. Caregivers, on the other hand, may be
encouraged to use cognitive coping skills in relation to distressing trauma-related
thoughts at this stage of treatment.
The middle phase of treatment focuses on trauma narration and processing.
During this phase, youth are engaged in narration of specific traumatic memories
through a gradual process that eventually includes their most feared memories.
Additionally, the cognitive processing of the traumatic memories allows for correc-
tion of unhealthy beliefs and placement of the event(s) in the context of the youth’s
present life and future. A final focus and often a final narrative chapter reflect the
youth’s improvement, growth, and future plans for life. During trauma narration with
the youth, the therapist also meets individually with the caregiver(s) to prepare for
the upcoming conjoint sharing of the youth’s trauma experiences when clinically
appropriate.
In the final phase, treatment focuses on helping the child integrate and consolidate
skills, addressing any remaining avoidant behaviors through in vivo mastery, parti-
cipating in conjoint sessions to create open communication relating to the traumatic
experiences with caregivers, and developing skills for enhancing safety and the
child’s future development. More specifically, in vivo mastery targets any non-
harmful real-life stimuli that trigger fear or avoidant responses. For example,
a youth abused near train tracks may develop a fear reaction to trains and train
sounds. A fear hierarchy is established with the youth to guide an exposure and
desensitization plan. Caregivers are integral in the implementation of the plan as they
will be responsible for encouraging non-avoidance behaviors during in vivo expo-
sure activities outside of sessions.
Conjoint trauma-processing sessions entail the youth sharing of their trauma
experiences with the caregiver(s), caregiver(s) involvement in validation of youth
and corrective processing of dysfunctional beliefs, and celebration of all the youth
has accomplished. Safety, as mentioned, is imbued throughout all trauma-focused
therapy sessions, as creating an emotionally and physically safe environment is
essential to treating trauma survivors. Thus, safety skills training and concerns
may be a focus at both the onset and end of treatment depending on the presenting
concerns. The focus of safety sessions is tailored to the unique concerns of the
family. Personal safety skills training may include the development of healthy
boundaries and relationships, teaching and monitoring private parts rules, creation of
safety plans for potentially high-risk and unsafe environments, and/or providing
sexual health education.
Summary of Evidence Base Supporting TF-CBT

Several independent research studies examining trauma-focused CBT-
based therapies for children who experience child sexual abuse (CSA) were con-
ducted in the early 1990s and provided strong support for the therapy model
currently known as TF-CBT. In their first randomized controlled trial (RCT),
Deblinger, Lippmann, and Steer (1996) compared a 12-session CBT protocol pro-
vided to the child alone, the parent alone, or the child and parent combined to
treatment as usual (TAU) in a community sample of children and adolescents
(aged 7 to 13 years) who had developed PTSD after being sexually abused.
Treatment effects on PTSD symptoms, depression, externalizing behavior problems,
and parenting practices were evaluated via pre- and post-assessments. It was found
that the CBT interventions with the child alone and with the combination of child and
parent were superior in reducing PTSD symptoms when compared to TAU. Those
participants where only the parents received treatment did not report a significant
decrease in PTSD symptoms when compared to those who received TAU. Further,
the parent alone and the child and parent combined conditions were better in
improving parenting practices, as well as reducing externalizing behaviors and
child depression. A subsequent assessment of the youth participating in this trial
showed that these treatment gains were largely maintained at a two-year follow-up
(Deblinger, Steer, & Lippmann, 1999). Around the same time of this study, Cohen
and Mannarino (1996a) conducted a randomized trial that examined a 12-session
CBT treatment for preschoolers who had a history of CSA and found significant
improvements in externalizing behaviors, inappropriate sexual behaviors, and inter-
nalizing symptoms compared to those children who received nondirective suppor-
tive therapy (NST), with these gains being maintained at one-year follow-up (Cohen
& Mannarino, 1997). Another study by Cohen and Mannarino (1998a) replicated
these findings in children aged 7 to 14 years impacted by sexual abuse by demon-
strating the superiority of trauma-focused CBT compared to NST for reducing
depressive symptoms and improving social competence. Further, examination of
trauma-focused CBT provided in a group format demonstrated increased efficacy in
both caregiver and child outcomes as compared to a supportive group (Deblinger,
Stauffer, & Steer, 2001).
These initial findings led to the first multisite evaluation of the current TF-CBT
protocol (Cohen et al., 2006; Cohen, Mannarino, & Deblinger, 2016; Deblinger
et al., 2015). In this large RCT including 229 children and adolescents (aged 8 to 14
years), TF-CBT was found to be superior to client-centered therapy for reducing
PTSD, depression, behavior problems, shame, and abuse-related attributions.
In addition, caregivers demonstrated benefits of reduced depression and abuse-
related emotional distress and improved parenting practices and support for their
child (Cohen et al., 2004). These gains were maintained at 6- and 12-month follow-
ups (Deblinger, Mannarino, Cohen, & Steer, 2006). Further, while this study focused
primarily on CSA, youth in the sample experienced on average 3.66 trauma types
(e.g., physical abuse, exposure to domestic violence, bullying, natural disaster),
demonstrating the effectiveness of TF-CBT with poly-victimization.
Expanding the evidence base for various trauma types and settings, a pilot study
(n=39) demonstrated that a modified version of TF-CBT was effective in reducing
PTSD symptoms and traumatic grief in youth (aged 6 to 17 years) who had
experienced a traumatic loss of a family member (Cohen, Mannarino, & Staron,
2006). More recently, an abbreviated (8-session) version of TF-CBT was found
superior to community treatment in a RCT (n=124) for children (aged 7 to 14
years) exposed to intimate partner violence and their non-offending caregivers
(Cohen, Mannarino, & Iyenger, 2011).
The treatment developers have further examined TF-CBT for effectiveness of key
components, treatment length, and its application in combination with psychotropic
medication. A dismantling study (Deblinger, Mannarino, Cohen, Runyon, & Steer,
2011) varied treatment length (8 vs. 16 sessions) and written trauma narratives
(present vs. absent) in TF-CBT. Findings demonstrated that all TF-CBT conditions
were effective in reducing PTSD symptoms; however, specific findings may guide
tailoring treatment to client presentation. Specifically, abuse-related fear and distress
in both youth and caregivers responded well to the 8-session intervention with
a trauma narrative, whereas parenting practices were most improved and the largest
decreases in externalizing behavior problems were found among families participat-
ing in the 16 sessions with no trauma narrative condition (Deblinger et al., 2011).
The positive results documented in this study were maintained at 6- and 12-month
follow-up (Mannarino, Cohen, Deblinger, Runyon, & Steer, 2012). A RCT compar-
ing TF-CBT with or without addition of sertraline, a selective serotonin reuptake
inhibitor, found no significant, additive benefit of medication in reducing PTSD
symptoms over and above the effects of the psychological intervention (Cohen,
Mannarino, Perel, & Staron, 2007).
Investigations in other clinics across the United States and the rest of the world
have replicated the positive outcomes associated with TF-CBT that were documen-
ted in the research conducted by its developers. In an early RCT conducted in
Australia (King et al., 2000), 36 youth who had experienced sexual abuse (aged 5
to 17 years) received individual CBT, family CBT, or a wait-list control condition.
Children in both trauma-focused CBT conditions reported significantly fewer PTSD
symptoms compared to those on the wait-list. Inclusion of family members in
treatment was important as that group showed the greatest reduction in anxiety
symptoms at 3-month follow-up (King et al., 2000). Allen and Hoskowitz (2016)
also carried out a study involving 260 youth (aged 3 to 12 years) with a history of
sexual abuse who received TF-CBT from community therapists trained in this
method. Greater improvements were associated with a greater use of the structured
CBT techniques, while poorer outcomes were associated with the use of more play/
experiential techniques. Several investigations have documented the efficacy of TF-
CBT for helping children in foster care overcome the impact of trauma. A seminal,
quasi-experimental study conducted by Lyons, Weiner, and Schneider (2006) docu-

mented significant larger reductions in trauma symptoms, placement disruptions,
and episodes of running away from foster care homes for those foster children (aged
3 to 18 years) who had received TF-CBT as compared to TAU. A more recent RCT
reported on foster caregivers of 46 children (aged 5 to 16 years) who had received
TF-CBT plus engagement strategy offered over the phone or in-person or standard
TF-CBT. Significantly more children and caregivers attended the initial session and
completed TF-CBT in the TF-CBT plus engagement condition when compared to
those in the standard TF-CBT condition. Children in both conditions reported
significant reductions in trauma symptoms at posttreatment (Dorsey et al., 2014);
however, fewer children accessed treatment in the standard condition. In addition to
the short-term positive outcomes associated with TF-CBT for both children and
caregivers, the early identification and treatment of traumatized youth with TF-CBT
may result in a long-term cost savings as well (Greer, Grasso, Cohen, & Webb,
2014).
Research documenting the positive outcomes for families participating in TF-
CBT has also been replicated in several studies conducted in Europe. In a RCT
conducted by Goldbeck, Muche, Sachser, Tutus, and Rosner (2016) in eight German
outpatient clinics, youth (aged 7 to 17 years), presenting with PTS symptoms were
assigned to 12 sessions of TF-CBT or a wait-list control condition. TF-CBT was
associated with significantly greater reductions of PTS symptoms and other emo-
tional and behavioral problems. A similar RCT evaluating TF-CBT in Norway
demonstrated that traumatized youth (aged 10 to 18 years) who received TF-CBT
had significantly greater reductions in PTS symptoms, depression, general mental
health problems, and functional impairments than those receiving TAU (Jensen
et al., 2014). In another investigation conducted in the Netherlands, Diehle,
Opmeer, Boer, Mannarino, and Lindauer (2015) randomly assigned children (aged
8 to 18 years) to 8 sessions of TF-CBT or EMDR. TF-CBT and EMDR were both
associated with significant pre- to posttreatment improvements in PTS symptoms,
and there was no difference in length of treatment between the two conditions. While
both TF-CBT and EMDR were associated with reductions in children’s trauma
symptoms, an equal dose of TF-CBT was also associated with significant reductions
in children’s depression and hyperactive symptoms demonstrating that TF-CBT was
somewhat more effective in producing symptom improvements across multiple
domains of functioning.
Several studies examining the efficacy TF-CBT have been conducted in non-
Western countries, especially on the African continent. In one study, children (aged 5
to 16 years) presenting with trauma-related symptoms to five community sites in
Lusaka, Zambia, were randomly assigned to 10 to 16 sessions of TF-CBT or regular
community services. At follow-up, there were significantly greater improvements in
PTS symptoms and daily functioning for those receiving TF-CBT from lay counse-
lors as compared to those receiving community services (Murray et al., 2015). Two
randomized, controlled studies also examined outcomes associated with TF-CBT for
youth who had been exposed to trauma in the Democratic Republic of Congo. In the
first study, 12- to 17-year-old girls who were victims of sexual abuse and on average
had experienced as many as 11 other traumatic experiences were randomly assigned

to a 15-session TF-CBT group or a wait-list control group. The results demonstrated
that compared to a wait-list control condition, TF-CBT led to significantly greater
improvements in scores of scales measuring PTS symptoms, depression, anxiety,
conduct problems, and prosocial behavior (O’Callaghan, McMullen, Shannon,
Rafferty, & Black, 2013). The second study involved boys (aged 13 to 17 years)
who were former child soldiers exposed to numerous traumatic experiences includ-
ing the atrocities of this war-torn nation. Compared to the wait-list control group, the
TF-CBT group demonstrated significantly greater improvements in all areas
(McMullen, O’Callaghan, Shannon, Black, & Eskin, 2013). Another study examined
child outcomes associated with a 12-session group TF-CBT Traumatic Grief proto-
col for 58 orphaned children (aged 5 to 18 years) in Tanzania. After participation in
group TF-CBT delivered by lay counselors, significant improvements in grief, PTS,
and depressive symptoms and behavior problems were reported and maintained at 3-
and 12-month follow-up. Finally, research has also demonstrated reductions in
PTSD symptoms for youth in Japan and Canada after their participation in TF-
CBT, further highlighting TF-CBT’s applicability and efficacy across various coun-
tries and cultures (Kameoka et al., 2015; Konanur, Muller, Cinamon, Thornback, &
Zorzella, 2015).
Predictors, Moderators, and Mediators Associated with TF-CBT

Treatment Outcomes
Early TF-CBT clinical trials not only supported the model’s efficacy in
treating child trauma as compared to wait-lists and other available treatments (see for
a review, Morina et al., 2016), but these studies and subsequent studies also identified
predictors of optimal treatment outcomes for participating youth. Early research
examining the model demonstrated the importance of caregiver involvement and
caregiver support for optimal outcomes for traumatized youth (Cohen & Mannarino,
1996b; Deblinger et al., 1996). For example, Deblinger and colleagues (1996)
reported significant improvements in PTS symptoms when treating the child alone.
However, parental involvement in treatment was critical to the significant improve-
ments seen with respect to behavior problems, child depression, and parenting
practices. Further evidence supported the important role of the parent in the child’s
recovery when Cohen and Mannarino (1996b) reported that parental abuse-related
emotional distress was significantly correlated with treatment outcomes for pre-
school children receiving TF-CBT or NST. The best predictor of treatment outcomes
at 6- and 12-month follow-up was parental support.
Caregiver support plays an important role in youth’s ability to process traumatic
events and replace unproductive thoughts with healthy ones during the trauma
narration and processing phase. In a study examining the relationship between in-
session caregiver behavior and children’s symptomology (Yasinski et al., 2016),
caregivers’ emotional processing during the trauma narrative and processing phase
predicted decreases in both internalizing and externalizing symptoms for children.
At follow-up, caregiver support predicted lower internalizing symptoms for chil-

dren while caregiver avoidance of abuse-related material and blame of the child
was associated with increases in internalizing and externalizing symptoms.
Caregiver blame and avoidance had a negative impact on the child’s emotional
processing of the traumatic events (Yasinski et al., 2016). Recent studies have
shown that caregiver mental health diagnosis and emotional symptoms may predict
early dropout from TF-CBT, thereby possibly attenuating the treatment response
(Wamser-Nanney & Steinzor, 2017; Lai, Tiwari, Self-Brown, Cronholm, &
Kinnish, 2017). These findings highlight the importance of involving a non-
offending caregiver in TF-CBT, as well as the parallel process of teaching the
caregivers PRAC skills to manage their abuse-related emotions and thoughts in
order to enhance their ability to support their children and serve as positive coping
models (Cohen & Mannarino, 1996b, 1998b).
Therapeutic alliance, a common element of all therapies, also predicts optimal
outcomes for youth in TF-CBT. In a study conducted in Norway (Ormhaug, Jensen,
Wentzel-Larsen, & Shirk, 2014), the association between the quality of the thera-
peutic alliance and treatment outcome was examined in traumatized youth (aged 10
to 18 years) who were randomly assigned to TF-CBT or TAU. Results demonstrated
that youth receiving TF-CBT reported significantly lower PTS symptoms compared
to those receiving TAU, with therapeutic alliance serving as an important predictor
of reductions in PTS and other symptoms for only those receiving TF-CBT. These
findings highlight the importance of the therapeutic alliance for the successful
delivery and outcome of TF-CBT (Cohen, Mannarino, & Deblinger, 2016;
Deblinger et al., 2015). In a structured EBT such as TF-CBT, therapists ask children
and their caregivers to engage in PRACTICE assignments both in therapy and at
home, as well as to engage in recounting details of highly aversive experiences and
share related intimate thoughts and feelings. A strong therapeutic alliance likely
encourages youth cooperation with these assignments as well as the gradual expo-
sure process that requires a sense of safety and trust in the therapist and the treatment
approach.
As a part of an effectiveness trial conducted by Webb, Hayes, Grasso, Laurenceau,
& Deblinger (2014), predictors of outcomes associated with TF-CBT were examined
for 81 children (aged 6 to 15) who received an average of 10 treatment sessions
(Ready et al., 2015). Ready et al. (2015) coded accommodation (adaptive/productive
trauma-related thoughts about self, others, or the world) and overgeneralization
(maladaptive/unproductive trauma-related thoughts about self, others, and the
world) in youth during trauma narration and processing sessions. As expected,
higher levels of overgeneralization predicted less improvement in internalizing
symptoms at posttreatment and increases in externalizing symptoms at 12-month
follow-up. Whereas, more accommodation predicted decreased internalizing symp-
toms. Accommodation also moderated the negative impact of overgeneralization on
internalizing and externalizing symptoms. In a related study, Hayes et al. (2017)
examined how accommodation and overgeneralization were associated with unpro-
ductive versus constructive processing of traumatic events during trauma narration
and processing. Sessions during this phase of TF-CBT were coded for indicators of
unproductive processing (overgeneralization, rumination, avoidance) and construc-

tive processing (de-centering ability to gain insight and distance oneself from
trauma-related material to promote cognitive processing and change), accommoda-
tion of corrective information), as well as levels of negative emotion. Higher levels
of rumination, less de-centering, and more negative emotion were associated with
overgeneralization, while less avoidance and more de-centering were associated
with accommodation that might allow for processing and cognitive change. De-
centering also predicted improvement in posttreatment externalizing symptoms.
These findings highlight the importance of cognitive change replacing unproductive
trauma-related beliefs with adaptive/productive thoughts in the processes of treating
PTSD and other behavioral difficulties.
Studies examining TF-CBT have examined moderating and mediating vari-
ables. According to Papakostas and Fava (2008), moderators of treatment out-
come involve factors present at the initiation of treatment that influence the
likelihood of a particular outcome occurring following treatment. In contrast,
mediators of treatment outcome (sometimes referred to as correlates) are mea-
surable changes that occur over the course of treatment and correlate with
treatment outcome. A study seeking to triage youth in treatment examined pre-
treatment characteristics (potential moderators) in relationship to early treatment
response (defined as subclinical symptom level at session four) and found that
approximately 32 percent to 45 percent (per parent or self-report, respectively)
of children could be defined as early treatment responders. Children with lower
pretreatment symptom level, fewer traumas, younger age, and non-White ethni-
city were more likely to be early treatment responders (Wamser-Nanney,
Scheeringa, & Weems, 2014). Notably, these symptom reductions were achieved
prior to engaging in trauma narration and processing, replicating the improve-
ments found in the abbreviated conditions in a previously conducted dismantling
study (Deblinger et al., 2011).
Before engaging in trauma narration and processing, therapists prepare youth
by teaching them PRAC skills, which aid them in self-regulation and manage-
ment of painful emotions both in and outside the therapy sessions. Interestingly,
Sharma-Patel and Brown (2016) examined whether self-blame and emotional
dysregulation mediate and/or moderate treatment outcomes, including PTS,
depressive symptoms, and conduct problem, for youth who completed trauma-
focused treatment. Caregivers and youth completed assessment measures at pre-
treatment, mid-treatment prior to beginning the trauma narration and processing,
and again at posttreatment. Changes in self-blame, but not in emotional regula-
tion, at mid-treatment was a partial mediator of conduct problems. Emotional
dysregulation moderates improvements in PTS symptoms and conduct problems
at posttreatment. Specifically, youngsters with higher levels of emotional dysre-
gulation reported reductions in posttreatment PTS symptoms, while youngsters
with low levels of emotional dysregulation demonstrated improvements in PTS
symptoms at mid- and posttreatment. As such, emotional regulation and self-
blame, which are important targets of TF-CBT, appear to impact the treatment
response.
TF-CBT Case Illustration

Beckham, a 13-year-old boy, was referred for TF-CBT after being sexually
abused on multiple occasions by his paternal uncle. In addition to a history of CSA,
Beckham witnessed extensive domestic violence between his biological parents that
resulted in his mother seeking care at the local emergency room due to broken bones
on at least two occasions. Beckham sustained injuries ranging from mild bruises to
severe cuts and abrasions while intervening to protect his mother from his father’s
assaultive behavior. He was also the target of severe physical abuse (PA) and
emotional abuse by his father. As a result, Beckham was placed in foster care and
experienced placement changes on three separate occasions over a period of 6 months
when his respective foster parents complained of his aggressive and noncompliant
behaviors, until his placement with Ms. Roberts, his current pre-adoptive mother.
Beckham is an intelligent student who is capable of doing well academically, but
his emotional and behavioral reactions to his traumatic past interfere with his
functioning in school and several other important domains. Despite his history of
multiple, complex traumas, Beckham is capable of forming relationships and has
maintained some friendships that are important to him. He also reports a desire to
have a forever family, though he remains skeptical about the reality of this
possibility.
Beckham was also referred for a medical examination to diagnose and treat the
impact of his CSA when it was revealed that he had not received an exam as part of
the initial investigation. The child abuse pediatrician who conducted the examination
assessed for any physical injury and sexually transmitted infections and took
a complete medical history during which Beckham disclosed the CSA experiences
by his uncle. Beckham’s uncle was charged and arrested for multiple counts of sexual
assault of a minor and endangering the welfare of a minor. Beckham has had no
contact with his father for more than two years since his father’s incarceration on
a drug charge. Child Protective Services records indicate that Beckham’s father was
substantiated for child physical abuse of Beckham at ages 6 and 9. Beckham was
waiting for his mother at the child protection office visitation room when he received
notification that his mother overdosed and died.
During his initial therapy assessment, Beckham disclosed that the CSA began with
his uncle hugging him a lot, which made Beckham feel loved, yet uncomfortable at
times. He reported that he did not recall any hugs or affection from his parents. He
added that he feels angry, like he’s going to explode, when Ms. Roberts hugs him.
In response to a trauma history inventory, Beckham also disclosed that he had
frequently witnessed violence between his parents and that his father beat him
with his fist and objects (such as a belt and bat), and that his father frequently called
him names, such as stupid and cursed at him. Beckham stated that he had difficulty
concentrating at school and sleeping because thoughts of his uncle touching him, his
dad hurting his mother, and the day the case worker told him his mother died were
always popping into his mind.
Ms. Roberts revealed that Beckham was a loving child who was very kind and
helpful to others at times, but that his mood changed to rage with the “flip of
a switch.” She stated that she never knew what was going to set him off. She
indicated that she recently noticed he was somewhat irritable and withdrawn at
home, and there had been a few incidents where he had minor physical altercations
with peers at school. She described Beckham as distant and having difficulty forming
relationships with others. Ms. Roberts became tearful and stated that although she
loved Beckham, she feared he was permanently damaged and would never be able to
truly bond with and love her or anyone else. After all, “how could a child overcome
what Beckham has experienced,” she proclaimed.
Based on his responses to standardized assessment measures, Beckham met
criteria for PTSD; had mild depressive symptoms; and reported negative cognitions
about himself, the world, and others, and he described himself as often angry. Ms.
Roberts reported a mild level of depression herself, significant parenting distress, and
significant behavior problems for Beckham. She described him as thoughtful toward
her at times, but uncooperative and aggressive toward others.
During the initial phase of TF-CBT, the stabilization and skill-building phase, the
PRAC components were presented to Beckham and Ms. Roberts in individual
sessions. During these sessions, the therapist offered psycho-education about
trauma-related reactions to normalize Beckham’s responses; provided basic infor-
mation about the prevalence, impact, and dynamics of sexual abuse, physical abuse,
and domestic violence; and gave treatment expectations including the documented
efficacy of TF-CBT. The therapist instilled hope by emphasizing that Beckham had
two things associated with the best possible outcome for a youth exposed to trauma:
a supportive caregiver and his participation in effective treatment.
Coping skills were then introduced to help Beckham and his caregiver cope with
general life stressors as well as trauma reminders and the associated thoughts,
feelings, and behaviors that those reminders elicited. Given Beckham’s emotional
liability and dysregulation, the therapist spent three additional sessions focusing on
PRAC skills, until in-session observation as well as reports by Ms. Roberts and
Beckham demonstrated some increased ability to exercise self-control and regulate
his emotional reactions. He enjoyed yoga poses and controlled deep breathing and
indicated these skills helped him remain slightly more focused and calm.
Noting that Beckham was somewhat avoidant of discussing the abuse, domestic
violence, and loss of his mother, the therapist initially encouraged him to share
a positive narrative about making the winning shot in the final game of a local
basketball tournament. Next, he was gently encouraged to provide a similar narrative
(i.e., baseline trauma narrative) about the traumatic experiences that resulted in his
being removed from his biological mother’s care. Beckham responded by disclosing
that his father had hurt him and his mother really bad and that “She’s [mom] dead
now.” He spontaneously added, “Everybody hurts me and leaves me. I guess it’s my
fault for being such a bad kid all the time. You know, even my uncle did sexual stuff
to me and my mom killed herself.” The therapist reflected back Beckham’s state-
ments about his traumatic experiences in an effort to acknowledge the abuse and
trauma and to validate his feelings. In subsequent sessions, the therapist would
continue to gently encourage Beckham to talk about the abuse, violence, and loss
of a loved one in general terms, as this was considered as lower-level gradual
exposure that served to increase comfort and a sense of mastery over discussing
trauma-related material. The development of a trauma narrative was purposely not
mentioned in the initial phase, as the therapist did not wish to increase Beckham’s
tension and anxiety. In addition to the lower-level exposure exercises to desensitize
Beckham and decrease his anxiety, the therapist focused on psycho-education and
skill-building activities to help Beckham feel less alone and cope with daily life
stressors. This work also helped to gradually prepare Beckham for the trauma
narration and processing component during the middle phase of treatment.
Given the critical role of parenting in TF-CBT for reducing undesirable behaviors,
Ms. Roberts was reminded of the importance of providing a great deal of structure,
clear limits, and positive feedback to children after they have experienced traumatic
events to enhance their sense of safety, security, and confidence. The therapist
emphasized the benefits of specific praise and positive reinforcement as powerful
tools for increasing Beckham’s positive, prosocial behaviors. Ms. Roberts was also
encouraged to pay special attention and to praise Beckham when he was using PRAC
skills to regulate his emotions. Ms. Roberts was instructed to praise Beckham every
time he engaged in yoga and deep breathing to stay focused and regulated, as well as
every time he was kind; expressed his anger in a calm, appropriate manner; or
interacted in a positive way with peers or adults. Ms. Roberts also learned reflective
listening, so she could help Beckham to feel heard when he expressed feelings or
thoughts in appropriate ways. The therapist reviewed parent-child interactions to
help Ms. Roberts identify trauma reminders that seemed to underlie Beckham’s
intense emotional reactions to seemingly innocuous statements or even positive
gestures (e.g., hugs) on her part. Early in treatment due to safety concerns,
Beckham and Ms. Roberts negotiated a behavioral contract where Beckham was
expected to be kind to others (no aggressive behavior toward others). The contract
outlined negative consequences for aggressive behavior and rewards for prosocial
behavior that were agreed upon by Beckham and Ms. Roberts.
Next, Beckham and Ms. Roberts participated in coping skills practice activities
focused on relaxation, affective expression and modulation, and cognitive coping.
Emotional regulation skills were particularly important to Beckham given his emo-
tional liability and how easily he became dysregulated. The therapist helped
Beckham identify a range of emotions by examining the feelings that were under-
neath his surface reaction of anger, including feeling abandoned, alone, betrayed,
sad, scared, damaged, shameful, unloved, and worthless. There was a noticeable
decrease in Beckham’s aggression toward others as he practiced removing himself
from situations and using deep breathing and yoga with self-talk to handle anger-
provoking situations in a calm manner. Both Ms. Roberts and the therapist gave
Beckham praise and positive feedback to encourage the use of adaptive coping skills.
Ms. Roberts had a lot of negative beliefs about Beckham and his ability to
overcome the impact of trauma and to develop long-term, healthy relationships.
After teaching Ms. Roberts the interrelationship between thoughts, feelings, bodily
sensations, and behavior, the therapist elicited a number of dysfunctional thoughts
Ms. Roberts had about Beckham. These thoughts included: “Beckham will be just
like his father (violent/aggressive toward others.” “Beckham will never be able to
recover from all of the horrible things he’s experienced.” “He will never have a close
relationship with anyone.” and “Why isn’t my love and attention enough to help him
change?” These thoughts were related to a number of distressing emotions, such as
hopelessness, helplessness, sadness, frustration, and failure. Over time, the therapist
used Socratic questioning to challenge Ms. Roberts’s distortions, such as “Do you
think most children who have experience adversity bounce back?” “What do you see
in Beckham’s behavior that suggests that he is quite resilient?” “What positive
qualities has he inherited from his parent(s) and what qualities has he learned from
you?” and “How do you think you are influencing his future?” Ms. Roberts began to
identify many kind and positive traits that Beckham displayed in conjunction with
many strengths he possessed that demonstrated that the trauma did not define who he
was as a person and hence would not affect his entire life. This contradictory
evidence was used to help Ms. Roberts challenge her distortions and identify more
productive replacement thoughts.
The therapist used a card game with questions related to sexual abuse, physical
abuse, and violence to continue psycho-education (Deblinger, Neubauer, Runyon, &
Baker, 2006). Beckham read several therapeutic books about boys who were sexu-
ally abused (Satullo & Bradway, 1987) and had been exposed to domestic violence
and physical abuse by a parent. Beckham and his therapist also reviewed a website
with a list of celebrities who had experienced sexual abuse and violence. These
activities served as lower-level gradual exposure exercises and prepared Beckham to
progress to trauma narration and processing. Beckham and Ms. Roberts were well
prepared before participating in brief conjoint sessions where Beckham demon-
strated to Ms. Roberts the coping skills he was learning. Together they practiced
yoga poses and deep breathing and shared some very positive, warm moments while
exchanging specific praise with each other. These experiences seemed to help
Beckham develop greater feelings of control and mastery.
During the trauma narration and processing phase, the therapist and Beckham
reviewed his coping skills toolkit and discussed how deep breathing, yoga, and other
strategies could be used to enhance his comfort and sense of control and mastery
throughout the process. Beckham was encouraged to use the subjective units of
distress scale (SUDS) to make his therapist aware of the intensity of his feelings
during the narration of his traumatic experiences, so the sessions could be gradually
paced and provide opportunity to use skills to decrease his distress levels. Beckham
and his therapist engaged in positive rituals (e.g., listening to music for 5 minutes
together) before ending the weekly sessions. Due to his extensive trauma history,
Beckham was invited to develop a timeline that listed the multiple traumas, as well as
the positive events he experienced over the course of his life. While reviewing his
timeline, Beckham asked the therapist why everyone was always leaving him. He
quickly followed by saying that he was a “bad kid,” so bad that his mom killed
herself to get away from him, his Dad had beaten him, and Ms. Roberts would
probably also leave. He also added that he didn’t remember a time when he felt safe.
The distress associated with these thoughts was acknowledged with compassion, and
the importance of identifying the events that led to these beliefs through trauma
narration was highlighted.
The therapist encouraged Beckham to create a trauma narrative as a means to

improve his sleep and concentration at school and reduce the disturbing, recurring
thoughts of trauma and loss. He was reluctant but agreed once the therapist explained
that he would potentially help the therapist understand how these types of experi-
ences affected other kids, so she could be of help to them as well. Subsequently,
Beckham wrote a brief introductory chapter that included a description of his current
family, as well as his favorite activities. To increase his sense of control, Beckham
was given two choices for each chapter of his narrative. Examples of choices were
general information about abuse and trauma, positive interactions with his dad and
uncle and/or the first or last episode of abuse. The therapist also paid particular
attention to eliciting experiences that reflected themes related to his feelings of loss,
abandonment, safety concerns, and being bad, worthless, and unlovable. As therapy
continued, the therapist gave Beckham choices each session focusing on experiences
that reflected these themes. During each session, he was encouraged to add chapters
ultimately including the scariest and worst incidents of sexual abuse and domestic
violence to ensure the therapist was accessing all of Beckham’s most negative
cognitions that were contributing to his symptoms. Each chapter was carefully
recorded and read back to Beckham as part of the gradual exposure process. Next,
the therapist reviewed the chapter line-by-line and inquired about Beckham’s
thoughts, feelings, and bodily sensations. Each time, he reported feeling relief and
his SUDS scores over time reflected less anxiety.
Beckham expressed many unhelpful cognitions, including “Everyone leaves me
because I’m an unlovable and bad kid.” “All people will eventually hurt me.” and
“The world is not a safe place.” Psycho-education, Socratic questioning, and best
friend role plays were used to help Beckham process his experiences, while also
identifying, challenging, and replacing dysfunctional thoughts with healthy, produc-
tive ones that were incorporated into his narrative. After Beckham had processed his
entire narrative, he added a positive ending to his book by writing a final chapter
about what he learned in therapy, his new family, and positive feelings about his
family, friends, and expectations for the future. Over the course of treatment, the
therapist determined that the sharing of the trauma narrative would bring Beckham
and Ms. Roberts closer. Thus, both Beckham and Ms. Roberts were carefully
prepared for this conjoint session for optimal therapeutic outcomes. As Beckham
completed the chapters, the therapist shared the chapters with Ms. Roberts indivi-
dually to gradually assist her in coping with hearing about the traumas Beckham had
experienced.
The final phase of TF-CBT focused on the consolidation of skills, trauma-focused
conjoint sessions, and final therapeutic activities that enhance safety and future
development. During the conjoint session, Beckham shared his trauma narrative
with Ms. Roberts while pausing between chapters so she could reflect back some of
his words, acknowledge his feelings, and praise his ability to write and describe his
experiences in detail. Ms. Roberts praised Beckham for all of his hard work in
therapy and for trusting her enough to share his experiences, thoughts, and feelings
with her. Beckham was offered education about healthy sexuality, healthy relation-
ships, dating, and dating violence. In both individual and conjoint sessions, Beckham
practiced safety skills and problem solving through role-plays that depicted poten-
tially violent or uncomfortable situations.
At the end of therapy, the therapist assisted Beckham in navigating the grief
process related to the loss of his mother by incorporating additional traumatic grief
components (Cohen, Mannarino, & Deblinger, 2006, 2016) from TF-CBT. First, she
offered psycho-education about the stages of grief and read a book together with
Beckham about a child who lost his mother. To say goodbye, Beckham wrote
a farewell letter to his mother. Beckham and Ms. Roberts planned a symbolic funeral
service that they held at his mother’s grave since he was unable to attend her burial.
Beckham created a journal including positive memories about his mother along with
photos of her and him that had been retrieved from his mother’s house after her death.
Beckham talked about not having his mom attend his graduation and wedding and
participate in his children’s lives. The therapist helped him identify other people that
could fulfill these roles in his life, and Ms. Roberts was identified as his primary
person.
After this session, the family completed standardized assessment measures, which
revealed improvements with respect to PTSD and depressive symptoms and aggres-
sive behaviors. The therapist noted improvements in Ms. Roberts’s parenting skills
as well as enhanced parent-child interactions. In fact, Ms. Roberts began to express
more enthusiasm and confidence about the adoption process and expressed greater
appreciation for Beckham’s strengths in overcoming his traumatic experiences and
traumas. A graduation celebration was finally planned that involved a review of
therapy progress and sharing of favorite snacks, graduation certificates, and music.
Emerging Innovations, Challenges, and Recommendations for

Future Research
TF-CBT is an evidence-based treatment that continues to evolve in response
to research. Thus far, research has both replicated earlier findings with diverse
populations and settings and helped to identify factors that appear to be associated
with varied treatment needs in terms of length, intensity, and focus of treatment.
In addition, recent research is attempting to vary efforts to increase access to TF-
CBT, acknowledging that the standard provision of outpatient mental health is
insufficient to address the overwhelming therapeutic needs resulting from childhood
trauma. Toward this end, Salloum and colleagues tested a stepped-care provision of
TF-CBT, in which families attended only three in-person therapy sessions and
completed parent-led home activities, followed by a second evaluation to determine
if additional treatment was needed. The study provided preliminary support for
effectiveness and family receptiveness to a stepped-care TF-CBT (Salloum,
Dorsey, Swaidan, & Storch, 2015; Salloum, Small et al., 2015; Salloum, Wang
et al. 2015). These studies indicate that for some youth, abbreviated or parent-
facilitated treatment may be both clinically effective and cost-effective.
Another focus of TF-CBT research has been on the dissemination of training in
this model of treatment. Cohen, Mannarino, Jankowski et al. (2016) examined
methods of training therapists to implement TF-CBT with youth in residential

settings by comparing treatment outcomes between therapists trained via web-
based training courses and those who received web-based training plus face-to-
face training and bimonthly phone consultation. The findings of this investigation
demonstrated that significantly more therapists who participated in face-to-face
training and phone consultation conducted trauma screenings, completed treatment,
and more frequently implemented treatment with fidelity as compared to therapists
randomly assigned to the other condition. Other research efforts have also begun to
examine the ongoing sustainability of TF-CBT implementation practices beyond the
training period. Research examining TF-CBT supervision in terms of the potential
benefits of incorporating symptom and fidelity monitoring, with and without beha-
vior rehearsal (in which the clinician practices a TF-CBT component for an upcom-
ing session, with supervisor feedback) is currently underway (see Dorsey et al.,
2013), and the results may have important implications for supervision practices
across evidence-based interventions.
Integration of technology into the provision of TF-CBT seeks to address barriers
of both therapist fidelity and client engagement by means of standardized and
engaging software. For example, the TF-CBT Triangle of Life smartphone applica-
tion was developed to help youth learn and apply cognitive coping skills. Additional
computer programs and apps have been developed to support therapists’ efforts to
teach other effective coping and parenting skills to TF-CBT clients. In fact, an initial
feasibility pilot project demonstrated the potential value of technological innova-
tions in enhancing the implementation of TF-CBT with youth and their caregivers,
and further research on technology-assisted TF-CBT treatment is underway
(Ruggerio et al., 2017).
Another area of developing research concerns the measurement of physiological
and neurological correlates of treatment response. In this vein, MRI findings have
been examined within a sample of adolescent girls with PTSD who participated in
TF-CBT. Adolescents with greater amygdala activity to both threat and neutral
stimuli at pretreatment showed less improvement in PTSD symptoms compared to
adolescents with greater discriminatory amygdala response to threat versus neutral
stimuli (Cisler et al., 2015). In a second analysis conducted on the data of this sample,
findings showed self-reported emotional regulation improvement and PTSD symp-
tom reduction paired with greater changes in inhibition of amygdala to frontal cortex
(Cisler et al., 2016). While research documents the negative effects of trauma and
abuse on brain development, future research examining the potential benefits of
therapy on brain development is encouraged as such studies may have important
implications that highlight the plasticity of the brain in terms of healing.
Key Practice Components of TF-CBT

Research has indicated that the support and emotional well-being of
a caregiver is associated with positive outcomes for children (Cohen &
Mannarino, 1996b, 1998b). In addition, it has been documented that the caregivers’
participation in treatment is critical for change in terms of children’s behaviors

(Deblinger et al., 1996). Parenting guidance is regarded as a critical component of
TF-CBT for optimal outcomes related to trauma recovery (Cohen & Mannarino,
1998b; Deblinger et al., 1996). Thus, the research on caregiver engagement and
involvement, cited earlier, is of great importance and should continue to be pursued
to enhance treatment fidelity and positive outcomes for children and adolescents.
All of the TF-CBT PRACTICE components are conceptualized as equally important
to the therapeutic process (Cohen, Mannarino, & Deplinger, 2006). However, the
trauma narration and processing component, which involves gradually encouraging
children to write about their traumatic experiences has been examined more closely in
terms of its impact on outcomes in a randomized trial (Deblinger et al., 2011).
The results of a multisite clinical trial demonstrated that TF-CBT produced significant
symptom improvements among participants as well as enhanced reports of parenting
practices and children’s personal safety skill knowledge across all four TF-CBT
treatment conditions regardless of the number of TF-CBT sessions (8 vs. 16) or whether
a trauma narrative was written. Interestingly, the eight-session TF-CBT condition that
included the trauma narration component seemed to be the most effective and efficient
means of ameliorating parental abuse–specific distress and children’s levels of abuse-
related fear and general anxiety. Despite these and other positive outcomes with respect
to TF-CBT in general, therapists new to the model sometimes express concern about
encouraging a child to discuss their traumatic experiences due to a fear of interfering
with the development of the therapeutic relationship and potentially “re-traumatizing”
the child. To our knowledge, no findings have supported such concerns. Moreover, it
should be noted that when children have been asked what was most helpful in the
therapy process, the majority of children assigned to TF-CBT have reported that talking
about the abusive experiences endured was the most helpful aspect of TF-CBT
(Deblinger et al., 2006, 2011). More recently, Dittmann and Jensen (2014) replicated
the previous findings when they interviewed adolescents who experienced an array of
traumatic events about their experiences with TF-CBT. One theme identified across
interviews was that while it was most difficult to talk about the traumas, discussing the
traumas was the most helpful aspect of their TF-CBT experience.
In terms of concerns about interfering with the development of the therapeutic
relationship, recent research has examined the influence of the therapeutic alliance
outcomes among children and caregivers impacted by trauma. In fact, the results of
a RCT conducted by Ormaug et al. (2014) found that the therapeutic alliance affected
outcomes significantly more among those families randomly assigned to TF-CBT as
compared to those assigned to TAU. These results highlight the value of research
with respect to the therapeutic alliance as well as the importance of clinically
attending to the therapist-client relationship in the context of treatment.
Though there is still much to be learned about the impact and treatment of
childhood trauma, it is gratifying to know that clinicians and researchers share the
desire to pose important questions to the field to ensure that interventions produce
optimal outcomes for children and adolescents who have faced adversity. As a result,
research, training, and clinical efforts all will likely continue to contribute to the
field’s advancements in important ways.
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25 Trauma-Focused Cognitive

Melissa K. Runyon, Elizabeth Risch, and

Importance of Evidence-Based Therapies to Help Children

TF-CBT Practice Components

Treatment is provided in three phases, stabilization (PRAC), trauma narrative and

practiced with support of caregivers in the home environment. Often a version of

Summary of Evidence Base Supporting TF-CBT

quasi-experimental study conducted by Lyons, Weiner, and Schneider (2006) docu-

had experienced as many as 11 other traumatic experiences were randomly assigned

Predictors, Moderators, and Mediators Associated with TF-CBT

At follow-up, caregiver support predicted lower internalizing symptoms for chil-

unproductive processing (overgeneralization, rumination, avoidance) and construc-

TF-CBT Case Illustration

The therapist encouraged Beckham to create a trauma narrative as a means to

Emerging Innovations, Challenges, and Recommendations for

methods of training therapists to implement TF-CBT with youth in residential

Key Practice Components of TF-CBT

participation in treatment is critical for change in terms of children’s behaviors

clinical trial. American Psychological Association, 82(1), 52–64. doi:10.1037/

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