The application of TF_CBT to complex trauma

1. Lecture 7:CBT approaches
to complex
trauma
Complex Casework
Kevin Standish
1

2. Treatment Principle for All
Types of Trauma treatment
“First, do no more harm”
Treatment can help and treatment can hurt
both the helper and the client
2

3. Learning Outcomes
1. Review of research on CBT with complex trauma
2. Trauma focused CBT (TF-CBT)
3

4. REVIEW OF RESEARCH ON CBT WITH
PTSD/COMPLEX TRAUMA
4

5. CBT and PTSD
1. More published well-controlled studies on CBT than on any other PTSD treatment
2. CBT treatments usually involve some combination of psycho-education and
therapeutic relationship
3. Other CBT treatment methods may be added to address related problems
1. anger (anger management training, assertiveness training)
2. social isolation (social skills training, communication skills training)
4. Have proven very effective in producing significant reductions in PTSD symptoms
(generally 60-80%) especially rape survivors
5. Magnitude and permanence of treatment effects appears greater with CBT than with
any other treatment
Compelling evidence it works!
5

6. SOME CBT INTERVENTIONS FOR PTSD
1. Stress Inoculation Training
2. Cognitive Therapy
3. Cognitive Processing Therapy
4. Systematic Desensitization
5. Exposure
6

7. Stress-inoculation training
1. Meichenbaum (1974)
1. Anxiety management
2. Female assault survivors
2. Skills for managing and reducing anxiety
1. Muscle relaxation
2. Diaphragmatic breathing
3. Covert modeling
4. Role playing
3. Anxiety management = decreases in avoidance and anxiety
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8. Cognitive Therapy
1. Beck (1976)
1. Identify their trauma-related negative beliefs (e.g., guilt or distrust of others)
and change them to reduce distress
2. Pay attention to appraisals of safety and danger.
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9. Systematic desensitization
1. Wolpe (1958)
1. Exposure and relaxation
2. Mostly only imaginal exposure
3. Create hierarchy/SUDS
4. Become proficient and relaxation
5. Exposure for hierarchy
9

10. Ways of changing trauma memories : How
CBT models differ from normal CBT
1. Prolonged exposure to trauma memory
2. Updating worst moments in memory (Ehlers & Clark)
3. Brief exposure to image with rapid eye movements or other
bilateral stimulation (Shapiro)
4. In vivo exposure
5. Discrimination of triggers (Ehlers & Clark)
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11. Evidence Base reviewed by NICE
1. EMDR: 11 studies compared with Waiting List (W/L) or
other psychological interventions
2. TF-CBT: 16 studies compared with W/L or other
psychological interventions
3. E-CBT: 16 studies compared with W/L or other
psychological interventions
4. Stress Management: 7 studies compared with W/L or
other psychological interventions
5. General CBT: 4 studies compared with W/L or other
psychological interventions
6. Other: 6 studies compared with W/L or other
psychological interventions
11
http://www.nice.org.
uk/nicemedia/live/10
966/29769/29769.pdf
Deal with Simple
PTSD only
Guidelines do NOT
deal with Complex
PTSD or Chronic
PTSD.

12. NICE Guidelines 2005: Systematic Review of
Psychological Treatments for PTSD –
Effect sizes compared to wait list
0 0.5 1 1.5 2
Other
CBT: Stress
management
EMDR
TF-CBT
A priori threshold d = .08
13 RCTs
4 RCTs
3 RCTs
2 RCTs
12

13. Psychological Interventions
1. Exposure based CBT demonstrated more
clinically important effects on self report
PTSD symptoms and PTSD diagnosis than
W/L.
2. Limited evidence of superiority on clinician
rated PTSD symptoms , depression and
anxiety
3. Not superior to stress management or other
treatments and outcomes varied
substantially
13

14. Psychological Interventions
1. EMDR found support but not as strong as
TFCBT
2. Clinically important benefits on clinician
rated but not self report PTSD symptoms
compared to W/L
3. Limited evidence for clinically important
effects on anxiety and depression
4. EMDR was superior to supportive/non-
directive therapy but not stress
management.
14

15. Evidence base since NICE
1. Several new studies but no change in conclusions above
2. 4 additional studies comparing trauma focused CBT with
waiting list
3. 1 additional study comparing trauma focussed CBT with
other treatment
15

16. Recommendations from evidence base: 1
1. All PTSD sufferers should
be offered a course of
trauma focused
psychological therapy on
an individual, out-patient
basis (A)
2. Trauma focused
psychological
interventions should be
offered regardless of the
time elapsed since the
trauma (B) 16

17. Recommendations from evidence base: 2
1. CBT should be offered even if key trauma
was a long time ago
2. Individual face to face therapy is first choice
3. Course of treatment for a single trauma is 8-
12 60 min. sessions
4. Treatment must be flexible with longer
sessions if trauma story being related.
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18. Recommendations from evidence base: 3
1. Trauma focused psychological
interventions should be 8-12 sessions long
when the PTSD has arisen from a single
incident. (B)
2. If the traumatic event is being discussed
sessions should be longer (90 mins),
offered on a regular and continuous basis
(weekly) with the same person. (B)
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19. Recommendations from evidence base: 4
1. In cases of multiple trauma, traumatic
bereavement, chronic disability arising from
the trauma, significant co-morbidity or
social problems longer treatment duration
should be considered (> 12 sessions). (C)
2. Treatment should be delivered by
competent individuals with appropriate
training and supervision. (C)
19

20. UK Trauma Group Statement on CPTSD
(May 2008)
1. NICE states that PTSD develops following a stressful event or
situation of an exceptionally threatening or catastrophic nature, and
examples that are given include single events such as assaults or
road traffic accidents.
2. For adults, we believe that this refers to “simple” PTSD, which
commonly develops following a single traumatic event occurring in
adulthood. The recommended treatment is brief, trauma-focused
psychological therapy.
3. However, the guideline does not apply to situations involving
complex trauma, for example where there is a history of multiple
traumatic events, including previous childhood trauma and
attachment disorder.
20

21. UK Trauma Group (May 2008)
1. The NICE guidelines do not provide adequate guidance in relation
to the assessment and treatment of Complex PTSD.
2. This results in lack of appropriate provision, resources and training
to treat people with Complex PTSD, and ensuing limited access to
effective treatment services.
3. We propose that a review of the literature on complex PTSD is
urgently needed to refine the definition of complex PTSD, and
provide more detailed guidance for good practice in the
assessment and treatment of complex PTSD.
4. We advise that the multi-phasic treatment recommendations
outlined above should be followed as best practice for the
treatment of Complex PTSD as we currently understand it.
21

22. UK Trauma Group (May 2008)
1. Literature on effective treatment for complex PTSD is
limited, but what there is so far shows that multi-phasic
and multi-modal treatment is indicated for children and
adults (e.g. Luxenberg et al., 2001).
2. The literature recommends that the following three stages
are included:
3. Establishing stabilisation and safety;
4. Psychological therapy, incorporating trauma-focused
elements and some exposure to the trauma;
5. Rehabilitation.
22

23. SCHEMA THERAPY and PTSD
1. Schema therapy was designed to help people who have chronic difficulties.
2. It was derived from traditional CBT and incorporates practices from other
psychotherapies, including psychodynamic, emotional focused therapy, and
Gestalt.
3. It retains the structure of a cognitive model but has more of a focus on client
needs and core emotional experiences.
4. Recent adaptations to schema therapy such as the mode model have been
shown to be effective in treating emotionally dys-regulated clients with
extensive trauma histories.
5. Schema therapy is not a treatment model for PTSD per se
6. Although the treatment process and structure can help those with complex
trauma as it follows some of the core elements of trauma treatment:
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24. SCHEMA THERAPY:
1. Cognitive models have informed understanding of the development, maintenance, and
treatment of posttraumatic stress disorder (PTSD). Limited research, however, has
examined the relationship of early maladaptive schemas to PTSD among trauma survivors.
2. Harding et al (2011), using a sample of 127 female child sexual abuse survivors, applied a
model-based clustering procedure to the 15 subscales of the Young Schema
Questionnaire-Short Form and revealed three clusters differentiated primarily by level of
schema elevation.
3. Women in the cluster characterized by the highest schema scores reported the most
severe PTSD symptoms.
4. A discriminant analysis indicated that schemas of Mistrust/Abuse, Vulnerability to Harm,
and Emotional Deprivation contributed most to distinguishing women differentiated on the
basis of presumptive PTSD diagnostic status.
5. Results underscore the importance of cognitive factors in the development and/or
maintenance of PTSD symptoms and suggest possible treatment targets for cognitive
therapy with CSA survivors
24

25. TRAUMA FOCUSED CBT MODEL:
TF-CBT
25
https://www.youtube.com/watch?v=hKAzsf-VqdQ
4min 30 sec

26. The origins of TFCBT
1. Developed for treating sexually abused children
2. Viewed working with parents as an integral part of treatment
Esther Deblinger, Ph.D.
Center for Children‟s Support
University of Medicine and Dentistry of New Jersey
&
Judith Cohen, M.D., and Anthony Mannarino, Ph.D.
Center for Traumatic Stress in Children and Adolescents
Alleghany General Hospital
26

27. What is TF-CBT?
A hybrid treatment model that integrates:
 Trauma sensitive interventions
 Cognitive-behavioral principles
 Attachment theory
 Developmental Neurobiology
 Family Therapy
 Empowerment Therapy
 Humanistic Therapy
27

28. What is TF-CBT?
• Evidenced Based treatment model developed by Deblinger, Cohen,
and Mannarino that integrates trauma sensitive interventions with
cognitive-behavioral strategies.
• The therapist structures sessions such that there is a focus on skill
building and direct discussion and processing of the abuse
experience.
• TF-CBT is a time limited, structured model that takes place over 12 –
20 sessions.
• Children between the ages of 3 and 18 that have a memory of the
trauma and have a diagnosis of Post Traumatic Stress Disorder
(PTSD) or Post Traumatic Symptoms.
28

29. TF-CBT elements
1. Psycho-education
2. Disclosure / Exposure / Working Through of Traumatic
Material
3. Cognitive restructuring
4. Problem solving
5. Use of behavioural techniques
for example anxiety management
29

30. TF-CBT Approaches
1. Exposure:
The therapist helps confrontation of the traumatic
memories (written, verbal, narrative).
Detailed recounting of the traumatic experience –
repetition.
In vivo repeated exposure to avoided and fear-
evoking situations that are now safe but that are
associated with the traumatic experience.
30

31. TF-CBT Approaches
1. Cognitive Therapy
Focus on the identification and modification of
misinterpretations that lead PTSD sufferer to
overestimate current threat (fear)
Modification of beliefs related to other aspects of the
experience and how the individual interprets their
behaviour during the trauma (eg: issues
concerning shame and guilt).
31

32. Other - CBT Approaches
1. Stress Management
2. Relaxation Training
3. Breathing re-Training
4. Positive thinking and Self-talk
5. Assertiveness Training
6. Thought Stopping
7. Stress Inoculation Training
32

33. Difficulties Addressed by
TF-CBT
1. CRAFTS
 Cognitive Problems
 Relationship Problems
 Affective Problems
 Family Problems
 Traumatic Behavior Problems
 Somatic Problems
33

34. Core Values of TF-CBT
1. CRAFTS
 Components-Based
 Respectful of Cultural Values
 Adaptable and Flexible
 Family Focused
 Therapeutic Relationship is Central
 Self-Efficacy is emphasized
34

35. Choosing TFCBT
RCTs demonstrating efficacy/effectiveness of TFCBT for:
1. Ages 3-18 but is being extended to adults
2. Multiple racial/ethnic backgrounds
3. Varying socio-economic status
4. Single or multiple trauma history
5. Placement with biological parents or child welfare
6. Children with behavior problems
35

36. TFCBT is not for:
1. Clients with extreme therapy-resistant behavior
2. Clients with active suicidal behavior
3. Clients with severe cognitive disabilities
36

37. 37

38. Components of
TF-CBT Treatment
• Developing an empathic and supportive relationship.
• Psycho-education and providing a rationale for treatment.
• Stress management.
• Exposure
– Imaginable (prolonged)
– In-vivo
• Cognitive re-structuring
38

39. Overview of Re-living
• Initially neutral imagery;
• Then complete sequence of traumatic imagery, verbal or
written to start - (possible hierarchical list);
• Rewind and hold - concentrate on the worst part of memory,
freeze and hold image, while repeatedly describing in detail all
they can remember of the trauma;
• Cognitive restructuring during exposure;
• Audio-tape;
• Constant rating of anxiety - use 0 -10 SUD‟s scale;
• Listen to tape as homework
• Intersession tasks
39

40. Hotspots
• Notice changes in affect (What was going through
your mind? How does it feel?)
• Discuss „meaning‟ associated with hotspots
• Verbal re-appraisal of hotspots (or imagery) to deal
with them
• Re-living just hotspots (re-wind and hold)
• Build in new meanings
40

41. After re-living
• Rate vividness
• Ask how they found doing it
• How it compared to what they thought it would be like?
• Were they holding anything back?
• H/W
41

42. Imagery Rescripting
• What would happen if you allowed the image to
continue? Can you change the ending…
• What would the image look like projected onto a
cinema screen, or seen from a moving train?
• Imagine watching the image on TV – switching it
off, dimmer,…freeze the image or make it black
& white.
• Through a zoom lens - make it smaller, or out of
focus or further away 42

43. Additional treatment strategies
• Exposure in vivo
• Behavioural experiments (to „test out‟ unhelpful appraisals –
“I‟m going out of control”, “I‟m vulnerable/weak” etc)
43

44. Cognitive Restructuring
1. Appraisals of the traumatic event –
2. “this could happen again”
3. “I should have been able to prevent it”
4. Appraisals of symptoms of PTSD –
5. “I am going mad”
6. “I should be over this by now”
7. Some characteristic biases / thinking errors –
8. Using hindsight to evaluate what happened
9. Personalisation
10. Overgeneralization (e.g.. of risk)
11. Catastrophisation (e.g.. if I face my memories ….)
44

45. Useful ‘Restructuring’ Questions
• What other explanations might there be?
• Who else was involved?
• How much power did you actually have to
influence what happened?
• How did things appear to you at the time?
• What was your reason for acting as you did, at
the time?
• How could you have known what was going to
happen?
45

46. Useful ‘Restructuring’ Questions:
(cont)
• How much time for reflection and choosing the
best course of action did you have?
• What was your emotional and physical state at
the time?
• What did you do that was helpful?
• If this was another person, what more would
you expect of them? How would you explain
their behaviour?
• Apart from your feelings, what else might you
take into account when considering how you
acted?
46

47. 47

reconstruct the
fragmented trauma
memory & anchor it
in the past through
discussion, tapes &
writing
understand & reduce
avoidance, encourage
desensitization, tackle
substance abuse etc

48. TFCBT – A PRACTICE!
A ssessment!
P sychoeducation and Parenting Strategies
R elaxation
A ffective expression and regulation
C ognitive coping
T rauma narrative and processing
I n vivo exposure
C onjoint parent child sessions
E nhancing personal safety and future growth
48

49. Assessment
Goal: Identify trauma history and presence of trauma-related
symptoms.
1) Trauma History
2) Internalizing
3) Externalizing
4) Avoidance
5) Re-experiencing
6) Hyperarousal
7) Interference with daily functioning
49

50. Trauma-focused
Cognitive Behavioral Therapy
Child‟s Treatment
Coping Skills Training:
Emotional Expression
Cognitive Coping
Relaxation
Gradual Exposure & Processing
Education:
Child Sexual Abuse
Healthy Sexuality
Personal Safety
Caregiver‟s/partner Treatment
Coping Skills Training:
Emotional Expression
Cognitive Coping
Relaxation
Gradual Exposure & Processing
Education (like child sessions)
Behavior Management
Joint Sessions
Coping Skills Exercises
Gradual Exposure & Processing
Education Regarding Sexuality
and Sexual Abuse
Personal Safety Skills
Family Sessions
From Deblinger & Heflin (1996)
50

51. The Therapist sets an agenda and sticks to
the agenda, dealing with “COWS” or
Crisis of the Week at the end of each
session.
51

52. TF-CBT is adaptable and flexible to address developmental issues,
gender, culture, family values (especially sensitive to sexuality
and parenting styles).
The therapeutic relationship is central.
52

53. 1/3 1/3 1/3
Sessions 1 - 4
 Psychoeducation
/Parenting Skills
 Relaxation
 Affective
Expression and
Regulation
 Cognitive Coping
Sessions 5 - 8
 Trauma Narrative
Development and
Processing
 In vivo Gradual
Exposure
Sessions 9 - 12
 Conjoint Parent
Child Sessions
 Enhancing
Safety and
Future
Development
TFTF--CBT Sessions FlowCBT Sessions Flow
Entire process is gradual exposure
Baseline
assessment
53

54. Psychoeducation
Goal: Normalize symptoms, validate experience and reactions, instill hope for recovery.
1) What is trauma?
2) What is PTSD?
3) What is TFCBT?
54

55. Parenting
Goal: Support caregivers to reduce their own stress/anxiety,
improve the child-adult relationship, help the caregiver support
the child‟s recovery.
1) Praise
2) Rewards
3) Active Ignoring
4) Time Out
Specific for kids with PTSD:
1. Confidence in limit-setting
2. Not reinforcing avoidance
3. Coping coaching
55

56. 1. Teach parents/caregivers active ignoring and how to praise
positive behaviors
2. Role play strategies with caregiver
3. Look at fact sheets in regards to trauma
4. Play psycho educational card game with child then child and
family
What
do A therapeutic card
you game about child
know child sexual development
? Physical abuse &
domestic violence
56

57. Relaxation
Goal: Create “tool box” that the client can use in his/her own environment to manage
symptoms.
Relaxation is not just progressive muscle relaxation and deep breathing…
1. What do you do to relax?
2. Relaxation vs. Distress Tolerance
57

58. Affective Regulation
Goal: Normalize multiple conflicting feelings, teach varying levels of feelings, teach
vocabulary for talking about traumatic events competently.
1. Feelings Education (what are emotions?)
2. Connecting feelings to traumatic or difficult events
3. Feelings thermometers
4. Learning self-soothing techniques
58

59. Affective Regulation
EMOTION IDENTIFICATION AND EXPRESSION
1. Ask client to talk about feelings
2. Encourage client to expand feelings
vocabulary and match feelings to
appropriate situations/events
1. Engage youth in activity that encourages
expression of feelings
59

60. Cognitive Coping
Goal:
1. Essential to help clients/families evaluate the ways in
which trauma changed their thinking and correct
distorted thoughts.
2. Make sure clients don‟t define themselves by their
traumatic experiences.
Cognitive Processing occurs before and after the
Trauma Narrative.
First teach the skill, then use it.
60

61. Cognitive Coping
The heart of TFCBT:
GOALS:
1. Clarify the difference between thoughts, feelings, and behaviors.
2. Demonstrate how thoughts, feelings, and behaviors affect each other.
61

62. Cognitive Coping
COPING SKILLS
Explain at least two of the following strategies: (1) grounding, (2)
mindfulness, and or (3) relaxation, including deep breathing, progressive
muscle relaxation or guided meditation.
62

63. TF-CBT Triangle Demonstration
63
https://www.youtube.com/watch?v=g6hMfQOsma4
11min

64. Trauma Narrative
Goal: “To gradually expose client to thoughts, memories, and other
innocuous reminders of the abusive experience until they can tolerate
those memories without significant emotional distress and no longer
need to avoid them.” (Deblinger & Heflin, 1996, p. 71)
1. Comes from Anxiety Framework
2. Un-pairing of harmless stimuli with learned anxiety response.
Should include:
1) Before the trauma
2) Components of the trauma (chapters) with specific details, thoughts,
feelings, and associated memories
3) The “worst” part
4) “What I learned” or “What I would tell other kids”
5) The future 64

65. Cognitive Processing of the Trauma
Narrative
Goal: Identify latent or overt cognitive distortions or unhelpful
beliefs and challenge them with the client.
1. Revisit the cognitive triangle, add consequences
2. Use Socratic questioning
3. Never “tell” the clients to change their beliefs
4. Review cognitive coping (thought stopping, positive self-talk)
5. Practice strategies in session
6. Assign homework to practice skills at home
65

66. CBT Trauma Narrative Lecture
66
https://www.youtube.com/watch?v=evEL5l9QAks
1: 38 min

67. Common Trauma-Related
Thoughts/Feelings
1. Guilt
2. Shame / Disgust
3. Self-Blame
4. Hopelessness
5. Fearfulness
6. Worthlessness
7. Lack of control
8. Depression
67

68. In-Vivo Exposure
Goal: Unpair feared stimuli (triggers) from the learned response of
anxiety/fear.
Examples:
1. The dark
2. Streets
3. Men
Use general and specific fear ladders, set up homework and practice
activities with reward systems.
68

69. Enhancing Safety
Goal: Prepare for the future
1. Learn to recognize signs/symptoms that indicate the need
for a return to treatment
2. Create usable, meaningful safety plans
3. Plan for using coping skills
4. Consider environmental supports
69

70. Personal Safety Skills
1. Identify good and bad touch
2. Use “uh-oh” feeling analogy
3. Use role play to teach client assertiveness skills
4. Client practice assertiveness skills in session or taught skills to caregiver
70

71. Conjoint Sessions
Goal:
1) Increased exposure / opportunity for mastery
2) Increase child & caregiver communication
3) Support asking and answering questions
1. Essential to prepare adequately
1. (individual with CG and with client before joint session)
2. Invite prepared questions, comments, feedback
3. Celebrate success!
71

72. Summary
Assessment!
P sychoeducation and Parenting Strategies
R elaxation
A ffective expression and regulation
C ognitive coping
T rauma narrative and processing
I n vivo exposure
C onjoint parent child sessions
E nhancing personal safety and future growth
TF-CBT – it works!
72

73. Core readings
1. Courtois & Ford (2009) chapter 12. Cognitive Behavioral Therapy, Christie Jackson,
Kore Nissenson, and Marylene Cloitre
2.Doron, Miki & Lahad, Mool (2010) Protocol for Treatment of Post Traumatic Stress
Disorder : SEE FAR CBT Model: Beyond Cognitive Behavior Therapy
73

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