What’s the Best Therapy for Trauma?

Trauma is an area of mental health that is widely discussed due to its unfortunate prevalence, especially in teens and young adults. Trauma, however, does not define who a person is. In fact, with mental health support and resources such as therapy, people struggling with conditions such as post traumatic stress disorder, traumatic stress, complex-PTSD, acute trauma, or even intergenerational trauma or ancestral trauma can find lasting healing.

What's the role of childhood trauma? 

Traumatic events that occur in early childhood or adolescence, often called adverse childhood experiences (ACES), can have serious impacts on an individual’s lifelong physical and mental health. 

Examples of adverse childhood experiences include:  

• Experiencing violence, abuse, or neglect
• Witnessing violence inside or outside the home 
• Having a family member attempt suicide or die by suicide
• Growing up with household members who have substance use problems
• Growing up with household members who have mental health problems 
• Loss of access to a parent due to parental separation 
• Loss of access to a family member or household member due to that individual member being in jail or prison 

Trauma, the collection of symptoms and emotions that can follow these events, is an example of how adverse childhood experiences and other types of childhood trauma can have a lasting effect. Trauma treatment, therefore, needs to go all the way back to childhood trauma in order to create sustainable mental wellness.

{{mid-page-newsletter}}

What does trauma look like? 

Signs and symptoms of trauma include the following: 

• Intense, long-term emotional feelings of anger or guilt  
• Depression 
• Anxiety and heart pounding 
• Behavioral changes 
• Academic changes 
• Difficulty sleeping
• Difficulty eating
• New aches and pains 
• Difficulty paying attention 
• Withdrawing and spending time alone 
• Fixating on the traumatic event 

Sometimes, these symptoms last for a short amount of time, and this is called acute trauma. Other times, trauma can last for months or years and is called chronic trauma. When trauma is associated with specific symptoms like intrusive thoughts, avoidant symptoms, mood changes, and increased reactivity such as being startled easily, a trauma therapist may even diagnose you with post-traumatic stress disorder, a medical diagnosis.  

What is trauma-focused CBT?

In this article, we will review a form of talk therapy offered at Charlie Health that is specifically designed to treat individuals who are experiencing difficulty with trauma. This type of family-focused therapy is called trauma-focused cognitive behavioral therapy, or TF-CBT for short. While other talk therapy modalities focused on trauma exist, this one will be the focus of this article. 

TF-CBT is designed to help children, adolescents, as well as their parents or caregivers, address trauma. It works by combining many treatment approaches and psychological theories together. These trauma focused treatment approaches include: 

• Cognitive therapy, a type of therapy that seeks to help clients help understand their thoughts and behaviors 
• Behavioral therapy, a form of therapy that focuses on changing the way that you behave in situations  
• Family therapy, a type of therapy that includes parents or guardians  
• Attachment theory, which emphasizes the importance of forging a healthy relationship between a child and their guardian 
• Exposure therapy, a type of therapy in which treatment involves a therapist guiding a client dealing with trauma through their “triggers” in a safe environment. When a trauma survivor is able to navigate prolonged exposure to the things that might trigger, for example, their childhood trauma, they are ultimately better able to handle everyday stress and create deeper relationships. 

{{mid-page-cta="/dev-resources/staging"}}

Who would benefit from trauma-focused CBT? 

An evaluation completed by a clinician usually precedes trauma-focused CBT or trauma therapy. The trauma therapist can then determine whether you would benefit or be a good fit for this type of therapy. A clinical evaluation includes information gathered from the child and guardian, as well as school records, pediatric records, Child Protective Services caseworkers and/or other information when it is available or needed. 

Appropriate individuals for TF-CBT include the following two groups: 

1. Children and adolescents who have experienced and can remember a traumatic event. In addition, these children or adolescents may also experience prominent symptoms of trauma or PTSD listed above such as having behavioral concerns related to the trauma or experiencing high levels of anxiety, depression, or shame surrounding the trauma. A diagnosis of post traumatic stress disorder is not required for a child or adolescent to participate. 
2. In addition to these children and adolescents, TF-CBT also includes parents or caregivers of these children. It is important to note that parents or guardians are only included in TF-CBT if they are not the cause of the trauma. 

If a child or adolescent is acutely suicidal, actively participating in self-harm, or partaking in illegal drug use, these concerns may take precedence and the individual should be treated for these issues prior to beginning TF-CBT. Furthermore, if a child or adolescent cannot remember the trauma, this type of trauma or PTSD treatment would not be appropriate for them. 

What can trauma-focused CBT help me or my child with? 

TF-CBT helps children and their parents or guardians in multiple aspects of their lives, including the following domains: 

Mood symptoms

Mood symptoms such as anxiety, depression, anger, or difficulty with regulating emotions are often experienced by those who lived through a traumatic experience. 

Behavioral disturbances

Examples of negative behaviors may include avoiding any reminder of the trauma, injuring oneself, aggression, acting out sexually, and more. 

Social skills

TF-CBT can help individuals repair relationships with friends and family, overcome social withdrawal, do better with school performance and attendance, and learn how to trust again.  

Negative thought processes

Negative thought processes related to trauma can include intrusive thoughts and memories, psychotic symptoms, and more. 

Physical symptoms

Physical bodily symptoms like feeling hypervigilant and having an increased startle, having poor sleep, experiencing stomach aches or headaches, and other physical ailments can severely worsen quality of life. 

What happens in trauma-focused CBT?  

As described above, trauma-focused CBT is a collaborative form of therapy that involves the child or adolescent, their parent or guardian, and the clinician.  At the beginning of therapy, the clinician may review information with the parent and child that helped them decide TF-CBT was appropriate. Boundaries and guidelines should also be established early on.  Time will be split between the parent and child, and information from parent-clinician or child-clinician may be shared with the individual not in that session.

Each clinician may structure TF-CBT in a different manner. The below descriptions are meant to serve as a guide to help you understand what this type of therapy looks like. 

Stabilization phase 

The first phase of TF-CBT is called the stabilization phase, and it often involves a few different component pieces, discussed below. 

Psychoeducation

Psychoeducation is the process by which the clinician teaches the child and guardian about trauma. What was the child’s adverse childhood experience and how are their current problems related to it? 

The clinician reviews behaviors or thought processes that the child experiences and educates the parent and child about how these negative behaviors or emotions are related to the experience of traumatic events. Learning how items are connected can help parents and children start to recover.  

A part of psychoeducation may also include a discussion on trauma reminders. A trauma reminder is any situation, person, smell, sound, memory, etc. that reminds the child of a traumatic event. For example, for an individual who was sexually assaulted in the home, a trauma reminder may be their bedroom and the child may not want to sleep in their bedroom or sleep alone. By identifying triggers and connecting the child’s response to the trigger and trauma, the clinician can help the child and their guardian better make sense of the emotions the child experienced. 

Parenting skills

As stated above, sessions will often be split in half. The parent and clinician will take up half the time and then the child and clinician will take up the other half of the time. Clinicians will use age appropriate and culturally appropriate information when discussing trauma with the child to ensure the child understands the material. 

Trauma narrative and processing phase 

The next phase of TF-CBT allows the child or adolescent who has experienced trauma to process what has occurred or is occurring. This occurs through a process in which the child describes the traumatic event to their therapist over the course of multiple one-on-one sessions as the child becomes comfortable. Being able to “speak the unspeakable” helps the child further process what happened to them. After describing the trauma, the therapist may also have the child write about the trauma or narrate it in another creative form. In addition, the child continues to work on all the strategies listed above. 

At the same time, the therapist has parallel one-on-one sessions with the parent. Many parents may not even know the full details of the traumatic incident their child or adolescent faced. By learning about their child’s trauma, parents are able to learn more about the event or events and process the trauma themselves in preparation for future combined sessions. 

The therapist works with both the child and parent to help them gain mastery over the traumatic event and practice coping skills throughout this challenging phase. 

Integration and consolidation phase 

In this final phase of TF-CBT, a few events may occur. 

In vivo mastery: In vivo mastery is an optional component of TF-CBT in which the child slowly begins to practice facing a fearful situation. For example, if a sibling died in a car accident and the child is afraid of riding in cars, the child works with the therapist to slowly take steps to face that fear. This may take many weeks of therapy and will occur at the child’s comfort level. Persistence and patience on the parents end is also required during this challenge. 

Sessions with both the child and the parent: These conjoined sessions occur in the last phase of TF-CBT. They allow the child and parent to openly discuss trauma, the effects of trauma, new coping mechanisms developed, setting boundaries, future house rules and more. Children and parents are able to ask one another questions in a safe space. Some questions may include “Do you blame me for what happened to you?” or “How did you feel when I told you about my assault?”

Before therapy concludes, it is important to make sure parents and their children feel safe moving forward, especially because trauma occurs in a situation in which the child did not feel safe. Discussing how to keep everyone safe – for example enacting a strict no-drugs house policy, deciding to openly discuss private matters, setting ground rules – is a conversation that can be facilitated with the therapist.  

How can parents help with dysregulation? 

When talking with parents, clinicians can help parents develop strategies to help their child when their child is experiencing emotional or behavioral dysregulation. Examples of parental strategies include:

• Placing children in quiet, safe “time out” environments when needed to encourage the child to relax and re-regulate their own emotions 
• Praising the child for positive behaviors through verbal praise and attention, hugs, high fives etc. instead of only scolding the child for negative behaviors 
• Working with the clinician, a parent can develop a reward and “punishment” (loss of electronics time) system to help improve certain behaviors 

Relaxation skills

Both children affected by trauma and parents of traumatized children experiencing stress can benefit from relaxation techniques. Personalized relaxation skills depend on the individual family. This could include meditation, yoga, singing a favorite song, participating in an activity that requires hands like artwork, performing certain exercises, progressive muscle relaxation, and more. 

Children and their parents can try out multiple different relaxation techniques and decide individually which ones work for them, letting the therapist know in one-on-one sessions. Working as a clinician, the child or parent can identify times when they feel anxious, stressed, or scared and practice the relaxation techniques discussed. 

Affect modulation skills

When children experience trauma, they may cope by hiding or burying emotions. But expressing emotions, a key feature of affect, in a positive way is healthy. In this component of therapy, children work with their therapist to discuss and practice how they can express emotions in a healthier or more productive way. What are positive ways to problem-solve? To ask for help? To seek social support from friends? To distract themselves when feeling negative emotions? These methods are discussed with their therapist and practiced in real life. 

In the parent sessions, clinicians discuss these new strategies with parents and can role-play with parents so that parents know how to react to these changes. If a parent feels that their child continues to act out or express their emotions in a negative way, it may be helpful for the parent to keep a diary to better understand when and why their child is acting out. 

Cognitive processing skills

Part of cognitive behavioral therapy is learning how thoughts, feelings, and behaviors are all connected to one another. For example, a negative thought can turn into a negative emotion and a negative behavior. By nipping this process in the bud and replacing negative thoughts with healthier ones, the therapist hopes to help the child practice avoiding negative feelings or behaviors. There are many ways in which the therapist can explore this concept with a child depending on their age, level of development, and trauma. 

Parents too can have negative thoughts that lead to negative feelings and behaviors. Common negative thoughts a guardian whose child has experienced trauma may have is “I should have protected my child” or “My child is going to be messed up forever because of what happened to them.” By working through these negative thoughts and this negative cycle, parents can benefit from TF-CBT just as much as their children. 

Charlie Health is here to help.

TF-CBT has been effective in many studies across the world, and has been proven to lead to improved parenting practices as well as a reduction in child depression and poor behavior. 

At Charlie Health, we have therapists trained and experienced in TF-CBT who are ready to assist you and your family face struggles related to trauma or any other mental health concern 24/7. Reach out now. 

‍