when she experiences a trauma trigger.

CCPR: And now the A.

Dr. Cohen: That is for affective expression and modulation. Kids who havebeen traumatized sometimes have difficulty expressing how they feel, or how tomodulate difficult emotions. For example, i saw a girl who had been raped byher father from the time that she was a baby. her mother was a drug addict—mypatient would say, “please mommy, stop him,” but she was too strung out ondrugs to respond or to protect her daughter. The girl learned to keep her mouthshut and to hold her feelings inside, but the feelings don’t go away. her feelingscame out as anger, and one day she hit a kid at school, and that night her fatherbeat her up. When she came to school the next day black and blue, socialservices was called, and this was how the abuse was originally discovered.

CCPR: So how do you help a girl with this kind of history?

Dr. Cohen: once we identified that one of her problems was an inability to appropriately express any emotion, we practiceddoing just that, especially with safe adults. Now she is in foster care, and we are working both with her and her foster parents.she needs help expressing difficult emotions to her foster parents, and her foster parents need to respond positively when she expresses feelings in adaptive ways rather than through aggression. For example, if she talks about being sad or asks for help with these upsetting feelings, they stop what they are doing and respond positively to this rather than ignoring her until she becomes aggressive, as they had previously done. This teaches her that expressing feelings is a useful strategy for dealing with upsetting feelings. We also use the well-known technique of distraction—and while this can be overused, in general, if a kids turns on the TV or does a puzzle, that’s a lot better than getting into a fight.

CCPR: So now we’re up to the PRA in the treatment mnemonic. What’s next?

Dr. Cohen: c is for cognitive coping. often kids who have experienced trauma have never considered that their thoughts might have an impact on their feelings. They have maladaptive automatic thoughts about themselves, others, and their place in the world. We start with everyday cognitive coping at this point, and save trauma-related cognitive processing for later. For example, if a child was not invited to a party, his assumption might be that it was because, “no one likes me.” if he did poorly on a test, it might be because, “i’m stupid.” We try to come up with alternative explanations: maybe he wasn’t invited to the party because there wasonly room for a small number of kids and many other kids were also not invited. Maybe he didn’t do well on the test because he studied the wrong things or because it was just a really tough test. if these other explanations were true, how would the child feel, and how would these feelings affect his behavior compared to the original thought? This component allows children and parents to understand that their automatic thoughts are not the only possible ways of viewing the world; suggesting other perspectives opens the door to other possibilities that may help the child and parent feel better and have more choices about their behaviors.

CCPR: T must stand for Trauma.

Dr. Cohen: The T is for trauma narrative and processing. Based on children’s feedback, this is often the most meaningful part ofthe treatment, and generally takes up about one-third of the total treatment time. We have kids talk in detail about personal trauma experiences. We’ve found that many therapists who are not providing a specific trauma-focused treatment model wait for kids to bring up the trauma, on the theory that they don’t want to rush them. But kids are avoidant and when not directly encouraged to address their traumatic experiences they rarely spontaneously talk about these experiences.

CCPR: What is the point of having kids recount the trauma? How is that inherently therapeutic?

Dr. Cohen: Trauma memories are generally incoherent and disjointed, and recounting their trauma experiences helps kids develop a more coherent and accurate understanding of what happened. They have been walking around saying to themselves, “i’m a bad person, i don’t deserve to be loved,” and this is a theme that colors their lives. For example, one child who was sexually molested said, “i didn’t tell anyone because i wanted it to happen.” her abuser had told her that she liked it and wanted it too. so she lived with tremendous guilt and a feeling of being a bad, immoral person. But as she recounted her trauma narrative, a light bulb went off—she remembered that she didn’t like it, that she was terrified, and that her abuser threatened that he would abuse her sister if she ever told. she had suppressed that memory because it was so scary, and it was in some ways easier for her to believe that she had control over the situation and that she “wanted” it to happen. so this was the belief that she held onto, even though it came along with negative feelings and guilt, until she went back and remembered what actually happened. once she did, she was able to say, “i didn’t tell anyone because i was afraid he would do it to my sister.” The retelling of the narrative allowed her to repair her distorted thoughts and it allowed her parents to understand why she didn’t disclose the abuse sooner, and why she had some very negative behaviors during the time before she told. Kids who have been traumatized develop a thesis about who they are because of the trauma, and it becomes a theme, such as “adults don’t protect me, they hurt me.” We work on replacing these themes with positive ones.

CCPR: And the final “ICE” stands for what?

Dr. Cohen: The i is for in vivo mastery of trauma reminders. Kids might avoid bathrooms or schools, depending on where the trauma happened. We come up with a graded hierarchy of triggers and encourage kids to expose themselves in order to mastertheir fears. The c is for conjoint sessions. We bring the parent into the room and the child shares the narrative with parent and we address other positive communication with parents. as TF-cBT draws to a close the therapist wants the youth and parent to be able to directly talk about trauma and other important topics without needing the therapist. Finally, the e is for enhancing safety. Trauma is a violation of safety, so it is important for youth and parents to know that there is a plan for assuring safety in the future. The therapist may work together with the family to develop a family safety plan during the conjoint sessions. additional areas of focus may include healthy sexuality and helping kids with drug refusal skills. at the end of TF-cBT treatment we have a graduation ceremony to acknowledge the progress youth and parents have made.