CCPR: Dr. Cohen, you are a developer of trauma-focused cognitive behavioral therapy (TF-CBT) for children and adolescents and their parents or caregivers. Can you give us some of the background?
Dr. Cohen: We have been developing and testing TF-cBT for almost 30 years. it is the most tested trauma treatment for children and adolescents—nine randomized controlled trials thus far. When my colleagues esther deblinger, phd, and Tony Mannarino, phd, and i wrote the TF-cBT book (Treating Trauma and Traumatic Grief in children and adolescents, cohen, Mannarino & deblinger, 2006, available from www.guilford.com), our goal was to deliver it to as many providers with as much fidelity as possible. so we chose a user friendly, simple description of TF-cBT rather than a more nuanced, in-depth one, sacrificing complexity for acceptability and ease of dissemination. TF-cBT is sometimes viewed as a simplistic, “cookie cutter” model as a result—but on the other hand, more than 100,000 mental health providers have taken our free web-based course, in 110 different countries (available at www.musc.edu/ tfcbt). TF-cBT has strong evidence of improving a wide variety of problems, including pTsd, depression, anxiety and fear, behavior problems, and trauma-related shame, as well as improving parental functioning. We are now evaluating TF-cBT in a variety of different settings including residential treatment and foster care.
CCPR: Can you describe your treatment approach?
Dr. Cohen: We start by realizing that most of our patients have experienced multiple traumas, and are often manifesting complex trauma outcomes. They don’t necessarily fit into a dsM-4 diagnosis of pTsd. We are more interested in understanding the nature of the traumatic impact on their lives.
CCPR: You use the mnemonic PPRACTICE (pronounced “practice”) to describe the treatment. Please go through it with us.
Dr. Cohen: The first part of the treatment model provides skills for youth and parents to cope with and gain mastery over the negative impacts of trauma. We emphasize the use of gradual exposure throughout TF-cBT. This involves helping youth learn to apply certain skills when they experience trauma reminders or triggers. The first p is for psychoeducation. We want both the parents and the children to understand the impact of trauma, how common it is, and that their responses are not atypical. We provide information that families often don’t know, such as that one out of four girls experience sexual abuse, or that 20% of kids experience domestic violence. a father might be wondering why his son is so afraid all the time after a trauma, and i’ll use the analogy of service members who have been fighting. When they come back from war, they have a startle reflex when they hear a car backfire. some fathers need to hear this to know that their sons are not “sissies.”
CCPR: How do you gear psychoeducation specifically for kids?
Dr. Cohen: When a child is really fearful and worries that scary things are about to happen, i say something like, “When we were cavemen, we were attacked by wild animals, and those who were on alert for lions or tigers or bears were more likely to protect themselves and their children. you have the same kind of jumpiness as our caveman ancestors because of what happened to you. But now that the person who abused you is no longer in your life, the scary part is over, and we have to help you learn how to get rid of the fear, because it’s not helping you. We need to tell your brain there are no more lions to worry about anymore.” We also educate kids about trauma triggers, things in their environment that are continuing to remind them of the trauma and are making them scared. The fear doesn’t come out of the blue, so identifying the triggers helps to provide a meaning and a context.
CCPR: You actually identify two Ps for PPRACTICE.
Dr. Cohen: The second p is for the parenting component. in TF-cBT, parents or other caregivers receive the same amount of time as the youth. We initially provide individual, parallel sessions for youth and parents, and later have conjoint youth-parent sessions. parents receive information about all of the components described in the ppracTice acronym, including effective parenting skills. Many parents have experienced their own personal traumas along with the youth’s traumas, and/or they are vicariously traumatized by the youth’s experiences. some parents focus on the youth’s negative behaviors and we need to help them see that the youth is not bad, but is responding to bad things that have happened to him or her. so, encouraging parents to think about “what has happened to my child” rather than “what is wrong with my child” is an important tool that can help them to become more supportive. We teach and model the use of effective praise, selective attention, and effective behavioral management strategies while trying to increase the positive interactions between youth and parents.
CCPR: The R is for relaxation. How do you teach kids to relax?Dr. Cohen: i ask kids, “What makes you happy, or what makes you laugh?” For some kids, that’s knitting, or basketball, or whatever they think is fun. recently one girl liked to visualize a favorite toy and for some reason it always made her laugh. so she can use that
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.
CCPR: Thank you, Dr. Cohen.
PO Box 626, Newburyport MA 01950