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© 2011 American Psychological Association 0033-3204/11/$12.00 DOI: 10.1037/a0023133
EVIDENCE-BASED CASE STUDY
Trauma-Focused Cognitive Behavioral Therapy of a Child With Posttraumatic Stress Disorder
Damion J. Grasso
University of Delaware
The Tides Behavioral Health Lewes, Delaware
Albert Einstein Medical Center, Philadelphia, Pennsylvania
Delaware Division of Prevention and Behavioral Health Services, Wilmington, Delaware
This case study involves the use of Trauma-Focused Cognitive Behavioral Therapy to treat a preadolescent male patient referred to the Delaware public mental health system due to a history of family violence and symptoms associated with Posttraumatic Stress Disorder. Pre- to post-treatment data on selfand parent-report measures demonstrate symptom reduction and exemplify the effectiveness of the model. Data on parent participation in the session and facilitation of trauma discussion at home illustrate the parent’s contribution to the therapeutic process. Excerpts of clinical dialogue between child, parent, and therapist highlight the capacity of the model to accommodate individual needs and circumstances. Clinical recommendations supplement the treatment manual and provide clinicians with practical information for use in their own practices. Keywords: Trauma-Focused Cognitive Behavioral Therapy, childhood, PTSD, child maltreatment, case study
Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is a 12- to 16-session intervention designed to reduce behavioral and emotional problems associated with child trauma exposure (Cohen, Mannarino, & Deblinger, 2006). The first three components equip the child and parent with a prerequisite knowledge-base and skill-set that include psychoeducation about trauma, posttraumatic stress, and treatment rationale, as well as relaxation techniques, emotion identification and regulation skills, and cognitive coping strategies. During this initial phase of treatment, the child and parent also undergo gradual exposure to trauma content. As the sessions advance, discussion about trauma becomes increasingly focused on the child’s personal experience. Following the first phase, the child begins to develop a trauma narrative, a detailed account of the traumatic event that functions as a means of therapeutic exposure and helps to facilitate emotional and cognitive processing. When a parent is involved, he or she meets with the therapist separately from the child until the completion of the
Damion J. Grasso, Department of Psychology, University of Delaware; Beth Joselow, The Tides Behavioral Health, Lewes, Delaware; Yahaira Marquez, Department of Pediatrics, Albert Einstein Medical Center, Philadelphia, Pennsylvania; Charles Webb, Delaware Division of Prevention and Behavioral Health Services, Wilmington, Delaware. This research was supported in part by a grant from the Substance Abuse and Mental Health Services Association. Correspondence concerning this article should be addressed to Damion J. Grasso, Department of Psychology, University of Delaware, 108 Wolf Hall, Newark, DE 19716. E-mail: email@example.com 188
trauma narrative. Depending on the comfort level of the child and the readiness of the parent, the therapist encourages the child to share the narrative with his or her parent in a conjoint session. The final phase of treatment focuses on safety skills and future development. The efficacy of TF-CBT has been tested in a number of randomized controlled trials demonstrating that TF-CBT achieves and maintains greater symptom reduction compared with other treatment alternatives (Cohen & Mannarino, 2008). In addition, studies have revealed significantly greater improvements (i.e., effect sizes ranging from d .30 – .81) in posttraumatic stress disorder (PTSD), internalizing symptoms, dissociation, sexualized behavior, and social competence in sexually abused children who received TF-CBT compared with alternative treatments (Cohen et al., 2004; Cohen & Mannarino, 1998; Cohen, Mannarino, & Knudsen, 2005). Moreover, these authors have demonstrated that the therapeutic effects of TF-CBT are sustained over time (Cohen et al., 2005). This case study involves the treatment of a preadolescent male patient referred to the Delaware public mental health system due to a history of family violence and symptoms associated with PTSD. Our objectives are as follows: (a) to demonstrate the effectiveness of the model using pre- to post-treatment and follow-up data on self- and parent-report measures; (b) to illustrate parent contribution to the therapeutic process, using data on parent participation in session and facilitation of trauma discussion at home; (c) to highlight the capacity of the model to accommodate individual needs and circumstances, using excerpts of clinical dialogue between patient, caregiver, and therapist; and (d) to supplement the treat-
as well as relaxation techniques. EPT emerged from the Bioinformational Theory of Emotions by Lang et al. Initial sessions provided psychoeducation about trauma and posttraumatic stress. CBCL Internalizing and Externalizing Behavior Problem t-scores were in the normal range ( 60). In addition. Sandra reported that whenever Marc would see a truck resembling his father’s he would duck down to the floor and tremble.. was administered by a masters-level trained research assistant. As a child. community outreach. “Michael. a technique based on Foa and Kozak’s (1986) Emotional Processing Theory (EPT). a well-validated and reliable measure yielding scores on internalizing and externalizing behavior problems.” participated in the intake assessment. since adolescence.” an 11-year-old European–American male who was referred by a nonprofit community outreach program due to symptoms of PTSD associated with family violence. keeping a baseball bat near his bed in case his father returned. At intake. Fourth Edition (DSM–IV) diagnoses. and hyperarousal. Marc’s responses on the UCLA PTSD RI were consistent with this diagnosis. The caregiver and child provided informed consent/assent to participate in this research. physiologic/behavioral response. Development of the trauma narrative functions as a means of therapeutic exposure. Sandra reported that she had witnessed ongoing domestic violence between her parents. which was standard practice for all children receiving outreach services. a semistructured diagnostic interview for Diagnostic and Statistical Manual of Mental Disorders. Sandra was taking antidepressant and anxiolytic medications prescribed by her primary physician. Background Information The patient is “Marc. treatment rationale. when he was living with his biological father.ILLUSTRATING TF-CBT 189 ment manual by providing clinicians with practical information for use in their own practices. Participants in the effectiveness study were referred to DPBS from three primary sources: juvenile justice. Sandra reported that she had experienced feelings of depression and anxiety most of her life. The UCLA PTSD RI. activation of . which resulted in outpatient treatment for alcohol dependence 2 years prior to intake. Marc remained in the cage for over 2 hours before fleeing to a neighbor’s house. and the Child Behavior Checklist (CBCL. 1998). and conceptual meaning. names were altered and all identifying information was removed from the material presented. which yields PTSD symptom severity scores (i. The administration of the abbreviated University of Southern California Posttraumatic Stress Disorder Reaction Index (UCLA PTSD RI. respectively. EPT defines a fear structure as a special kind of emotion network comprised of associations among the traumatic stimuli. and high anxiety. determined that Marc had a history of physical abuse by his father and had witnessed domestic violence. Baseline Assessment Marc and his 48-year-old biological mother. In addition. Kaufman et al. hyperarousal) and assesses DSM–IV criteria for PTSD. In phase II. TF-CBT was administered in three phases. Sandra also lost a teenage daughter to a drug overdose 5 years prior to the intake assessment. 9. the therapist facilitated development of the trauma narrative and cognitive and emotional processing of the event.” Michael was hosting a barbecue for friends and relatives when he suddenly grabbed Marc and shoved him into an outdoor dog cage. Stuber & Frederick. Because of these injuries. At intake. No other Axis I diagnoses were present. which describes the emotion network as a system comprised of three components: sensory-based perception.e. Treatment Course Marc’s provider was a 30-year-old masters level clinical therapist with a cognitive– behavioral background and 4 years of TFCBT experience. Michael hit and kicked Marc when he tried to escape.. were completed by Marc and Sandra. Since then. Thus. Sandra was unemployed. Steinberg. According to EPT. Pynoos. He came to the attention of the outreach program because of an incident in which he was assaulted and injured by two peers in the neighborhood. Rodriguez. and was diagnosed with Major Depressive Disorder after a suicide attempt in her late 20s. Sandra reported frequent alcohol use. due to a chronic back and neck injury related to a serious vehicle accident. modifying the fear structure through intervention necessitates activation of all three components while new information challenges maladaptive features of the structure (Foa & Kozak. causing the death of her unborn son. intrusive thoughts about his father returning. To protect the identity of all participants. and his symptom severity scores were 12. 1997). the therapist provided Sandra with parenting skills to address behavioral problems at home and support Marc through the treatment process. Prior to meeting Michael. Marc has lived with his mother at his maternal grandmother’s house. Marc met full DSM–IV criteria for a diagnosis of PTSD. Sandra claimed that Marc would chew his shirts to threads because of constant worry. Marc and Sandra received a battery of diagnostic assessments. and child protective services. Most nights Marc would insist on sleeping in San- dra’s room after failing to fall asleep or waking from a nightmare. Sandra was on a combination of pain and sleep medications. avoidance. 1986). constant checking of the locks on the doors. A background interview with Sandra revealed that she had a significant history of loss and victimization. Marc identified the physical abuse as the most bothersome experience. respectively. the stress response. both alcoholics. re-experiencing. 2001). Moreover. 1986). and cognitive coping strategies. emotion identification and regulation skills. The caregiver-child dyad was selected from a sample of 66 dyads recruited to participate in a community-based effectiveness study of TF-CBT following outpatient referral to the Delaware Division of Prevention and Behavioral Health Services (DPBS). The therapist also provided written consent. and 13 for re-experiencing. and reliant on federal disability assistance. “Sandra. The Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and lifetime Version (K-SADS-PL. and meaning representations (Foa & Kozak. Based on the K-SADS-PL.. Achenbach. Marc described the worst episode of abuse which had occurred 2 years prior to the intake assessment. one who repeatedly raped her and one who beat her when she was 8-months pregnant. and in reference to the abuse. Marc reported frequent nightmares. Sandra had been involved in two violent relationships with men. avoidance. met criteria for a probable diagnosis of PTSD. Finally.
and Fatigue (5-items). JOSELOW. our thinking brain gets temporarily shut off and our bodies go into survival mode. doing so may have important clinical utility. The baseline narrative yields an estimate of avoidance and is a springboard for trauma narrative development later in treatment. what do you think would happen if 1 month later. He would throw things at her and push her into walls and stuff. a large bear entered your path? Marc: probably run for my life or climb a tree. [Pauses] I wouldn’t Have to Think About it. The purpose for these questions was to examine processing of the traumatic event and therapeutic exposure occurring outside of session. an area to process further during the narrative phase. suggesting he may have entered the program with a relatively low level of avoidance. A weekly diary measure was administered to Sandra prior to each session. This is called the stress response. after the bear was gone and you were safe. Therapist: Right! When someone’s body goes into alarm mode and the alarm does not turn off. the therapist met with Marc and Sandra individually and discussed prevalence data and theory pertaining to trauma exposure and PTSD using basic facts and analogies. my heart would probably start beating really fast. Would you have to think about it first or would you just do it? Marc: It’s Like an Instinct. 2004). Therapist: You are good! Yes. A lot! One time he poured hot coffee on my mom and gave her third degree burns. This scale was used to examine the pattern of Marc’s behavior at home throughout the course of treatment. The weekly diary obtained Sandra’s rating of Marc’s behavior problems on a Likert Scale ranging from 1 (“No Problem”) to 5 (“Very Much a Problem”) and asked her to describe the behavior. Higher scores indicate a more positive alliance. By the third session. Mean scores for each scale are calculated by summing the endorsed items and dividing by the total available items. The therapist also worked with Marc and Sandra to prepare for a conjoint session during which Marc would share the narrative with his mother.g. Therapist: Marc. Marc was direct about the abuse during the baseline narrative. Six items are scored to reflect the emotional bond between patient and therapist. the client’s initial telling of the event. rapport between Marc and his therapist was already well established as indicated by his responses on the TASA (emotional bond 36/36. and I would be out of breath. What changes happen to your body? Marc: Well. 1983). an adjective checklist measuring transient mood and yielding six scales: Depression (9-items).g. The latter case may necessitate additional client-therapist rapport building strategies. even after the danger is gone— that’s called posttraumatic stress. growing evidence suggests that successful modification occurs when the fear structure is fully activated and memory is reconsolidated (Le Doux. and on average. which in turn facilitates learned inhibition of the fear response and cognitive restructuring. but I am not in danger”) is thought to establish a new emotion network that inhibits the learned fear response (Bouton. your body would go through all of these changes to help you to survive. MARQUEZ. memory of the trauma) together with new. Schafe. “I am thinking about the trauma. 1992). my dad physically abused us. Tension (6-items). stimulates the child’s fear network and activates the traumatic memory. [Pauses] I wonder how he’d feel then. sharing Marc’s developing narrative and eliciting Sandra’s thoughts and emotions. the weekly diary obtained Sandra’s self-reported mood during the past week using the Short Mood and Feelings Questionnaire (S-POMS. AND WEBB the fear structure via repeated exposure to feared stimuli (e. Phase III sessions targeted safety skills and future development and culminated in a graduation session that celebrated Marc and Sandra’s accomplishments. It’s like an alarm goes off in your body telling you that something is wrong. Therapist: What would you do if you were walking in the woods and out of nowhere. therefore I am incompetent”) undergo restructuring and reinterpretation (Foa & Cahill. can You tell me more about the physical abuse? Marc: Well. The TASA is a 12-item scale that measures children’s perceptions of the therapy relationship. using the Therapeutic Alliance Scale for Adolescents (TASA. Phase I: Psychoeducation and Coping Skills Case 1 Marc. Marc’s baseline narrative also indicated an underlying feeling of anger toward his father and desire for retribution. the content. When we respond to danger. Shirk & Saiz. It’s actually a good thing. The therapist engaged in parallel work with Sandra. According to the theory. In Session One. Finally.. your body didn’t return to normal? What would happen if the alarm didn’t get turned off? Marc: I probably wouldn’t be able to do much of anything. 2001). Confusion (5-items). 1996. In addition. Shacham. . The purpose of examining the pattern of Sandra’s mood over the course of the program was to identify particular points in the program during which caregivers may experience high negative affect. Anger (7-items). incompatible information that challenges maladaptive beliefs (e. Therapist: Good call.190 GRASSO. Narrative sharing functions to unite the child and parent in acknowledging their progress and strengthen the parent– child alliance. One of our goals is going to be to train your body to turn that alarm off. trauma narrative development. then. and six items are scored to reflect the degree of task collaboration. the length of time they spoke. I would freeze up. Lastly.. Items are scored on a 6-point Likert Scale.g. task collaboration 31/36). Therapist: Exactly. “I could not stop him. Although trauma discussion between sessions is not typically examined. Nader. the therapist assisted Marc with developing a baseline narrative. a greater number of sessions involving gradual and persistent exposure to trauma material prior to the narrative phase. Vigor (6-items)..and out-ofsession. 2000). Prior to the end of the first session. & Le Doux. [Pauses] Now. During this process. [Pauses] I wish someone would do to my dad all of the things that he did to us. The weekly diary also asked whether Sandra and Marc had discussed the traumatic experience during the past week and to describe the frequency of discussions. Another time he threw me into a dog cage and would kick me whenever I tried to get out. therapeutic alliance between Marc and his therapist was measured twice during the treatment program (sessions 3 and 7). maladaptive meaning representations (e. Baseline narratives suggesting a higher level of avoidance may indicate more work on the part of the therapist to reduce avoidance prior to the trauma narrative. or greater facilitation and utilization of parent support both in.
caregivers. the stronger and more frequently they would return (i. This all makes me very sad. how do You think you would feel if you had so many thoughts stuck to your brain at once? Marc: It probably would be pretty overwhelming. it has emerged in adaptations of the model and is a clever way of connecting the relaxation and cognitive coping components. but limited practical applications and exercises. the therapist discussed intrusive thoughts and introduced the practice of thought stopping. “Do Not Disturb. During another activity.. We put them aside for later.. The therapist taught Marc controlled breathing techniques and muscle-tension relaxation. or just take this all away. many who are victims of the traumatic event. The therapist engaged Sandra in parallel work.g.g. encouraged using controlled breathing techniques during those times. Therapist: We’ve cleared the brain of all of those intrusive thoughts and hung a “do not disturb” sign on it. Doing so may also reveal pertinent cognitive distortions. Sandra’s narrative was replete with guilt. He is such a kind-hearted boy. the therapist taught Marc to identify the intrusive thoughts and then imagine peeling them off of his brain and putting them into an envelope for later.” The therapist further explained that being mindful meant identifying one’s thoughts and feelings without getting stuck in them. 2009). Sandra finished her narrative by stating: It just makes me so angry that Marc has to go through this because of his father. which in turn might enhance her ability to support Marc. however. The mood chart exercise was a creative application of the emotional vocabulary-building objective in the affective modulation component of the program. The therapist elaborated on these ideas by establishing an imaginal scenario (i. employed controlled breathing. and helped her to reconceptualize her role in court. Do you see what we’ve just done? Marc: I think so. and focused on all of the sounds happening around him. [Waits for Marc to peel them off] Good. The therapist validated Sandra’s fears. comprised of statements including: “I should have gotten out of that marriage a long time ago. the therapist helped him to create a personalized mood chart using a computer and built-in camera to capture several facial expressions.” [Waits] Okay. Notice that we didn’t throw the thoughts in the trash. A primary concern for Sandra was the ongoing court hearings during which she and Marc would encounter Michael. In several cases.g. To expand Marc’s emotional vocabulary.” “I should never have let these things happen to Marc. also exhibit symptoms of PTSD.” [Waits] Now. which he explained as an “awareness of all that is going on around you. which provides thorough descriptions of the treatment components and their objectives. As a form of thought stopping. Currently. In a conjoint session. snapping an elastic band). “I am feeling nervous about court tomorrow. sure. the rebound effect). “Stop!”) and cue behavior (e.. Sandra’s description of the family violence was consistent with Marc’s. as well as her level of avoidance. the therapist introduced the idea of mindfulness. Although not explicit in the TF-CBT treatment manual. the therapist taught that negative emotion signals when something is wrong. Therapist: So. go ahead and peel them off. emphasizing the importance of incorporating relaxation into his lifestyle. there is no published clinical TF-CBT workbook to accompany the treatment manual. Phase I was completed in six sessions. The therapist suggested that Sandra pursue individual psychotherapy to help reduce her symptoms of depression (e. obtaining a baseline narrative from a caregiver helps to gauge her knowledge of the traumatic event. [Waits] Good. take a sticky note and write on it. Marc participated in a mindfulness exercise in which he closed his eyes. what can we do about these thoughts? Marc: We can just peel them off. Put them in this envelope. . This is what you can do when you are in school or somewhere else and you have negative thoughts that interfere with what you are doing. the act of attending to the thoughts and filing them away for later may help to avert the rebound effect and break the ruminative cycle (Bakker. Now that you have them in the envelope. It makes me feel helpless and sad that I cannot help him.. the therapist pushed the exercise further by emphasizing the importance of returning to the thoughts and using problem-solving strategies to deal with them.e.ILLUSTRATING TF-CBT 191 According to Sandra. and that by identifying and labeling one’s feelings one can elicit social support (e. [Laughs] Therapist: Okay. The therapist also encouraged the use of praise and positive reinforcement and used role-play to help Sandra incorporate these strategies at home. stick it to the brain. In addition. Sandra provided a baseline narrative. may be exacerbated in parents with depression. These negative feelings and cognitions. After the brain was entirely full of sticky notes. avoidance). rumination. which falls within the cognitive coping component of TF-CBT.. contained greater detail about the domestic violence. Marc did not deserve this. Sandra became highly tearful when discussing Marc’s abuse and it became evident that Sandra often ruminated about her inability to protect him from it. For example. He emphasized the importance of relaxation and helped Sandra to find ways to reduce stress in her life. Sometimes I feel uncertain about how to handle everything. appropriate. however. In another session. Marc presented the mood chart to his mother. Therapist: So. do you think we can talk about it?”). Sandra expressed intense fear of Michael and explained that she would become noticeably upset and panicky when court dates approached. and may interfere with the parent’s ability to support the child during treatment. Unlike active avoidance. more overt techniques. seal it up and write “thoughts to deal with later.e.. The therapist explained that modeling effective emotion regulation would also help to decrease Marc’s anxiety.g.” and “I pick them well don’t I?” The therapist noted these cognitions with the intention of revisiting them when processing Marc’s trauma narrative with Sandra. The therapist explained that the harder Marc tried to ignore or avoid intrusive thoughts. Sandra’s feelings of guilt are common among parents of abused children. the therapist presented a model of the human brain and asked Marc to write several negative thoughts on sticky notes and stick them to the brain. Although the practice of mindfulness has not been incorporated into the TF-CBT treatment manual.” and “being in the present time and place without interference from the past or future. and in some cases. and the therapist facilitated a discussion with Marc and Sandra about the functionality of emotion. as well as any thoughts entering his mind. In her second session. The TF-CBT treatment manual presents thought stopping techniques that involve using a cue word (e. In addition. Marc looked forward to his weekly sessions. and then label them with feeling words. peeling off the sticky notes from the brain) that the child could use in place of or in addition to the other.
.5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Sessions 70 60 Total Minutes per Week 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Sessions 9 0. For example. Patterns of change across sessions.3 2 0.g. Marc’s behavior problems fluctuated and included sleep difficulties. and failed to address oppositional behavior with appropriate consequences Phase II Phase III Behavior Ratings 5 3.5 1 5 0.2 0.5 2 5 1.8 POMS Scale Scores 7 0.1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Sessions Depression Anxiety Anger Fatigue Confusion Vigor Figure 1. “After court he was yelling at me in response to anything I would say and was throwing stuffed animals around”)..9 8 0.4 3 0. and insisting on sleeping in his Phase I 5 5 4.5 3 5 2. and temper flares (e.5 4 mother’s bed (Figure 1. top). complaining about stomachaches and pains. worrying about court. MARQUEZ.g. failed to set appropriate boundaries (e.6 5 0. AND WEBB According to Sandra.7 6 0. .5 4 0. sleeping in her room). JOSELOW.192 GRASSO. Sandra struggled with providing discipline to Marc. she often conceded to Marc’s frequent requests to make purchases. Because of her guilt.
as well as the child. out of nowhere. The therapist revisited Marc’s baseline narrative and asked him to read it aloud. processing stage. who was a little older than me. Confusion. My grandmother threw a bone in front of the cage and starting saying. and the therapist feels less comfortable being direct with the child and challenging avoidance. And no one deserves to be hurt even if they did something wrong. His friends and some of our relatives were there.ILLUSTRATING TF-CBT 193 (e. the therapist presented two examples of trauma narratives. Then he asked Marc to elaborate on the time his father threw him into the dog cage. picks me up. He was scared he was going to die. The only discussion during phase I occurred during the initial 2 weeks of the program (Figure 1. and may reflect how the caregiver is applying what she has learned in session. task collaboration 35/36). I was crying. My mom used to be drunk a lot but she hasn’t had a drink for like a year. Obtaining information about trauma discussion outside of session may help shed light on the child’s level of avoidance. Combining the practice of thought stopping with problem-solving strategies helps to reinforce the idea that thought stopping is a temporary means of derailing intrusive thoughts. Early in the program. I would have thrown my father into the cage. Marc opted to use computer software to illustrate his narrative.g. and Fatigue scales were relatively high during the first 2 weeks of the program (Figure 1. Sandra reported little out-of-session discussion concerning the trauma. Responses such as. I make sure of it. When Asked how Sandra responded to Marc’s statements she said: I would just tell him that it is not nice to say things like that and no matter what has happened your dad loves you. everyone stopped paying attention to me. the child is less willing to fully engage in the exposure and processing. All we ever did was cry. Anxiety.” or “I can understand why you are so upset at your father. bottom). One of his friends tried to block me but I pushed through him and ran to a neighbor’s house and called my mother.” encourage further processing and validate the child’s feelings. Marc’s revised narrative read: The physical abuse happened at a picnic my dad was having. my dad comes. He talked about his dad dragging him to his room because he wouldn’t listen and how he would beat him. If I had more courage. These strategies comprise the cognitive processing component of TF-CBT. He never wanted to see his dad. I was just talking to my cousin. After a while. I also told him I was sorry and I love him and it would never happen again. In the seventh session.” and they kept on laughing. temper tantrums). His friends and some of our relatives were there.g. It really hurt. picks me up. I wish that I was big enough to fight back and then these things wouldn’t have happened and my dad wouldn’t have been able to hurt me or my mom. Phase II: The Trauma Narrative Therapeutic alliance remained high into phase II (TASA emotional bond 36/36. . He brought up when his dad would hit him every year they put up the Christmas tree and how he didn’t want to help anymore. The therapist talked openly about his observations and worked with Sandra to establish a reasonable behavior management plan. These scores decreased by the middle of phase I. For inspiration. I was happy until. Marc’s expanded narrative read: It happened at a picnic my dad was having. and that the child must revisit these thoughts and ultimately address them. The therapist also used Socratic questioning to challenge beliefs that he should have been strong enough to protect himself and his mother from his father. Ultimately. The therapist typed while Marc dictated. Making recommendations for caregivers with depression or trauma-related psychopathology to pursue their own treatment may help improve their ability to support the child in TF-CBT. I got the courage to run out. . I was just talking to my cousin. Out of nowhere. my dad comes. “. middle).. People starting to get drunk. People starting getting drunk.g. Incorporating the concept and practice of mindfulness into the cognitive coping component . may help to increase the child’s awareness of thoughts and feelings and lay the groundwork for writing the trauma narrative. His father told him it had to run its course.. He talked about the time his lung collapsed because his father wouldn’t take him to the hospital. and may reveal pertinent cognitive distortions to address when processing the child’s trauma narrative. He said that he wished that someone would do to his dad all the things his dad did to him so that he could see how it would feel. “Does doggy want a treat.g. Without a strong alliance. and throws me into the cage. each with a unique approach (e. and potential cognitive distortions. I hit my head on the way in. helps to gauge her knowledge of the traumatic event and level of avoidance. who was a little older than me. the therapist encouraged Marc to add emotion words and specific thoughts. He said he wished he had a bow and arrow so he could shoot him. talking back. trauma history) that can either promote or hinder the child’s progress in treatment. The therapeutic alliance is critical to the success of trauma narrative development. Every time I tried to come out my dad or his friends would kick or punch me. it is common for caregivers to report experiencing negative mood states when thinking about their child’s trauma exposure. Sandra reported that: Marc told me that if his dad showed up he would hit him in the head with a baseball bat... In two additional sessions. I should have tried to fight back. and throws me into the doghouse. Eliciting a baseline narrative from the caregiver. I hit my head on the way in. and that it was his responsibility to maintain his mother’s abstinence from alcohol. comic book style). however. Creative and stimulating activities (e. likely reflecting Sandra’s newly developed coping and parenting skills. the therapist discussed the format of the trauma narrative. Phase I: Considerations Comprehensive assessment of caregivers may reveal factors (e. “Tell me more about why you feel that way. Everybody was laughing except for me and my cousin. Everybody was laughing except for me and my cousin. it is not nice to say things like that” might discourage Marc from expressing these feelings and thoughts. Sandra’s POMS scores on the Depression. My mother started to cry. illustrated poem. The therapist explained that responses such as. The therapist introduced the practice of active listening and suggested that Sandra use responses that facilitate exploration of Marc’s feelings and thoughts about his father and the abuse. During phase I. computer software to create a personalized mood chart) help to promote and maintain child engagement in session. Marc told me he was so scared because he couldn’t move or breathe. Finally.
and we are still learning.. . You have gained confidence in yourself as a parent and. The therapist added that being candid about Michael’s depravity (e. Finally. [Pauses] I’m ashamed of myself for letting it get that far. The therapist motivated Sandra to make every effort to make Marc’s appointments by emphasizing the importance of consistency during the narrative development phase. [Eyes well up with tears] Therapist: How do you feel about him having that level of responsibility? Sandra: I don’t like it. Depression. I wish none of this had happened. “Yeah right mom. I guess I’m just doing the best I can.” Although therapeutic letter writing is not acknowledged in the TF-CBT treatment manual. I support her but it is up to her to stay away from drinking alcohol. Marc complained of nightmares involving his father. healing myself along the way. I was freaked out. Transportation was a barrier because she did not own a car and relied on a friend’s availability. I have seen much improvement. but I can never see you again [pauses] because all you ever did was hurt me and mom. not caring to bring Marc to the hospital) and her animosity toward him. The therapist asked Sandra to imagine the situation from Marc’s perspective. Marc read the letter aloud in session as though he was reading it to his father. then had Sandra read it aloud on subsequent iterations. . Now I am safe from my dad. You have a very important role in his life. which resulted in a collapsed lung. Since the start of therapy. My grandmother threw a bone in front of the doghouse and starting saying. You both have come a long way. In discussion. Marc’s resilience). It is very important that you continue to support Marc— but also to take care of yourself. AND WEBB I felt embarrassed and sad that everyone was laughing even though I was hurt. He also brought up the asthma attack and how he had begged his father to take him to the hospital. The therapist coached Sandra on ways to support Marc during the conjoint session. Every time I tried to come out my dad or his friends would kick or punch me. Sandra’s POMS scores during phase II indicated increases in the Anger. Marc’s father stopped pursuing visitation. “Does doggy want a treat. the more likely is the risk of treatment dropout. My mom used to be drunk a lot but she hasn’t had a drink for like a year. the longer the gap between sessions. The therapist read the narrative aloud the first time. “Part of me still loves you. I was crying. My mother started to cry. Sandra: I guess I’m not a bad parent. the therapist encouraged Marc to write a letter to his father—not with the intent to deliver the letter. Sandra pointed out that she had supported Michael’s behavior— often making excuses for him in an attempt to restore peace in the household. Marc created an additional section concerning the time his father refused to take him to the hospital during an asthma attack. Michael’s a bad parent. Marc responded. instead of protecting Marc from these feelings. In the letter Marc read. everyone stopped paying attention to me. might help to validate Marc’s feelings and actually strengthen Marc and Sandra’s working alliance. Sandra realized the frustration and helplessness Marc must have felt to witness his mother being beaten without the will or strength to defend herself. I got the courage to run out. Sandra had cancelled Marc’s appointment six times because of last minute issues. Your ability to parent depends on your ability to take care of yourself. The therapist suggested responding to Marc’s question during the narrative sharing session. I know you blame yourself for what happened to Marc and for much of what he’s going through right now. I was just 10 years old and there were a lot of big adults around. Grandmothers aren’t supposed to be so mean. 2002). We cried a lot because of what we were going through.g. Sandra sobbed when she heard the narrative for the first time. She noted that this must have been confusing for Marc. I had a lot of courage to be able to run away and get help . The letter proved to be an important addition to the trauma narrative.” To process his conflicted feelings. She also expressed feeling hurt and embarrassed by Marc’s question.. Sandra’s medical problems also compromised attendance. I guess we’ve both come a long way. he was hurt and confused that his father simply “gave up. [Pauses] A child should never feel like he is responsible for his mother.” and they kept on laughing. but rather to provide Marc with a therapeutic outlet. and you know. I couldn’t fight back. In doing so. I can stand up to Michael now [pauses] and I think that Marc can see that. One of his friends tried to block me but I pushed through him and ran to a neighbor’s house and called my mother. [Pauses] Last week you criticized yourself for choosing abusive partners. Anxiety. Sandra: I never knew he felt that he had to protect me. as it helped to organize Marc’s conflicted feelings about his father and redefine his role toward him. In addition.g. I get the sense that you see yourself as a bad parent. White & Murray. He remembered a time when Michael threw Sandra across the room and then nearly destroyed everything in the house. Moreover. in turn. I’m getting better. why didn’t you do anything?” Sandra reported that she did not know how to respond to Marc. Gaps in treatment may compromise therapeutic alliance and cognitiveemotional processing of the traumatic event. Marc added. Sandra stated that she was surprised by how much Marc had remembered. . JOSELOW. as well as newfound self-confidence and determination. renewed anger toward Michael. Sandra said she responded by suggesting that perhaps his father did not know any better. “I was very scared for us Mom . At this point in therapy. Marc has gained confidence in you. During the narrative phase. He loves you very much. Trauma discussion at home increased markedly during the narrative development stage (Figure 1. The therapist helped Sandra process these interactions. but after several exposures was able to focus on positive aspects of the story (e. and evaded the question. Marc expressed that although he was relieved that he no longer had to see his father. Therapist: I agree with you. According to Sandra. After a while. likely reflecting an increase in trauma discussion at home. Over four sessions. Therapist: Marc also wrote that he felt safe because of you. and Vigor scales. I didn’t know he put that kind of responsibility on himself. I was never able to do that before.” Marc also reminded his mother of the times his father would come home intoxicated and start screaming at them. MARQUEZ. Sandra had not yet pursued psychotherapy and stated that her life was currently too hectic to do so. middle). 2007. it has been incorporated as a processing tool in a number of therapy approaches (Kerner & Fitzpatrick.194 GRASSO. the therapist shared Marc’s developing narrative with Sandra in order to gradually build her tolerance level and process her own thoughts and feelings about the abuse.
and had Marc generate ways in which he may have become stronger or more capable because of the trauma-exposure. He also introduced the idea of growth after trauma.g. The therapist encouraged Marc and Sandra to consider returning to the clinic for a booster session should problems reemerge or new developments surface. Phase III: Safety Skills and Future Development Marc’s therapy finished in three more sessions. more awards. at the graduation session. I am not around people like my father anymore. In addition. I would like to help animals because animals love me—they hardly ever growl or show aggression toward me. He learned about identifying and expressing emotions and how emotions relate to thoughts and behaviors. It read: Despite all of the stressful things that have happened in my life. loss of privileges) to address this behavior. and I am very happy. I am proud of Marc and his mother for a job well done. Sandra tactfully offered praise and support. the therapist discussed future plans to follow through with the divorce and pursue a clinical therapist of her own to work more intensely on her depression. Sandra used the behavior modification techniques gleaned in phase I (e. 5-min work chore. Phase II: Considerations When helping the child choose a format for the trauma narrative.” The therapist encouraged Sandra to praise Marc for using his resources and contacting the therapist. Therapeutic letter writing may facilitate exploration and organization of trauma-related thoughts and feelings associated with interpersonal relationships. Also not standard practice. “I hated him for hurting you”) and/or realizations during therapy (e. the frequency of nights spent with his mother decreased. which Marc was eager to read to his mother. Congratulations! It takes a lot of courage and effort to successfully complete this program. Marc continued to spend many nights sleeping in his mother’s room. She has been a very important part of the process. Sandra was receptive and explained that she had relapsed but had since “gotten back on the wagon. Sandra began to praise Marc for time spent in his own bedroom. 2 – 3 weeks) may compromise progress. which is typical of this phase of treatment. The therapist finished by facilitating a three-way conversation with Marc and Sandra on separate telephones. With Sandra. and both Marc and Sandra seemed impressed by the progress made. At one point.. but not a standard topic in the treatment manual. The therapist explored Marc’s fears about his mother relapsing and emphasized that alcoholism is a lifelong struggle that sometimes results in setbacks. Finally. While Marc read the narrative. going to a good college and coming out as a veterinarian.g. The therapist explored Marc’s concerns and obtained permission to discuss them with his mother. Marc’s mom has been very supportive throughout the program and has learned about trauma and how to help kids cope with trauma. Marc used the computer graphics program to create an afterword to supplement his trauma narrative. should he find himself in a potentially dangerous situation because of his mother’s problem with alcohol (e.ILLUSTRATING TF-CBT 195 Behavior problems at home continued during the narrative phase. Phase III: Considerations Reflecting on stress-related growth may help highlight the positive attributes of the child and caregiver and set the stage for . The therapist offered a booster session.. With these in mind. I see myself as a very successful person. Marc contacted the therapist by telephone with concern that his mother had started drinking again. Examining trauma discussion at home during the trauma narrative phase may inform the therapist about additional caregiver and child cognitive-emotional processing and reveal unresolved areas worth addressing in session. but Marc and Sandra ultimately resolved the issue at home. During one session. I am bringing home better grades. Marc informed the therapist that he had found an empty bottle concealed in one of the cupboards. consistent with the goals of this phase. I have no more abuse going on in my life. “I realized that I made excuses for your father”) may help to validate the child’s feelings and strengthen the parent– child alliance.g. The therapist met with each of them for 10 min prior to bringing them together.. The therapist used a chart to illustrate Marc’s reduction in symptom scores since baseline. praising positive behavior. the therapist discussed alcohol abuse and dependence. Sandra also followed up by explaining to Marc that it is her responsibility to be a parent to him and that he should not feel responsible for protecting her or ensuring that she remain abstinent from alcohol. Sandra connected Marc’s progress and achievement with her own and professed that they made quite an effective team. I am around people who care about me.g. The therapist encouraged Marc to keep the afterword. the therapist discussed Marc’s personal goals and future aspirations. Troubleshooting attendance problems becomes particularly critical during the narrative phase in which long gaps between sessions (i. I have a lot more friends. providing creative and inspiring examples may help to motivate the child and circumvent some of the anxiety and avoidance associated with starting to talk more in depth about the trauma.. About 1 year after his final session. and in turn. During Marc’s 10th treatment session he and Sandra were ready to share and discuss the narrative together. Marc opted to allow the therapist to use his finished narrative to share as an example to other children entering the program.. The therapist stressed the importance of Marc attending to his own safety and helped him to establish a plan. Using data to illustrate the reduction in symptoms across sessions substantiates the child’s progress and acknowledges the nearing end of the program. the therapist added a written piece to the afterword. Marc also wrote a story about the physical and emotional abuse that he experienced and is devoted to helping other kids who have been abused by sharing his story. Marc learned about managing his stress using relaxation skills and by involving himself in activities that he enjoys. Sandra reported that Marc seemed irritated by her and would often become disrespectful. Marc received a certificate of completion and celebrated with pizza and refreshments. It read: Marc and his mom came into the program determined to work hard and do their best to better understand what had happened in the past and deal with it. mom blacks out from drinking). Encouraging the caregiver to also share certain negative thoughts and feelings associated with the child’s trauma (e. The therapist and Sandra brainstormed ways of reducing the barriers to her own treatment.e. however. whereas the rest of the narrative would remain in the clinic. During another session.
Marc’s scores on the Re-experiencing and Avoidance Scales at 6-month follow-up. and all scales at 9. Evaluating Outcome The K-SADS-PL was readministered at post-treatment. or as part of the certificate of completion provides them with a future reminder of the progress made and the material learned in the program.. demonstrated a greater reduction in symptom severity at post-treatment and follow-up.36). but to a lesser degree.34. respectively). sample) divided by the standard deviation from the sample. a paragraph in the afterword. .and 12-month follow-ups were lower than those from the larger sample (ds . while Marc’s Externalizing Scale t-scores were significantly lower (ds . whereas sample means increased from posttreatment to 12-month follow-up. with the exception of a temporary increase in hyperarousal at the 6-month follow-up.69). . These comparisons suggest that Marc entered treatment with high symptom severity scores relative to the sample. using an effect-size analysis (i.41. 9-. Marc’s re-experiencing score was comparable to that from the sample at pretreatment (d .80 a large effect. MARQUEZ. and 12-month follow-up were moderately lower than the larger sample’s scores (ds . UCLA PTSD RI scores continued to decline. and in general. Marc no longer met criteria for PTSD as indicated by the K-SADS-PL. Marc’s scores on the CBCL Internalizing and Externalizing Problem Scales remained in the normal range across all three follow-up assessments. giving the child the option of sharing it with future children in the program may help to justify the effort spent developing the finished product.20 reflects a small effect.196 GRASSO. Marc’s Internalizing Scale t-scores at 6-..48. Marc’s scores on the UCLA PTSD RI Reexperiencing and Hyperarousal Scales were somewhat higher than scores from the larger sample (ds . and that these scores were maintained from post-treatment to 12-month follow-up. . 9-. whereas Marc’s score on the Avoidance Scale was lower (d . respectively). Changes in PTSD symptoms across sessions. These comparisons suggest that Marc entered treatment with less severe parentreported internalizing and externalizing behavior problems relative to the sample. the UCLA PTSD RI and CBCL were completed at posttreatment and readministered in the home at 6. Additionally. we compared Marc’s preand post-treatment and follow-up scores on the UCLA PTSD RI and CBCL with data from the remaining 65 participants in the effectiveness sample. In addition. . his avoidance and hyperarousal scores were significantly lower (ds . At pretreatment.50 a medium effect.24 .54. AND WEBB termination.03. Data from the CBCL indicate that Marc had lower Internalizing and Externalizing Scale t-scores at pretreatment relative to the sample (ds .01. Although taking home the trauma narrative is generally discouraged of the parent and child. helps to reinforce healthy utilization of resources and continuity of care.08). and 12 months following the baseline assessment. 9.36 .89. Marc’s CBCL scores remained in the normal range ( 60). At post-treatment. and . Marc’s responses on the UCLA PTSD RI indicated a significant reduction in PTSD symptom severity (Figure 2). as well as his responses on the UCLA PTSD RI.. 1988). Discussing the availability of booster sessions and normalizing them as a part of the process rather than a relapse.21. d dif- ference between means (Marc vs.90).e. . d . Discussion Marc’s case study illustrated the implementation of TF-CBT in treating childhood PTSD associated with physical abuse and wit- 14 12 UCLA PTSD RI Scores 10 8 6 4 2 0 Baseline Post-Treatment Reexperiencing 6-Month Avoidance 9-Month Hyperarousal 12-Month Figure 2. however. respectively).62 .. To better understand how Marc’s outcome scores compared to the sample of children and adolescents participating in the community-based effectiveness study. respectively) compared with the sample’s scores. At follow-up assessments 6-. and comparable t-scores at posttreatment (ds . 2. Highlighting the efforts and achievements of the child and parent in a letter.88). and 12-month postbaseline. JOSELOW. Cohen.
& Kozak. 406.. This pattern suggests that trauma narrative development may negatively affect caregivers’ mood during this phase. (1983).. . Journal of Mental Health Counseling. 44. Child Abuse & Neglect. University of Vermont. Clinical.. doi:10. (1992). S. 59 – 68. Rodriguez. A. B. New York. K. 24. P. J. S. Mannarino. Training. Kerner. . & Fitzpatrick. M. NY: Academic Press. Thus. Treating childhood traumatic grief: A pilot study. S. cognitive and emotional processing of the trauma was extended to the home environment. the trauma narrative development phase. Research. Brent. Integrating writing into psychotherapy practice: A matrix of change processes and structural dimensions. Kaufman. T. (2001).. C.3. 2006). increased during phase II. & Deblinger. (1997). M. 166 –176. Statistical power analysis for the behavioral sciences (2nd ed. C.. A. White. 43. M. 47. Burlington: ASEBA. M. B. (1986). A. change processes in caregivers may be an important area for future research. C. Trauma-focused cognitive behavioural therapy for children and parents. Passing notes: The use of therapeutic letter writing in counseling adolescents. Treating trauma and traumatic grief in children and adolescents. A shortened version of the profile of mood states questionnaire. B. Pre. Birmaher. 722–726. 135–145. E.333 Le Doux. New York. Psychological Bulletin. and developmental perspectives on the therapeutic relationship in child psychotherapy. Because trauma discussion at home appeared to be an important part of the therapeutic process. Shirk. 2010 Revision received January 4. A.. Cohen. E. P. L. 305–306.. & Cahill. 36. Smelser & P. Pynoos. 2011 Accepted January 14. & Frederick.. Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): Initial reliability and validity data. A.. Cohen. Journal of the American Academy of Child & Adolescent Psychiatry. Interestingly. NY: Simon & Schuster. Learning & Memory. parenting skills such as active listening and praising were taught to improve the quality of parent– child interactions. parent self-reported negative mood on the POMS was high at the beginning of treatment.. & Mannarino. Mannarino. 29.. V. (2005).. N. Therapists are taught to inform caregivers about the possibility of child behavior problems and symptoms worsening during trauma narrative development. Practice.). Oxford: Elsevier. caregiver. 12363–12369). Flynn. E. G.. J. The UCLA PTSD reaction index for DSM–IV. B. Bakker. J. Psychological therapies: Emotional processing.. 20 –35. this pattern corresponds to changes in child behavior problems and trauma-discussion at home. Clinical Psychologist. E. Journal of Personality Assessment. E. child behavior problems remained moderately high during the trauma narrative phase. 1225–1233. (2004). likely reflecting the salience of trauma material during this time. These reductions are consistent with data from efficacy studies of TF-CBT (Cohen & Mannarino. M... 158 –162. Bates (Eds. (2001). J. (2008). U. A. J. Cohen.. E.. 2008). 99. J. . (1996). & Le Doux. Consistent with our understanding of the TF-CBT model (Cohen et al. A. Weekly diary data revealed the presence of out-of-session trauma discussion between child and caregiver which increased substantially during phase II of treatment.. 485– 494. J.. Stuber. relatively low during the mid to late part of phase I. and therapist highlighted the capacity of TF-CBT to accommodate individual and family needs and circumstances. In addition. C. R. M. Mannarino. NY: Guilford Press. Moreci. In N. Bouton. M. Steinberg. excerpts of clinical dialogue between the child. Foa. 9-. UCLA PTSD RI scores were further reduced at 6-. Received August 13. Thus. 11. 13.1037/0033–3204. (2000). Shacham. Treating sexually abused children: 1 year follow-up of a randomized controlled trial. Schafe. and 12-month follow-up.. The emotional brain: The mysterious underpinnings of emotional life. R. A. Cohen. Nature. (2002).. Psychotherapy: Theory. P.. Ryan. 4. (2007). P. References Achenbach. R. The Child Behavior Checklist. 333– 346. J.44. 713–728. and decreased substantially in phase III. M. & Knudsen. (1998). A. 2011 . International encyclopedia of social and behavioral sciences (pp. 13. D. Child and Adolescent Mental Health. N. Emotional processing of fear: Exposure to corrective information. (2009). Journal of the American Academy of Child & Adolescent Psychiatry. Foa. J. E.. & Knudsen. The content of this discussion revealed a number of child and parent cognitions worth processing further in session. perhaps increasing vulnerability to their own mental health or substance abuse issues. In defense of thought stopping. Cohen. empirical. when trauma reminders are most salient. J. E. Finally. B. New York. and absent during phase III. A.to post-treatment data on the UCLA PTSD RI indicated a significant reduction in symptoms following treatment.. Development & Psychopathology. Rao. K. & Murray. Context and behavioral processes in extinction. (2006). G. (2004).ILLUSTRATING TF-CBT 197 nessing domestic violence. (1988). P. Nader. Fear memories require protein synthesis in the amygdala for reconsolidation after retrieval. & Saiz. Los Angeles: UCLA Trauma Psychiatry Program.). K. 980 –988. E. A.
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