The Family Journal: Counseling and

Therapy for Couples and Families

Trauma-Focused Family Therapy With 1-8
ª The Author(s) 2019
Article reuse guidelines:
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DOI: 10.1177/1066480719832503
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Wanda Boyer1

Abstract
Family life is considered to be a context in which children can safely learn life skills such as managing and directing their cognitive,
physical, emotional, and behavioral responses to events as a way to achieve a sense of purpose and mastery in life. Traumatic
events such as natural disasters, serious accidents, and violence in our homes, schools, or communities may alter an individual’s
ability to manage cognitive, physical, emotional, and behavioral functioning. Trauma can significantly affect children and their
families, impacting relationships, interactions, and their context. There is evidence to support the use of family therapy with
children who have experienced trauma. Family support can improve interactions and relationships and can assist children in
resolving trauma symptomology. Trauma-focused cognitive behavioral therapy (TF-CBT) is professionally recognized as an
evidence-based intervention. There are also TF-CBT intervention derivations that have been developed to support children
experiencing trauma. TF-CBT and TF-CBT intervention derivations are explored in this article including core components of
evidence-based trauma-focused family therapy necessary to support traumatized children and their families. Discussion also
includes the importance and evidence-based support for honoring cultural diversity and including optimism and hope into family
experiences as both a preventative and interventive measure to manage trauma symptomology.

Keywords
trauma-focused family therapy, self-regulation, emotion regulation, play therapy, cultural diversity

Trauma by definition is unbearable and intolerable: “It takes
tremendous energy to keep functioning while carrying the
memory of the terror, and the shame of utter weakness and
vulnerability” (van der Kolk, 2014, pp. 1, 2). Trauma “changes
how we think, what we think about . . . our capacity to
think . . . how we heal” (van der Kolk, 2014, p. 21), how we
make safe connections, and nurture self-leadership (van der
Kolk, 2014).
For children who have experienced trauma, there is evi-
dence to support the use of family therapy. Specifically, there
is improvement in children’s response to the trauma and pos-
itive parent-reported evaluation of outcomes after parental
inclusion in the intervention (Cohen, 2010). Furthermore, the
resolution of children’s trauma-focused symptoms is “best
facilitated by working with and considering the family or set
of relationships as a whole . . . to accurately assess an individ-
ual’s concern [while] observing the interaction of the other
family members, as well as the broader contexts in which the
person and family live” (Corey, 2013, p. 435).
Trauma-focused family therapy addresses “the child’s trau-
matic experiences . . . [and is] superior to nonspecific or nondir-
ective therapies in resolving PTSD symptoms” (Cohen, 2010, p.
421) within the family constellation. Children and their families
can benefit from trauma-focused therapy because it is a way for
children to talk about traumatic experiences in a safe and
supportive environment (Cohen, 2010). Specifically, trauma-
focused psychotherapies: “(1) directly address children’s
traumatic experiences, (2) include parents in treatment in some
manner as important agents of change, and (3) focus not only on
symptom improvement but also on enhancing functioning, resi-
liency, and/or developmental trajectory” (Cohen, 2010, p. 422).
In this article, we will consider use of trauma-focused fam-
ily therapy with children and their families. We will begin by
further defining trauma and child trauma and identifying the
prevalence of child trauma and its effect(s) on the individual
and family functioning. We will then review existing literature
describing a family-based treatment approach and evaluate its
quality based on empirical support. Within this exploration of
the existing literature, we will also note trends, gaps, profes-
sional applicability, potential policy changes, and areas of
future research. In the conclusion, we will integrate and
1
Department of Educational Psychology and Leadership Studies, University of
Victoria, Victoria, Canada
Corresponding Author:
Wanda Boyer, Department of Educational Psychology and Leadership Studies,
University of Victoria, 3800 Finnerty Road (Ring Road), P.O. Box 1700 STN
CSC, Victoria, British Columbia, Canada V8W 2Y2.
Email: wboyer@uvic.ca
2 The Family Journal: Counseling and Therapy for Couples and Families XX(X)
summarize the findings and recommendations and learning
from this review for effective practice with children and their
families.
The Impact of Trauma on Children and Their
Families
Trauma is “a basic rupture- loss of connection- to ourselves,
our families, and the world” (Levine & Frederick, 1997, p. 23).
Trauma can happen in one or more of the following ways when
an individual directly experiences, witnesses, or learns about
traumatic event(s) violently or accidentally happening to fam-
ily members or close friends, or experience repetitive exposure
to aversive details of traumatic events such as “actual or threat-
ened death, serious injury, or sexual violence” (American
Psychiatric Association, 2013, p. 271). Trauma- and stressor-
related disorders . . . include “reactive attachment disorder,
disinhibited social engagement disorder, posttraumatic stress
disorder (PTSD), acute stress disorder, and adjustment dis-
orders” (American Psychiatric Association, 2013, p. 265).
Traumatic experiences or events may include “childhood
abuse, war, terrorism, natural disasters, large-scale transporta-
tion accidents, fires, burns, motor vehicle accidents, rape, sex-
ual assault, stranger physical assault, intimate partner violence,
sex trafficking, homicide or suicide, life threatening medical
conditions, and emergency worker exposure to trauma” (Briere
& Scott, 2015, pp. 11–21). In the following sections, we will
explore the definition of childhood trauma, its prevalence, and
a detailed description of how trauma interferes with the func-
tioning of the child and their family.
Definition of Child Trauma and Prevalence of the
Problem
Child trauma refers to traumatic events that a child experiences
in early childhood (birth to 6 years of age) or childhood (under
the age of 18; Briere & Scott, 2015). According to data reported
by the U.S. Department of Health and Human Services,
Administration for Children and Families, Administration on
Children, Youth, and Families, Children’s Bureau (2017), the
reported number of victims in 2015 was 683,000 with 75.3% of
the victims having experienced neglect, 17.2% had been phy-
sically abused, and 8.4% of these children were sexually
abused. The perpetrators in 78.1% of the cases were a parent
of the child (Letter from the Commissioner, p. ii, para. 1). In
2015, professionals such as “teachers, police officers, lawyers,
and social service staff” made 63.4% of the reports of child
maltreatment including child abuse and neglect. Education per-
sonnel made the highest number of reports, that is, 18.4%; legal
and law enforcement personnel made 18.2%; and social ser-
vices personnel made 10.9% of the reports alleging maltreat-
ment (U.S. Department of Health and Human Services,
Administration for Children and Families, Administration on
Children, Youth, and Families, Children’s Bureau, 2017, Sum-
mary, p. ix, para. 5). Victim cultural affiliation included 43.2%
White, 23.6% Hispanic (Latino/Latina/Chicano), and 21.4%
Black. From these statistics, it is clear that childhood trauma
is a prevalent issue that needs to be addressed.
Description of Living With Child Trauma: Impact on
Individual and Family Functioning
Trauma experienced by children may have an impact on their
developmental processes; for example, physical trauma and
neglect can affect learning and academic performance by
impacting neurodevelopment of the brain and nervous system
development (Navalta, 2011). Physical trauma and neglect can
also impact psychosocial development related to personality
and temperament, moral decision-making, and social relation-
ships (Navalta, 2011).
In response to trauma, toddlers and preschool children may
experience separation anxiety, phobic reactions, and enuresis
(Scheeringa, Weems, Cohen, Amaya-Jackson, & Guthrie,
2011) and feel a sense of helplessness, insecurity with care-
givers, and peril everywhere. As a result, they may seek to
sleep with their parents, withdraw from play, and may experi-
ence developmental regression or lack the ability to regulate
emotional responses (Goldbeck & Jensen, 2017; Lester et al.,
2008). Children under 5 years of age who experience traumatic
events may manifest reactive attachment disorders such as
being “emotionally withdrawn behavior toward caregivers
and persistent social and emotional disturbance” (Hilt &
Nussbaum, 2016, p. 180). Further, trauma- and stressor-
related disorders for children 6 years or younger include PTSD,
which is diagnosed as follows: (a) at least 1 month of at least
one intrusive experience, such as distressing memories,
dreams, flashbacks, reminders, or physical responses; (b) at
least 1 month of at least two arousal symptoms, such as dis-
turbed sleep or concentration, hypervigilance or exaggerated
startle reflexes, or irritability or anger outbursts; and (c) at least
1 month of at least one avoidance symptom (avoidance of
internal or external reminders) or at least two negative cogni-
tion symptoms, such as “negative emotional states; diminished
interest in significant activities; socially withdrawn; [and]
reduced expression of positive emotions” (Hilt & Nussbaum,
2016, p. 181).
With children older than 6 years of age who experience
traumatic events, the symptom categories of intrusive experi-
ences, arousal, and avoidance parallel children 6 years and
younger, and they are diagnosed as posttraumatic stress reac-
tions if the child manifests at least one of each symptom cate-
gory, and at least two arousal symptoms, for 1 or more months
(Hilt & Nussbaum, 2016). For children 6 years or older to be
diagnosed with PTSD, the child must also experience at least
two negative cognition symptoms (Hilt & Nussbaum, 2016).
Moreover, the symptomology for negative cognitions includes
developmentally appropriate recognition of the child’s growing
abilities and how trauma can impact developmental pathways
and neurobiology: “impaired memories; negative self-image,
blame; negative emotional states; decreased participation;
detachment; [and] inability to experience pleasure” (Hilt &
Nussbaum, 2016, p. 182). School-aged children may
Boyer
experience concern for the safety of self and others, reflect with
shame and guilt on their responsibility for the traumatic event,
and manifest stomach aches and headaches, lack of concentra-
tion in school, learning problems, and developmental regres-
sion (Goldbeck & Jensen, 2017; Lester et al., 2008).
Individuals caring for children need to sensitively consider
patterns of behavior and whether they are developmentally
appropriate for that child’s age and the child’s context in order
to diagnostically understand the impact of trauma on that child
(Hilt & Nussbaum, 2016).
Contemporary researchers recognize that children depend
on parents, caregivers, and guardians to take note of these
patterns of posttraumatic behavior, recognize the implications
of these behaviors, take action to begin the process of accessing
mental health services and premental health service to help
“manage their children’s problem” (Hoagwood, 2005, p. 691)
and cope with the emotional and behavioral changes over time
(Lester et al., 2008). If these parents, caregivers, and guardian
have directly or indirectly witnessed the trauma or the suffering
of the child in their care, they may in turn suffer from traumatic
symptomology or bidirectionally be reminders to the child of
the trauma (Briere & Scott, 2015). If parents, caregivers, and
guardians experience trauma themselves, they may be less
capable of empathically recognizing the posttraumatic symp-
tomology of their child, helping their child, maintaining family
life routines or roles, or providing secure attachment, nurtur-
ance, and positive and effective parenting practices that have
been identified as being a protective factor for children’s men-
tal health and well-being (Dishion & Stormshak, 2007; Lester
et al., 2008). Caregivers of children who have experienced
trauma may not access mental health services for their child
because they feel shame, guilt, or remorse that the traumatic
event impacted their child, that they were negligent, or that
they could not help save the child from the traumatic experi-
ence (Hoagwood, 2005).
Current researchers have identified hope for the child and
their family (Landolt, Cloitre, & Schnyder, 2017). A positive,
stable family environment with family cohesiveness and a uni-
fied sense of purpose can be maintained through the use of
effective parenting practices and positive parental adjustment
to support children and their families (Dishion & Stormshak,
2007).
Trauma-Focused Family Therapy
Evidence-based treatments should provide “an overall
approach that is respectful, positive, and compassionate, and
that provides support and validation in the context of an
empathically attuned therapeutic relationship” (Briere & Scott,
2015, p. 97). This section includes an exploration of an
evidence-based trauma-focused family therapy intervention
featuring trauma-focused cognitive behavioral therapy
(TF-CBT; Cohen, Mannarino, & Deblinger, 2012), TF-CBT
intervention derivations, trends and gaps in the literature, and
professional solutions.
3
TF-CBT
TF-CBT (Cohen et al., 2012) is an empirically supported inter-
vention and advocated by the U.S. Substance Abuse and Men-
tal Health Services Administration (2015). This intervention is
appropriate for use with “children ages 3-18 who have experi-
enced a trauma and are subsequently exhibiting significant
trauma-related difficulties, such as post-traumatic stress disor-
der (PTSD), depression, and behavior problems” (Kliethermes,
Drewry, & Wamser-Nanny, 2017, p. 167). The following CBT
principles are used to address trauma-related symptomology:
stress management, gradual exposure, and desensitization to
traumatic content, cognitive interventions to address inaccurate
beliefs about self and the world, and caregiver involvement
(Cohen et al., 2012; Kliethermes et al., 2017). The TF-CBT
has nine components that are unified under the acronym
PRACTICE: “Psychoeducation . . . [and] Parent Skills Trai-
ning . . . Relaxation Training . . . Affective Expression and
Modulation Training . . . Cognitive Coping . . . Trauma Narrative
Development and Processing. In Vivo Exposure . . . Conjoint
Parent-Child Sessions . . . [and] Enhancing Safety and Future
Development” (Deblinger, Cohen, & Mannarino, 2012, pp.
11–19). TF-CBT includes 8–16 treatment sessions that are
50–60 min in length. If a child is experiencing a complex
trauma, 16–24 sessions may be needed for further child and
parent support. Half of the sessions are dedicated to stabiliza-
tion training and skill development, one fourth of the sessions
include trauma narration and personal processing of the
trauma, and one fourth in conjoint/in vivo mastery of the
PRACTICE skills and ensuring the safety of the child
(Kliethermes et al., 2017).
In a meta-analysis of 10 studies from 1996 to 2011, Cary and
McMillen (2012) found a medium effect size for PTSD and a
modest effect size at the posttreatment and 12-month posttreat-
ment between TF-CBT and comparison conditions (e.g., atten-
tion control, standard community care, and waitlist control
conditions). These authors also found a small pooled effect size
for depressive and behavioral symptomology arising from
trauma at immediate posttreatment and at the 12-month post-
treatment between TF-CBT and comparison conditions (Cary
& McMillen, 2012). The limitations of this study include a
small meta-analytic study sample, no examination of mediating
and moderating effects of the intervention components, and no
trials that compared the manualized version of the TF-CBT to
active alternative intervention conditions. Despite the study
limitations, Cary and McMillen (2012) indicate that TF-CBT
is an effective treatment for PTSD.
In a recent study in Germany, researchers included 159
children and adolescents ages between 7 and 17 as participants
who had experienced trauma of medium severity of PTSD
symptoms after the age of 2 (Sachser, Keller, & Goldbeck,
2017). Based on the “Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition” (American Psychiatric Asso-
ciation, 2013), the children were diagnosed with PTSD symp-
toms including reexperiencing, avoidance, and sense of threat
and the complex PTSD (CPTSD) of emotion regulation,
4 The Family Journal: Counseling and Therapy for Couples and Families XX(X)
negative self-concept, and interpersonal problems (Sachser
et al., 2017). Pre-post effect sizes were large for PTSD and
CPTSD indicating a significant statistical significant impact
of TF-CBT in reducing children’s posttraumatic stress symp-
toms (Sachser et al., 2017). Pre-post effect sizes were moderate
for improving emotion regulation and large for self-concept
and ability to solve interpersonal problems (Sachser et al.,
2017). The limitations of this study were that treatment
responses to the TF-CBT were not the primary focus of the
larger treat child trauma study (Sachser et al., 2017).
Further reviews of empirical studies exploring TF-CBT as
an intervention noted change over time in reduction and mod-
ulation of posttraumatic stress symptoms, compared with com-
parison conditions and with other cognitive-behavioral
interventions for children and adolescents who are survivors
of traumatic life experiences (de Arellano et al., 2014; Schnei-
der, Grilli, & Schneider, 2013). As well, children continued to
improve after TF-CBT treatment, but these improvements were
not sustained at 6- and 12-month follow-ups (Mannarino,
Cohen, Delinger, Runyon, & Steer, 2012). The explanation was
that those children who manifested internalizing behavior
problems above the average by 2 SDs or who self-reported
above average depression scores by 1 SD at the pretreatment
phase were more likely at the 6- and 12-month follow-up to
meet PTSD criteria (Mannarino et al., 2012). TF-CBT has been
found to statistically reduce symptoms of depression with
variability of effective size ranging from small to moderate
with one outlier of a large effect size at immediate posttreat-
ment (de Arellano et al., 2014) and with no consistent treatment
effect at posttreatment follow-up times (Schneider et al., 2013).
TF-CBT has been endorsed by national centers for crime vic-
tims research on traumatic manifestation of sexualized beha-
vior (Schneider et al., 2013). It has been noted that TF-CBT
reduced general and sexual behaviors over time (de Arellano
et al., 2014; Schneider et al., 2013). Counselors are cautioned
to “conceptualize trauma treatment along a continuum that
seeks to initially decrease symptoms of PTSD and functional
impairment, while remaining vigilant in the months following
treatment for co-occurring conditions that may persist”
(Schneider et al., 2013, p. 334).
Derivations of TF-CBT
New therapies have been derived from the TF-CBT model and
should be considered as worthy of ongoing and future research
(Schneider et al., 2013). The combined parent–child cognitive
behavioral therapy (CPC-CBT; Runyon, Deblinger, & Steer,
2010) intervention has been used with 60 children ages ranging
from 7 to 13 with a mean age of 9.88, who were at risk for child
physical abuse. This study included parents, ranging in age from
25 to 51 with a mean age of 33.02 years, who had reported the
use of some type of force to discipline their child (Runyon et al.,
2010). In the CPC-CBT condition (child interventions, parent
interventions, and parent–child interventions), there were 34
children and 24 parents, and in the parent-only CBT condition,
there were 26 children and 20 parents (Runyon et al., 2010).
Children who received CPC-CBT with their parents experienced
reductions in PTSD symptoms with large effect sizes supporting
the findings, and the parents reported positive parenting with
medium effect size (Runyon et al., 2010). However, it was noted
that parents who participated in treatment alone reported greater
reductions in corporal punishment although in the pre-post treat-
ment both CPC-CBT and parent-only conditions reduced their
use of corporal punishment (Runyon et al., 2010). The study was
limited by a small sample size, lack of ethnic diversity, partici-
pant attrition, and the need for a “larger dose of parent skills
training” (Runyon et al., 2010, p. 213). The parents in this study
needed to learn more about parenting behaviors to support their
children. Future research could benefit from considering inclu-
sion of children who may have varied behavioral disorders and
developmental needs.
Stepped care TF-CBT (SC-TF-CBT; Salloum et al., 2014)
was an open trial research study intended to gather data on parent
acceptability, efficacy, and economic cost of Step 1 of SC-TF-
CBT. This pilot study included nine parent–child dyads with
78% male children ages 3–7 (mean of 4.7) and a mean parent
age of 33 years (Salloum et al., 2014). The children’s cultural
affiliations include 78% Caucasian, 11% African American, and
11% Hispanic/Latino/Latina. Parents were required to have
Internet access to retrieve information from the National Child
Traumatic Stress Network workshop (http://www.nctsn.org/)
and the parent–child workbook based on the preschool SC-TF-
CBT manual. Step 1 consists “of three (1 h) in-office therapist-
led sessions every week” (Salloum et al., 2014, p. 70). After each
therapist-led session, parents were responsible for independently
working with their child on PTSD preschool treatment manual
topics. After the first in-office session, the parent must have four
sessions at home with their child where they work on the work-
book topics of behavior management, relaxation, affect identifi-
cation and regulation, and development of a scary ladder or
stress hierarchy. After the second session, parents must have
four sessions where they work on trauma exposure activities
using the trauma reminders drawn on the scary ladder and then
imagining it for 30 seconds and then finishing off with a next
step or in vivo activity to “Draw it, Imagine It, and Next Step”
(Salloum et al., 2014, p. 70). The last in-office session is used to
complete the “trauma exposure activities, discuss a relapse plan,
and for the parent and child to review the child’s [personal] My
Steps book” (Salloum et al., 2014, p. 71). At this point, the
therapist ascertains via diagnostic infant and preschool assess-
ment if the child should end treatment after Step 1 or if the child
needs to go on to Step 2.
Children who meet responder status of SC-TF-CBT have
been assessed as being able to enter into the maintenance phase
and are not demonstrating PTSD symptomology. At this phase,
parents are encouraged to independently (a) provide effective
communication of requests; (b) practice relaxation 3 times a
week with the child; (c) help the child use Step 1 resources to
communicate feelings; (d) meet once a week to just relax, play,
and have fun with the child; and (e) attend the next assessment
meeting. Those who do not fall into the Responder status or
who need Step 2 will go on to Step 2, which is nine sessions of
Boyer
the TF-CBT sessions based on the TF-CBT acronym
“PRACTICE” (Deblinger et al., 2012). The authors found that
only six children completed treatment. At baseline, these chil-
dren met the criteria for PTSD, and at midassessment, only one
child met the PTSD criteria and was recommended for Step 2,
but the parent chose not to participate with their child. There
are important limitations to consider related to this study of SC-
TF-CBT. The program objective is to be fiscally responsible
and parent approved. Parents are given weekly 15-min remin-
ders and a website URL for psychoeducational material, but the
intervention has only three therapist-led sessions. The program
authors have not considered the impact that the child’s trauma
or the family trauma has had on the child and family and
whether they can appropriately and satisfactorily work through
the workbook material independently of therapist guidance in
between sessions. Further, if the parents have been impacted by
the trauma, they may be incapable of handling the scary ladder
and in vivo activity where parents and children are encouraged
to remember the scary (traumatic) experience and visually
depict it and hold it in their memory.
Trends in the Literature
An important trend in the literature is consideration of core
components of evidence-based trauma-focused family therapy
with children and their families that can improve the quality of
life for children and their families (Landolt et al., 2017).
Trauma-focused family therapy includes an exploration of the
family context and relationships as well as the interactional
pattern that is causing ongoing posttraumatic dysregulation for
the child and dysfunction for the family, all with the intent to
“help the family system amend that pattern” (Hilt & Nussbaum,
2016, p. 271). There are ethical and evidence-based core com-
ponents of therapies that address child trauma. The emphasis
within these core components is “tailored to the specific family
and culture of the child” (Landolt et al., 2017, p. 512) and must
reflect respect for the dignity of the child and their family,
responsible caring, and integrity in this therapeutic relationship
(American Psychological Association, 2017; Canadian Psycho-
logical Association, 2016). The core ethical and evidence-
based components of trauma-focused family therapy include:
 Phase-based treatment including a physical, emotional,
and social evaluation and plan for safety and stabiliza-
tion of the child and their family system, and
“processing of traumatic memories through exposure
and personal narratives, and re-integration and
reconnection” (Landolt et al., 2017, p. 512)
 Developmentally and culturally appropriate treatment
for the child and their family
 Caregivers within varied relevant systems (e.g., school,
afterschool care, and recreation; Landolt et al., 2017)
 Psychoeducation on child trauma and trauma sympto-
mology to support the child, caregivers, and members of
other relevant systems in the process of posttraumatic
recovery (Briere & Scott, 2015; Landolt et al., 2017)
5
 Self-regulation and emotion regulation skills training
 Support for cognitive processing of dysfunctional
trauma-related cognitions, beliefs, assumptions, and per-
ceptions that are harmful, debilitating, or degrading
(Briere & Scott, 2015; Landolt et al., 2017)
 “Reconstruction and/or reconsolidation of the traumatic
memories through exposure and/or creation of a trauma
narrative” (Landolt et al., 2017, p. 512)
 Identification of child and family competencies and
hopeful future (Landolt et al., 2017)
 The opportunity to process issues within a therapeuti-
cally facilitative relationship
 Opportunities for the child and family to increase their
self-awareness and self-acceptance in relation to the
effects of a traumatic history (Briere & Scott, 2015)
Another core component that should be considered is opti-
mism. Optimism is the extent to which a person has positive
expectations for their future in spite of adversity (Carver, Sche-
ier, & Segerstrom, 2010). Childhood trauma has been related to
lower levels of optimism and a higher risk of affective disor-
ders (Broekhof et al., 2015). For individuals who have experi-
enced childhood trauma, optimism has been associated with
coping, that is, with flexibly adjusting to trauma while demon-
strating and positive mental and physical health and well-being
(Sarafino, Smith, King, & DeLongis, 2015). It has also been
noted that individuals who demonstrate optimism use problem-
focused coping strategies aimed at doing something about the
stressor itself to blunt its impact (Carver et al., 2010, p. 882). In
a meta-analytic study of optimism and coping, the researchers
indicated that optimism was associated with engagement cop-
ing strategies involving problem-focused coping to plan and
seek instrumental support and emotion-focused coping to pro-
mote cognitive restructuring and ongoing goal engagement
(Nes & Segerstrom, 2006). It should be noted that optimism
was associated both with increased problem-focused coping
with controllable stressors such as daily life demands and with
increased emotion-focused coping with uncontrollable stres-
sors such as trauma (Nes & Segerstrom, 2006). Optimism pre-
dicted active approach coping strategies to eliminate, reduce,
or manage stressors or their emotional consequences (Nes &
Segerstrom, 2006, p. 248), thereby enabling the individual to
make psychological adjustments and accommodations to
stressful circumstances in a flexibly engaged manner that sup-
ports autonomy restoration, effective action, learning new ways
of being, and a sense of purpose (Nes & Segerstrom, 2006; van
der Kolk, 2014).
Gaps in the Literature and Professional Solutions
There is a gap in the knowledge of counselors and counselors in
training regarding empirically supported interventions for
treatment for child trauma (Kaminer & Eagle, 2016; Schneider
et al., 2013). To address this gap, I featured TF-CBT and the
intervention derivations as “important new therapies that show
promise” (Schneider et al., 2013, p. 334).
6 The Family Journal: Counseling and Therapy for Couples and Families XX(X)
Another gap is based on the core components of child
trauma therapy, which are not addressed by TF-CBT interven-
tions. Core component 1 involves the three phase-based treat-
ment plan (Landolt et al., 2017). Phase 1, safety and
stabilization, and Phase 3, reintegration and reconnection, pro-
tect the child from further trauma. Both require a plan to imple-
ment child protection measures, should an adverse event arise,
as well as a plan for a strong future based on the competencies
and strengths of the child and their family. These are consid-
ered ethical and relational responsibilities that should be in
place to ensure that participants are protected and
emotionally ready for intervention termination (American
Psychological Association, 2017; Canadian Psychological
Association, 2016). Core component 2 involves the issue of
developmentally appropriate interventions that meet the cul-
tural context needs of the child and family. Many of the present
interventions are more developmentally appropriate for use
with school-aged children (Landolt et al., 2017). Interventions
with young children who have survived trauma and who may
have limited language could capitalize on sensorial experiences
involving play, art, music, and movement (Malchiodi, 2015). In
order to express cultural sensitivity, we must convert our
knowledge into action by providing a safe space in the counsel-
ing room/playroom where parent and child can look with curi-
osity, touch miniatures and other objects, put them down, learn
how to safely interact with each other, and reestablish their
sense of security with one another (Gils, 2005). The second
and third core components are intertwined. Developmentally
appropriate practices can be improved with empathic parent
and caregiver involvement. Although TF-CBT does include
caregivers in the process with conjoint sessions (Deblinger
et al., 2012; Mannarino et al., 2012; Runyon et al., 2010; Sach-
ser et al., 2017; Salloum et al., 2014), parents, caregivers, and
guardians may need to “learn to speak a new language to
empathically communicate with [a child who has experienced
a traumatic event] . . . the Be With Attitudes . . . I am here, I hear
you, I understand, I care” (Landreth & Bratton, 2006, pp. 83–
84). The fifth core component is psychoeducation is a “map for
understanding the child’s symptoms and the treatment” (Land-
olt et al., 2017, p. 513), and the eighth core component should
address the child’s competencies and future. Developmentally,
young children and school-aged children could benefit from
hands-on learning experiences to put the psychoeducational
components into practice with their parents, caregivers, or
guardians. Together they could learn how to create a safe space
during play. This safe space could involve the parent/caregiver
setting the stage and setting limits, letting their child lead, join-
ing in as a follower, verbally tracking, reflecting the child’s
feelings, reinforcing the child’s strengths and effort, and being
verbally engaged and active (Landreth & Bratton, 2006, pp.
203–204). The final core component of strength recognition,
building, and utilization can arise through play. The learning
that happens in hands-on play experiences, specifically noting
the child’s strengths and efforts, can support discussions about
how the child’s strengths are presently being used to thrive and
can be used to enhance daily functioning, development, and
resiliency in the future (Landolt et al., 2017, p. 514).
Conclusion
In order to support evidence-based practices, we must under-
stand what trauma is and how it is manifested in traumatic
stress responses in real children (DeRosa, Amaya-Jackson, &
Layne, 2013). Counselors need to continue to develop the foun-
dational reasoning skills to implement evidence-based practice
that matches the developmental and cultural needs of the child
who has survived trauma. DeRosa, Amaya-Jackson, and Layne
(2013) indicate that “practice” in evidence-based practice is a
verb that requires practitioners to review current trauma liter-
ature and systematic assessments to enhance critical thinking,
clinical judgments and ethical decisions by seeking team and
peer consultation. This policy recommendation of linking col-
legial relationships to create an evidence-based practice envi-
ronment may enhance our clinical first impressions of the child
and their family, our ability to creatively adapt to the needs of
the child and their family, our competence, and our ability to
put theory into practice (DeRosa et al., 2013).
Several avenues of future research were evident from the
current literature on TF-CBT and its intervention derivations.
With specific regard to SC-TF-CBT, future research must
address concerns related to the impact of child or family trauma
on the ability of the child or family to perform the independent
intervention work. This may be addressed by increasing
therapist-led sessions and parent support, and by including a
foundational psychoeducational component for parents and
assessment of parent trauma. It would also be important to
assess and collect data on what parents actually did during the
independent work sessions with their children. Threats to inter-
nal validity such as maturation must be addressed in order to
ensure that it is the program that is positively impacting the
child’s PTSD symptomology. At a more general level, future
TF-CBT research should study how interventions may be
addressing the specific trauma-based developmental needs of
the child based on their specific trauma experiences (Briere &
Scott, 2015). In a number of studies, small sample size and
parent–child attrition could be addressed with programmatic
changes to the level of psychoeducational and parent support
as well as having comparison and control group interventions.
Finally, future research on TF-CBT should also explore cul-
tural variation as well as optimism enhancing play therapy
interventions with culturally varied populations.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
Boyer
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