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Components of TF-CBT


  • Psychoeducation
  • Parent Component includes parenting skills
  • Relaxation
  • Affect identification and regulation
  • Cognitive coping
  • Trauma narration and cognitive processing of traumatic experiences
  • In vivo mastery of trauma reminders
  • Conjoint child-parents sessions
  • Enhancing safety and future development


What is the importance of a trauma narrative? 

  • Control intrusive & upsetting trauma imagery
  • Reduce avoidance of “triggers” - cues, situations, people, places & feelings associated with the trauma
  • Identify unhelpful thoughts about the trauma
  • Help the child / caregiver recognize, anticipate & prepare for reminders of the traum
  • Desensitize to talking about the trauma


Do Nots: Child Trauma Narratives

  • Problematic/Suggestive Questions
    1. Very specific questions
    2. Repeat the same questions
    3. The “question stem” sets up the answer
    4. Subtly reinforce certain responses
    5. Gather only confirmatory evidence & avoid questions that may produce other responses
    6. Use threats or bribes
    7. “Stereotype inducement” of perpetrator
    8. Tell the child they are helping the investigation
    9. Tell the child that their friends have already helped (peer pressure)
    10. Repeat misinformation
    11. Use visualization
    12. Provide misinformation (false memory)


DOs: Child Trauma Narratives

  1. Reasons to directly discuss traumatic events:
    1. Desensitization (aka gradual exposure)
    2. Resolve avoidance symptoms
    3. Correction of distorted cognitions
    4. Give context to traumatic experiences
    5. Reduce intrusive imagery
    6. Model adaptive coping
    7. Identify and prepare for trauma/loss reminders


3 primary strategies to prepare parents for hearing a child trauma narrative

  1. assess readiness
  2. prepare parent along the way
  3. address parent blocking beliefs 


How do you assess parent readiness to hear a trauma narrative? 

  1. Handle their own & child’s emotions
  2. Can support & praise the child
  3. Own concerns have been addressed
  4. Can model coping
  5. Has willingness & ability to hear about trauma
  6. Committed to improved & open communication
  7. Able to ask open ended & non-threatening questions
  8. Is comfortable with own narrative of the event
  9. Sharing trauma narrative may be an ongoing process


How do you prepare a parent along the way to hear a trauma narrative? 

  1. Explore parent’s knowledge about traumatic event
  2. Ask parent to share own experience of trauma
  3. Share with parent what child says in therapy & narrative
  4. Practice supportive response
  5. Help prepare parent questions for child
  6. Moving from primacy of the therapist-child and therapist-parent interactions to the parent-child interactions during sessions


What are a few examples of parent blocking beliefs?

  • I should have known this would happen
  •  I should have kept my child safe
  •  My child will never be happy again
  •  Our family is destroyed
  •  My child’s childhood is ruined
  •  The world is terribly dangerous
  •  My child can never recover
  •  I can only be happy if my child is happy
  •  I can’t trust anyone anymore
  •  Being strong for my child means I should never feel upset
  •  Good parents know the right thing to say to their children
  •   Why is this so upsetting for my child?
  •  I can’t believe I have to do all this work


DBT-A dialectical dilemas 

  1. DBT-A Dialectical Dilemmas:  Miller & Rathus’ Middle Path
    1. Too loose v. too strict
      1. Clear, consistent rules AND negotiate on some issues
    2. Making light of problem behaviors v. making too much of typical adolescent behavior
      1. Recognize when bx crosses the line/try to get help AND recognize what is typical
    3. Holding on too tight v. forcing independence too soon
      1. Give adolescent guidance/support and rules so they can figure out how to be responsible AND slowly give greater amounts of freedom while some reliance on others


DBT-A Middle Path

  1. Acknowledging the other person’s thoughts and feelings (and self)
    1. “I get it”, “That must be hard”, “I see why that must be so nerve wracking”
    2. “I am trying to/I want to understand…”
  2. Can deescalate emotions
  3. Validation is NOT agreement
    1. Also not praise or reassurance
  4. Teach family members to validate in context of current situations!


Way to define a problem in parent-adolescent conflict

  1. Barkley’s PSCT: Define the Problem
    1. Short, nonaccusing statement of the situation or person’s bx & why it is a problem
    2. Avoid blame with “I” v. “you” statements
    3. Okay to have different perspectives
      1. Don’t have to agree on each other’s problem definitions
    4. Check for accuracy in understanding each perspective
      1. Speaker says they understood


What are philosophies of a BEH contract?

  1. Too many fun things make taking things away or offering rewards useless
  2. Fun activities need to be recontextualized as privileges, which can be earned
  3. Psychoeducation: parents have control over many things… identify what & when
  4. **Need to provide consistent, specific, predictable, & immediate feedback!!


What are parts of an actual BEH contract?

  • I, _____, agree that I will make my bed every day before I leave. If my bed is made, I can…If it is not made, I cannot...
  • Can use a point system with daily and weekly privileges (age 13 and younger)
  • Tell parents to hang in there! Goal is to alter parent bx, teen’s bx is a bonus at first
  • Add response cost later (take pts away)
    • Parent needs to follow-through and be able to oversee punishments (e.g. be home)


Ben-Porah: Validation Strategies to Adjuct Parent Training 

  1. Techniques for parents
    1. Parental psychopathology: a poor predictor of child psychopathology and child treatment outcome
    2. Parents often have difficulty generalizing BMT skills when feeling emotional during actual conflicts
    3. Affect regulation difficulties often combined with an invalidating environment
    4. Most PT programs do not focus on parental symptom management
  2. DBT Techniques
    1. Validating parents’ own experiences
    2. Mindfulness: observing and describing thoughts, physiological sensations, and behaviors (self and child’s) nonjudgmentally & in the moment (not past or future)
    3. Emotion coaching: labeling self and child’s emotions
    4. Opposite action: do the opposite of the behavioral urge following an emotion


Vidair: Key Aspects of a Termination Session

  1. Consolidate gains made in treatment, plan for the future, and celebrate work
  2. teach children to become their own therapists from the start of treatment, clarifying expectations and eliciting parental assistance as developmentally appropriate,
  3. foster a therapeutic alliance early on to engage children and parents in the process of skills acquisition
  4. facilitate skills generalization and maintenance to prepare families for termination
  5. consolidate treatment gains and a final therapy product in the final session
  6. plan for relapse prevention and booster sessions
  7. celebrate child and parent progress
  8. facilitate a “good goodbye” by modeling, eliciting, and validating positive and negative feelings while reinforcing the idea that the child is ready to be their own therapist.


Kazdin: Improving Attendance in Treatment

  • Early research: Single prompts such as reminder calls
  • RCT: 30-minute phone call prior to intake appointment.
    1. Those who received a phone call or phone call + intake were more likely to show up for sessions.
    2. Only call + intake showed improved attendance in subsequent appointments
  • Strategic Structural Systems Engagement (SSSE)
    1. Family techniques to reduce resistance and increase initial engagement
    2. RCT for Latino adolescents with substance abuse disorder in the SSSE Tx condition were more likely to attend intake and less likely to drop out
    3. Second Latino RCT confirmed efficacy in increased engagement
  • Question Formulation Technique
    1. Why: Increase participation in treatment-related decisions and decrease dropout
    2. Teaches: identification important decisions treatments relevant to care and generate carefully constructed questions directed to providers. Empowerment shifting model.
    3. Studies
      1. Successful in minority groups
      2. Higher use of mental health providers, higher attendance, low dropout
    1. Studies
      1. Greater engagement with providers and more self-management. NOT associated with a greater increase in retention
      2. RCT in motion
  • Overview
    1. Most focus on initial engagement and not drop out
    2. No engagement strategies found for Asian and Native American youth
    3. Issues
      1. Limited reporting of demographic information
      2. Lack of representation
      3. Need to know if rates of participation vary based on SES
      4. Not to health access inequity