Wednesday, July 25, 2012

Trauma-Focused Cognitive Behavioral Therapy: Aiming to Become an ‘Effective Coach’ for Abused Children and Their Caregivers

By: Carla Kmett Danielson, Ph.D.

“I am worthless.”

“I am unlovable.”

“You can’t trust anyone in this world.”

“I will never be the same.”

“I brought the abuse upon myself.”

If you have provided mental health services to one of the millions of people in the U.S. who have experienced child abuse, then these aforementioned statements may not be unfamiliar to you. These statements are what some clinicians and researchers refer to as ‘core beliefs’— unspoken, self-proclaimed ‘truths’ (about themselves, others or the world at large) that people have internalized as a function of having endured abuse in childhood. Although disturbing to think about our children walking around life (into adolescence and adulthood) carrying the burden of these core beliefs, it is even more concerning to consider the ways in which these beliefs translate into impairment in daily functioning, such as in school attendance and behavior, relationships with caregivers, siblings, and peers, sleep, affect regulation, and mood. Whether we are working with an abused client that is engaging in school refusal behavior or engaging in non-suicidal self-injurious behavior (e.g., cutting), in many instances, the core beliefs that have developed (and may have been reinforced) during the course of maltreatment are likely serving as a driving force in the onset and maintenance of the mental health symptoms and problems with which they present to the clinic. Consider the adolescent girl who was sexually abused by a step-father between ages of 7-9, and during the abuse, was told, “I can’t help but touch you because you look so sexy.” Core beliefs may develop about her responsibility in the abuse (‘the sexual abuse is/was my fault due to the way I looked or dressed”), which may be triggered during other moments of self-blame later in life and ultimately lead to self-punishing behaviors, like cutting.

That is the bad news. The good news is that we have treatments that have been demonstrated through rigorous research to work really well in addressing the mental health problems and symptoms that extend from the unfortunate experience of child abuse –potentially by addressing abuse-related negative core beliefs, such as the ones described above. With regard to child and adolescent populations, Trauma Focused Cognitive Behavioral Therapy (TF-CBT; Cohen, Mannarino, & Deblinger, 2006) is the treatment with the most evidence supporting its utility in addressing post traumatic stress symptoms and other forms of anxiety, depression, and behavioral problems. TF-CBT typically involves both the youth who experienced the abuse and his or her non-offending caregiver and includes (but is not limited to): psychoeducation about abuse/trauma, normal reactions to trauma and importance of talking about the abuse (i.e., rather than avoiding thoughts, feelings and memories of the experience), relaxation training, feeling identification and expression, learning how to change the way you feel and act by changing the way you think about a given situation, talking about specific memories, feelings and thoughts about the abuse that was experienced (through creation of a ‘trauma narrative’), gently challenging and reframing negative core beliefs extending from the traumatic stress experiences, making meaning of the abuse experience for the youth and enhancing safety to reduce risk for future revictimization and relapse prevention. Work with the caregivers in TF-CBT also involves helping with parenting issues (e.g., addressing problematic behaviors), teaching the caregivers the same coping skills taught to the youth (e.g., relaxation) so as to increase integration of the skills into everyday life, addressing the caregivers’ own unhelpful or inaccurate thinking in relation to their child’s abuse (e.g. “I am a bad mother for not recognizing that my child was being abused by this person”), and, perhaps most importantly, helping the caregiver develop a healthy, positive way of communicating about the abuse with their child.

So, if we know that TF-CBT accomplishes all of these goals and has been shown to work well in the treatment of a range of mental health problems in the aftermath of abuse and other forms of trauma, why isn’t it used with all trauma victims? There are multiple answers to this question. First, not all abuse and other trauma victims need therapy. A great many are resilient and are able to accomplish their daily tasks without impairment. Second, for the youth who do present for treatment and have a history of abuse or other forms of trauma—the trauma may not be the driving force of the clinical problem. This is particularly the case for youth who have been experiencing the presenting clinical problem well before the abuse or trauma experience. Third, many abused youth and their caregivers avoid thinking about and talking about the victimization experience. This avoidance is a hallmark symptom of Post Traumatic Stress Disorder; thus, many families will present for treatment following the discovery of abuse but will have never really spoken about it with one another. Sometimes caregivers will state, ‘we just want to put this past us,’ inadvertently sending the message to the child that it isn’t OK to talk or think about the abuse. Also, caregivers often have their own abuse histories—and talking about their child’s abuse serves as a cue for their own painful memories of victimization.

Finally, another reason some youth with trauma-related mental health symptoms do not receive TF-CBT, despite its known utility, is avoidance on our part as therapists. I like to ask clinicians I meet, ‘Why did you become a therapist?’ The response typically speaks to a person’s long standing wish and goal to help people deal with their problems and ‘feel better.’ Thus, the challenge with models such as TF-CBT that involve exposing a youth to his or her memories, thoughts, and feelings of an abuse experience, is questions or concerns that we are causing the client more ‘distress’ and less ‘feeling better’. Indeed, there may be a period of time during TF-CBT treatment that there may be some discomfort experienced by the youth, by the parent, or by both parties. However, as clinicians, we typically recognize that helping our clients learn to manage their distress (rather than the goal being to avoid and never experience distress) is a cornerstone of healthy affective functioning. The analogy used most often is that of a splinter being stuck in a child’s finger. Do we leave the splinter in or remove it? If we select ‘remove it’ as the response, the next question becomes, ‘Isn’t that painful? Won’t it just go away on it’s own?’. Here we might say, ‘Yes, there is some discomfort but it is temporary and crucial for healing—and, no, it will not just go away on its own. In fact, it will likely get infected if we don’t remove the splinter”. Thus, helping a child talk about his or her abuse experience is much like taking the splinter out. There may be some distress (although it is important to note, coping strategies are taught early on in TF-CBT to help the child manage this distress), but imagine the feeling of power and mastery and control children experience when they learn that, while they cannot control whether certain cues prompt memories of the abuse at any given time, they can control their reactions to these cues. Imagine the relief and self-efficacy—and perhaps joy—they feel when they come to the conclusion that their negative core beliefs about themselves, others and the world around them are not accurate or helpful—and they replace these beliefs with more positive and inspiring beliefs.

What is the alternative to NOT doing TF-CBT with child abuse victims who are experiencing trauma-related mental health problems and negative core beliefs? That they do NOT learn how to gain mastery over their memories and cues related to the abuse. That they do NOT challenge negative core beliefs that have developed from the victimization experience—and instead hold onto these beliefs for life (e.g., going through life believing they are worthless). What is our goal for our clients? These are the questions to ask ourselves when finding that we are shying away from TF-CBT or other forms of exposure-based treatment—out of fear of causing distress in our clients. Of course, it is essential that safety and stability needs are met first before engagement in any type of mental health treatment—but once these conditions are met—the most important question a clinician may ask him/herself is, “What happens if I don’t implement this trauma-focused treatment with this client? What will be the long term consequence?”
Consider the exercise trainer who only wants to listen to the client talk about their woes of diet and exercise –without gently pushing the challenging workouts and teaching the client how he or she has the capacity to do the workout… ….or the coach who is OK with the sports team quitting or not using a certain play that worked well, because it required hard work. The trainer and the coach in these scenarios may be deemed as ‘nice’ and ‘supportive’—but likely not ‘effective’ in helping their client or their team meet their goals. As we work with our clients impacted by child abuse and trauma, let’s ask ourselves what kind of a trainer, what kind of a coach do I want to be? For me the answer is simple; the kind that will help our clients live richer, happier, more fulfilled lives --by gently challenging and teaching the clients that they are in control of their reactions to their abuse/trauma history and not the other way around; and that they are loveable and worthwhile through and through.

Dr. Carla Kmett Danielson is an Associate Professor at the National Crime Victims Research and Treatment Center at the Medical University of South Carolina. Her research focuses on both treatment and prevention with high-risk adolescent populations and traditionally underserved populations. Dr. Danielson has an active program of translational research focused on factors and mechanisms underlying the cause of Post Traumatic Stress Disorder and addiction among trauma exposed young people. She has published more than 50 papers on issues related to high risk adolescents, addiction and mental health and has received numerous awards in recognition of her work.