Psychoeducation

Psychoeducation usually is implemented near the beginning of treatment but often continues throughout the course of treatment. Psychoeducation typically consists of normalization of the child and parent experiences in response to the trauma, including discussion of common responses to trauma. Information about the nature of the particular trauma often is provided, including the frequency and causes of trauma. Clinicians also address common myths and misconceptions about abuse. Psychoeducational handouts are available for distribution (see Cohen et al., 2006; TF-CBTWeb, www.musc.edu/tfcbt).

In relation to sexual abuse, psychoeducation typically includes three basic components:

1. Information about the traumatic event. This typically includes defining sexual abuse, discussions about the reasons that perpetrators commit sexual abuse, typical responses to abuse, and the reasons that children do not immediately tell others about the abuse.
   
2. Sex education. Children and adolescents are provided with factual information, and misinformation about sexual abuse is clarified. Further, body awareness and the child or adolescent’s feelings about sexuality are discussed, and health-related issues, such as sexually transmitted diseases, often are discussed.
   
3. Risk reduction. Children and adolescents learn how to identify high-risk situations and how to develop a safety plan if they were to end up in a high-risk situation in the future. The difference between appropriate touch and inappropriate touch also is discussed, and a child’s right to say no is reinforced. Further, role-plays can be used to practice effective limit setting.

Parenting Skills

The clinician discusses the use of basic parenting skills, such as praise, selective attention, time-out, and contingency reinforcement. These skills may serve to improve the parent–child relationship and reduce disruptive behaviors. Further, a discussion of parenting skills may be particularly helpful for parents who experience less effective parenting in response to the trauma or who exhibited ineffective parenting skills before the occurrence of the trauma. Although a discussion of basic parenting skills may be particularly beneficial for the parents of children and adolescents who exhibit externalizing symptoms, these skills also are likely to be beneficial for parents of children who are not exhibiting behavioral difficulties. More specifically, these skills may enhance the effectiveness of other components of TF-CBT. For example, parent praise is an important skill for parents to use when children and adolescents begin to engage in exposure later in treatment (see the sections titled “Trauma Narrative Development and Processing” and “In Vivo Exposure”).

Relaxation/Stress Management

Relaxation strategies can be particularly beneficial to manage physiological arousal due to trauma-related memories and triggers. In this module, children and adolescents typically learn a variety of skills. One skill that is introduced is controlled breathing (diaphragmatic breathing), and for older children and adolescents, meditation also can be taught. Muscle relaxation (progressive muscle relaxation) typically is included as well. In addition, thought stopping often is introduced as a strategy to manage intrusive thoughts that occur at inopportune times.

In general, all these skills should be introduced and practiced in session. Clinicians also should make an effort to adjust technique descriptions to the developmental level of the child or adolescent. Further, parents typically are taught the relaxation strategies in session, often by the child or adolescent. As a result, parents develop strategies to manage their own stress and can assist the child and adolescent with between-session practice. Especially detailed descriptions of these relaxation strategies, including scripts, are provided in the TF-CBTWeb training program (www.musc.edu/tfcbt).

Affective Expression and Modulation Training

The purpose of this module is to help children and adolescents develop the ability to identify and label emotions so that they can appropriately express and manage emotions. First, the clinician works with the child or adolescent to identify and rate the intensity of emotions. Next, strategies to address appropriate management of emotions are discussed. For example, children or adolescents are taught effective communication skills, including the use of I statements, active listening, and the benefit of sharing feelings in the appropriate context. Further, children and adolescents are encouraged to use the previously discussed relaxation skills as a strategy when negative emotions are experienced. Finally, role-plays often are conducted in session.

Cognitive Coping

In this module, children and adolescents discuss how to identify and challenge inaccurate and unhelpful thoughts. In particular, clinicians often begin with the connection among thoughts, feelings, and behaviors, which usually is presented in the form of a cognitive triangle. The clinician typically discusses how some thoughts can be inaccurate and/or unhelpful and how these thoughts may lead to negative emotions and behaviors, including avoidance. Further, the clinician and the child or adolescent work together to identify and challenge unhelpful thoughts and to generate helpful/accurate thoughts. Finally, generalization of this skill is discussed. It is noteworthy that skills from this module can be helpful in the cognitive processing of the trauma narrative (see next module).

Trauma Narrative Development and Processing

The goal of trauma narrative development and processing is to break the connection between thoughts and memories of the traumatic event and both negative emotions and physiological arousal. Through gradual exposure and repetition, habituation occurs, and the end result is that trauma-related thoughts no longer lead to excessive distress.

The trauma narrative is developed in a gradual, progressive manner. In particular, the child or adolescent is asked to provide an account of the trauma over time, with increased detail. One option is for the child or adolescent to develop the narrative in sections, starting with sections of the narrative that create the lowest level of distress and eventually progressing to the most distressful components of the narrative. During the development of the narrative, the clinician also asks the child or adolescent to describe feelings and cognitions about the trauma, which can assist in the integration and processing of the traumatic event. Older children and adolescents typically are asked to provide a written narrative; however, therapists often dictate the narrative for younger children. The narrative also can be made into a book, and younger children can include drawings.

Cognitive and emotional processing typically occurs following the completion of the narrative. The purpose of this processing is to elicit and modify distorted thoughts about the trauma, and this process allows thoughts and feelings to be consolidated into an understandable experience. Through this experience, the child or adolescent can recognize that the trauma is part of his or her self-concept rather than central to his or her self-concept.

As part of the trauma narrative process, the child or adolescent typically is asked to read the narrative out loud to the therapist, and, typically, the narrative eventually is shared with the parent. The parent is often exposed to the narrative in a stepwise manner. First the therapist may read the narrative to the parent, and eventually the child is asked to read the narrative in the presence of the parent. This task provides the parent an opportunity to model positive coping behavior and also serves to improve support and communication between the parent and child in relation to the trauma.

In Vivo Exposure

The trauma narrative likely will decrease reactivity to thoughts and images that remind the child or adolescent of traumatic event; however, children and adolescents still may experience continued fear and avoidance of external cues that serve as reminders of the traumatic event. For example, a child may continue to experience a fear of the dark, even when safe in his or her own bedroom. As a result, in vivo exposure can be used to overcome the fear and avoidance of these external cues. As with the narrative, in vivo exposure should be gradual. It is noteworthy that in vivo exposure is not recommended for situations that may signify an actual threat to the child or adolescent’s safety.

Conjoint Parent–Child Sessions

Parent involvement is considered an important component of TF-CBT, and sessions with both the parent and child typically occur throughout treatment. Conjoint sessions may be particularly important when discussing components of the psychoeducational module. Further, as discussed earlier, conjoint sessions are an important component of review of the trauma narrative. In particular, once the child and parent are adequately prepared, the child typically is asked to read the narrative to the parent and therapist. The parent and child are then provided an opportunity to ask each other questions about the trauma. In addition to desensitization, these conjoint sessions provide parents and children an opportunity to learn how to communicate about the trauma in a more open manner.

Enhancing Safety and Future Development

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