Trauma-focussed CBT is recommended by NICE. An excellent web-based resource is provided by the Medical University of South Carolina at:

http://tfcbt.musc.edu/

This web resource is highly recommended, and although it will not turn the trainee into a "certified" practitioner it will build on skills and knowledge to support improved practice. Trauma-focussed CBT builds on the work of many dedicated individuals and we quote from the TF-CBT website here:

Trauma-Focused Cognitive-Behavioral Therapy, was developed jointly by Esther Deblinger, Ph.D., Co-Director of the New Jersey CARES Institute at the University of Medicine and Dentistry of New Jersey's School of Osteopathic Medicine, and Judith Cohen, M.D., and Anthony Mannarino, Ph.D., who are the Medical Director and Director of the Center for Traumatic Stress in Children and Adolescents, Allegheny General Hospital, in Pittsburgh, PA.

Key elements:

Here we distil the key elements that distinguish Trauma-focussed work.

Setting up sessions

Most CBT is about making and carrying out rational plans (see also Active Planning) - and in trauma-focussed work this planning is particularly important. Trauma-focused work should not be something that a young person and worker 'dip into', but instead it is something that they spend time setting up, so that there are a pre-arranged number of sessions (usually a minimum of 6 - 8) about a week apart.

1. Psychoeducation

PsychoEducation is where to start, as it frames what you will be doing, and why. It needs to be pitched at the right level for the young person (and/or carer) to understand. In particular attention needs to be given to explaining the way that AVOIDANCE in PTSD tends to amplify fear, and that in fearful states it is very difficult to think (mentalize, if you like).

Rather as in Marking the Task, it is easy to skip over the preparatory work involved in setting the scene for what will follow once the 'work' gets started - and particularly in this work this is unhelpful.

At least one session will be devoted to this

2. Managing Stress

This is important, and is achieved using

• Rating Scales that help to increase the accuracy with which feelings can be communicated and understood, and if necessary directing action to help manage these feelings.
• Progressive Muscle Relaxation and Re-breathing are among many other relaxation techniques that can help to give a young person more of a sense of mastery over their own feeling states (knowing that moods come and go, and that I can to some extent alter them at will, is useful knowledge, but also reduces my anxiety in and of itself.)

Some evidence suggests this part of the work is mostly important because it reassures the young person that their therapist cares - i.e. because it supports Engagement, rather than being the most important 'change-engine' which is probably the graded exposure (see below).

At least one session will be devoted to this.

3. Telling the Story

This is really a special version of Graded Exposure and this forms the heart of the therapy. You can read about this in more detail at Graded Exposure.

This may take 4 or more sessions.

4. Reworking Beliefs

This is only possible when some Mentalization has been recovered - i.e. when the levels of anxiety have reduced a bit. Here you are focussing on some of the beliefs about the self ("I was a coward", "I am a failure", "I can never be safe in the street again"...) and are using gentle questioning (Weighing Pros and Cons) and Coaching. We usually use coaching in relation to how a young person might handle a parent in a given situation, but in this setting it would be how they might handle the appearance of a particular thought in their mind.

To some extent this work is interlaced with the sessions recalling the narrative, and as the narrative work continues it may be found that more time is spent homing in on, and addressing particular beliefs (or "cognitive disortions"). It is important not to rush into this aspect of the work before the anxiety provoked by 'being in the act of remembering' has begun to reduce through the repeated telling of the story.

Allow 2 sessions for this work

5. Reinforcing Behaviour Change

This is about setting up Contingencies for the young person, that will support new ways of managing the self addressing some of the more 'outward signs' of the PTSD, such as the avoidance of going out, etc. Other Graded Exposure programmes may be relevant here, along with a range of other Cognitive Behavioural techniques.

The key point is that although changes can happen quite quickly (not always!) there is a natural tendency for people to 'slip back' into previous habits, such as AVOIDANCE (which as you will remember is one of the key features of PTSD.) This element of the work is directed at strengthening and sustaining new patterns of behaviour.

This work, again, is increasingly "interlaced" with the earlier stages, and is largely about setting up Training Challenges (or 'homework'!) for the young person, preferably supported by carers.

6. Working with Carers

Although FamilyWork alone has not been shown to be effective for childhood PTSD, there is good reason to focus some energy on ensuring that family members understand the nature of the problem, and the plan for treatment, as family members may be absolutely key players in reinforcing some of the key therapy tasks and 'homework' (Training Challenges.)