Dr. Cohen is one of the principal developers of TF-CBT, an evidence-based practice for treating childhood trauma. She has recently authored, along with her colleagues, Anthony P. Mannarino and Esther Deblinger, “Treating Trauma and Traumatic Grief in Children and Adolescents.” This book provides a comprehensive framework for assessing post-traumatic stress disorder (PTSD), depression, anxiety, and other trauma-related symptoms, as well as a method for devising a flexible, individualized treatment plan.

TF-CBT is being used to treat children in foster care. It is most recently being integrated in the “Enhanced Model of Treatment Foster Care,” Together Facing the Challenge (TFC), as part of The National Institute of Mental Health (NIHMH) five year funded study entitled “Therapeutic Foster Care in a Systems of Care” being conducted by the Department of Psychiatry and Behavioral Sciences at Duke University School of Medicine.

Dr. Cohen is a board-certified child and adolescent psychiatrist and Medical Director of the Center for Traumatic Stress in Children and Adolescents, Allegheny General Hospital, Pittsburgh, PA. With Dr. Mannarino, she has received funding to assess and treat traumatized children since 1986 from the National Institute of Mental Health (NIMH), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the U.S. Department of Justice. A recipient of the American Professional Society on the Abuse of Children (APSAC) Outstanding Professional Award and the American Academy of Child and Adolescent Psychiatry Rieger Award for Scientific Achievement, Dr. Cohen is Associate Editor of the Journal of Traumatic Stress.

Dr. Cohen presented the TF-CBT model at the 20th Annual FFTA Conference this your in Pittsburgh. The Editorial Committee of the FOCUS newsletter asked FFTA Research Committee member Paul Brylske, MSW, LCSW-C, Director of the Kennedy Krieger Family Center’s Therapeutic Family Care Program to interview Dr. Cohen about the TF-CBT Model, the research supporting the model, and how it could be adapted to TFC.

Dr. Cohen, what got you originally interested in the treatment of traumatized children?

In college, my senior honors thesis was about the psychobiology of biology and psychology of contraception use. Part of what I was realizing was that the use, or the lack of use, was related to the sexual abuse of children, adolescents, or adults. I recognized “sexual abuse” at that point. When I went to medical school there wasn’t a lot of emphasis on sexual abuse. I did a pediatric internship before I started in child psychology and I was fortunate to have a residency director in pediatrics who was both a medical doctor and a JD, so we had a lot of emphasis on identifying child abuse in our pediatric rotation. This was back in the 1970’s, and we recognized child abuse more than some other pediatricians.

When I started psychiatry, I did a combined child psychiatry and adult psychiatry residency and fellowship, which I started right after pediatrics. I did a year of child psychiatry and then two years of adult psychiatry, then a final year of child psychiatry; so I completed my psychiatry studies in an unusual kind of way.

In my residency, I immediately met Ellen Frank, who was doing a treatment study on treating rape victims. This was one of the earliest randomized trials, and her study included rape victims as young as 15-years-old. I already had an interest in the sexual abuse of children, so we connected early and I got to learn about the kinds of treatments that they were looking at for rape victims. In exchange, I provided some of the pharmacologic treatments for the younger rape victims that were being seen in their study.

Early in my residency, I also met Tony Mannarino, who was also doing a lot of forensic evaluations for child protection; I decided that was also an area that I wanted to look at. Tony and I decided that if we were going to look at the kinds of treatments that we were going to provide to these children, we should also determine what research has been done. We determined that we’d look throughout the field to see what the best treatment studies were; we discovered that there weren’t any. Much to our shock we saw that there hadn’t been any randomized studies for treating sexually abused or even traumatized children; this was in the early 1980’s. Therefore, we set out to basically start a programmatic study of how to develop treatment for sexually abused/traumatized children.

We began our study with sexual abuse, because that was what I had been studying, and these were also the primary types of children that Tony was evaluating for his child protection program. Needless to say, most of these children had experienced other kinds of traumas as well, but both the children that he was seeing for child protections and the children that I was seeing through Ellen Frank’s rape project were mostly sexually abused victims. In the early 1980’s, these were the children that made everybody else so nervous. Most professionals weren’t even going to touch the subject; the common reaction was, “Oh my God, we don’t even talk about that. We are not going to even see those kinds of kids.” So our programmatic plan was to first do a study about the symptoms and problems that these children had.

We received funding to look at sexually abused children and compare them to children who weren’t sexually abused, but who were referred to a psychiatric outpatient program. We compared those two groups (sexually abused and non-sexually abused but in a psychiatric outpatient program) to children who were just attending school. Believe it or not, in the early 1980’s the schools had a lot of problems with us even asking students if they had ever experienced sexual abuse. We had to even go as far as Erie, PA, which is three hours north of Pittsburgh, to even find control schools to do this first study. And, that was the first study we did: to look at the symptoms and problems that sexually abused children had compared to psychiatric control and so-called “normal” control children.

The second study we did was to look at what factors mediate or moderate sexual abuse problems. We were looking at children’s cognitions, family factors, child factors, and demographic factors. We looked at parent support, parent emotional distress related to the child’s abuse, the child’s own cognitions of blame, and if they felt different from other kids. Although we didn’t really expect this, we developed a couple of instruments that are still being used today and have even been translated into Spanish.

What instruments, which ones are these?

The Parent’s Emotional Reaction Questionnaire and the Parent’s Support Questionnaire.

That’s how we got interested in traumatized children, and we have done six treatment studies since then. We have expanded far beyond sexual abuse into domestic violence and traumatic grief, terrorism, and disasters, but that’s how we initially started.

We began by treating hundreds of children, looking at the kinds of mediators and moderators, and then trying to aim the treatment at addressing those kinds of mediators.

Could you give me an overview of the model and its components?

The treatment model is basically a hybrid. It’s based on cognitive behavioral principals, but it goes beyond cognitive behavioral therapy. It also incorporated a very strong family component, as you know. The parents are a very important component and we really want the parents to become a very strong agent of change. We also think there is a difference between parents and therapists -- where the parents fit into this model, how they are distinguished from the therapist role, and how that fits in with the treatment foster care model. Therefore, the core treatment components are summarized by the PRACTICE acronym and PRACTICE stands for: Psycho-education, parenting skills; Relaxation; Affective modulation; Cognitive processing – of which there are 2 parts: Trauma narrative, In vivo mastery or desensitization; Conjoint child-parent sessions; and Enhancing future safety and development.

I think it’s really important to emphasize the therapeutic relationship and the importance of enhancing trust – that it’s not just a bunch of components, that there’s more to it than that, and that it’s not a mechanistic kind of treatment model. It’s important to emphasize that the model is flexible and it needs to fit the child and the family, not the other way around.

So, what types of children do benefit from TF-CBT?

It’s very important that there be a good fit between the child and the model. This is not the appropriate treatment for every child in foster care or every child who’s experienced a traumatic event. It’s really the best kind of treatment for children whose primary difficulty is related to post-traumatic stress symptoms, depression, and anxiety.

Children of all ages can benefit from the TF-CBT; children from 3-years-old through 18 years with any kind of trauma. Children with multiple traumas can especially benefit. I would say it’s not appropriate, or particularly beneficial, for children whose primary problems are not related to their traumatic event or whose primary problems are related to externalizing behavior problems. But, if there is a child, for example, who was abused or traumatized several years ago, who doesn’t have trouble thinking/talking about it, or their main problem is behavior and they don’t care about other people’s reactions – they’re oppositional, they’re angry, they have severe conduct problems – this is probably not the first treatment model you would think of.

You mentioned research, in terms of the development of the model. What is some of the current evidence behind TF-CBT?

There have been six randomized trials, five of which have compared TF-CBT to other active treatments. As you know, it’s more difficult to find significant differences between two active treatments than it is to a “wait list” or a “no treatment” control. It’s especially exciting to us that we found that TF-CBT is superior to other active treatments.

Our goal is to replicate the kinds of treatments that children would actually get in community settings. We’re also impressed that the children receiving the alternative treatments have also gotten significantly better, so we haven’t selected meaningless treatments or treatments that were not good. We wanted to replicate the kinds of treatments that community therapists actually gave, and that were going to be helpful to children. We got very significant findings. We wanted all of the children in the study to get better, we wanted to provide a very credible comparison, and we wanted to provide the very best supportive therapy we could think of to short-circuit the kinds of criticism that we thought we would get. I think it’s important that we carefully supervised our therapists to provide the very best supportive therapy that we could for ethical reasons, because we wanted to see children get better.

Overall, we found that in every study, TF-CBT was superior in improving children’s PTSD symptoms and depressive symptoms. In several of the studies, the children got better in terms of their behavioral symptoms and their shame, and they continued to maintain their gains over the follow-up period, which lasted from one to two years depending on the study. When we looked at how the parents in the TF-CBT condition did in a few of these studies, they had also improved in their personal symptoms, including depression, parenting skills, and their own emotional distress, even though the TF-CBT was not targeting the parents’ personal symptomotology.

Very impressive, please tell me more.

In terms of broadly addressing how TF-CBT addresses the needs of children in foster care, we’re currently working with Systems of Care in Illinois. Specifically, these are children in the highest level of foster care settings – children who are about to lose their placement because of severe difficulties in their placements. The children are about to go into residential placement or become an inpatient because of their difficulties. Systems of Care is providing TF-CBT to these children in order to try to maintain their foster placements.

So far we’re finding that this model is working very well for these children. We’ve had to make some adaptations in terms of how the model is implemented, mostly because they’ve chosen the highest need cases – the children at greatest risk – those who are having the most problems, the most symptoms. Basically these were the most dis-regulated children, so obviously we needed to make some adjustments.

Some of the problems were that these children had so many other services that the parents were saying, “Hey, we don’t want one more service, we can’t do this.” So the issue was, is this the right time or is there some other intervention that could be deleted now? Or, can it be provided in the home? Or, how can you work around this to make it more palatable to the family, in terms of the intervention itself? Or, are you going to need to adapt the length of time over which it’s provided? Because it’s going to take longer to get these children effectively regulated, that’s just the reality of the situation. These children are more dis-regulated than the others; you can’t expect it to simply take two weeks.

What did you find, in terms of how it went when applying the model in the home?

It’s working great. Primarily, I think it’s a matter of working with the providers and giving more information/consultation to them about how to administer the model, mostly because it’s something very new to them.

Now you say providers. Are you talking about the treatment parents, the therapists, or the agency staff that supports parents?

We’re working with the therapists in the home, and indirectly they’re working the parents.

When we’re on these phone consultations; there are several people on the consultation. There are primary therapists and then there are people, also on the phone, who are primary. They’re what I would call case managers. They may not call themselves case managers, though. They may call them something else. But, they’re all involved.

Over time, you said one of the adaptations was over time, how has the model been adapted or needed to be adapted for time?

I think it’s taking more time for some of these children. Part of that is also something we’ve just seen with community therapists. They need to be encouraged to move to the trauma narrative a little more quickly, and that’s not unique to children in the foster care system. I think it’s unique to therapists who haven’t used this model.

I think one of the biggest things we’ve dealt with is selecting the appropriate children, and I talked about this in the training. Determining which children have a specific trauma to work on versus which children were removed because of years of neglect because the mother’s a drug addict; the child was removed from the parent who wasn’t able to care for them, and they’re seeing that as a trauma. They need to be cognitively processing their situation, but they don’t have the avoidance of a horrible, frightening event that happened. I think they can use some elements of this treatment model, a cognitive behavioral approach, but they don’t have PTSD, and they don’t have the avoidance of a trauma.

In adapting the model, what roles could treatment parents play?

I think there are many aspects of this model that parents or foster parents can take on. We don’t need to argue whether they take it on as a “therapeutic role” or as a “parental role,” because if they’re doing it effectively, the child probably doesn’t need therapy. For example, if the parent is good at the parent management skills, providing praise, providing limits, providing consistency and so on, a lot of that is what a therapist would provide – education, practice, training, etc. If the parent is doing that effectively, the therapist doesn’t have to teach the parent how to do that. The parent is doing that in the home and that’s fine.

The same is probably true for relaxation skills and for effective modulation skills. If the parent can help the child with these skills, then the parent can do that and the child doesn’t need a therapist to assist. What I would say is, there’s a difference in the tone that a parent uses versus the tone that a therapist uses. In therapy, a therapist needs a certain neutrality or objectivity in their emotion and tone with a patient. That’s not to say that the therapist doesn’t have warmth or connection or a therapeutic bond, but it’s not the same bond that a parent or even a foster parent has with a child.

There are different roles and there should be a different kind of connection between someone who’s taking a parental role versus a more therapeutic role. But, with that said, the instruction piece can be conveyed by a parent, just as it can be conveyed by a therapist, in terms of how do you relax, how can you help modulate your affect. A lot of people can convey the information. I would say the emotional tone is somewhat different than how it’s done. We have certainly asked parents to practice this in between sessions; that’s why we involve parents, because we want them to be reinforcing it and practicing it at home. Obviously, if a therapist is doing this for an hour, and there was nobody to reinforce it during the 6 days and 23 other hours, it’s not going to happen. The parent is critical in making the techniques work.

What other roles can the treatment parent have?

The treatment parents can be extremely effective and helpful in the cognitive processing. I certainly have helped my own kids to cognitively process things in their lives and I still do. I think that cognitive processing is one thing that parents can do very effectively, in terms of helping children look at things in ways that are more accurate and more helpful. This is an absolutely critical role for parents to take with children. But, the trauma narrative is a very tricky and different thing; it’s not that we don’t share it with parents and it would be very helpful for foster parents to hear it. But, it’s in the overall development of the trauma narrative and where it takes place for these children.

Children need the option of being able to leave the narrative behind and not have the home be the place that becomes a trauma reminder. It would be helpful if therapy could be a place where children have the chance to work through their trauma, develop the trauma narrative, overcome their avoidance so that they are able to talk about it, and then they have the option of saying, “Ok, I’m leaving it here. What happens in Vegas stays in Vegas. I want to leave it here, and it’s not because I’m afraid or it’s too hard to talk about, but because I’m done and if I need to talk about it again, I can. I will be able to, but I don’t want to talk about it day and night. I want to have a place that is a talk-free place.” Ultimately, we don’t want the foster home to become another trauma reminder or for the foster parents to become the trauma reminder. If the foster parent is the one who had to work the child through this whole thing, they don’t have that option.

Sharing the trauma narrative with the foster parents “in therapy” is one thing. Going into therapy and sharing the trauma, working through it with the therapist, and then sitting down when you are finally done in the therapist’s office with the foster parent and saying, “I’m done, hallelujah, hooray, I did it!” Having a celebration at the therapist’s office and then coming home and being done with it is fantastic. To have developed the trauma narrative and worked through that very painful, difficult process at home with the foster parent in their dining room is a completely different process.

So it’s not that the child could not talk about it at home, but it’s the choice of the child to talk about it at home.

Exactly. Some of the kids bring their trauma narratives home and they’re proud of it – it’s their choice, and they’re in control of it.

They’re in control of it.

Yes, and that’s a very different kind of feeling and dynamic to me, because the child is not in complete control of the process. The therapist is really leading the child. I don’t like to use the term leading, but it’s modeling for the child that you can do this, you are brave; it’s a different relationship than that of the parent. It’s similar to the surgeon who has to do the painful procedure that’s going to hurt but it’s going to help in the end; and the parent is the one who provided the soothing balm that makes it all better.

That’s why your family isn’t supposed to operate on you. First of all, surgery by a family member is a little too close for comfort. The surgeon is objective since they’re not family. The surgeon has the ability to say, “I know you can do this, I can take your pain, I can take the tears, because I know you can do this. I’ve done this a hundred times before, and I know you’re going to get through it.” But when the child is scared, crying, or angry, it’s difficult for the parent to do it. It takes a certain amount of confidence; there’s a possibility that the foster parent won’t be able to do it either. It’s two different roles. That’s the best I can say; it’s two different roles.

Two different roles, now what complicates Treatment Foster Care is that you have a third role. There is the parent, the therapist, and there is also the staff person – the person who works with the family and the various program models.

I don’t know, what is that staff person supposed to be doing?

Well, I think in some instances they’re doing case management, and sometimes they’re providing support, and in some they’re attempting to use some of the TF-CBT components. Overall, that staff person is seen as more of a therapist than a case manager.

So would that be like the supports of the parent?

It is support for the parent but also working with the parent around the behaviors for the child.

Well, then that would be a perfect role for the child who also has severe behavior problems. We have a lot of children like this. If the child has a lot of behavior problems, that would free the therapist to be able to say, “You know what, we’re going to really focus on the trauma issues.” When the parent says to the therapist, “But the teacher called and the child is getting kicked out of school,” the therapist can say, “You need to talk to the staff person about this.” This gives the therapist the opportunity to say, “I’m not negating the importance of Billy getting kicked out of school today, because that’s really important, and that’s why you have the staff person.” Does that make sense?

It makes sense. Would there be other areas or components?

Well, yes, I think the therapist should probably go over all of the components with the child and run through them with the parent if you wanted to divide it up.

Could one aspect be, perhaps, in supporting the parent’s ability to be prepared for the trauma narrative?

Yes, I think that would be great.

I could possibly see that as a function of support, working with the parents regarding relaxation techniques in addition to their own feelings that the trauma could, or will, stir up.

Yes, my only concern about that is what we’ve heard from some people in Illinois, for example, that the foster parents are just over scheduled and overwhelmed. For example, their reactions have been, “If I have to do this, I’m not going to do that.” So at a certain point, it’s not supportive anymore, it’s just too much. For some parents, I think that support is going to be very much needed and very welcomed, and for others it’s just going to be one more hour. Most likely, the type of support that might be needed would be to drive the child somewhere or to take them to their appointments.

So, if more of the work could be done in the home, or certainly supported at home, when the narrative takes place in the office, then the staff person can be more supportive of the parent. Also, when the child wants to talk about the trauma again at home, or if the trauma becomes overwhelming, the staff person can again support the parent.

Yes. There will be crises, because the therapist might not always be available. This support person would be an excellent resource for the parent.

I have seen the TFC staff person help the parent maintain what I call a neutral stance during a crisis, so as not to feed into the child’s negative behavior patterns or crisis escalation cycle, often related to past trauma. Also, TFC programs train the treatment parent in the skills of helping children manage their feelings and behaviors.

It might be very helpful if the foster parent has been working on these components at home – ahead of time. I have to emphasize that even if the foster parent is practicing with the child techniques to manage their feelings and behaviors, it’s still important for the therapist to practice these components with the child in the office. The child can’t simply come into the therapist’s office and start a trauma narrative during the first visit. The child doesn’t know the therapist at this time. The first time that the child needs a therapist, they are not going to be able to start the trauma narrative, no matter how good they are at relaxation and affective modulation at home – the child needs to develop a relationship with the therapist first. Overall, it might help to speed up the process so that these children in foster care will be able to move forward with this model in 8 or 12 sessions instead of 30, which we often have in foster care.

I would think if roles were clear and if the team is working together, then it can work even quicker; then the treatment parent doesn’t feel pulled.

Yes, this way the parent knows that they have a critical role. They have really laid the groundwork for the child to start therapy and the work that they’ve done at home is so important for the child to be able to move through the therapy components much more quickly. The fact that they’ve learned the model ahead of time is going to help the child in the long run. The parent is a critical part of the team with the therapist and the staff person. It’s all a symphony of support for the child.