Psychotherapy 2011, Vol. 48, No.

2, 188 197

2011 American Psychological Association 0033-3204/11/$12.00 DOI: 10.1037/a0023133

EVIDENCE-BASED CASE STUDY

Trauma-Focused Cognitive Behavioral Therapy of a Child With Posttraumatic Stress Disorder

Damion J. Grasso
University of Delaware

Beth Joselow
The Tides Behavioral Health Lewes, Delaware

Yahaira Marquez
Albert Einstein Medical Center, Philadelphia, Pennsylvania

Charles Webb
Delaware Division of Prevention and Behavioral Health Services, Wilmington, Delaware

This case study involves the use of Trauma-Focused Cognitive Behavioral Therapy to treat a preadolescent male patient referred to the Delaware public mental health system due to a history of family violence and symptoms associated with Posttraumatic Stress Disorder. Pre- to post-treatment data on selfand parent-report measures demonstrate symptom reduction and exemplify the effectiveness of the model. Data on parent participation in the session and facilitation of trauma discussion at home illustrate the parents contribution to the therapeutic process. Excerpts of clinical dialogue between child, parent, and therapist highlight the capacity of the model to accommodate individual needs and circumstances. Clinical recommendations supplement the treatment manual and provide clinicians with practical information for use in their own practices. Keywords: Trauma-Focused Cognitive Behavioral Therapy, childhood, PTSD, child maltreatment, case study

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is a 12- to 16-session intervention designed to reduce behavioral and emotional problems associated with child trauma exposure (Cohen, Mannarino, & Deblinger, 2006). The first three components equip the child and parent with a prerequisite knowledge-base and skill-set that include psychoeducation about trauma, posttraumatic stress, and treatment rationale, as well as relaxation techniques, emotion identification and regulation skills, and cognitive coping strategies. During this initial phase of treatment, the child and parent also undergo gradual exposure to trauma content. As the sessions advance, discussion about trauma becomes increasingly focused on the childs personal experience. Following the first phase, the child begins to develop a trauma narrative, a detailed account of the traumatic event that functions as a means of therapeutic exposure and helps to facilitate emotional and cognitive processing. When a parent is involved, he or she meets with the therapist separately from the child until the completion of the

Damion J. Grasso, Department of Psychology, University of Delaware; Beth Joselow, The Tides Behavioral Health, Lewes, Delaware; Yahaira Marquez, Department of Pediatrics, Albert Einstein Medical Center, Philadelphia, Pennsylvania; Charles Webb, Delaware Division of Prevention and Behavioral Health Services, Wilmington, Delaware. This research was supported in part by a grant from the Substance Abuse and Mental Health Services Association. Correspondence concerning this article should be addressed to Damion J. Grasso, Department of Psychology, University of Delaware, 108 Wolf Hall, Newark, DE 19716. E-mail: dgrasso@psych.udel.edu 188

trauma narrative. Depending on the comfort level of the child and the readiness of the parent, the therapist encourages the child to share the narrative with his or her parent in a conjoint session. The final phase of treatment focuses on safety skills and future development. The efficacy of TF-CBT has been tested in a number of randomized controlled trials demonstrating that TF-CBT achieves and maintains greater symptom reduction compared with other treatment alternatives (Cohen & Mannarino, 2008). In addition, studies have revealed significantly greater improvements (i.e., effect sizes ranging from d .30 .81) in posttraumatic stress disorder (PTSD), internalizing symptoms, dissociation, sexualized behavior, and social competence in sexually abused children who received TF-CBT compared with alternative treatments (Cohen et al., 2004; Cohen & Mannarino, 1998; Cohen, Mannarino, & Knudsen, 2005). Moreover, these authors have demonstrated that the therapeutic effects of TF-CBT are sustained over time (Cohen et al., 2005). This case study involves the treatment of a preadolescent male patient referred to the Delaware public mental health system due to a history of family violence and symptoms associated with PTSD. Our objectives are as follows: (a) to demonstrate the effectiveness of the model using pre- to post-treatment and follow-up data on self- and parent-report measures; (b) to illustrate parent contribution to the therapeutic process, using data on parent participation in session and facilitation of trauma discussion at home; (c) to highlight the capacity of the model to accommodate individual needs and circumstances, using excerpts of clinical dialogue between patient, caregiver, and therapist; and (d) to supplement the treat-

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ment manual by providing clinicians with practical information for use in their own practices. The caregiver-child dyad was selected from a sample of 66 dyads recruited to participate in a community-based effectiveness study of TF-CBT following outpatient referral to the Delaware Division of Prevention and Behavioral Health Services (DPBS). Participants in the effectiveness study were referred to DPBS from three primary sources: juvenile justice, community outreach, and child protective services. The caregiver and child provided informed consent/assent to participate in this research. The therapist also provided written consent. To protect the identity of all participants, names were altered and all identifying information was removed from the material presented.

Background Information
The patient is Marc, an 11-year-old EuropeanAmerican male who was referred by a nonprofit community outreach program due to symptoms of PTSD associated with family violence. He came to the attention of the outreach program because of an incident in which he was assaulted and injured by two peers in the neighborhood. The administration of the abbreviated University of Southern California Posttraumatic Stress Disorder Reaction Index (UCLA PTSD RI; Pynoos, Rodriguez, Steinberg, Stuber & Frederick, 1998), which was standard practice for all children receiving outreach services, determined that Marc had a history of physical abuse by his father and had witnessed domestic violence. Marc identified the physical abuse as the most bothersome experience, and in reference to the abuse, met criteria for a probable diagnosis of PTSD.

Baseline Assessment
Marc and his 48-year-old biological mother, Sandra, participated in the intake assessment. Marc and Sandra received a battery of diagnostic assessments. The Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and lifetime Version (K-SADS-PL; Kaufman et al., 1997), a semistructured diagnostic interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSMIV) diagnoses, was administered by a masters-level trained research assistant. The UCLA PTSD RI, which yields PTSD symptom severity scores (i.e., re-experiencing, avoidance, hyperarousal) and assesses DSMIV criteria for PTSD, and the Child Behavior Checklist (CBCL; Achenbach, 2001), a well-validated and reliable measure yielding scores on internalizing and externalizing behavior problems, were completed by Marc and Sandra, respectively. Marc described the worst episode of abuse which had occurred 2 years prior to the intake assessment, when he was living with his biological father, Michael. Michael was hosting a barbecue for friends and relatives when he suddenly grabbed Marc and shoved him into an outdoor dog cage. Michael hit and kicked Marc when he tried to escape. Marc remained in the cage for over 2 hours before fleeing to a neighbors house. Since then, Marc has lived with his mother at his maternal grandmothers house. At intake, Marc reported frequent nightmares, intrusive thoughts about his father returning, constant checking of the locks on the doors, keeping a baseball bat near his bed in case his father returned, and high anxiety. Most nights Marc would insist on sleeping in San-

dras room after failing to fall asleep or waking from a nightmare. Sandra reported that whenever Marc would see a truck resembling his fathers he would duck down to the floor and tremble. Moreover, Sandra claimed that Marc would chew his shirts to threads because of constant worry. Based on the K-SADS-PL, Marc met full DSMIV criteria for a diagnosis of PTSD. No other Axis I diagnoses were present. Marcs responses on the UCLA PTSD RI were consistent with this diagnosis, and his symptom severity scores were 12, 9, and 13 for re-experiencing, avoidance, and hyperarousal, respectively. CBCL Internalizing and Externalizing Behavior Problem t-scores were in the normal range ( 60). A background interview with Sandra revealed that she had a significant history of loss and victimization. Prior to meeting Michael, Sandra had been involved in two violent relationships with men, one who repeatedly raped her and one who beat her when she was 8-months pregnant, causing the death of her unborn son. Sandra also lost a teenage daughter to a drug overdose 5 years prior to the intake assessment. As a child, Sandra reported that she had witnessed ongoing domestic violence between her parents, both alcoholics. Sandra reported that she had experienced feelings of depression and anxiety most of her life, and was diagnosed with Major Depressive Disorder after a suicide attempt in her late 20s. In addition, since adolescence, Sandra reported frequent alcohol use, which resulted in outpatient treatment for alcohol dependence 2 years prior to intake. At intake, Sandra was taking antidepressant and anxiolytic medications prescribed by her primary physician. Finally, due to a chronic back and neck injury related to a serious vehicle accident, Sandra was on a combination of pain and sleep medications. Because of these injuries, Sandra was unemployed, and reliant on federal disability assistance.

Treatment Course
Marcs provider was a 30-year-old masters level clinical therapist with a cognitive behavioral background and 4 years of TFCBT experience. TF-CBT was administered in three phases. Initial sessions provided psychoeducation about trauma and posttraumatic stress, treatment rationale, as well as relaxation techniques, emotion identification and regulation skills, and cognitive coping strategies. In addition, the therapist provided Sandra with parenting skills to address behavioral problems at home and support Marc through the treatment process. In phase II, the therapist facilitated development of the trauma narrative and cognitive and emotional processing of the event. Development of the trauma narrative functions as a means of therapeutic exposure, a technique based on Foa and Kozaks (1986) Emotional Processing Theory (EPT). EPT emerged from the Bioinformational Theory of Emotions by Lang et al., which describes the emotion network as a system comprised of three components: sensory-based perception, physiologic/behavioral response, and conceptual meaning. EPT defines a fear structure as a special kind of emotion network comprised of associations among the traumatic stimuli, the stress response, and meaning representations (Foa & Kozak, 1986). According to EPT, modifying the fear structure through intervention necessitates activation of all three components while new information challenges maladaptive features of the structure (Foa & Kozak, 1986). Thus, activation of

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the fear structure via repeated exposure to feared stimuli (e.g., memory of the trauma) together with new, incompatible information that challenges maladaptive beliefs (e.g., I am thinking about the trauma, but I am not in danger) is thought to establish a new emotion network that inhibits the learned fear response (Bouton, 2004). During this process, maladaptive meaning representations (e.g., I could not stop him, therefore I am incompetent) undergo restructuring and reinterpretation (Foa & Cahill, 2001). In addition, growing evidence suggests that successful modification occurs when the fear structure is fully activated and memory is reconsolidated (Le Doux, 1996; Nader, Schafe, & Le Doux, 2000). According to the theory, trauma narrative development, then, stimulates the childs fear network and activates the traumatic memory, which in turn facilitates learned inhibition of the fear response and cognitive restructuring. The therapist engaged in parallel work with Sandra, sharing Marcs developing narrative and eliciting Sandras thoughts and emotions. The therapist also worked with Marc and Sandra to prepare for a conjoint session during which Marc would share the narrative with his mother. Narrative sharing functions to unite the child and parent in acknowledging their progress and strengthen the parent child alliance. Phase III sessions targeted safety skills and future development and culminated in a graduation session that celebrated Marc and Sandras accomplishments. A weekly diary measure was administered to Sandra prior to each session. The weekly diary obtained Sandras rating of Marcs behavior problems on a Likert Scale ranging from 1 (No Problem) to 5 (Very Much a Problem) and asked her to describe the behavior. This scale was used to examine the pattern of Marcs behavior at home throughout the course of treatment. The weekly diary also asked whether Sandra and Marc had discussed the traumatic experience during the past week and to describe the frequency of discussions, the content, and on average, the length of time they spoke. The purpose for these questions was to examine processing of the traumatic event and therapeutic exposure occurring outside of session. Although trauma discussion between sessions is not typically examined, doing so may have important clinical utility. Finally, the weekly diary obtained Sandras self-reported mood during the past week using the Short Mood and Feelings Questionnaire (S-POMS; Shacham, 1983), an adjective checklist measuring transient mood and yielding six scales: Depression (9-items), Vigor (6-items), Confusion (5-items), Tension (6-items), Anger (7-items), and Fatigue (5-items). Mean scores for each scale are calculated by summing the endorsed items and dividing by the total available items. The purpose of examining the pattern of Sandras mood over the course of the program was to identify particular points in the program during which caregivers may experience high negative affect. Lastly, therapeutic alliance between Marc and his therapist was measured twice during the treatment program (sessions 3 and 7), using the Therapeutic Alliance Scale for Adolescents (TASA; Shirk & Saiz, 1992). The TASA is a 12-item scale that measures childrens perceptions of the therapy relationship. Six items are scored to reflect the emotional bond between patient and therapist, and six items are scored to reflect the degree of task collaboration. Items are scored on a 6-point Likert Scale. Higher scores indicate a more positive alliance.

Phase I: Psychoeducation and Coping Skills

Case 1 Marc. In Session One, the therapist met with Marc and Sandra individually and discussed prevalence data and theory pertaining to trauma exposure and PTSD using basic facts and analogies. Therapist: What would you do if you were walking in the woods and out of nowhere, a large bear entered your path? Marc: probably run for my life or climb a tree. Therapist: Good call. Would you have to think about it first or would you just do it? Marc: Its Like an Instinct. [Pauses] I wouldnt Have to Think About it. Therapist: Exactly. When we respond to danger, our thinking brain gets temporarily shut off and our bodies go into survival mode. What changes happen to your body? Marc: Well, I would freeze up. my heart would probably start beating really fast. and I would be out of breath. Therapist: You are good! Yes, your body would go through all of these changes to help you to survive. This is called the stress response. Its actually a good thing. Its like an alarm goes off in your body telling you that something is wrong. [Pauses] Now, what do you think would happen if 1 month later, after the bear was gone and you were safe, your body didnt return to normal? What would happen if the alarm didnt get turned off? Marc: I probably wouldnt be able to do much of anything. Therapist: Right! When someones body goes into alarm mode and the alarm does not turn off, even after the danger is gone thats called posttraumatic stress. One of our goals is going to be to train your body to turn that alarm off. Prior to the end of the first session, the therapist assisted Marc with developing a baseline narrative, the clients initial telling of the event. The baseline narrative yields an estimate of avoidance and is a springboard for trauma narrative development later in treatment. Therapist: Marc, can You tell me more about the physical abuse? Marc: Well, my dad physically abused us. A lot! One time he poured hot coffee on my mom and gave her third degree burns. He would throw things at her and push her into walls and stuff. Another time he threw me into a dog cage and would kick me whenever I tried to get out. [Pauses] I wish someone would do to my dad all of the things that he did to us. [Pauses] I wonder how hed feel then. Marc was direct about the abuse during the baseline narrative, suggesting he may have entered the program with a relatively low level of avoidance. Baseline narratives suggesting a higher level of avoidance may indicate more work on the part of the therapist to reduce avoidance prior to the trauma narrative. The latter case may necessitate additional client-therapist rapport building strategies, a greater number of sessions involving gradual and persistent exposure to trauma material prior to the narrative phase, or greater facilitation and utilization of parent support both in- and out-ofsession. Marcs baseline narrative also indicated an underlying feeling of anger toward his father and desire for retribution, an area to process further during the narrative phase. By the third session, rapport between Marc and his therapist was already well established as indicated by his responses on the TASA (emotional bond 36/36, task collaboration 31/36).

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According to Sandra, Marc looked forward to his weekly sessions. Phase I was completed in six sessions. The therapist taught Marc controlled breathing techniques and muscle-tension relaxation, emphasizing the importance of incorporating relaxation into his lifestyle. To expand Marcs emotional vocabulary, the therapist helped him to create a personalized mood chart using a computer and built-in camera to capture several facial expressions, and then label them with feeling words. The mood chart exercise was a creative application of the emotional vocabulary-building objective in the affective modulation component of the program. Currently, there is no published clinical TF-CBT workbook to accompany the treatment manual, which provides thorough descriptions of the treatment components and their objectives, but limited practical applications and exercises. In a conjoint session, Marc presented the mood chart to his mother, and the therapist facilitated a discussion with Marc and Sandra about the functionality of emotion. For example, the therapist taught that negative emotion signals when something is wrong, and that by identifying and labeling ones feelings one can elicit social support (e.g., I am feeling nervous about court tomorrow, do you think we can talk about it?). During another activity, the therapist presented a model of the human brain and asked Marc to write several negative thoughts on sticky notes and stick them to the brain. After the brain was entirely full of sticky notes, the therapist discussed intrusive thoughts and introduced the practice of thought stopping, which falls within the cognitive coping component of TF-CBT. Therapist: So, how do You think you would feel if you had so many thoughts stuck to your brain at once? Marc: It probably would be pretty overwhelming. Therapist: So, what can we do about these thoughts? Marc: We can just peel them off. [Laughs] Therapist: Okay, sure, go ahead and peel them off. Put them in this envelope. [Waits for Marc to peel them off] Good. Now that you have them in the envelope, seal it up and write thoughts to deal with later. [Waits] Okay, take a sticky note and write on it, Do Not Disturb. [Waits] Now, stick it to the brain. [Waits] Good. Do you see what weve just done? Marc: I think so. Therapist: Weve cleared the brain of all of those intrusive thoughts and hung a do not disturb sign on it. Notice that we didnt throw the thoughts in the trash. We put them aside for later. This is what you can do when you are in school or somewhere else and you have negative thoughts that interfere with what you are doing. The therapist explained that the harder Marc tried to ignore or avoid intrusive thoughts, the stronger and more frequently they would return (i.e., the rebound effect). As a form of thought stopping, the therapist taught Marc to identify the intrusive thoughts and then imagine peeling them off of his brain and putting them into an envelope for later. Unlike active avoidance, the act of attending to the thoughts and filing them away for later may help to avert the rebound effect and break the ruminative cycle (Bakker, 2009). The TF-CBT treatment manual presents thought stopping techniques that involve using a cue word (e.g., Stop!) and cue behavior (e.g., snapping an elastic band). The therapist elaborated on these ideas by establishing an imaginal scenario (i.e., peeling off the sticky notes from the brain) that the child could use in place of or in addition to the other, more overt

techniques. In addition, the therapist pushed the exercise further by emphasizing the importance of returning to the thoughts and using problem-solving strategies to deal with them. In another session, the therapist introduced the idea of mindfulness, which he explained as an awareness of all that is going on around you, and being in the present time and place without interference from the past or future. The therapist further explained that being mindful meant identifying ones thoughts and feelings without getting stuck in them. Marc participated in a mindfulness exercise in which he closed his eyes, employed controlled breathing, and focused on all of the sounds happening around him, as well as any thoughts entering his mind. Although the practice of mindfulness has not been incorporated into the TF-CBT treatment manual, it has emerged in adaptations of the model and is a clever way of connecting the relaxation and cognitive coping components. The therapist engaged Sandra in parallel work. He emphasized the importance of relaxation and helped Sandra to find ways to reduce stress in her life. The therapist also encouraged the use of praise and positive reinforcement and used role-play to help Sandra incorporate these strategies at home. A primary concern for Sandra was the ongoing court hearings during which she and Marc would encounter Michael. Sandra expressed intense fear of Michael and explained that she would become noticeably upset and panicky when court dates approached. The therapist validated Sandras fears, encouraged using controlled breathing techniques during those times, and helped her to reconceptualize her role in court. The therapist explained that modeling effective emotion regulation would also help to decrease Marcs anxiety. In her second session, Sandra provided a baseline narrative. Although not explicit in the TF-CBT treatment manual, obtaining a baseline narrative from a caregiver helps to gauge her knowledge of the traumatic event, as well as her level of avoidance. Doing so may also reveal pertinent cognitive distortions. In several cases, caregivers, many who are victims of the traumatic event, also exhibit symptoms of PTSD. Sandras description of the family violence was consistent with Marcs, however, contained greater detail about the domestic violence. In addition, Sandras narrative was replete with guilt, comprised of statements including: I should have gotten out of that marriage a long time ago, I should never have let these things happen to Marc, and I pick them well dont I? The therapist noted these cognitions with the intention of revisiting them when processing Marcs trauma narrative with Sandra. Sandra finished her narrative by stating: It just makes me so angry that Marc has to go through this because of his father. It makes me feel helpless and sad that I cannot help him, or just take this all away. Sometimes I feel uncertain about how to handle everything. This all makes me very sad. Marc did not deserve this. He is such a kind-hearted boy. Sandras feelings of guilt are common among parents of abused children, and in some cases, appropriate. These negative feelings and cognitions, however, may be exacerbated in parents with depression, and may interfere with the parents ability to support the child during treatment. Sandra became highly tearful when discussing Marcs abuse and it became evident that Sandra often ruminated about her inability to protect him from it. The therapist suggested that Sandra pursue individual psychotherapy to help reduce her symptoms of depression (e.g., rumination, avoidance), which in turn might enhance her ability to support Marc.

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According to Sandra, Marcs behavior problems fluctuated and included sleep difficulties, complaining about stomachaches and pains, worrying about court, and temper flares (e.g., After court he was yelling at me in response to anything I would say and was throwing stuffed animals around), and insisting on sleeping in his
Phase I
5 5 4.5 4

mothers bed (Figure 1, top). Because of her guilt, Sandra struggled with providing discipline to Marc. For example, she often conceded to Marcs frequent requests to make purchases, failed to set appropriate boundaries (e.g., sleeping in her room), and failed to address oppositional behavior with appropriate consequences

Phase II

Phase III

Behavior Ratings

5 3.5 3 5 2.5 2 5 1.5 1 5 0.5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Sessions 70 60

Total Minutes per Week

50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Sessions 9 0.9 8 0.8

POMS Scale Scores

7 0.7 6 0.6 5 0.5 4 0.4 3 0.3 2 0.2 0.1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Sessions Depression Anxiety Anger Fatigue Confusion Vigor

Figure 1.

Patterns of change across sessions.

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(e.g., talking back, temper tantrums). The therapist talked openly about his observations and worked with Sandra to establish a reasonable behavior management plan. During phase I, Sandra reported little out-of-session discussion concerning the trauma. The only discussion during phase I occurred during the initial 2 weeks of the program (Figure 1, middle). Sandra reported that: Marc told me that if his dad showed up he would hit him in the head with a baseball bat. He said he wished he had a bow and arrow so he could shoot him. He never wanted to see his dad. He brought up when his dad would hit him every year they put up the Christmas tree and how he didnt want to help anymore. He talked about his dad dragging him to his room because he wouldnt listen and how he would beat him. He talked about the time his lung collapsed because his father wouldnt take him to the hospital. His father told him it had to run its course. Marc told me he was so scared because he couldnt move or breathe. He was scared he was going to die. He said that he wished that someone would do to his dad all the things his dad did to him so that he could see how it would feel. When Asked how Sandra responded to Marcs statements she said: I would just tell him that it is not nice to say things like that and no matter what has happened your dad loves you. And no one deserves to be hurt even if they did something wrong. I also told him I was sorry and I love him and it would never happen again. The therapist introduced the practice of active listening and suggested that Sandra use responses that facilitate exploration of Marcs feelings and thoughts about his father and the abuse. The therapist explained that responses such as, . . . it is not nice to say things like that might discourage Marc from expressing these feelings and thoughts. Responses such as, Tell me more about why you feel that way, or I can understand why you are so upset at your father, encourage further processing and validate the childs feelings. Sandras POMS scores on the Depression, Anxiety, Confusion, and Fatigue scales were relatively high during the first 2 weeks of the program (Figure 1, bottom). Early in the program, it is common for caregivers to report experiencing negative mood states when thinking about their childs trauma exposure. These scores decreased by the middle of phase I, however, likely reflecting Sandras newly developed coping and parenting skills.

may help to increase the childs awareness of thoughts and feelings and lay the groundwork for writing the trauma narrative; Eliciting a baseline narrative from the caregiver, as well as the child, helps to gauge her knowledge of the traumatic event and level of avoidance, and may reveal pertinent cognitive distortions to address when processing the childs trauma narrative; Obtaining information about trauma discussion outside of session may help shed light on the childs level of avoidance, processing stage, and potential cognitive distortions, and may reflect how the caregiver is applying what she has learned in session.

Phase II: The Trauma Narrative

Therapeutic alliance remained high into phase II (TASA emotional bond 36/36, task collaboration 35/36). The therapeutic alliance is critical to the success of trauma narrative development. Without a strong alliance, the child is less willing to fully engage in the exposure and processing, and the therapist feels less comfortable being direct with the child and challenging avoidance. In the seventh session, the therapist discussed the format of the trauma narrative. For inspiration, the therapist presented two examples of trauma narratives, each with a unique approach (e.g., illustrated poem, comic book style). Ultimately, Marc opted to use computer software to illustrate his narrative. The therapist revisited Marcs baseline narrative and asked him to read it aloud. Then he asked Marc to elaborate on the time his father threw him into the dog cage. The therapist typed while Marc dictated. Marcs expanded narrative read: It happened at a picnic my dad was having. His friends and some of our relatives were there. People starting getting drunk. I was just talking to my cousin, who was a little older than me. Out of nowhere, my dad comes, picks me up, and throws me into the cage. I hit my head on the way in. Everybody was laughing except for me and my cousin. My grandmother threw a bone in front of the cage and starting saying, Does doggy want a treat, and they kept on laughing. I was crying. I should have tried to fight back. Every time I tried to come out my dad or his friends would kick or punch me. After a while, everyone stopped paying attention to me. Finally, I got the courage to run out. One of his friends tried to block me but I pushed through him and ran to a neighbors house and called my mother. My mother started to cry. My mom used to be drunk a lot but she hasnt had a drink for like a year. I make sure of it. All we ever did was cry. I wish that I was big enough to fight back and then these things wouldnt have happened and my dad wouldnt have been able to hurt me or my mom. If I had more courage, I would have thrown my father into the cage. In two additional sessions, the therapist encouraged Marc to add emotion words and specific thoughts. The therapist also used Socratic questioning to challenge beliefs that he should have been strong enough to protect himself and his mother from his father, and that it was his responsibility to maintain his mothers abstinence from alcohol. These strategies comprise the cognitive processing component of TF-CBT. Marcs revised narrative read: The physical abuse happened at a picnic my dad was having. His friends and some of our relatives were there. People starting to get drunk. I was just talking to my cousin, who was a little older than me. I was happy until, out of nowhere, my dad comes, picks me up, and throws me into the doghouse. I hit my head on the way in. It really hurt. Everybody was laughing except for me and my cousin.

Phase I: Considerations
Comprehensive assessment of caregivers may reveal factors (e.g., trauma history) that can either promote or hinder the childs progress in treatment; Making recommendations for caregivers with depression or trauma-related psychopathology to pursue their own treatment may help improve their ability to support the child in TF-CBT; Creative and stimulating activities (e.g., computer software to create a personalized mood chart) help to promote and maintain child engagement in session; Combining the practice of thought stopping with problem-solving strategies helps to reinforce the idea that thought stopping is a temporary means of derailing intrusive thoughts, and that the child must revisit these thoughts and ultimately address them; Incorporating the concept and practice of mindfulness into the cognitive coping component

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I felt embarrassed and sad that everyone was laughing even though I was hurt. My grandmother threw a bone in front of the doghouse and starting saying, Does doggy want a treat, and they kept on laughing. Grandmothers arent supposed to be so mean. I was crying. I couldnt fight back. I was just 10 years old and there were a lot of big adults around. Every time I tried to come out my dad or his friends would kick or punch me. I was freaked out. After a while, everyone stopped paying attention to me. Finally, I got the courage to run out. One of his friends tried to block me but I pushed through him and ran to a neighbors house and called my mother. My mother started to cry. My mom used to be drunk a lot but she hasnt had a drink for like a year. I support her but it is up to her to stay away from drinking alcohol. We cried a lot because of what we were going through. I wish none of this had happened. I had a lot of courage to be able to run away and get help . Now I am safe from my dad. Marc created an additional section concerning the time his father refused to take him to the hospital during an asthma attack, which resulted in a collapsed lung. During the narrative phase, Marcs father stopped pursuing visitation. In discussion, Marc expressed that although he was relieved that he no longer had to see his father, he was hurt and confused that his father simply gave up. To process his conflicted feelings, the therapist encouraged Marc to write a letter to his fathernot with the intent to deliver the letter, but rather to provide Marc with a therapeutic outlet. Marc read the letter aloud in session as though he was reading it to his father. The letter proved to be an important addition to the trauma narrative, as it helped to organize Marcs conflicted feelings about his father and redefine his role toward him. In the letter Marc read, Part of me still loves you, but I can never see you again [pauses] because all you ever did was hurt me and mom. Although therapeutic letter writing is not acknowledged in the TF-CBT treatment manual, it has been incorporated as a processing tool in a number of therapy approaches (Kerner & Fitzpatrick, 2007; White & Murray, 2002). At this point in therapy, Sandra had not yet pursued psychotherapy and stated that her life was currently too hectic to do so. Transportation was a barrier because she did not own a car and relied on a friends availability. Sandras medical problems also compromised attendance. Since the start of therapy, Sandra had cancelled Marcs appointment six times because of last minute issues. The therapist motivated Sandra to make every effort to make Marcs appointments by emphasizing the importance of consistency during the narrative development phase. Gaps in treatment may compromise therapeutic alliance and cognitiveemotional processing of the traumatic event. In addition, the longer the gap between sessions, the more likely is the risk of treatment dropout. Over four sessions, the therapist shared Marcs developing narrative with Sandra in order to gradually build her tolerance level and process her own thoughts and feelings about the abuse. The therapist read the narrative aloud the first time, then had Sandra read it aloud on subsequent iterations. Sandra sobbed when she heard the narrative for the first time, but after several exposures was able to focus on positive aspects of the story (e.g., Marcs resilience). The therapist coached Sandra on ways to support Marc during the conjoint session.

Sandra: I never knew he felt that he had to protect me. I didnt know he put that kind of responsibility on himself. [Eyes well up with tears] Therapist: How do you feel about him having that level of responsibility? Sandra: I dont like it. [Pauses] A child should never feel like he is responsible for his mother. [Pauses] Im ashamed of myself for letting it get that far. Therapist: Marc also wrote that he felt safe because of you. He loves you very much. You have a very important role in his life. I know you blame yourself for what happened to Marc and for much of what hes going through right now. [Pauses] Last week you criticized yourself for choosing abusive partners. I get the sense that you see yourself as a bad parent. Sandra: I guess Im not a bad parent. Michaels a bad parent. I guess Im just doing the best I can, and you know, healing myself along the way. Im getting better. I can stand up to Michael now [pauses] and I think that Marc can see that. I was never able to do that before. I guess weve both come a long way, and we are still learning. Therapist: I agree with you. You both have come a long way. I have seen much improvement. You have gained confidence in yourself as a parent and, in turn, Marc has gained confidence in you. It is very important that you continue to support Marc but also to take care of yourself. Your ability to parent depends on your ability to take care of yourself. Trauma discussion at home increased markedly during the narrative development stage (Figure 1, middle). According to Sandra, Marc complained of nightmares involving his father. He also brought up the asthma attack and how he had begged his father to take him to the hospital. Sandra said she responded by suggesting that perhaps his father did not know any better. Marc responded, Yeah right mom. Marc also reminded his mother of the times his father would come home intoxicated and start screaming at them. He remembered a time when Michael threw Sandra across the room and then nearly destroyed everything in the house. Marc added, I was very scared for us Mom . . . why didnt you do anything? Sandra reported that she did not know how to respond to Marc, and evaded the question. The therapist helped Sandra process these interactions. Sandra stated that she was surprised by how much Marc had remembered. She also expressed feeling hurt and embarrassed by Marcs question. The therapist asked Sandra to imagine the situation from Marcs perspective. In doing so, Sandra realized the frustration and helplessness Marc must have felt to witness his mother being beaten without the will or strength to defend herself. Moreover, Sandra pointed out that she had supported Michaels behavior often making excuses for him in an attempt to restore peace in the household. She noted that this must have been confusing for Marc. The therapist suggested responding to Marcs question during the narrative sharing session. The therapist added that being candid about Michaels depravity (e.g., not caring to bring Marc to the hospital) and her animosity toward him, instead of protecting Marc from these feelings, might help to validate Marcs feelings and actually strengthen Marc and Sandras working alliance. Sandras POMS scores during phase II indicated increases in the Anger, Anxiety, Depression, and Vigor scales, likely reflecting an increase in trauma discussion at home, renewed anger toward Michael, as well as newfound self-confidence and determination.

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Behavior problems at home continued during the narrative phase. Sandra reported that Marc seemed irritated by her and would often become disrespectful. Sandra used the behavior modification techniques gleaned in phase I (e.g., praising positive behavior, 5-min work chore, loss of privileges) to address this behavior. In addition, Marc continued to spend many nights sleeping in his mothers room, however, Sandra began to praise Marc for time spent in his own bedroom, and in turn, the frequency of nights spent with his mother decreased. During Marcs 10th treatment session he and Sandra were ready to share and discuss the narrative together. The therapist met with each of them for 10 min prior to bringing them together. While Marc read the narrative, Sandra tactfully offered praise and support. At one point, Sandra connected Marcs progress and achievement with her own and professed that they made quite an effective team. Sandra also followed up by explaining to Marc that it is her responsibility to be a parent to him and that he should not feel responsible for protecting her or ensuring that she remain abstinent from alcohol. The therapist used a chart to illustrate Marcs reduction in symptom scores since baseline, and both Marc and Sandra seemed impressed by the progress made.

Phase II: Considerations

When helping the child choose a format for the trauma narrative, providing creative and inspiring examples may help to motivate the child and circumvent some of the anxiety and avoidance associated with starting to talk more in depth about the trauma; Therapeutic letter writing may facilitate exploration and organization of trauma-related thoughts and feelings associated with interpersonal relationships; Troubleshooting attendance problems becomes particularly critical during the narrative phase in which long gaps between sessions (i.e., 2 3 weeks) may compromise progress; Examining trauma discussion at home during the trauma narrative phase may inform the therapist about additional caregiver and child cognitive-emotional processing and reveal unresolved areas worth addressing in session; Encouraging the caregiver to also share certain negative thoughts and feelings associated with the childs trauma (e.g., I hated him for hurting you) and/or realizations during therapy (e.g., I realized that I made excuses for your father) may help to validate the childs feelings and strengthen the parent child alliance; Using data to illustrate the reduction in symptoms across sessions substantiates the childs progress and acknowledges the nearing end of the program.

Phase III: Safety Skills and Future Development

Marcs therapy finished in three more sessions. During one session, the therapist discussed Marcs personal goals and future aspirations, which is typical of this phase of treatment. He also introduced the idea of growth after trauma, consistent with the goals of this phase, but not a standard topic in the treatment manual, and had Marc generate ways in which he may have become stronger or more capable because of the trauma-exposure. With these in mind, Marc used the computer graphics program to create an afterword to supplement his trauma narrative. It read: Despite all of the stressful things that have happened in my life, I am bringing home better grades, more awards, and I am very happy. I have no more abuse going on in my life. I am not around

people like my father anymore. I am around people who care about me. I have a lot more friends. I see myself as a very successful person, going to a good college and coming out as a veterinarian. I would like to help animals because animals love methey hardly ever growl or show aggression toward me. Also not standard practice, the therapist added a written piece to the afterword, which Marc was eager to read to his mother. It read: Marc and his mom came into the program determined to work hard and do their best to better understand what had happened in the past and deal with it. Marc learned about managing his stress using relaxation skills and by involving himself in activities that he enjoys. He learned about identifying and expressing emotions and how emotions relate to thoughts and behaviors. Marc also wrote a story about the physical and emotional abuse that he experienced and is devoted to helping other kids who have been abused by sharing his story. Marcs mom has been very supportive throughout the program and has learned about trauma and how to help kids cope with trauma. She has been a very important part of the process. I am proud of Marc and his mother for a job well done. Congratulations! It takes a lot of courage and effort to successfully complete this program. The therapist encouraged Marc to keep the afterword, whereas the rest of the narrative would remain in the clinic. Marc opted to allow the therapist to use his finished narrative to share as an example to other children entering the program. With Sandra, the therapist discussed future plans to follow through with the divorce and pursue a clinical therapist of her own to work more intensely on her depression. The therapist and Sandra brainstormed ways of reducing the barriers to her own treatment. During another session, the therapist discussed alcohol abuse and dependence. The therapist explored Marcs fears about his mother relapsing and emphasized that alcoholism is a lifelong struggle that sometimes results in setbacks. The therapist stressed the importance of Marc attending to his own safety and helped him to establish a plan, should he find himself in a potentially dangerous situation because of his mothers problem with alcohol (e.g., mom blacks out from drinking). The therapist encouraged Marc and Sandra to consider returning to the clinic for a booster session should problems reemerge or new developments surface. Finally, at the graduation session, Marc received a certificate of completion and celebrated with pizza and refreshments. About 1 year after his final session, Marc contacted the therapist by telephone with concern that his mother had started drinking again. Marc informed the therapist that he had found an empty bottle concealed in one of the cupboards. The therapist explored Marcs concerns and obtained permission to discuss them with his mother. Sandra was receptive and explained that she had relapsed but had since gotten back on the wagon. The therapist encouraged Sandra to praise Marc for using his resources and contacting the therapist. The therapist finished by facilitating a three-way conversation with Marc and Sandra on separate telephones. The therapist offered a booster session, but Marc and Sandra ultimately resolved the issue at home.

Phase III: Considerations

Reflecting on stress-related growth may help highlight the positive attributes of the child and caregiver and set the stage for

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termination; Although taking home the trauma narrative is generally discouraged of the parent and child, giving the child the option of sharing it with future children in the program may help to justify the effort spent developing the finished product; Highlighting the efforts and achievements of the child and parent in a letter, a paragraph in the afterword, or as part of the certificate of completion provides them with a future reminder of the progress made and the material learned in the program; Discussing the availability of booster sessions and normalizing them as a part of the process rather than a relapse, helps to reinforce healthy utilization of resources and continuity of care.

Evaluating Outcome
The K-SADS-PL was readministered at post-treatment. Additionally, the UCLA PTSD RI and CBCL were completed at posttreatment and readministered in the home at 6, 9, and 12 months following the baseline assessment. At post-treatment, Marc no longer met criteria for PTSD as indicated by the K-SADS-PL, as well as his responses on the UCLA PTSD RI. Marcs responses on the UCLA PTSD RI indicated a significant reduction in PTSD symptom severity (Figure 2). In addition, Marcs CBCL scores remained in the normal range ( 60). At follow-up assessments 6-, 9-, and 12-month postbaseline, UCLA PTSD RI scores continued to decline, but to a lesser degree, with the exception of a temporary increase in hyperarousal at the 6-month follow-up. Marcs scores on the CBCL Internalizing and Externalizing Problem Scales remained in the normal range across all three follow-up assessments. To better understand how Marcs outcome scores compared to the sample of children and adolescents participating in the community-based effectiveness study, we compared Marcs preand post-treatment and follow-up scores on the UCLA PTSD RI and CBCL with data from the remaining 65 participants in the effectiveness sample, using an effect-size analysis (i.e., d dif-

ference between means (Marc vs. sample) divided by the standard deviation from the sample; d .20 reflects a small effect, .50 a medium effect, and .80 a large effect; Cohen, 1988). At pretreatment, Marcs scores on the UCLA PTSD RI Reexperiencing and Hyperarousal Scales were somewhat higher than scores from the larger sample (ds .41, .34, respectively), whereas Marcs score on the Avoidance Scale was lower (d .69). Marcs re-experiencing score was comparable to that from the sample at pretreatment (d .08); however, his avoidance and hyperarousal scores were significantly lower (ds .89, .48, respectively) compared with the samples scores. Marcs scores on the Re-experiencing and Avoidance Scales at 6-month follow-up, and all scales at 9- and 12-month follow-ups were lower than those from the larger sample (ds .36 - .90). These comparisons suggest that Marc entered treatment with high symptom severity scores relative to the sample, and in general, demonstrated a greater reduction in symptom severity at post-treatment and follow-up. Data from the CBCL indicate that Marc had lower Internalizing and Externalizing Scale t-scores at pretreatment relative to the sample (ds .54, 2.21, respectively), and comparable t-scores at posttreatment (ds .01, .03, respectively). Marcs Internalizing Scale t-scores at 6-, 9-, and 12-month follow-up were moderately lower than the larger samples scores (ds .24 - .36), while Marcs Externalizing Scale t-scores were significantly lower (ds .62 - .88). These comparisons suggest that Marc entered treatment with less severe parentreported internalizing and externalizing behavior problems relative to the sample, and that these scores were maintained from post-treatment to 12-month follow-up, whereas sample means increased from posttreatment to 12-month follow-up.

Discussion
Marcs case study illustrated the implementation of TF-CBT in treating childhood PTSD associated with physical abuse and wit-

14

12

UCLA PTSD RI Scores

10

0 Baseline Post-Treatment Reexperiencing 6-Month Avoidance 9-Month Hyperarousal 12-Month

Figure 2.

Changes in PTSD symptoms across sessions.

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nessing domestic violence. Pre- to post-treatment data on the UCLA PTSD RI indicated a significant reduction in symptoms following treatment. UCLA PTSD RI scores were further reduced at 6-, 9-, and 12-month follow-up. These reductions are consistent with data from efficacy studies of TF-CBT (Cohen & Mannarino, 2008). Weekly diary data revealed the presence of out-of-session trauma discussion between child and caregiver which increased substantially during phase II of treatment, the trauma narrative development phase. Thus, cognitive and emotional processing of the trauma was extended to the home environment. The content of this discussion revealed a number of child and parent cognitions worth processing further in session. Because trauma discussion at home appeared to be an important part of the therapeutic process, parenting skills such as active listening and praising were taught to improve the quality of parent child interactions. Consistent with our understanding of the TF-CBT model (Cohen et al., 2006), child behavior problems remained moderately high during the trauma narrative phase, and decreased substantially in phase III. Therapists are taught to inform caregivers about the possibility of child behavior problems and symptoms worsening during trauma narrative development, when trauma reminders are most salient. Interestingly, parent self-reported negative mood on the POMS was high at the beginning of treatment, relatively low during the mid to late part of phase I, increased during phase II, and absent during phase III. This pattern suggests that trauma narrative development may negatively affect caregivers mood during this phase, perhaps increasing vulnerability to their own mental health or substance abuse issues. Thus, change processes in caregivers may be an important area for future research. In addition, this pattern corresponds to changes in child behavior problems and trauma-discussion at home, likely reflecting the salience of trauma material during this time. Finally, excerpts of clinical dialogue between the child, caregiver, and therapist highlighted the capacity of TF-CBT to accommodate individual and family needs and circumstances.

References
Achenbach, T. M. (2001). The Child Behavior Checklist. Burlington: ASEBA, University of Vermont. Bakker, G. M. (2009). In defense of thought stopping. Clinical Psychologist, 13, 59 68. Bouton, M. E. (2004). Context and behavioral processes in extinction. Learning & Memory, 11, 485 494. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). New York, NY: Academic Press.

Cohen, J. A., Mannarino, A. B., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New York, NY: Guilford Press. Cohen, J. A., & Mannarino, A. P. (2008). Trauma-focused cognitive behavioural therapy for children and parents. Child and Adolescent Mental Health, 13, 158 162. Cohen, J. A., Mannarino, A. P., & Knudsen, K. (2004). Treating childhood traumatic grief: A pilot study. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 12251233. Cohen, J. A., Mannarino, A. P., & Knudsen, K. (2005). Treating sexually abused children: 1 year follow-up of a randomized controlled trial. Child Abuse & Neglect, 29, 135145. Foa, E. B., & Cahill, S. P. (2001). Psychological therapies: Emotional processing. In N. J. Smelser & P. B. Bates (Eds.), International encyclopedia of social and behavioral sciences (pp. 1236312369). Oxford: Elsevier. Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20 35. Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., . . . Ryan, N. (1997). Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): Initial reliability and validity data. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 980 988. Kerner, E. A., & Fitzpatrick, M. R. (2007). Integrating writing into psychotherapy practice: A matrix of change processes and structural dimensions. Psychotherapy: Theory, Research, Practice, Training, 44, 333 346. doi:10.1037/00333204.44.3.333 Le Doux, J. E. (1996). The emotional brain: The mysterious underpinnings of emotional life. New York, NY: Simon & Schuster. Nader, K., Schafe, G. E., & Le Doux, J. E. (2000). Fear memories require protein synthesis in the amygdala for reconsolidation after retrieval. Nature, 406, 722726. Pynoos, R., Rodriguez, N., Steinberg, A. M., Stuber, M. L., & Frederick, C. (1998). The UCLA PTSD reaction index for DSMIV. Los Angeles: UCLA Trauma Psychiatry Program. Shacham, S. (1983). A shortened version of the profile of mood states questionnaire. Journal of Personality Assessment, 47, 305306. Shirk, S. R., & Saiz, C. C. (1992). Clinical, empirical, and developmental perspectives on the therapeutic relationship in child psychotherapy. Development & Psychopathology, 4, 713728. White, V. E., & Murray, M. A. (2002). Passing notes: The use of therapeutic letter writing in counseling adolescents. Journal of Mental Health Counseling, 24, 166 176.

Received August 13, 2010 Revision received January 4, 2011 Accepted January 14, 2011