The word trauma elicits many responses from people. Some don’t know exactly what it means, others would just prefer to move around it, but the truth is, that a disturbingly high number of people have experienced some form of trauma in their lives. Trauma can be anything: sexual assault, car accident, dog attack, sudden death, childhood abuse or neglect, divorce, combat, and so many other things. The main component of deciphering if something is traumatic is: how is it affecting you?
Many people get divorced and move on with their lives without a hitch. Others feel that divorce is the worst thing that has ever happened to them, and have trouble getting out of bed in the morning, and have intrusive thoughts and dreams about the experience. The former may not feel traumatic, whereas the latter may. The important thing is that if you feel that you are struggling from something that has happened to you and you just can’t seem to move past, this article is for you!
Trauma has the capacity to take someone’s world and turn it upside-down.
After experiencing a traumatic event, many things change in a person’s life. Some people feel numb, and disinterested in the things that used to bring them joy. Others feel angry or sad. Many have a decline in work performance, begin sleeping a lot more or a lot less, and have disruptions in both romantic relationships and friendships. Often times people have nightmares, or flashbacks, and have intrusive thoughts about the trauma. There is no one specific way that trauma presents, but the main theme is that trauma takes a person’s normal level of functioning and drops it significantly.
What is TF-CBT?
Trauma-Focused Cognitive Behavioral Therapy is an evidence-based treatment that was developed to help children, adolescents, and their families overcome a traumatic event. TF-CBT is made up of 8 modules: Psychoeducation, relaxation, effective regulation, cognitive coping, trauma narrative, in-vivo exposure, conjoint trauma narrative, and enhancing safety.
Have you been having trouble sleeping? Having panic attacks or flashbacks? Feel unsafe in your own home or life? Then trauma therapy may be for you! TF-CBT basically gives you the tools to manage the unpleasant symptoms in your life and then provides a way to reprocess and reintegrate the trauma into your life in the correct way, so that it stops becoming triggered by neutral things in your life. Lastly, it provides planning for the future, so that you are better equipped when future triggers arise. It would be impossible to name all of the benefits to TF-CBT, but some of these include having better relationships, increased self-confidence, a greater sense of safety, more happiness, and improved functioning.
Easy Guide to TF-CBT
The first stage of TF-CBT is to learn about trauma in general, and about what treatment will be like. Psychoeducation is just a fancy name for teaching you something. If we reason it through, it would make sense that you would need to find out what you are experiencing is a normal trauma reaction, and learn what you will be working on with your therapist at the beginning of treatment.
At this point, you may be beginning to ask yourself, where is the trauma part? Well, there is a very specific reason that we focus on providing necessary skills such as relaxation, effective regulation, and cognitive coping before ever touching the trauma portion of treatment. The fact is, beginning with the traumatic event before any skills have been learned can actually become another traumatic experience!
By the time that the trauma narrative is reached, you need to have skills like being able to relax, so that you can use them in the session while going over the trauma narrative. As clients start to become dysregulated, I stop the narrative and ask clients to use relaxation skills such as progressive muscle relaxation (tightening and relaxing each muscle group until your body feels more relaxed) and deep breathing to self-soothe before moving on in the narrative. When the client goes home, they are asked to continue to practice these relaxation skills as they become triggered, or have other trauma responses such as flashbacks, nightmares, and panic attacks.
Similarly, effective regulation focuses on providing more tools to the client to help calm down. Some of these skills include grounding and problem-solving. Like relaxation, the goal is to help the client regulate himself or herself before moving on. In the session, we will review different distraction techniques so that clients are prepared when something comes up. Calm clients can list several things they do to distract themselves when a problem arises (e.g. take a walk, listen to music) but in the heat of the moment, it is easy to draw a blank. Spending time planning for when challenging situations occur leaves clients more able to tackle them when they arise.
This is the last part of our coping skills section. Cognitive coping addresses the third type of self-regulation. As you may guess from the title, cognitive coping is about identifying and managing thoughts in a way that provides support and confidence to the client. During this time, I teach people about the connection between thoughts, feelings, and behavior, and how to challenge negative thinking patterns. In sessions, we practice searching for facts that challenge the negative thoughts (examining the evidence against the negative thought), begin using positive self-talk (saying good things to yourself), and practice thought stopping (stopping negative thoughts before they spiral into something worse). Once these skills have been practiced with different problems that have arisen in treatment, the client is ready to begin the trauma work.
The narrative is the meat and potatoes part of treatment. The beginning sections of treatment allow the client to be able to tolerate the narrative and keep from being re-traumatized by discussing the trauma, but the re-processing is what helps clients rewire their brains so that they are able to move past the trauma. The narrative is usually a written representation of the traumatic event, that is gone over several times in the session, and changed as the client sees fit.
The client divides the narrative into chapters and can begin wherever he or she likes. Each draft integrates new thoughts, and feelings, and promotes a new understanding for the client. You may be asking, “why do we even ask you to do something like this?!” I promise you we wouldn’t ask you to do this unless there was a good reason! Research shows that by going through the trauma in a safe environment at your own pace, you are able to gain mastery over the trauma that has taken a hold of your life. After all, isn’t that what this is all about??
After the trauma narrative has been mastered, the next step is to address trauma reactions due to environmental triggers. In this stage, the client identifies things that now bring up anxiety due to the trauma. I help clients create what is called a fear hierarchy, which just means that we will decide which things bring up the most worry, and which things bring up the least, and rank them in order. The therapist and client will work through each of the items in the hierarchy until they no longer bring up worry in the client. This state also requires using those skills we learned about in the first three sections!
Conjoint Trauma Narrative
After mastering the trauma narrative with the client in session, I help clients share their trauma narrative with a safe person in their life. For children and adolescents, this is sharing the narrative with a parent/family member that is safe and has had family sessions at different points in the treatment with client and therapist. Family members are coached about how to react positively to the narrative before the child shares it.
Sharing the narrative with a SAFE family member promotes better understanding for the child and family, provides support and praise to the child, gives an opportunity for questions and answers that may have previously been missed, and promotes a higher level of exposure, which creates a further sense of mastery. For adults, this step is sometimes skipped, but it can be valuable to do if there is a SAFE partner, family member, or friend that is willing to participate, and that the client would like to share the narrative with.
This last step is to create a safety plan for the future. If safety is a large concern, I would move this step to the beginning of treatment, as keeping the people safe is the first priority. If not, this step begins to plan for when treatment ends. Self-harm, suicidal thoughts, healthy boundaries, and identifying which coping skills are particularly beneficial is a main component of this section. I typically work with clients to identify future triggering situations, find solutions to problems, teach them about safe boundaries and relationships, and role play triggering situations, so that clients feel confident and equipped to handle whatever comes up!
Trauma treatment is not easy.
Neither is living in a state of fear or experiencing the many negative effects of trauma that can appear and create chaos in your life. If you or a loved one have experienced a trauma, and are finally ready to address what’s going on, please call to set up an appointment!