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Global Mental Health

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

What it is

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an evidence-based treatment for children and adolescents impacted by trauma and their parents or caregivers.  Multiple research studies have shown that TF-CBT successfully resolves a wide array of emotional and behavioral difficulties associated with single, multiple and complex trauma experiences. It was developed by Drs. Anthony Mannarino, Judith Cohen and Esther DeblingerCurrently 14 randomized controlled trials have been conducted in the United States, Europe, and Africa, comparing TF-CBT to other active treatment conditions. All of these studies have document that TF-CBT was superior for improving children’s trauma symptoms and responses.  

Cohen JA, Mannarino AP, Deblinger E. Treating Trauma and Traumatic Grief in Children and Adolescents; 2nd Edition. 
 
Cohen JA, Mannarino AP, Deblinger E. Trauma-Focused CBT for Children and Adolescents: Treatment Applications. 

 

How it works

TF-CBT is a structured, short-term treatment model consisting of 8-25 sessions (usually 50-90 minutes long). It has been shown to be effective in both individual and group treatment formats. Although TF-CBT is highly effective at improving youth posttraumatic stress disorder (PTSD) symptoms, a PTSD diagnosis is not required to receive this treatment. Many children and adolescents present with a wide array of internalizing and externalizing symptoms after experiencing a traumatic event. TF-CBT effectively addresses these trauma impacts including affective (e.g., depressive, anxiety), cognitive and behavioral problems, as well as improving the participating parent’s or caregiver’s personal distress, effective parenting skills and supportive interactions with the child. TF-CBT is skill-based, providing tools for the child/youth and caregivers (if available) to overcome current problems and also deal with future reminders and stressors. The skills taught are:

P: Psychoeducation 

R: Relaxation 

A: Affective Modulation 

C: Cognitive Coping 

T: Trauma Narrative and Emotional Processing 

I: In vivo Desensitization 

C: Conjoint Session 

E: Enhancing Safety 
 

Our Studies

Our global mental health group has led four feasibility and evaluation studies of TF-CPT in Zambia, one feasibility study in Cambodia, and an ongoing trial in South Africa for which we are providing clinical training and supervision.   

Zambia

In Zambia, since 2009 we have completed a series of studies examining the effectiveness, feasibility and adaptation of TF-CBT delivered by lay providers.  The first study, in collaboration with the University Teaching Hospital (UTH) and the University of Zambia (UNZA), examined the psychosocial issues associated with experiencing child sexual abuse.  Four mental health assessment measures were chosen, adapted, tested and validated in a UTH One-Stop Centre for sexually abused children. Training was completed for 16 Zambians on TF-CBT, during which the local counselors helped adapt the treatment.  A feasibility study was conducted examining the acceptability of TF-CBT for clients and counselors, the ability of lay counselors to implement TF-CBT with adherence, and a pre/post measure of mental health outcomes. This was followed by a collaboration with Catholic Relief Services (CRS) to examine the feasibility of integrating TF-CBT into existing HIV service infrastructures to serve orphans and vulnerable children (OVC). A cohort of 18 Zambian counselors were trained in TF-CBT and supervised through training cases. Results showed significant improvement in symptoms among OVC in a pre/post evaluation. 

Given the success of the formative research we have now completed two randomized controlled trials of TF-CBT in Lusaka, Zambia.  The first, funded by the USAID Displaced Children’s and Orphan’s Fund (DCOF), was implemented in collaboration with SHARPZ, a local NGO in Lusaka, to evaluate the effectiveness of TF-CBT with OVC.  131 youth were randomly allocated to receive TF-CBT in their communities or to the comparison condition of 126.  Participants in the TF-CBT arm received 10 to 16 sessions of treatment.  Follow up was conducted 1-month post treatment.  TF-CBT participants reported, on average, an 82% reduction in trauma symptoms from baseline as compared to a reported average of 21% reduction among comparison group participants.  The second trial, funded by a grant from the National Institute of Child Health and Development (NICHD) examined the effectiveness of TF-CBT, compared with general psychosocial counseling, on reducing HIV risk behavior among OVC.  Data collection for this trial was completed in mid-2017, results are forthcoming. 

Murray LK, Skavenski S, Kane K, Mayeya J, Dorsey S, Cohen J, Michalopoulos L, Imasiku M, Bolton P.  Effectiveness of Trauma Focused Cognitive Behavioral Therapy Among Trauma-Affected Children in Lusaka, Zambia: A Randomized Controlled Trial. Journal of the American Medical Association Pediatrics, June 2015.  DOI: 10.1001/jamapediatrics.2015.0580 
 
Murray LK, Dorsey S, Skavenski S, Jere J, Kasoma M, Imasiku M, Bolton P, Bass J, Cohen J. Identification, modification and implementation of an evidence-based psychotherapy for children in a low-income country: the use of Trauma- Focused Cognitive Behavioral Therapy in Zambia. International Journal of Mental Health Systems. 2013 7:24. DOI:10.1186/1752-4458. 
 
Murray LK, Familiar I, Skavenski S, Jere E, Mayeya J, Cohen JA, Bass J, Bolton PA. An Evaluation of Trauma-Focused Cognitive Behavioral Therapy for Children in Zambia. International Journal of Child Abuse and Neglect. 2013; Jun 12. DOI: pii: S0145-2134(13)00125-7. 10.1016/j.chiabu.2013.04.017. 
 
Murray LK, Skavenski S, Michalopoulos L, Bolton P, Bass J, Cohen J. Youth, Family and Counselor perspectives on the Implementation of TF-CBT in Zambia. Journal of Clinical Child and Adolescent Psychology – Qualitative Issue. 2014; 0 (0) 1-13. DOI: 10.1080/15374416.2013.859079. 

 

Cambodia

In Cambodia, we completed an open trial of TF-CBT with implementing partner World Vision. This study began in 2007 with a qualitative needs assessment to examine the mental health needs of trafficked and/or exploited girls who had been rescued and were living in transition shelters in and around Phnom Penh.  The goal of these interviews was to ascertain, from the young women’s perspective what problems they faced, factors associated with coping and resiliency, and what tasks and activities they felt were important to their ability to function. The results were used to adapt and validate a series of instruments to assess the presence of depression, PTSD, and suicide-related symptoms as well as broader mood and anxiety symptoms.  Concurrently to the instrument development stage, our group adapted TF-CBT to be delivered by shelter staff.  Our group trained local staff in 2008 and 2009 at two local shelters, and provided weekly supervision via Skype during a feasibility study completed in 2010. To assess feasibility and acceptability, qualitative and quantitative data were collected together with a clinical record review.  Results showed feasibility and acceptability among counselors, as well as significant decreases in symptomatology from pre-to-post treatment. 

Bolton, P., Nadelman, S., & Wallace, T. (2008). Qualitative Assessment of Trafficked Girls in Cambodia (pp. 1-21, Rep.). Boston, MA: Boston University. 
 
Bass, J., Bearup, L., Bolton, P., Murray, L., & Skavenski, S. (2011). Implementing Trauma Focused Cognitive Behavioral Therapy (TF-CBT) among Formerly Trafficked-Sexually Exploited and Sexually Abused Girls in Cambodia: A Feasibility Study. Phnom Penh, Cambodia: World Vision. 
 
Bass, J., Bolton, P., & Bearup, L. (2010). Assessment of Trafficked and Abused Girls living in Shelters in Cambodia: Development and Testing of a Locally-Adapted Psychosocial Assessment Instrument (pp. 1-46, Rep.). Baltimore, MD: Johns Hopkins Bloomberg School of Public Health. 

 

South Africa

In South Africa, our team is working with the Universities of Cape Town and Stellenbosch to provide clinical consultation on a randomized controlled trial examining the efficacy of an abbreviated 8-session version of TF-CBT in addressing symptoms of PTSD, depression and aggression in a clinic sample of adolescents who have experienced ongoing, cumulative community violence.  In addition to examining the impact of abbreviated TF-CBT on trauma-related symptoms related to past violence exposures, the study aims to explore whether TF-CBT can facilitate resilience in the face of new trauma exposures post-treatment. A sample of 75 adolescents is being randomized to either TF-CBT or an enhanced treatment as usual condition, and will be followed up until one year post-treatment.   A process evaluation is also being conducted to explore client and counselor experiences of the 8-session TF-CBT model. The study is currently in progress. 

For more information about Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) generally, please go to https://www.musc.edu/tfcbt or www.tfcbt.org.  For questions specifically related to international application of TF-CBT or for international adaptations or trainings, please contact the Global Mental Health group at Johns Hopkins University School of Public Health.