Chapter 2: Review of Literature and Theories
2.5.1 Trauma-Focused Cognitive Behavior Therapy (TF-CBT)
CBT is a behavioral model of therapy that was derived from psychological learning theories of perception and information-processing (Payne, 2005). CBT, as a developmental and integrative model of several theories, contains two major parts: social learning theory and cognitive theory (Payne, 2005). CBT, as a treatment intervention, is a process of recognizing people’s maladaptive thoughts and patterns, which maintain problem behaviors and negative emotions, to achieve behavioral changes and alleviation of emotional pain (Payne, 2005; Cully & Teten, 2008). The main components of CBT are
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the stimulus-response pattern, operant conditioning, learning that the stimulus-response pattern is helplessness, social learning and modeling, and cognitive factors such as disorders of perception or attribution and catastrophic thinking (Payne, 2005). Scott and Dryden (1996) classified cognitive-behavior therapies into four categories: coping skills, problem-solving, cognitive restructuring, and structural cognitive therapy. CBT has superior advantages compared with pharmacotherapy in both long-term effectiveness and physical side effects (Swift et al., 2012). From a behavior and cognitive approach, CBT has no side effects, whereas medication can cause side effects.
A special CBT approach that was designed particularly for trauma-related issues is known as Trauma-Focused CBT (TF-CBT). TF-CBT is one of the most popular treatments designed to meet the psychosocial needs of people with PTSD or trauma- related problems by combining trauma-sensitive interventions with cognitive behavioral therapy (Child Sexual Abuse Task Force and Research & Practice Core, National Child Traumatic Stress Network, 2004). The major components of TF-CBT consist of trauma exposure, cognitive processing and reframing, stress management, and parental treatment (Cohen, Mannarino, Berliner, & Deblinger, 2000). In many rigorous studies, the
treatment has been proven to be one of the most effective treatments for a variety of populations, especially children and their non-offending parents or primary caregivers (Child Sexual Abuse Task Force and Research & Practice Core, National Child Traumatic Stress Network, 2004; Cohen & Mannarino, 1997; Deblinger et al., 1996;
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Deblinger, Stauffer, & Steer, 2001; Polak et al., 2012). TF-CBT was originally designed for, and most widely used with, treating victims of sexual abuse; however, it has also been used widely for various other traumas such as grief, domestic violence, disasters, terrorism, and multiple traumatic events. TF-CBT can significantly reduce major PTSD symptoms as well as anxiety, depression, dissociation, and behavioral problems, as well as significantly improve interpersonal relationships and social competence (Child Sexual Abuse Task Force and Research & Practice Core, National Child Traumatic Stress Network, 2004; Cohen, Deblinger, Mannarino, & Steer, 2004; Cohen & Mannarino, 1997; Deblinger et al., 1996, 2001). TF-CBT can be used for a wide age range of children, from 3 to 18 years old, because therapists can individualize the treatment plan for each case according to specific needs and situations (Child Sexual Abuse Task Force and Research & Practice Core, National Child Traumatic Stress Network, 2004;
Jessiman, Hackett, & Carpenter, 2017).
Although TF-CBT has contributed significantly in the treatment of children with trauma-related issues, disadvantages have been noted regarding this well-developed intervention. Because children with PTSD usually have cognitive deficits such as lack of abstract reasoning, learning, concentration, and poor semantic organization ability (Beers
& De Bellis, 2002; Benton, Hamsher, & Sivan, 1994), interventions that require high cognitive processing and information acquisition will be difficult for them.
Consequently, the effectiveness of CBT is likely diminished where a child’s cognitive
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capacity is insufficient for full and articulate participation in the treatment process.
Another limitation of TF-CBT is the relatively high drop-out rate and low retention rate which are common issues of trauma-related interventions with children (Cohen et al., 2011; Imel, Laska, Jakupcak, & Simpson, 2013; Schottenbauer et al., 2008). A meta- analysis shows that exposure-based treatment such as TF-CBT has the highest dropout rate (33%) (Bradley, Greene, Russ, Dutra, & Westen, 2005), whereas the average dropout rate is 20% for all PTSD clinical treatments (Imel et al., 2013). The dropout rate for TF- CBT can be as high as 50% in some studies (Cohen et al., 2011; Schottenbauer et al., 2008). This high dropout rate may be caused by the mismatch between high cognitive processing requirements of CBT and deficient cognitive development of children with PTSD (Rodenburg et al., 2009). Literature has shown that young children lack the fully developed, complex cognitive introspection that CBT may require (Rodenburg et al., 2009). Another potential cause of the low retention rate during TF-CBT may be
associated with the key component: trauma exposure (Imel et al., 2013; Hembree et al., 2003).