Trauma-Focused CBT A-PRACTICE Checklist

Remember: Include Desensitization/Gradual Exposure in Every Component

Assessment and Engagement

Goal:
 Identify history of trauma exposure.
 Assess level of PTS symptoms and/or PTSD dx.
 Determine co-morbidity; especially if trauma behavior problems are caregiver priority.
 Determine context within which trauma is embedded (e.g., neglect, parental
abandonment/rejection, placement).
 Identify other relevant clinical considerations that require immediate response (e.g.,
out of control aggression, severe emotion dysregulation, suicidality, active substance
abuse).
 Establish treatment goals (e.g., reduce PTS, improve behavioral functioning).
 Get buy-in to active treatment from the client/family.
 Problem-solve barriers.

Assessment Methods:
 Conduct clinical interview with child and caregiver.
 Administer formal, standardized measures to child and parent (e.g., UCLA or other
trauma screen, UCLA or CPSS PTSD assessment; GAIN-SS; PSC-17).
 Give feedback to child regarding trauma history; assess capacity to talk about the
trauma(s) and get a sense of child’s cognitive processing of the events (e.g., “why do
you think it happened?”).
 Observe client/family during assessment process (clinical observations).

Engagement Methods:
 Refer to assessment results and symptoms; solicit agreement.
 Identify how treatment progress will be determined (e.g., scores will go down, routines
will be restored).
 Discuss beliefs about therapy and/or prior therapy experiences; allay concerns.
 Elicit concrete barriers and problem solve solutions.
 When ambivalence is a barrier use Motivational Interviewing techniques: (use
reflections; roll with resistance; be nonjudgmental; rate importance and confidence to
change; use decisional balance work sheet).

Psychoeducation
Goals:
 Normalize exposure to trauma: “You’re not alone/not the only one”.
 Explain and normalize PTS symptoms/PTSD and avoidance: “You’re not crazy”.
 Establish social norms regarding child responsibility for trauma and trauma coping:
“It’s not your fault and you did the best you could”.
 Describe TF-CBT (components, structure, and homework expectation): “There’s hope,
we’ve got a treatment that works”.

WA State CBT Plus 2011

  Explain how treatment works (e.g., learn skills to feel better when scared/worried;
learn how thoughts drive feelings and behavior; talking about what happened lowers
the emotions when remembering or being reminded; putting the trauma into
perspective helps put it into the past).

Methods:
 Discussion
 Handouts
 Books
 Games (Charades, What Do You Know? Pretend game show)
 Internet Search, You Tube video
 Worksheets for discussion
 Make a radio show, public service announcement, poster, etc. (something creative)

Parenting (Caregiver)
Goal:
 Improve the relationship (e.g., enhance closeness, warmth and support)
 Teach/reinforce use of skills:
o Support child use of PRAC skills in the home.
o Apply positive parenting (e.g., praise, selective attention/ignoring, instructions,
rewards and consequences).
o Prepare for conjoint TN.
Methods:
 Establish special play time/one-on-one time routine.
 Teach functional behavior analysis; basic principles of behavior management.
 Identify specific concerns and problem behaviors; provide worksheets and handouts.
 Follow model for identified problem behavior: Teach  Model  Discuss  Role Play
 Feedback  Assign Weekly Practice.
 Observe interactions with kids and take opportunity to apply and practice new skills
with in session coaching.

[If the child’s behavior problems are quite significant and the primary concern of the parent,
triage the positive parent focus to the priority; consider meeting with the parent first during
sessions. Be sure to link the behaviors to the trauma when addressing with the parent]

Relaxation
Goal:
 Create awareness of capacity to change from state of tense/distressed state to state of
relaxation.
 Teach specific skills for calming/reducing distress in the moment (e.g., at home,
school, in the community).

Methods:
 Identify and bolster current skills already using (e.g., hobbies, music, sports, etc.).

WA State CBT Plus 2011

  Teach Progressive Muscle Relaxation to illustrate capacity to change body
tension/stress.
 Play relaxation games (wet noodle/tin soldier; toss the ball, shoot baskets).
 Teach yoga, mindfulness, guided imagery.
 Practice controlled breathing (aka Secret Calming).
 Listen to music, mp3s downloads of relaxation activities online.

Affective Modulation
Goal:
 Increase capacity to identify range of feelings, have a feelings vocabulary, and link to
appropriate expression.
 Teach the Cognitive Triangle: Relationship between Thoughts, Feelings, and Behavior
 Learn to rate feelings at different intensities (1-10, small/medium/large burrito;
thermometer).
 Normalize conflicting feelings – normalize multiple simultaneous feelings.
 Identify/learn strategies to improve/calm affect (modulate affect)
 Identify feelings associated with the traumatic event (when it happened, thinking about
it now).

Methods:
 Feelings brainstorm.
 Books about feelings, feelings cards.
 Feelings games (bingo, jenga, pickup sticks).
 Practice rating feelings using some kind of scaling method.
 Feelings pie (1 event, show different feelings and how much of each)
 Develop a list of things to do that help to regulate or tolerate emotions that are causing
distress (can be behavioral, cognitive, support seeking, problem solving, a whole
RANGE of things!)

Cognitive Coping
Goal:
 Teach (or revisit) the CBT Triangle.
 Help the client learn to identify automatic unhelpful or inaccurate thoughts that the
client may not immediately be aware of, but which are causing distress.
 Get buy in to the idea that thoughts drive feelings and thoughts can be changed.
 Generate coping self-statements.

Methods:
 Practice CBT Triangle (identify thoughts, feelings, and behaviors) for non-trauma
related, real life scenarios (lunchroom, birthday, etc.).
 Read books/do handouts that identify/label Thoughts, Feelings, and Behaviors.
 Matching or other Thoughts, Feelings, and Behavior games.
 Identify thoughts and feelings relevant to the client’s trauma-related
memories/experiences.
 Brainstorm coping statement.

WA State CBT Plus 2011

  Identify more helpful or accurate ways to think that will lead to feeling better.

Trauma Narrative [Exposure and Cognitive Processing]

Goal:
 Client is able to “face up” to trauma experiences (e.g., think and talk about the
trauma), especially hotspots or worst moments.
 Identify unhelpful or inaccurate trauma-related cognitions (“it was my fault”; “I shouldn’t
have…”) and altered core views of self (“I’m not a good person”), others (“people
cannot be trusted”), or the world (“nothing is safe”).
 Identify more helpful or more accurate ways to think about traumatic exposure, self,
others, family, the world, and the future.
 Client develops a helpful understanding of what happened that acknowledges the
trauma but does not define the child and contains hope and lessons learned.

Exposure Methods:
 ALMOST ANYTHING THAT ENGAGES THE CLIENT IN THINKING ABOUT THE
TRAUMA: Book with chapters, talking about it, comic strip, collage, drawing/poster,
radio show, song, rap, poem, video, audio recording, puppet show or doll house with
therapist writing down the narrative, etc.
 Use analogies (removing splinter, cleaning skinned knee, beach balls in the pool) to
engage in exposure.
 Rank order traumas or select moments/hotspots to start with, work up to worst time(s).
 Set up rewards, incentives for effort or small steps (try to work with caregivers to make
these natural and/or family related).
 Reward with Fun/Free Time at the end of session.

Cognitive Processing Methods:

 Identify unhelpful/inaccurate thoughts throughout treatment and from the Trauma
Narrative.
 Use Socratic Questioning and thought classifications (accurate vs. inaccurate; helpful
vs. unhelpful; regret vs. responsibility).
 Use specific strategies: Best Friend Role Play, You (client) be the Therapist,
Responsibility Pie, Examine the Evidence, Lists and Definitions, Logical Questioning.

[If child still living with abuser or in dangerous situations, focus less on mastering past
traumas and more on addressing cognitive distortions, teaching to distinguish reminders from
real danger, and sharing the experiences with a supportive caregiver]

In-Vivo Exposure
Goal:
 Separate harmless conditioned fear responses (e.g., trauma reminders or triggers)
from real danger.
 Reduce avoidance that interferes with daily functioning.

Methods:
 Create a fear ladder list (triggers and specifics related to the trigger).

WA State CBT Plus 2011

  In session practice combined with weekly practice at home.
 Get buy-in from caregivers and support people in the client’s environment.
 Use incentives and rewards (in session; at home: Parenting skills of praise, rewards).
 Remind re using coping skills (including cognitive coping) taught in earlier sessions.

Conjoint TN
Goal:
 Provide opportunity for child to: ”face up” and share narrative with key trusted adult(s)
and receive validation, praise, support.
 Allow trusted adult to learn about child’s perspective.
 Promote opportunity for caregiver and child to practice talking about the trauma
(questions, concerns, feedback, etc.).
 Create opportunity (if appropriate) for parent to make amends/acknowledge (e.g.,
failure to be resource, disbelieving/blaming initial response, discounting, etc).

Methods:
 Prepare for conjoint sessions by reading TN to caregiver over repeated sessions.
 Prepare and role play questions, responses, feedback, with the caregiver prior to
session with the child etc.
 Identify helpful coping skills for caregiver, if needed.

Enhancing Safety
[Reminder – move this up if safety is a concern]
Goal:
 Create safety plan to help child (and caregiver) be safer re ongoing dangers (e.g., lives
with DV or physical abuser, in violent neighborhood).
 Teach safety skills for use in risky situations that may arise in the future (e.g., home
alone, kids pressuring, dangerous neighborhoods, dating)
 Develop specific safety plan for self injury or suicidal thoughts (e.g., promises).
 In cases of sexual abuse, provide psychoed regarding normal sexual development to
counter the negative experience of abuse.

Methods:
 Make a formal written, tailored safety plan (e.g., what if…).
 Identify risks/triggers/warning signs of danger (either from self or others).
 Role play skills (e.g., getting away, calling police, refusal), ideally with the caregiver.
 Teach about appropriate boundaries, friendships, etc.

WA State CBT Plus 2011