PTSD: Trauma-Focused CBT
Trauma-Focused Cognitive Behavioural Therapy; helping young people to overcome trauma today.
Recent awareness of psychological and emotional wellbeing has led to rising mental health diagnoses and an increased need for evidence-based treatments. Around 25% of people experience a mental health problem each year in England alone, with one-sixth experiencing a common mental health issue in any given week. Over 26% of young women between the ages of 16-25 report having a common mental health problem in a given week, whilst suicide rates amongst young males continue to rise. Similarly, diagnoses of post-traumatic stress disorder (PTSD) continue to rise with the aforementioned statistics; especially amongst vulnerable young people in the current Covid-19 pandemic. Recent research from Kings College London found that 31% of young people had suffered a traumatic experience during childhood, whilst 8% of young people have had PTSD before the age of 18. Worryingly, many do not receive adequate support, with only a fifth of those diagnosed seeing a mental health professional. Evidently, with diagnoses for PTSD rising amongst young people today, research must continue to develop and deliver effective evidence-based treatments for sufferers.
Cognitive Behavioural Therapy (CBT)
CBT is a widely researched and empirically supported psychotherapy that can assist with the treatment of a variety of mental health disorders. Clinically, it is often a first-line treatment for common disorders such as depression, anxiety disorders, panic disorder and PTSD. CBT is founded on Beck’s cognitive model for treating mental illness. He recognised that our emotions and behaviours are influenced by our thoughts and perceptions of experiences and events. Indeed, this suggests that our feelings and behaviours are determined by how we interpret situations.
In practice, CBT is a directive, structured, and versatile multi-component psychotherapy. The approach explores the connection between thoughts, emotions and behaviours with past and present experiences, to make sense of and better one’s life. It aims to actively improve negative psychological patterns that affect daily functioning and mental health. The therapist implements each CBT component; psychoeducation, affective modulation, cognitive restructuring and reappraisal, SMART goal setting, and desensitisation or exposure techniques, as part of a collaborative strategy to facilitate positive psychological change with the patient. Typically, CBT is time-limited (12-16 sessions on average) and therefore cost-effective, benefiting public health services and educational interventions. Importantly, studies show that Trauma-Focused CBT (TF-CBT) can significantly reduce symptoms of PTSD amongst children, adolescents and young people, making it a first-line early intervention for young sufferers.
Post-Traumatic Stress Disorder
Traumatic experiences are unique. Victims can endure lasting psychological problems, impaired functioning, and increased susceptibility to comorbid disorders, drug abuse and suicide, as well as other physical health complications. Clinically, diagnostic criteria for PTSD are the reexperience of a traumatic event or experience, intrusive associated symptoms, avoidance of associated stimuli, negative alterations to mood and cognition, and marked changes in arousal. In other words, PTSD can manifest as panic attacks, nightmares, flashbacks, extreme arousal to triggers, depression, avoidance, and a loss of one’s sense of self. Whilst symptoms may reduce over time, PTSD is scary for young people, and TF-CBT is recommended for treatment.
Sadly, PTSD can diminish a person’s ability to lead a life of pleasure and meaning. This is because the memory of the trauma dominates consciousness and therefore affects a person’s capacity to cope, biological threat perceptions, and concepts of themselves. Indeed, physiological symptoms can include sweating, increased heart rate and raised blood pressure, whilst chronic neuroendocrine (hormonal) stress can severely affect cortisol levels. Moreover, psychobiological studies suggest that trauma can leave profound changes in neocortical functions that affect self-regulation. Typically, due to shock, confusion, and dissociation, victims focus on survival and self-protection. Often, this results in withdrawal, emotional numbness, depersonalisation, avoidance and sometimes depression. These cyclical maladaptive cognitions and behaviours can cause relationship decline with family and friends, poor social and occupational functioning, all of which negatively impacting mental health and overall wellbeing.
This highlights the importance of treating PTSD in young people who deserve the chance to lead long, fulfilled, and healthy lives. It is crucial that they, the next generation, receive effective therapeutic support to overcome trauma. Indeed, research explains that early intervention treatments can have positive, even transformational effects on young people’s futures, causing them to lead more meaningful lives as a result.
Trauma-Focused Cognitive Behavioural Therapy
Currently, TF-CBT is the most prevalent evidence-based treatment for young people with PTSD. This targeted psychotherapy has been shown to improve patients’ future outcomes, demonstrating its importance as an early intervention for young people’s mental health, development and wellbeing. Moreover, evidence shows its versatility and potential across various care settings with diverse young individuals and their families. Arguably, the evidence for TF-CBT’s treatment outcomes, and its ability to hasten recovery of comorbid depression and behavioural issues, make it a superior practice for use with young people. TF-CBT uses specific components from CBT; psychoeducation, affective modulation and relaxation skills, gradual exposure or desensitisation, and cognitive restructuring. Studies place particular emphasis on the importance of the role of the therapist, the therapeutic alliance, and the use of gradual exposure techniques when treating young PTSD sufferers today.
Exposure Methods in TF-CBT
Modern PTSD studies stress the crucial inclusion of TF-CBT’s gradual exposure and desensitisation techniques for treating child and adolescent sufferers. Exposure methods gradually introduce the patient to tangible reminders of the trauma, typically people and places, or less tangible specific memories of the event. This is used to desensitise and overcome fear responses to stimuli, reexperiences, and avoidances that affect daily functioning and quality of life. Understandably, youths are typically reluctant to reexperience trauma and its associated emotions, which can make implementing exposure work challenging for therapists. Equally, maladaptive behaviours have aided the patient’s survival thus far, which can make instigating changes difficult for therapists. Indeed, young patients who feel pressured by therapists can become anxious and avoidant of exposure work and therapy, highlighting traumatised adolescent’s needs for autonomy and control.
Studies have shown that due to these challenges, exposure strategies are rarely utilised in PTSD treatment in community settings. Confidence implementing exposure methods is deemed critical to the success of completing a narrative with young patients; a rationale to aid the reprocessing of the patient’s trauma. Indeed, research has shown that typically, therapists with PhD’s and positive beliefs around the resiliency of young people tend to use these necessary and successful exposure tools. Therefore, modern psychotherapy training must consider building therapist’s confidence with exposure methods via experiential learning, with the aim of increased delivery of exposure work with young patients. TF-CBT must include exposure work for sustained reduction, and ability to lessen the severity, of symptoms in young people. However, therapists do require a small degree of cooperation from a self-aware patient, for better responses to therapy.
Whilst exposure methods challenge young patients and therapists alike, they remain critical to cognitive restructuring; the reprocessing, consolidation and closure of trauma. The key to exposure work with children and adolescents is that it is introduced gradually and handled with sensitivity by the therapist. This makes TF-CBT developmentally sensitive for young people and their caregivers, reducing distress, and decreasing trauma-related reactions. Meaningful and knowledgeable delivery of difficult TF-CBT techniques has been shown to positively impact children’s perceptions of the process and their progress. These factors contribute to a positive and engaged therapeutic relationship which greatly impacts treatment outcomes.
The Therapist
Of equal importance to exposure and desensitisation work, studies state that young people deem therapist qualities, the relationship, and the collaborative alliance paramount for positive TF-CBT outcomes. The TF-CBT approach requires a directive, active and composed therapist; a professional to help guide young patients through the complex components of TF-CBT that are required to treat PTSD. A primary symptom amongst young PTSD sufferers is avoidance, something a directive therapist must help patients to overcome to benefit from structured therapy. Initially, many young patients experience feelings of anxiety and negative expectations surrounding TF-CBT (often manifested as avoidance), emotions that can be reduced with empathy. Studies state that empathetic and kind therapists typically generate feelings of openness and protection amongst young patients. Indeed, these are qualities that young PTSD patients seek out. With this, confidentiality allows victims to feel trust and honesty, sharing their expectations and disclosing their experiences, whilst re-establishing feelings of support, privately.
Moreover, Dittmann’s study explains that traumatised youths have ‘voiced’ high regard for the importance of ‘therapist qualities’ where feelings of safety, protection and trust were concerned. Recent studies highlight that young people with PTSD find their ‘protective shield fractured,’ and amongst their confusion and loss of sense of self, is a loss of perceived safety. In terms of safeguarding, therapists must ensure that both physical and emotional safety are met for the patient, with support from competent caregivers and their community. Therapists can utilise advocacy as a means to enhance community support for their young patient; communicating with teachers and parents, increasing resources to safety, and building resilience. It is these factors that foster trust and predictability in the therapist-patient relationship which can prevent therapy avoidance and facilitate progress with treatment. This determines the outcome of TF-CBT for young PTSD sufferers.
Alternative Therapies and Future Research
Studies show that children and adolescents regard the qualities and skills of the therapist crucial to successful TF-CBT outcomes. However, due to the complex nature of TF-CBT’s exposure and desensitisation methods where younger, less resilient patients or less confident therapists are concerned, effective, alternative treatments are available.
Some studies state that younger children find exposure work and processing narratives harder than their elders. Similarly, understanding psychoeducational components and concepts can prove challenging for some young people. Creative methods have been shown to assist such sufferers. Art therapy is a promising alternative treatment for trauma; drawing, painting, writing, and play tools can activate oxytocin release to break a patient’s defence barriers. Moreover, sensory engagement is an emotional outlet for inner states and offers a self-soothing mechanism. Similarly, the use of Socratic dialogue, comprehensive activities, and homework tasks can engage children with special learning and developmental needs.
In truth, no one treatment exists for PTSD in youths, however patients have been found to prefer CBT’s, exposure techniques, and psychotherapeutic methods to novel technologies and medication. Eye Movement Desensitisation and Reprocessing (EMDR) has shown positive effects on children experiencing PTSD and has been found to perform as well as trauma-focused cognitive approaches amongst adults. Much like EMDR, Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) have shown similar evidence for trauma treatment amongst adults, although little is known about their effects on children and adolescents. Still, research has limited access to children in therapy and youth samples are small, which is why it is necessary to continue research to improve and increase effective PTSD interventions. Finally, use of pharmacological agents (MDMA) for both adult and young PTSD sufferers remain in infancy, compared to use of non-pharmacological agents like exercise and cognitive training.
Conclusively, it is evident that TF-CBT is the most effective treatment for young people with PTSD, today. The need for a sensitive, empathetic and knowledgeable therapist is paramount for shifting young people’s perceptions of therapy and progress. Formal training for therapists can instigate confidence and creativity with each component of TF-CBT; an approach that can be introduced amongst communities via teaching practices, school programmes and mental health schemes. Moreover, regaining group membership and social identity offers young people belonging and security. These resources can facilitate changes in young people’s self-esteem and confidence, giving them back their sense of self, hope and agency whilst deepening their self-understanding. Indeed, Post-Traumatic Growth is certainly possible. Studies show that PTSD can reinvigorate life, by changing a person’s trajectory; giving life more meaning and satisfaction than before. Valued young people can, and should, thrive in the face of PTSD.
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