In a recent study of young people in England and Wales, it was found that as many as nearly one in three young people had experienced a traumatic event, with one out of four going onto develop PTSD by 18 years old (Lewis et al, 2019). Unfortunately, few of the affected young people were able to access treatment. This study also found that following exposure to trauma, young people are at greater risk of developing other conditions such as depression, conduct disorder and alcohol dependence, to an even greater extent than PTSD. In fact, Lewis et al (2019) found that affected young people face double the risk of developing these conditions compared to young people who had not experienced a traumatic event. This latest study adds to previous research by Hillier et al (2016) and Alisic et al (2014) with findings that between 21% and 12% of young people who experienced a traumatic event, had PTSD at up to 6 months after a traumatic event. Many young people may will recover spontaneously and the rates of PTSD tend to decrease in the period following the trauma. However, after six months, recovery without treatment is less likely. This makes the case for effective treatments that can help young people affected by trauma overcome their problems, rebuild their lives and achieve their potential.
There are different approaches to psychological treatment of trauma and PTSD in young people which can really make a difference to young people’s lives, transforming them for the better. These range from mainly Trauma Focused Cognitive Behavioural Therapy (TF-CBT), Prolonged Exposure (PE), Cognitive Therapy for PTSD (CT for PTSD), to Narrative Exposure Therapy (Kid-NET) and Eye Movement Desensitization & Reprocessing (EMDR) Therapy which have been proven to be particularly effective. The difference between trauma and PTSD has been covered in a previous article(https://www.successintherapy.co.uk/trauma-and-post-traumatic-stress-disorder-ptsd/).
This article focuses on TF-CBT, with an emphasis on treatment of a single traumatic event rather than multiple events or developmental trauma which may require versatile adaptations and/or a different approach. This is an evidence-based approach that is recommended by National Institute for Clinical Health and Excellence (NICE, 2018). Although initially focused on treating adults, increasing evidence has proven it as being effective and efficient in treating children and young people (Smith et al, 2019). TF-CBT helps young people address unhelpful patterns of their thoughts (cognitions) and what they do in (behaviours) as well as how they feel in their bodily and emotional responses following a traumatic event. Although in some countries, medication may be recommended, within the UK, NICE (2018) advise against this as a form of treatment or prevention of PTSD in children and young people aged under 18 years.
There are different aspects that are covered within TF-CBT. At the start of therapy with the first meeting, the therapist strives to help the young person feel at ease and address any questions they may have before getting into their story. As in any therapy approach, building a therapeutic relationship with the young person is a key first step, as well as an important and necessary ingredient to successful therapy outcome. Often, people may find it difficult to talk about what has happened to them and how they are feeling. This can be due to a variety of reasons including feeling ashamed, fear of being judged, not able to make sense of why it happened to them which can lead them to think it was their fault, and also it may be their very first time in therapy and they are unsure what to expect. It helps to have a mixture of a warm, friendly but also structured manner which helps for the young person to feel more comfortable and also confident that the meeting has a purpose and will lead to something positive. Although it is difficult to talk about upsetting traumatic experiences, the first meeting sets the tone for a good assessment of the young person’s problems as an incomplete assessment is unhelpful towards the young person getting better (Smith et al, 2019). This is also a good time for building hope in the young person without making unrealistic promises. Setting goals which are specific, measurable, achievable, realistic and timely (smart) can be helpful for guiding therapy. I refer to these as the satnav in therapy to track progress and identify where more emphasis may need to be placed. At the end of therapy, both therapist and the young person can evaluate and review initial ratings which can help to boost confidence. Another useful tool is the use of certain questionnaires which can facilitate identifying the severity and extent of problems.
A helpful way of understanding why some people but not everyone develops PTSD following a traumatic event is the model based on CBT suggested by Ehlers and Clark (2000). In this explanation, it can be seen that some people may develop PTSD due to dealing with the traumatic event in a way that means that the sense of still being in danger is kept going. Once the sense of being in danger again is brought on by reminders of the traumatic event, then the person may feel as if they are back at that time, have flashbacks, unwanted thoughts which just come into the mind, and memories about the past, and intense feelings such as anger, shame, sadness, tension, butterflies, raised heart beat and increased breathing. activated manner in which the danger is symptoms persist. Furthermore, the person may feel bad about themselves for example that they are worthless, it was their fault and they deserved it.
Ehlers and Clark also explain that traumatic memories are different from normal memories (which can be pleasant or unpleasant) in that they are stored and recalled differently in the brain so that the person finds it difficult to tell the difference between the past and the present when experiencing PTSD symptoms. Additionally, traumatic memories are seen as different in not being accessible to new information and updates unlike normal memories. For example a person may have survived a road traffic accident two year ago, in which they were hit by a car but when they remember bits about what happened, their mind may seem still stuck on that they should have died and they also feel like there are in imminent danger whenever they hear a car speeding away on the street. Therefore even though on one hand logically they know they are alive, on the other hand, emotionally they still feel still in danger and the traumatic memory is not updated with the new information that they are safe and not in immediate danger, and the car speeding away is not the same car that hit them.
Helping the young person develop an understanding about trauma is another useful step. The young person as well as other family members/significant others may be involved in discussing possible explanations for what reactions they are experiencing due to the trauma. An explanation will typically include finding out about how the brain works when a traumatic event occurs, how the body reacts at the time and afterwards. This can help people to understand that what happened to them is a normal reaction due to the way the brain and the body work together. In CBT, diagrams are typically used to illustrate the various factors maintaining the problems as a psychological explanation or formulation. In sessions, I will usually do this together with the young person on a whiteboard and include symbolic objects that creatively add to the visual illustration.
Other aspects of treatment include helping the young person rebuild their life and resume activities that they used to enjoy previously rather than avoid them. It is also helpful for the young person to have an understanding about feelings and breaking these down to emotions and physical sensations in order to be able to cope with them. In this phase t is helpful for the young person to be able to understand what the different sensations. Part of the treatment involves facing up to the memory of what happened in a safe and sensitive way in order to understand where the mind is ‘stuck’, what the worst parts are and how the young person’s view of themselves may have changed. This is called memory work and can be done in several ways such as telling it in person, writing it down or a combination of using symbols and storytelling. An important part of the memory work is adding new information to the original memory so that it is updated with current and realistic information.
Unhelpful thoughts and beliefs are also specifically addressed so that the young person can look at situations differently from more helpful points of view, and cope better in situations. Towards the end of therapy, a plan to maintain wellbeing and to manage situations in the future is developed with the young person. This helps the young person to feel more confident about having had therapy and now having useful skills and techniques to deal with challenging situations beyond the therapy. It also helps them to deal with setbacks as they become more resilient and bounce back from these and succeed in their lives.
TF-CBT is an approach that I frequently use when helping young people and adults in my practice often with remarkable results. I have seen how effective it can be in transforming young people’s lives so that they feel happier and enjoy life more, and more able to pursue their goals and lead meaningful lives, and this also impacts on others around them who notice positive changes.
Alisic E, Zalta AK, Van Wesel F, Larsen SE, Hafstad GS, Hassanpour K, Smid GE (2014) Rates of post‐traumatic stress disorder in trauma‐exposed children and adolescents: Meta‐analysis. The British Journal of Psychiatry, 204, 335– 340.
Ehlers A, Clark D M (2000) A cognitive model of persistent posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319-345.
Hiller RM, Meiser‐Stedman R, Fearon P, Lobo S, McKinnon A, Fraser A, Halligan SL (2016) Research Review: Changes in the prevalence and symptom severity of child posttraumatic stress disorder in the year following trauma – A meta‐analytic study. Journal of Child Psychology and Psychiatry, 57, 884– 898.
Lewis SJ, Arseneault L, Caspi A, Fisher HL, Matthews T, Moffitt TE, Odgers CL, Stahl D, Teng JY, Danese A (2019) The epidemiology of trauma and post-traumatic stress disorder in a representative cohort of young people in England and Wales. The Lancet Psychiatry, 6(3), 247-256.
National Institute of Clinical Health and Excellence (2018) Post-traumatic stress disorder. NICE guideline [NG116]: Psychological interventions for the prevention and treatment of PTSD in children and young people. London: NICE.
Smith P, Dalgleish T, Meiser‐Stedman R (2019) Practitioner Review: Posttraumatic stress disorder and its treatment in children and adolescents. Journal of Child Psychology and Psychiatry. 60, 500-515.