Trauma-focused CBT

1. Introduction

Version followed: the PRACTICE components model of Cohen, Mannarino and Deblinger, Treating Trauma and Traumatic Grief in Children and Adolescents, 2nd ed. (Guilford, 2017), as operationalised in the developers' own later implementation manuals (TF-CBT LGBTQ Implementation Manual, Cohen, Mannarino, Wilson and Zinny, 2018; TF-CBT for Youth with Parental Substance Use-Related Trauma Implementation Manual, Cohen, Mannarino, Deblinger et al., 2026) and the TF-CBT Brief Practice Checklist (Deblinger, Cohen, Mannarino, Murray and Epstein, 2008). The 2017 book itself is drawn on only for its table of contents; component content below comes from the developer papers and manuals. [source: Guilford contents page; LGBTQ manual 2018; PSA manual 2026; Brief Practice Checklist 2008]

TF-CBT is a structured, components-based treatment for children and adolescents with trauma-related symptoms (PTSD, plus linked depression, anxiety, behaviour problems), delivered to the child and a non-offending caregiver in parallel individual sessions and then joint sessions. Its theory of change: trauma leaves the child with physiological hyperarousal, dysregulated affect, avoidance of reminders and distorted trauma-related beliefs (self-blame, shame, feeling damaged); caregivers' own distress and changed parenting maintain the problems. The child first builds coping skills, then, through gradual exposure built into every component, approaches the memory in a trauma narrative, cognitively processes the distortions it reveals, masters avoided reminders, and shares the story with a prepared, supportive caregiver, who has meanwhile learned to respond to trauma-driven behaviour. Mastery of reminders, corrected beliefs and a strengthened caregiver relationship are what produce change. [source: Cohen & Mannarino 2008, CAMH; PSA manual 2026]

Acronym: PRACTICE = Psychoeducation and Parenting skills, Relaxation, Affective expression and modulation, Cognitive coping, Trauma narrative and processing, In vivo mastery of trauma reminders, Conjoint child-caregiver sessions, Enhancing safety and future development. The 2017 book adds four grief-focused components for childhood traumatic grief. [source: Brief Practice Checklist 2008; Guilford contents page]

2. Framework

Three phases [source: PSA manual 2026; LGBTQ manual 2018]

Session count and proportionality

• Standard PTSD presentation: 8 to 16 sessions, about one-third per phase [source: LGBTQ manual 2018]. The 2026 PSA manual gives 12 to 16 sessions with about 4 to 6 per phase [source: PSA manual 2026]. [uncertain: the two developer manuals differ slightly; both keep roughly equal thirds.]
• Complex trauma presentation: 16 to 25 sessions (LGBTQ manual) or 16 to 24 (PSA manual); stabilisation takes up to half of sessions, narration and integration about a quarter each; Enhancing safety moves to the start and continues throughout. [source: LGBTQ manual 2018; PSA manual 2026]
• Both manuals note that many complex-trauma youth respond to standard TF-CBT with equal proportions (e.g., Sachser et al., 2016, 12 sessions); choose by clinical judgment. [source: LGBTQ manual 2018]
• Not every component needs a full session; the Brief Practice Checklist codes one primary component per session across up to 20 slots. [source: Brief Practice Checklist 2008]

Format

• Individual child session plus parallel caregiver session covering the same component, roughly half the time each; plus about 3 to 6 conjoint sessions, mainly in phase 3. [source: PSA manual 2026; Cohen & Mannarino 2008]
• Caregiver = the non-offending current caregiver (parent, kin, foster parent). A perpetrating parent is not included and is not given trauma details. A caregiver with active substance use joins only if stable, able to listen and support, and acknowledging responsibility. [source: PSA manual 2026]
• TF-CBT can be delivered without a caregiver, and a group application exists (book chapter 16) [source: Guilford contents page]; [uncertain: group procedures].
• Age range and session length were not stated in the sources; TF-CBT is generally described for ages about 3 to 18 [uncertain].
• Certification (tfcbt.org National Therapist Certification Program): eligibility review, then TF-CBTWeb 2.0 online course, a 2-day live or 3-day virtual introductory training, at least 12 consultation calls with an approved national trainer, then a knowledge test. [source: tfcbt.org; PSA manual 2026]

Assessment before starting [source: PSA manual 2026; Cohen & Mannarino 2008]

• Interview child and caregiver separately; use collateral sources (e.g., child welfare caseworker). Ask concretely about each trauma type, including ones families rarely volunteer.
• Standardised PTSD measures named by the developers: CPSS-5, CATS-2 (also screens ICD-11 PTSD and complex PTSD), UCLA PTSD Reaction Index for DSM-5; adolescent substance screen (BSTAD or S2BI). Re-administer after the PRAC skills, and at the end. Low initial scores may reflect avoidance, not low severity.
• Treatment fit: offer TF-CBT only if trauma is a core driver of the problems. If other conditions dominate (primary substance use, primary externalising problems, acute suicidality), treat or refer first (e.g., DBT for acute suicidality; RRFT, MDFT or FFT for adolescent substance use) or choose another model.
• Agree a collaborative treatment plan with explicitly trauma-focused goals, and tell the family most sessions will focus on trauma before starting.

Criteria for moving between phases

• Developer guidance: skill-building precedes the narrative; the skills phase should not be prolonged; each skill should already be practised in relation to the child's trauma reminders (the gradual-exposure task). [source: Cohen & Mannarino 2008; Brief Practice Checklist 2008]
• [synthesis] Move from PRAC to narrative when: the child can name feelings and rate their intensity; has at least two coping skills they have used at home or school; can link thoughts, feelings and behaviours in an everyday example; the caregiver understands the rationale and can support practice; there is no active safety crisis (current abuse, uncontrolled self-harm or suicidality). Move to integration when the narrative covers the whole trauma including worst moments, distress on rereading has fallen, the main distortions have been processed into more accurate beliefs and the caregiver has heard the narrative in individual session and can respond supportively. End when target symptoms on repeat measures have improved, the conjoint sharing is done and a safety and future plan is in place.
• Ongoing crises are handled with skills and safety planning inside the model rather than by abandoning the trauma focus (the PSA manual warns against therapy being derailed by "crises of the week"). [source: PSA manual 2026]

3. Guiding principles

[source: Cohen & Mannarino 2008; PSA manual 2026; LGBTQ manual 2018; Brief Practice Checklist 2008, unless marked]

• Gradual exposure runs through every component. Each skill is practised in relation to the child's own trauma reminders, with intensity rising across sessions. Practical meaning: from session 1, name the trauma, and in each component end with a small step toward reminders.
• Skills before the narrative. Practical meaning: build coping first, but keep the skills phase time-limited so it does not become avoidance.
• Proportionality. Practical meaning: aim for roughly thirds across phases; lengthen stabilisation only for complex trauma or safety needs.
• Therapist models non-avoidance. Practical meaning: use direct, accurate words for what happened ("sexual abuse", "when your dad hit your mum") and for body parts; don't collude with family avoidance.
• Caregiver as partner and co-client. Practical meaning: give every caregiver a parallel session on each component so they can coach skills and respond to reminders at home.
• Non-offending caregiver only; child consents to sharing. Practical meaning: don't involve a perpetrator; share the narrative with a caregiver only with the child's permission.
• Trauma focus is maintained. Practical meaning: weave the week's crisis into the current component instead of dropping the plan.
• Components-based, individualised, culturally fitted. Practical meaning: keep the sequence, tailor activities to age, interests, culture and family context.
• Collaboration and hope. Practical meaning: tell families early that most children recover and that this treatment helps.
• Between-session practice. Practical meaning: assign and review home practice for child and caregiver every session.
• Trauma is the core problem. Practical meaning: confirm fit at assessment; refer or sequence if another problem is primary.
• Safety first when safety is compromised. Practical meaning: with complex trauma, ongoing threat or unsafe behaviour, start with Enhancing safety and keep monitoring it.
• Expect setbacks. Practical meaning: treat recurrence of old unsafe habits over several weeks as predictable, not as failure.
• Respect unsafe behaviour's past function. Practical meaning: acknowledge how a behaviour once protected the child before weighing its current costs.
• Fidelity with tailoring. Practical meaning: deliver all components in order; adapt how, not whether. [source: PSA manual 2026]

4. Intervention inventory

Order follows the PRACTICE sequence. Each skills component has a child part, a parallel caregiver part and a gradual-exposure (GE) task linking it to trauma reminders, as coded in the Brief Practice Checklist. All example language is illustrative unless quoted. [source: Brief Practice Checklist 2008; Cohen & Mannarino 2008]

4.1 Engagement and treatment-fit conversation

• Purpose / when: Session 1 (and before), to engage child and caregiver, agree trauma-focused goals and confirm TF-CBT fits. [source: PSA manual 2026; Teen Workbook]
• Steps: (1) Meet caregiver and child separately; gather trauma history, symptoms, current safety. (2) Ask the young person about goals, interests, strengths and important relationships (teen workbook engagement pages). (3) Give the results of measures in plain language and link symptoms to the trauma. (4) Explain the three phases and that most sessions focus on the trauma; get explicit agreement. (5) If the youth distrusts adults or sees no reason for therapy, use Motivational Interviewing to elicit their own reasons to invest. [source: PSA manual 2026]
• Example language (illustrative): "The checklists you filled in tell me your body is still on alarm about what happened. That's common, and it's very treatable. We'll build skills first, then talk about what happened a little at a time."
• Watch for: Under-reporting (scores may rise once trust grows); a caregiver who will not support the work (the PSA manual advises not proceeding with an unsupportive parent); a problem other than trauma dominating.

4.2 Psychoeducation (child and caregiver)

• Purpose / when: From first contact and throughout; inform, normalise, give the rationale for treatment and instil hope. [source: Cohen & Mannarino 2008; LGBTQ manual 2018]
• Steps: (1) Start early with hope: most children recover. (2) Give general information about the child's trauma type: what it is, how common, why it happens, who is responsible (e.g., prevalence of sexual abuse; for parental substance use: an illness neither the child nor parent caused or can cure, relapse is common). (3) Review common reactions across body, feelings, behaviour, thoughts and relationships, and link each to the child's own symptoms. (4) Explain the brain's alarm response; the developers recommend the "Trauma and the Brain" handout (McLaughlin, 2014) and use neurobiology to explain why daily skill practice matters. (5) Introduce trauma reminders and help the child begin identifying their own. (6) Explain the TF-CBT plan and how it helps. (7) Give legal and victim-assistance information where relevant. (8) Caregiver session: the same content plus common parental reactions; check what the caregiver actually knows about the trauma before assuming. [source: Cohen & Mannarino 2008; LGBTQ manual 2018; PSA manual 2026]
• Activities: Q&A sheets about the trauma type, reaction checklists, a pros-and-cons comparison of avoiding versus facing reminders, educational games and books. [source: Teen Workbook; Cohen & Mannarino 2008]
• GE task: The child uses accurate words for the events and body parts and names their own triggers. [source: Brief Practice Checklist 2008]
• Example language (illustrative): "When something reminds your brain of the abuse, like a smell or a raised voice, it sounds the alarm as if it's happening again. That's a trauma reminder. Let's make a list of yours."
• Watch for: The child being able to name reminders and link them to reactions; caregiver reframing behaviour from "bad" to "trauma-driven". In identity-related trauma, ask rather than assume whether identity links to the trauma. [source: LGBTQ manual 2018]

4.3 Parenting skills: overview

• Purpose / when: Throughout treatment, about half of each session with the caregiver; support the non-offending caregiver, help them recognise and respond to trauma reactions and reminders, and manage behaviour changes after trauma (overprotection, permissiveness, lapsed routines). [source: Cohen & Mannarino 2008; LGBTQ manual 2018]
• Sequence: Trauma psychoeducation first; then relationship-building (specific praise, global affirmations); then selective attention, functional behaviour analysis, behaviour plans and negotiation; time-out and other discipline only after the relationship is strengthened. The caregiver also learns every child skill (relaxation, affect, cognitive coping) to coach it at home and during gradual exposure. [source: PSA manual 2026; LGBTQ manual 2018]
• GE task: Help the caregiver link their own responses and the child's behaviour problems to the trauma, including how their tone or actions may act as reminders. [source: Brief Practice Checklist 2008; PSA manual 2026]
• Watch for: Ambivalence or resistance from caregivers who feel they already know how to parent (acknowledge their expertise and present trauma knowledge as an addition); youth unused to consistent parenting will resist structure at first. Explain that predictability reduces fear and that structure is support, not harshness. [source: PSA manual 2026]

4.4 Praise (specific and global)

• Purpose / when: First parenting skill; increases positive behaviour and repairs the relationship. [source: Cohen & Mannarino 2008; PSA manual 2026]
• Steps: (1) Caregiver lists behaviours they want more of (including using TF-CBT skills and facing reminders). (2) Teach specific, immediate, enthusiastic praise naming the behaviour. (3) Add global affirmations (e.g., saying "I love you"). (4) Role-play in session; set a daily target; review next session. [synthesis on role-play and targets]
• Example language (illustrative, coaching the caregiver): "Instead of 'good job', try 'You used your breathing when the dog barked. That was brave.'"
• Watch for: Praise followed by criticism ("...but why can't you always..."); a caregiver who cannot find anything to praise (spend more time on their own feelings first).

4.5 Selective attention (planned ignoring)

• Purpose / when: Reduce minor attention-seeking or annoying, non-dangerous behaviours. [source: Cohen & Mannarino 2008]
• Steps (paraphrased standard procedure, [synthesis] on detail): (1) Pick target behaviours that are not dangerous. (2) Caregiver withdraws attention while the behaviour continues. (3) Warn that it often worsens briefly before improving. (4) Caregiver praises the opposite behaviour immediately when it appears.
• Example language (illustrative): "When she whines, look away and stay calm; the moment she asks in a normal voice, turn back and praise it."
• Watch for: Never ignore unsafe behaviour or trauma disclosures; distinguish trauma-reminder distress (needs coping support) from attention-seeking.

4.6 Time-out

• Purpose / when: Consequence for aggressive or serious rule-breaking in younger children; introduced only after praise and relationship work. [source: Cohen & Mannarino 2008; PSA manual 2026]
• Steps ([synthesis] standard behavioural procedure): (1) Choose a few target behaviours. (2) Pick a safe, boring, non-frightening spot. (3) Give one calm instruction; brief time-out; no lecture. (4) Afterward, return to normal interaction and praise the next good behaviour.
• Watch for: Time-out in a place resembling the trauma setting (e.g., a closed room for a child confined during abuse) can be a reminder; adapt. Harsh tone or yelling may trigger the child. [source on harsh tone as reminder: PSA manual 2026]

4.7 Contingency reinforcement and behaviour charts

• Purpose / when: Build new behaviours (bedtime routine, school attendance, practising skills) through rewards. [source: Cohen & Mannarino 2008]
• Steps ([synthesis] on details): (1) Define 1 to 3 concrete target behaviours. (2) Agree small, frequent rewards with the child. (3) Track on a chart daily. (4) Review in session; adjust targets as they are met.
• Watch for: Inconsistent follow-through; rewards contingent on not having trauma symptoms (reward coping, not absence of fear).

4.8 Functional behaviour analysis, behaviour plans and negotiation (adolescents)

• Purpose / when: Older youth and unsafe or disruptive behaviour; understand what triggers and maintains it, then agree a plan. [source: LGBTQ manual 2018; PSA manual 2026]
• Steps: (1) With caregiver (and youth), identify antecedents (often trauma reminders) and consequences of the behaviour. (2) Hypothesise its function. (3) Negotiate a plan with consistent, predictable consequences and alternative coping. (4) Where the youth lives across homes, align rules across them, directly or through the caseworker. [source: PSA manual 2026; LGBTQ manual 2018]
• Example language (illustrative): "Let's look at last Tuesday: what happened right before he left the house? What happened after?"
• Watch for: Split loyalties in foster or kinship care; the caregiver should avoid negative comments about the birth family and support contact where appropriate. [source: PSA manual 2026]

4.9 Relaxation toolkit

• Purpose / when: Phase 1; reduce trauma-related physiological arousal and restore a sense of control. [source: Cohen & Mannarino 2008]
• Steps: (1) Explain the body's stress response and how it links to reminders. (2) Teach and practise several options, chosen to fit age and interests: focused (slow, deep) breathing; progressive muscle relaxation; blowing bubbles for young children; yoga, guided meditation or mindfulness for older children; music, art, sport or exercise, soothing self-care, apps, talking to friends, reading. (3) Build a "toolkit" with options for each setting (home, school, playground, friends' homes). (4) Assign practice; the child reports what worked; if a skill failed, adjust and practise again. (5) Caregiver learns the same skills and prompts or praises their use. [source: Cohen & Mannarino 2008; Teen Workbook]
• GE task: Practise skills in response to the child's named reminders (e.g., breathe while you briefly picture the school corridor). [source: Brief Practice Checklist 2008]
• Example language (illustrative): "Let's breathe in slowly while I count to four, and out to six. Rate how tense your shoulders are now, 0 to 10... and after three breaths?"
• Watch for: Body tension or SUDS ratings falling with practice; reports of use outside session. Some children find closed eyes or body focus frightening; keep eyes open or switch to an active skill [synthesis].

4.10 Grounding and mindfulness

• Purpose / when: Phase 1, for teens prone to dissociation, numbness or overwhelming feelings. [source: Teen Workbook]
• Steps: (1) Teach the five-senses grounding sequence (name 5 things seen, 4 touched, 3 heard, 2 smelled, 1 tasted). (2) Offer mindfulness options: mindful breathing, eating, walking, colouring or listening; a "mindfulness jar"; concentration games. (3) Practise in session; check home use next session. [source: Teen Workbook]
• Example language (illustrative): "Your mind just went back there. Let's come back to this room: tell me five things you can see right now."
• Watch for: Speed of return to the present; use during narrative work when distress spikes.

4.11 Feelings identification and expression

• Purpose / when: Phase 1 (Affective expression and modulation, first part); widen emotional vocabulary and recognise feelings safely. [source: Cohen & Mannarino 2008; Teen Workbook]
• Steps: (1) Brainstorm and name as many feelings as possible, with situations that evoke them. (2) For affectively constricted children, play feelings games first to broaden expression. (3) Body mapping: where in the body each feeling is felt (colour it in). (4) Facial-expression activities: act out, mirrors, selfies, magazine collages, guessing feelings. (5) Discuss numbness and safe ways to notice feelings. (6) Caregiver learns to label and validate the child's feelings. [source: Cohen & Mannarino 2008; Teen Workbook]
• Example language (illustrative): "When you get that tight stomach before visits, what feeling might that be? Could more than one feeling be there at once?"
• Watch for: Ability to name mixed feelings, especially about the trauma or the person involved.

4.12 Feelings intensity ratings and self-monitoring

• Purpose / when: Phase 1 onward; give a shared language for intensity used later during the narrative and in vivo work. [source: Teen Workbook; LGBTQ manual 2018]
• Steps: (1) Introduce a 0 to 10 scale (thermometer or volume dial). (2) Practise rating feelings in recent situations. (3) Have the child self-monitor mood, body tension and daily use of coping on a 1 to 10 scale between sessions; adjust the plan from the log. [source: Teen Workbook; LGBTQ manual 2018]
• Watch for: Ratings that are always 0 or 10 (coach finer distinctions); ratings falling after coping use.

4.13 Affect modulation skills

• Purpose / when: Phase 1; manage distressing affect, particularly in response to reminders. Individualised by the child's profile: over-reacting to negative cues, under-responding to positive ones, or lacking social or problem-solving skills. [source: Cohen & Mannarino 2008]
• Steps: (1) Identify which pattern applies. (2) Teach matched skills: problem-solving, social skills, using coping skills to bring intensity down (with the message that feelings pass), and activities that raise positive affect. (3) Practise with role-play of real situations. (4) Caregiver coaches the skills. [source: Cohen & Mannarino 2008; Teen Workbook]
• [uncertain: the 2017 book chapter 9 is understood to also cover positive self-talk, thought interruption and safe-place imagery; details are not given here.]
• GE task: Apply the skills to feelings evoked by reminders. [source: Brief Practice Checklist 2008]
• Example language (illustrative): "When your brother teases you and you feel the rage hit 9, what's one thing from your toolkit that brings it to 6?"
• Watch for: Fewer outbursts or shutdowns at home and school; the child spontaneously choosing a skill.

4.14 Cognitive coping: the cognitive triangle

• Purpose / when: Phase 1; teach that thoughts, feelings and behaviours are linked and thoughts can be changed, giving control over feelings and actions. Practised on everyday, non-trauma situations before trauma content. [source: Cohen & Mannarino 2008; Guilford contents page]
• Steps: (1) Define thoughts, feelings and actions. (2) Use an event-thought-feeling-behaviour chart on everyday examples (e.g., a friend not replying). (3) Generate alternative thoughts and compare the feelings and actions each produces. (4) Introduce unhelpful thinking patterns (e.g., all-or-nothing). (5) Examine the evidence: test whether a thought is accurate and helpful; develop a more balanced alternative. [source: Cohen & Mannarino 2008; Teen Workbook]
• Example language (illustrative): "If you think 'she hates me', how do you feel and what do you do? What if you thought 'her phone's dead'? Which one fits the evidence better?"
• Watch for: Child generating alternatives without help. Do not challenge trauma-related beliefs yet; that is done within narrative processing (premature challenge can feel like the therapist taking the system's side). [source on premature challenge: PSA manual 2026]

4.15 Caregiver cognitive coping

• Purpose / when: Parallel to 4.14; caregivers often hold their own trauma-related distortions (e.g., "I should have known"). [source: Brief Practice Checklist 2008; Cohen & Mannarino 2008]
• Steps: (1) Teach the triangle to the caregiver. (2) Identify the caregiver's upsetting thoughts about the trauma. (3) Check them for accuracy and helpfulness; develop alternatives. (4) Continue as the caregiver hears the narrative.
• Example language (illustrative): "You're telling yourself it was your fault for working nights. What did you know at the time? Who made the choice to abuse?"
• Watch for: Caregiver guilt or anger lessening enough to stay child-focused.

4.16 Preparing for the trauma narrative

• Purpose / when: Start of phase 2; consent, safety and planning for exposure work. [source: Teen Workbook; Cohen & Mannarino 2008]
• Steps: (1) Explain the rationale: telling the story bit by bit makes memories less overwhelming, shows what the child tells themselves about it, and puts the trauma in the context of their whole life. (2) Discuss the child's feelings about starting. (3) Choose a format: written book, poem or song; typing on a computer; dictating to the therapist; or art, dance or song, kept in permanent form for rereading. (4) Plan possible chapters and a title. (5) Make a self-care plan for the expected temporary rise in symptoms, and tell the caregiver to expect it. (6) Agree with the child what will be shared with the caregiver. [source: Cohen & Mannarino 2008; Teen Workbook; LGBTQ manual 2018]
• Contraindications and safety (exposure): Do not start narration during acute suicidality, active ongoing abuse or with no safe living situation; stabilise and refer first (e.g., hospitalisation or DBT for acute suicidality). [source: LGBTQ manual 2018] [synthesis: also defer if severe dissociation or substance intoxication prevents the child staying present in session.]
• Example language (illustrative): "You've built a great toolkit. Now we'll use it to write your story, one piece at a time. You decide the title, and we'll keep checking your 0 to 10."

4.17 Trauma narration

• Purpose / when: Phase 2; gradual exposure to the memories, overcoming avoidance, surfacing distortions in the child's own words. [source: Cohen & Mannarino 2008]
• Steps: (1) Begin with a non-trauma chapter about the child (who they are, life before). (2) Move to the trauma, gradually, across sessions; for multiple traumas, cover the main ones or a theme across them [uncertain: approach for multiple traumas not detailed in the sources]. (3) Prompt for what happened, plus thoughts, feelings and body sensations at each point, not just facts. (4) Include the worst moments, approached gradually as tolerance builds. (5) At the start of each narrative session, reread what has been written so far (a gradual-exposure task), then add the next part. (6) Structure the whole as "before, when, since this happened to me" so the trauma sits within the child's life. (7) Monitor distress ratings and use toolkit skills as needed, but return to the narrative in the same session. (8) Note distorted beliefs as they appear, without challenging them while the account is still being written [uncertain: timing of challenge during versus after narration is not specified in the sources; the book splits narration (ch. 11) from processing (ch. 12)]. [source: Cohen & Mannarino 2008; Brief Practice Checklist 2008; Guilford contents page]
• Example language (illustrative): "You wrote that you heard the door open. What were you thinking right then? What did your body feel like?" / "What was the very hardest moment? We can write just that sentence today."
• Watch for: Distress on rereading falling across sessions (habituation); the account gaining detail and coherence; skipping or glossing over the worst moment (gently return); temporary rise in nightmares or behaviour (expected; coach the caregiver).

4.18 Cognitive processing of the narrative

• Purpose / when: Phase 2, once the narrative is complete or as distortions emerge; correct trauma-related beliefs such as self-blame, shame, feeling damaged, low self-worth, inability to trust, permanent unsafety. [source: Cohen & Mannarino 2008; Teen Workbook]
• Steps: (1) Reread the narrative together and mark thoughts that are inaccurate or unhelpful. (2) Apply the cognitive coping skills from 4.14: evidence for and against, alternative explanations, responsibility. (3) Work through common post-trauma questions: Was it my fault? Am I safe now? Who can I trust? What does this say about me? (4) Write the more accurate, helpful beliefs into the narrative. (5) Close with a final chapter or product summarising what the child has learned, what they would tell another child, and how they see themselves now; some youth create educational material. [source: Cohen & Mannarino 2008; Teen Workbook]
• Example language (illustrative): "You wrote 'I should have stopped him.' You were seven and he was an adult. What could a seven-year-old actually do? What would you say to your little cousin if this happened to her?"
• Watch for: Change in conviction (rate belief 0 to 100 before and after [synthesis]); new beliefs appearing in the child's own words; self-blame shifting to accurate responsibility.

4.19 Caregiver narrative preview and preparation

• Purpose / when: Phase 2 parallel sessions, before any conjoint sharing. [source: Cohen & Mannarino 2008]
• Steps: (1) With the child's permission, share the narrative with the caregiver in individual sessions as it develops. (2) Help the caregiver process their own reactions (shock, guilt, anger, self-blame) using cognitive coping. (3) Coach supportive responses: praise for courage, belief, no blame, no questions that imply fault. (4) Rehearse how they will respond in the joint session. (5) The caregiver may prepare a brief written response; in family rejection cases this may include accepting responsibility for rejecting behaviour. [source: Cohen & Mannarino 2008; Brief Practice Checklist 2008; LGBTQ manual 2018]
• Example language (illustrative, to caregiver): "When she reads this to you, the most powerful things you can say are that you believe her, you're proud of her, and it wasn't her fault."
• Watch for: A caregiver who cannot yet listen without blame or collapse; delay the conjoint session and keep working individually. Don't share details with an unstable or unsupportive caregiver. [source: PSA manual 2026]

4.20 In vivo mastery of trauma reminders

• Purpose / when: Phase 3 (or earlier if avoidance blocks functioning, e.g., school refusal); only for generalised avoidance of cues that are innocuous now. [source: Cohen & Mannarino 2008; Brief Practice Checklist 2008]
• Steps: (1) Confirm the avoided situation is actually safe now (never expose to genuine danger or to the perpetrator). (2) List avoided situations and rate each 0 to 10. (3) Build a graduated hierarchy (e.g., for a child abused in a bathroom: standing at the school bathroom door with a parent, then entering briefly, then using it alone). (4) Agree a plan with child, caregiver and school; practise each step until distress drops, using coping skills. (5) Caregiver and school staff prompt and praise each step. (6) Move up only when the current step is manageable. [source: Cohen & Mannarino 2008; Teen Workbook; graduated steps follow standard exposure principles cited by the developers (Kendall, 1990)]
• Consent and safety: Explain the rationale and get the child's agreement on each step; distress is expected but should not be overwhelming. [synthesis]
• Example language (illustrative): "This week, just walk to the bathroom door with Mrs. Jones, breathe and rate your number. When it's a 3, we'll try going in."
• Watch for: Ratings falling with repetition; return to normal routines; caregivers inadvertently allowing avoidance.

4.21 Conjoint child-caregiver sessions

• Purpose / when: Phase 3 (about 3 to 6 sessions); share the narrative, open family communication about the trauma, and practise skills together. [source: Cohen & Mannarino 2008; PSA manual 2026]
• Steps: (1) Meet briefly with each separately to check readiness. (2) Joint session: the child reads the narrative (or the agreed parts); the therapist moves to the background; the caregiver responds as rehearsed. (3) Structured question exchange: each writes and asks questions they find hard to ask. (4) Joint projects: e.g., a public service announcement about domestic violence; a child asking about healthy sexuality; practising skills together. (5) End with praise and plans for continued open communication. [source: Cohen & Mannarino 2008; Brief Practice Checklist 2008]
• Example language (illustrative): "Sara has worked very hard on her story and wants to share it with you today. Mum, after she reads, tell her what you've been wanting to say."
• Watch for: Caregiver responding with blame, minimising or overwhelming distress (pause, return to individual work); child checking caregiver's face throughout (prepare more). Where the caregiver is rejecting, use brief joint sessions focused on an agreed plan. [source: LGBTQ manual 2018]

4.22 Enhancing safety: individualised safety plan

• Purpose / when: Usually the final component; first and ongoing for complex trauma, ongoing threat or unsafe behaviour. Builds developmentally appropriate safety strategies for daily life and for reminders. [source: LGBTQ manual 2018; PSA manual 2026]
• Steps: (1) With child and caregiver, identify current and likely future threats. (2) Sort people, places, situations and internal states into safe and unsafe. (3) Map the support system: trusted adults and what each can help with. (4) Write a crisis and safety plan: warning signs, coping steps, who to contact. (5) Lethal-means counselling with the caregiver: check for and remove or lock away weapons and other means in the home. (6) Both youth and caregiver role-play the steps to test feasibility; review and revise across sessions. (7) For supervised visits with a separated parent, agree in advance (with the visit supervisor and caseworker) a signal the child can use to get help. [source: Teen Workbook; PSA manual 2026; LGBTQ manual 2018]
• Example language (illustrative): "If you feel unsafe at a visit, what's the signal you and Ms. Lee agreed on? Show me how you'd do it."
• Watch for: Plans that are realistic for both youth and caregiver; caregiver commitment to specific actions even if their values have not changed. [source: LGBTQ manual 2018]

4.23 Safety and future-development skills (menu)

• Purpose / when: Phase 3 (or earlier as needed); skills chosen to fit the trauma type and age, taught individually or conjointly. [source: Cohen & Mannarino 2008; Brief Practice Checklist 2008]
• Options named by the developers: body safety and "no, go, tell" for young children; healthy sexuality and preventing inappropriate sexual behaviour after sexual abuse; developmentally tailored domestic-violence safety plans; bullying safety skills; drug-refusal skills; assertive communication; problem-solving and social skills; sexual health education for older youth. [source: Cohen & Mannarino 2008; Brief Practice Checklist 2008; PSA manual 2026]
• Steps: (1) Pick the relevant skills. (2) Teach briefly, then role-play realistic scenes (not a single demonstration). (3) Rehearse with caregiver present where suitable. (4) Encourage use in non-trauma situations after therapy ends. [source: LGBTQ manual 2018; Cohen & Mannarino 2008]
• Example language (illustrative): "If someone touches you in a way that's not OK, what are the three things you do? Let's practise saying 'no' loudly."
• Watch for: Skills linked to the child's own trauma (GE task); avoid implying the child should have prevented past abuse [synthesis].

4.24 Working with trauma-related unsafe behaviour

• Purpose / when: Any phase, when self-harm, aggression, running away, substance use or risky sex appear. [source: PSA manual 2026; LGBTQ manual 2018]
• Steps: (1) Separate trauma-related unsafe behaviour from behaviour better treated elsewhere. (2) Functional analysis with youth and caregiver: antecedents (often reminders) and consequences. (3) Acknowledge how the behaviour once protected or helped the youth (e.g., securing food, caring for siblings, numbing pain). (4) Weigh current pros and cons; the original threat may be gone. (5) Link the triggering reminders to the past trauma and current reactions. (6) Teach, role-play and practise replacement PRAC skills tailored to those reminders, building on skills the youth already enjoys (music, sport). (7) Self-monitor daily and adjust. (8) Caregiver reduces avoidable reminders at home (e.g., harsh tone) while holding reasonable expectations. [source: PSA manual 2026; LGBTQ manual 2018]
• Example language (illustrative): "Cutting made sense back then; it stopped the pain fast. What does it cost you now? What else could bring the pain down when the reminder hits?"
• Watch for: Old habits returning for several weeks is expected. Escalating suicidality requires standard risk assessment and may require hospitalisation or a suicide-focused treatment before continuing. [source: PSA manual 2026; LGBTQ manual 2018]

4.25 Treatment review and closure

• Purpose / when: Final 1 to 2 sessions; consolidate gains and end well. [source: Teen Workbook; Guilford contents page]
• Steps: (1) Re-administer the baseline measures and review progress with the family. (2) Review what was most and least helpful and the key lesson learned. (3) Optional anonymous letter of advice to other young people, which may be shared with future clients. (4) Set goals for 1, 5 and 10 years. (5) Mark the ending: written or creative goodbye, congratulations, often a celebration or certificate [uncertain: celebration format not specified in the sources]. (6) Plan with the caregiver for future reminders (anniversaries, court dates, developmental stages). [synthesis for step 6] [source: Teen Workbook; PSA manual 2026]
• Example language (illustrative): "If another teen were just starting what you started in March, what would you want them to know?"

4.26 Grief-focused components (childhood traumatic grief)

• Purpose / when: When a child's grief is complicated by traumatic circumstances of a death, so trauma symptoms block normal grieving. Delivered after the trauma-focused components in the 2017 version. [source: Guilford contents page]
• Components (titles from the 2017 book): (1) Grief psychoeducation; (2) Grieving the loss and addressing ambivalent feelings ("What I miss and what I don't miss"); (3) Preserving positive memories; (4) Redefining the relationship and committing to present relationships. [source: Guilford contents page]
• Related guidance from the sources: encourage caregivers to tell the child the true cause of death in age-appropriate, destigmatising terms (e.g., addiction as an illness like heart disease); address the child's fears of future loss and who would care for them. [source: PSA manual 2026]
• [uncertain: the step-by-step procedures for these four components (book chapters 17 to 20; tfcbt.org grief page) are not drawn on. Do not deliver them from this guide alone; consult the book or the tfcbt.org grief resources.]

5. Handling problems

Child avoidance of trauma talk or the narrative

• Distinguish PTSD avoidance from ordinary reluctance, depressive irritability or other difficulties. [source: Cohen & Mannarino 2008]
• Keep gradual exposure going in every session so the narrative is not a sudden jump: name the trauma, use accurate words, link each skill to reminders. [source: Brief Practice Checklist 2008]
• [synthesis] Offer more control: alternative formats (drawing, dictating, typing, song), shorter bursts with a pre-agreed break skill, contingent rewards for narrative work, the caregiver praising courage. Avoid letting skills sessions extend indefinitely; set a start date for the narrative.

Distress or overwhelm during narration (the main known risk)

• Expect temporary increases in symptoms; prepare child and caregiver in advance with a self-care plan. [source: Teen Workbook]
• [synthesis] In session: pause, rate distress, use grounding or breathing, then return to the same point rather than ending on peak distress; slow the pace (one sentence on the worst moment). If dissociation is frequent, increase grounding and consider extending stabilisation per the complex-trauma proportions. If symptoms escalate to self-harm or suicidality, do a standard risk assessment, update the safety plan and pause narration.

Crises of the week and ongoing chaos

• Address behaviour through current-component skills and parenting strategies; do not abandon the trauma focus. [source: PSA manual 2026]
• For complex trauma, start with Enhancing safety and extend stabilisation to up to half the sessions. [source: LGBTQ manual 2018; PSA manual 2026]

Unsafe behaviour, suicidality, substance use

• Use the functional approach in 4.24; expect recurrence for several weeks. [source: PSA manual 2026]
• Acute suicidality: hospitalisation or a suicide-focused treatment (e.g., DBT) before trauma work. [source: LGBTQ manual 2018]
• Primary substance problem: refer to a model such as RRFT, MDFT or FFT; otherwise treat use as a trauma response within safety work. [source: PSA manual 2026]

Caregiver problems

• Overwhelmed or guilty caregiver: early hope-focused psychoeducation; individual sessions to process feelings and self-blame before conjoint work. [source: Cohen & Mannarino 2008]
• Caregiver who believes they need no parenting help: acknowledge experience, present trauma knowledge as an addition. [source: PSA manual 2026]
• Rejecting or ambivalent caregiver: assume fear or concern drives it; validate the motive without endorsing the behaviour; give psychoeducation on effects of rejection; ask for small, concrete supportive steps; protect the youth from rejecting comments in session. [source: LGBTQ manual 2018]
• Unsupportive, unstable or offending parent: no trauma details shared; offending parent excluded; if no supportive caregiver is available, the developers advise against proceeding with that parent [source: PSA manual 2026]. [synthesis: proceed child-only or with another supportive adult (kin, foster carer) where possible.]
• Split loyalties (foster or kinship care): support birth-family contact within agency limits; caregiver avoids negative comments about the birth family; align rules across homes. [source: PSA manual 2026]

Non-adherence to home practice [synthesis]

• Shrink the task to one skill once a day tied to an existing routine; use a chart and praise; review practice first thing each session; ask what got in the way and problem-solve with the caregiver. If attendance is the problem, address practical barriers and revisit the treatment agreement.

Ruptures in the therapeutic relationship [synthesis, unless marked]

• Youth who distrust adults: Motivational Interviewing to find their own reasons for investing in therapy. [source: PSA manual 2026]
• Avoid challenging the youth's trauma-related beliefs prematurely; it can make the youth see the therapist as aligned with the system. [source: PSA manual 2026]
• When a youth feels pushed by narrative work: name it, acknowledge the courage asked of them, restore choice over pace and format, and repair before continuing.

Modality-specific difficulties

• Low scores at intake despite clear history: likely avoidance; re-measure after PRAC. [source: PSA manual 2026]
• Multiple traumas: [uncertain: the sources do not specify how to sequence; synthesis: choose the trauma driving most current symptoms or build the narrative around a life-story timeline.]
• Child does not want caregiver to hear the narrative or learn about identity-related trauma: do not share without permission; work on general supportive parenting instead; explore fears and benefits of disclosure and let the youth decide. [source: LGBTQ manual 2018]
• Caregiver may not know the full trauma history (e.g., extent of parental substance use): assess what they know and educate before expecting appropriate responses. [source: PSA manual 2026]
• Forensic or custody pressures: keep therapy separate from forensic or custody roles. [source: PSA manual 2026]
• Comorbid conditions dominating: treat them first, in parallel, or choose another evidence-based model. [source: Cohen & Mannarino 2008]

Sources

Sources

• TF-CBT National Therapist Certification Program
• TF-CBT for Youth with Parental Substance Use-Related Trauma: Implementation Manual (Cohen, Mannarino, Deblinger et al., 2026) [uncertain: only the early chapters are drawn on (assessment, safety, psychoeducation, parenting); later chapters are not drawn on]
• TF-CBT LGBTQ Implementation Manual (Cohen, Mannarino, Wilson & Zinny, 2018) [early chapters only, as above]
• TF-CBT Brief Practice Checklist (Deblinger, Cohen, Mannarino, Murray & Epstein, 2008)
• Cohen & Mannarino (2008). Trauma-focused cognitive behavioural therapy for children and parents. Child and Adolescent Mental Health, 13(4), 158-162
• Treating Trauma and Traumatic Grief in Children and Adolescents, 2nd ed.: table of contents (Guilford)
• Dealing with Trauma: A TF-CBT Workbook for Teens (Hendricks, Kliethermes, Cohen, Mannarino & Deblinger)

Books and papers cited (not drawn on in full)

• Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2017). Treating Trauma and Traumatic Grief in Children and Adolescents (2nd ed.). Guilford Press. (Primary manual; only contents page drawn on.)
• Cohen, J. A., & Mannarino, A. P. (2019). Strategies for traumatic separation, cited in the PSA manual (not drawn on).
• Cohen, J. A., Berliner, L., & Mannarino, A. P. (2010). Functional behaviour analysis for trauma-related unsafe behaviour, cited in the LGBTQ manual (not drawn on).
• Sachser, C., et al. (2016). Complex PTSD response to standard TF-CBT, cited in the LGBTQ manual (not drawn on).
• Kendall, P. C. (1990). Graduated exposure principles, cited by Cohen & Mannarino (2008) (not drawn on).
• McLaughlin (2014). Trauma and the Brain handout, recommended in the LGBTQ and PSA manuals (not drawn on).