Group trauma-focused CBT

1. Introduction

Version followed: two published group forms of trauma-focused CBT for children and adolescents. (a) The school form is CBITS, Cognitive Behavioral Intervention for Trauma in Schools, 2nd edition (Jaycox, Langley & Hoover, RAND, 2018). It was read in the authorised German translation by Universitätsklinikum Ulm, plus programme profiles. (b) The clinic and community form is group TF-CBT: the Cohen, Mannarino & Deblinger PRACTICE components delivered in parallel child and caregiver groups, with individual sessions for the trauma narrative and conjoint sessions at the end. The session plan here follows Dorsey and colleagues' Tanzania/Kenya protocol (NCT01822366) and the description by Deblinger, Pollio & Dorsey (2016). Where the two forms differ, each is labelled CBITS or Group TF-CBT.

"Group trauma-focused CBT" is a delivery format and family of manualised programmes, not one branded therapy. Adult group trauma-focused CBT protocols (for example group Cognitive Processing Therapy) are not covered here. [source: EPIS FAQ; RAND TL-272 page; NCT01822366]

What it is. It is a time-limited, skills-first CBT programme for children and adolescents with PTSD symptoms after trauma, sometimes with depression or grief as well. It is delivered to small groups of peers and, in the TF-CBT form, to their caregivers in parallel. The skill-building components run in group. Detailed trauma-memory work happens in individual sessions or in structured, limited form in group. [source: EPIS FAQ; ACF Clearinghouse CBITS; NCT01822366]

Core idea of change.

• Thoughts, feelings and actions influence one another (the CBITS "triangle"), so a child can change how they feel by changing thoughts and actions. [source: CBITS-DE manual]
• Fear falls through habituation: staying with a safe trigger or memory until anxiety drops. Avoidance is replaced by safe approach, and the trauma is processed by talking, writing and drawing about it. [source: CBITS-DE manual]
• Gradual exposure runs through every component. [source: Cohen & Mannarino 2008]
• The group adds normalisation and peer support, which may reduce shame, isolation and stigma. Caregiver involvement strengthens the caregiver as a source of support. [source: Deblinger, Pollio & Dorsey 2016 abstract; Cohen & Mannarino 2008]

2. Framework

Entry: screening and selection (both forms)

• CBITS. Screen about 3–6 months after the event, because many reactions settle without help. The Hoover slides say at least several weeks. [source: CBITS-DE; Hoover slides]
  • Confirm exposure to a significant traumatic event with a checklist, then apply a validated cut-off on a PTSD symptom measure.
  • Follow with a short clinical interview to confirm the answers and the student's interest. Then obtain caregiver consent and student assent.
  • Do not ask directly about abuse or domestic violence on school screening forms, because such disclosures trigger reporting duties. [source: CBITS-DE]
  • One published trial (6th graders) screened with a trauma-event inventory plus a PTSD-symptom subscale cut-off. [source: Blueprints 2016 presentation]
• CBITS exclusions:
  • students in crisis or needing immediate intensive treatment;
  • students whose severe behaviour problems prevent group participation;
  • students with marked cognitive limitation (reading below about 4th-grade level). [source: CBITS-DE]
• Group TF-CBT. A full trauma-focused assessment comes first. TF-CBT is "not optimal" for children whose main problems are not trauma-related. Where a comorbid problem takes precedence, treat it alongside or stabilise it first. [source: Cohen & Mannarino 2008]
  • The East African trial included children aged 7–13 whose parent had died at least 6 months earlier, above a grief or PTS cut-off. It excluded children with known developmental or cognitive disability. [source: NCT01822366]
• Composition.
  • CBITS: 6–8 students of similar age, balanced for gender, age and culture, with no bully–victim pairings. Grades 4–12; the manual was originally designed for ages 11–15. [source: CBITS-DE; ACF Clearinghouse]
  • Group TF-CBT trial: 8 child–caregiver dyads per group. Local focus groups recommended single-gender groups and separate age bands. [source: NCT01822366]
  • Mixed-gender groups are a poor place for sexual-abuse detail, which belongs in individual sessions. [source: CBITS-DE]

CBITS course (10 group + 1–3 individual + 2 caregiver + optional teacher session; about 10–12 weeks)

[source: CBITS-DE agendas; ACF Clearinghouse; Blueprints 2016]

• Format: weekly sessions of one class period (about 45 min). The two caregiver sessions last about 45 min, ideally in the evening with food. [source: CBITS-DE; ACF]
• Timing of individual sessions [uncertain]: the ACF profile places them between group sessions 2 and 5. The Hoover slides show the individual session after session 5 and before sessions 6–7. Either way, every student has one before the group exposure sessions. Up to two more are added according to symptoms and progress. [source: ACF; Hoover slides]

Group TF-CBT course (Dorsey et al. protocol: 12 weekly 90-min groups + 3 individual 60-min sessions)

[source: NCT01822366]

• Staffing: two facilitators for the child group and one for the caregiver group. [source: NCT01822366]
• Other formats: Deblinger's earlier groups for young children aged 2–8 and their non-offending mothers ran child and mother groups and used role-plays, with parents involved in teaching body-safety skills. The session count and length are [uncertain]. [source: Deblinger et al. 2001 abstract]

Criteria for moving between phases

• Skills before trauma processing. This is the published sequence in both forms. [source: Cohen & Mannarino 2008; CBITS-DE]
• Readiness for narrative work [synthesis]: the child can name feelings and rate them on the thermometer, and can bring their own rating down with at least one coping skill. In addition:
  • no active suicidal crisis;
  • the current environment is safe enough;
  • the caregiver (TF-CBT) supports the work.
• Ongoing danger. With chronic or ongoing trauma such as current domestic violence, establish safety first, then reassess. If a new trauma occurs during the course, decide case by case whether to continue or pause. [source: CBITS-DE]
• Several traumas. Focus the narrative on the most distressing trauma, which may change. If the child says they are all equally bad, ask which was worst when it happened. [source: CBITS-DE]
• Conjoint sharing (TF-CBT). The narrative is shared with the caregiver only with the child's permission, and only after the caregiver has heard it in their own sessions and can respond supportively. [source: Cohen & Mannarino 2008]

3. Guiding principles

• Skills first, trauma work second. Do not start the narrative until coping tools are in place. [source: Cohen & Mannarino 2008; CBITS-DE]
• Gradual exposure throughout. Every component approaches trauma content a little more, from naming the event in one sentence to the full narrative. Pace the steps; do not avoid. [source: Cohen & Mannarino 2008]
• Habituation. Stay with a safe trigger or memory until the distress rating falls before stopping. [source: CBITS-DE]
• Approach replaces avoidance, but only towards things that are actually safe. Never build exposure to a genuinely dangerous person or place. [source: CBITS-DE; Hoover slides]
• Thoughts, feelings and actions are linked. Every skill is taught through the triangle, so children see where to intervene. [source: CBITS-DE]
• Limit disclosure in group. Trauma detail goes in individual sessions. Early group sharing is one sentence, and narrative work in group is kept free of detail that could trigger others. [source: CBITS-DE; NCT01822366]
• Never force sharing. Normalise hesitation, and offer to speak for the child. [source: CBITS-DE]
• Confidentiality with clear limits. Members may say they attend but not repeat what others said. State reporting duties up front. [source: CBITS-DE]
• Concrete rules and reinforcement. Behaviour-specific rules made with the group and posted each week, with points or a shared treat. [source: CBITS-DE]
• Predictable, engaging sessions. Post the agenda, keep the same structure each week, and make it fun. [source: Blueprints 2016]
• Caregivers are partners. Caregivers learn the same skills and are coached to support practice and, in TF-CBT, to hear the narrative. [source: Cohen & Mannarino 2008; NCT01822366; ACF]
• Challenge only unhelpful thoughts. Do not dispute thoughts that are accurate and adaptive, such as a judgement that a situation is unsafe; problem-solve those instead. Do not swap in unrealistically positive thoughts. [source: Blueprints 2016]
• Practise between sessions. Each skill is practised at home and in other settings, then reviewed. [source: Cohen & Mannarino 2008; CBITS-DE]
• Cultural fit. Adapt examples, analogies and sayings to the group's culture. [source: CBITS-DE; NCT01822366]
• Hopeful but realistic tone. Affirm achievable goals and gently redirect unrealistic ones. [source: CBITS-DE]
• Facilitator stance. Be consistent and predictable, be careful with touch, watch for your own anger, and avoid re-enacting cycles of mistreatment. Keep a self-care plan. [source: CBITS-DE; Blueprints 2016]
• Treat the narrative as the child's experience. It is processed, not investigated. Never use suggestion or leading questions to "find" memories; forensic questioning belongs to investigators. [synthesis]

4. Intervention inventory

The sections follow the order of a CBITS course, then add the group TF-CBT components that CBITS lacks or does differently.

Procedure detail was read in the CBITS German manual only for sessions 1–2. For sessions 3–10, the individual sessions and the caregiver sessions, the manual's agendas and the programme profiles were read, but not the step-by-step text. Steps for those parts are marked [uncertain] where the source gave only the component name, and [synthesis] where the steps are my own.

All example language is illustrative.

4.1 Group launch: schedule, confidentiality and rules (CBITS session 1)

• Purpose: Make the group safe and predictable, and set expectations for attendance and homework. Use this at session 1, and restate the rules whenever they are broken. [source: CBITS-DE]
• Steps:
  1. Hand out the printed schedule. Explain that each session builds on the last, so being on time, attending and doing homework matter.
  2. Discuss why privacy matters, and let members give their own reasons.
  3. Agree the confidentiality rule: you may say you attend, but not what others said.
  4. Test understanding with concrete scenarios, for example whether it is fine to repeat a classmate's story in the corridor. An optional signed agreement may be used.
  5. Draft a short list of concrete rules with the group, such as one speaker at a time and no phones. Turn vague rules like "be respectful" into specific behaviours.
  6. Post the rules every session.
  7. Set up reinforcement: points for younger groups, a shared treat for older ones. [source: CBITS-DE]
  8. State your own limits of confidentiality: risk to self, risk from others, abuse. [synthesis]
• Example language: "What's said here stays here. You can tell people you come to this group, but other people's stories aren't ours to share. One exception: if I'm worried someone is unsafe, I have to tell someone who can help, and I'll tell you first." (illustrative)
• Watch for: Rules that stay vague. Members testing confidentiality with gossip. When it is working, members remind each other of the rules.

4.2 Colour-candy icebreaker (CBITS session 1)

• Purpose: Build early cohesion with low-risk self-disclosure. [source: CBITS-DE]
• Steps:
  1. Each member takes a small handful of coloured sweets and may eat each one only after answering the question linked to its colour.
  2. The leader answers first.
  3. Questions come from prepared cards. They are personal but not intimate, such as a favourite food or something you are good at.
  4. Do not ask follow-up questions that open up deeper disclosure. Keep everyone involved, and point out what members have in common and how they differ. [source: CBITS-DE]
  5. Check food allergies and dietary or religious restrictions first, and offer a non-food alternative. [synthesis]
• Watch for: A member steering into trauma content too early. If so, acknowledge it briefly and say there will be a place for that later.

4.3 Explaining the programme with the triangle (CBITS session 1; also in TF-CBT cognitive coping)

• Purpose: Give the rationale that thoughts, feelings and actions affect each other after a stressful event, and show the three aims: feel (relaxation), think (cognitive skills) and do (approach rather than avoid). [source: CBITS-DE]
• Steps:
  1. Draw the triangle with "stress or trauma" as the trigger.
  2. Brainstorm kinds of stressors with the group.
  3. Work through a relatable example, such as a young person scared to ride in a car after a crash. Show how a frightening thought raises fear, fear leads to avoiding cars, and avoiding cars keeps the thought alive.
  4. Name the three aims of the programme. [source: CBITS-DE]
• Example language: "After the crash, Sam thinks 'cars aren't safe', feels scared, and refuses to get in a car. Avoiding cars makes the fear stick around. In this group we work on all three corners." (illustrative)
• Watch for: Members who can map an example of their own onto the triangle. That shows the rationale has landed.

4.4 One-sentence naming of why you are here (CBITS session 1)

• Purpose: Begin gradual exposure and show members they are not alone, without detail. [source: CBITS-DE]
• Steps:
  1. Model with a fictional character's stressor and walk through their triangle.
  2. Invite each member to say in one sentence what happened. Members who hesitate may let the facilitator say it for them, based on the screening interview.
  3. Stop elaboration kindly.
  4. Summarise what the group shares, for example "several of you have lost someone; several saw violence". [source: CBITS-DE]
  5. Note each student's main trauma for later sessions. [source: CBITS-DE]
• Example language: "Just one sentence today, like 'I saw a shooting near my house.' If you'd like, I can say it for you." (illustrative)
• Watch for: Flooding, and detailed or graphic accounts. Interrupt gently and redirect to the individual session. A student who names a different trauma than at screening should be followed up privately to find the most distressing one. [source: CBITS-DE]

4.5 Goals worksheet (CBITS homework 1)

• Purpose: Set personal targets (feelings and behaviours to change) and bring the caregiver in early. [source: CBITS-DE]
• Steps:
  1. Introduce the goals sheet and start it in session if there is time.
  2. The caregiver completes a section at home.
  3. In session 2, volunteers share their goals. Affirm achievable goals, reshape unrealistic ones into realistic, hopeful ones, and normalise families who did not complete the sheet. [source: CBITS-DE]
• Watch for: Goals that are about other people's behaviour. Reframe them to what the student controls. [synthesis]

4.6 Psychoeducation on common reactions (CBITS session 2; TF-CBT "P")

• Purpose: Reduce stigma, link symptoms to the trauma, and build peer support and caregiver–child communication. [source: CBITS-DE; Cohen & Mannarino 2008]
• Steps (CBITS):
  1. Write the common reactions on the board: nightmares and sleep trouble, intrusive thoughts, avoidance, poor concentration, being on guard, and startle.
  2. Explain that these are the mind's way of processing stress, and that avoiding reminders only helps briefly.
  3. Ask members which reactions apply to them. To increase participation, they can highlight items on a handout, or draw reaction cards from a hat and read them aloud, with volunteers describing their own experience.
  4. Accept other problems members raise and link them to stress where possible. If there is no link, note gently that this group focuses on stress reactions.
  5. Send a handout home to caregivers. [source: CBITS-DE; Blueprints 2016]
• Steps (TF-CBT addition):
  1. Begin at first contact, give hope about recovery, and share how common the trauma type is.
  2. Explain the diagnosis and treatment plan.
  3. Where relevant, give information on court processes and victim services. [source: Cohen & Mannarino 2008]
• Example language: "Lots of people who go through something scary have trouble sleeping or keep seeing pictures of it in their head. That isn't you being weak or crazy. It's your brain trying to deal with something big." (illustrative)
• Watch for: Members recognising themselves ("that's me"), and laughter or relief. That signals normalisation is working.

4.7 Feelings (fear) thermometer (CBITS session 2 onward)

• Purpose: A shared scale for rating anxiety or distress. It is used in relaxation, exposure and the narrative to show change. [source: Blueprints 2016; CBITS-DE agenda]
• Steps [uncertain; the manual's procedure for this tool is not drawn on]:
  1. Draw a thermometer with anchor points from calm to the most upset.
  2. Ask each member for an example situation at the low, middle and high points.
  3. Practise rating, then use ratings before and after relaxation and during exposure. [synthesis]
• Example language: "Where are you on the thermometer right now, from calm at the bottom to as upset as you've ever been at the top?" (illustrative)
• Watch for: Children who rate everything at the extremes. Use concrete anchors from their own life.

4.8 Relaxation training (CBITS session 2; TF-CBT "R")

• Purpose: Lower trauma-related arousal and restore a sense of control. Taught before exposure. [source: Cohen & Mannarino 2008; Hoover slides]
• Steps:
  1. Teach slow breathing, progressive muscle relaxation and calming imagery. [source: Hoover slides; Blueprints 2016]
  2. In TF-CBT, build a personal menu of options that work at home, at school, in the playground and at friends' houses. Examples include bubble-blowing for young children, and yoga or mindfulness for older ones. [source: Cohen & Mannarino 2008]
  3. Take thermometer ratings before and after the exercise. [synthesis]
  4. Assign daily home practice, review it the next session, and refine strategies that did not work. [source: Cohen & Mannarino 2008; Blueprints 2016]
• Example language: "Breathe in slowly through your nose while I count to four, hold, and let it out slowly like you're cooling soup. Notice your shoulders dropping." (illustrative)
• Watch for: Ratings that fall after practice. For trauma survivors, eyes-closed or body-focus exercises can be triggering. Offer eyes-open versions and let the child choose. [synthesis]

4.9 Linking thoughts and feelings (CBITS session 3; TF-CBT "C")

• Purpose: Show that thoughts, not just events, drive feelings, and that thoughts can be checked. [source: CBITS-DE agenda; Cohen & Mannarino 2008]
• Steps:
  1. Introduce thoughts and feelings.
  2. Use a neutral situation and generate several different thoughts about it, rating the feeling each thought produces.
  3. Move to trauma-related situations. [source: CBITS-DE agenda; Blueprints 2016]
  4. TF-CBT method: identify the thought behind an upsetting event, note the feelings and behaviours that follow, then test whether the thought is accurate and helpful. Alternatively, generate other thoughts and look at the feelings and actions each would lead to. [source: Cohen & Mannarino 2008]
• Example language: "Two kids get a text from a friend saying 'call me'. One thinks 'I'm in trouble', the other thinks 'she has news'. How does each one feel?" (illustrative)
• Watch for: Children confusing thoughts with feelings. Practise sorting examples into "thought" and "feeling". [synthesis]

4.10 The hot seat: Helpful Other Thoughts (CBITS sessions 3, 4 and 9)

• Purpose: Practise challenging unhelpful negative thoughts with the group's help. [source: Blueprints 2016; Hoover slides; CBITS-DE agenda]
• Steps [uncertain; the published component is named but the manual's step text is not drawn on; the steps are a reconstruction]:
  1. A volunteer, or the facilitator for the first round, sits in the "hot seat" with an unhelpful thought, written up.
  2. Members offer helpful other thoughts, which must be realistic rather than falsely positive.
  3. The person in the seat rates how believable each thought is and how they feel.
  4. They pick the most helpful one and practise saying it.
  5. Rotate the seat. [synthesis]
• Rule from the source: do not challenge accurate, adaptive thoughts, such as a child judging that a parent's drunkenness makes home unsafe. Take those to problem solving instead. Avoid unrealistically positive replacements. [source: Blueprints 2016]
• Example language: "The thought in the hot seat is 'It's my fault my brother got hurt.' What's another way to look at it that's actually true?" (illustrative)
• Watch for: Pile-ons, or peers making the student feel wrong. Coach supportive phrasing. It is working when the student generates their own alternative thought.

4.11 Fear hierarchy and real-life exposure (CBITS session 5; TF-CBT "I")

• Purpose: Reduce avoidance of reminders that are safe but have become frightening. [source: CBITS-DE; Hoover slides; Cohen & Mannarino 2008]
• Steps:
  1. Introduce avoidance and coping: avoidance brings short-term relief but keeps the fear going.
  2. Each student lists people, places and things they avoid because of the trauma that are both safe and important to approach.
  3. Rate each one on the thermometer and order them from easiest to hardest. [source: Hoover slides; CBITS-DE agenda; Blueprints 2016]
  4. Choose the first step and plan to approach it gradually, staying until the rating falls. Repeat until it is easy, then move up. [source: Blueprints 2016; CBITS-DE principle of habituation]
  5. Discuss alternative coping strategies to use during exposure. [source: CBITS-DE agenda]
  6. In TF-CBT, in vivo work is reserved for generalised avoidance of harmless cues that interferes with functioning, such as school refusal or avoiding all bathrooms after abuse in a bathroom. Use standard graded steps. [source: Cohen & Mannarino 2008]
• Safety and consent:
  • Confirm with the caregiver or school that the target is genuinely safe. Never include the perpetrator or a still-dangerous setting.
  • Get the student's agreement to each step.
  • Enlist the caregiver to support practice. [synthesis consistent with CBITS-DE "safe approach"]
• Example language: "Let's list the things you've been staying away from that are actually safe now, like the bus stop or the park. Which one would be a 3 out of 10 to try this week?" (illustrative)
• Watch for:
  • Steps that are too big, leading to escape and failure.
  • Hidden safety behaviours, such as only going with headphones on.
  • Signs it is working: ratings falling within and across repeats, and the student going further up the ladder.

4.12 Individual trauma-narrative session(s) (CBITS: 1–3 sessions of 30–45 min; Group TF-CBT: weekly individual visits from after group 4)

• Purpose: Let each child tell the story of the trauma in a safe one-to-one setting. This gets them used to thinking and talking about it, and prepares them for the group exposure sessions without exposing peers to the details. [source: Hoover slides; NCT01822366; ACF]
• CBITS agenda items:
  • update on current problems;
  • processing the trauma narrative;
  • planning how the group can support the student;
  • deciding whether more individual sessions are needed. [source: CBITS-DE agenda]
• Readiness check before starting [synthesis]:
  • the student can rate distress and lower it with a skill;
  • no current crisis or suicidal intent;
  • circumstances are safe;
  • the student agrees after hearing the rationale and knows they can pause.
• In-session dosing [the manual's step text is not drawn on; structure below is synthesis based on the published habituation principle (CBITS-DE) and gradual exposure (Cohen & Mannarino 2008)]:
  1. Give the rationale: remembering is painful but not dangerous, and distress falls when you stay with it. Agree a stop signal.
  2. Take a thermometer rating.
  3. The child tells, writes or draws the story from just before to just after the event, in the first person and present or past tense as they prefer. Include what they saw, heard, thought and felt, and the worst moment.
  4. Take ratings at intervals and at the worst point.
  5. Repeat the account, or the worst part, within the session until the rating clearly drops. If time does not allow, continue next session. Do not end at peak distress.
  6. Process: ask what the child makes of it now. Note self-blame and other unhelpful thoughts for cognitive work.
  7. Plan what the child will share in group (a drawing, a short written piece, no graphic detail) and how peers can support them.
  8. Close with a relaxation exercise and a rating. Make sure the student is calm before they return to class.
• TF-CBT form: the narrative is developed over several sessions, usually written (a book, poem or song), or by dictation, drawing, computer or dance. It is organised as "before, during, since" so the child is seen as more than a victim, and includes thoughts, feelings, body sensations and the worst moments. It is kept and re-read across sessions. Then distortions such as self-blame, shame, feeling damaged and low self-worth are identified and revised with cognitive coping. [source: Cohen & Mannarino 2008]
• Example language: "Start just before it happened. Where were you, what did you see? ... You're at a 7 now. Stay with it; you're doing it. ... Let's go through it once more ... and now where are you on the thermometer?" (illustrative)
• Watch for:
  • Skipping the worst moment, a flat or summarised telling, or distress that does not fall (move in smaller steps).
  • Dissociation: glazed look, no response, or the child reporting feeling unreal. Stop the telling and ground the child (see section 5).
  • New disclosures of abuse, which may trigger mandatory reporting.
  • It is working when ratings fall across tellings and the story becomes more coherent and less self-blaming.

4.13 Group trauma exposure (CBITS sessions 6–7)

• Purpose: Continue exposure to the trauma memory through imagining, drawing, writing and sharing, with peer support. [source: Blueprints 2016; Hoover slides; ACF; CBITS-DE agenda]
• Published elements: imaginal exposure; writing or drawing; sharing; a closing exposure activity. Session 7 encourages talking about the trauma at home. [source: CBITS-DE agenda; Blueprints 2016]
• Steps [synthesis; the manual's step text is not drawn on]:
  1. Review homework and the in vivo steps.
  2. Restate the rule on limits to disclosure.
  3. Students write or draw about their trauma, building on their individual session, taking ratings at the start and end.
  4. Volunteers share a portion they agreed in advance with the leader. Peers respond with a planned supportive comment.
  5. Run a group relaxation exercise to close, and check everyone's rating before they leave.
  6. Set a home task: share part of the story with a trusted adult, if the caregiver has been prepared.
• Example language: "Today you'll draw or write about what happened, building on what you did with me one-to-one. You choose how much to share with the group. We'll end with breathing so everyone leaves feeling steady." (illustrative)
• Watch for:
  • Peers who are triggered by another student's account.
  • Students who stay silent: let them share the drawing only, or have the leader read their piece.
  • Ratings that stay high at the end: the student needs an extra individual session.

4.14 Social problem solving (CBITS sessions 8–9)

• Purpose: Deal with real current problems, including situations where the negative thought is accurate. [source: Blueprints 2016; Hoover slides]
• Steps:
  1. Link unhelpful thoughts to actions.
  2. Define the problem.
  3. Brainstorm all possible solutions without judging them.
  4. List the pros and cons of each.
  5. Choose one, try it, and evaluate the result. [source: Hoover slides; Blueprints 2016; CBITS-DE agenda]
  6. Session 9 practises on real problems members bring, combined with the hot seat, and reviews key concepts. It sets no homework. [source: CBITS-DE agenda]
• Example language: "Problem: kids at the bus stop keep teasing you about what happened. Let's list every idea, even silly ones, before we judge any." (illustrative)
• Watch for:
  • Aggressive solutions chosen for short-term payoff. Let the pros-and-cons list reveal the costs.
  • Safety problems, such as violence at home, which need adult action rather than a student-only solution. [synthesis]

4.15 Relapse prevention and graduation (CBITS session 10)

• Purpose: Consolidate the skills, plan for future stressors and reminders, and end with a celebration. [source: Blueprints 2016; ACF; Hoover slides]
• Steps:
  1. Review the skills learned.
  2. Each student identifies likely upcoming stressors and anniversaries, and which skill they would use.
  3. Troubleshoot future stressors as a group.
  4. Hold a graduation: certificates, a special activity, celebration. [source: Blueprints 2016; CBITS-DE agenda]
  5. Tell students how to get help later. Decide individually who needs further treatment. [synthesis]
• Example language: "Your birthday is the one-year mark this spring. What might you notice, and which of your tools will you reach for first?" (illustrative)
• Watch for: Distress about the group ending. Name it, and link the student to ongoing support.

4.16 Caregiver sessions (CBITS: 2 sessions)

• Purpose: Help caregivers understand trauma reactions and support skill practice at home. [source: ACF; CBITS-DE]
• Contents:
  • Session 1: common reactions, an explanation of CBITS, the feelings thermometer, and relaxation.
  • Session 2: unhelpful thoughts, real-life exposure, trauma exposure, problem solving, and closing.
  • Hold them in the evening with food where possible, about 45 min each. [source: CBITS-DE]
• Steps [synthesis]:
  1. Demonstrate each skill and have caregivers practise it.
  2. Give them a home role: prompt practice, praise approach behaviour, and listen to the story without pushing for detail.
  3. Ask about the caregiver's own trauma and stress, and refer them on if needed.
• Watch for: Low attendance. Use invitations and reminders, and offer phone versions [synthesis].

4.17 Teacher education session (CBITS, optional)

• Purpose: Build teacher support and understanding of CBITS. [source: ACF]
• Contents: common trauma reactions; CBITS and its components; tips for teaching traumatised students; questions. [source: CBITS-DE agenda]
• Watch for [synthesis]: Protect student confidentiality. Share the programme's content, not individual students' stories.

4.18 Parallel caregiver group: parenting skills (Group TF-CBT, "P")

• Purpose: Address changes in parenting after trauma, such as overprotection or permissiveness, and new behaviour problems such as bedwetting, aggression and non-compliance. Caregivers learn every child skill in parallel. [source: Cohen & Mannarino 2008; NCT01822366]
• Steps:
  1. In each caregiver group, preview the skill the children are learning that week so caregivers can coach it at home. [source: NCT01822366: same skills in both groups]
  2. Teach praise, selective attention to positive behaviour, appropriate time-out, and behaviour charts or other contingency programmes, fitted to each child, family and culture. [source: Cohen & Mannarino 2008]
  3. Use group role-plays of praise and of handling a typical problem behaviour, plus a home-practice plan, and review it the next week. [synthesis]
• Example language: "This week, catch your child doing one thing right every day and say exactly what you liked: 'You got ready for school on time; that really helped me.'" (illustrative)
• Watch for:
  • Caregivers who are themselves highly symptomatic or bereaved; refer them for their own help.
  • Harsh discipline, which needs individual follow-up and possibly safeguarding action.
  • It is working when the caregiver reports using praise and the child's behaviour charts improve.

4.19 Affective expression and modulation (Group TF-CBT, "A")

• Purpose: Widen the range of feelings a child can name and express, and build regulation. [source: Cohen & Mannarino 2008]
• Steps:
  1. For constricted children, start with feelings games in group, such as naming feelings from faces or a feelings charades round. [game format is synthesis; "feelings games" from source]
  2. Identify the child's specific difficulty: over-reacting to negative cues, under-responding to positive ones, or lacking social or problem-solving skills.
  3. Teach targeted skills for that difficulty and practise them between sessions. [source: Cohen & Mannarino 2008]
• Example language: "Pick a card and act out the feeling without words; the group guesses. Then tell us a time you felt that way this week." (illustrative)
• Watch for: Children who name only "fine" or "angry". It is working when they use more feeling words and choose a coping skill when upset.

4.20 Consolidating the narrative in group without detail (Group TF-CBT groups 5–8)

• Purpose: Let children build on individual narrative work in group while protecting peers from triggering detail. [source: NCT01822366]
• Steps:
  1. Children revisit their individual narrative work, for example by redrawing a picture or rewriting part of a story, with facilitator support.
  2. The group discusses coping and the meanings they take from their stories, not the details of what happened. [source: NCT01822366]
  3. Use group cognitive work on shared themes such as self-blame or "it will happen again". [synthesis]
• Watch for: A child starting to describe graphic content. Redirect gently to the individual session.

4.21 Caregiver preparation and conjoint sessions (Group TF-CBT groups 9–12)

• Purpose: Strengthen child–caregiver communication and the caregiver as a source of support. [source: Cohen & Mannarino 2008; NCT01822366]
• Steps:
  1. With the child's permission, share the child's narrative with the caregiver in the caregiver's own session first. This lets the caregiver process their own reactions, for example self-blame, and practise supportive responses. [source: Cohen & Mannarino 2008]
  2. In the conjoint session, the child shares the narrative with the caregiver while the therapist steps progressively into the background. The caregiver offers reassurance and praise, coached by the therapist.
  3. Child and caregiver may ask each other questions they have avoided.
  4. Joint projects can follow, prepared in caregiver sessions first. Examples are a public service announcement, or a child quizzing the parent on healthy sexuality. [source: Cohen & Mannarino 2008]
  5. In group format, conjoint work happens as joint child–caregiver activities. In the Dorsey protocol, narrative details are kept out of the group [source: NCT01822366]. Hold any actual narrative sharing in separate dyad time [synthesis].
• Example language (coaching the caregiver): "When she finishes, tell her what you're proud of. You don't need to fix anything." (illustrative)
• Watch for:
  • Caregivers who blame, minimise or break down. Postpone the conjoint session and do more caregiver preparation.
  • Never hold a conjoint session with an offending caregiver. [synthesis]

4.22 Enhancing safety and future development (Group TF-CBT, "E")

• Purpose: Build skills that protect the child from future harm. [source: Cohen & Mannarino 2008]
• Steps:
  1. Choose the safety skills relevant to the trauma: body safety and healthy sexuality, "no, go, tell" for young children, a domestic-violence safety plan, responses to bullying, or drug refusal.
  2. Practise them in individual or joint sessions, and encourage use in other situations too. [source: Cohen & Mannarino 2008]
  3. Rehearse through role-plays, with caregivers helping to teach the child personal-safety skills. [source: Deblinger et al. 2001 abstract]
• Example language: "If anyone touches you in a way that feels wrong, what are the three steps? Say no, get away, tell a grown-up. Who are the grown-ups you'd tell?" (illustrative)
• Watch for: Safety plans that put responsibility for preventing abuse on the child. Make sure adults own protection. [synthesis]

4.23 Grief-focused components (Group TF-CBT for childhood traumatic grief)

• Purpose: The East African protocol treated childhood traumatic grief as well as PTS after a parent's death. It added coaching for guardians on talking with children about the deceased parent, along with local analogies, sayings, and orphan-specific thoughts and behaviours. [source: NCT01822366; O'Donnell et al. abstract]
• Steps [uncertain]: the session-level grief modules (Appendix B of the protocol) are not drawn on, so specific grief exercises are not described here. See the individual TF-CBT for Childhood Traumatic Grief literature before running these.

4.24 Fidelity monitoring and supervision

• Purpose: Keep group delivery on model, especially with lay or new facilitators. [source: NCT01822366]
• Steps:
  1. After each session, facilitators send a short written group report to their supervisor within two days.
  2. Sessions are audio-recorded, and a sample is coded with a group version of the TF-CBT fidelity checklist. [source: NCT01822366]
  3. CBITS training is offered in person (about 12 hours over two days), virtually, or self-led online, with certified trainers recommended. [source: ACF]
  4. Group delivery needs group-specific skills beyond standard individual TF-CBT training. [source: EPIS FAQ]
• Watch for: Drift into unstructured support talk. The 2001 trial contrasted CBT groups with supportive groups, and the CBT groups gave the larger gains on several outcomes. [source: Deblinger et al. 2001 abstract]

5. Handling problems

Tags show what the sources say ([source]) and what is my own guidance ([synthesis]).

Overwhelm and dissociation during narrative or exposure

• Overwhelm or dissociation in an individual session [synthesis]:
  1. Stop the telling.
  2. Ground the child: feet on the floor; name five things you can see; hold a cold object; say aloud the date and where we are.
  3. Run a familiar relaxation skill and re-rate.
  4. Resume at a smaller step, for example drawing instead of telling, or the moment before the worst part. Do not end the session until the rating is back near baseline.
  5. Tell the caregiver or school what to expect that evening.
• A student overwhelmed in group:
  • CBITS keeps disclosures short and puts detail in individual sessions. [source: CBITS-DE; NCT01822366]
  • [synthesis] Have a co-facilitator take the student to a quiet space to ground them. Briefly reassure the rest of the group and run a group breathing exercise. Follow up individually before the next group, and add an individual CBITS session (up to three are allowed). [source for extra individual sessions: ACF]
• Persistent dissociation, or distress that does not fall over two or three sessions [synthesis]: reassess, and consider individual trauma treatment with longer stabilisation instead of the group.

Risk, disclosure and safety

• Exclusion of students in crisis: students in crisis, or who need immediate intensive treatment, are excluded from CBITS. [source: CBITS-DE]
• Suicidal thoughts, abuse disclosure or other safety concerns:
  • Facilitators call on clinical backup when concerned about child safety, such as suicidal thoughts or abuse. [source: NCT01822366]
  • [synthesis] Have a written escalation plan before the group starts: who assesses, the local crisis pathway, and the safeguarding lead. Use a standard risk assessment and safety planning, including lethal-means counselling with caregivers (secure storage and removal). Continue group attendance only if it is safe and helpful.
• New abuse disclosure: disclosures trigger reporting duties. Avoid screening questions that elicit them in a public way. [source: CBITS-DE]
  • [synthesis] Follow mandatory reporting law. Do not interview for forensic detail; record the child's words. Coordinate with child protection before any further narrative work.
• Ongoing danger: for example current domestic violence. Establish safety first, then reassess. A new trauma during the course means deciding case by case whether to continue or pause. [source: CBITS-DE]

Avoidance, refusal and non-adherence

• Students who will not share: normalise hesitation, never force disclosure, and offer to speak for them. [source: CBITS-DE]
  • [synthesis] Offer lower-exposure options: a drawing, writing read by the leader, or sharing only the coping part.
• Avoidance of the worst trauma: watch for a student who keeps switching to a less distressing event. Follow up privately to identify the worst one. [source: CBITS-DE]
• Absences: use invitations, reminders and a buddy system. [source: CBITS-DE]
  • [synthesis] Do a brief catch-up before the next group. If a student misses the individual narrative session, reschedule it before sessions 6–7.
• Homework not done: normalise it when families did not complete the goals sheet. [source: CBITS-DE]
  • [synthesis] Shrink the task, practise it in the session, and enlist the caregiver.
• Low caregiver attendance: in the Dorsey trial, willingness to attend a 12-week group was an entry condition. [source: NCT01822366]
  • [synthesis] Offer evening or virtual sessions, food and transport. Phone the caregivers who missed a session with a short summary of the week's skill.

Group process problems

• Disruption: use the group rules and a points or reward system, especially with younger groups. Keep sessions predictable with a posted agenda. [source: CBITS-DE; Blueprints 2016]
  • [synthesis] Seat co-facilitators near the most disruptive students, and give active roles such as board writer or timekeeper.
• Peer conflict, bullying or retraumatising remarks: compose groups to avoid bully–victim pairings. [source: CBITS-DE]
  • [synthesis] Stop the remark at once, restate the rule, and repair privately with both students. Move a student to another group if the conflict persists.
• Confidentiality breaches [synthesis]:
  1. Address the breach in group, without naming the student whose story was shared.
  2. Revisit the rules.
  3. Meet privately with the student whose story was spread, and offer support.
  4. Consider removing the student who breached confidentiality if it happens again.
• Mixed trauma types: keep sexual-abuse detail out of mixed-gender groups and handle it individually. [source: CBITS-DE]
  • [synthesis] Find themes common to all members: fear, avoidance, self-blame.

Stuck progress and cognitive work

• Hot seat not working: do not dispute accurate thoughts; move them to problem solving. Avoid replacement thoughts that are unrealistically positive. [source: Blueprints 2016]
  • [synthesis] Try the cognitive-processing questions on the narrative in an individual session.
• No improvement by mid-course [synthesis]:
  • Recheck the target trauma, ongoing stressors, and comorbid depression or ADHD.
  • Consider extra individual sessions or stepping up to individual TF-CBT.
  • Comorbid problems that take precedence should be treated alongside or stabilised first. [source: Cohen & Mannarino 2008]

Ruptures [synthesis]

• Signs: a student feels exposed or pushed after a narrative session, or feels singled out in the hot seat.
• Response: name the rupture in a private check-in, acknowledge your part, and agree a smaller next step. Give the student control over what is shared in group.

Facilitator strain

• Signs and response: if you are preoccupied with students' trauma, sleeping or concentrating poorly, or feeling numb, seek consultation. Keep a self-care plan, and watch for your own anger and for being pulled into re-enacting mistreatment. [source: Blueprints 2016; CBITS-DE]

Modality-specific cautions [synthesis]

• Group exposure is not individual exposure. Plan what each student will share before the group, and never use a peer's graphic story as exposure for others.
• Schools are not clinics. Plan in advance:
  • private space;
  • timetabling that does not always take students out of the same subject;
  • how students return to class calm;
  • who in the school knows what.
• Bereaved children: if the child's caregiver is also bereaved, check the caregiver's own grief and functioning before conjoint work.

Sources

Sources

• Cognitive Behavioral Intervention for Trauma in Schools (CBITS), German manual, Universitätsklinikum Ulm translation of Jaycox, Langley & Hoover 2018. Front matter, introduction, session 1 and part of session 2 read in full; all other session agendas read from the contents.
• RAND TL-272: Cognitive Behavioral Intervention for Trauma in Schools (CBITS), 2nd ed., product page.
• Title IV-E Prevention Services Clearinghouse: Cognitive Behavioral Intervention for Trauma in Schools
• Blueprints conference 2016 presentation on CBITS (T5-C)
• Hoover, S.: CBITS conference slides (Learning to End Abuse)
• Cohen, J. A. & Mannarino, A. P. (2008). Trauma-focused cognitive behavioural therapy for children and parents. Child and Adolescent Mental Health 13(4), 158–162 (tfcbt.org)
• Randomized Controlled Trial of Trauma-focused CBT in Tanzania and Kenya, protocol NCT01822366 (Dorsey, Whetten et al.). Appendix B (session content) was not included.
• Deblinger, Pollio & Dorsey (2016). Applying trauma-focused cognitive-behavioral therapy in group format. Child Maltreatment (abstract only)
• EPISCenter FAQ: Can TF-CBT be delivered as group therapy?
• O'Donnell et al. (2014). Treating maladaptive grief and posttraumatic stress symptoms in orphaned children in Tanzania: group-based TF-CBT (abstract record)
• Deblinger, Stauffer & Steer (2001). Comparative efficacies of supportive and cognitive behavioral group therapies for young children who have been sexually abused and their nonoffending mothers (NCJRS abstract)

Further reading (not drawn on)

• Jaycox, L. H., Langley, A. K., & Hoover, S. A. (2018). Cognitive Behavioral Intervention for Trauma in Schools (CBITS) (2nd ed.). RAND Corporation.
• Deblinger, E., Pollio, E., & Dorsey, S. (2016). Applying trauma-focused cognitive-behavioral therapy in group format. Child Maltreatment, 21(1), 59–73. Full session protocol not drawn on [uncertain].
• Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006/2017). Treating Trauma and Traumatic Grief in Children and Adolescents. Guilford Press.