There is increasing evidence supporting the efficacy of the trauma-focused CBT treatment model described in this chapter. Based on the treatment comparisons made thus far, the findings suggest at least two important general guidelines for working with children who have suffered trauma. First, findings across several of the treatment outcome investigations highlight the value of involving a nonoffending parent-figure in treatment. This person may be a supportive mother, father, grandparent, foster parent, or other individual serving in a guardian role. Helping a caregiver to function as a supportive resource for a child has value that may exceed what a therapist can offer in weekly sessions and may produce therapeutic benefits that last long after therapy has terminated. Thus, when possible, it behooves therapists to engage both nonoffending maternal and paternal figures in the therapy process. Second, it appears that the structure and directive nature of the CBT model enables parents and children to focus effectively on skills and/or information relevant to overcoming the traumatic experience(s). The results from several studies in which nondirective and/or client-centered approaches were utilized indicate that children are not likely to focus on the abuse without the structured and directive guidance of a skilled therapist.
Given the mounting evidence that the aftereffects of abuse may not only disrupt children's emotional, behavioral, and social development but also may negatively impact brain development, it is critical that effective treatment models, such as the one described here, be identified and utilized as early as possible. However, there is much work to be done in terms of enhancing the availability and utilization of evidence-based treatment models in community settings. Most children who have suffered abuse either never receive treatment or receive services at agencies where up-to-date training is limited. Recently, however, several organizations, including the Kauffman Foundation, the National Child Traumatic Stress Network, and the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration, have recognized the efficacy and/or supported efforts to further training and dissemination of this evidence-based treatment model. Additionally, as noted, this model has been modified and expanded for use with children who have suffered traumatic loss, children exposed to domestic violence, and children who have experienced physical abuse (Cohen et al., in press; Runyon et al., 2004; Cohen et al., 2004).
Although these developments are exciting, much remains to be learned about the effective treatment of children who have suffered abuse and/or other traumas. For example, current treatment practices may be enhanced by research efforts aimed at identifying important underlying psychological processes as well as "critical therapy ingredients." In addition, research may help us better understand differential treatment responses as a function of cultural background, gender, developmental stage, coping style, and other child and family characteristics. Finally, there is a critical need for continued development of innovative treatment approaches for less responsive youngsters as well as high-risk adolescents, such as those engaging in self-destructive behaviors. Continued research efforts in these areas will not only help to improve general practice, but most importantly, may help us to individually tailor treatment approaches to achieve optimal outcomes for all children and families who have suffered traumatic experiences.
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Bringing Cognitive-Behavioral Psychology to Bear on Early Intervention with Trauma Survivors
Accident, Assault, War, Disaster, Mass Violence, and Terrorism
Increasing recognition of the potential impact of trauma exposure, coupled with humanitarian concern about responding to victims, has led to widespread implementation of trauma-related services in recent years. In particular, interest in working with trauma survivors in the first weeks and months following their traumatic experiences has grown, with goals that include reducing acute distress, limiting suffering, maintaining functioning, and reducing rates of chronic problems. Several systems of early posttrauma intervention have evolved, relatively independently, to serve survivors of diverse traumas, including physical and sexual assault, natural and technological disaster, terrorism and mass violence, war, and the exposure to life threat, human suffering, and loss often associated with emergency response work and peacekeeping operations. Scrutiny of existing early intervention efforts has increased as the field of traumatic stress studies has developed, and has gained greater urgency due to recent terrorist attacks (e.g., September 11, 2001), the Iraq war, and widespread ethnic conflicts. In parallel with an increasing availability of posttrauma services, researchers are beginning to test the efficacy and effectiveness of existing interventions and to design and test new ones. In this context, studying cognitive-behavioral interventions designed to reduce problems associated with traumatic stress has become of increased importance.
In this chapter I look at the trauma resulting from these sources in order to (1) describe the potential for cognitive-behavioral psychology to inform the efforts to help survivors in established domains of post-trauma care; (2) explore the implications of cognitive-behavioral theory and research in relation to the goals and practices embodied in conventional early intervention efforts; (3) outline several key issues that must be confronted during the development of new approaches; and (4) draw attention to the need to plan, at the outset in hwat is a developing field, for the dissemination of new concepts and methods to the real-world settings where professionals work with trauma survivors.
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