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Most children in the United States have experienced at least one traumatic event (Copeland et al., 2007), which can lead to mental health problems for them later in life, like nightmares, panic attacks, anxiety, and depression (Kessler et al., 2012). Trauma-focused cognitive behavior therapy (TF-CBT) is a treatment used by therapists for children with trauma symptoms. TF-CBT can teach children coping skills to help with their symptoms like how to calm their bodies, identify unhelpful thoughts, and talk about their trauma with a trained professional. TF-CBT also teaches parents different ways to manage and support their children as they recover from their traumatic experience.
Scientists have researched TF-CBT and found that TF-CBT improves a variety of mental health symptoms associated with trauma (for a review, see de Arellano et al., 2014). Unfortunately, TF-CBT is not often used by therapists in the community (Allen & Johnson, 2012), and many children who would benefit from TF-CBT do not receive this treatment. This is particularly concerning given the recent rise in global, national, and local epidemics and disasters that increase children’s risk of experiencing trauma symptoms (for a review, see Guessoum et al., 2020), like COVID-19, the war in Ukraine, race-related violence, school shootings, increased rates of domestic violence during lockdown, and natural disasters like hurricanes. 
We were interested in learning about therapists' beliefs and attitudes that might keep them from delivering TF-CBT, so that we can better support them in learning TF-CBT in training and supervision. Assessing therapists' beliefs is especially important because many therapists hold specific concerns about childhood trauma and trauma therapy that are unique to trauma-focused interventions like TF-CBT (Allen & Crosby, 2014). Concerns about TF-CBT and childhood trauma treatment could potentially interfere with therapists’ learning and delivery of TF-CBT (Allen & Crosby, 2014). Building off a similar questionnaire created for adult trauma treatment, Cognitive Processing Therapy (CPT; LoSavio et al., 2019), we created a questionnaire of therapists’ “stuck points” about TF-CBT. The term “stuck points” comes from CPT and within our questionnaire reflects inaccurate beliefs that may get in the way of using TF-CBT.
Over 70 therapists completed a survey that included our newly created TF-CBT Stuck Points questionnaire. These therapists worked in community mental health centers participating in a TF-CBT training. The instructions for the TF-CBT Stuck Points questionnaire asked therapists how much they believed a series of statements, on a scale from 0% (do not believe the statement) to 100% (completely believe the statement). Sample questions include:

  • If I address my client’s avoidance, it will damage our relationship.
  • If I point out my client’s inaccurate or unhelpful thoughts about their trauma, it will damage our relationship.
  • Working with the child alone, without caregiver involvement, is best for trauma treatment. 

We found that 26 items out of an original 42 item questionnaire most efficiently measured TF-CBT stuck points. The shortened 26 item questionnaire showed good psychometric properties, like excellent reliability. Our findings also suggest that the TF-CBT Stuck Points questionnaire offers a unique perspective not fully captured by existing measures. We found that most therapists endorsed at least one stuck point. The most endorsed stuck points were: 

  • I need to implement TF-CBT therapy components perfectly for treatment to work.
  • Children shouldn’t be forced to talk about their trauma until they are ready.
  • Clients need preparatory treatment before they are ready to deal with their trauma.

Although these are just three of many stuck points examined, confidence in how well a therapist can deliver TF-CBT could interfere with therapists newly trained in TF-CBT flexibly and confidently using TF-CBT. Additionally, two of these commonly endorsed beliefs (i.e., that clients need preparatory work and that therapists should wait until clients are ready to talk about their trauma) suggest that TF-CBT stuck points could lead therapists to delay starting TF-CBT or key TF-CBT components, like the trauma narrative (i.e., telling or writing the story of their traumatic event), with children. Indeed, previous studies have found that less than 25% of providers treating childhood trauma use a trauma narrative (Ascienzo et al., 2020). These commonly endorsed stuck points could also potentially prevent referrals to TF-CBT altogether. However, future research is needed to examine whether the stuck points this questionnaire measures predict using TF-CBT and its components in clinical practice. In the meantime, the TF-CBT Stuck Points questionnaire may be useful in training and supervising therapists new to TF-CBT. 

Reference Article

Patel, Z. S., Casline, E., Shaw, A. M., Jensen-Doss, A., & Ramirez, V. (2022). Measuring clinician stuck points about trauma-focused cognitive behavior therapy: The TF-CBT Stuck Points Questionnaire. Journal of Traumatic Stress, 1–11. https://doi.org/10.1002/jts.22835 

Discussion Questions

  1. Do therapist stuck points predict their use of and adherence to TF-CBT?
  2. Could intervening on therapist stuck points during early training and supervision make TF-CBT training more effective? 

About the Authors 

Ashley M. Shaw, PhD is a Clinical Assistant Professor at Florida International University and a Licensed Clinical Psychologist who has research expertise in training therapists in evidence-based interventions and clinical expertise in treating PTSD. She self-identifies as a heterosexual, cis gender, White woman.
Zabin S. Patel, MS, MPH is a Predoctoral Psychology Intern at the University of California Los Angeles Semel Institute for Neuroscience and Human Behavior. Her research interests include assessment and implementation strategies to increase youth access to mental health care. She self-identifies as a heterosexual, cis gender, South Asian American woman.
Elizabeth Casline, MS is a Doctoral Candidate at University of Miami. Her research focuses on implementation of trauma-focused evidence-based treatments and evidence-based assessment practices, including measurement-based care, in community mental health settings. She self-identifies as a heterosexual, cis gender, White woman. 
Amanda Jensen-Doss, PhD is a Professor at University of Miami. Her research seeks to characterize and improve youth clinical care, particularly by testing the benefits of employing evidence-based assessment tools and treatments in clinical care settings. She self-identifies as a heterosexual, cis gender, White woman.
Vanessa Ramirez, PsyD is the Chief Program Officer at Kristi House, located in Miami, Florida. Kristi House is a program dedicated to preventing and intervening against child abuse and sex trafficking in youth. She has expertise in implementation of evidence-based practices within organizations  and self-identifies as a cis gender Latina woman.
References Cited:
Allen, B., & Crosby, J. W. (2014). Treatment beliefs and techniques of clinicians serving child maltreatment survivors. Child Maltreatment19(1), 49–60. https://doi.org/10.1177/1077559513518097
Allen, B., & Johnson, J. C. (2012). Utilization and implementation of trauma-focused cognitive-behavioral therapy for the treatment of maltreated children. Child Maltreatment17(1), 80–85. https://doi.org/10.1177/1077559511418220

Ascienzo, S., Sprang, G., & Eslinger, J. (2020). Disseminating TF- CBT: A mixed-methods investigation of clinician perspectives and the impact of training format and formalized problem-solving approaches on implementation outcomes. Journal of Evaluation in Clinical Practice26(6), 1657–1668. https://doi.org/10.1111/jep.13351  

Copeland, W. E., Keeler, G., Angold, A., & Costello, E. J. (2007). Traumatic events and posttraumatic stress in childhood. Archives of General Psychiatry64(5), 577–584. 

de Arellano, M. A. R., Lyman, D. R., Jobe-Shields, L., George, P., Dougherty, R. H., Daniels, A. S., Shoma Ghose, S., Huang, L., & Delphin-Rittmon, M. E. (2014). Trauma-focused cognitive-behavioral therapy for children and adolescents: Assessing the evidence. Psychiatric Services65(5), 591-602. https://doi.org/10.1176/appi.ps.201300255

Guessoum, S. B., Lachal, J., Radjack, R. Carretier, E., Minassian, S., Benoit, L., Moro, & M. R. (2020). Adolescent psychiatric disorders during the COVID-19 pandemic and lockdown. Psychiatry Research, 291, https://doi.org/10.1016/j.psychres.2020.113264

Kessler, R. C., Avenevoli, S., Costello, E. J., Georgiades, K., Green, J. G., Gruber, M. J., He, J., Koretz, D., McLaughlin, K. A., & Petukhova, M. (2012). Prevalence, persistence, and sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement. Archives of General Psychiatry69(4), 372–380. https://doi.org/10.1001/archgenpsychiatry.2011.160  

LoSavio, S. T., Dillon, K. H., Murphy, R. A., & Resick, P. A. (2019). Therapist stuck points during training in cognitive processing therapy: Changes over time and associations with training out- comes. Professional Psychology: Research and Practice50(4), 255– 263. https://doi.org/10.1037/pro0000224