Applying Trauma-Focused Cognitive–Behavioral Therapy in Group Format

Overall TF-CBT group structure

Group sessions need to be carefully structured for both the caregivers and children. A potential challenge in the caregiver group is the leader allotting roughly equal time to all participants. In addition, the careful selection of activities is important, particularly for groups with young children or children with behavioral difficulties. Activities should teach and reinforce the various skills in an engaging, fun, and interactive manner. Some activities that work well in individual therapy are not as effective in a group. For example, activities that can get a child overly excited often lead to the group losing focus. Activities that allow for some physical movement in a controlled manner often work well in a group, particularly with young children who may have a limited attention span and excess energy. Behavior management is also important in the child group, again particularly with young children or children with behavioral difficulties. Praise should be used liberally in all groups. The necessity of using more formal point systems and rewards should be determined on a group-by-group basis, as some groups may require frequent, concrete reinforcements throughout the session. Time-out can be utilized in a group with younger children. An explanation of time-out, when it is used (e.g., a child gives another child a not OK touch), and the procedure (e.g., which corner the child sits in) should be explained to both children and caregivers. The use of praise, reflective listening, selective attention, positive reinforcement, and negative consequences such as time-out is consistent with the principles and skills taught in the caregiver group.

When implementing TF-CBT individually, the treatment model is often tailored to the child and caregiver’s particular needs. Group TF-CBT, however, typically requires therapists to maintain a commitment to the planned weekly agendas in order to best accommodate all participants. Outlined below are the general objectives of group treatment sessions. It should be noted that there is considerable flexibility in the order of the proposed session activities and there are a wide array of creative activities that can achieve the described session goals. Thus, the outline offers general concepts that are important to cover across the three phases of treatment: the stabilization and skill building phase (PRAC), the trauma narrative and processing phase (T), and the integration and consolidation phase (ICE). Although fidelity to the overall flow of TF-CBT sessions is important, TF-CBT therapists are encouraged to address the specific needs and concerns presented by clients with compassion, creativity, and some flexibility while remaining aware of the importance of forward movement for the benefit of all group participants. For example, for groups in which there is a concern about ongoing risk for multiple children, the safety skills component can be moved to earlier in treatment, as would be done in individual therapy (Cohen et al., 2006). Given the time-limited nature of group, it is important to have a general outline and at least tentative agendas that can be modified depending on the needs of the families. The protocol given subsequently, Table 1, and online supplemental Table 2 provide general topics and activities covered and can also serve as a fidelity checklist designed for implementing TF-CBT in group format similar to the way that another TF-CBT fidelity checklist has been used to guide individual TF-CBT (Deblinger et al., 2015). The session-by-session guide for the group intervention for children who experienced the death of a parent (and includes coverage of the grief elements) is available here: http://cmx.sagepub.com.

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Table 1.

Group TF-CBT Session-by-Session Outline.

Session No.	Caregiver Group	Child Group	Conjoint
1	Introductions Gradual Exposure—what brought caregivers to group Psychoeducation—trauma, PTSD, treatment overview, reasons to be optimistic Parenting—introduce parental role, praise PRACTICE assignment	Introductions Group rules (including confidentiality and rules about appropriate boundaries) Psychoeducation about the trauma, PTSD, and TF-CBT Art project/game	Children introduce themselves and their caregivers Therapists model praise of each child for the introductions Describe parallel group process
2	PRACTICE review Parenting—increase use of specific and global praise, positive child–caregiver time/rituals Relaxation/mindfulness Gradual exposure—use of skills in response to trauma reminders PRACTICE assignment	Review group rules Psychoeducation Relaxation/mindfulness PRACTICE assignment	Children teach relaxation Caregivers praise children
3	PRACTICE review Affect expression and modulation—encourage caregivers to model and praise sharing of feelings Parenting—reflective listening PRACTICE assignment	PRACTICE review Affect expression and modulation Gradual exposure—identifying feelings experienced during trauma PRACTICE assignment	Children share one negative and one positive emotion about something they experienced during the week (nontrauma related) Caregivers respond with reflective listening and praise
4	PRACTICE review Parenting—selective attention Cognitive coping (trauma or nontrauma related) PRACTICE assignment	PRACTICE review Introduce cognitive coping (nontrauma related) Introduce concept of praise Use of skills in response to trauma cues PRACTICE assignment	“Feelings charades” or children teach caregivers about cognitive coping—giving examples of thoughts that lead to different feelings Caregivers practice selective attention in conjoint session when praising child presentation while minimizing attention to any negative behavior Mutual exchange of praise between caregivers and children
5	PRACTICE review Cognitive coping Parenting—gaining children’s cooperation, introduction of family rules, effective instructions, and negative consequences Psychoeducation PRACTICE assignment	PRACTICE review Cognitive coping Psychoeducation game (e.g., What Do You Know? card game) PRACTICE assignment	Psychoeducation game—What Do You Know? card game in “Family Feud” format Caregivers practice selective attention Mutual exchange of praise
6	PRACTICE review Review of parenting and coping skills Introduce concept/rationale for trauma narrative PRACTICE assignment	PRACTICE review Read story in preparation for trauma narrative Title and introduction to trauma narrative Coping index card PRACTICE assignment	Children share coping index card Mutual exchange of praise
7	PRACTICE review Review of parenting and coping skills Gradual exposure Parenting—age-appropriate family rules and consequences Assess readiness to hear trauma narrative PRACTICE assignment	PRACTICE review Trauma narrative (individual) Group activity (review of skills, continue to create coping skills toolkit, create artwork related to feelings about the trauma/what to tell other children about the trauma, etc.)	Children sharing their art projects Mutual exchange of praise
8	PRACTICE review Review of parenting and coping skills Preparation for sharing of the trauma narrative, if clinically indicated (individual) PRACTICE assignment	Trauma narrative (individual) Group activity (as described above)	Children sharing their art projects Mutual exchange of praise
9	PRACTICE review Review of parenting and coping skills Preparation for sharing of the trauma narrative, if clinically indicated (individual) PRACTICE assignment	Trauma narrative (individual) Group activity (as described above) In vivo mastery (when appropriate)	Children sharing their art projects Mutual exchange of praise
10	PRACTICE review Review of parenting and coping skills Preparation for sharing of the trauma narrative, if clinically indicated (individual) PRACTICE assignment	Trauma narrative (individual) Group activity (as described above) In vivo mastery (as needed)	Sharing of trauma narrative, if clinically indicated (individual) Mutual exchange of praise (individual)
11	PRACTICE review Safety skills Preparation for graduation PRACTICE assignment	Practice safety skills In vivo mastery (as needed) Preparation for graduation	Children demonstrate safety skills role plays Mutual exchange of praise
12	PRACTICE review Practice skills and plan for future reminders Acknowledgment of progress	Safety skills review Practice skills and plan for future reminders Acknowledgment of progress	Graduation celebration Review skills and plan for future reminders Mutual exchange of praise Awarding of certificates

Note. PTSD = post-traumatic stress disorder; TF-CBT = trauma-focused cognitive–behavioral therapy.

Conjoint Session 1

The group program may begin with a brief conjoint child–caregiver session, particularly for young children, during which therapists introduce themselves and briefly but enthusiastically describe the parallel groups for children and their caregivers. Therapists should describe the separate but parallel caregiver and child groups emphasizing the fun and creative therapy activities for children and the important opportunities for learning and support for the caregivers. While the trauma focus may be briefly acknowledged, it is important that the written trauma narrative is not highlighted, as this can be anxiety provoking particularly for children. Therapists may encourage children to briefly introduce themselves and their caregivers by name. This provides an opportunity for therapists to model specific praise of each child’s introduction, while also assessing each child’s comfort level with the group format before separating the caregiver and child groups.

Caregiver Session 1

Evidence-based engagement strategies may be utilized to review and address any concrete (e.g., transportation and childcare obstacles) as well as attitudinal barriers to full therapy participation (McKay & Bannon, 2004). This includes inquiring about prior therapy experiences and highlighting differences between the planned therapy program and prior less than optimal therapy experiences. This type of therapeutic engagement is important because it has been documented that such engagement significantly reduces drop-out rates and increases TF-CBT completion rates (Dorsey et al., 2014). Gradual exposure also begins in the first session of the caregiver group, as caregivers are asked to briefly describe what brought them to group. This discussion shows caregivers they are not alone in their experience. Psychoeducation about TF-CBT is then provided to the caregivers, emphasizing the efficacy of the treatment model, the positive impact of parental support on children’s adjustment, and other information that instills hope. For example, research has documented that parental support and involvement in treatment strongly predict positive adjustment in children who have experienced trauma (Cohen & Mannarino, 2000; Deblinger et al., 1996; Kliewer, Murrelle, Mejia, Torres, & Angold, 2001; Laor, Wolmer, & Cohen, 2001). Highlighting these findings when discussing the benefits of caregiver involvement in this approach to treatment can be very comforting to caregivers. Psychoeducation about the trauma(s), PTSD, and traumatic grief may be supplemented by the distribution of educational handouts (available through the National Child Traumatic Stress Network, http://nctsn.org/trauma-types) that emphasize prevalence, dynamics, and other helpful information. The treatment plan overview incorporating parenting and coping skill exercises is introduced in this session. Time permitting, the value, impact, and steps for praising children’s positive behaviors are described as a first step toward encouraging caregivers to refocus their attention on their children’s strengths.

Child Session 1

Following introductions, group rules are typically established by asking the children for rules that may be reviewed at the start of sessions when necessary. Children often spontaneously suggest listening and following directions. A rule about appropriate boundaries is typically included. With younger children, this rule may be described using the terms OK and not OK touches; for example, “Only use OK touches and OK words.” A brief discussion about OK and not OK touches follows, so the children are clear on what these rules mean. A rule about confidentiality is also included, such as “What is shared in group stays in group.” However, given that many traumas, such as sexual abuse, are generally surrounded by secrecy, a caveat is made that children may share what they are discussing in group with their caregivers to encourage open child–caregiver communication. At some point in this first session, it is important to note that all of the children in the group have experienced some type of trauma. The trauma(s) to be discussed may then be listed (e.g., sexual abuse, domestic violence exposure, traumatic loss, etc.) depending on the group makeup. As noted above, this shows children they are not alone in their experience and begins the gradual exposure process. Psychoeducation about the trauma(s) experienced, PTSD, and TF-CBT also begins in Session 1. Ideally, the group should end with a fun activity to facilitate group members getting to know one another, such as an art activity and/or a charades game in which participants share favorite hobbies. Time permitting, children may also be taught and engaged in a relaxation activity or exercise.

Caregiver Session 2

Session 2 may begin with a review of caregivers’ reactions and questions regarding the information and the educational handout provided in the last session. This allows the therapist an opportunity to validate reactions and continue gradual exposure highlighting information that is destigmatizing and hopeful (e.g., prevalence of the trauma(s) experienced and reasons to be optimistic about child’s recovery), while also checking in on caregivers’ efforts toward the identification of resilient child behaviors exhibited between sessions.

The parenting component may begin, or continue, in this session with a focus on helping caregivers understand the development of PTSD symptoms, while learning to encourage adaptive child behaviors with positive family rituals and specific praise. The therapist may focus on encouraging caregivers to initiate and/or reinstate positive family rituals (e.g., child–caregiver walks, bedtime stories, family dinners, etc.) or one-on-one time that will create natural opportunities for caregivers to use praise with their children. During caregiver group sessions, it is important to repeatedly emphasize the power of positive caregiver attention, while also reviewing factors that enhance the effectiveness of praise for positive behaviors (e.g., specificity, enthusiasm, and avoidance of negative tags). Each week, caregivers’ feedback on their experience using praise during the past week should be elicited, providing an opportunity for the therapist to acknowledge that children who are not accustomed to receiving praise do not always respond favorably to praise initially but with time they will not only appreciate it but will often begin to return expressions of praise. As the group progresses, therapists’ predictions are often reinforced by various caregivers’ reports of their experiences with praise. Caregiver behavior rehearsals often begin with the sharing of the specific praise each caregiver plans to express to the child during a brief conjoint session. This provides an opportunity for caregivers to receive positive and constructive feedback from the group therapist as well as other group members before they actually share the planned praise with their child during a brief conjoint group activity. Caregivers’ initial praise examples often inadvertently include negative tags (e.g., Nice job, if you would only do that every day). Thus, caregiver behavior rehearsal and feedback from other caregivers, who are similarly attempting to master the use of specific and purely positive praise have been found to be particularly valuable during group.

The caregiver and child groups move in parallel and therefore relaxation is also typically taught in the caregiver group with an activity that engages caregivers in focused breathing or a mindfulness exercise. As a PRACTICE assignment this session, caregivers may be encouraged to practice and model for their children the use of relaxation skills (e.g., focused breathing) and continue to specifically praise adaptive child behaviors. The caregivers are each encouraged to select specific adaptive child behaviors that can replace problem child behaviors, so the therapist can follow-up on progress with praising those particular behaviors. Caregivers also should be apprised of the rationale for gradual exposure and the plan for the child group sessions to ensure they are comfortable with the activities, including, for example, teaching children the names of private parts (in the case of a group focused on child sexual abuse). Therapists generally utilize a combination of didactics, modeling, and behavioral rehearsal throughout the group program.

Child Session 2

During this early session, it is important to engage in gradual exposure by modeling and reviewing language that will help the children speak clearly and comfortably about the trauma(s) endured (e.g., sexual abuse, physical abuse, domestic violence, death, etc.). With younger children who have experienced sexual abuse, for example, body parts identification may be taught using cutouts of a boy and a girl in bathing suits. Children identify all body parts including “nonprivate” and private parts (i.e., vagina, breasts, penis, and buttocks; as noted above, caregiver permission is obtained in advance). For adolescents, following a playful competition during which the teens compete on the number of terms they know for the private parts (including slang terms), the group then may be encouraged to use the doctors’ terms when discussing sexual abuse and/or other sex education. Basic information about the prevalence, impact, and dynamics of types of traumas experienced by group participants may be reviewed in a manner appropriate to the developmental stage of the children.

As in individual TF-CBT, relaxation is taught in an age-appropriate manner relatively early in treatment often starting with deep breathing. Other relaxation skills such as progressive muscle relaxation, imagery, and/or mindfulness techniques can be taught. The use of these relaxation skills between sessions may be discussed and encouraged as a PRACTICE assignment particularly when coping with trauma reminders. The children may then be prepared to teach at least one relaxation skill to their caregivers in the conjoint portion of Session 2.

Conjoint Session 2

The conjoint activity typically involves the children as a group teaching their caregivers a relaxation skill. This activity is often followed by caregivers one at a time offering their children praise (as prepared) for a previously identified positive child behavior. This conjoint activity is often repeated across group sessions, so that caregivers can practice and hone their praise skills over the course of the group program.

Child Session 3

This child group may continue psychoeducation with a review of the use of relaxation skills to cope with daily stressors and trauma reminders. Next, affect expression is typically introduced by asking the children to generate a list of as many feelings as they can (e.g., within 45 seconds) and later engaging in an activity in which children explain what a particular feeling word means or giving an example of a time they felt that way. Teens may enjoy identifying situations that have a range of different emotions (e.g., starting a new school and going on a date) and listing all of the related emotions. Once a long list of feelings has been generated with hints by the therapists, if necessary, the various feelings listed may be combined and utilized throughout the group program. As part of ongoing gradual exposure, children may be asked to share feelings from the list, either verbally or by circling those that they experienced at the time of the trauma(s). “Feeling charades” (acting out a feeling without words while others guess the feeling) is another fun activity that can be played. After the game, the therapist emphasizes how much more effective it is in the long run to share feelings in words so others do not have to guess what they are feeling since sometimes people guess wrong. Next, children may begin a list of tools/skills they can utilize to help manage distressing emotions (e.g., talking to others, deep breathing, listening to music, etc.), creating a coping toolkit that can be added to throughout the group. Therapists may need to gently steer children away from problematic affect regulation activities such as punching walls or yelling and screaming by having them examine the consequences of such methods. As a PRACTICE assignment, children may be encouraged to share their feelings in words with their caregivers between sessions and take note of the skills and activities they naturally use to manage their emotions with an emphasis on incorporating the use of skills discussed in group.

In preparation for the conjoint session, children may be encouraged to share how they felt in nontrauma-related situations (“I felt…when…”). In fact, children may prepare to share with caregivers in the conjoint session a negative feeling and a positive feeling they experienced during the week by practicing specific I felt…when…statements. For this exercise, therapists should steer children away from sharing trauma-related feelings with caregivers this early in treatment instead focusing them on sharing mildly negative feelings they may have had about school, friends, or other recent experiences. It is also helpful to encourage children to share a positive feeling about something their caregiver did that they liked (e.g., “I felt happy when you helped me with my homework”). Therapists are encouraged to prepare notes about the feeling statements children plan to share to prompt them during the conjoint group sessions when nerves cause some children to forget their plan.

Caregiver Session 3

The caregiver group therapist may initiate group with a review of the caregivers’ PRACTICE assignment, which involves eliciting detailed descriptions of caregivers’ efforts to praise the adaptive child behaviors identified in the previous session as well as children’s reactions to those efforts. Caregivers often report surprise at the effectiveness of praise for specific behaviors. Once again, the therapist provides positive as well as constructive feedback regarding the caregivers’ PRACTICE assignment efforts with respect to praise.

The children’s group agenda may then be described to caregivers, including the activities planned to help the children expand their emotional vocabulary and verbally express their feelings, while also learning to more effectively manage their feelings. The rationale for such activities should emphasize research that children who express feelings in words rather than behaviors exhibit more positive adjustment (Eisenberg, Cumberland, & Spinrad, 1998).

The parenting topic that may be introduced in this session is reflective listening, which is designed to encourage adaptive behaviors and the effective expression of feelings by the children. It is important to encourage caregivers to role-play reflective listening skills in the group, as caregivers tend to be highly directive and jump quickly to problem solving when children share problems or express negative feelings. Rather, caregivers are reminded that there are many problems for which there are no real solutions, and children often simply want to feel heard. Thus, it is very helpful to have caregivers practice reflective listening via role plays with the therapist playing their child, while other caregivers observe and signal with a raised hand when the role-playing caregiver inadvertently moves into problem-solving mode as opposed to purely listening and validating the expressed feelings. During these role-play exercises, caregivers should be encouraged to minimize their attention to negative behaviors and focus on listening and specifically praising the child’s efforts to share feelings. Caregivers may be prepared for the conjoint activity by briefly practicing reflective listening via role plays that utilize the positive and negative feelings the child is planning to share (i.e., one of the child group therapists can provide that information in advance of the conjoint session).

For their PRACTICE assignment, caregivers are encouraged to model the appropriate sharing of feelings (e.g., frustration with work or disappointment) and catch and praise not only the adaptive child behaviors identified previously but also children’s efforts to appropriately share positive and/or negative feelings with words during the week. In terms of self-care, caregivers may also be asked to identify individuals in their lives with whom they can share their feelings and receive positive support particularly with regard to the crisis they are facing.

Conjoint Session 3

The conjoint activity may involve each child first sharing his or her prepared negative and then positive feeling statements with his or her caregiver(s), who practices responding simply with reflective listening and specific praise (e.g., “You felt sad and frustrated when you did poorly on the math test. I am really glad you shared your feelings with me about that test.”). In addition, the caregiver may share another specific praise regarding a positive adaptive behavior the child exhibited during the week. Global praise (e.g., “I’m so proud to be your parent”) or other means of expressing unconditional love for the child (e.g., hugs, high fives, and “I love you”) may be encouraged as well during these conjoint PRACTICE activities.

Child Session 4

The child group typically starts with a review of coping skills learned thus far and children’s successful efforts sharing and managing their feelings between sessions. Next, the therapist may offer an introduction to cognitive coping in relation to nontrauma-related thoughts and feelings. Even very young children can master cognitive coping skills, but it is preferable to explain and offer examples of the simple relationship between thoughts and feelings to them, while the interrelationships between thoughts, feelings, and behaviors may be explained to older children and teens using the cognitive triangle. The group format allows children to share everyday examples of common social stressors (e.g., fight with a friend) that often highlight the fact that all children talk to themselves about their troubles and often have very similar thoughts and feelings. Children are then introduced to the concept of helpful and unhelpful thoughts and are given nontrauma-related example thoughts to decide if they are helpful or unhelpful as well as accurate or inaccurate. Again, working together, children determine the helpfulness of the thoughts by imagining how such thoughts might impact children’s feelings and behaviors. Older children and adolescents may be encouraged to begin trying to take note of their thoughts outside of session as a PRACTICE assignment using an automatic thought record. This important skill may then be added to each child’s individualized coping skills toolkit, which they may be encouraged to continue to draw on between sessions.

In preparation for the conjoint session, the therapists typically also introduce the concept of praise to the child group members and ask the children to identify a statement of praise they can say to their caregivers in the conjoint portion of the session. Over time, the children are steered away from praising their caregivers for things that cost money, as these things often need to be limited and it is preferable to encourage praise of the caregiver’s assistance, kind words, time spent together, and so on. Children’s statements of praise may be written down in order to prompt them during the conjoint session if they forget what they had planned to say. Other choices to offer children for conjoint activities include engaging their caregivers in a group feelings activity such as “feelings charades” or presenting their knowledge of cognitive coping to the caregiver group with each child, for example, presenting a thought and the resulting emotion. These examples can include both helpful and unhelpful thoughts as well as positive and negative emotions. The therapist might prompt the children in the conjoint session by asking them to describe the emotions generated by particular thoughts (e.g., “I am no good at anything”; “If I work hard, I can succeed”).

Caregiver Session 4

The caregiver group begins as usual by reviewing parenting PRACTICE assignment efforts and providing feedback. After eliciting caregivers’ accounts of their experiences with PRACTICE assignments at home, the parenting topic of selective or differential attention may be introduced. Caregivers are asked to identify a mild negative behavior the child has repeatedly exhibited that they may begin to actively ignore while they simultaneously identify and praise a positive replacement behavior. Caregivers, however, must be forewarned that when initiating active ignoring, the ignored behavior will sometimes get worse before it gets better (i.e., extinction burst) requiring a commitment to continue ignoring the behavior (assuming it is not dangerous in any way) until it diminishes. Caregivers may also be prepared to use praise and active ignoring skills during the conjoint session when children’s anxieties lead them to misbehave a bit in conjoint session. The parenting PRACTICE assignment then typically encourages a focus on utilizing selective attention, which combines active ignoring of a mild problem behavior with praising an identified positive replacement behavior.

Next, the planned agenda for the child group may be shared. Typically, cognitive coping skills are then introduced using the cognitive triangle with caregivers as well. Unlike the children who learn to apply these skills to nontrauma-related experiences only (at this stage of therapy before the narrative is completed), caregivers are encouraged to identify times they have found themselves feeling distressed about the trauma(s) endured by the child. The therapist can then elicit from caregivers the types of feelings experienced as well as underlying thoughts. The therapist may continue to elicit thoughts, recording them on a white board, until there are both functional and dysfunctional thoughts shared by caregivers, which then allows the group to begin to identify thoughts that are accurate and helpful as well as thoughts that are unhelpful and/or inaccurate. Once problematic thoughts are identified by the group, the therapist may challenge unhealthy thoughts through the use of Socratic questioning and the review of contradictory evidence. The group format also allows the therapist to encourage caregivers to help one another with problematic thoughts using the information they have learned thus far, which can be particularly therapeutic for participants.

Caregivers’ PRACTICE assignment is typically to continue to implement parenting skills including praise and active ignoring and to record in a journal or automatic thought record (provided by the therapist) their feelings and thoughts during the week when they find themselves dwelling on the trauma(s) or other distressing situations. After identifying problematic thoughts that seem to underlie their distressing feelings, caregivers are asked to practice replacing those problematic thoughts with more accurate, helpful thoughts while also recording how those new thoughts impact their feelings. One caregiver, for example, who had been blamed for the death of his or her spouse used the cognitive restructuring technique to combat feelings of shame and depression. Caregivers should also be prepared for the conjoint activity by being asked about the praise for their child. Even at this point in treatment, caregivers often need some coaching to remain purely positive and avoid negative tags when they praise. Thus, it is important to continue to have caregivers share the praise they will offer their child before the conjoint session, so they can receive constructive feedback if needed.

Conjoint Session 4

As noted above, this conjoint session may involve the children presenting or teaching cognitive coping skills to caregivers or the children engaging the caregivers in an affect expression or regulation activity, such as feelings charades. The children act out feelings without using words and the caregivers attempt to guess the feelings. Caregivers are encouraged to practice their selective attention skills. Following the conjoint activity, there may be a mutual exchange of praise, which can become an ongoing ritual to end sessions throughout the program. Children and caregivers may need some encouragement to make eye contact while delivering and receiving praise. Some teens balk at this activity at first but come to look forward to exchanging praise by the end of the group program.

Child Session 5

The child group may start with additional activities related to cognitive coping such as reading a story that demonstrates the concept, drawing people with thought bubbles on a white board, and so on, and following up on the PRACTICE assignment if one was encouraged. During this session, an emphasis is placed on the children identifying different types of (nontrauma related) problematic thoughts as well as helpful replacement thoughts. Older children and adolescents may be given a PRACTICE assignment of catching everyday dysfunctional thoughts and replacing them with healthier replacement thoughts using automatic thought records and/or a journal. It is then critical to review the children’s experience with this assignment in the session that follows.

In preparation for the conjoint session activity, psychoeducation may be reviewed, often using the What Do You Know? card game when the groups are in English or Spanish (Deblinger, Neubauer, Runyon, & Baker, 2006). Group format is quite conducive to engaging in a question and answer game using a game show-type format in which the question is read and children compete for points. It is important to carefully select the game questions to include those that cover the trauma(s) experienced by the group participants as well as those that are age appropriate. Children are often surprisingly excited about the possibility of showing off their newfound knowledge to their caregivers in the context of a conjoint session game. As in prior sessions, the children may also prepare praise statements for their caregivers.

Caregiver Session 5

In the caregiver group, the cognitive coping PRACTICE assignments may be reviewed as it is likely to take some time for caregivers to overcome the dysfunctional thoughts with which they may be struggling. The therapist, with the help of the other caregivers, may continue to utilize Socratic questioning to challenge dysfunctional thoughts that caregivers share in group. This session’s parenting topic is typically related to caregivers gaining their children’s cooperation with effective instructions and the introduction of family rules and negative consequences.

Psychoeducation is reviewed in preparation for the conjoint activity that is designed to begin the process of helping caregivers and children discuss the trauma(s) experienced in general terms. Depending on group progress, therapists may suggest to caregivers that children may begin to have individual time with their therapists in order to focus more on their personal experiences. The trauma narrative, however, is not typically highlighted until it becomes clear that most children will be responsive to creating some type of trauma narrative or other trauma exposure product (e.g., drawing, poem, rap, etc.). Praise statements for the children are also prepared and reviewed by therapists. Caregivers are encouraged to implement parenting and individualized coping skills PRACTICE assignments during the week. Therapists are often more successful in encouraging caregivers’ commitment to engaging in healthy coping practices between sessions by frequently emphasizing their important influence as coping role models for their children.

Conjoint Session 5

For this session’s conjoint activity, the families often review psychoeducation through the game show format referred to as “Family Feud.” The format of this game requires each family to agree on a team name, which is written on the dry erase board where points will be tracked. Questions are read and children and their caregivers raise their hands to answer the question; team members can help each other out with their responses. Points are earned for effort (i.e., volunteering to answer a question) and correct answers as well as for team members praising each other for correct responses. Although specific details of children’s traumatic experiences are not discussed, the game likely triggers traumatic memories that are essentially paired with neutral, and in many cases, positive emotions as the competitive game format often elicits laughter and feelings of pride. These emotions may then replace the overwhelming negative emotions that have been associated with the traumas being discussed. Again, this activity might lead to some mild negative child behaviors due to discomfort or overly enthusiastic competitive child behaviors. Caregivers thus have another opportunity to use praise and selective attention. The conjoint session may again end with a positive end-of-session ritual such as the mutual exchange of praise that each caregiver–child dyad engages in one at a time.

Child Session 6

This child group typically starts by introducing the concept of a trauma narrative through the reading of a story, handout, or published narrative about the type of trauma(s) experienced by group participants (e.g., Please Tell, Jessie, 1991, Something is Wrong at My House, Davis, 2010). The children are then prompted to share a title and introduction similar to the character in the book as if they were going to write their own book. If chapters more directly related to the trauma will not begin until the next session, the trauma narrative is not explicitly introduced to avoid raising anxiety about the narrative over the course of the week. A fill-in-the-blank introduction can be utilized with younger children to facilitate completion in the group setting. After completing a title and introduction, depending on the progress and makeup of the group, therapists may turn the focus of the group to continuing to integrate coping skills by encouraging the creation of coping skills index cards in which children list their top three coping skills they can use at home when they become upset. Groups that are progressing well may be ready to begin the development of the outline for their trauma narrative and the second more detailed chapter of their trauma narrative in individual pull-out sessions. See Session 7 below for more details regarding the process for beginning the trauma narrative. Children may also be introduced to the concept of self-praise by learning to make self-statements such as “I’m proud of …” or “I’m good at …” while also generating praise statements for their caregivers in preparation for the conjoint session.

Caregiver Session 6

The caregiver group begins as usual with a discussion about the previous week’s PRACTICE assignment. The concept and rationale for the increased focus on trauma narration and processing in the children’s group is shared with caregivers when appropriate. The therapist may emphasize the focus on helping children discuss, express verbally, and/or write about their thoughts and feelings about the traumatic experiences through individualized activities. It is important not to overly focus on a written narrative as the children in the group may vary in the way they are engaged in the trauma narrative and processing. However, it is important to emphasize the overall goals of reducing children’s trauma-related avoidance and/or shame while supporting their efforts to make sense of their experiences. The caregiver group also continues to focus on the implementation and review of effective parenting and coping skills. Thus, caregivers may continue to be given individually tailored parenting and coping PRACTICE assignments.

Conjoint Session 6

For the conjoint activity, children typically share their coping skills index cards with their caregivers, so the caregivers can prompt them to use these skills throughout the week. Children and caregivers then may exchange praise.

Child Session 11

During this session, safety skills are introduced or reviewed if previously discussed and role plays are typically taught and practiced by the children in an age-appropriate manner relevant to the primary trauma(s) endured (Deblinger et al., 2001). Safety plans and role plays that involve the practicing of calling 911 might be incorporated in groups with children exposed to domestic violence. For children who have been sexually abused, the safety skills component may start with psychoeducation about touches or age-appropriate sex education. Younger children may review OK, not OK, and confusing touches. For older children, age-appropriate sex education is provided (with caregiver permission) as well as a discussion of timelines for ideal “romantic” relationships (i.e., when one begins holding hands, kissing, hugging, engagement, marriage, sex, etc.). Safety skill scenarios (e.g., abuse threats, exposure to domestic or community violence, etc.) are created and roleplayed that are relevant to the children in the group. During this session, therapists may also elicit from the children ideas that might contribute to their final group celebration. Even older children often enjoy making and decorating graduation caps for the end of therapy celebration. Finally, they generate their praise statements for the caregivers.

Caregiver Session 11

The caregiver group may start as usual with the PRACTICE assignment review. The rationale and limitations (e.g., these skills are not a guarantee that the child will never experience victimization again) for teaching children personal safety skills are presented in an interactive manner, so that caregivers can ask questions and prepare for the conjoint activity. This may involve caregivers participating in brief preparatory role plays in which they act as themselves demonstrating how they would respond to the child disclosing a new threat or an experience of abuse or exposure to violence. Later during the conjoint session, caregivers will engage in very similar role plays with their children. Depending on the potential concerns for revictimization and/or acting out behaviors, more than one session may focus on safety skills. During this session, preparations may also be discussed for the graduation celebration. Caregivers may be encouraged to collaborate in planning the celebration party by contributing music, decorations, drinks, snacks, and/or desserts. The PRACTICE assignment is typically the continued use of the parenting and coping skills.

Conjoint Session 11

Children typically demonstrate the safety skills role plays for the caregivers during this conjoint session with each child participating in a role play with his or her caregiver playing the part of the adult the child tells. When appropriate, caregivers reflect back what the child has disclosed and specifically praise the child for his or her use of the safety skills. Children and caregivers then may engage in the mutual exchange of praise.

Child Session 12

The final child group typically starts with a review of the safety skills role plays as well as a discussion of the various skills learned in group. Depending on the age of the children, a graduation activity may be planned. Young children may enjoy singing the “My Body” song (www.peteralsop.com) with or for their caregivers. In the final session, older children and teens may enjoy presenting to their caregivers a group art project, rap, or news show about what they learned about the trauma(s) experienced. The children may also be encouraged to prepare self-praise and praise for their caregivers related to the caregivers’ group participation or changes at home as a result of their group participation.

Caregiver Session 12

The caregiver group begins as usual with the PRACTICE assignment review. The various skills taught throughout therapy are reviewed with a focus on the continued use of skills after therapy ends to reduce the risk of relapse while also encouraging caregivers to feel free to contact the therapist for support if such needs arise. Caregivers may be encouraged to prepare praise for the final conjoint session that acknowledges their children’s behavioral progress and participation in group. This final praise also often includes global expressions of praise (e.g., I love you) and affection, including hugs and high fives.

Conjoint Session 12

For the conjoint activity, children often enjoy entering the caregiver group room wearing their graduation caps with “pomp and circumstance” playing. A planned group activity may then be introduced as previously described. Children sit next to their caregivers and graduation certificates are distributed to children and caregivers one by one. The final mutual exchange of praise may take a bit longer than usual, as caregivers are encouraged to be as effusive as possible with their praise. Finally, a relaxed, unstructured celebration begins with the sharing of food brought by the caregivers, music, and casual conversation. When the children leave, they may be encouraged to walk through the office suite or clinic setting wearing their graduation caps to share their accomplishment with office staff that may be on hand with congratulatory remarks, handshakes, and high fives.