Youth trauma narratives: meaning-making during trauma-focused CBT
Children and young people that have been through multiple traumatic experiences can experience high levels of post-traumatic stress symptoms (PTSS). One of the most effective trauma-focused treatments (de Arellano et al. 2014; Lewey et al., 2018) is Trauma-Focused Cognitive Behavioural Therapy (TF-CBT). TF-CBT is the NICE recommended treatment for children experiencing PTSS (NICE, 2018) and the positive effects have been found to be maintained at follow-up (Jensen, Holt, & Ormhaug, 2017).
A key part of the TF-CBT treatment is the creation of a trauma narrative, where patients talk through their experiences repeatedly and associate thoughts and feelings with events in a form of ‘gradual exposure’. This is followed by a period of processing cognitive distortions, misappraisals, and emotions (Ascienzo, Sprang, & Royse, 2022).
According to the current study’s authors, previous research on trauma narration has occurred ‘outside a treatment context’ and focused more on the relation between PTSS and trauma narratives (Ascienzo, Sprang, & Royse, 2022). This study instead aimed to look at how, during these narratives, young people interpret and create meaning from their experiences, and the products of this meaning making. The authors investigated the following research questions:
- How do youth appraise and make meaning of their traumatic experiences?
- What products of the meaning-making are evident in the youth trauma narratives?
Children and young people aged 7 and above were recruited from a US trauma treatment clinic. Children were eligible to participate if they had received TF-CBT (Trauma-Focused Cognitive Behavioural Therapy) and completed a trauma narrative as part of treatment. The final, completed versions of participants’ trauma narratives were analysed in this study.
Participants must have experienced multiple forms of child mistreatment within a caregiving relationship, and at least one placement disruption, to ensure findings were representative of the typical youth at the clinic. Caregivers gave consent and participants assented to participate.
This study used thematic analysis (Braun & Clarke, 2006) to explore the trauma narratives. The authors explained their choice of thematic analysis was to focus on the ‘essence’ of the youth narratives, and felt thematic analysis allowed for participants’ social context to be considered; important for meaning-making and its products.
16 youths participated in the study, eight males, ranging from 8-16 years old (mean 13.25). Participants experienced chronic child maltreatment, (mean 5.38 different types), such as physical/psychological/sexual abuse, domestic violence, and neglect. All had experienced maltreatment from a primary caregiver and had past/current child welfare involvement.
Meaning-making of traumatic experiences
For youths’ meaning-making of traumatic experiences (RQ1), four themes were identified:
1. I Am Not Safe
Lack of safety was felt by all youths. This included lack of physical safety, such as physical abuse or impaired caregiving due to substance misuse, and lack of psychological safety, including feelings of fear and powerlessness.
2. It’s My Fault: Misattributions of responsibility
Participants identified a sense of responsibility, divided into three subthemes. First, participants felt responsibility for the maltreatment and removal from care, believing it a result of their behaviour.
Participants also discussed responsibility to protect and care for parents, for example when their biological mother was a victim of interpersonal violence, and had ongoing concerns about parents’ safety with mixed emotions about leaving.
Participants also felt they had to protect their siblings (especially younger), and discussed a desire to protect but also resentment, guilt, and anger around having to do so.
3. I Am Changed
All participants mentioned the negative impact of their trauma on their sense of self, relationships, and their world view. This came under three subthemes: difficulty trusting others, negative cognitions related to self (for example ‘I was bad’), and complicated emotions related to self, (including sadness, loss, shame, and guilt).
4. Why Did This Happen to Me?
One of the most prominent themes, this described participants attempts to make sense and meaning out of their experiences. All participants struggled with cognitive dissonance regarding their attachment to their offending caregivers, and their mistreatment, and this was associated with conflicting emotions.
Meaning-making in youth trauma narratives
For products of the meaning-making in youth trauma narratives (RQ2), the authors identified three themes:
1. Now I Know: Reappraisals
All 16 participants showed evidence of reappraisals, mostly around blame and responsibility. For example, ‘I don’t feel worthless anymore. I know the abuse wasn’t my fault’.
2. I Am Safe/r: Improved Sense of Safety
All 16 participants mentioned an increase in their sense of safety, with both youths who did and didn’t want to return to living with their offending caregivers.
3. I Can Do This: Perceptions of Growth
All participants spoke about their growth and changes over the course of treatment, including expressing and managing emotions, coping skills, their experiences no longer defining them, fewer concerns about their future behaviour as parents/partners, and considering professions involving helping others.
This study highlights and provides a deeper understanding of youths’ experiences of creating trauma narratives during TF-CBT treatment, their meaning-making process, and the products of this process.
Strengths and limitations
This study was the first to focus on youths’ meaning-making process, and products of this, in their TF-CBT (Trauma-Focused Cognitive Behavioural Therapy) trauma narratives. The study methodology was sound, and the authors ensured the sample recruited represented the typical trauma clinic patient, thus making the results relevant to this population. The authors use of thematic analysis (rather than previous studies’ use of narrative analysis) was well rationalised, and their process clearly outlined, including additional steps such as the scrutiny techniques of repetition and similarities and differences (Ryan & Bernard, 2003). The focus on complex trauma prevented single-incident trauma narratives potentially conflating or diluting themes, and the sample was not limited by presentation, which allowed for a variety of experiences to be captured.
As stated by the authors, however, the sample size was small, and only from one trauma clinic in the US, making the results unlikely to be generalisable (although this is not the focus of qualitative research). The authors also mention that the trauma narratives were collected retrospectively and therefore may have missed some in-session details that could have informed the themes further.
Interestingly, all participants appeared to have successfully completed TF-CBT and showed evidence of change/recovery in the themes. Whilst a complete trauma narrative was a requirement to be included in this study, I wonder if the fact that all participants were successful in changing their cognitive distortions, for example, gave a positively skewed tale of TF-CBT in this instance, and whether inclusion of participants who had struggled to change their cognitions (despite completing TF-CBT on paper) might provide even more insight.
Implications for practice
As stated by the authors, this study has several clinical implications, particularly for clinicians using TF-CBT and how this can inform their practice within treatment. The researchers suggest that paying attention to young people’s meaning-making can help to know when to move to the next stage of treatment, and if clinicians prompt this sort of processing, this can help to identify cognitive distortions that need to be targeted.
In terms of research implications, further research comparing those who have successfully completed TF-CBT, those who attempted but did not complete TF-CBT, and those who did not have treatment at all, may help to provide further insight. I would also be interested in follow-up studies, to see if these reappraisals, meaning-making and products are maintained over time. Further research could also replicate this research in different geographical locations and cultures, to see if this alters themes. For me, I am glad that research is shifting to pay more attention to young people’s personal perspectives and interpretations, and I welcome further research into this area.
Statement of interests
Ascienzo, S., Sprang, G., and Royse, D. (2022). “My Bad Experiences Are Not The Only Things Shaping Me Anymore”: Thematic Analysis of Youth Trauma Narratives. Journal of Child & Adolescent Trauma, 15, 741-753.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101.
de Arellano, M. A. R., Lyman, D. R., Jobe-Shields, L., George, P., Dougherty, R. H., Daniels, A. S., & Delphin-Rittmon, M. E. (2014). Trauma-focused cognitive-behavioral therapy for children and adolescents: Assessing the evidence. Psychiatric Services, 65(5), 591–602.
Jensen, T.K., Holt, T. & Ormhaug, S.M. (2017). A Follow-Up Study from a Multisite, Randomized Controlled Trial for Traumatized Children Receiving TF-CBT. Journal of Abnormal Child Psychology, 45, 1587–1597.
Lewey, J.H., Smith, C.L., Burcham, B., Saunders, N.L., Elfallal, D., and O’Toole, S.K. (2018). Comparing the Effectiveness of EMDR and TF-CBT for Children and Adolescents: A Meta-Analysis. Journal of Child and Adolescent Trauma, 11, 457–472.
National Institute for Health and Care Excellence (NICE). (2018). Post-traumatic stress disorder: treatment for children and young people.
Ryan, G. W., & Bernard, H. R. (2003). Techniques to identify themes. Field. Methods, 15(1), 85–109.
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