Incorporating cultural considerations into TF-CBT

As you may know, Teresa Huizar, head of the National Children’s Alliance, does a newsletter every Monday morning, and yesterday’s was about implementing the TF-CBT therapy model with Black youth and families.  It’s reproduced in full below:  

Incorporate cultural considerations into evidence-based treatment for better outcomes

Photo of Teresa HuizarGood morning and welcome back to Monday. I hope this finds everyone continuing to stay safe and healthy. This morning, I want to turn your attention to Trauma-Focused Cognitive Behavioral Therapy, or TF-CBT. As I’m sure you’re all aware, the Mental Health Standard of our Standards of Accreditation requires that Children’s Advocacy Centers (CACs) demonstrate that their mental health providers are trained to deliver evidence-supported mental health treatments to children who have experienced trauma from abuse. There are several modalities from which to choose, including TF-CBT, Parent Child Interaction Therapy (PCIT), Alternatives for Families: A Cognitive Behavioral Therapy (AF-CBT), Child and Family Traumatic Stress Intervention (CFTSI), Eye Movement Desensitization and Reprocessing (EMDR), for example. But TF-CBT is often favored, not only because of the strong empirical support showing that it helps to significantly reduce the impact of trauma but also because it is designed for the population that CACs typically serve: children 3-18 who have experienced trauma and have related, clinically significant mental health symptoms.
With that in mind, I want to alert you to an important new resource titled “Integrating Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and Racial Socialization for Black Youth and Families: An Implementation Manual.”[1] Before examining the manual, I want to reiterate what the authors emphasize at the outset—that this manual is designed as an extension of the TF-CBT model. This extension maintains the “core elements of an existing treatment while integrating the culture of at-risk populations in order to increase treatment relevance, acceptability, and sustainability of evidence-based interventions.” Id., p. 3. Therefore, the authors “strongly recommend that therapists complete the TF-CBT basic training prior to implementing the TF-CBT applications for Black youth and families who experience racial trauma or stress described in this manual.” Id., p. 4.
We have understood, for some time now, the long-term, detrimental impact of racism on its victims. The Black Lives Matter movement of the last few years has revived this conversation and placed it in the context of the larger youth mental health crisis this country is facing. This manual is particularly timely, and “provides therapists with guidance and information about how to implement TF-CBT with appropriate cultural considerations for Black youth and families who have experienced interpersonal and racial stress or trauma.” Id., p. 8. Importantly for our purposes as CACs and multidisciplinary teams, though, the manual is not meant to be solely for use in the context of racial stress and trauma. Indeed, the authors note that it is “not restrictive to youth who have identified specific racial traumas, … it is also applicable and relevant for all Black youth who qualify for TF-CBT treatment due to any remembered trauma experience; any of these youth can benefit from racial socialization and other culturally protective processes that can be integrated into TF-CBT.” Id.
What is racial socialization? The authors define it as “the protective process of transmitting cultural behaviors, attitudes, and values to prepare youth to cope with stressors associated with their ethnic minority status.” Id., p. 13. By way of example, the authors point to “The Talk”—a practice that is common in Black households and is a way for adults to “pass on the values and practices of their ethnic group, and … help youth prepare for and heal from negative racial encounters.” Id. Prior research has identified seven primary types of racial socialization messages, which focus on different aspects of racial identity, “like culture, discrimination, and group relations.” Id. The authors give examples: “racial pride messages teach children about Black heritage, history, and culture to promote group unity and combat negative experiences. … Racial barrier messages … focus on preparing for, coping with, and healing from experiences with discrimination and racism.” Id., p. 14 (emphasis in the original).
The importance of integrating racial socialization into TF-CBT is that it “may provide Black children and youth with practical cognitive, emotional, and behavioral strategies that could enable them to notice/attend to, make meaning of, and contend with the racial events they have encountered.” Id., p. 16. Moreover, “racial socialization fits well within the cognitive behavioral framework, which seeks to identify and correct inaccurate/unhelpful thoughts, distressing feelings, and problematic behaviors.” Id.
The manual itself is a practical guide that offers step-by-step guidance for integrating racial socialization theory and TF-CBT practice. For example, it emphasizes the “practice and use of vocabulary that are both inclusive and transparent.” Id., p. 7. It discusses “that in building rapport early on in the therapeutic relationship, clinicians should be comfortable discussing aspects of their identity that impact the lens that they bring to therapeutic settings (e.g., a white clinician discussing their position of power and/or privilege). The current manual is also designed to foster clinicians’ comfort discussing issues including stigma and system mistrust, and better prepares clinicians to identify themselves as an ally or advocate, and to set clear intentions to help clients better understand, navigate, and thrive despite individual, organizational, systemic, and structural experiences with racism.” Id.

Adaptations such as this mean more individualized treatment for children and families—and can lead to greater engagement and more successful completion of treatment. I strongly encourage you to share this manual with your clinicians and your team partners. And if your clinicians need basic training in TF-CBT, National Children’s Alliance is here to help, with three virtual training opportunities:

For more information on prerequisites, costs, and other details, please click the registration links for each training session. And it is worth noting that even though these training sessions are considered basic training, they do address issues of racism and racial stress. For example, participants are asked to consider application of TF-CBT with families of color, and to consider how the child/caregivers’ experiences with discrimination and racial inequality have impacted the family. Additionally, participants will be asked to consider a family’s strengths to draw upon as resources. The basic training also includes standardized measures for assessing racial stress and racial trauma, as well as racial socialization resources.
We know that providing evidence-supported, trauma-focused mental health treatments to our clients is the key to helping them heal, recover, and thrive—and we must also adapt these treatments to improve efficacy and accommodate different families and different cultural needs. Integrating racial socialization to TF-CBT treatment is a first step to accomplishing this goal.
As always, I appreciate all your work on behalf of the children and families we serve.
Warmest regards,

[1] This manual is open access.