Reducing trauma in sexually exploited and trafficked girls through Trauma-Focused Cognitive Behavioural Therapy (TF-CBT): World Vision and Hagar Cambodia
Location: Phnom Penh, Cambodia
Names: Sateka Thy and Khun Channary of World Vision Cambodia and Linat Tiv and Sue Taylor of Hagar Cambodia
Email addresses: Sateka_Thy(at)wvi.org, Channary_Khun(at)wvi.org,Linat.Tiv(at)hagarinternational.org, sue.taylor(at)hagarinternational.org
Date of profile: October 2011
Intervention: 16-18 week treatment plan of TF-CBT
Aim: To address the unique needs of traumatised girls, between five to eighteen years of age, affected by sexual assault, sexual abuse, and/or trafficking for sexual exploitation and residing in residential care.
Background and context:
The Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) pilot was undertaken as part of a larger collaborative project between World Vision and Hagar Cambodia, World Vision US and Johns Hopkins University’s Applied Mental Health Research Group. The project aimed to conduct thorough staged assessments and develop locally validated tools for the purpose of piloting and evaluating interventions in a number of country contexts. The project thereby aimed to contribute towards the identification of evidence based approaches in child protection.
In 2007, in collaboration with the project partners and students of the Sociology Department at the Royal University of Phnom Penh, a qualitative study was undertaken with survivors of sexual abuse and trafficking for commercial sexual exploitation residing in five residential centres in Cambodia.. The study aimed to identify the problems facing the study population, from their own perspective, and to also identify the attributes and prosocial activities of children like them now ‘doing well’. The girls described depression like and Post-Traumatic Stress Disorder (PTSD) like symptoms, suicidal thoughts and broader problems of mood and anxiety. The girls also spoke about the rejection they felt from family and society.
Following the qualitative study, a literature review was undertaken to explore treatments designed for similar populations experiencing trauma that demonstrated effectiveness. TF-CBT was identified as the treatment with the strongest evidence base. TF-CBT was adapted and piloted with 12 children residing in residential care in Phnom Penh between May 2008 and September 2009 as part of a feasibility study aimed at assessing whether TF-CBT could be adapted to context by Khmer counsellors working with sexually exploited and trafficked girls. The pilot was led by Dr Laura Murray of the Johns Hopkins’ University Applied Mental Health Research Group and undertaken in World Vision’s Trauma Recovery Project and Hagar Cambodia?s Counselling Programme.
Based on the completion of a feasibility study and promising early indications from the pilot, the provision of TF-CBT and investment in staff training continues today. At the time of writing, more than 70 children have completed TF-CBT in Cambodia.
What the therapy plan does:
The psychotherapeutic model aims to address the unique needs of children with PTSD and other problems associated with the experience of traumatic events. The therapy helps children learn how to cope with negative feelings and problem behaviours, as well as helping them reframe their thoughts over what happened to them and what it means. The model incorporates elements of cognitive behavioural, humanistic, attachment, family and empowerment theory into a 16?18 week treatment plan. The plan however, is flexible and should be individualised to each and every child. The eight TF-CBT components are incorporated under the acrostic PRACTICE:
1. Psycho-education – provides information to the child about traumatic stress, normal reactions to traumatic events and the precedents for recovery
2. Relaxation – helps the child to physically relax and control their bodies
3. Affective regulation – assists the child to identify negative emotions, fears and anxieties and helps them deal with and cope with these feelings
4. Cognitive processing – helps the child to reframe unhelpful thoughts and negative perceptions about themselves
5. Trauma narrative – supports the child to tell their story verbally to increase their sense of control and help them manage their symptoms
6. In vivo desensitisation – supports the child to safely experience the problem area or fear in a real life situation through a gradual, managed process in the presence of the therapist
7. Co-joint parental sessions – works with parents to support positive parenting
8. Enhancing safety/social skills – teaches the child ways to feel safe, develop safety plans and establish safe relationships with others
The results of the pilot intervention involving the eleven girls and one boy were measured using the Child Exploitation Psychosocial Assessment Tool (CEPAT). Pre and post TF-CBT interviews were conducted with each child using CEPAT to record their individual symptoms and if and how these symptoms changed over the course of the treatment. As the CEPAT is validated for use with girls, only the girls CEPAT results were included in the analysis.
The average age of the girls who took part in the pilot was 15 years of age. The change in the symptom scores from pre-test to post-test showed an average reduction of 20% in depression symptom severity, a 26% reduction in symptoms of PTSD and a 44% reduction in symptoms of shame.
The girls participated in qualitative interviews two weeks after completing the intervention. They were asked about changes that had occurred in their life since the programme began. The most frequently reported change was a reduction in arguing and aggression. Several children talked about improvements in their ability to focus on their studies, other changes noted concerned girls? interactions with other children, such as the ability to make new friendships. Positive changes were experienced with regard to managing thoughts and feelings, and some children also talked about feeling braver and being able to confront their problems.
Interviews were also carried out with the 11 counsellors who completed the TF-CBT programme. The counsellors noted some of the positive aspects for children, including that children felt increasingly brave about sharing their experiences and talking about what happened to them. Others felt children could understand their thoughts and feelings better and that the intervention helped create a good relationship between the child and counsellor.
Non-discrimination and individual response:
TF-CBT is and should be discriminatorily provided to those identified as experiencing high levels of trauma. The intervention is currently available to Cambodian and Vietnamese boys and girls and is provided by Hagar Cambodia and World Vision Cambodia?s Trauma Recovery Programme.
TF-CBT, while modular in approach, is to be adapted to the needs of each client in accordance with the skills and abilities of the counsellors and with the support of weekly clinical supervision.
The therapy is modular in approach and the goals of the first session include ensuring that children are fully informed about the process they are entering. Provision of TF-CBT necessarily involves completion of therapy goals whilst being guided by the interests and needs of each client.
Stringent fidelity standards, supervision and a parallel coaching method are in place to ensure that children are protected during the intervention and that confidentiality is assured.
The decision to invite a child to receive the intervention is not considered lightly, and is done using the CEPAT findings and case management files and in consultation with counselling staff, and where appropriate, other family members or professionals engaged in supporting the child.
Sustainability and replication:
To date counsellors have been trained to deliver TF-CBT and a manual developed. TF-CBT has a strong evidence based in the Western developed world context and is beginning to be piloted in other cultural and low-resource contexts. As a modular approach there is a clear process, and the TF-CBT method has been fully documented for replication within the country. The provision of training for additional counsellors or significant expansion of the capacity to provide TF-CBT is dependant upon further funding.
Learning and gaps:
Qualitative interviews were undertaken with counsellors and the clinical supervisors involved in the training. From the perspective of counsellors receiving the training and implementing the intervention with children, the following feedback was provided:
Helpful to have a step by step process
The amount of time and energy required to complete TF-CBT with individual children meant some of the counsellors involved felt too busy. They had to spend more time with the child and the planning before each meeting took time and preparation, as did the writing up of notes
Difficult to always get the children to tell their stories and talk about what happened to them openly. A couple of counsellors were also concerned that the intervention affected the children?s feelings, especially having to tell their story in detail
Some felt that the plan was too strict and not enough flexibility was given
The process took longer with younger children as they required more time to take in the detailed information
In some cases the Vietnamese children did not know the Khmer language properly and this was a problem
Some counsellors were not always sure about choosing the children to take part and those that would benefit from the treatment
Counsellors wanted more support and supervision, including more time for learning how to implement the intervention
Some felt hearing stories had an impact on their own health and care
Clinical supervisors supporting counsellors felt that:
The time bound model worked well in a low resource environment
A lot of time is needed for supervision
The defined steps and process gave more confidence to counsellors, though at the same time, some supervisors felt defined steps meant some counsellors would follow them to the letter rather than thinking through and being flexible
The model led to deeper working with the clients
Some interagency confusion exists regarding TF-CBT provision as other service providers in Cambodia claim to offer TF-CBT but have trained counsellors without using official TF-CBT training providers or the same level of rigour in training and supervision
Divisions exist between those that are trained and those that are not
Changes in job descriptions are needed as counsellors need to be freed up from general case management responsibilities so they can focus on clinical work
A workbook or something similar would help counsellors keep notes and learning in place
Clinical supervisors from Johns Hopkins University noted that:
Improvements in the supervision model was needed
In order to teach the model it is not necessary to start with highly trained counsellors, trainers can work with relatively untrained staff to teach TF-CBT
A full impact evaluation has been identified by Johns Hopkins University as advisable before a scale up of service provision is attempted. The motivation to conduct an impact evaluation however is not completely shared by the NGO partners. It may be that positive indications drawn from the feasibility study findings are regarded as evidence enough by NGO practitioners working within limited means. Conversely, University based Academics or those with broader policy objectives for improving provision of mental health services may be more inclined to desire scientifically proven impact. As yet, whether there will be planning and collaboration on an impact evaluation of the TF-CBT pilot in Cambodia remains unclear. Clearly, such an evaluation, though costly, would represent a significant advance towards the goal of strengthening the provision of mental health services to traumatised children in Cambodia and in low resource contexts more generally.
 Bolton, P. Nadleman, S, Wallace, T, Qualitative Assessment of Trafficked Girls in Cambodia, Johns Hopkins Bloomberg School of Public Health, World Vision International, Phnom Penh, 2008.
 Bass, J; Bearup, L, Bolton P, Murray L, Skavenski, S., Implementing Trauma Focussed Cognitive Behavioural Therapy Among Formerly Trafficked Sexually Exploited and Sexually Abused Girls in Cambodia: A Feasibility Study; Johns Hopkins Bloomberg School of Public Health, World Vision International, Phnom Penh, 2011.
 Bass, J., Bolton, P. and Bearup, L. (2010) Assessment of trafficked and abused girls living in shelters in Cambodia: Development and testing of a locally-adapted psychosocial assessment instrument. World Vision, Johns Hopkins Bloomberg School of Public Health: Phnom Penh