Clinical Social Work Journal

, Volume 47, Issue 4, pp 343–352 | Cite as

An Attachment-Informed Approach to Trauma-Focused Cognitive Behavioral Therapy

  • Kristin E. PleinesEmail author
Original Paper


Trauma-focused cognitive behavioral therapy (TF-CBT) is a widely utilized evidence-based practice for treating children exhibiting symptoms of trauma. The model is theoretically grounded in principles of cognitive behavioral therapy (CBT) and incorporates a safe caregiver throughout treatment. TF-CBT’s use of a safe parental figure is supported by attachment theory, but the model does not fully address the complex needs of the families frequently served by social service organizations. Through the lens of attachment, the TF-CBT model holds more potential by directly supporting the parent/child bond and enhancing a caregiver’s role as a secure base. As the field of neuroscience advances rapidly, new research supports attachment based interventions, and thus, also supports the importance of enhancing the parent child bond in trauma treatment. The purpose of this paper is to highlight ways that attachment theory, if made more explicit in training and education programs, could enhance clinicians’ understanding and involvement of the caregiver in TF-CBT, thus making the model more applicable to families who have experienced complex, intergenerational trauma. An overview of literature related to attachment and trauma and the efficacy of TF-CBT will be provided, as well as a case illustration integrating TF-CBT and attachment principles with a highly complex family.


Attachment trauma-focused cognitive behavior therapy Trauma Complex trauma Child therapy Intergenerational trauma 


Compliance with Ethical Standards

Conflict of interest

The author declares that she has no conflict of interest.


  1. Ainsworth, M. D., Blehar, M., Waters, E., & Wall, S. (1978). Patterns of attachment. Hillsdale: Lawrence Erlbaum.Google Scholar
  2. Ainsworth, M. D. S., & Bell, S. M. (1970). Attachment, exploration, and separation: Illustrated by the behavior of one-year-olds in a strange situation. Child Development, 41(1), 49–67.CrossRefGoogle Scholar
  3. Amaro, H., Dai, J., Arévalo, S., Acevedo, A., Matsumoto, A., Nieves, R., & Prado, G. (2007). Effects of integrated trauma treatment on outcomes in a racially/ethnically diverse sample of women in urban community-based substance abuse treatment. Journal of Urban Health, 84(4), 508–522.CrossRefGoogle Scholar
  4. Amatya, P. L., & Barzman, D. H. (2012). The missing link between juvenile delinquency and pediatric posttraumatic stress disorder: An attachment theory lens. ISRN Pediatrics. Scholar
  5. Barocas, H., & Barocas, C. (1973). Manifestations of concentration camp effects on the second generation. American Journal of Psychiatry, 130(7), 820–821. Scholar
  6. Beebe, B., & Lachmann, F. (2002). Co-constructing inner and relational processes: Self-and interactive regulation in infant research and adult treatment (Chap. 6). In Infant research and adult treatment: Co-constructing interactions. Hillsdale: Analytic Press.Google Scholar
  7. Bombay, A., Matheson, K., & Anisman, H. (2009). Intergenerational trauma. Journal de la santé autochtone, 5, 6–47.Google Scholar
  8. Boulanger, G. (2007). Wounded by reality: Understanding and treating adult onset trauma. New York: Routledge.Google Scholar
  9. Bowlby, J. (1969). Attachment and loss: Attachment. New York: Basic Books, Inc.Google Scholar
  10. Carlson, E. B., et al. (2011). Development and validation of a brief self-report measure of trauma exposure: The Trauma history screen. Psychological Assessment, 23, 463–477.CrossRefGoogle Scholar
  11. Cary, C. E., & McMillen, J. C. (2012). The data behind the dissemination: A systematic review of trauma-focused cognitive behavioral therapy for use with children and youth. Children and Youth Services Review, 34, 748–757. Scholar
  12. Cohen, J., Deblinger, E., & Mannarino, A. (2018). Trauma-focused cognitive behavioral therapy for children and families. Psychotherapy Research, 28(1), 47–57. Scholar
  13. Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2012). Trauma-focused CBT for children and adolescents: Treatment applications. New York: Guilford Press.Google Scholar
  14. Cohen, J. A., Mannarino, A. P., Kliethermes, M., & Murray, L. A. (2012). Practical strategies: Trauma-focused CBT for youth with complex trauma. Child Abuse & Neglect, 36, 528–541. Scholar
  15. Coltoff, P. (2006). The challenge of change: Leadership strategies for not-for-profit executives and boards. York: The Children’s Aid Society.Google Scholar
  16. Cook, A., Spinazzola, J., Blaustein, M., Ford, J., Lanktree, C., Cloitre, M. & … Van Der Kolk, B. (2005). Complex trauma in children and adolescents. Psychiatric Annals, 35(5), 390–398.CrossRefGoogle Scholar
  17. Dagan, O., Asok, A., Steele, H., Steele, M., & Bernard, K. (2017). Attachment security moderates the link between adverse childhood experiences and cellular aging. Development and Psychopathology. Scholar
  18. Dorsey, S., Pullmann, M. D., Berliner, L., Koschmann, E., McKay, M., & Deblinger, E. (2014). Engaging foster parents in treatment: A randomized trial of supplementing trauma-focused cognitive behavioral therapy with evidence-based engagement strategies. Child Abuse & Neglect, 38(9), 1508–1520.CrossRefGoogle Scholar
  19. Esposito, E. A., & Gunnar, M. R. (2014). Early deprivation and developmental psychopathology. In Handbook of developmental psychopathology (pp. 371–388). Boston, MA: Springer.Google Scholar
  20. Felitti, V., Anda, R., Williamson, D., Spitz, A., Edwards, V., Marks, J., & Koss, M. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4), 245–258. Scholar
  21. Foa, E. B., Treadwell, K., Johnson, K., & Feeny, N. (2001). Child PTSD symptom scale (CPSS): Validation of a measure for children with PTSD. Journal of Clinical Child Psychology, 30, 376–384.CrossRefGoogle Scholar
  22. Fonagy, P., & Target, M. (1997). Attachment and reflective function: Their role in self-organization. Development and Psychopathology, 4, 679–700.CrossRefGoogle Scholar
  23. Ford, J. D., & Cloitre, M. (2009). Best practices in psychotherapy with children and adolescents. In C. Courtois & J. Ford (Eds.), Treating complex traumatic stress disorders: Scientific foundations and therapeutic models (pp. 59–81). New York, NY: Guilford Press.Google Scholar
  24. Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery. A psychoanalytic approach to the problems of impaired infant-mother relationships. Journal of the American Academy of Child & Adolescent Psychiatry, 14(3), 387–421.CrossRefGoogle Scholar
  25. George, C., Kaplan, N., & Main, M. (1985). The Adult Attachment Interview. Unpublished manuscript. University of California at Berkeley.Google Scholar
  26. Herman, J. L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5(3), 377–391.CrossRefGoogle Scholar
  27. Jaycox, L. H., Cohen, J. A., Mannarino, A. P., Walker, D. W., Langley, A. K., Gegenheimer, K. L., & … Schonlau, M. (2010). Children’s mental health care following Hurricane Katrina: A field trial of trauma-focused psychotherapies. Journal of Traumatic Stress, 23(2), 223–231. Scholar
  28. Jensen, T. K., Holt, T., Ormhaug, S. M., Egeland, K., Granly, L., Hoaas, L. C., … Wentzel-Larsen, T. (2014). A randomized effectiveness study comparing trauma-focused cognitive behavioral therapy with therapy as usual for youth. Journal of Clinical Child & Adolescent Psychology, 43(3), 356–369.CrossRefGoogle Scholar
  29. Kliethermes, M. D., & Wamser, R. (2012). Adolescents with complex trauma. In J. A. Cohen, A. P. Mannarino & E. Deblinger (Eds.), Trauma-focused CBT for children and adolescents: Treatment applications (pp. 175–196). New York: Guilford Press.Google Scholar
  30. Main, M., & Hesse, E. (1990). Parents’ unresolved traumatic experiences are related to infant disorganized attachment status: Is frightened and/or frightening parental behavior the linking mechanism? In M. T. Greenberg, D. Cicchetti & E. M. Cummings (Eds.), The John D. and Catherine T. MacArthur foundation series on mental health and development. Attachment in the preschool years: Theory, research, and intervention (pp. 161–182). Chicago: University of Chicago Press.Google Scholar
  31. Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood, and adulthood: A move to the level of representation. Monographs of The Society for Research in Child Development. Scholar
  32. Main, M., & Solomon, J. (1986). Discovery of a new, insecure-disorganized/disoriented attachment pattern. In T. B. Brazelton & M. Yogman (Eds.), Affective development in infancy (pp. 95–124). Norwood: Ablex.Google Scholar
  33. McClelland, S., Korosi, A., Cope, J., Ivy, A., & Baram, T. Z. (2011). Emerging roles of epigenetic mechanisms in the enduring effects of early-life stress and experience on learning and memory. Neurobiology of Learning and Memory, 96, 79–88. Scholar
  34. McEwen, B. S., Gray, J. D., & Nasca, C. (2015). Recognizing resilience: Learning from the effects of stress on the brain. Neurobiology of Stress, 1, 1–11.CrossRefGoogle Scholar
  35. Morgan-Mullane, A. (2017). Trauma focused cognitive behavioral therapy with children of incarcerated parents. Clinical Social Work Journal. Scholar
  36. Munson, M. R., & Jaccard, J. (2018). Mental health service use among adults: A communication framework for program development. Administration and Policy in Mental Health and Mental Health Services Research, 45(1), 62–80.CrossRefGoogle Scholar
  37. Munson, M. R., Jaccard, J., Smalling, S. E., Kim, H., Werner, J. J., & Scott, L. D. Jr. (2012). Static, dynamic, integrated and contextualized: A framework for understanding mental health service use among young adults. Social Science and Medicine, 75(8), 1441–1449.CrossRefGoogle Scholar
  38. Murphy, A., Allman, B., Bonuck, K., Steele, H., Bate, J., Nikitiades, A., & Meissner, P. (2015). Group attachment-based intervention: Trauma-informed care for families with adverse childhood experiences. Family and Community Health, 38(3), 268–279. Scholar
  39. Sachser, C., Keller, F., & Goldbeck, L. (2017). Complex PTSD as proposed for ICD-11: Validation of a new disorder in children and adolescents and their response to trauma-focused cognitive behavioral therapy. Journal of Child Psychology & Psychiatry, 58(2), 160–168. Scholar
  40. Schore, A. N. (2009). Relational trauma and the developing right brain. Annals of The New York Academy of Sciences, 1159, 189–203. Scholar
  41. Schore, J. R., & Schore, A. N. (2008). Modern attachment theory: The central role of affect regulation in development and treatment. Clinical Social Work Journal, 36(1), 9-20.CrossRefGoogle Scholar
  42. Slade, A. (2005). Parental reflective functioning: An introduction. Attachment & Human Development, 7(3), 269–281.CrossRefGoogle Scholar
  43. Spitz, R. (1949). The role of ecological factors in emotional development in infancy. Child Development, 3, 145. Scholar
  44. Steele, H., & Steele, M. (2008). Ten clinical uses of the adult attachment interview. In H. Steele & M. Steele (Eds.), Clinical applications of the adult attachment interview (pp. 3–30). New York: Guilford Press.Google Scholar
  45. Tosone, C. (2013). On being a relational practitioner in an evidence-based world. Journal of Social Work Practice, 27(3), 249–257.CrossRefGoogle Scholar
  46. Tucker, C., & Smith-Adcock, S. (2017). Theraplay: The evidence for trauma-focused treatment for children and families. In R. Steene (Ed.), Emerging research in play therapy, child counseling, and consultation (pp. 42–59). Hershey: IGI Global.CrossRefGoogle Scholar
  47. Van der Kolk, B., & Fisler, R. (1994). Childhood abuse and neglect and loss of self regulation. Bulletin of the Menninger Clinic, 58(2), 145.PubMedGoogle Scholar
  48. Van der Kolk, B. A. (2005). Developmental trauma disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35(5), 401.CrossRefGoogle Scholar
  49. Weiner, D. A., Schneider, A., & Lyons, J. S. (2009). Evidence-based treatments for trauma among culturally diverse foster care youth: Treatment retention and outcomes. Children and Youth Services Review, 31(11), 1199–1205.CrossRefGoogle Scholar
  50. Yasinski, C., Hayes, A. M., Ready, C. B., Cummings, J. A., Berman, I. S., McCauley, T., & … Deblinger, E. (2016). In-session caregiver behavior predicts symptom change in youth receiving trauma-focused cognitive behavioral therapy (TF-CBT). Journal of Consulting and Clinical Psychology, 84(12), 1066–1077. Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.New York UniversityNew YorkUSA

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