TF-CBT: Helping Kids Get Better

In the mid-90s, little was known about how to effectively treat trauma, especially that trauma that can arise from child sexual abuse. Victims often languished in treatment for years with symptoms that might—or might not—ever improve. Then more research emerged on evidence-based treatments. These effective treatments—with Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) at the fore—were brief, reducing symptoms for many clients swiftly, and therefore swiftly getting kids back to their job of being kids. This has meant reduced suffering and improved healing for kids.

The most exciting part of TF-CBT has been its ongoing evolution as applications have been developed for many different populations. What’s next for TF-CBT? Take a listen to our conversation with Dr. Tony Mannarino, renowned expert in child trauma and one of the co-developers of TF-CBT.

Topics in this episode:

• Origin story (1:41)
• The impact of TF-CBT (4:51)
• Evolving different applications of TF-CBT (9:38)
• The most used applications (12:16)
• Up next: Parental substance abuse (20:06)
• The development process (25:32)
• Kids fill in the blanks (31:43)
• See kids as resilient, not broken (36:47)
• Ukrainian therapists (42:25)
• For more information (45:04)

Links:

Anthony P. Mannarino, Ph.D., professor and chair; director, Center for Traumatic Stress In Children and Adolescents, Psychiatry and Behavioral Health Institute, Allegheny Health Network, Drexel University College of Medicine 

TF-CBT.org

Esther Deblinger, Ph.D.

Judith A. Cohen, MD

TF-CBT implementation manuals

Center for Traumatic Stress in Children and Adolescents

Isha W. Metzger, Ph.D., has previously been a guest on One in Ten (“The Meaning of Healing for Black Kids and Families”) and will join us on our next episode to discuss the new TF-CBT adaptation    

Ashley Dandridge, PsyD.

TF-CBT and Racial Socialization Implementation Manual

For more information about National Children’s Alliance and the work of Children’s Advocacy Centers, visit our website at NationalChildrensAlliance.org. Or visit our podcast website at OneInTenPodcast.org. And join us on Facebook at One in Ten podcast.

Transcript

Season 5, Episode 16

“TF-CBT: Helping Kids Get Better,” with Anthony P. Mannarino, Ph.D.

[Intro music begins]

[Intro]

[00:09] Teresa Huizar:
 Hi, I’m Teresa Huizar, your host of One in Ten. In today’s episode, “TF-CBT: Helping Kids Get Better,” I speak with Dr. Tony Mannarino, renowned expert in child trauma, author, researcher, and perhaps most importantly, co-developer for Trauma-Focused Cognitive Behavioral Therapy, that we all know as TF-CBT. 

In the mid-90s, when I entered the CAC workforce, little was known about how to effectively treat trauma, especially that trauma that can arise from child sexual abuse. Victims often languished in treatment for years with symptoms that might—or might not—ever improve. Then more research emerged on evidence-based treatments. And surprisingly, these effective treatments—with TF-CBT really at the fore—these were brief, reducing symptoms for many clients swiftly, and therefore swiftly getting kids back to their job of being kids. I’m so grateful for what that has meant in reduced suffering and improved healing for kids.

And while Tony and I spend a little time talking about those early days, the most exciting part of TF-CBT has been its ongoing evolution as applications have been developed for many different populations. “What’s next for TF-CBT?” you say. I’m glad you asked. To get an answer to that question, please take a listen.

[Intro music begins to fade out]

[01:41] Teresa Huizar:
Welcome to One in Ten, Tony. 

Anthony Mannarino:
Glad to be here. 

Teresa Huizar: 
So, many of our listeners know you and your role as a developer of—a co-developer, I should say—of TF-CBT, Trauma-Focused Cognitive Behavioral Therapy, and all the work you’ve done to train hundreds and thousands of clinicians around the country in that. 

For those folks who are not familiar with TF-CBT—which I know that in the [Children’s Advocacy Center] CAC world it feels like everybody would be, but no, we have listeners who are not—can you just talk a little bit about, first of all, what it is, but also what led you in your own clinical practice and with your colleagues who are co-developers to say that there was a need for another evidence-based intervention for kids who had experienced trauma?

Anthony Mannarino: 
When we first started our work 25 to 30 years ago, there were no evidence-based treatments for children who had experienced trauma. None whatsoever.

Teresa Huizar: 
Wow.

Anthony Mannarino: 
Despite that, of course, there were lots of children at that time who had experienced trauma. And basically, most of these kids were receiving some sort of nondirective interventions or play therapy, which had not been studied. Doesn’t mean they can’t be effective, but they hadn’t been studied. And so really, our entry into developing a treatment for youth who had experienced trauma was to begin to provide some data that could show that some type of treatment could be empirically supported to be effective. So that’s where we were starting from.

And then the other part really had to do with the prevailing notion at that time was that you can’t really ask children about what happened. Because if you ask them about what happened and somehow encourage them to talk about it, you would retraumatize them. 

Teresa Huizar: 
Mmm.

Anthony Mannarino: 
And it was our belief at that point that if they don’t talk about it, they don’t have the opportunity to process what happened, it’s just going to stay inside of them. And affect them negatively emotionally, psychologically, physiologically, and so forth. So our treatment that we developed, TF-CBT, was not only the first evidence-based treatment for youth exposed to trauma but the first where there was strong encouragement for children to actually talk and process what happened.

[04:18] Teresa Huizar: 
You know, it’s so interesting that you mentioned that element around the trauma narrative, because I had not really realized that there had been this prevailing belief that it was harmful to children to actually talk about what happened to them. When you look back over that history, which if you think about it is not that long—what are we talking about in terms of the year that you guys first sort of published around TF-CBT? Would that have been the 80s?

Anthony Mannarino: 
No, not the 80s, but the mid-90s— 

[Cross-talk]

Teresa Huizar:
Mid-90s.

Anthony Mannarino: 
—[muffled] and our studies began publishing. 

[04:51] Teresa Huizar: 
What would you say overall—you know, as you kind of reflect and look over the field since that time—what has been the impact? I mean, I can think of it in the CAC world, and we can spend an hour just me talking about that. [Laughter]

But I’m thinking about you. You’ve had this broader exposure. You’ve seen TF-CBT used not just in the U.S., and certainly not just with CAC populations but many, many others. What do you think is its unique contribution? 

Anthony Mannarino: 
Well, I think the most unique contribution is that Esther Deblinger, Judy Cohen, and myself, the three developers, have always focused on making sure we have the science to direct our clinical efforts to help children.

And so all of our initial studies became more refined with subsequent studies to really focus in on: What is it about a treatment for children exposed to trauma would be effective, what components are most effective? 

And then, you know, starting with our research studies, now there have been 25 randomized clinical trials around the world looking at the efficacy of TF-CBT. And that’s important because if you start with the developers of the model, you can always suggest with, you know, the developers have a bias. They want their treatment to work. That’s natural, right? But when you have studies being done in Norway and Germany and Japan or other places around the world with people who don’t have an interest in making sure that TF-CBT looks effective, then you begin to see that, in study after study after study, TF-CBT has proven to be effective for children with a variety of trauma, including complex trauma, kids with a variety of outcomes, including PTSD, depression, anxiety, sexual behavior problems, and so forth.

So I think the contribution has been the focus on science and how that’s allowed the dissemination of TF-CBT to occur not only across the U.S. but around the world. 

[07:05] Teresa Huizar: 
Just to sort of set it for our listeners, how common is it that an evidence-based intervention would have 25 randomized control trials?

Anthony Mannarino: 
Yeah, well, pretty, pretty uncommon, actually.

[Cross-talk]

Teresa Huizar: 
  [Laughter] Yeah, that’s what I thought. 

Anthony Mannarino: 
Yeah, we’ve had the good fortune that not only did Esther, Judy, and I do the studies, but I think we set them up in such a way that TF-CBT was relatively easy to study. And so researchers around the world kind of jumped on board and did their own studies in their own countries.

So 25 randomized clinical trials is incredibly unusual. You know, most evidence-based treatments for youth exposed to trauma might have two or three. And sometimes just one. So to have 25, that’s a really large number. 

[07:58] Teresa Huizar: 
Yes, it’s incredibly robust. And, you know, that gives us confidence in our own world and our use of it because there’s so much evidence that we can expect that we’re going to see the same results if it’s delivered with fidelity. So I think that that’s very comforting to many clinicians—

Anthony Mannarino: 
Yeah.

Teresa Huizar: 
—who might be learning it for the first time.

Anthony Mannarino: 
Yeah, so you have kids from different cultures, different backgrounds, different races, different ages, and so forth. And you know, when you look at all the studies around the world, you can probably say with some degree of confidence that, yeah, we’ve had that sort of child with that background that age in a study somewhere with that kind of trauma background—

Teresa Huizar: 
Mmm.

Anthony Mannarino: 
—that sort of clinical presentation.

So therefore, there’s a good likelihood that they’ll get better. In fact, the data show that about 80 to 85% of children who have participated in our trials make clinically significant improvement. 

[09:00] Teresa Huizar: 
And when you say “clinically significant improvement,” what might that look like?

Anthony Mannarino: 
Well, it might mean, for example, that a child who starts out with a PTSD diagnosis no longer has PTSD, or at the most has mild symptoms. Or a child that starts out with severe depression Uh, after evaluation now has at the most mild depressive symptoms. It’s not like all symptoms completely disappear, but they go from a higher level of severe range to a much more manageable range that’s typically in the lower end.

[09:38] Teresa Huizar: 
Tell me a little bit about how you all begin thinking about differing applications of TF-CBT. I think now—I can’t remember the number. You’ll have to tell me how many different applications there are, but—you know, how did that all evolve? And I know you guys have been so involved in trying to provide consultation to people who were interested—

Anthony Mannarino: 
Yeah.

Teresa Huizar: 
—in developing those so that they were still sort of faithful to the overall model.

Anthony Mannarino: 
Yeah. So we began to think quite a few years ago that: How could we refine the model for different populations of children or children in different settings so that therapists in those settings who are working with those populations would feel like the model is really tailored for the work that they do?

So we began, over the course of really the past 10 years or so to have learning communities that have included therapists from around the country—often from centers associated with the National Child Traumatic Stress Network—who were interested in a particular application of the model.

So some of our earlier applications included one for TF-CBT for military families.

Teresa Huizar: 
Mmm.

Anthony Mannarino: 
And then we had one early on for children in foster care. And also one early on for children in residential treatment settings. So you just look at those three alone: military families, foster children, those in residential settings—three really different populations of children, different cultures, therapists who work in settings that are so different from each other. So how could we tailor TF-CBT that would be appropriate for those settings or for those children? 

So it was necessary, of course, to include in those learning communities therapists from those settings so that they could provide feedback and information that would allow us to create a manual that would really underscore the kinds of applications that made sense for their work while at the same time respecting the fidelity of the model, as you said.

And that’s what all the manuals have turned out to be: a combination of respect for the fidelity of the model overall but yet tailored in such a way to fit the needs of a group or a setting and therefore would be clinically useful for clinicians with that group of kids or that setting.

[12:16] Teresa Huizar: 
When you think about all the different applications that now exist, are there some where you say it’s good that these were developed, but perhaps they have not had as widespread usage as even you might like to see? And are there others that you say they’ve really changed the nature of working with this population dramatically?

Anthony Mannarino: 
Yeah. 

Teresa Huizar: 
Do you know what I mean? Are some—I don’t want to say in any way more important—but are some more used, or however you would capture that, than others? 

Anthony Mannarino: 
Yeah, I would say the more recent ones are the most used. And honestly, I’m not quite sure why that is, but that seems to be the case. For example, the learning community that we had for tailoring TF-CBT for clinicians who work with youth who self-identify as LGBTQ has been a popularly downloaded manual from our website. You know, we’re able to keep track of how many downloads there are, and that that’s been a really popular one and one that seems to be used quite a bit. Also, one of the more recent ones is a TF-CBT manual for work with kids who are commercially sexually exploited. And again, that’s been downloaded a lot.

And now, of course, our most recent manual is the integration of racial socialization, of racial discrimination, with TF-CBT. This is very new. We’ve just finished the manual in the last few months. It was on the website only for a couple, three months at this point, and it’s been downloaded a lot already. And I think the reason for that is that, you know, we’re in an era where racial justice, concern about discrimination, inequities in health care, and so forth are really important and prominent.

And, you know, so we had a learning community in which we had therapists from around the country, representing organizations from the National Child Traumatic Stress Network, really work with us to look at how we could tailor TF-CBT for Black children and families who present with trauma backgrounds.

And, you know, I think we’ve learned some interesting things. First is that, let’s say for Black children and families, typically they’re not asked about discrimination or other inequities that they face. They’re asked a lot of questions about, you know, whatever trauma they presented with—sexual abuse, domestic violence—but no one’s ever asked them about racial inequities, discrimination, injustices. And what we’ve found for the learning community is that children benefit from being asked those kinds of questions, even if they decide that it may not be what they want to focus on in their clinical work. At least we’ve asked them, we’ve made it a topic that it’s OK to talk about. And we learn more from that. So that’s been something interesting that we’ve learned. 

We’ve also learned that, similar to our other applications, the application that incorporates racial socialization also continues to respect the fidelity of TF-CBT while making sure we embed the model within the culture of Black families so that clinicians feel like it’s going to be a model that’s going to be appropriate from a cultural competence perspective for that group.

And I think we—you know, we’ve tried our best and it’s been downloaded a lot. It’s obviously not perfect, but it is our attempt to try to recognize what’s going on in the current era, the injustice, the discrimination, and that Black children and families may not always feel welcome when they come to an organization for health care and specifically mental health care. And can we do something to help them feel more welcome, more received in a positive way and feel like the provider has better understanding of what they might be going through?

[16:30] Teresa Huizar: 
You know, in listening to you talk about that, I was just thinking about how powerful it must be for kids and families to feel like the person sitting in the room with them really understands something about their experience and wants to know about those experiences.

Because I think it often doesn’t—as you’re saying—doesn’t get talked about enough. And it could be, for some children, the most pressing thing that they’re thinking about is how they’re treated in their community every day. Not necessarily the thing that brought them to the CAC or brought them to the attention of social services in some way.

So I think, you know, it’s been interesting, as a person who’s not a clinician, to watch the development of these various applications. And it just—it feels like there’s one thing that has kept TF-CBT so robust has been kind of holding in both hands both the fidelity of the model but also making sure it’s responsive to populations that you’re seeing come into clinical settings every single day.

And I think that probably bodes well for its future. You know, it’s long-term survivability. 

Anthony Mannarino: 
Yeah. Well, I think our goal right from the start, Esther, Judy, and myself has been, can we do work in this space that will help the greatest number of children over time? That—you know, if there’s been one unifying theme among the three of us, it’s been that.

And can we find a way to give away most of what we do so that people don’t have to pay for it? So we’ve had the good fortune that we’ve created all these manuals through federally sponsored programs. And, therefore, we’ve been able to just put them online, and people can download them for free, and it’s that simple. And that’s been great. Because I think by giving things away for free, you have a greater likelihood of people using them and therefore disseminating your work.

So that’s been our goal. Help as many children as possible in the U. S., around the world. And I think  we’ve … we’ve stayed pretty dedicated to that theme and all the work we’re doing. And we’re, you know, of course, incredibly grateful that we’ve gotten funding for many years that’s allowed us to do the work.

[18:41] Teresa Huizar: 
We’re really grateful for the connection with Children’s Advocacy Centers, I think, you know, when we realized that there was an evidence-based treatment that seemed to align so very well with the kinds of issues that were needing to be addressed in our population. And the willingness that all of you as co-developers, and then as you had a coterie of master trainers, your trainers and consultants, your willingness to partner with CACs and with Chapters to get this training out.

It’s been wonderful to see the adoption of that just across the network in such a deep, rich way. And we’re always, you know, working on that and wanting to make sure that we maintain the quality of that work as clinicians come and clinicians go. But I think that it has been something that in one sense, when I think about the history of CACs, kind of came late to the model. At first we were very focused on justice-related things.

Anthony Mannarino: 
Right. 

Teresa Huizar: 
And I think it was really in recognizing that, for so many of these kids, there is never going to be any criminal justice of any kind—and that that wasn’t the most important thing to them anyway in most cases—that it really gave us an opportunity to pivot and say: What’s most important to kids long term? And what kind of adults do we want them to be? And what can we do to reduce their suffering? And so much of that had to tie to reducing their trauma symptoms. And so we’re grateful for what that partnership has been. 

[20:06]
 Where do you go from here? I mean, my goodness, so much has been done. What do you think is next for you all? 

Anthony Mannarino: 
Well, before I go there— 

Teresa Huizar: 
Yeah.

Anthony Mannarino: 
—just to comment about what you said, Teresa, and that is that, interestingly, our connection, uh, to the CACs really was kind of there from the outset because our initial studies were on children exposed to sexual trauma. And I know with the CACs, that is a group of children that you’re forensically evaluating and now providing treatment services for in many cases. So we seem to, in our early work, have developed this connection to CACs right from the start because that was where you guys have focused and that was our original focus. 

Believe it or not, Teresa, all these years later in our center, which is now in its 30th year, our Center for Traumatic Stress in Children and Adolescents, the number one referral type trauma for kids at our center remains sexual abuse or assault. Now—

Teresa Huizar: 
That’s interesting. 

Anthony Mannarino: 
—we have others that have kind of begun to catch up, in terms of domestic violence, parental substance abuse, and that sort of thing. But still, sexual assault, which was number one 30 years ago, still leads the way. It’s incredibly sad because some of the demographic data had suggested that perhaps sexual abuse of children had been on the decline. But then I saw recent statistics suggesting perhaps not. 

But back to your other question: Where do we go from here? Well, we have an upcoming learning community sponsored by another grant that’s focused in on youth with parents with parental substance abuse issues.

Teresa Huizar: 
Oh, interesting. 

Anthony Mannarino: 
That’s such a common theme right now. 

Teresa Huizar: 
Mm-hmm.

Anthony Mannarino: 
And for example, in Pittsburgh, we have one of the biggest opioid addiction issues in the country. And at our center in the last three years, we’ve had over 500 children referred because of primarily parental substance abuse. And what does that cause?

Well, it causes kids who might have a parent who overdoses and dies. So not only do they have that problem, but now they have a traumatic loss. Or you have kids who wind up living, over time, with a parent with substance use issues and the instability that that can create. We have kids who may be placed out of their home with grandparents or in foster care. So you have the trauma of parental substance abuse complicated by the traumas of separation and displacement. 

that’s our next application. We’re starting a learning community in that regard in November of this year, a yearlong learning community with the endpoint, similar to the other learning communities, with creating a manual for therapists that will hopefully tailor TF-CBT for kids whose parents have substance abuse issues.

[23:21] Teresa Huizar: 
I am so interested in this, I have to tell you. I think that this is something that we see just like you do so frequently, you know, in the population. And, you know, these kids, even if their parent doesn’t have a fatal overdose, thank goodness, watching your parent overdose repeatedly and be sort of brought back to life with Narcan in and of itself is so disturbing—and terrifying, I think—

Anthony Mannarino: 
Yes.

Teresa Huizar: 
—for these kids. And—

Anthony Mannarino: 
Yes.

Teresa Huizar: 
—and the environments in which, depending on the state of addiction, that kids are placed in such unusual and unsupervised settings that, you know, sexual abuse can arise in those settings from people that are wandering in and out of the house and just—I’m not telling you anything you don’t already know, but I’m just excited and talking out loud about it because I think this is going to be just incredibly helpful and useful to kids and families.

Anthony Mannarino: 
And you’re really hitting the nail on the head, Teresa. Because it’s not just the parental substance abuse, it’s the instability of the home environments. 

Teresa Huizar: 
Mmm.

Anthony Mannarino: 
You have people in and out of the home where kids could be at risk, as you said, for sexual abuse, for witnessing domestic violence—

Teresa Huizar: 
Right.

Anthony Mannarino: 
—physical abuse, and then ultimately, perhaps, being separated from their parent, being in foster care, with extended family members.

So it’s not just the parental substance abuse, but all that and all of the associated problems that follow. And sadly, you know, there are many communities across the country that have been hit by the opioid epidemic, and it just so happens that the Pittsburgh region is one of those areas. And we thought, wow, this would be an opportunity for us again to try to learn more about this work, how to tailor it, and create a manual that might be useful for therapists around the country. 

[25:22] Teresa Huizar: 
Well, CACs, stay tuned a year from now, because I think that we have such an overlapping population, it’s going to be really, really interesting to see that work when it’s completed. 

[25:32]
 So, in general, when you set up these learning communities, Tony, do they work—did you say about a year?

Anthony Mannarino: 
Yeah, usually about a year. 

Teresa Huizar: 
Yeah.

Anthony Mannarino: 
And the way we do that, Teresa, we’ll have maybe four to six therapists from— 

Teresa Huizar: 
Mmm.

Anthony Mannarino: 
—each community program that will join us. So they have a little bit of a group together at each center.

Teresa Huizar: 
That’s great.

Anthony Mannarino: 
And they present cases during the course of the year so we can learn about the application. We also ask therapists to evaluate the children pre- and post-treatment, even though it’s just an open trial, gives us some information about whether kids are responsive to the tailored product or not.

So it’s a combination of a very rich clinical implementation with some mild degree of science coming together with a group of folks invested in working in that area. And then we asked, you know, there might be a handful of us who create the manual, but we then will ask members of the community to review the manual, provide feedback. What do we need to add? What did we miss? Did we couch something in the wrong way?

For example, with the racial socialization and TF-CBT manual, those efforts, of course, headed by Isha Metzger, who developed the original concept paper. You know, Isha, Judy, myself, and one of our psychologists, Ashley Dandridge, all contributed to the development of the manual, but then we got feedback from a dozen other people about what I mentioned earlier: What we needed to add, delete, change, edit, not only in terms of content but appearance. You know, even the actual photograph on the front page of the manual. We thought it was so important to get it right, and we worked hard and reviewed a variety of potential options before we settle on the one we settled on. So it’s like a cover of a book, you know. People want it to be meaningful in a certain kind of way. So we try to get a lot of input and feedback and incorporate that. 

You know, you were asking earlier about things that have affected our work. We’ve always tried to get feedback from people in the field. As an example of that, Teresa, in our original TF-CBT book, we didn’t talk a lot about the therapeutic alliance between children and their therapists. And we all know, of course, that’s half the battle, that therapists develop a good therapeutic alliance, they’re halfway there. 

But we didn’t say much about that in the original book. I think because we took it for granted and we sort of thought that therapists might take it for granted as well. So we got feedback in that regard. “Hey, Tony, Judy, and Esther don’t care about the therapeutic alliance.” 

Teresa Huizar: 
[Laughter] Oh my goodness. 

Anthony Mannarino: 
And, but that was great feedback. 

Teresa Huizar: 
Yes. 

Anthony Mannarino: 
And we made sure in the new edition that we incorporated that in the first chapter in a very big way to help people understand that if you don’t get that part right, it doesn’t matter what your evidence-based treatment is. 

Teresa Huizar: 
Mmm. Mmm.

Anthony Mannarino: 
We really try to incorporate the feedback from therapists in the field to make the model better for kids that they serve. 

[28:59] Teresa Huizar: 
You know, one of the things that I was thinking about as you—well, so many things, but the one I’m going to ask you about that I was thinking about while you were talking is: I just want to go back to the substance abuse one for just a second. I’m thinking about the caregiver engagement portion of that. What are you expecting to see, or do you have any idea what you will see?, that may be different in terms of the way that caregivers either interact, respond …

Anthony Mannarino: 
Yeah.

Teresa Huizar: 
What happens with their own symptoms? I mean, I’m just so curious. 

Anthony Mannarino: 
So we have some idea already just based on the number of children we’ve treated at our center. So, typically, the caregiver involved in TF-CBT would be the caregiver with whom the child is living. 

Teresa Huizar: 
Mmm.

Anthony Mannarino: 
So if that’s a foster parent or grandparent, they’re more likely to be involved the most.

Teresa Huizar: 
Hmm.

Anthony Mannarino: 
And they might have their own sort of opinions and perspectives about the issue at hand. Particularly a grandparent, because it might be their own adult child— 

Teresa Huizar:
Yes.

Anthony Mannarino: 
—who’s having substance abuse issues. So we’ve got that, number one. 

Number two, in our preliminary work so far, we’ve noted that these kids have more unstable placements than other children who’ve received TF-CBT. 

Teresa Huizar:
Hmm.

Anthony Mannarino: 
In other words, they might be with a grandparent or a foster parent for a while, then they’re back with the parent who was abusing substances. That may last for a while. Then they’re back in that original placement or a different placement. So these kids have had more instability—

Teresa Huizar:
Mmm.

Anthony Mannarino: 
—in their placements than a lot of kids with whom we work. And that’s an added traumatizing factor. 

Teresa Huizar:
Yes.

Anthony Mannarino: 
You know, you begin to get comfortable in a certain home and then you’re gone. That’s part of it. 

Then I think the third part is: How about the parent who’s been abusing substances? You know, what, what’s their role in the treatment? And their role can be important, but it’s important that they also support the kids to tell the story—

Teresa Huizar:
Yes.

Anthony Mannarino:
—from their own perspective.

And that may not necessarily be what the parent wants to hear. Because kids will sometimes say things in their narration where, like, “My mom cared more about drugs than she cared about me.” And that may not be true, because that’s the nature of addiction, but that’s the child’s perception, and of course, it’s going to be painful for a parent to hear that, and therefore difficult to support that, even though that’s the child’s perspective.

[31:43] Teresa Huizar:
You know, so much, I think, of treatment is, in part, helping caregivers understand what children are experiencing. And so, even if some of it is painful to hear, like, when children who’ve been sexually abused think that their non-offending caregiver doesn’t care about them because they must have known it was going on. 

Anthony Mannarino:
Yes. Yes.

Teresa Huizar:
You know, I feel like it’s somewhat analogous that just hearing kids say it out loud, so then you can deal with what they actually have been thinking and what’s been keeping them up at night, you know, I think is still really, really important. And I can just imagine that these are going to be hard sessions and hard conversations, but also really, really valuable in terms of long-term relationships—

Anthony Mannarino:
Yes.

Teresa Huizar: 
—between caregivers and kids.

Anthony Mannarino: 
And we encourage therapists to not be judgmental.

Teresa Huizar: 
Right.

Anthony Mannarino: 
Not to shame parents and so forth. So that as they’re working with a parent who’s had a substance abuse issue to try to talk with the parent about how the child sees it, even if that’s not the way the parent sees it. So the parent can understand more about what the child’s gone through.

If you have a child growing up thinking that your mom “loves drugs more than she loves me,” even though that’s not true, perhaps, that’s a really tough thing for a kid to live with. 

Teresa Huizar:
Oh, absolutely.

Anthony Mannarino: 
That’s why we’ll do education with the child about addiction and how it takes over someone’s life. But it’s important on the other side for the parent to understand how the child might be growing up thinking that. And then the parent can begin to explain to a child what they’ve been through and how “It never was that I didn’t love you; I just had my own struggles.” So I think that’s where it comes together.

[33:27] Teresa Huizar: 
You know, as you’re talking, I’m thinking about, for kids, they often fill in blanks for things they don’t understand with things that turn out to be misunderstandings. You know, like, “I don’t know why my mom or dad is acting this way.”

Well, if they don’t have a clear understanding of addiction, which this can be helpful with, then you can sort of make up in your own head a whole lot of stories about why something’s happening to you. Why you’re having to move. Why, you know, mom is passed out all the time. Why—whatever. You know, and I think that struggling with the truth is hard, but better than these stories where you’re trying to fill in the—

Anthony Mannarino: 
Yeah.

Teresa Huizar: 
—the blanks, you know?

Anthony Mannarino: 
So what you’re saying is so true: Kids fill in the blanks. And often how they fill them in may not be accurate.

Teresa Huizar: 
Yes.

But they try their best to understand. One of the things we’ve learned from the work during all these years is that, even though the truth might be painful, if shared with children in a developmentally appropriate way, kids can handle it. They can deal with it. 

Teresa Huizar:
Mmm. Mmm. Mmm.

Anthony Mannarino: 
I mean, a good example of that, Teresa, would be when there’s a suicide in the family.

Teresa Huizar:
Oh, yes.

Anthony Mannarino: 
And often the first instinct that a parent might have is, “Well, we don’t want the kids to know. That’s going to be too hard, too painful. They can’t grow up understanding that somebody in their family took their own life.” But as it turns out, if shared in a way that kids can understand that, you know, Dad was so depressed and he just began to get hopeless that nothing would ever get better. And he didn’t see any other way out. Without sharing all the details—

Teresa Huizar:
Yes.

Anthony Mannarino: 
—kids can often deal with that. The other part is that they find out anyway from someone else.

Teresa Huizar:
It’s true. 

Anthony Mannarino: 
Yeah, they really do. 

Teresa Huizar:
Yeah.

Anthony Mannarino: 
And then they’re really upset with the other parent because they were never told the truth and they feel a sense of betrayal about that. My experience has been, whether it be suicide or parental substance abuse or other things that kids go through, they are remarkably resilient to handle the truth. As long as we’re supportive, as long as we do it in a way that they can understand and not have to share all of those details that are unnecessary. Kids are capable of understanding.

[Cross-talk]
 Anthony Mannarino: 
And they’re grateful, they’re grateful.

Teresa Huizar:
And often empathetic.

Anthony Mannarino: 
Yeah. Yeah.

[35:52] Teresa Huizar: 
You know, it’s surprising, I think, how often that’s … you know, people are worried that their reaction—and it may initially be angry, but often, I think, there’s a lot of kindness in kids too, you know.

Anthony Mannarino: 
There is, there really is. And they’re looking for the better side of people. The good side of people. And if people can come forward and be honest, share the truth, kids often are looking for the better side. And, you know, that that’s—I think for Judy, Esther, and myself, that’s always been a big part of the work is that we see children as inherently good, inherently capable—

Teresa Huizar: 
Yes.

Anthony Mannarino: 
—of going forward in a resilient way in their lives. And honestly, one of the most gratifying things about the work is that kids get better. 

Teresa Huizar: 
Absolutely. 

Anthony Mannarino: 
If you’re going to do this work, knowing that they get better, that’s pretty gratifying. 

[36:47] Teresa Huizar: 
You know, it’s funny that you say that, but I think even with multidisciplinary teams, that builds their resilience to see kids get better.

I think it’s been so helpful within the CAC movement as we’ve made more and more of this pivot to focus on therapeutic intervention that, you know, if you think about it, if you’re in law enforcement or an investigator for CPS [child protective services], you see kids and essentially at their worst, at their low point. And if all you see is a factory of children coming in and disclosing but you never see anything that makes them better and healthier, I think that can feel very hopeless over time and really lead to a lot of negative impact on the professionals. And I think that when multidisciplinary teams see that kids get better and that they’re healthier and they go on to do well in school and have good relationships and all those things, I just think it’s as good for their mental health almost as it is for the kids, you know?

Anthony Mannarino: 
One of the most difficult things for me is when kids go through trauma and, you know, there’s a headline in a newspaper—

Teresa Huizar: 
Oh.

Anthony Mannarino: 
—locally somewhere that says: “Look what these kids have gone through. They’ll never be okay.”

Teresa Huizar: 
Oh, I hate that. 

Anthony Mannarino: 
And that, that’s just not true no matter what they’ve been through. Doesn’t mean they forget.

Teresa Huizar: 
No, no.

Anthony Mannarino: 
Doesn’t mean they’ve, they’ve been impacted. But they find a way to be resilient and go forward and, in some cases, stronger than they were. When you think about all the school-related violence in our country, and you know, what kids have gone through in a variety of different locations, we know those kids survive, get good help from the mental health world, from their families, and so forth. And yes, they never forget, but they do get better. And so when I hear those headlines, you know, on the radio or TV or in the news, that “these kids will never be okay,” that’s just not true. They won’t forget, but they can be okay. In fact, not only are they often okay, but they find a way to make meaning of their experience that they actually bring even greater good to the world. 

[39:03] Teresa Huizar: 
As you were talking, I was thinking about two things. One was all the lectures I’ve given reporters on that very subject, like: Make sure that you are not just talking about kids being broken, being … I don’t know all the horrible words they use to describe child sexual abuse. And it’s like, let’s remember that survivors are reading this very newspaper and how incredible, you know, they are in the face of having experienced some very difficult things. 

But I also was just thinking about the fact that, now, the CAC movement has been around almost 40 years. So we’ve been around long enough that we’ve had lots of these kids we’ve interviewed grow up and become adults. You know, they’re young adults now, and some of them closer to middle age. And so it’s been interesting the number of them that reach out, you know, over time to talk about their experience at the CAC or how they’re doing. And what you’re saying is true that for so many, they have—they might not have been within the field at all, or in the field of human services, but there’s some way in which they’ve given back, you know, and it’s just really gratifying to see that.

I mean, maybe they decided to be a Girl Scout leader so they could be a safe one. Or decided to be a Boy Scout leader so they could be a safe one. Or got involved in their church so they could be a safe volunteer. Or—I mean, whatever it is, but it’s really a wonderful thing, I think.

Anthony Mannarino: 
Right, yeah, I couldn’t agree with you more. And, you know, even if a child goes through therapy when they’re young and it’s not completely successful, but if they had a positive sense of their experience, that might help them be more open to getting help later on as well with another therapist—

Teresa Huizar: 
That’s right.

Anthony Mannarino: 
—when they encounter any issues as adults. 

And you’re right. When these kids grow up and they become parents, maybe they’re going to serve in the kinds of roles that you mentioned because they realize the importance of it. 

So, yes, kids are amazingly resilient. They bounce back from issues and problems and with, you know, appropriate support from their family, get good treatment. They really do okay. And I think when we began to disseminate TF-CBT, that’s the feedback we got from therapists, that they finally felt like they had a strategy that they could use that would make a difference. Because before then, they felt like they didn’t sort of know what direction to go in, and now they felt like they could go forward and actually talk with kids about what happened, deal with some of their beliefs about what happened that may not have been accurate, help them understand more about what happened, and then move on. Again, not forget, but move forward. 

[41:43] Teresa Huizar: 
You know, I just … I think what a gift TF-CBT has been. Truly. You know, when I think about the hundreds of thousands of kids who, you know, go through TF-CBT and CACs every single solitary year—285,000. Most of them getting that, 80% of them, maybe of those who get therapy, that’s what they’re getting.

It’s like, that is so much reduced suffering in the world, if you think about it. And setting kids up for an adulthood in which they can be good parents if they choose to be parents. In which they can be good aunts and uncles and safe folks. And just not suffer, you know, in that way. And I just am … I’m enormously grateful for it, Tony, and honestly could talk your ear off for another hour. But I won’t.

[42:25]
 But I do want to ask you as a final question: First of all, is there anything else that I should have asked you and didn’t, or that you want to make sure that we talk about before I let you go? 

Anthony Mannarino: 
Well, I did want to mention we’ve had a unique effort going on in the Ukraine. 

Teresa Huizar: 
Oh, interesting. 

Anthony Mannarino: 
We’ve been collaborating with our European TF-CBT trainers to train therapists in the Ukraine in regard to TF-CBT. And as of—and the way we’ve done this, Teresa, is that our European trainers— now our American trainers—have all been willing and able to do all of this work for free. 

Teresa Huizar: 
That’s just amazing.

Anthony Mannarino: 
So far, I believe about 100 Ukrainian therapists have taken the training and consultation. Fortunately, even before the war in the Ukraine, our book had already been translated into Ukrainian.

Teresa Huizar: 
Ah!

Anthony Mannarino: 
So we’ve been able to provide that for free to Ukrainian therapists. And we’re hoping that, by like mid-year next year, we’re going to have about 200 therapists trained in the Ukraine. And most importantly, we’ve just started a new cohort of our international Train the Trainer program, and we have four trainers from the Ukraine who are participating.

Teresa Huizar: 
I love it.

Anthony Mannarino: 
So that by the end of 2024, we will have four TF-CBT trainers in the Ukraine. 

[44:01] Teresa Huizar: 
That is so awesome. When you think about all the kids who’ve been exposed to war and these horrible conditions, to have a group of trained clinicians right there that can support them, that’s incredible. So good.

Anthony Mannarino: 
What’s really so interesting about this, and sad, is that some of these therapists are providing TF-CBT there in bomb shelters, and there might actually be like an explosion or something outside of where they are during their hour of time with a child. And you talk about providing treatment in the context of a dangerous situation, it’s way more than I could have imagined. So I’m really grateful that our colleagues in Europe have collaborated with us to be able to, you know, go forward with this initiative in such a difficult situation. So that that’s that’s been our new, uh, project in these last several months. 

[44:54] Teresa Huizar: 
I just love it. 

[Outro music begins]

You guys just keep advancing the field, and I just truly appreciate it. Love it. So thank you, Tony, for coming on to One in Ten and talking to me.

Anthony Mannarino: 
Pleasure to be on the broadcast.

[Outro]

[45:04] Teresa Huizar:
Thank you for listening to One in Ten. If you liked this episode, please share it with a friend or colleague. And to get more information about this episode or any of our other ones, please visit our podcast website at OneInTenPodcast.org.

[Outro music fades out]