Conceptual Application of Trauma-Focused Cognitive Behavioral Therapy to Treat Victims of Bullying

Abstract

Bullying is a critical pediatric public health problem; estimates across diverse methodologies generally indicate that roughly 36% of youth are bullied. Although policy initiatives aim to address the universal prevention of bullying, and school-level secondary prevention programs aim to reduce the occurrence of bullying, tertiary prevention and intervention programs that mitigate the negative consequences experienced by victims of bullying remain an understudied need. The nature of bullying (that it occurs as events, leaves children feeling unsafe, and engenders emotional distress) and the association of bullying with posttraumatic stress symptoms among youth suggests that trauma treatment for bullying is promising. This manuscript presents the rationale for treating victims of bullying with trauma-focused cognitive behavioral therapy (TF-CBT), describes the components of TF-CBT, and discusses how to use TF-CBT specifically for bullying. Conducting research on treatment outcomes when using TF-CBT for bullying is critical to evaluate its efficacy and effectiveness in this group. Behavioral clinical trials would provide evidence for whether TF-CBT reduces the mental health harm experienced by youth victims of bullying. This evidence is an essential step to address the public health problem of bullying because the scientific literature currently does not have a well-established individual-level treatment for victims of bullying that mental health providers in diverse settings can deliver, despite individuals’ beliefs that health care providers are important sources of help for youth who have been bullied.

Significance

Estimates across diverse methodologies generally indicate that roughly 36% of youth are bullied (Lumeng et al., 2010; Modecki et al., 2014). Because bullying is a serious threat to child health at the individual level as well as public health level (Srabstein & Leventhal, 2010), research has sought to reduce bullying frequency. Existing intervention programs have been tested in school settings (Cantone et al., 2015; Hutson et al., 2018). While several programs are promising for reducing the incidence of bullying (Cantone et al., 2015; DeRosier, 2004; Hutson et al., 2018; Ortega-Baron et al., 2019; Palladino et al., 2016), fewer have focused on mitigating the negative psychological consequences of bullying (Berry & Hunt, 2009; Cantone et al., 2015).

Victims of bullying are more likely than non-bullied peers to experience a plethora of negative sequelae including, for example, psychosomatic health problems such as insomnia and headaches (Landstedt & Persson, 2014; Sourander et al., 2010), social and academic impairment (Abreu & Kenny, 2018; Olenik-Shemesh & Heiman, 2017; Schneider et al., 2012; Sourander et al., 2010), posttraumatic stress symptoms (Mateu et al., 2020; Ranney et al., 2016), body image concerns (Abreu & Kenny, 2018; Kenny et al., 2018; Landstedt & Persson, 2014; Olenik-Shemesh & Heiman, 2017; Ramos Salazar, 2021), disordered eating (Marco et al., 2018; Pistella et al., 2019; Ramos Salazar, 2021), and anxiety and depression (Abreu & Kenny, 2018; Berne et al., 2014; Gamez-Guadix et al., 2013; Kowalski & Limber, 2013; Landstedt & Persson, 2014; Schneider et al., 2012). Bullying is also associated with self-harm and suicidality (Abreu & Kenny, 2018; DeSmet et al., 2014; Hinduja & Patchin, 2010; Schneider et al., 2012; Van Geel et al., 2014).

School-based interventions are multi-faceted and include components that could improve youth mental health, such as coping skills training, communication and social skills training, and internet safety (Cantone et al., 2015; Hutson et al., 2018). In the literature, interventionists delivered most programs to the whole school (rather than the individual) and focused on involving as much of the community as possible to promote an anti-bullying culture (Cantone et al., 2015). Only one program was an individual-level intervention; that program was also in a school setting rather than a health care setting. The individual-level program only included boys with anxiety. Encouragingly, the program reduced revictimization and anxiety and improved self-esteem (Berry & Hunt, 2009).

Research on bullying commonly recommends that concerned parents, school professionals, and pediatricians refer youth to appropriate mental health care. Yet, the scientific literature provides minimal evidence supporting individual-level bullying treatments (Hutson et al., 2018; Srabstein & Leventhal, 2010).

Bullying and Posttraumatic Stress Disorder (PTSD)

Bullying is a highly distressing and repetitive event that some children experience (Aboujaoude et al., 2015; DeSmet et al., 2014; Schneider et al., 2012). Adverse experiences during childhood increase the risk of youth developing PTSD (Heim & Nemeroff, 2001) and stress-related physical health problems (Ehlert, 2013). Core features of PTSD include intrusive and distressing memories or dreams about a traumatic event, avoidance of stimuli (psychological or external) that remind the child of the event, negative or altered thoughts or mood related to the event, and altered arousal or reactivity after the event (American Psychiatric Association, 2013). Accordingly, posttraumatic stress is among the serious mental health consequences of bullying and warrants attention as a potential avenue to improve child health. The nature of bullying (that it occurs as stressful events, leaves children feeling unsafe, and engenders emotional distress) fits the description of traumatic stressors (American Psychiatric Association, 2013; National Institute for Health and Care Excellence, 2018). Although bullying may—but does not necessarily—involve physical harm or life-threatening injury, the psychological harm stemming from bullying causes significant impairment, even to the point where families choose to cope by switching school systems or opting for homeschooling. In a community study of adolescents, approximately 35% of bullying victims developed PTSD (Mateu et al., 2020) and 60% of adolescents presenting to an emergency department who reported being victims of bullying met PTSD criteria (Idsoe et al., 2012; Ranney et al., 2016). Taken together, the nature of bullying and the presence of PTSD suggests that bullying victims could benefit from trauma therapy (American Psychiatric Association, 2013; Kaess, 2018; The National Child Traumatic Stress Network, n.d.).

Treating Bullying with Trauma-focused Cognitive Behavioral Therapy (TF-CBT)

TF-CBT is a natural choice for the treatment of bullying victimization in youth for several reasons. First, experts recommend TF-CBT as a first-line treatment for youth with PTSD (Bastien et al., 2020; National Institute for Health and Care Excellence, 2018) because TF-CBT has well-established efficacy and effectiveness for the treatment of PTSD in youth, across many forms of trauma, in diverse health care, community, and telehealth settings (Bastien et al., 2020; Cohen et al., 2018; Jones et al., 2014; National Institute for Health and Care Excellence, 2018; Ovenstad et al., 2020; Silverman et al., 2008; Stewart et al., 2021; Stewart et al., 2017; Webb et al., 2014). Second, CBT is a treatment of choice for anxiety and eating disorders and has strong evidence that it is effective for treating depression, non-suicidal self-harm, and suicidality, and is generally effective at reducing symptomatology among adolescents with psychiatric disorders. Therefore, a CBT-based treatment would treat posttraumatic stress as well as psychopathology that could emerge from bullying. Third, TF-CBT includes the gradual exposure intervention activity that is common to effective PTSD treatments, directly targets and challenges negative and distorted thoughts and beliefs about the world, and provides coping skills education and practice. TF-CBT helps children regulate emotions surrounding a highly distressing stressor and enhance safety to prevent revictimization (Ascienzo et al., 2020; Morina et al., 2016; National Institute for Health and Care Excellence, 2018). Regulating emotions is important because maladaptive coping strategies, such as disordered eating or substance use, can come from a perceived lack of adaptive coping options. Maladaptive coping can also come from a desire to dissociate or zone out to avoid the stimuli related to bullying or recurring thoughts about the bullying. By confronting avoidance with adaptive coping strategies and challenging thoughts about the self and the world, overall functioning should improve.

TF-CBT Components

TF-CBT was originally developed as a treatment for PTSD stemming from childhood sexual abuse (de Arellano et al., 2014). As such, much of the theoretical underpinning maps onto bullying, which is a form of interpersonal abuse that can be physical, emotional, and/or relational. TF-CBT is a semi-structured evidence-based intervention. It is generally delivered in 12–16 sessions that include parent-only, child-only and joint parent/child sessions (Cohen & Mannarino, 2008). Although the treatment has distinct components, as detailed later in this section, the philosophy of TF-CBT is that the clinician should respond to the child’s developmental needs (Cohen & Mannarino, 2008), thereby allowing clinicians to spend time as needed to ensure mastery of different components.

TF-CBT emphasizes treatment of the child and involvement of the (non-offending) parent or caregiver. Unlike treatments that are solely child-focused, TF-CBT acknowledges that trauma experienced by a child can be traumatic directly or by proxy to the parent as well. Therefore, parents have individual sessions that focus on positive communication and reinforcement and that also prepare the parent to hear and respond supportively to the child’s trauma narrative.

TF-CBT’s core elements include psychoeducation, coping skills, gradual exposure (including cognitive processing), and safety planning. Psychoeducation and coping skills provide an important foundation for later elements of the treatment and are at the beginning of the treatment to help the youth adjust to the idea of the gradual exposure before that activity begins. Psychoeducation provides the rationale, over several sessions, for TF-CBT and its components to the child and the parent. Time spent on the rationale helps to build rapport and trust in the clinician and helps to build trust in the process of trauma therapy. Trauma therapy can be aversive for anyone, but particularly for youth whose focus prioritizes short-term rather than long-term well-being. Psychoeducation also provides some degree of normalization of trauma, helping communicate to youth—who might otherwise feel isolated by their experience—that they are not alone. Clinicians introduce coping skills at the beginning of therapy and youth practice skills throughout the treatment to provide early mastery of skills and self-efficacy around therapy.

Critically, coping skills are also available and practiced during the gradual exposure stage of therapy. TF-CBT uses a “trauma narrative” as a gradual exposure. The trauma narrative is the story the child tells of the trauma–the context, the event, and all associated stimuli, feelings, and thoughts. The clinician and child create the narrative as either a written story or an artistic story (e.g., graphic novel). In creating the narrative together, the clinician and child first capture the essential elements, then elaborate with as much detail as the child can generate, then engage in cognitive processing to challenge distorted thoughts or beliefs related to the trauma. At the end of therapy, the child shares their trauma narrative with a parent or caregiver who is caring and trusted; the clinician works with the caregiver prior to hearing the narrative to help prepare them for what they will hear and to coach them on responding in a caring and supportive way.

The “enhancing safety” element serves to prevent behavioral habits that could increase the child’s risk for revictimization or self-harm, such as developing interpersonal relationships very quickly or not feeling empowered to decline unwanted sexual advances.

TF-CBT for Bullying

Most TF-CBT components require minimal adaptation for implementation among youth who have been bullied; however, some key areas require adaptation and would therefore benefit from testing in clinical trials research.

Psychoeducation.

The psychoeducation for TF-CBT focuses on the rationale of why PTSD occurs after a traumatic event and why gradual exposure effectively reduces posttraumatic stress symptoms. These aspects of TF-CBT apply to bullying. In addition, TF-CBT allows clinicians to include psychoeducation about the specific stressors that the child experienced, which allows the clinician to share information about the prevalence and seriousness of bullying with the child to normalize that they are not the only youth who has been bullied. Later in therapy, prior to the cognitive work that comes with the trauma narrative, the therapist provides psychoeducation about how thoughts, behaviors, and feelings are all interconnected, which applies to bullying as much as other traumatic stressors.

Coping Skills.

The coping skills presented in TF-CBT, such as feelings identification, deep breathing, and thought stopping, are not specific to the type of trauma and therefore are just as helpful for bullying as other events. Bullying is an adverse childhood experience, which increases risk for mental health problems in later childhood and into adulthood (Heim & Nemeroff, 2001; Kaess, 2018). As such, treating bullying is tertiary prevention for mental health problems associated with bullying (e.g., depression, suicidality, anxiety, eating disorders). The coping skills training that is part of TF-CBT can also help prevent maladaptive coping strategies associated with the downstream consequences of bullying and should be discussed as an alternative to maladaptive coping. For example, youth who are bullied because of their weight can become desperate to escape the bullying and therefore try to lose weight in extreme ways, or can turn to binge eating for the dissociative experience (Puhl & Luedicke, 2012). When youth have familiarity with more adaptive coping strategies, they are less likely to feel like the maladaptive coping strategies are their only option.

Safety Planning.

The safety planning in TF-CBT originated as part of the treatment for childhood sexual abuse and focused on body safety skills. Safety planning meant teaching the youth what were acceptable and unacceptable physical touch boundaries, among other skills. Broadly, TF-CBT places safety planning in the context of maximizing child safety and developmental growth. This planning includes having a set of options to enact if the child feels threatened, recognizing dangerous situations, and practicing assertive communication. Safety planning is necessary for youth who have experienced bullying, as revictimization (being bullied again by the same or a new perpetrator) is a risk. Clinicians implementing TF-CBT with youth who have been bullied can teach the youth to identify appropriate (non-bullying) and inappropriate peer interactions, as well as to identify situations where they can use communication and coping skills learned in TF-CBT, and when a situation has become dangerous and requires an adult. Deciding these boundaries is helpful to navigate in therapy, ideally in a joint session with a parent, to avoid potential mixed messages. Children might be told to “fight back” or to “ignore” the bullying. Discussing these options as well as compromises between the two polarities (e.g., assertive communication) can help model problem-solving. In addition, talking through options to maximize physical and mental health safety can reduce the chance that the child who is bullied could feel blamed for causing the bullying or could feel shame for being bothered by the bullying. In addition, safety planning can help prevent the child from becoming a “bully-victim,” that is, a victim of bullying who becomes a perpetrator of bullying. “Bully-victims” have worse mental health outcomes and functioning than victims (e.g., Gini & Pozzoli, 2009; Mateu et al., 2020; Sourander et al., 2010; Wolke & Lereya, 2015). Therefore, to minimize individual negative consequences and minimize the public health burden of bullying by stopping the cycle of victimization, safety planning around how to respond assertively to protect oneself without creating conflict or hurting others should be the focus of safety-planning sections of TF-CBT for bullying.

Parent Sessions.

One of the essential elements of TF-CBT is that the parent (or caregiver) be non-offending. That is, the parent cannot be causing the traumatic stressor for which the child is receiving therapy. TF-CBT allows, however, that if the parent were part of the traumatic experience and subsequently received effective treatment and the child considered the parent to be supportive, then they could participate in TF-CBT (de Arellano et al., 2014). For the majority of bullying experiences, including bullying by peers in school settings and cyberbullying, parents are not the perpetrators and therefore this essential element of TF-CBT is met. Nonetheless, parents can explicitly and intentionally perpetrate bullying; in this case, a different parent or caregiver should participate in TF-CBT. Some forms of bullying, however, the child may experience as bullying but the parent may be unintentionally or inadvertently bullying. Most notably, weight-related bullying is (at least in part) an expression of the pervasive weight stigma in society. Weight-related teasing or bullying from parents may be experienced by their child as bullying but the parent may believe they are encouraging their child to lose weight. In this scenario, or if bullying from parents is discovered midway into treatment (e.g., peer bullying is the focus and the clinician later discovers that the parent is also bullying the child), the overarching idea of TF-CBT can be applied: the participating caregiver should be an adult identified by the child as supportive. Separate parent and child sessions at the beginning of treatment can improve parent awareness of caring and supportive communication as well as when their child could perceive their communication and actions as bullying.

The Bullying Narrative.

One of the conceptual adaptations to make TF-CBT appropriate for the treatment of bullying is conceptualizing the “trauma narrative” as a “bullying narrative.” Bullying is, by its nature and definition, something that occurs repeatedly. Other forms of trauma can also include repeated events (such as repeated occurrences of abuse or exposure to community violence). While the trauma narrative can include repeated events, the bullying narrative assumes multiple occurrences or perceived occurrences of bullying. Cyberbullying, in particular, can be nuanced in terms of how it is experienced and captured in the bullying narrative. A single post can be experienced as repetitious because it is viewed over and over if it is not taken down from the website. Each time it is viewed by the child, or each time the child learns of someone viewing or reposting the post, can be conceptualized as an “event” in the bullying narrative (Aboujaoude et al., 2015).

TF-CBT addresses repeated traumatic events in the narrative by focusing on the “first,” “worst,” and “most recent” event. This guidance can help the child with the task of creating the initial narrative by making the activity less overwhelming. When considering bullying as a trauma, it is important to remember that the repeated victimization is a key aspect of the definition of bullying. Many bullying events might not, if they occurred in isolation, cause enough distress as to be categorized as a traumatic event with posttraumatic stress as a potential consequence. However, repeated victimization can lead to physiological and psychological changes in how youth respond to stressful or threatening circumstances (Wolke & Lereya, 2015). Therefore, when creating the bullying narrative, it is helpful for the clinician to work with the child to identify the “first,” “worst,” and “most recent” events, as well as any other occurrences that felt significant enough to the child to highlight. The elaborative process that is part of the gradual exposure, and the cognitive processing of associated thoughts and affect, can focus on the highlighted events rather than all the events that occurred. With added time, the therapist and child can explore additional events for any associated thoughts or feelings that should be included in the cognitive processing and narrative. As this process is similar to but not exactly the same process as the trauma narrative, research exploring the effectiveness of TF-CBT for bullying with the bullying narrative is needed to ensure expected outcomes are achieved.

Future Research Directions

Despite the important potential translational implications, the implementation of TF-CBT for bullying has potential barriers that warrant future research. First, one of the assumptions of the conceptualized relevance of TF-CBT is that bullying is a traumatic stressor. Research should examine physiological and psychological stress surrounding bullying events and compare them with events more traditionally considered to be trauma (e.g., interpersonal and community violence, assault, natural disasters) to describe key similarities and differences. Likewise, although bullying is associated with posttraumatic stress, not all victims of bullying develop PTSD. The effectiveness of TF-CBT amongst victims of bullying should be compared between the individuals who have PTSD and those who do not have PTSD. Along these lines, feasibility trials need to test whether children, parents, and other key stakeholders in children’s lives (e.g., teachers, guidance counselors, coaches) perceive bullying to require psychological treatment so that individuals seek treatment (or stakeholders refer to treatment). Research studies also need to test at what point families seek treatment and stakeholders refer to treatment, as information about timing could inform critical periods for tertiary prevention and intervention work.

Similarly, the role of parents, with particular attention to parents who unintentionally or inadvertently bully their child, needs to be tested in clinical trials. Specifically, it is not known whether parents who bully or tease their child need different content or different frequency of parent sessions, or whether they should, once identified as an offender, be replaced by a nonoffending caregiver.

Finally, youth can be bullied in different forms (e.g., direct, relational, cyberbullying) and for different reasons (e.g., intelligence, weight/size, race/ethnicity/national origin, disability). Clinical trials needs to examine whethere TF-CBT can be implemented across forms and reasons for bullying, or whether adaptation would improve the effectiveness of TF-CBT in specific cases. For example, clinical trials could examine whether, if youth are bullied for being a racial or ethnic minority, the TF-CBT treatment (including psychoeducation and cognitive processing of the bullying) needs to be adapted for culture-congrugent messages that promote resilence. As it is likely that intersectionality plays a role – that is, that some youth are bullied for multiple reasons rather than a single reason – studies and treatment need to consider children’s priorities and perceived distress.

Conclusion

Bullying is a critical pediatric public health problem with implications at the individual, family, and community level. To address this public health problem, intervention must occur at the individual and family level as well as at the community (e.g., school) level. To complement the promising work on bullying prevention and school-level intervention, treatment also needs to occur at the individual level. While this could indicate individual treatment in clinics and medical settings where clinicians are already trained in TF-CBT, TF-CBT has accessible training resources (e.g.,(TF-CBT, 2021) and school psychologists and counselors could also deliver TF-CBT to individual students (e.g., (Connors et al., 2021). TF-CBT has a strong conceptual rationale to be considered as a viable treatment for bullying, but research needs to establish evidence for its use.

TF-CBT is a promising intervention that research studies can test for feasibility, efficacy, and effectiveness. Much research is needed on how mental health providers in health care settings and embedded in school settings (such as psychologists and counselors) can provide treatment for youth who have been bullied so that the negative mental and physical health consequences of bullying do not cause long-term impairments. Given the seriousness of the consequences of bullying, key research questions include whether TF-CBT can be delivered to youth victims of bullying (feasibility), whether TF-CBT in a controlled research study produces meaningful improvements in children’s health and wellbeing (efficacy), and whether TF-CBT can be implemented across diverse settings and providers and show improvements in child health and wellbeing (effectiveness). Notably, however, TF-CBT is one of several possible interventions. Testing other approaches to improve the lives and wellbeing of youth who have been bullied is also warranted and could potentially expand the number of bullied youth who have improved well-being and fewer consequences of bullying.