What steps should be taken in the initial trauma‑focused cognitive‑behavioral therapy (CBT) session, including safety assessment, informed consent, psychoeducation, and teaching of grounding or relaxation skills?

First Session of Trauma-Focused CBT: Essential Components

The first session of trauma-focused CBT should prioritize establishing safety, providing psychoeducation about trauma responses, teaching initial grounding/relaxation skills, and building rapport—not diving into trauma narrative work. 1, 2, 3

Establish Safety and Engagement First

Begin by creating an emotionally safe environment through rapport-building, active listening, and ensuring the patient feels heard without judgment. 1, 2 The American Academy of Pediatrics emphasizes maintaining a balance between professionalism and friendliness while being fully present in the moment. 1, 2

Critical Safety Assessment Components

• Screen immediately for current safety concerns: suicidality, self-harm intent, intent to harm others, and whether the patient remains in an unsafe environment due to ongoing abuse or neglect. 1, 2
• For children and adolescents, always ask if they want to be interviewed separately from caregivers—failure to do so can limit disclosure and facilitate ongoing harm. 2
• Assess whether the trauma is ongoing or the patient has achieved physical safety from the traumatic situation. 1, 4

Provide Trauma-Focused Psychoeducation

Educate the patient about normal trauma responses to shift focus away from pathology toward resilience and natural recovery. 1 This psychoeducation should cover:

• Normalize common trauma reactions including intrusive memories, hyperarousal, avoidance, sleep disturbances, and emotional reactivity—explaining these are expected responses, not signs of weakness or permanent damage. 1
• Explain the cognitive triangle: how thoughts impact feelings, which impact behaviors, which then reinforce thoughts—this framework will be used throughout treatment. 1
• Describe the treatment structure and rationale: explain that TF-CBT consists of stabilization skills first, followed by gradual trauma processing, and that 40-87% of patients no longer meet PTSD criteria after completing 9-15 sessions. 1, 5, 3

Informed Consent Elements

• Explain that temporary symptom exacerbation may occur during trauma narrative work but resolves by treatment end—this prepares patients and prevents premature dropout. 6
• Clarify the phase-based approach: stabilization skills come first, trauma processing comes later, and the therapist will not push the patient into trauma discussion before they have adequate coping tools. 5, 3, 7

Teach Initial Grounding and Relaxation Skills

Introduce at least one concrete calming technique the patient can use immediately when distressed. 1 The most evidence-supported techniques include:

• Breathing retraining (diaphragmatic/belly breathing): the most frequently used technique across validated protocols. 1
• Progressive muscle relaxation: systematically tensing and releasing muscle groups to reduce physiological arousal. 1
• Grounding exercises: using five senses to anchor to the present moment when experiencing flashbacks or dissociation. 1

Practice the chosen technique in-session so the patient leaves with a skill they can actually use, not just theoretical knowledge. 1, 3

Assess Trauma History and Current Symptoms (Without Detailed Narrative)

Conduct a brief trauma assessment to understand what happened, but do not ask for detailed trauma narrative—that comes in later sessions after stabilization. 1, 2, 3

Use the FRAYED Framework for Symptom Screening

• Frets: anxiety, fears, worry 1, 2
• Regulation difficulties: behavioral/emotional dysregulation, hyperactivity, impulsivity, aggression 1, 2
• Attachment challenges: insecure relationships with caregivers, poor peer relationships 1, 2
• Yawning and yelling: sleep problems, nightmares, aggression 1, 2
• Educational/developmental delays: school problems, attention difficulties 1, 2
• Defeated: hopelessness, depression, dissociation 1, 2

Ask open-ended questions first, then progress to specific probing questions based on responses—never ask the same question multiple times, as this causes confusion and distress. 2

Identify Strengths and Resilience Factors

Begin by asking about strengths and protective factors before discussing difficulties—this frames the conversation positively and identifies resources for treatment. 2

• Assess social support: who does the patient trust, who can they talk to, what relationships provide comfort? 1
• Identify existing coping strategies: what has helped in the past, even if only partially effective? 1
• Explore cultural and spiritual resources: beliefs, practices, or community connections that provide meaning or support. 2

For Children/Adolescents: Include Caregiver Psychoeducation

Provide parallel psychoeducation to caregivers about trauma responses and how to support the child at home. 1, 3, 7

Key Caregiver Guidance

• Repeatedly assure the child they are safe now if the trauma has ended. 1
• Allow emotional expression and listen attentively without minimizing or dismissing feelings. 1, 2
• Maintain predictable routines to restore a sense of order after the chaos of trauma. 1
• Remain calm when the child is dysregulated to model self-regulation and avoid retraumatization—the child's strong emotions may be directed at the caregiver but are usually not about the caregiver. 1

Assess caregiver trauma history when relevant, as parental adverse childhood experiences affect child health and development—use a two-generation approach. 2

Set Expectations and Schedule

Explain the typical treatment duration (12-17 sessions for most TF-CBT protocols) and frequency (usually weekly). 5, 3, 7

• Clarify that trauma narrative work will not begin until the patient has learned and practiced stabilization skills—this typically occurs after 3-5 sessions of skills-building. 3, 7, 4
• Schedule the next session within one week to maintain momentum and allow practice of the grounding technique taught. 3, 6

Critical Pitfalls to Avoid in Session One

• Never conduct psychological debriefing or ask for detailed trauma narrative in the first session—randomized controlled trials show this worsens outcomes, with 26% PTSD rates versus 9% in non-debriefed controls. 1, 8
• Do not assume mature-appearing youth are less credible or less traumatized—this is a documented bias. 2
• Avoid expecting trauma survivors to fit a stereotypical profile—presentations vary widely. 2
• Never challenge inconsistencies in the patient's account—trauma affects the ability to provide coherent, consistent narratives, and children exposed to trauma are more susceptible to changing responses under pressure. 2
• Do not delay treatment to achieve "stabilization" before beginning TF-CBT—current evidence shows trauma-focused therapy can proceed safely even with complex presentations, and prolonged stabilization phases may be iatrogenic. 5

Protect the Therapist

Recognize that listening to trauma narratives can trigger secondary traumatic stress in providers, potentially compromising professional functioning. 2

• Ensure adequate supervision, peer support, and self-care practices including rest, exercise, and mindfulness. 2
• This is particularly important as treatment progresses into trauma narrative phases, but awareness should begin from session one. 2