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The Integration of Trauma Focused Cognitive Behavioral Therapy with Art Therapy for
Sexually Abused Children and Adolescents Exhibiting PTSD Symptomology
R. Aleatha Thrush
ARTT/790 Art Therapy Research
Penn West University

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Abstract

This abstract explores the potential benefits of combining Trauma Focused-Cognitive Behavioral
Therapy (TF-CBT) with art therapy for children and adolescents who have developed Post
Traumatic Stress Disorder (PTSD) as a result of sexual abuse. Research has shown that both TFCBT and art therapy are effective interventions for trauma related symptoms, and combining the
two may provide a more comprehensive and holistic approach to treatment. The paper reviews
theoretical foundations of both modalities, as well as the evidence supporting their efficacy in
treating PTSD. Additionally, it examines the unique contributions of each and how they can
complement each other in the treatment of trauma. Practical considerations for implementing a
combined TF-CBT and art therapy approach are also discussed including therapeutic techniques
and interventions. Finally, future directions for research and clinical practice in this area are
proposed.

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Section I: Introduction

Childhood sexual abuse is a profoundly traumatic experience that can have long-lasting
effects on the mental health and well-being of survivors, such as psychological, emotional,
physical, and social. Among the many potential consequences, Post-Traumatic Stress Disorder
(PTSD) is one of the most prevalent and debilitating. Treating PTSD in sexually abused children
and adolescents is essential to help them heal and regain control over their lives.
While evidence-based therapies such as Trauma Focused- Cognitive Behavioral Therapy
(TF-CBT) have shown great efficacy in reducing PTSD symptoms, the integration of art therapy
can further enhance the healing process. This combination provides a comprehensive approach
that addresses the unique needs of these young survivors, allowing them to express and process
their trauma safely and creatively.
Problem to be Investigated.
Sexual abuse is an egregious form of trauma that impacts children and adolescents, often
leading to long-lasting psychological issues including depression, anxiety, and Post Traumatic
Stress Disorder (PTSD). PTSD is a mental health condition that develops in children who have
been traumatized through sexual abuse. Children who experience PTSD can have a wide array of
symptoms which can severely impact a child’s daily functioning. The debilitating nature of PTSD
necessitates a comprehensive therapeutic approach that addresses the unique needs of sexually
abused children. Therefore, it is important for children and adolescents who have suffered sexual
abuse to receive appropriate and timely mental health support. They need to effectively process
and cope with their traumatic experiences.
Purpose Statement

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Art therapy can complement Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
in promoting healing and recovery among children and adolescents who have developed PTSD
due to sexual abuse. Both TF-CBT and art therapy are rooted in the understanding of trauma’s
impact on individuals. The integration of art therapy and TF-CBT offers a unique perspective on
trauma treatment. It combines emotional expression alongside cognitive restructuring, which is
important because it utilizes the strengths of two modalities. Ultimately, it allows therapists to
provide a comprehensive and integrated approach addressing the complex needs of trauma
survivors.
Justification
Child sexual abuse is a prevalent and devastating issue that has significant consequences
for the mental health and well-being of victims. According to the National Center for Victims of
Crime, 1 in 5 girls and 1 in 20 boys are victims for child sexual abuse in the United States
(National Center for Victims of Crime, 2010). These victims often experience long-term effects.
According to the National Child Traumatic Stress Network (2018), it is estimated that
approximately 30% of children who have been sexually abused will develop PTSD. Studies have
also shown that adolescents who have experienced sexual abuse are at even greater risk of
developing PTSD compared to those who have not experienced such trauma (Alisic et al., 2014).
The prevalence rates of PTSD among this population are alarming, highlighting the
urgent need for early intervention and support. It is essential for mental health professionals to
have a specialized course of action that addresses the unique needs of these survivors to
effectively treat trauma and PTSD resulting from childhood sexual abuse. There are numerous
ways to address these issues and help young people heal from their wounds.

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Unfortunately, there is a significant gap in research regarding an integrated approach
which has limited empirical evidence that examines the efficacy and outcomes of art therapy as
an adjunct to TF-CBT. Studies should investigate the impact of a combination of both modalities
on specific therapeutic outcomes, such as symptom reduction, increased emotional regulation,
and improved quality of life. Longitudinal studies could also explore the long-term effects of the
integrated approach, providing valuable insights into its potential as a standardized treatment
option. Currently, there is a scarcity of research specifically focusing on such integration, making
it difficult to draw definitive conclusions about its efficacy.
Though very limited, some studies have supported the effectiveness of combining TFCBT and art therapy as a means for the reduction of PTSD symptoms in sexually abused
children. One such study has postulated that over the past ten years art therapy has been growing
as a legitimate treatment for trauma. However, there is still reluctance to validate it as a
legitimate form of treatment for traumatic experiences. According to the International Journal of
Art Therapy, Bowen-Salter, and colleagues (2021), recognized the sparsity and rigorous
methodology supporting the use of art therapy with the practice of treating trauma victims. More
needs to be done to show effectiveness not only with the use of art therapy but as an adjunct to
TF-CBT.
Terms Related to the Study
Post Traumatic Stress Disorder (PTSD), sexual abuse, Trauma Focused-Cognitive Behavioral
Therapy (TF-CBT), and Art Therapy.
Definition of Terms

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Sexual Abuse. A form of abuse in which individuals are subjected to unwanted sexual
activity, coercion, or behavior without their consent (American Psychological Association, 2021).
Trauma. A psychological or emotional response to even or series of events that are
distressing, often perceived as threatening to one’s physical or emotional well-being.
Post Traumatic Stress (PTSD). A mental health condition that can develop after a
person has been exposed to a traumatic event (American Psychiatric Association, 2013).
Trauma Focused-Cognitive Behavioral Therapy (TF-CBT). An evidence-based
treatment approach specifically designed to help children and adolescents who have experienced
traumatic events (Cohen et al., 2017).
Art Therapy. A form of therapy that utilizes artmaking as means of expression and
communication in which individuals explore thoughts and emotions through the creative process,
providing a non-verbal outlet for them to work through their experiences (American Art Therapy
Association, 2022).
Conclusion
When looking at child sexual abuse and the development of PTSD, there are modalities
that can be used to help these survivors heal and flourish. TF-CBT and art therapy can be powerful
and affective approaches in addressing complex needs of individuals who have experienced trauma.
Survivors can work towards recovery in a holistic manner. This integrative method will address
the symptomology that follows a diagnosis of PTSD. Furthermore, it will allow for the
development of coping skills, self-expression, and empowerment. Through the synergy of these
therapeutic approaches, individuals can find healing, resilience, and a path towards reclaiming their
lives after experiencing the devastating effects of child sexual abuse.

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Section II: Review of Literature

Post Traumatic- stress disorder (PTSD), Trauma Focused Cognitive Behavior Therapy
(TF-CBT), and art therapy all intersect in meaningful ways, especially when addressing the needs
of sexually abused children and adolescents. Sexual abuse can have devastating and lifelong
effects, leading to the development of PTSD. Symptoms of PTSD in sexually abused children
and adolescents can manifest in different ways, including but not limited to flashbacks,
nightmares, anxiety, and avoidance. However, a combination of TF-CBT and art therapy has
shown promising results in reducing these symptoms and promoting healing. By addressing the
cognitive distortions and negative beliefs associated with trauma, through the integration of TFCBT and art therapy, sexually abused children can begin to heal from their traumatic experiences
and gain a sense of control and empowerment in their lives. An all-inclusive approach can help
reduce the impact of PTSD symptoms, improve coping mechanisms, and promote recovery and
resilience in these vulnerable individuals.
Sexual Abuse
Sexual abuse is a form of abuse that can occur in various settings, such as within families,
schools, communities, and even online. The impact of sexual abuse on victims can be
overwhelming, affecting their physical, emotional, and psychological well-being, as well as their
relationships and overall development. Childhood sexual abuse includes sexually connotated
physical contact or non-contact activities (Lo Iacono et al., 2021). Sexual abuse is defined as any
sexual activity between a child and an adult or an older child that includes touching, penetration,
and non-contact acts such as showing pornography or exposing oneself (Centers for Disease
Control and Prevention, 2021). Non-contact acts may include exhibitionism or exposing a child
to pornography.

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Research has also shown that the effects of sexual abuse can extend to adulthood, making
it essential for receiving treatment early (“Committee Opinion No. 498: Adult Manifestations of
Childhood Sexual Abuse,” 2011). A study of fourteen reviews with 270,000 persons in 586
studies reveals the lifelong effect of child sexual abuse can have on children leading to a
variety of complications that are medical, behavioral, psychiatric, and sexual (Maniglio, 2009).
Adults of childhood sexual abuse experience long term consequences such as difficulties in
forming and maintaining relationships, problems with intimacy and sexuality, and ongoing
mental health issues. They also struggle with issues related to self-esteem and trust. They are at
risk for future victimization and engaging in unsafe sexual behaviors. In a study published in the
Journal of Traumatic Stress, researchers found that adults who had experienced childhood sexual
abuse were more likely to report symptoms of depression, anxiety, and PTSD compared to those
who had not experienced abuse (Banyard et al., 2001). The impact of child sexual abuse later in
life also varies in consequences such problems with general health, gastrointestinal, gynecologic,
or reproductive health, pain, cardiopulmonary symptoms, to chronic pain, obesity, psychological
symptoms, and psychiatric disorder (Maniglio, 2009). Therefore, it is important to recognize
abuse early to stop the residual effects of childhood sexual abuse.
Prevalence
About one in four girls and one in thirteen boys will experience sexual abuse before they
reach the age of eighteen (Centers for Disease Control and Prevention, 2021). These alarming
figures highlight the urgent need for increased awareness, prevention efforts, and support services
for victims of sexual abuse. A meta-analysis of 217 studies on child sexual abuse prevalence
found that an estimated 7.9% of boys and 19.7% of girls in the United States experience sexual
abuse before they become adults (Pereda et al.,2009). Additionally, 91% of reported child and

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adolescent child abuse is perpetrated by someone they know (Centers for Disease Control and
Prevention, 2021). It is also important to note that sexual abuse is often underreported, and actual
prevalence rates may be even higher than those reported in research studies. Many victims of
sexual abuse may not disclose their experiences due to fear, shame, or other factors. Therefore, it
is essential for healthcare providers, educators, and other professionals to be vigilant in
identifying and addressing cases of sexual abuse among children and adolescents. Young people
are affected more often by sexual assault or abuse, especially if they have pre-existing
vulnerabilities. They could be disadvantaged due to socioeconomic status, mental health
problems, and previous experiences with abuse are at increased risk (Khadr et al., 2018).
Consequently, associations have been shown between adolescent sexual assault and a range of
adverse outcomes such as, suicide risk, substance use, teenage pregnancy, poorer educational
outcomes, and poorer self-rated health (Khadr et a., 2018).
Physical Symptoms
It is important to recognize the physical signs of sexual abuse to provide support and
intervention for those who have experienced it. Physical signs can vary depending on the nature
of the abuse and the individual’s response to it. The injuries may be in areas typically covered by
clothing, such as the thighs, buttocks, or breasts. These types of injuries may be the result of
physical force or violence during the abuses. Additionally, sexual abuse may also be described as
trauma which may include tears, bruising, or swelling in the genital area (Vrolijk-Bosschaart et
al., 2018). Changes in sexual behavior or attitudes can also be a physical sign of sexual abuse.
Those who have been abused may exhibit hypersexuality, promiscuity, or an aversion to sexual
activity. Changes in sexual behavior can be a manifestation of the trauma experienced during the

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abuse. Other physical symptoms could also include the presence of sexually transmitted diseases
(STDs), anogenital abrasions, incontinence, and constipation (Vrolijk-Bosschaart et al., 2018).
Sexual abuse in children and teens can be manifested through various somatic symptoms
and signs such as chronic pain. Studies have shown that children and teens may report headaches,
stomach aches, or muscle soreness (Casanovas et.al., 2022). Furthermore, there has been a link
between gastrointestinal issues like irritable bowel syndrome and diarrhea in the aftermath of
sexual assault or abuse (Vranceanu, 2016). They also exhibit changes in sleep patterns, for
example falling asleep, staying asleep or frequent nightmares. There are changes in their eating
habits like sudden weight gain or loss. These symptoms are a manifestation of stress and anxiety
caused by the abuse and can affect a victim’s quality of life.
Behavioral Signs
According to the American Academy of Child and Adolescent Psychiatry (AACAP) (2014),
common behavioral signs of sexual abuse in children and adolescents include but are not limited
to an interest or avoidance of things of a sexual nature, seductiveness, refusal to go to school,
delinquency, conduct problems, and secretiveness. They also exhibit sudden and unexplained
changes such as becoming more withdrawn, anxious, or aggressive. Young children often exhibit
more regressive behaviors like thumb sucking or bedwetting (Whealin & Barnett, n.d.).
Additionally, sexualized behaviors become more prominent and are inappropriate for their age,
like mimicking sexual acts or using sexual language (Castro et al., 2019). They may also engage
in self-harming behaviors or have difficulty forming healthy relationships with others. Children
will show increased signs of fear and anxiety, particularly around the abuser or in situations that
remind them of the abuse. Victims of sexual abuse tend to avoid certain places or people that
remind them of the abuse, or they may become more isolated and withdrawn from social

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interactions. Survivors of these traumatic experiences often use dissociation as a survival
mechanism. Dissociation is a mental process in which there is a disconnection in a person’s thought,
memories, and feelings, actions, sensations, or sense of self (Balla et al., 2023). Finally, changes
in academic performance may see a decline in grades or have difficulty concentrating in school. It
is important to note that these behavioral signs are not definitive proof of sexual abuse but may
serve as red flags that warrant further investigation.
Emotional Signs
Some common emotional symptoms of sexual abuse in this population include feelings
of guilt, shame, fear, and confusion (Edwards, 2018). These emotional symptoms can be
debilitating and typically interfere with the child’s ability to function in daily life and
relationships. Additionally, they can have long-lasting effects on the individual’s mental health
and overall quality of life.
One of the key emotional symptoms of sexual abuse is an overwhelming sense of guilt
and shame. In their 2005 review, Whiffen and MacIntosh inferred that a variety of emotional
disturbance such as self-blame and avoidant coping strategies made connections between child
sexual abuse and psychological distress. Victims blame themselves for the abuse and take on the
responsibility for what happened to them, leading to low self-esteem. This can make it difficult
for the child to trust others and seek help, due to feeling responsible for the abuse (Alix et
al.,2019). This sense of shame can be so overwhelming, and lead to feelings of isolation and
withdrawal from others and may even lead to self-harm or suicidal ideation (Alix et al., 2019).
Furthermore, victims live in constant fear of similar situations occurring again, leading to
heightened anxiety and hypervigilance.

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It is important for children and adolescents who have been sexually abused to receive
appropriate support and therapy to address the emotional symptoms of the abuse. The effects of
sexual abuse on children and adolescents can manifest in a variety of ways and can last well into
adulthood. Victims of sexual abuse are more likely to suffer from a range of mental health issues,
including anxiety, depression, and Post-Traumatic Stress Disorder (PTSD) (Maniglio, 2009).
Post-Traumatic Stress Disorder (PTSD)
According to the DSM5 (2013), PTSD is defined as actual or threatened sexual violence
by direct exposure, witnessing, or learning about trauma, or indirect aversive details of the
trauma. The trauma must be reexperienced by unwanted upsetting memories, nightmares,
flashbacks, emotional distress after trauma reminders, or physical reactivity to those reminders.
There must be an avoidance of trauma or trauma related thoughts, feelings, or related reminders.
Negative thoughts or feelings that began or worsened after the trauma, with an inability to recall
key features of the trauma accompanied by overly negative thoughts and assumptions about
oneself or the world, exaggerated blame of self or others for causing the trauma, negative affect,
decreased interest in activities, feeling isolated, or difficulty experiencing positive affect. There
must be trauma-related arousal and reactivity that began or worsened after the trauma with
irritability or aggression, a display risky or destructive behavior, experience hypervigilance, have
a heightened startle reaction, difficulty concentrating and difficulty sleeping. There must be one
or two requirements met under each category. Symptoms must last for more than one month,
create distress and functional impairment, and not due to medication, substance use or illness.
Child sexual abuse is linked to multiple long-term negative effects. Risk factors include
psychological disorders such as depression, suicidal ideations, anxiety, and PTSD (Hébert et al.,
2021). The development of PTSD is the most common disorder among children and adolescents

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who have been sexually abused (McLean et al., 2014). Research has shown that children and
adolescents who have been sexually abused are at a higher risk for developing PTSD than those
who have not experienced sexual abuse (McLean et al., 2014). This suggests that because of the
nature of trauma, sexual abuse plays a significant role in the development of PTSD.
The symptoms of PTSD in those who have experienced sexual abuse include intrusive
thoughts or memories of the traumatic event, avoidance of reminders of the trauma, negative
changes in mood or thinking, and heightened arousal or reactivity. Children and adolescents may
also experience difficulties with concentration, sleep disturbances, and emotion dysregulation.
These symptoms can significantly impact a child's ability to adapt to life’s challenges.
Consequently, children often experience a fear of presence of re-experience, avoidance and
numbing, and arousal symptoms (Hamblen & Barnett, 2011). Additionally, children and even
adolescents may engage in reenactment play in which they replay the events through actual play
scenarios, or a verbal repetition of what happened (Hamblen & Barnett, 2011). For the sexually
abused it will show up in role play with toys such dolls or stuffed animals. For teens, it shows up
as consistent intrusive unwanted thoughts that affect their daily functioning.
Treatments
In terms of treatment and intervention, it is essential to provide comprehensive and
trauma informed care. This may include therapy to address psychological and emotional effects
of trauma. Cognitive behavioral therapy (CBT) has been shown to be effective in treating PTSD,
as it helps individuals process and reframe their traumatic experiences. It aims to help individuals
identify and challenge maladaptive thoughts and beliefs related to their traumatic experiences, as
well as develop coping skills to manage symptoms of PTSD. CBT is widely used with a variety
of mental health concerns such as depression, anxiety, and substance use disorders (Beck, 2011)

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Eye Movement Desensitization and Reprocessing (EMDR) therapy has also been shown
to be effective in treating PTSD in individuals who have experienced sexual abuse. EMDR is a
type of therapy that helps clients process traumatic memories through eye movements or other
forms of bilateral stimulation (Hudson, 2011). Research has found that EMDR can help reduce
PTSD symptoms and improve overall functioning (Shapiro, 2013).
Medication may also be prescribed to help manage symptoms of PTSD, such as anxiety,
depression, and sleep disturbances. According to the American Academy of Child and
Adolescent Psychiatry (2019), selective serotonin reuptakes inhibitors (SSRIs) are commonly
used to treat children and adolescents, as they can help alleviate symptoms and improve overall
functioning.
Expressive arts therapy has been shown to be an effective form of treatment for children
and adolescents who have experienced sexual abuse and are struggling with PTSD. This form of
therapy allows individuals to express their thoughts and feelings, and experiences in a non-verbal
way, which can be particularly beneficial for those who may have difficulty articulating their
emotions verbally. One study by Malchiodi (2015) found that expressive arts therapy can help
individuals process traumatic experiences, reduce symptoms of PTSD, and improve overall
mental health. By engaging in activities such as drawing, painting, writing, or music children and
adolescents can explore their emotions in a safe and supportive environment, which can lead to
increased self-awareness and emotional regulation (Malchiodi, 2015). Furthermore, expressive
art therapy can facilitate communication and connection with others, which is important for
individuals who have experienced sexual abuse and may struggle with feelings of isolation and
alienation. By engaging in creative activities with a therapist or in a group setting, individuals can
build trust, establish a sense of safety, and develop healthy relationships with others.

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One of the most used therapeutic approaches for treating PTSD in this population is traumafocused cognitive behavioral therapy (TF-CBT). Trauma-focused cognitive behavior therapy is
even more effective in treating children and Adolescents with PTSD. Unlike CBT, TF-CBT has a
target population. It is for individuals who have experienced trauma, particularly children and
adolescents who have been exposed to abuse, violence, or natural disasters (Cohen et al., 2017).
Trauma Focused- Cognitive Behavioral Therapy
TF-CBT is an evidence-based treatment that helps individuals process their traumatic
experiences, develop coping skills, and address negative thoughts and beliefs about related abuse
(Cohen et al., 2017). It typically involves individual and family therapy sessions that focus on
building a sense of safety, trust, and empowerment for the child or adolescent. It consists of
various components in a structured approach to help individuals who have experienced trauma. It
is delivered by a specially trained mental health professional in a structured time limited format,
with the focus on collaboration between therapist, individual, and family to address the impact of
trauma and promote healing and recovery.
Psychoeducation involves providing information to the individual and their families about
the specific trauma they have experienced, which includes its impact on mental health and the
goals and structure of TF-CBT. The three phases of TF-CBT are stabilization and skill building,
trauma narration and processing, and integration and consolidation of lessons learned (Pollio &
Deblinger, 2017). The components of TF-CBT are identified with the use of the acronym
P.R.A.C.T.I.C.E. which stands for Psychoeducation, Relaxation, Affect, Cognitive coping,
Trauma Narrative, In vivo mastery, Conjoint sessions, and Enhancing safety (Pollio & Deblinger,
2017).

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Parents often have little understanding of normal age-appropriate behaviors and can
unintentionally overreact to those behaviors. Therefore, it is important to educate parents and
caregivers of young children on their child’s emotions and behaviors deciphering what is
problematic and normative behaviors. Some fears (e.g., monsters), sexual behaviors (e.g.,
touching one’s private parts), and noncompliant behaviors are common in young children (Pollio
& Deblinger, 2017). Psychoeducation specifically for children and adolescents is equally
important. It should be developmentally appropriate so the child can understand the information
being received. A good example of conveying information, especially to young children, is
through the use of picture books. Furthermore, to assess understanding of what the child has
retained clinicians can ask open-ended questions.
Relaxation skills offer techniques to help manage stress and anxiety related to trauma
(Mannarino et al., 2004). When sexual abuse has occurred children may feel they have little to no
control of their bodies. Relaxation skills give them back the ability to control body sensations.
Children are encouraged to develop and practice mindfulness skills through various exercises and
using their own imagination. Counselors can help children visualize relaxing scenes or they can
devise their own by drawing pictures or describing images of comforting scenes to use when
feeling anxious (Pollio & Deblinger, 2017). Young children also respond well to images (e.g., the
beach) and/or cue words (i.e., breathe) to help them physically relax their bodies.
Affect expression and regulation focuses on helping individuals identify and express their
emotions related to trauma and learn healthy ways to regulate their emotions (Mannarino et al.,
2004). Children and adolescents who have been sexually abused may exhibit a wide range of
affect expressions, including but not limited to sadness, anger, fear, shame, guilt, and confusion.
These emotions can be intense and overwhelming and may be difficult for the child to adequately

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process or regulate. If these emotions are not regulated it may cause further distress to the child
or adolescent. A safe and supportive environment must be provided for victims to identify and
process their emotions.
Cognitive coping is where clients learn to identify and challenge negative thoughts and
beliefs related to trauma and develop more adaptive ways of thinking (Mannarino et al., 2004).
The aim is to get children to understand how thoughts, feelings and behaviors relate to one
another. Through this cognitive triangulation unhelpful thoughts can arise and be challenged and
reframed into more accurate and helpful ways.
Trauma narrative is where individuals are guided in telling their story of traumatic
experience in a safe and structured way, to help them process and make sense of the trauma
(Mannarino et al., 2004). It is a crucial component of the treatment. It is meant to help children
and adolescents confront their traumatic memories in a safe and structured way. The narrative
can help empower victims, challenge negative beliefs, and develop healthier coping strategies.
The narrative itself is set up in book form with titles the child can choose from such as “all about
me” or “telling my story. By allowing the child a choice of where they would like to begin or go
next gives them a sense of control over the process and increases cooperation (Pollio &
Deblinger, 2017).
In vivo mastery or trauma reminders is where individuals gradually confront and master
situations of triggers that remind them of the trauma in a safe and controlled manner. This
involves helping the child face their fears and anxieties surrounding the trauma in a step-by-step
fashion, starting with a less threating situation and gradually working up to more challenging
ones. For example, if the abuse happened at a friend’s house, instead of avoiding all friends the
child could be on an outing with a group of friends and gradually go to a trusted friend’s house.

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This helps minimize avoidant behaviors which are common in sexually abused children. The
parent or guardian is essential in these exposure exercises since they occur outside the therapy
session. Praise must be given toward desired behaviors, while minimizing attention to avoidant
behaviors.
Conjoint parent child sessions involve both the parent/caregiver and the child to
participate in sessions to learn how to support the individual, reinforce skills learned in therapy,
and improve family communication relationships (Mannarino et al., 2004). Involving parents,
caregivers, and guardians in conjoint sessions allows the child to express the skills they have
learned throughout the treatment sessions. It is especially important during the trauma narrative
phase in which the child shares their stories with their caregivers. This empowers the child and
shows a tremendous amount of growth and resilience on their part. A supportive environment is
necessary throughout the process, but especially during conjoint sessions.
Enhancing safety and future development focuses on teaching individual’s skills to stay
safe, prevent future trauma, and build resilience for the future. Children are taught about personal
safety and assertiveness skills (Mannarino et al., 2004). The type of trauma the child experiences
determines what safety protocols are addressed. In this phase children practice competence and
build confidence in how they present themselves to others, such as using body language to
convey certain messages. Role plays are useful in teaching safety skills. Research has shown that
practicing safety skills in role plays improves children’s learning of those skills, and that the
involvement of caregivers enhances children’s ability to retain and use these skills (e.g.,
Deblinger, Stauffer, & Steer, 2001).
TF-CBT provides a substantial framework for helping children and adolescents move
from one phase to the next. However, what this approach lacks are a non-verbal aspect that

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allows clients to proceed through the phases with a more confident sense of agency. They can
take more ownership in retelling their story through creative experiences that not only provides
an outlet for releasing strong emotions but gives them a sense of control throughout the process.
This is why adding art therapy to this structure is so beneficial.
Art Therapy
Art therapy is a form of therapy that utilizes the creative process of making art to improve
a person’s physical, mental, and emotional well-being (Shukla et al., 2022). This therapeutic
approach allows individuals to express themselves non-verbally through various art forms such
as painting, drawing, sculpting, and collage to name just a few. Art therapy is based on several
principles and techniques that help clients explore their thoughts, emotions, and experiences in a
safe and supportive environment.
Non-verbal expression is a key aspect of art therapy, as it allows individuals to
communicate their thoughts, feelings, and experiences through the creation of art. For children
and adolescents who have been victims of sexual abuse, talking about their trauma can be
incredibly difficult and overwhelming. According to Malchiodi (2012) “art can be a powerful
form of self-expression that allows individuals to communicate complex emotions and
experiences” (p.45). By engaging in artistic expression, they can communicate their emotions in
a more abstract and symbolic way, which can become more accessible. Furthermore, an
individual can improve their value and self-esteem by utilizing this visual and symbolic language
through art therapy (Shukla et al., 2022). Having a sense of control over their experiences can
help them explore and express emotions that may be difficult to put into words. By tapping into
their creative side, clients can have access to thoughts and emotions in a non-threatening way,
fostering self-awareness and insight.

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Symbolism and metaphor are also important tools in art therapy, as they allow individuals
to explore complex emotions and experiences through the use of representation in imagery. For
the sexually abused child, creating art that incorporates symbols and metaphors can help
individuals process their trauma in a more indirect way. This can provide them with a sense of
detachment from their traumatic experiences, while still allowing them to explore and make
sense of their emotions. By allowing the client to create distance they can utilize implicit
expressions, making the therapeutic process less confrontational (Moon, 2007) The artwork then
becomes an externalized object created by the client that translates into an element of safety
(Moon, 2007). These symbols and metaphors also allow clients to analyze deeper meanings and
connections to their artwork while still allowing them to distance themselves from it.
Process orientation is another key principle of art therapy, as it focuses on the creative
process rather than the product. For children and adolescents who have been sexually abused the
process of creating can be just as important if not more important than the final piece itself.
According to Rubin (2001), “it allows client to explore their emotions and experiences in a fluid
and spontaneous manner” (p.92). Through the act of creating, individuals are able to explore their
thoughts and feelings in a non-linear and intuitive way, allowing for greater insight and selfdiscovery.
Lastly, one of the most important elements of creating art with children who have been
victimized is catharsis. Catharsis is an emotional release. The act of creating art can be incredibly
cleansing, allowing clients to release pent-up emotions and process their trauma in a safe and
supportive environment. Additionally, choices in art media are typically more powerful methods
of reaching catharsis than words alone (Appleton, 2001). Using specified art materials,

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individuals can externalize their emotions and experiences. This in turn leads to a greater sense
of relief and release, which may be difficult to confront in other settings (Klorer, 2014).
Applications in trauma treatments
Art therapy has emerged as a valuable tool in the treatment of trauma, particularly in
children and adolescents who have been sexually abused. For instance, because it is often
difficult for traumatic recall for some children and adolescents, a process that does not rely on
verbal access, such as art therapy, are effective treatments (Lyshak-Stelzer et al., 2007). The use
of art therapy in trauma treatment allows individuals to express their emotions and experiences in
a non-verbal way, making it accessible to those who may struggle to articulate their feelings. In
the context of sexual abuse, art therapy can be beneficial in addressing a variety of components.
Therefore, art therapy paradigms have been able to show the unique and multifaceted ways art
can offer therapeutic experiences and integrative opportunities for progress that relies less on
cognitive and verbal abilities (Metzl, 2022).
One of the key benefits of art therapy in trauma treatment is its ability to help individuals
regulate their emotions. When considering sexual abuse, children often struggle with
overwhelming emotions such as fear, shame, anger, and confusion. Art is a way of engaging with
those big emotions. For example, when a child processes frightening, violent, or painful
experiences through drawings, it can alter a child’s emotional state (Sesar, 2022). Through the
process of creating art, individuals can externalize and process these emotions safely. This can
help them develop coping strategies and build emotional resilience, enabling them to better
manage their feelings in the future.

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In addition to emotional regulation, art therapy can also facilitate the process of trauma.
Sexual abuse can have a profound impact on a child’s sense of self and understanding of the
world. Through art therapy, individuals can explore and make sense of their experiences, helping
them integrate their trauma into their personal narrative, fostering a sense of coherence and
understanding. It is done by desensitization that gradually exposes the child to thoughts,
memories, and reminders of abusive experience until they can be tolerated without significant
emotional distress (Pifalo, 2009). By externalizing their trauma through art, individuals can also
begin to separate themselves from the experience, reducing feelings of shame and self-blame.
Art therapy can also play a crucial role in empowering children and adolescents. Many
individuals who have experienced sexual abuse may feel a sense of powerlessness. Through
therapy, individuals can reclaim their sense of control and autonomy and reduce vulnerability by
controlling the level of exposure to their creative process and expressing their own unique voice
(Pifalo, 2009). This empowerment can be a transformative experience, helping individuals
develop a sense of self-efficacy and agency in their own lives.
Integration with TF-CBT
Two therapeutic approaches have shown promising treatments for children who have
experienced trauma such as sexual abuse. The TF-CBT approach is flexible and adaptable yet
structured enough to make it a good fit for art therapy integration (Wymer et al., 2020). This
pairing can be a powerful combination in combating trauma associated with trauma (Pifalo,
2007). Art therapy can provide a safe non-threatening way for children and adolescents to
express thoughts, feelings, and experiences too difficult to talk about. Through art they can
externalize and process their trauma, gain insight into emotions, develop healthy cognitions, and
develop coping skills. TF-CBT, on the other hand, can provide a framework for addressing

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23

specific symptoms associated with trauma, such as anxiety, avoidance, and negative beliefs about
oneself and the world. Several components of TF-CBT will be looked at for further investigation
as to how art therapy can serve as an equalizer.
For instance, affect expression refers to the ability to accurately identify, label, process,
express, and regulate emotions, particularly negative emotions. It involves recognizing different
emotions and understanding that emotions can vary in intensity. The goal is to encourage the
expression of feelings in words. The purpose is to normalize response to traumatic events and art
therapy provides the means to do that.
Art therapy is a powerful method that nurtures emotional expression. Art therapy
provides individuals with a nonjudgemental and safe space to explore feelings. Art therapy is a
place to not only obtain information but to process information (Pifalo, 2002). Unlike hurried
conversations, art therapy allows for gradual exploration. Participants can take their time,
allowing emotions to surface at their own pace. The act of creating art becomes a form of
emotional excavation. Artmaking enables individuals to externalize their emotions visually. As
they create, they begin to translate these visual expressions into words. Expressive art mediums
are an effective way to go beyond just words alone (Graves-Alcorn & Green, 2014). This process
helps organize thoughts and feelings, making them more manageable. The ability of art to contain
powerful emotions is uniquely designed for affecting the processing of traumatic material (Pifalo,
2007). Through art, individuals explore their inner world, gaining a deeper understanding of their
emotions and conflicts, and can even restructure their thought processes.
TF-CBT is based on cognitive learning theories designed to help reduce the negative
behavioral responses of the traumatized child (Pifalo, 2007). Cognitions of children or
adolescents who have been sexually abused have been distorted due to the nature of the trauma.

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24

Cognitive restructuring is a technique used to modify maladaptive thoughts and negative
cognitive patterns. This process involves identifying maladaptive thoughts, challenging, and
modifying thoughts, and reorganizing thinking. Therapists help children recognize distorted or
unhelpful thinking related to their traumatic experiences. Clients learn to challenge invasive
thoughts of guilt, fear, or self-blame. By addressing cognitive distortions, children can restructure
their thinking in a healthier and more positive way.
Art therapy has emerged as a complementary and alternative form of mental health
management. It offers a unique avenue for therapeutic exploration and expression. When it
comes to cognitive restructuring, incorporating art into traditional TF-CBT can be particularly
influential. Through the act of creating art, individuals can access and express emotion that may
be difficult to verbalize. Children and adolescents can express themselves and make meaning of
experiences through a variety of art modalities (Wymer et al., 2020). By allowing the client to
make meaning underlying beliefs and assumptions that contribute to negative thought patterns
can be uncovered. By externalizing these thoughts and feelings new insights can be gained into
cognitive patterns and begin to challenge and reframe them. Furthermore, the creative process
can help individuals develop a more flexible and creative thinking style, allowing them to explore
alternative perspective solutions to problems.
Exposure therapy and desensitization are crucial components in the treatment of
individuals experiencing trauma related symptoms. TF-CBT when used with art therapy can
enhance the effectiveness of exposure and desensitization techniques supporting individuals
through their healing process. This process can be supported by providing a creative outlet for
individuals to confront and work through traumatic memories (Malchiodi, 2011). Clients can
safely explore and process trauma-related thoughts and emotions in a way that allows them to

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25

distance themselves from the trauma (Cohen et al., 2017). This becomes more manageable in a
more controlled environment.
Moreover, art therapy can also facilitate the desensitization process through gradual
exposure. Symbolic representations of triggers allow individuals to approach and engage with
those triggers in a safe and contained manner (Malchiodi, 2012). This can help them build
tolerance and resilience, reducing reactivity and distress. Through the creation of art, individuals
can externalize their thoughts and emotions, allowing them to distance themselves from the
intensity of the trauma (Malchiodi, 2012). In TF-CBT, desensitization is a key component of the
therapy process, specifically in the exposure phase. This phase involves helping children and
adolescents confront and process their traumatic memories and associated emotions in a
structured gradual manner. Through techniques such as imaginal exposure and in vivo exposure,
individuals are guided to recount and confront their traumatic experiences in a safe and
supportive environment, which helps reduce the emotional charge of the memories over time
(Cohen et al, 2006).
The final components to consider are safety and stabilization. Integrating safety and
stabilization process in both art therapy and TF-CBT is crucial in providing effective treatment
for children and adolescents who have experienced sexual abuse. It involves building a trusting
therapeutic relationship with client, providing psychoeducation about trauma and the effects, and
collaboratively developing coping strategies to manage distress. By creating a s safe and stable
foundation for healing, clients can begin to process their traumatic experiences and work toward
recovery in a supportive and empowering environment.
In art therapy, safety and stabilization can be promoted through the establishment of a
safe and supportive environment, where clients feel comfortable expressing themselves through

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26

art. Art therapist can also incorporate grounding techniques, such as deep breathing exercises or
guided imagery. Safety and stabilization are foundational elements in trauma therapy, as they
create a sense of security and control for the client, which is essential for healing to take place
(Courtois et al., 2009).
Conclusion
The integration of art therapy and TF-CBT for children and adolescents who have
developed PTSD because of sexual abuse shows promising resulting in promoting healing and
recovery. Art therapy provides an outlet for expressing overwhelming emotions related to
processing trauma, while TF-CBT offers evidence-based techniques for addressing cognitive
distortions and challenging negative beliefs. When combined, these two therapies create a
comprehensive approach that addresses both the emotional and cognitive aspects of trauma. More
research is needed to further understand the effectiveness to this integrated approach, but current
literature suggests that it holds immense potential in helping young survivors of sexual abuse
navigate their healing journey and move towards a brighter future. By providing a safe space for
expression, validation, and empowerment, art therapy and TF-CBT offer a holistic and clientcentered approach to supporting the mental health and well-being of children and adolescents
affected by trauma.
Section III: Methodology
TF-CBT and art therapy are both evidence-based treatments used for treating children and
adolescents who have been sexually abused. They both have been shown to reduce symptoms of
PTSD which is commonly developed by this population. By addressing these issues early on,
individuals can learn valuable coping techniques that will take them from victim to survivor. This

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curriculum aims to help improve overall mental health outcomes in children and teens who have
experienced this type of trauma. The curriculum will incorporate key components of TF-CBT to
provide a structured and comprehensive approach to helping the targeted population cope with
the effects of sexual abuse and PTSD, promoting healing and recovery.
Target Audience
A curriculum with an integrative approach to art therapy and TF-CBT for children and
adolescents who have PTSD because of sexual abuse would be beneficial to professionally
trained art therapists. It can provide them with a deeper understanding of the impact of trauma on
children and adolescents, as well as providing strategies for supporting these individuals in their
healing process.
Curricular Structure
The curriculum is based off the TF-CBT and art therapy interventions specifically
designed for trauma work as they relate to P.R.A.C.T.I.C.E components, which are as follows:
Psychoeducation involves teaching, normalizing, and validating symptoms related to
trauma. Parenting skills are also enhanced in this phase. They are to improve the caregiver-child
relationship. Caregivers learn strategies to manage difficult or inappropriate behavior both
trauma-related and general and support the child’s use of coping skills at home.
Relaxation skills are where the clients acquire techniques to manage distress in their
environment such as home or school. These skills create a “toolbox” for coping and include
relaxation exercises, mindfulness, controlled breathing, and more.
Affective modulation skills help regulate emotions and manage intense feelings related to
trauma. They contribute to emotional stability during therapy. This helps clients regain control
over emotional responses and improve overall well-being.

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Cognitive coping skills focus on thoughts and beliefs, these skills challenge faulty or
maladaptive cognitions. Socratic questioning techniques that stimulate critical thinking exposing
contradictions to one’s own beliefs and creative activities aid in this process.
Trauma narrative is when clients work through their traumatic experiences by
constructing a trauma narrative or a retelling of their story. This involves discussing and
processing the events, thoughts, and emotions associated with the trauma.
In vivo mastery of trauma reminders is gradual exposure to trauma-related cues helps
reduce fear and avoidance. Clients learn to confront reminders of the trauma in a controlled
manner. This exposure helps clients develop confidence and mastery in facing their fears,
reducing anxiety giving them the ability to cope with stressors.
Conjoint child-parent sessions involve both the child and caregiver. They enhance
communication, understanding, and collaboration within the family context. By working
collaboratively, both child and parent can learn coping skills, process trauma, and work towards
healing together.
Enhancing safety and future developmental trajectory involves safety planning and
supporting growth and development. This can include establishing boundaries and enhancing
coping skills. By prioritizing safety, clients feel more open and engaging in the therapy process.
Curricular Overview
TF-CBT is designed to be a short-term treatment modality which ranges from 8-24
weekly 50-minute sessions. Ages range from four to eighteen. The curriculum will highlight each
component of the TF-CBT framework. The duration is approximate and determined by how well
the client progresses through each phase. Some phases extend beyond one session. All sessions

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will follow the same format. Each session will begin with a weekly check-in, an art directive
warm-up, an art intervention with a target on a P.R.A.C.T.I.C.E. component. It will end with
processing and discussion, and a closing transition.
Conclusion
The TF-CBT art therapy curriculum designed for children and adolescents who have
experienced sexual abuse and suffer from PTSD symptoms is a comprehensive and holistic
approach to treating their trauma. This curriculum aims to empower these individuals to process
their traumatic experiences, develop coping strategies, and heal from past trauma so they can live
a healthy and productive life. The structured and goal-oriented nature of TF-CBT and the
inclusion of art therapy provides a clear framework for therapist to work within, ensuring each
session is purposeful and focused on the specific needs of the client. Through the implementation
of this curriculum, therapists can effectively help their young clients in their journey towards
recovery and help them reclaim their senses of safety and well-being.
Section IV: Curriculum

This section will consist of art therapy interventions, goals, directives, and processing
prompts for each of the P.R.A.C.T.I.C.E components within TF-CBT (See Appendix A). This
evidence-based approach is for children and adolescents who have experienced trauma. The
P.R.A.C.T.I.C.E. components emphasize the importance of building a therapeutic relationship,
providing psychoeducation, teaching, and coping skills, and promoting safety and support. Art
therapy is incorporated as a creative outlet for clients to express their emotions and experiences.
Together, these components create a comprehensive and effective approach to addressing trauma
and promoting healing.

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Each intervention will consist of objectives, a warm-up, directives, and processing
prompts. Additionally, some interventions may be accompanied by homework assignments that
align with the TF-CBT components such as practicing relaxations skills during times of panic or
arousal from trauma, combating negative thought processes through cognitive restructuring
exercises, art or reflective writing journaling, and weekly self-care directives. It is important to
note that not all interventions are not appropriate for all clients. It is based on the specific needs
of each individual. Therapists must assess what is acceptable and when for their clients.
Although the interventions can be used with any age, some modifications may need to be made
especially for younger children. This curriculum works best for ages eight through eighteen.
Conclusion
Integrating the components of TF-CBT with art therapy has shown to be an effective
holistic approach for treating sexually abused children who suffer from PTSD. By combining
evidence-based techniques with the creative process or art making, therapists can provide a safe
and empowering environment for clients to process their trauma, develop coping skills, and heal
from their experiences. This integrated approach not only addresses the psychological and
emotional needs of the clients, but also allows for non-verbal expression of emotions. By using
the strength of both modalities, therapists can help clients build resilience, regain a sense of
control and agency, and move towards a path of recovery and healing. This curriculum aims to
do that.
Section V: Discussion
Sexual abuse is a traumatic experience that can have a long-lasting effect on children and
adolescents, particularly in the form of PTSD. TF-CBT has been shown to be effective in treating
PTSD in this population. but incorporating art therapy provides additional benefits. Art therapy

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allows clients to express their emotions and experiences in ways traditional talk therapy does not.
This is particularly helpful in individuals who may struggle to articulate their feelings verbally. A
more comprehensive and holistic approach can address both cognitive and emotional aspects of
trauma.
Research
Research has shown that a combination of TF-CBT and art therapy can be highly
effective in treating sexually abused children and adolescents who suffer from PTSD. It has
shown a reduction of symptoms from PTSD, as well as overall improvement in mental health and
well-being of the client. TF-CBT is already a well-established evidence-based highly structured
therapy modality that focuses on helping individuals process and cope with traumatic experiences
such as managing cognitive distortions and maladaptive behaviors associated with trauma.
Adding art therapy to this mode of treatment allows for expression and communication of
emotions that may be difficult to verbalize. Some emerging research supports art therapy as an
effective means of processing traumatic experiences. By addressing the complex needs of young
survivors of sexual abuse their trauma can be approached more comprehensively.
Studies have demonstrated that the integration of art therapy into TF-CBT can enhance
the therapeutic process by providing a creative outlet for clients to explore their thoughts and
feelings surrounding the trauma. Art therapy helps externalize their experiences, providing a safe
distance from the trauma itself. This allows them to make meaning of their trauma and develop
coping strategies. Addtitionally, the non-verbal nature of art therapy can be particularly beneficial
for clients who struggle to articulate emotions verbally. This approach not only helps clients
process trauma and develop coping skills, but it also empowers them and helps them regain a
sense of control and agency over their own healing process. Research has also found that

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participants who received the combined treatment saw increased feelings of self-efficacy and
self-expression.
What the research means
Research in the areas of both TF-CBT and art therapy indicate promising results when
aligned with one another. They both have very specific attributes and components that can be
combined to reinforce the purposes, goals, and objectives in therapeutic process. One of the goals
is to get individuals to intentionally talk about the traumatic experience art allows them to do that
when words are difficult, and TF-CBT provides the structure to accomplish that goal with some
emotional regulation processes that are put in place by the TF-CBT model.
Implications of this research are significant for mental health professionals, especially for
trained art therapists. By incorporating art therapy with TF-CBT, therapists can better address the
complex emotional and psychological needs of this population. Both modalities provide a sense
of empowerment and control over their healing journey. Overall, it has the potential to enhance
treatment outcomes. However effective these approaches are, more research needs to be done.
There are limitations to treatment.
Limitations
A limitation t to consider when using this combination approach includes lack of
standardized protocols for integrating TF-CBT and art therapy, leading to variability in how the
two modalities are combined in practice. While evidence suggests that both interventions can be
effective in treating trauma-related symptoms, there is a need for more research to establish clear
guidelines for how these guidelines can be combined in a cohesive systematic manner.
Additionally, the use of art therapy lacks the same structured approach as TF-CBT. Having some

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33

consistency in the way these two approaches are used together will improve the soundness of the
culminating approach.
Furthermore, availability of trained art therapists who are also proficient in TF-CBT
techniques may be limited, making it challenging to implement interventions in certain settings.
Therapists require additional training and supervision to effectively integrate these two
modalities, and there may be logistical barriers to providing both types of therapy within the
constraints of a typical treatment setting.
Another limitation is the small sample sizes typically seen in studies examining the
effectiveness of combining TF-CBT and art therapy. This makes it difficult to draw generalizable
conclusions about the efficacy of this approach. Larger scale studies with diverse participant
populations are needed to provide more robust evidence of the benefits of integrating these two
therapeutic approaches.
Future Research
Further research is needed to establish best practices for combining TF-CBT and art
therapy, as well as to assess the long-term efficacy of this approach in treating sexually abused
children and adolescents with PTSD. Future research on combining TF-CBT and art therapy for
this population is vital to further understand the effectiveness of this integrative approach in
therapeutic interventions. Some potential areas of research include long-term outcomes,
comparison studies, process studies, and training and implementation.
Research could investigate the long-term effects of combining TF-CBT and art therapy
on sexually abused children with PTSD. Longitudinal studies could track participants over time
to determine if the benefits of the integrated approach are sustained and continue to improve
mental health outcomes beyond the immediate treatment period.

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34

Comparative studies could be conducted to compare the effectiveness of the combination
of the two modalities. This could help determine if the integrative approach is superior to
traditional methods or if certain populations may benefit more from one approach over the other.
Research could focus on specific mechanisms through which combining treatment
approaches leads to therapeutic benefits for sexually abused children and adolescents with PTSD.
By examining the process of change in therapy sessions, researchers can gain insight into how art
therapy enhances the effectiveness of TF-CBT and identify key elements that contribute to
positive outcomes.
Research could also focus on developing training programs for mental health
professionals to effectively integrate both approaches. Studies could even evaluate the impact of
training on therapist competence and adherence to the integrated approach, as well as client
outcomes.
Overall, future research on combining TF-CBT and art therapy for sexually abused
children and adolescence with PTSD has the potential to enhance our understanding of how to
best support this vulnerable population in their healing journey. By continuing to investigate the
effectiveness and mechanisms of this integrated approach, we can improve therapeutic
interventions and improve Mental health outcomes of those who have experienced sexual abuse.
Conclusion
Childhood sexual abuse is an extremely difficult traumatic experience for individuals to
process. To make that process more proficient, this paper explores the integration of TF-CBT and
art therapy as effective means of treatment. Research supports both the use of art therapy and TFCBT as modes of treatment as stand-alone options but rarely as culmination of both. This is due

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35

to not having enough research to back up the findings of how this integration could be beneficial
to individuals who have been sexually abused and suffer from PTSD. This research paper
explored the effectiveness of combining both as an affective mode of treatment in the therapeutic
setting. The integration of art therapy techniques with the TF-CBT components appears to
enhance the therapeutic process and leads to better outcomes for these individuals.
Summary
This research paper explores the integration of TF-CBT and art therapy as a
comprehensive intervention for children and adolescents who have experienced sexual abuse and
exhibit symptoms of PTSD. Given the complex psychological impact of sexual abuse, the study
aims to enhance therapeutic outcomes by combining the structured, evidence-based approach of
TF-CBT with the expressive and healing qualities of art therapy.
The paper begins with a thorough literature review, highlighting the prevalence of PTSD
among sexually abused youth and the limitations of traditional therapeutic modalities in
addressing their unique emotional and psychological needs. It discusses the core components of
TF-CBT, which include psychoeducation, cognitive restructuring, exposure technique, and parent
involvement, noting its efficacy in reducing PTSD symptoms. However, the paper identifies a
potential gap between TF-CBT’s ability to fully engage children and adolescents, particularly
those who may struggle with verbal expression or who have difficulty articulating their trauma.
To address this gap, research introduces art therapy as a complementary modality that
fosters non-verbal expression, allowing young clients to communicate their feelings and
experiences through creative means. Art therapy is presented as a valuable tool for building trust,
promoting emotional regulation, and facilitating processing of traumatic memories in a safe

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36

environment. The integration of the two approaches is posited to create a more holistic treatment
framework that can better meet the diverse needs of this vulnerable population.
Integrating the components of TF-CBT with art therapy has shown to be an effective
holistic approach for treating sexually abused children who suffer from PTSD. By combining
evidence-based techniques with the creative process or art making, therapists can provide a safe
and empowering environment for clients to process their trauma, develop coping skills, and
ultimately heal from their experiences. This integrated approach not only addresses the
psychological and emotional needs of the clients, but also allows for non-verbal expression of
emotions. By using the strength of both modalities, therapists can help clients build resilience,
regain a sense of control and agency, and move towards a path of recovery and healing. This
curriculum aims to do that.

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37
References

Alisic, E., Zalta, A. K., van Wesel, F., Larsen, S. E., Hafstad, G. S., Hassanpour, K., & Smid, G.
E. (2014). Rates of post-traumatic stress disorder in trauma-exposed children and
adolescents: meta-analysis. British Journal of Psychiatry, 204(5), 335–340.
https://doi.org/10.1192/bjp.bp.113.131227
Alix, S., Cossette, L., Cyr, M., Frappier, J.-Y., Caron, P.-O., & Hébert, M. (2019). Self-Blame,
Shame, Avoidance, and Suicidal Ideation in Sexually Abused Adolescent Girls: A
Longitudinal Study. Journal of Child Sexual Abuse, 29(4), 432–447.
https://doi.org/10.1080/10538712.2019.1678543
American Academy of Child and Adolescent Psychiatry. (2019). Practice parameter for the
assessment and treatment of children and adolescents with post-traumatic stress disorder.
Journal of the American Academy of Child Adolescent Psychiatry, 58(8), 1-16.
American Academy of Child & Adolescent Psychiatry. (2014). Sexual Abuse. Aacap.org.
https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFFGuide/Child-Sexual-Abuse-009.aspx
American Art Therapy Association. (2022). What is Art Therapy? American Art Therapy
Association. https://arttherapy.org/what-is-art-therapy/
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Pearson.
American Psychological Association. (2021). Sexual Abuse. Apa.org.
https://www.apa.org/topics/sexual-assault-harassment

TF-CBT AND ART THERAPY

38

Appleton, V. (2001). Avenues of Hope: Art Therapy and the Resolution of Trauma. Art Therapy,
18(1), 6–13. https://doi.org/10.1080/07421656.2001.10129454
Balla, U., Lev-Wiesel, R., Bhattacharyya, A., Israeli, D., & Daphna-Tekoah, S. (2023). The
Medical Somatic Dissociation Questionnaire Assessment for Childhood Sexual Abuse: A
Brief Report. Journal of Child Sexual Abuse, 1–11.
https://doi.org/10.1080/10538712.2022.2161439
Banyard, V. L., Williams, L. M., & Siegel, J. A. (2001). The long-term mental health
consequences of child sexual abuse: An exploratory study of the impact of multiple
traumas in a sample of women. Journal of Traumatic Stress, 14(4), 697–715.
https://doi.org/10.1023/a:1013085904337
Bowen-Salter, H., Whitehorn, A., Pritchard, R., Kernot, J., Baker, A., Posselt, M., Price, E.,
Jordan-Hall, J., & Boshoff, K. (2021). Towards a description of the elements of art
therapy practice for trauma: A systematic review. International Journal of Art Therapy,
27(1), 1–14. https://doi.org/10.1080/17454832.2021.1957959Casanovas, M., Kramer, T.,
Clarke, V., Goddard, A., M Elena, G., & Khadr, S. (2022). Somatic symptoms following
sexual assault in adolescents: a prospective longitudinal study. Psychology, Health &
Medicine, 27(3), 546–558. https://doi.org/10.1080/13548506.2021.1874437
Casanovas, M., Kramer, T., Clarke, V., Goddard, A., M Elena, G., & Khadr, S. (2022). Somatic
symptoms following sexual assault in adolescents: a prospective longitudinal study.
Psychology, Health & Medicine, 27(3), 546–558.
https://doi.org/10.1080/13548506.2021.1874437

TF-CBT AND ART THERAPY

39

Castro, Á., Ibáñez, J., Maté, B., Esteban, J., & Barrada, J. R. (2019). Childhood Sexual Abuse,
Sexual Behavior, and Revictimization in Adolescence and Youth: A Mini Review.
Frontiers in Psychology, 10. https://doi.org/10.3389/fpsyg.2019.02018
Centers for Disease Control and Prevention. (2021, May 11). Fast Facts: Preventing Child
Sexual Abuse. Www.cdc.gov.
https://www.cdc.gov/violenceprevention/childsexualabuse/fastfact.html
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2017). Treating trauma and traumatic grief in
children and adolescents (2nd ed.). The Guilford Press.
Committee Opinion No. 498: Adult Manifestations of Childhood Sexual Abuse. (2011).
Obstetrics & Gynecology, 118(2, Part 1), 392–395.
https://doi.org/10.1097/aog.0b013e31822c994d
Deblinger, E., Stauffer, L. B., & Steer, R. A. (2001). Comparative Efficacies of Supportive and
Cognitive Behavioral Group Therapies for Young Children Who have been Sexually
Abused and their Nonoffending Mothers. Child Maltreatment, 6(4), 332–343.
https://doi.org/10.1177/1077559501006004006
Edwards, E. (2018). The impact of child sexual abuse on mental health: a systematic review.
Journal of Trauma & Dissociation, 19(3), 389–410.
Graves-Alcorn, S. L., & Green, E. J. (2014). The expressive arts therapy continuum: History and
theory. In E. J. Green & A. Drewes (Eds.), Integrating expressive arts and play therapy
with children and adolescents (pp. 1-16). Wiley.

TF-CBT AND ART THERAPY

40

Hamblen, J., & Barnett, E. (2011). PTSD in Children and Adolescents - PTSD: National Center
for PTSD. Va.gov.
https://www.ptsd.va.gov/professional/treat/specific/ptsd_child_teens.asp
Hébert, M., Paradis, A., & Fortin, A. (2021). Symptom patterns of sexually abused teenage girls
seeking services. American Journal of Orthopsychiatry, 91(4), 464–476.
https://doi.org/10.1037/ort0000548
Hudson, P. (2011). Effective treatments for PTSD: practice guidelines from the International
Society for Traumatic Stress Studies. British Journal of Guidance & Counselling, 39(2),
194–195. https://doi.org/10.1080/03069885.2010.550798
Khadr, S., Clarke, V., Wellings, K., Villalta, L., Goddard, A., Welch, J., Bewley, S., Kramer, T.,
& Viner, R. (2018). Mental and sexual health outcomes following sexual assault in
adolescents: a prospective cohort study. The Lancet Child & Adolescent Health, 2(9),
654–665. https://doi.org/10.1016/s2352-4642(18)30202-5
Klorer, P. G. (2014). Art Therapy in Practice. Routledge.
Lo Iacono, L., Trentini, C., & Carola, V. (2021). Psychobiological Consequences of Childhood
Sexual Abuse: Current Knowledge and Clinical Implications. Frontiers in Neuroscience,
15. https://doi.org/10.3389/fnins.2021.771511
Lyshak-Stelzer, F., Singer, P., Patricia, St. J., & Chemtob, C. M. (2007). Art Therapy for
Adolescents with Posttraumatic Stress Disorder Symptoms: A Pilot Study. Art Therapy,
24(4), 163–169. https://doi.org/10.1080/07421656.2007.10129474
Malchiodi, C. A. (2012). Handbook of Art Therapy (2nd ed.). Guilford Press.

TF-CBT AND ART THERAPY

41

Malchiodi, C. A. (2013). Art therapy and health care. Guilford Press.
Malchiodi, C. A., & Duncan, B. (2015). Creative interventions with traumatized children (2nd
ed.). The Guilford Press.
Maniglio, R. (2009). The impact of child sexual abuse on health: A systematic review of reviews.
Clinical Psychology Review, 29(7), 647–657. https://doi.org/10.1016/j.cpr.2009.08.003
Mannarino, A., Mallah, K., Amaya-Jackson, L., Bennett, F., Berliner, L., Cohen, J., Deblilinger,
E., Gully, K., Putman, F., & Radingan, D. (2004). Learning from Research and Clinical
Practice Core Child Sexual Abuse Task Force National Child Traumatic Stress Network
How to Implement Trauma-Focused Cognitive Behavioral Therapy (TF-CBT).
https://www.nctsn.org/sites/default/files/resources//how_to_implement_tfcbt.pdf
McLean, C. P., Morris, S. H., Conklin, P., Jayawickreme, N., & Foa, E. B. (2014). Trauma
Characteristics and Posttraumatic Stress Disorder among Adolescent Survivors of
Childhood Sexual Abuse. Journal of Family Violence, 29(5), 559–566.
https://doi.org/10.1007/s10896-014-9613-6
Metzl, E. S. (2022). Art Is Fun, Art Is Serious Business, and Everything in between: Learning
from Art Therapy Research and Practice with Children and Teens. Children, 9(9), 1320.
https://doi.org/10.3390/children9091320
Moon, B. (2007). The Role of Metaphor in Art Therapy. Charles. C. Thomas.
https://research.ebsco.com/c/356ple/viewer/html/z6hittnb55
National Center for Victims of Crime. (2010). Child sexual abuse statistics. National Center for
Victims of Crime. https://victimsofcrime.org/child-sexual-abuse-statistics/

TF-CBT AND ART THERAPY

42

Pereda, N., Guilera, G., Forns, M., & Gómez-Benito, J. (2009). The prevalence of child sexual
abuse in community and student samples: A meta-analysis. Clinical Psychology Review,
29(4), 328–338. https://doi.org/10.1016/j.cpr.2009.02.007
Peterson, S. (2018b, May 25). Sexual Abuse. The National Child Traumatic Stress Network.
https://www.nctsn.org/what-is-child-trauma/trauma-types/sexual-abuse
Pifalo, T. (2002). Pulling Out the Thorns: Art Therapy with Sexually Abused Children and
Adolescents. Art Therapy, 19(1), 12–22.
https://doi.org/10.1080/07421656.2002.10129724
Pifalo, T. (2009). Mapping the Maze: An Art Therapy Intervention Following Disclosure of
Sexual Abuse. Art Therapy, 26(1), 12–18.
https://doi.org/10.1080/07421656.2009.10129313
Pifalo, T. (2007). Jogging the Cogs: Trauma-Focused Art Therapy and Cognitive Behavioral
Therapy with Sexually Abused Children. Art Therapy, 24(4), 170–175.
https://doi.org/10.1080/07421656.2007.10129471
Pollio, E., & Deblinger, E. (2017). Trauma-focused cognitive behavioural therapy for young
children: clinical considerations. European Journal of Psychotraumatology, 8(7),
1433929. https://doi.org/10.1080/20008198.2018.1433929
Rubin, J.A. (2016). Approaches to Art Therapy. Routledge.
Sesar, K. (2022). Creative Art Therapies in Work with Children and Adolescents with Traumatic
Experiences. The Central European Journal of Pediatrics, 18(1), 63–74.
https://doi.org/10.5457/p2005-114.319

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43

Sexual Abuse. (2023, September). Www.aacap.org.
https://www.aacap.org/AACAP/AACAP/Families_and_Youth/Facts_for_Families/FFFGuide/Child-Sexual-Abuse-009.aspx
Shapiro, F. (2013). The Case: Treating Jared Through Eye Movement Desensitization and
Reprocessing Therapy. Journal of Clinical Psychology, 69(5), 494–496.
https://doi.org/10.1002/jclp.21986
Shukla, A., Choudhari, S. G., Gaidhane, A. M., & Quazi Syed, Z. (2022). Role of Art Therapy in
the Promotion of Mental Health: A Critical Review. Cureus, 14(8).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9472646/
Vranceanu, A. M., Hobfoll, S. E., & Johnson, R. J. (2016). Child sexual abuse and
gastrointestinal symptoms: The role of abuse severity, abuse exposure, and mental health
in a nationally representative sample. Journal of Pediatric Psychology, 41(8), 863–871.
Vrolijk-Bosschaart, T. F., Brilleslijper-Kater, S. N., Benninga, M. A., Lindauer, R. J. L., &
Teeuw, A. H. (2018). Clinical practice: Recognizing Child Sexual Abuse—what Makes It
so difficult? European Journal of Pediatrics, 177(9), 1343–1350.
https://doi.org/10.1007/s00431-018-3193-z
Whealin, J., & Barnett, E. (n.d.). Child Sexual Abuse - PTSD: National Center for PTSD.
Www.ptsd.va.gov.
https://www.ptsd.va.gov/professional/treat/type/sexual_abuse_child.asp
Whiffen, V. E., & MacIntosh, H. B. (2005). Mediators of the Link between Childhood Sexual
Abuse and Emotional Distress. Trauma, Violence, & Abuse, 6(1), 24–39.
https://doi.org/10.1177/1524838004272543

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Wymer, B., Ohrt, J. H., Morey, D., & Swisher, S. (2020). Integrating Expressive Arts
Techniques into Trauma-Focused Treatment with Children. Journal of Mental Health
Counseling, 42(2), 124–139. https://doi.org/10.17744/mehc.42.2.03

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Appendix A

TRAUMA FOCUSED COGNITIVE
BEHAVIORAL ART THERAPY
FOR SEXUALLY ABUSED CHILDREN AND ADOLESCENTS

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RUBY ALEATHA THRUSH

TABLE OF CONTENTS
Introduction
Art Therapy
TF-CBT
How to use this curriculum
Risks and benefits
P.R.A.C.T.I.C.E Components
Psychoeducation
Relaxation skills
Affect modulation!
Cognitive coping
Trauma Narrative
In Vivo mastery
Conjoint sessions
Enhancing safety
Intervention Resources
Fact sheets

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Feelings chart
Color wheel
Trauma box template
Guided Visualization prompt
References

Introduction
Art Therapy
Art therapy is a valuable addition to Trauma Focused Cognitive Behavioral Therapy (TFCBT). It provides a non-verbal means of expression, allowing clients to communicate and
process traumatic experiences in a way that is less intimidating than traditional talk therapy. It
helps individuals access and work through traumatic memories that may be too difficult to
process any other way. Through art, these experiences can be externalized in a supportive and
non-judgmental environment. Additionally, art therapy can help clients develop coping skills and
self-soothing techniques that can be used during the therapeutic process and in their daily lives,
enhancing the overall well-being of the client.

TF-CBT
TF-CBT is designed to be a short-term treatment modality which ranges from 8-24
weekly 50-minute sessions. The curriculum will highlight each component of the TF-CBT
framework; psychoeducation, relaxation, affect modulation, cognitive restructuring, trauma
narrative, conjoint sessions, and enhancing safety. The duration is approximate and determined
by how well the client progresses through each phase. Some phases extend beyond one session.

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All sessions will follow the same format. Each session will begin with a weekly check-in, an art
directive warm-up, an art intervention with a target on a P.R.A.C.T.I.C.E. components in
succession as listed above. It will end with processing and discussion, and a closing transition.
Interventions are listed in a brief overview:

How to use this curriculum
This curriculum is a specialized form of treatment that combines elements of both
art therapy and the components of TF-CBT. This unique approach aims to help sexually abused
children and adolescents. To use this curriculum effectively, it is essential to have a thorough
understanding of both art therapy and TF-CBT. Both require specialized training to facilitate the
contents of this manual. It is structured with activities and interventions that incorporate various
forms of artistic expression, such as drawing, painting, sculpting, and collage to be used
alongside TF-CBT techniques such as cognitive restructuring and exposure therapy.
When using this curriculum, assessments are done to identify the client’s trauma history,
symptoms, and strengths. From there, clients are introduced to art-based interventions to help
clients explore, and process their emotions, thoughts, and traumatic memories. The curriculum
can be modified to meet the specific needs and age of the individual client. Not all interventions
are suitable for clients. The interventions provided will serve as a non-threatening way for clients
to express themselves, build coping skills, and promote healing. Additionally, therapists will
challenge negative beliefs, target traumatic experiences of sexual abuse, and reduce symptoms of
trauma.

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Risks and benefits

It is important to note the risks and benefits in using this curriculum. The benefits include
enhancing emotional expression and creative exploration, promotes empowerment and selfawareness, strengthens therapeutic relationship, and helps process and heal from trauma. The use
of this curriculum may trigger intense emotions and memories related to trauma which can be
distressing to some individuals. Furthermore, without proper guidance from a trained art therapist
specializing in TF-CBT, clients may inadvertently re-traumatize themselves through the process
of creating art and revisiting traumatic experiences. Some individuals may even be resistant to
the process of either art or processing traumatic experiences. Therapists must be mindful if and
when to use this guide. They should assess the appropriateness of when to use art therapy in
combination with TF-CBT in treatment planning.

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Psychoeducation
Relaxation skills
Affect modulation
Cognitive coping
Trauma narrative

50

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In Vivo mastery
Conjoint sessions
Enhancing safety
psychoeducation
Creation of visual aids or infographics
Objectives: To facilitate understanding and communication of complex emotions and
experiences related to trauma while learning about body safety, setting boundaries, and the effects
of violence on teens.
Warm-up: Play calming music and create one continuous line using markers or color
pencils. Fill in the spaces with patterns or colors to represent emotions.
Materials: Various fact sheets about body safety (see pages 15&16), paper, pencils, markers,
crayons, and a variety of collage materials.

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Directives: The client will use a variety of materials to create an image about body safety. Once
body safety components have been addressed such as boundaries, consent, safe touch, and unsafe touch,
individuals will make an infographic or visual aide to emphasize key points. Use visual symbols or
metaphors to represent a variety of emotions and experiences such as broken hearts or shattered images to
represent trauma, closed doors, or locked gates to represent boundaries, or bright colors for positive feelings
and dark colors for negative feelings. Collaborate with the client to develop an age appropriate and fact
heavy content about body safety that also includes emotional content.
Processing prompts: What does body safety mean to you? When was a time you
felt unsafe or vulnerable? Have you ever felt empowered or in control? How do you define
boundaries, respect, consent in your interactions with others? How can you communicate
those boundaries to others? Use symbols or metaphors to describe body safety. What do
those symbols mean to you? Reflect on any past experiences of trauma or abuse that may
have impacted your sense of safety. How have these experiences shaped your
understanding of consent?

Relaxation skills
Guided Visualization Exercise
Objective: To practice relaxation skills through guided visualization. To explore inner
thoughts, feelings, and experiences.
Warm-up: Practice breath work through watercolor painting. Allow the paint to move
across the page with each inhale and exhale. For example, painting a mountain as the lines go up
inhale and as the lines go down exhale.
Materials: A variety of mediums for clients to choose from: watercolor paints, oil pastels,
color pencils, markers, and 8 ½ x 11 or larger paper.

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Directives: Guide the client through a visualization exercise (See page 20). Invite them to
imagine a peaceful and serene place in their mind such as a peaceful meadow. Encourage the client
to use all their senses to fully immerse themselves in this imaginary space. Once the client is fully
connected with their visualization, invite them to begin creating art that expresses their experience.
This could be a drawing, painting, collage, or any other medium that resonates with the client.
Continue to guide them through the visualization asking open-ended questions.
Processing prompts: What do you see, hear, smell, or even taste?
What emotions are coming up as you create? How does this artwork
relate to your inner thoughts and feelings?

Affect modulation
Exploration of emotions through color theory/ color wheel
Objectives: For the client to effectively communicate emotions and feelings.
Warm-up: If you could be any color, what would you be and why? Using markers draw
what your color looks like or feels like.
Materials: Feelings chart (see page 17), color wheel (see page 18), a six-inch diameter
round circle on drawing paper, watercolor paints, paintbrush, markers.
Directives: Divide the circle into eight or 12 sections (determined by age ability of the
client). Create a color wheel by placing primary colors down first. Mix primary colors together to
create secondary colors. Mix primary colors with secondary colors to create tertiary colors. Once

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the color wheel is dry add feeling words with marker to each color. Discuss what each feeling word
means to the client. Tents and shades can also be added to further convey depth and complexity of
our emotions.
Processing prompts: What feelings are associated with each color? Why do they make
you feel a specific way? Are there different shades and tones or levels of emotions that are felt?
Reflect on how creating a color wheel can help better understand and express emotional
experiences. After creating an accurate color wheel create one that reflects your own emotionally
unique landscape.

Cognitive coping skills
Cognitive coping and processing: Collage Distortions
Objective: To challenge negative thought patterns, beliefs, or self-perceptions. To express
emotions through collage.
Warm-up: Clients will collect images for collage distortions. Intuitive selection of images
will help tap into the subconscious and uncover certain emotions and themes.
Materials: Magazines, clippings, clip art, collage books, a variety of words, fonts, or texts,
glue, scissors, drawing paper to glue image to, and paint markers.
Directives: Explore themes or emotions that surfaced from the warmup. Find a base image
to build on or distort. Find elements in the image that can be altered in some way. For example, if
working with a figure the facial features can be changed i.e... a large head on a small body, different

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shaped eyes, a large expressive mouth to replace the old. Sort the altered pieces until the image has
been distorted. Glue the image and pieces down to the drawing paper. Find words or phrases that
enhance the image, theme, or emotion that came up during the warmup.
Processing prompts: How does the distortion or manipulation of images reflect the ways
in which negative thoughts distort your perception of reality? What emotions arose when created
the distorted images? How might the act of physically cutting and rearranging images in your
collage mirror the process of challenging and reframing negative thoughts? How might this
challenge lead to growth and healing? How can you use this experience as a tool for developing
greater self-awareness and self-compassion in the face of negative thought distortions?

Trauma narrative
Objective: To facilitate narrative exploration. To visually represent different aspects of
their trauma narrative, such as the event itself, their feelings during and after the event, and their
coping mechanisms. To promote empowerment and control.
Warm-up: Guide the client through a relaxation exercise by having them close their eyes
and visualize a safe and peaceful place in which they feel secure and comfortable.
Materials: Explosion box templates and instructions for assemblage (see page19), 4 pieces
of 12x12 colored cardstock or scrapbook paper, scissors, glue stick, other design elements and
embellishments like ribbon, lace, stickers, or even personal drawings.
Directives: Trace the templates for the box, two inserts, and the lid. Cut each piece out and
follow the instructions for assembling the box and lid. Use the scraps to make pockets for the
inserts of the box. Glue pockets down to each flap of the inside of the box. On each of the flaps

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create a symbol or a word prompt that defines certain elements of the story such as all about me,
my family, the event, emotions, body sensations, reactions from others, support system, coping
skills, and advice to others.
Processing prompt: How does the trauma box represent different aspects of your trauma
narrative such as the initial impact, the aftermath, and the healing process? What emotions arose
as you created each layer of the box? What symbolism, if any, did you use in the creation of the
box? How do they help you process your experiences? What insights and realizations did you gain
throughout the process, and as you completed your narrative?

In vivo mastery
Title of directive her.

Objective: To help clients develop better emotional regulation skills. To encourage
mindfulness and present moment awareness. To increase coping skills when exposed to trauma.
Warm-up: Free drawing or painting with a focus on sensory exploration. By engaging in
free-form art making, clients can access inner thoughts and feelings more easily, allowing for a
deeper exploration of trauma-related issues.
Materials: Drawing and painting supplies, paper, canvas, pencils, markers, pastels,
paintbrushes. Other materials may include blending stumps, sponges, and other tools for creating
textures.
Directives: discuss the concept of in vivo mastery. The client will use drawing or painting
to explore and confront fears related to the trauma. Choose a specific trauma-related theme or
memory to focus on such as an event, emotion, or trigger. Experiment with different drawing or

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painting mediums and techniques to express their thoughts and feelings visually. Encourage
patterns, symbols, or simple expression through form and color. Reflect on the experience and how
it relates to the trauma.
Processing prompt: What emotions or memories are coming up as you engage in this
artistic process? Are there specific colors, shapes, or symbols that resonate with you as you create
artwork? How does this relate to your experience of trauma? What connections do you see between
the trauma and art? What strengths or coping skills are you using as you work through this artistic
process?

Conjoint sessions
Collaborative storytelling with finger puppets
Objective: To strengthen parent/guardian and child bond. To enhance communication
skills. To promote emotional expression and regulation. To develop problem-solving skills. To
strengthen family dynamics and cohesion.
Warm-up: Provide each participant with a piece of paper and crayons, pencils, or markers.
Each person will draw a simple image of how they are feeling in the present moment.
Materials: Model magic
Directives: Both the child and parent will decide on a theme such as animals, or people.
They will create at least three characters out of model magic. Once the characters have dried the
clients will use the characters to tell a story. Start by telling an imaginary story about the characters,

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making it as expressive as possible. Once the clients are comfortable switch to more complex or
difficult themes using the characters they made.
Processing prompt: What key emotions do you notice being expressed through
storytelling? How can we process these feelings together? What themes or symbols are emerging
through the storytelling? How can the characters be used to create a narrative of positive growth
and healing from trauma? How can this be used to discuss and process difficult or challenging
topics?

Enhancing safety
Objective: To help clients identify and visualize their goals, aspirations, and desires
through the creation of visual representations on a vision board. To encourage self-awareness and
insight. To support clients in setting achievable goals and objectives for their healing journey,
using the vision board as a tool for motivation and inspiration. To empower clients to take
ownership by actively engaging and reflecting on their progress.
Warm-up: Completing the Bridge Assessment. This will serve as a foundation for the
creation of the vision board.
Materials: Poster boards, magazines, newspapers, printed images, scissors, glue sticks or
tape, markers, colored pencils, crayons, stickers, or other embellishments.
Directives: Collaboratively set goals, intentions, and areas of focus. Clients should reflect
on their strengths, values, and aspirations. Choose images, words, and symbols that resonate with
them that represent their goals and intentions. Choose and arrange elements that feel meaningful

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and visually appealing to them. Discuss next steps and action plans. Encourage reflection and
integration.
Processing prompt: What emotions are you currently experiencing? What goals, hopes,
and dreams do you have for moving forward? How do you envision feeling and behaving
in a healthy and positive way? How does the use of symbols represent your desired
future? How can the images and symbols support your healing journey and reinforce the
skills and techniques learned in therapy?
Intervention Resources
Fact sheet www.nsvrc.org

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Teenagers & Sexual Violence
Who Experiences Teen Sexual Violence?
Rates of sexual violence against youth aged 12-18 are very high,1 and the survivor normally knows the
person who committed the offense.2 Nationally, about 8% or 10 million girls and 0.7% or 791,000 boys
under the age of 18 have experienced either rape or attempted rape.2 Experiencing sexual violence as
a child or teen makes it more likely the survivor will experience re-victimization in adulthood.2 One in
three (30.1%) victims of completed rape experienced their first rape between ages 11-17.3
It is difficult to determine the full impact of sexual violence against teenagers since most research
focuses on children or college-aged youth. There are many gaps in research on sexual violence
against teens, especially those from marginalized, unserved, and underserved communities.
Throughout this document we will alternate
between using teen, youth, and young people
to reflect the variety of ways people identify.

1 in 4 girls and 1 in 6 boys
have been sexually abused
before the age of 18.4

Who Commits Sexual Violence Against Teens?
Youth who experience sexual violence are more likely to be victimized by a peer
or someone they know.2
10.1% of girls were
victimized by a
stranger.

28%

43%

43.6% of girls were
victimized by an
acquaintance.

28.8% of girls were victimized by a
current or former intimate partner.

35%

27%

27.7% of girls were
victimized by a
family member.

victimize someone else (completed
or attempted) by an acquaintance.

Effects of Sexual Violence
Young people who experience sexual violence may experience: Poor academic performance,5
Sexual risk taking behavior,6 Pregnancy,7 and Self-harm.8
Sexual assaults against youth happen in
familiar places.
10-31% Survivor’s home9,10
24% Survivor’s neighborhood10
15-44% Survivor’s school9,10

Teens who experience sexual violence may
suffer from mental health conditions:
Post-Traumatic Stress Disorder11
Substance abuse12
Low self-esteem14

Eating disorders13
Depression15

Anxiety16

Consider or attempt suicide17

National Sexual Violence Resource Center • www.nsvrc.org • 1-877-739-3895

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Feelings chart.

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Color Wheel

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Trauma box template

63

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Sample guided visualization.

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Begin reading the relaxation script here:
Take a moment to relax your body. Get comfortable. Notice how your body feels and make
some slight adjustments to increase your comfort. Take a deep breath in. Hold it… and
breathe out, releasing tension.
Breathe in again, and as you exhale, allow your body to relax slightly.
Continue to breathe slowly…deeply.
As you visualize the following scene, let your body and mind become more and more
relaxed with each moment.
Imagine yourself walking outdoors.
You are walking through the trees…small aspens, their leaves moving in a slight breeze.
The sun shines down warmly.
You walk toward a clearing in the trees. As you come closer to the clearing, you see that it is
a meadow.
You walk out of the trees, into the meadow. Tall green grass blows gently…
You are probably feeling a bit tired…
It would be so nice to sit down in the grass.
Walk further into the meadow now…looking around…
Imagine the meadow in your mind’s eye…what does the meadow look like?
Find a place to sit. You might want to sit or lie down in the grass…perhaps you have a
blanket with you that you can unroll over the soft grass and lie down.
Feel the breeze caress your skin as you sit or lie down in the sun.
It is a pleasant day…warm, but not hot…quiet and peaceful.
Notice the sights around you. The grass, whispering…see the mix of meadow grasses,
clover, wildflowers around you.
Watch a small ladybug climb a blade of grass. Climbing up toward the top, pausing for a
moment, and then flying away.
Imagine closing your eyes and listening to the sounds of the meadow. Hear birds
singing…the breeze rustling the grass softly…
Feel the sun on your face. Imagine turning your face up toward the sky, eyes closed,
enjoying the warmth of the sun.

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Smell the grass…the wildflowers…the smell of the sun on the earth…
Look around again to see the sights around you. Notice how the ground follows gentle
contours of hills. See the blue sky above you…a few wispy clouds drifting slowly by.
See the trees at the edge of the meadow.
The meadow is lush and green, a haven for birds and animals. As you watch, a deer peers
out through the trees, and emerges to graze at the edge of the meadow.
The deer raises its head to look at you, sniffing the breeze, and then turns, disappearing
silently into the trees.
Rest and luxuriate in this peaceful, beautiful meadow. Notice the sights, sounds, and smells
around you. Feel the soft grass beneath you, the sun and breeze on your skin. Imagine all
the details of this place.
(pause)
Now it is time to leave the meadow and return to the present. Notice your surroundings.
Feel the surface beneath you. Hear the sounds around you. Open your eyes to look around,
re-orienting to the present.
Take a moment to stretch your muscles and allow your body to reawaken.
When you are ready, return to your usual activities, keeping with you a feeling of peace and
calm.
Peaceful Meadow Relaxation Script (innerhealthstudio.com)

References

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67

Body Safety. (n.d.). Educate2Empower Publishing. Retrieved July 26, 2024, from
https://e2epublishing.info/en-us/collections/body-safety
Feelings Chart for Kids Emotions Poster 18x24 Laminate. (n.d.). Vrogue.co. Retrieved July 26,
2024, from https://www.vrogue.co/post/feelings-chart-for-kids-emotions-poster-18x24laminated-emotions
National Sexual Violence Resource Center. (2018). Teenagers & Sexual Violence Who
Experiences Teen Sexual Violence?
https://www.nsvrc.org/sites/default/files/publications/2019-02/Teenagers_508.pdf
Peaceful Meadow Relaxation Script. (n.d.). Www.innerhealthstudio.com.
https://www.innerhealthstudio.com/peaceful-meadow.html
Turner, J. (n.d.). Templates Explosion Box Directions - 7 Free PDF Printables. Printable.
Retrieved July 26, 2024, from https://www.printablee.com/post_printable-templatesexplosion-box-directions_126693/