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A PMHNP is treating a 9-year-old girl using Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) after she witnessed repeated domestic violence between her parents over a two-year period. The child has completed the psychoeducation, relaxation, and affective modulation components. During the first session of the trauma narrative phase, she draws a picture of her father hitting her mother but then quickly scribbles over it, saying, 'I do not want to talk about it. Daddy said it was a secret and bad things happen if you tell secrets.' Her mother, who participates in parallel parent sessions, reports that the child's nightmares have worsened over the past week. Which action by the PMHNP is MOST appropriate?
Explanation
Understanding the TF-CBT protocol sequencing (PRACTICE: Psychoeducation, Relaxation, Affective modulation, Cognitive coping, Trauma narrative, In vivo mastery, Conjoint sessions, Enhancing safety) and how to handle expected challenges during the trauma narrative phase is essential for effective implementation. A temporary symptom increase at the start of narrative work is normal and does not indicate premature exposure. The correct clinical response is to validate, address maladaptive cognitions like secrecy, and use gradual exposure, not to retreat, force, or skip ahead in the protocol.
Key Takeaway
In TF-CBT, temporary symptom worsening during the trauma narrative phase is expected. The appropriate response is to validate, address trauma-related cognitive distortions like secrecy, and use gradual exposure at the child's pace, not to halt the narrative or skip ahead to conjoint sessions.