Scaling Up Evidence-Based Treatments: An Analysis of 25,000 Sessions of Trauma-Focused Cognitive Behavioral Therapy...

Most youth in routine mental health care do not receive evidence-based treatments, and when implemented in real-world settings, their effects are typically smaller than those observed in controlled efficacy trials. Trauma-focused cognitive behavioral therapy (TF-CBT) is one of the most efficacious and widely implemented evidence-based treatments for traumatized youth worldwide, yet little is known about how it is delivered and adapted in routine practice. We examined 25,000 treatment sessions to understand the following: (1) how TF-CBT is implemented in routine care; (2) what delivery adaptations are made based on child age and the presence of complex posttraumatic stress disorder (CPTSD) symptoms; and (3) whether adaptations are associated with outcomes.

Data came from an observational study of TF-CBT implementation (2018-2024) across Norwegian child and adolescent mental health services. Children and adolescents (6-18 years of age) with clinically significant posttraumatic stress symptoms (N = 1,373) received treatment from 357 therapists across 74 outpatient clinics representing 82% of such services in Norway.

Overall, 66% completed treatment and 59% showed reliable improvement. Clinicians applied TF-CBT flexibly as prescribed by the model. Patients with CPTSD received more trauma processing but had less caregiver involvement than those without CPTSD. Children received more stabilization and caregiver involvement than did adolescents. More trauma experiences predicted higher dropout, whereas more caregiver sessions predicted lower dropout. CPTSD was associated with reliable improvement. Number of potentially traumatic event types were more strongly associated with dropout for children than for adolescents, and caregiver sessions more strongly predicted improvement in CPTSD cases.

This study provides the first large-scale systematic documentation of TF-CBT delivery in routine care, and shows that TF-CBT can be scaled up in community clinics, with high improvement rates comparable to those in recent meta-analyses. A majority of the therapists received supervision, and future studies need to dismantle the importance of case consultation when scaling up evidence-based treatments.