121 -Trauma Focused Cognitive Behavioral Therapy Part 2
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Trauma Focused CBT
Part 2
Treating Trauma and Traumatic Grief in Children & Adolescents
Objectives
~    Continue learning about TF-CBT
~    Explore
~    Cognitive Triangle
~    Creating the Trauma Narrative
~    Cognitive Processing
~    Behavior Management
~    Parent-Child Sessions
~    Explore ways to use TF-CBT with adult clients
Cognitive Coping
~    Recognize and understand the difference between
~    accurate and inaccurate cognitions
~    helpful and unhelpful cognitions
~    Recognize the distinction and relation among feelings, thoughts, and behavior
~    Generate alternative thoughts that are more accurate or more helpful
~    Attempt to change their feelings and behavior by thinking differently
Cognitive Triangle
Cognitive Triangle
~    Application
~    Differentiate between thoughts, feelings and behaviors
~    Generate scenarios to illustrate how thoughts impact feelings and behaviors
~    Explore how changing a thought impacts the feelings and behaviors
~    Apply the skill to real life
~    Not everyone will be able to differentiate between thoughts and feelings
~    Children under 8 will likely struggle identifying their personal thoughts.  Ask what someone else might think

Parent Sessions During Cognitive Triangle
Common Thoughts
~    I can only be happy if my child is happy.
~    I can't trust anyone anymore.
~    Being strong for my child means I should never feel upset.
~    Good parents always know the right thing to say to their children
Alternate Thoughts
~    I can find things to be happy about, to show my child that happiness is possible
~    Most people are good at heart and many are trustworthy.
~    Being strong means doing what you have to do, and I am doing that.
~    Although we try our best, even the best parents sometimes don’t know the best thing to say.

Creating the Trauma Narrative
~    Purpose
~    Helping to control intrusive and upsetting trauma-related imagery
~    Helping to reduce avoidance of cues, situations, and feelings associated with trauma exposure
~    Identifying unhelpful cognitions about traumatic events
~    Helping the child recognize, anticipate, and prepare for reminders of the trauma.
~    Break apart thoughts, reminders, or discussions of the trauma from overwhelming negative emotions

Creating the Trauma Narrative
~    Legal issues
~    Encouraging discussion of the trauma may be perceived as “coaching,” “implanting memories,” or “tampering with testimony”
~    In TF-CBT, the therapist does not lead children by suggesting details or asking leading questions
Creating the Trauma Narrative
~    Decide on the best format (poem, book, pictures)
~    Start with a general introduction of the child/person
~    Next  (3 Approaches)
~    start with what happened before the day of the trauma and work forward
~    start with the day of the trauma
~    start from the present and work backwards.
~    Encourage sharing of thoughts and feelings during the event
~    If feelings are overwhelming, start with thoughts and add emotions later
~    Present/read the narrative
~    Add the worst part of the traumatic event
Creating the Trauma Narrative
~    Reading through the trauma narrative several times
~    Identifying thoughts and feelings
~    Correcting cognitive distortions and errors
~    After several “exposures” the child will typically experience progressively less extreme emotional reactions and physiological reactivity.
~    It is important to help the child
~    Create a positive and optimistic ending to the narrative
~    Realize that the traumatic events they experienced are only one part of their lives
~    Understand that they are not defined only by what happened to them.
Creating the Trauma Narrative
~    Encourage the children to include in the narrative ways in which they are
~    How they are different now from when the traumatic events happened and when therapy began
~    What they have learned from going through the trauma and creating the narrative
~    Advice they might give to other children who have experienced similar types of trauma.
Additional Points
~    Many people experience multiple traumas
~    Focus on those traumas which are currently causing the person distress
~    The goal is to have children discuss their traumatic experiences until the memories no longer cause significant symptoms of fear, anxiety, or avoidance
~    Predict and prepare for the distress from both the child and parents which will arise during the discussion of the trauma narrative
~    During the narrative phase of treatment, parents should be discouraged from questioning their child about the trauma narrative outside of the therapy session. Once the child completes the narrative, he/she will share it with their caregiver during the therapy session.
Parent Sessions During the Narrative
~    Explain why it's important
~    Prepare parents for the possibility that their child may initially seem more distressed (e.g., have more nightmares, display more “acting out”), but that these behaviors will decrease over time.
~    Prepare parents by asking them to describe their own knowledge about the event, and reactions to learning about it. This will help the parent to learn to tolerate discussion of the narrative with the child.
~    If parents are prepared to respond supportively, it will encourage the child to talk to about issues that arise in the future.
~    Sharing the trauma narrative is an ongoing process. Share parts of the narrative with the parent as it is being developed.
~    Devote parallel parent session to parent reading child's book to improve their ability to listen attentively and be supportive when the child shares it.

Cognitive Processing
~    The creation of the trauma narrative is both
~    An end in itself, helping the child or adolescent tell his or her story with reduced anxiety and healthier emotions
~    A starting point for the exploration of how the child thinks and feels about (or “processes”) the trauma and its impact.
~    Many issues may remain salient for the child, including:
~    Shame and/or stigmatization
~    Feelings of responsibility (either for the trauma itself or for events that occurred subsequent to the discovery of the trauma)
~    Unhealthy changes in trust of others
~    Attributions about the offender or trauma
~    Unhelpful changes in perceptions about the body or safety

Cognitive Processing
~    Goals of Cognitive Processing
~    Help children and parents
~    understand the difference between accurate and inaccurate cognitions related to their traumatic experience
~    correct cognitive errors to encourage more healthy thought processes around the trauma
~    Help parents examine their own thoughts about the child’s traumatic experience for accuracy and helpfulness
~    Teach parents how to effectively challenge the child’s cognitive errors

Cognitive Processing
~    Cognitive processing involves challenging thoughts and beliefs that the child may firmly believe
~    Go over the trauma narrative.
~    As each thought is expressed, inquire about whether that thought was accurate and helpful.
~    Pay close attention for thoughts or beliefs that reflect
~    Shame, guilt or responsibility for the trauma or its consequences
~    Low self-esteem
~    Lack of trust in others
~    Fears for current and/or future safety
Changing Cognitions
~    Best friend role play the client is instructed to take on the role of his or her best friend and “counsel” the client
~    Now and then role play the client is asked to ‘go back in time' to give him or herself advice about what to do about the trauma before and/or after it happens.
~    Responsibility pie Draw a pie chart and assign “pieces” of various sizes to different individuals who might bear some responsibility for the trauma. Revise as needed
~    Talk show host role play the client assumes the role of a radio psychologist. The therapist takes the role of a caller seeking advice regarding their own experiences with trauma.
~    The “callers'” questions address areas of particular concern for the client.

A few more things…
~    Many clients “know” it wasn’t their fault, but that doesn’t necessarily mean they believe it.
~    Explore attributions of responsibility
~    Don’t automatically present the notion that “It’s not your fault”
~    Some children may not have ever thought it was
~    Some children may have an element of responsibility (i.e. starting a fire that killed their family)
~    Ensure BOTH the child and parents have adequately progressed before terminating treatment
Cognitive Processing with Parents
~    Common cognitive distortions among caregivers
~    I should have known this would happen.
~    I should have kept my child safe.
~    My child will never be happy again.
~    Our family is destroyed.
~    My child's childhood is ruined.
~    The world is terribly dangerous.
~    My child can never recover.
~    Address absolutes by finding exceptions
~    Use the child’s progress to underscore resilience and provide hope

Behavior Management
~    Common consequences of trauma include disruptive, aggressive, and non-compliant behavior.
~    Parents who feel guilty often have difficulties controlling these types of behavior.
~    Teach parents to focus on actively praising the child for desirable behavior.
~    Review with the parent how to effectively give praise:
~    Praise specific forms of behavior.
~    Provide praise as soon as possible after the desirable behavior.
~    Be consistent in your use of praise.
~    Don’t negate praise with criticisms.
~    Use an enthusiastic tone when praising the child.

Behavior Management
~    Active Ignoring
~    Avoid responding to the child during the behavior and immediately after it. (Behavior strain)
~    Avoid verbal or emotional reactions, eye contact, facial expression, or any other form of communication toward the child. (Prepare for extinction burst)
~    NEVER ignore dangerous or unsafe behavior that could cause injury or worse.
~    Try to ignore behavior such as:
~        defiant or angry statements directed at the parent
~        nasty faces, eye rolling, or smirking at the parent
~        mocking, taunting, or mimicking the parent
~    Look for and reward times when the child accepts redirection or a negative response
Behavior Management
~    Time Out
~    Once the timeout “timer” is started, parents should actively ignore any behavior that the child exhibits, except for dangerous/unsafe behavior or behavior that allows the child to escape from timeout
~    Time out should last no longer than 1 minute/age year
~    Time outs should not be in a rewarding environment
~    Explore the motivation behind the time-out
~    Directly tie the time-out to the behavior, not the emotion

Behavior Management
~    Contingency management
~    Reward contingencies must be developmentally appropriate
~    Tokens/stars/credits can be earned to reduce behavior strain
~    Address only one behavior at a time
~    Involve the child in identification of what the reward should be
~    If the contingency seems to be ineffective re-evaluate for
~    What is maintaining the behavior
~    Reward intensity and frequency
Parent Child Sessions
~    Rationale
~    Parents will demonstrate their comfort in hearing and talking about the trauma, while modeling appropriate coping
~    The child has can share the narrative and experience a sense of pride further alleviating feelings of shame and distress associated with the trauma
~    Parent-child communication about the trauma is enhanced, and misunderstandings can be cleared up
~    The groundwork is laid for therapeutic parent-child interactions to continue
Parent Child Sessions
~    Prepare the parent
~    Ensure parents are able to effectively praise the child
~    Asking open-ended, non-threatening questions as opposed to questions that could be perceived as critical
~    “How did you decide to tell someone about what happened?”
~    “Why didn't you tell me before?”
~    Rehearsing/role-playing responses to the trauma narrative

Parent Child Sessions
~    Prepare the parent
~    Preparing the parent to discuss the child's questions for them about the trauma
~    Is mom mad at me?
~    Why didn’t you make it stop?
~    Why didn’t you take Fluffy too?
~    Is God mad at me? / Am I going to Hell?
~    End the session by having parents and kids express appreciation to one another for something positive they did in the last week
~    If, no matter how much preparation you do, the parent's own psychological problems prevent them from participating effectively in trauma-focused joint sessions, the answer is simple: skip it.
Summary
~    In many situations, the parents as well as the children may benefit from psychoeducation about feelings, coping skills, stress management and the cognitive triangle.
~    Parents review the child’s progress in parent-focused sessions with the therapist to help them
~    Understand what the child is experiencing
~    Better prepare for helping the child between sessions
~    Adapt to discussing the trauma narrative
Summary
~    Clinicians will help the parents address inappropriate child behaviors through the use of:
~    Praise
~    Active ignoring
~    Time out
~    Contingency Management
~    It is not always possible to do parent-child sessions, because the parent may be too overcome with their own issues to respond in a helpful manner
~    Further guidance can be found HERE