Discover Trauma-Focused Cognitive Behavioral Therapy (CBT): Part 2

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@Allce.com Counselortoolbox you. I'd like to welcome everybody to Part two of Trauma Focused Cognitive Behavioral Therapy. We're going to continue learning about trauma Focused Cognitive Behavior Therapy. Obviously, in this section we're going to explore the cognitive triangle, which is not going to be super new to any of you. We'll talk about creating the trauma narrative, cognitive processing, behavior management, and parent child sessions. And then we're going to continue to talk a little bit about how TF, CBT or Trauma Focused Cognitive Behavioral Therapy can be used with adult clients who are dealing with trauma related symptoms. So cognitive coping is kind of where we're going to start. Obviously helps you recognize and understand the difference between accurate and inaccurate thoughts about how safe you are, about how trustworthy other people are, about whether this incident is your fault or not. And it also helps identify helpful and unhelpful cognitions because sometimes things are accurate but they're unhelpful to really focus on. So we'll talk a little bit more about that as we go through the trauma narrative. Cognitive coping helps you recognize the distinction and relation among feelings, thoughts and behaviors. And we talk about that a lot in different venues in different ways. Whether you're talking about your emotional mind and your wise mind, or in your. Emotional mind and your wise mind. We want to help people figure out how to make that distinction. We want to help them generate thoughts that are more accurate or more helpful to a happy, healthy life. There are some unhelpful thoughts. For example, once a trauma has occurred, they are traumatized, they are victims, but they can also perceive themselves as survivors. Which way is more helpful to think about a situation? Is it accurate that they were a victim of some type of crime? Yes. Now how is it most helpful to think about that incident henceforth and forevermore? And cognitive coping can help to change people's feelings and behavior by helping them think differently. And as I just highlighted, the difference in a person's approach and perception and all kinds of things is drastic between people who view themselves as victims versus people who view themselves as survivors. You can hear it in their vocabulary, you can hear it in the tone of their voice. You can see it in some of the actions that they take many times. So our cognitive triangle. Now remember, TF CBT is really geared to be used with children and adolescents. So it's presented in a way that's Going to be a little bit more meaningful to them. Cognitive triangle helps you see that your behaviors can produce feelings. You can do things that make you make yourself happy, or you can do things that make yourself sad. When you have to clean your room, when you or your house or do laundry or whatever it is, that behavior kind of makes me unhappy having to do it. However, I can change my thoughts about having to do the laundry and reflect on how awesome it'll be when all the laundry is done or when the house is clean, because I really do prefer a clean house. So we can talk about very mundane things in terms of thoughts, feelings, and behaviors and how they're all connected and how if you're having unpleasant thoughts, it may cause unpleasant feelings and the desire to escape or lash out. Whereas if you have more pleasant thoughts or empowered thoughts, it can encourage you to feel more determined and optimistic and choose alternate behaviors. So we're going to talk about some early in therapy, about some of the presenting behaviors that we're seeing and ways that the youth can handle the thoughts and feelings that are causing those behaviors. So when we try to apply the cognitive triangle, we're going to differentiate between thoughts, feelings, and behaviors. We'll generate scenarios to illustrate how thoughts impact feelings and behaviors. So, like I said, you're going to talk about different things, like what behaviors make you happy when you do these? What is it that you can do that helps you feel happy? Those are things we're going to want to hang onto for later or even maybe right now. So when the person is having a dysphoric moment, we can suggest to them what pleasant behaviors, what pleasant activities can you try to engage in in order to help yourself feel a little bit better? If you go back to the standby, DBT accepts and improve the moment. And you can Google those. I'm not going to bore you with going through each one of those again, but those are things that we can talk about. Why do those things work? Why does it work? To go out and contribute or volunteer in order to help improve the next moment and help you accept how things are. So we'll talk about how that relates to the cognitive triangle and encourage youth to apply it to real life. And we're going to talk about things that cause negative feelings as well. And we'll talk about how changing their thoughts and help them see how changing their thoughts can change how they feel as well as how they act and how they interact with other people. The important thing to understand, though, is not everybody, especially children, but not everybody, is going to Be able to effectively differentiate between thoughts and feelings. If you go back to the Kirsty temperament disorder, the Myers Briggs, whatever you're familiar with, there is a dimension in temperament, thoughts and feelings, or thinker thinkers and feelers. But feelers tend to experience things very emotionally and they're comfortable with feeling words. Whereas thinkers tend to be less comfortable with feeling words. And they'll talk more about reactions and they're more into problem solving. So having them get over into those feeling words may not even be kind of who they are or how they're wired. So I don't want to squelch someone and make them feel like they're failing if they're not using the feeling words that I want. I do want them to be able to articulate when something happens what their reaction is. Even if we don't use the F word, feelings, we can talk about reactions. And sometimes reactions involve thoughts and that's okay. For example, optimism. If you have optimistic feelings, you also feel optimistic, probably. Or optimistic thoughts, you also feel optimistic. So separating was it the thought or the feeling that you were having? And it was kind of both. Because we generally don't think optimistically if we don't feel feel optimistic. Now you could argue that you could say when you're in a bad pessimistic mood, if you change your thoughts, you can change your attitude. But you see how the distinction starts to get a little bit gray because we use a lot of feeling words to describe our thoughts. So the take home message is if somebody gets stuck here and is having difficulty differentiating the triangle, you know, that's okay. We don't want to get stuck here. And you can move on past. Children under 8 will likely struggle identifying their personal thoughts. So one thing you can ask them is what would somebody else think? And when my. When my little girl was young, she used to watch a show called Max and Ruby and it was about a couple of bunny rabbits. So I could always ask something like what would Ruby feel? Or what would Ruby think? Or what would Max think or feel in this particular. And that helped her get outside of herself because what was going on inside of her head was not always what she was able to access and clearly articulate. So it gives you something to talk about once you figure out, you know, in Haley's case, if she would have told me what Ruby was thinking, I would ask her, well, do you think you're thinking something kind of similar or do you disagree with her? And we could talk about it a little bit more from there. So during this cognitive triangle, you're going to be doing a lot of work with the parents as well, because parents have some very unhelpful and somewhat inaccurate sometimes cognitions. Some common thoughts that you're going to be dealing with in the parent sessions are, I can only be happy if my child is happy. So we want to look at that and address it for how accurate it is versus how helpful it is. And we want to help them choose alternate thoughts. For example, I can find things to be happy about to show my child that happiness is possible. So it's really not helpful. If the parent chooses to remain unhappy until the child is happy, it's kind of holding the child hostage, too. And they're going to end up kind of in a struggle because the child may feel guilty or wrong for feeling happy. If mom, mom or dad or caregiver or whomever it is, is still upset and completely overwhelmed with whatever's going on, the parents again or caregivers may think, I can't trust anyone anymore. So are you hearing some cognitive distortions in here, the extreme thinking? So we want to look at who can you trust? Is it accurate that you can't trust anyone anymore ever again? Most likely not. So we want to look at who can you trust and in general, how do you feel about people? I mean, people will make mistakes. People will forget things. Most people are not 100% on the ball 100% of the time. And they'll goof, but they may not be malicious in their goof. So these are different shades of trust that we can examine with the parent to help them move towards a more helpful thinking of how can I interface with a world which now seems a lot more dangerous to me. Being strong for my child means I should never feel upset again. Cognitive distortions right here. Never feeling upset. Wow, I would love to never feel upset, but it doesn't happen. So what do we take from that? How can we help parents find a different, more helpful thinking or thought pattern here? Being strong means doing what you have to, and I'm doing that. So maybe the adult is getting upset, is having a depressive moment, is anxious, is, you know, dysphoric in some way. But that's okay. That's how that person feels, and they are working through it. In order to model to the child that sometimes you got to push through tough things. The final one that comes up, or one of the final ones that comes up often is good parents always know the right thing to say to their children. Now, I don't know about you, but if you're a parent, thinking back, did you ever say this to yourself? I know I did. You know, I'm a good parent, so I should know what to say all the time. And I get proven wrong so often. So is it helpful or even accurate? I mean, are good parents 100% infallible? And I think the answer is no, because none of us is 100% infallible. So how do we rephrase that in a way that's helpful? Although we try our best, Even the best parents don't know the best thing to say. Sometimes when parents are dealing with children in crisis, sometimes you know, what may go over well on Tuesday may fall completely flat on Wednesday. And part of that is just being human. I mean, the same thing can be said for dealing with anybody. But it's important for parents to understand that just because they didn't hit the mark doesn't mean they're a bad parent. It just means they didn't hit the marks and they need to step back and figure out, what do I need to do next? What's my next step? So you're going to spend quite a bit of time in TF cbt working on addressing current cognitions and what they think they should be doing and helping people feel stronger, more empowered, more capable to deal with life on life's terms before you get into the trauma narrative, because the trauma narrative is very powerful. The purpose of it is to help control intrusive and upsetting trauma related injury, basically through systematic desensitization. They don't say that in those words, but basically that's what we're looking at. Gradual repeated exposure until exposure doesn't cause the intrusive memories and the physiological and psychological upset, helping to reduce avoidance of cues, situations, and feelings associated with trauma exposure. So again, as the youth becomes and the parents become more used to being exposed to those cues and those situations, the idea, the goal is that they can be exposed to those situations and it won't make them be as physiologically or psychologically reactive. If you've worked with trauma clients before, you know how overwhelming it can feel to some of them. Most when they encounter a situation that was similar to the situation in which they were traumatized. Whether it's seeing it in a scene on TV or going past the place that it happened, or, you know, if it was something traumatic, maybe they got into a really bad car accident and somebody was killed or whatever on the interstate. Just getting on the interstate can be overwhelming for some people. So we want to start talking about what Situations trigger your emotional and psychological responses that relate back to this trauma. And how can we help you get to the point where you can be exposed to these cues without getting so upset because you don't want to be stuck in your house and kind of trying to avoid all of these cues? We're reducing avoidance issues here. We're also going to help identify unhelpful cognitions about traumatic events. I shouldn't have been talking to strangers. I shouldn't have been playing with matches. Whatever the unhelpful cognitions are that, you know and, you know, I guess matches is probably a bad example because probably shouldn't play with them. But looking back, we don't want the child to necessarily blame themselves. We really don't want the child to blame themselves for something that happened to them at the will of another person. So we want them to realize that in that particular situation, they didn't have control over what was going on, or they were trying to do the best they could at that point in time. We want to help the child recognize, anticipate, and prepare for reminders of the trauma so when they come up, the child can deal with them. Like I said, sometimes you'll be watching TV and a reminder will come up. It is not uncommon, especially with TV shows like Criminal Minds and whatever it is, Special Victims Unit, I can't think of the name, the series name, but there is a lot of really kind of graphic, traumatic stuff that's just on primetime tv. So if someone has experienced this, it can trigger an emotional, physiological reaction, and we want them to be able to figure out what to do. Now, is it necessary for them to sit there and watch an entire episode of svu? No. However, if that comes on, we want them to be able to change the channel or get up and leave the room or do whatever they need to do, but we want them to be able to do that without getting extremely upset first. And the trauma narrative also helps break apart thoughts, reminders, or discussions of the trauma from overwhelming negative emotions. So as you start to talk about will become more of a narrative, less of a overwhelming experience. So there's stepping back and almost becoming the authors of a narrative, which is why it's called a narrative. So legal issues, of course. You know, if you're like me, you're always thinking in the back of your head, what are the potential liabilities with this? I worked for a couple of years with Guardian ad litem as their criminal case case coordinator. So the kids that we were working with were kids who actually had had been victimized in a way that they had criminal cases, so they were abused or neglected in some way. And there were a lot of laws about who could talk to the kid, who could actually talk about the issue with the child, what procedures had to be used, et cetera. Encouraging discussion of the trauma may be perceived as coaching, implanting memories or tampering with testimony. Now there's a lot of evidence out there, a lot of research that says if it's done inappropriately, you can very certainly implant memories and tamper with testimony now. And I'm not saying people do it intentionally improperly, but that's why it's so important to make sure that if you're going to do a, if you're going to implement TF cbt that you actually get fully certified in applying the technique. In TF cbt, the therapist does not lead children by suggesting details or asking leading questions. And that can be really hard for us because one of the things we do a lot with adults is ask semi leading questions to try to get them to come along and pull out the narrative. And it has to be done so much more carefully with children. So that's. The trauma narrative is kind of a hotbed. It is somewhat controversial. So just putting that out there if you work with children who do have current pending legal cases. So if you are doing TF cbt, when you begin the trauma narrative, you decide on the best format and that is going to be up to the child. They may want to do a poem, they may want to do a book, they may want to do a song or an opera or a picture, a collage type book or a picture book, whatever it is that works for them and that's developmentally appropriate. Obviously a 7 or 8 year old is probably not going to write a 20 page narrative. So how can we help this child articulate what is going on with them? How can we help them get it out and get it on paper, so to speak. The other thing you can do now with the advent of computers is there are computer programs that allow them to do some illustration and some animation if they want to. So think about different multimedia ways that you can help the child get the narrative out there. Start with a general introduction of the child or person. So they start out by saying, you know, my name is Samantha Kelly, I am seven years old, I'm from Milwaukee, Wisconsin, blah blah, blah, blah, your basic introductory stuff. Because that helps the child just start talking about, you know, where they grew up, what life was like. And then you start to what happened during the trauma. And there are three ways to do it, depending on what works best for the child. You can start with what happened before the day of the trauma and work forward. So you can have them think back to the day before the trauma. Tell me what you were doing and what happened. And then on the day of the trauma, you woke up and you know what happened after that and what was the next step. So you can take help the child move sequentially through what's going on, using as many anchors as possible. You might ask them what you ate for breakfast. And obviously we don't want to implant memories or ask leading questions, so we want to ask things that are innocuous. What did you wear that day? Or did you go to school? Get some ideas about what happened and then prompt the person to keep going. You can also start with the day of the trauma. And so they've introduced themselves, they've talked about a little bit about who they are and maybe why they're doing this. And then they launch into on the morning of September 7th, yada, yada, yada. The other way you can do it, which is relatively difficult for most children, but it can be done. And for some it makes sense, is to start from the present and work backwards. So working back to right now, you're in therapy, what led to you getting in therapy? Okay, what happened that caused you to get in therapy? And then you're at that traumatic event again. But you can see how that can be challenging to kind of follow that path backwards, especially when we're getting into sort of nitty gritty detail. Most people do stories or narratives from the past to the present. You want to encourage sharing of thoughts and feelings during the event. So as the youth goes through the narrative, as they're writing it down, encourage them to talk about what were. What were you thinking at that point in time? What were you feeling? And if the feelings become overwhelming, you can back off. And then as the child is able to tell their story without getting completely upset, remember, this is. I said this is a lot like systematic desensitization. Once they can tell their story sort of objectively without getting dysphoric, go back and start adding thoughts and emotions later. And you're not going to get them the whole time or every time. Every time you go through, you're probably going to get new thoughts and new emotions that, oh, yeah, I was thinking this. And sometimes the thoughts and emotions are going to change. And it's important to help the youth understand that that's okay. That is their brain trying to remember and kind of put together all the pieces of what happened. And it doesn't mean they're lying. It doesn't mean they can't remember. We just want to know, what are you thinking that your thoughts and feelings were now? Because our memory about past events is never 100% accurate, and we're always going to remember it a little bit differently every time. So once they write the narrative and this will happen over several sessions, they're going to present and read the narrative to you. You may want to go back at that point, if it's not already included, and have them add or highlight, identify in this narrative what was the worst part for you, and talk about what was going on there and their thoughts and feelings. You continue to read through the trauma narrative several times over several sessions, identifying thoughts and feelings, correcting cognitive distortions and errors to the best that you can. I mean, obviously the child has their own beliefs, and I'm not going to tell them they're wrong for being scared or they're wrong for this or that, But I'm going to present some challenging questions about cognitive distortions, like everybody is dangerous or I am a bad person. So we're going to talk about some of those things. After several exposures, the child will typically experience progressively less extreme emotional reactions and physiological reactivity. Expecting it to go away completely is not going to happen, at least not in this first six or eight sessions, most likely. But you should see a dramatic reduction in their reactivity as they go through the narrative. It's important to help the child create a positive and optimistic ending to the narrative. You don't want to just say, okay, this was the trauma. You ended up at the emergency room. Whatever happened and the end, once they get through the trauma, we need to say, all right, what's the next chapter? How does this end? We want them to realize that the traumatic events they experienced are only one part of their life. It's one chapter. Chapter in a very, very long book. And that they don't have to be defined only by what happened to them. Is it going to affect them? Are they different now than they were before? Sure, but they're also different now than they were in fifth grade, than they were in fourth grade, because they know different things and they've done different things. So life changes us. And. But you don't have to be defined by the trauma. So we want to help them take all that. And that's very conceptual and very abstract, which is very difficult for children under the age of about 11 to even start wrapping their heads around. But they can. I mean, children are pretty smart. And encourage them to figure out, where do we go from here? What do I want my life to look like? What am I going to do with this now that I have it? Encourage the children to include in the narrative ways in which they are different now than when the traumatic events happened and when therapy began. So we've gone through writing the narrative, and we want to talk about, ideally, how things have improved. That's kind of what we're shooting for here. When the traumatic events happened, they may have been devastated, they may have been overwhelmed, they may have been really angry. How are they different now? And like I said, hopefully we're going to find some positive things. And there may have been a space between the trauma and when therapy began. So when therapy began, what were they like and how were they different? Now and again, hopefully, we'll find the things for the better. What have they learned from going through the trauma and creating the narrative? And that's a hard one. That's a hard one for most adults to answer. But the goal is to help them learn that they are really strong people and they have a lot of resilience and that it is possible to be happy even now. And you can ask them what advice they might give to other children who've experienced similar types of trauma. So sometimes I know when I used to come home from school and my mom would say, what did you learn today? I'd look at her and I'd roll my eyes because I was that kind of just wonderful child to be around. But you may get the same thing when you ask the child, what have you learned from going through this trauma? They're going to look at you like, whatever, possibly. Or they may look at you and not really understand the trauma or understand the question, how am I supposed to learn something from this? So you can turn it around and say, what advice might you give another child who has experienced this type of trauma? And that is just a different way of saying, what did you learn? So you may have to choose your words. You may have to pretend you're a reporter and ask the same question like, six different times to hit the mark and get to what you're talking about. Not to say that you're trying to get them to answer it the way you want them to, but sometimes they just don't understand what you're asking the first two or three or six ways you ask it. So working and working with the child to try to clarify what you're getting at and what you're hoping that they're going to be able to provide an answer to. Other things to consider is the fact that many people experience multiple traumas. Remember, on the Adverse Childhood Experiences survey, I have a hard time remembering what the ACEs stands for. Anyhow, most of those youth had experienced multiple traumas. And the more traumas they experienced, the more likely they were to have adverse consequences later in life. So understanding that it's not unusual to experience multiple traumas, we want to focus on the ones which are currently causing the person distress. If they have certain things in their life, maybe one of their parents went to jail, and that's not really bothering them. I worked for many, many years with an involuntary population in felony probation and parole. And for some of my clients, going to jail was more normal than being out of jail. So it was just. It was what it was. It wasn't like they were getting punished or something horrible was happening. It was just, I'm going to go visit Uncle Bob. Because I came from a relatively small county, so people often did have friends and family members that were still in jail. So a youth may not take their parent going to jail as something completely devastating. It may just be, well, dad's gone away again for another six months. So that's just the way it is. We want to focus on the things that are causing junior distress. The goal is to have children discuss their traumatic experiences until the memories no longer cause significant stress. Symptoms of fear, anxiety, and avoidance. Now, you can imagine when the youth starts writing the trauma narrative, or even if an adult is doing, can spawn all kinds of nightmares, can spawn some behavioral acting out, it can spawn flashbacks or make those things worse. So it's important to make sure that the parents are prepared for that and they understand how to handle it and what to do with it and the fact that it will get better. We want to help the parents as well as the youth, predict and prepare for the distress from both the child and the parents, which will arise during the discussion of the trauma narrative. So after the narrative is done, now you're going to talk about the narrative with the child in session, without the parents. But we want to prepare the child ahead of time so they have the tools to deal with the distress that comes up with writing it and talking about it. But then there's going to be a whole other level of distress when they've got to present it to their parents, when they go over it with their parents. And the parents are going to have their own issues to deal with relating to the trauma. So we want to make sure that we can predict and prepare for any uncomfortable feelings that may come up so we don't end up creating a situation where it becomes antagonistic or chaotic. During the narrative phase of treatment, parents should be discouraged from questioning their child about the trauma narrative outside the therapy session. And what they mean by that is, we don't want parents going home and saying, well, let me read your narrative. What did you write about in therapy today? It may be too raw, too sensitive for the youth to begin discussing. And if there are any feelings of blame towards the parents or guilt about what they did, a lot of things could go haywire in that kind of discussion. So when the youth is working on the narrative, parents are encouraged to be supportive of their feelings without having to know exactly why. Tell me exactly what's going through your mind. That may not be helpful right now. It's just helpful if the child is scared to be there to comfort him or her. Once the child completes the narrative, he or she will share it with their caregiver, parent, whomever, during a or multiple therapy sessions. So during the narrative session or part of therapy, you want to explain to the parent why it's important to write this narrative and help them understand why Writing the narrative can help desensitize the child to extreme distress at the presentation of certain stimuli that remind them of the trauma. Prepare parents for the possibility that the child may seem initially more distressed, but the parent behaviors will decrease over time. Ask them to describe their own knowledge about the event and reactions to learning about it. This will help the parent learn to tolerate discussion of the narrative with the child. So we're going to ask them, not what do you think Junior's going through, but tell me about what this experience has been like for you. So again, they're talking about something that is emotionally charged and potentially very devastating and encouraging them to get it out and get to the point where they can talk about it and still stay strong. If parents are prepared to respond supportively, it will encourage the child to discuss issues about the trauma or any other issues, as a matter of fact, that arise in the future, because this is probably one of the hardest things they're ever going to have to go through as parent and child. Sharing the trauma narrative is an ongoing process, though, so share parts of the narrative with the parent as it's being developed. So, you know, the child is obviously going to know what's going on and as the narrative is developed and as you think it's appropriate, and there's a whole lot of stuff that goes into deciding timing on this. But you'll present parts of what the youth has written so the parent is getting an idea about what's going through junior's head. And again, sometimes it's really hard for parents to not take that information and go home and go, let's talk about this. But it is imperative that they be patient in order to not make the child kind of withdraw and go, oh, I don't want to go there anymore. That was really an uncomfortable situation with my parents. After session, devote parallel parent sessions to the parent reading the child's book or narrative to improve their ability to listen attentively and be supportive when the child shares it. Sometimes parents feel guilty and they want to jump in and go, well, I didn't do that, or, you're remembering wrong. Or they want to add and comment and think about going to a movie and sitting in a movie theater with someone who just wants to comment through the entire movie about what's going on or what they should do or what they shouldn't do. If you've ever been to a horror movie, even when I'm at home, my family, like, narrates as they go through, oh, you shouldn't be going down the stairs. You know, we want to make sure that the parent can sit there and listen and hear without having to add their 2 cents throughout. And then when the narrative is done, then there's a discussion period. So 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 more sense of control, a sense of empowerment. But it's also a starting point for the exploration of how the child thinks and feels about the trauma and its impact. So they can tell their story now, but then there's a whole lot of stuff about, okay, how are you different now? And how do you feel about what happened and how do you feel about who you are now? Many issues may remain salient for the child, including shame and or stigmatization, because they're the only one, or they think they're the only one, which we go back to psychoed for that. Feelings of responsibility, either for the trauma itself or for events that occurred subsequent to the discovery of the trauma. So maybe they were victimized by a spouse's significant other, or not a spouse, a parent's significant other, and that significant other went to jail. So now the parent is angry because their significant other went to jail. And it's important for children to understand where their responsibility lies and Be okay and feel okay with what they did. Unhealthy changes in their trust of others. Yeah, it's not good to trust everybody. Unfortunately, that's just the way life is. But not trusting anyone ever sets people up to be very isolated. We want to look at attributions about the offender or the trauma. What are they thinking about that person, and what are they thinking about the trauma? And unhelpful changes in perceptions about their own body or their own safety. And remembering, as I said before, when we're talking about trauma, we're not just talking about physical or sexual abuse. We can be talking about being a victim of a massive hurricane. We can talk about being in a plane crash. Anything that is traumatic to the child is a trauma. So we need to look at how can we help them feel safe again? The goals of cognitive processing are to help children and parents understand the difference between accurate and inaccurate thoughts related to their traumatic experience. What could they have done? You know, in retrospect, you can look back and go, well, I could have done this, that, and the other, but maybe not. You know, you've got to look at the bigger situation. What were you able to do at that point in time? And we want to correct cognitive errors to encourage more healthy thought processes around the trauma. We want to help parents examine their own thoughts about the child's traumatic experience for accuracy and helpfulness in terms of how they feel about the child, how they feel about whatever the trauma was, and how they feel about themselves as parents in relation to the trauma. And we're going to teach parents how to effectively challenge the child's cognitive errors. So if the child has a cognitive error of I am defective now and I will never be whole again, then we're going to look at ways to challenge that so the child can feel okay about themselves and will help parents develop the school the skills to challenge that cognitive distortion. Cognitive processing involves challenging thoughts and beliefs that the child may firmly believe. So telling them, oh, no, you're not. That ain't gonna work. We need to make sure that we understand that this is what the child believes. So we need to provide them evidence to the contrary, or at least plant the seed that there may be some other alternatives, and the child may have to come around to that on their own. When you're going over the trauma narrative as each thought is expressed, you're going to inquire about whether that thought was accurate and helpful. So if they were having a particular thought that was inaccurate or that was one of those shoulda, coulda, Wouldas we want to talk about whether that was helpful and whether it's helpful in the present to their recovery process. You'll pay close attention for thoughts or beliefs that reflect shame, guilt, or responsibility for the trauma or its consequences. You'll pay attention for thoughts or beliefs that reflect low self esteem. And obviously we're good at helping with self esteem. That's one of those that we can kick in some tools really easy. There's a, a lack of trust in others or fears for current and or future safety. So again, remember I was talking about situations that included viewing domestic violence, being in a natural disaster, being in a plane crash or a car crash. There are a lot of different traumas that can happen that can make a child feel unsafe and not know when they are going to be safe. So it's important to be able to help identify cognitive issues or thoughts that are constantly telling them you're unsafe and you're never going to be safe and challenge those and help them develop a safety plan so they feel strong. You can change cognitions with a few things, and I liked these, which is why, obviously why I put them in here. A best friend role play. The client is instructed to take on the role of his or her best friend and counsel the client. So basically, if your best friend was in this situation, what would you tell him or her? You know, so you're stepping out of the client role and you're being the expert. So what would you tell somebody? The now and then role play. The client is asked to go back in time to give himself or herself advice about what to do about the trauma before and or after it happens. So it's important to look for areas of shame here, areas of guilt, responsibility. Pie. Draw a pie chart and assign pieces of various sizes to different individuals who might bear some responsibility for the trauma and revise as needed. So, you know, there could be one piece, but generally there are three or four pieces. When you're dealing with a child, mom and dad, or caregivers are in there somewhere. Finally, there's the suggestion of talk show host. The client assumes the role of a radio psychologist. You know, calling into Dr. Phil. The therapist takes the role of a caller seeking advice regarding their own experiences with a trauma. So as you hear cognitive distortions, you would take note of those. And then when you call in for advice, you would ask the child, you know, what should I do about this? And see if their distortions change, if their thought process change when they're telling somebody else what to do versus what they're Telling themselves. Many clients know the trauma wasn't their fault, but that doesn't necessarily mean they believe it. Head, heart and gut. There's often some attributions of responsibility. I know you say it's not my fault that I still feel guilty. Kind of heard that before. Don't automatically present the notion that it's not your fault. Because there are some kids out there who never thought it was their fault. They're like, no, it was a hurricane, it wasn't my fault. Some children may have an element of responsibility in a trauma as well. So if you start out with it's totally not your fault, but you find out that they were playing with the matches that set their house on fire, that killed their brother and sister, there's a little bit of a difference there. So you don't want to lose credibility by saying from the very beginning none of this was your fault. So know the story, know what's going on with it, and know what the child's attributions are. Ensure both the child and parents have adequately progressed before terminating treatment. We don't want to have them at the point where they're still really emotional or physiologically reactive when they encounter thoughts or reminders of the trauma. When you're talking with parents, common cognitive distortions. I should have known this would happen. I should have kept my child safe. My child will never ever be happy again. Our family is totally destroyed. My child's childhood is ruined. The world is terribly dangerous and my child can never recover. Okay, almost all of those, if not all of them, have extreme language in them. So you're going to want to look at those cognitive distortions and really challenge them to be more specific. Address absolutes by finding exceptions. So my child will never be happy again. Well, let's look over the past week. Did your child have any happy moments? Most likely yes. And you may even encourage them to keep a journal of times when Junior is actually happy. Because we want to see those increasing as therapy progresses. Use the child's progress to underscore the child's resilience and provide hope to the parent. Because most of the time if we see something our kid can do, we're like, well, I can do this too. So we want to help underscore the resiliency and self power in both the parent and the child and the family unit. Unfortunately, common consequences of trauma include disruptive, aggressive and non compliant behavior. The child doesn't feel safe. So the triangle child trying to get control again. Parents who feel guilty often have difficulties controlling These types of behavior, so the child kind of runs wild. We want to teach parents to focus on actively praising the child for desirable behavior and review with them. Don't just assume they know how to effectively praise. We want to review with them how to praise specific forms of behavior. So if somebody puts puts away their dishes after dinner, we're going to praise that instead of saying something more general like, you were a good girl today or you were a good boy today. We also want to encourage the parent to provide praise as soon as possible after the desirable behavior. Be consistent in their praise, not just praise for two or three days, and then quit doing it. Try not to negate praise with criticisms like, you did a really good job at school today. Why can't you do that every single day? We want to take that end part off and say, you did a really good job today. And encourage them to use an enthusiastic tone when praising the child, but not so much that it's obviously fake. You know, children pick up on that really fast. Active ignoring means avoiding responding to the child during a particular inappropriate behavior and immediately after it. When a behavior is done and it doesn't get rewarded with attention, eventually it won't be worth the effort and the child will stop. This is why temper tantrums in the grocery store or wherever it is, the child will escalate for a little bit. And if the parent gives in, then they're going to get even worse the next time. But at a certain point, the child is going to go, you know, not worth my effort. Okay, fine. So that's called behavior strain. When the effort for the behavior is more costly than the reward is worth. You want to avoid verbal and emotional reactions, eye contact, facial expression, or any other form of communication toward the child during this period. But like I said, it'll get a little bit worse before it gets better. Just like the temper tantrum in the grocery store. Prepare for what we call an extinction burst. The child will go, well, I'm not getting your attention by asking, so I'm going to ask a little louder and a little meaner, and I'm going to ask a little louder. So it's going to escalate until the behavior costs more than the reward is worth. Obviously, you never want the parent to ignore dangerous behavior that would cause injury or worse. But we want them to ignore behavior such as defiant or angry statements directed at the parent because it's going to happen. Nasty faces, eye rolling or smirking, mocking, taunting, or mimicking the parent. Things that they know, quote unquote, will probably get under your skin. If you can ignore them, eventually it's not going to be worth the effort. They're like, there's no reward in that. Additionally, you're going to look for reward times when the child accepts redirection or accepts a negative response. So if you go through active ignoring and they finally give up, then you can say something to the effect of I appreciate you recognizing that that wasn't a helpful way to go about asking for whatever it was you wanted. Timeout. Remember, once the timeout timer is started, actively ignore anything except for dangerous behaviors till then. And a timeout should last no longer than one minute per age year. So if a child is three, it's no more than a three minute timeout. Timeout should not be in a rewarding environment. If you send the child to their room, they have all kinds of stuff in their room. So that's not really an unrewarding environment. Sitting in a chair in the hallway, a little bit more unrewarding. Explore the motivation behind the timeout. Why was the child engaging in that behavior? Then directly tie the timeout to the behavior, not the emotion. So I'm not punishing you for being angry, I'm punishing you for kicking the dog. It's not appropriate to hurt the animal. Contingency management can also be used. Reward contingencies must be developmentally appropriate though, so tokens, stars, and credits can be earned to reduce behavior strain. That works really well with most children and adolescents. They can earn points in order to get TV time, in order to get video game time, whatever. But a small child can't add stuff up over the course of a week to get a reward. They're going to need rewards more quickly than that. Like at the end of every day, you can tally up how many stars or points they have, address only one behavior at a time, and involve the child in identification of what the reward should be. You know, they may not want the same thing that you think they want, so what do you want as a reward? If the contingency seems to be ineffective, reevaluate to identify what's maintaining the behavior. Why is this inappropriate behavior more rewarding than doing the right thing? Part of it may be that they're not getting rewards frequently and intensely enough to maintain the good behavior. And so there's a fine line you've got to walk there in order to make sure that the child thinks it's more rewarding to do the right thing. Parents will demonstrate their comfort in hearing and talking about the trauma while modeling appropriate coping in parent and child sessions, the child can share the narrative and experience with a sense of copy pride, which further alleviates feelings of shame and distress associated with the trauma. They can say, you know, look how far I've come. The parent child communication about the trauma is enhanced and any misunderstandings can be cleared up such as is mom mad at me? Or you know, whatever their feelings may be and the groundwork is laid for the therapeutic parent child interactions to continue. You do want to prepare the parent to be able to effectively praise the child and encourage them to ask open ended, non threatening questions as opposed to critical questions such as, you know well, why didn't you ever tell me this before? That seems attacking and critical. Instead you might say, how did you decide that now is the time to tell someone? So in order to prepare for that, you may need to rehearse or role play potential questions that the child might have in the parent sessions. Before you get into conjoint sessions, prepare the parent to discuss the child's questions for them about the trauma and end the session by having parents and kids express appreciation to one another for something positive that happened in the last week. If, however, no matter how much preparation you do, the parent cannot participate effectively in the conjoint sessions, you may need to skip it. Some parents may be too flummoxed with their own feelings and issues at that point in time and it would be more detrimental to both parties to go there. 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 will review the child's progress in parent focused sessions with the therapist to help them understand what the child's experiencing, prepare for helping the child between sessions and get used to discussing the trauma narrative. Clinicians will help the parents address inappropriate child behaviors through the use of praise, active ignoring, timeout and contingency management. And again, remember, it's not always possible to do the conjoint sessions because the parents may not be able to effectively manage their own emotions at this point in time. So if that happens, you can skip the conjoint sessions. Further guidance can be found here. And clickety click. Of course it's going to load. Trauma Focused CBT for Children and Adolescents Treatment Applications I gave you a link to the Google Book Preview. You can order the book if you want to. It's not part of this particular class, but if you're interested in getting certified in TF cbt, this would be one of the first places to go. Okay, so are there questions. It. Okay, that being the case, I am going to go ahead and end the meeting. Remember, you can always reach me. That's my direct email if you have any questions about the class, need any clarification, want further resources? If the child refuses to go to timeout and that's going to be something that you've got to take kind of on a case by case basis and you want to look at why is the child refusing and generally the child will end up losing other privileges if they don't go to timeout. But we can also in certain cases you may want to actively ignore that particular behavior. It depends on what the timeout is for, what the child's issues are, and whether actively ignoring it is going to be a better solution at that particular point in time. Generally you don't want to get into a power struggle where the parent and the child are going back and forth and back and forth. Definitely. As far as the time of the timeout, it doesn't go past the number of minutes per year age of the child. If you're going from basically strict behavioral guidelines, that is what I've always been taught and what seems to be most effective in the literature because three minutes is a really long time to a three year old and you know, to an eight year old, eight minutes is forever. I will look more on the if the child refuses to go to timeout and I will post that in the class to get an answer from child psychologists on that one though. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceus.com counselortoolbox this episode has been brought to you in part by allce.com, providing 24. 7 multimedia continuing education and pre certification training to counselors, therapists and nurses since 2006. Use coupon code counselortoolbox to get a 20% discount off your order this month.