Slide 34

TF-CBT Overview • • • • • • • •

Psychoeducation Stress Management Affect Expression and Modulation Cognitive Coping Creating the Trauma Narrative Cognitive Processes Behavioral Management Training Parent-Child Sessions

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Slide 35

TF-DBT-Psychoeducation • Educate Clients and their parents: – Different types of trauma – Why each type of trauma occurs – Effects of trauma – Why clients may not like to talk about what happened

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Slide 36

TF-DBT-Psychoeducation; Cont. • General Tips for Psycho-Education – Tailored to developmental level – Usually a question/answer format to determine the child’s knowledge

• Specific Information – Sexual Abuse: various types, why it occurs, who perpetrates it, how abused children feel, sexualized feelings and behaviors, why children don’t talk about it, etc. – Physical Abuse: understand difference between appropriate and inappropriate discipline, psychological abuse – Witnessed Violence: help them not blame themselves, normal emotional responses/cognitions, how to handle disagreements in healthy ways – Other Trauma: tailor to specific traumas, body safety, risk reduction, etc.

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Slide 37

TF-DBT-Psychoeducation; Cont. • Sex Education – Healthy sexuality and body awareness – Clarify misinformation

• Risk Reduction – Help clients identify red flags that indicate high risk situations – Safety plan – Right to say “No” – Appropriate and Inappropriate touch – Confident responses, assertiveness skills

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Slide 38

TF-DBT-Psychoeducation; Cont. • Parent Sessions – Educate about the treatment model and order of skills – Educate about trauma-related symptoms – Educate parent about the specific trauma – Be sensitive: gauge parental distress, be transparent, let them know there will be ongoing collaboration between you

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Slide 39

TF-CBT: Stress Management • Three components of Stress Management – Controlled Breathing – Relaxation Training – Thought Stopping

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Slide 40

TF-CBT: Stress Management— Controlled Breathing • Teaching breathing exercise to help with anxiety and distress • Role Play strategies to help child know when to use breathing exercises • Assign homework to practice twice per day – Use tracking sheet

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Slide 41

TF-CBT: Stress Management— Controlled Breathing • • • • • •

Explain rationale Demonstrate proper body position Demonstrate proper breathing Introduce relaxing word Have child demonstrate Same technique is used to teach parents in Parent Session

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Slide 42

TF-CBT: Stress Management— Relaxation Training • Progressive muscle relaxation used to help control client anxiety • Teach and practice PMR – Explain rationale – Demonstrate and induce relaxation – Teach parents

• Assign homework for practice

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Slide 43

TF-CBT: Stress Management— Thought Stopping • Distraction technique for intrusive thoughts • At first stop, then replace with pleasant thought • Helps children “short circuit” negative thoughts • Help them interrupt unwanted thoughts with pleasant thoughts • Teach how and when to use thought stopping

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Slide 44

TF-CBT: Stress Management— Thought Stopping, Cont. • Explain rationale • Demonstrate technique – Use loud clap and shout “Stop”

• Help child select a stopping method – Verbal or silent “Stop”, “Go Away”, etc. – Rubber band

• Introduce replacement thought – Practice in session—elaborate with sensory details

• Parent Session—Teach to parents and encourage child’s practice.

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Slide 45

TF-CBT: Affect Expression and Modulation • • • •

Feelings Identification Talk about emotions Identify levels of emotion intensity Homework that encourages feelings identification and feelings expression in vivo • Use role-play, games, drawing

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Slide 46

TF-CBT: Affect Expression and Modulation, Cont. • Children are given a rationale so they understand the benefits of accurate identification and talking about feelings • Get baseline of number of different feelings the child is able to identify, how comfortable they are. • Rating intensity: SUDS or Emotion Thermometer • Appropriate expression in various situations: Role Play

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Slide 47

TF-CBT: Affect Expression and Modulation, Cont. • Parent Session: – Normalize trauma responses re: emotion – Help child label emotions when they notice them – Encourage they use role play, games, books etc. to discuss emotion – Praise child for appropriate expression of emotion – Help the parent cope with their own emotion about the abuse.

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Slide 48

TF-CBT: Cognitive Coping • Differentiate between accurate and inaccurate thoughts • Differentiate between helpful and unhelpful thoughts • Increase awareness of interrelatedness of feelings, thoughts, and actions • Teach ways to construct alternative thoughts that are more accurate or helpful • Change feelings and behavior due to thinking more accurately

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Slide 49

TF-CBT: Cognitive Coping, Cont. • Help children notice the difference between a thought and a feeling • Show them how thoughts, feelings, and behavior are connected via the “Cognitive Triangle” • Use child’s experiences to illustrate how an inaccurate cognition in reaction to an event can seem “Normal”—use the Cognitve Triangle • Have the child generate scenarios of the Triangle • Have them generate more accurate or helpful thoughts • Help them see how to apply this in real life.

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Slide 50

TF-CBT: Cognitive Coping, Cont. • Homework: Identify situations when upset then draw triangle, then alternative thoughts, etc.; other games, worksheets • Parent Sessions: – Encourage positive self-talk – Teach parents Cognitive Triangle

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Slide 51

TF-CBT: Creating the Trauma Narrative • Help children better manage the emotionally dysregulating parts of their trauma • Help children decrease unhealthy avoidance • Use activities to facilitate the discussion and review of details • Help children and parents understand why writing the narrative is helpful even though it’s also upsetting at first

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Slide 52

TF-CBT: Creating the Trauma Narrative, Cont. • Special Considerations – Child discomfort – Parent discomfort – Therapist discomfort – Legal issues

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Slide 53

TF-CBT: Creating the Trauma Narrative, Cont. • Decide on best format for narrative – – – – –

Book Picture Song Poem Etc.

• Proceed from what happened before the trauma and work forward • Description of the event may take more than one session • Child reads narrative, therapist if too difficult • Add thoughts and feelings

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Slide 54

TF-CBT: Creating the Trauma Narrative, Cont. • Include worst moment, worst part of trauma • Review and add cognitive processes: – Correct cognitive distortions and errors

• Repeat several readings to decrease reactivity, use stress management strategies • Praise child • Create positive and optimistic ending: – It is just one part of their life – Ways they are different, stronger – Advice they might give other children

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Slide 55

TF-CBT: Creating the Trauma Narrative, Cont. • Special Considerations: – Multiple Traumas • Start with traumas with least distress, then more

– Processing to low distress – Extreme Distress • Increase Stress reduction skills • Remind of progress--rating

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Slide 56

TF-CBT: Creating the Trauma Narrative, Cont. – Instructing the Parent • • • • •

Do not ask about narrative outside of therapy Explain the importance of the narrative Work closely, repeat rationale, address concerns Prepare parents for increased distress Ask parent what they know about the trauma in an effort to prepare them • Teach parent to respond supportively • Sharing narrative is ongoing task • Parent will read the child’s book

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Slide 57

TF-CBT: Cognitive Processing • Increase understanding of accurate versus inaccurate thoughts • Learn to correct thinking errors to create healthier thinking processes • Help parents examine their own thinking about their child’s trauma for accuracy and helpfulness • Help parents learn to challenge child’s thinking errors

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Slide 58

TF-CBT: Cognitive Processing; Cont. • Review trauma narrative and note all the examples of thoughts • Re-read the narrative in session and review each thought for accuracy and helpfulness • Challenge unhelpful or inaccurate thoughts • Use role play or experiential exercises to examine cognitions – – – –

Best friend role play Now and then Responsibility pie Talk show host

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Slide 59

TF-CBT: Cognitive Processing; Cont. • Parent Sessions – Parent’s Cognitions: • • • • • •

I should have known… Safety Never be happy again Family is broken Childhood is ruined Etc.

– Be aware of “absolutes” • Never, always, etc.

– Use child’s work as example for their own corrections

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Slide 60

TF-CBT: Behavior Management Training • Help parents to manage negative behavior • Help parents decrease ineffective parenting skills • Help parents use effective praise, time out, contingency management, reward/punishment • Prepare parents to use skills in home, work, etc.

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Slide 61

TF-CBT: Behavior Management Training; Cont. • Psychoeducation about negative/disruptive behavior • Teach use of healthy praise – – – –

Specific behavior As soon as possible Consistent, enthusiastic, sincere Let is stand alone: Do NOT follow it with criticism

• Teach use of active ignoring – Avoid response during acting out, no verbal or emotional response, eye contact – Never ignore dangerous or unsafe behavior – Praise when child accepts redirection

• Teach use of time out • Teach contingency management—change one bx at a time • Role play each skill

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Slide 62

TF-CBT: Parent-Child Sessions • Evaluate parent and child readiness to participate in joint sessions • Help parents develop appropriate skills to respond to the trauma • Promote healthy communication • Continue work at home even after treatment

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Slide 63

TF-CBT: Parent-Child Sessions; Cont. • Do not include other siblings until all other goals regarding the trauma are resolved • Be aware of the parents own trauma history and how it may impact therapy • May not be able to conduct parent-child sessions if parents psychological problems precludes it • Help parents understand the unexpected is expected—it’s not a failure.

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