Trauma Focused Cognitive Behavioral Interventions: Trauma Informed Care

 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 at allceus.com/counselortoolbox I’d like to welcome everybody to today’s presentation on trauma-focused cognitive   behavioral therapy part 1 treating trauma and traumatic grief in children and adolescents   in this first part we’re going to define trauma-focused CBT and talk about what   we’re dealing with here because trauma-focused CBT is a best practice and it is a manualized   best practice so you’re going to learn about it today but you’re not going to have enough skills   where you can say you are certified in TF CBT however I will provide your resources should   you want to go out and pursue those so we are going to talk about TF CBT as a best practice   and implementing fidelity but I’m going to also take a few detours and as I always   do and talk about how this might be able be useful with adults who have a history of trauma   in childhood we’ll explore the components of trauma-focused CBT and their intended   functions, we’re not going to get through all of those today but we’re going to start and we’re   going to explore ways to use TF CBT with adult clients so TF CBT works for children who have   experienced any trauma including multiple traumas so what we’re talking about is children who   come to your office who are presenting with trauma-related issues it’s effective with   children from diverse backgrounds and works in as few as 12 treatment sessions so a lot   can be accomplished in 12 sessions they’re not necessarily weekly sessions they can be spaced   out a little bit part of it depends on the age level of the child how long ago the trauma was   any concurrent developmental or mental health issues that might be present yada yada yada so   it may be a little bit longer it may be a little a bit shorter in terms of calendar time but you   can also extend the number of sessions because some of these things for example when they start   talking about cognitive coping differentiating between thoughts and feelings, some children take a while to get the hang of the the nuance between the difference between thoughts   and feelings so you might have to do two or three sessions helped them to identify   feelings and use the feelings thermometer this has been used successfully in clinics schools   homes foster care residential treatment facilities and inpatient settings so there’s not an environment in which it can’t be used provided that there is a supportive caregiver that can be   of assistance obviously if you’re working with a 10 or 11-year-old or a little bit younger or   an older adolescent but you know any child who may need some support outside of session we don’t want   to be creating a crisis and then leaving them kind of defend for themselves between sessions   without some sort of emotional and cognitive support so there must be a relationship that there is a bond if you will a the rapport between the clinician and the caregiver who may not be the biological parent or the caregiver and the child it does work even if there is no   parent or caregiver to participate in treatment however again we need to be selective about how we’re using that so if you have a child and you’re going to use this particular approach and   there’s no parent or caregiver to participate it may be safer to use it in a residential   setting or an inpatient setting where there is a clinician somewhere where they can get emotional   support because as you’ll see when we get into the trauma narrative gets intense TF   CBT is intended for children with a trauma history whose primary symptoms or behavioral reactions are   related to the trauma so if you’ve got someone who has an unfortunate childhood but you think   their behaviors may be more related to the peer group maybe more related to conducting disorder or FASD   or something else that may not be appropriate because what we’re going to look at with TF CBT   is reducing the PTSD symptoms the hyper-vigilance avoidance behaviors etc as well as improving   social skills and helping the person identify and communicate their feelings and needs traumatic   stress reactions can be more than simply symptoms of PTSD and also present as difficulties with   affect regulation we’ve talked before about how people who are experienced who have experienced   trauma may develop a situation where they are more likely to experience emotional dysregulation the HPA axis kind of tightens up and holds on to the stress hormones hold on to the stress reaction   but then when it does perceive a stressor it goes from 0 to 250 there’s no I’m going to get a little   bit upset it is either nothing or it is a huge mountain there’s no mole hills there so there   may be problems with affect regulation there may be problems in relationships because of difficulty   trusting other people because of difficulties with their self-perception and systems of meaning which   you know we’re getting to in a few minutes but the way they conceptualize the world because all   of a sudden their world was turned upside down somatization feelings coming out as physical   symptoms so headaches body aches more illnesses more days where they just don’t feel well and you   know sometimes they just really don’t feel well however, is it because of a bacteria or a virus   or is it because of a stress reaction that is kicking off all kinds of imbalances in hormones   and neurotransmitters so we want to look at what the effect are these traumas having on this youth or   person and if we address this trauma and if we help help them come to some sort of resolution   or acceptance of the trauma and integration into their world view of why this trauma happened   and making meaning from it will help improve these areas will help them reduce their hyper-vigilance etc and for many clients the answer is yes and I talked earlier about the fact that this   may be useful now it was designed for children and adolescents but many of the adults I’ve worked   with are very Alex thymic they are very unable to identify their emotions their very unable to   express their feelings sometimes they don’t even know where their fear is coming from they’re just   sort of paralyzed with fear and don’t trust the world and they’re angry at everybody and if it   comes from a traumatic experience then helping them explore how that trauma is impacting   them in the present can be useful in their recovery process so these issues that TF CBT may   help improve aren’t just limited to children and adolescents they can present in adults who were   traumatized as children and who didn’t develop the skill to effectively deal with the trauma   components of CBT TF CBT psychoeducation we’re going to start by teaching them what they need   to know about the trauma we’re going to talk about in depth about these so I’m not going to detail them   very much here parenting skills and if you’re dealing with an adult oftentimes I will provide   what I call reap Aron ting skills if your parent were here or if your parent would have responded   how you would have wanted how would they have responded how can you do that for yourself   now because sometimes you don’t have a significant other or a caregiver with an adult client either   but we want to help them figure out how to self nurture if needed relaxation and stress management   skills because some of the stuff we’re fixing to talk about is going to be extremely distressful so   you have some wiggle room if you will in terms of what skills do you teach here they prescribe some but   as far as relaxation and stress management affect expression and modulation DBT skills seem to fit well into this framework for helping people tolerate the distress not act on their   impulses understand where the emotions are coming from and preventing vulnerabilities and all that   other stuff that can help them function outside of session and when they’re not doing their homework   help them feel like they’re able to focus on something besides the trauma because we’re   just kind of ripping the band-aid off that wound at a certain point and they may have difficulty   focusing on anything else likewise some children and adolescents will come to you when that trauma   is still relatively present and all they can think about is that trauma or it regularly comes up for   them and so we can help them learn skills so they can start living more of what they might   consider a meaningful life that’s not dominated by memories of this trauma while we’re working   through the process we want to give them a little hope that there’s relief in sight cognitive coping and   processing are provided next and enhanced by illustrating the relationships among thoughts   feelings and behaviors so initially cognitive coping skills are taught and then all of this   is going to be applied later as soon as we get into the trauma narration helping the   youth work through narrating the trauma and cope with the feelings and thoughts that come up in   vivo mastery of trauma reminders so any of those triggers that are triggering flashbacks that are   kicking off hyper-vigilant situations we’re going to address as they come up in the trauma narration   we’re going to help the person identify what it is about certain situations that bring up this particular memory and how we master how to do we deal with it and then finally conjoint Parent   Child sessions and these don’t come till the end all along the parents or the caregivers are   participating in the process assuming there is a parent or caregiver and understand learning a   little bit more about what’s going on but we’ll talk about what the clinician does in the parent   sessions as well as what the clinician does in the child sessions as we go through each stage effects of TF CBT reduction in intrusive and upsetting memory so that’s awesome and you know   if you think about what’s the function of these intrusive memories a lot of times it is because   either they haven’t been integrated into the person’s schema of the world and well-being and or   they still feel unsafe they have some cognitions that is telling them they need to be alert they   need to be aware they’re not safe so helping them identify any cognitions and triggers that may be   causing intrusive and upsetting memories and addressing those again in the in vivo desensitization avoidance helping people reduce their avoidance of certain situations and certain   activities so they don’t feel like they are confined basically to their prison it helps   reduce the emotional numbing of a lot of people when they go through trauma it’s so overwhelming and they’re   so afraid if they feel they won’t be able to stop feeling so they numb emotionally it’s protective   it makes sense and as they develop the skills to handle this and as they learn they can tolerate   the distress of the memories of the trauma it empowers a lot of clients there’s a reduction in   hyperarousal depression and anxiety behavior problems when you’re dealing with adolescents   or children, especially ones who don’t have the ability to articulate their feelings and their   thoughts that are underlying these feelings and how they relate to the trauma   I don’t know many adults that can do that so children typically act out physically to either protect themselves or try to get some sort of protection comfort attention so they   feel more secure so it’ll help reduce some of that as we empower the child to identify what’s   going on and articulate their needs more effectively communicate with their parent and also deal with   some of the stuff that’s making them still feel threatened or afraid reductions in sexualized   behaviors trauma-related shame interpersonal distrust and again social skills deficits if   a youth has been dealing with this trauma issue for a while, they may have avoided other people   because they don’t trust other people they’re afraid of other people haven’t made sense of it   so they may not have developed the social skills that other youth have developed because they have   been avoidant situations that might trigger the trauma memories so who is is inappropriate   for if the primary issue is defiant or conduct disordered it if you don’t believe from a   clinical standpoint that this is coming from a the root of trauma history and addressing trauma   is probably not going to do it now do these children who are oppositional defiant conduct   disordered have traumas in their history sure probably they do but are those traumas causing   the behavior or are those traumas sort of irrelevant and one thing that you’ll find   is a lot of we’ll talk about it more in a minute a lot of people have multiple traumas but they   may have resolved certain ones and be okay with they but others are still open wounds don’t use   it if the child is suicidal homicidal or severely depressed if a child is in that particular state   we don’t want to start poking the bear especially in an outpatient setting but even in   residential and even residential with adults I was always extraordinarily cautious and hesitant   to do any sort of trauma work in the first 30 to 60 days I had a client in residential substance   abuse treatment I mean the first 30 days they’re still kind of sobering up there are a lot of impulse   issues and in the next 30 days there’s usually a a lot of mood issues so I want them to feel like   they’ve got a handle on things before we start ripping band-aids off open wounds if possible   and if you’re obviously if you’re dealing with a a child the safety and ethics would just tell you   when this might not be appropriate additionally when children remain in high-risk situations with   a continuing possibility of harm such as in many cases of physical abuse or exposure to   domestic violence some aspects of TF CBT may not be appropriate for example attempting to   desensitize to trauma memories is contraindicated when real danger is present I took that   verbatim from the TF CBT training or one of them that is cited in your booklet or your class   it is important to understand that not all of these children are coming or existing living   in an environment that is healthy and you may have a parent who is court-ordered or ordered   by child welfare to bring the youth to counseling to address trauma issues but that child is going   back to a chaotic situation so again it’s going to be an ethical decision on your part once you have   all of the training and you’ve become certified and TF CBT it would be an ethical   decision at that point whether or not to implement the program to fidelity and you know we   want to make sure that the child is cognizant of any real and present dangerous challenges, they   always come up, especially when you’re dealing with families if the carrot parent or caregiver does   not agree that the trauma occurred and we’ve all dealt with this whether you deal with adults who   were traumatized as children and they say nobody believed me when I was a child and I tried to   get somebody to here or whether you’re dealing with a child right now who is with a caregiver   or removed from a caregiver it doesn’t matter but the caregiver was present at the time and   the caregiver doesn’t believe the trauma occurred it can be a huge barrier because that caregiver is   not going to be able to be as supportive if the The caregiver agrees the trauma occurred but believes that it is not affecting the child significantly or thinks that addressing it will make matters   worse then we can do some education here we can identify symptoms that are coming out that are   present which may be caused by the trauma and we can show the research of TF CBT as well as other   methods if you choose not to use TF CBT but you can show the caregiver how addressing this trauma   can mediate or mitigate some of those symptoms if the parent is overwhelmed or highly distressed by   his or her emotional reactions and is not able to attend to the child’s experience so if   the parent feels guilty for what happened or you know such as in the cases of domestic violence the   parent is dealing with their trauma because they are surviving domestic violence they   may not be able to attend to the issues of the child at that point and it’s not a judgment it’s   just how much energy you have and if you’re trying to survive yourself you’re probably not   going to be able to devote your full attention to jr. Over here so we need to look at timing if the   parent is suspicious distrustful or doesn’t believe in the value of therapy again we can   do some education here rapport building and go slow if the client and I my experience has been   this occurs when the client is court-ordered or ordered by child welfare the parent does not trust   the system and by the fact the system referred them to you you’re part of the system   so start low go slow try to be as compassionate open and honest as possible I try with all of my   clients but especially with my clients who are involuntary I am very open about what’s in my   records and what I write down because that could go to the court which could you know potentially   reflect upon them you know we talked about what’s going in into the chart I don’t use subjective   judgment everything’s objective unless we talk about something and they say yeah I’ve made   progress here or I feel like I’m backsliding here and then we talk about how to how that’s going to   be put in the notes I don’t lie I don’t cover-up but I do want to make them feel more comfortable   with what’s being written in that magic file that gets stored away that nobody can see if the parent   is facing many concrete problems such as housing but consume a great deal of energy again if it’s   a domestic violence issue and they’ve moved out and they’re living in a homeless shelter or a   domestic violence shelter the parents may be exhausted and just not able to fully attend to   the increased emotional and psychological demands of the child during this therapy you know they’re   going to be doing good to help junior through the present crisis let alone anything else or   if the parent is not willing or prepared to change parenting practices even though this   may be important for treatment to succeed and there are few and far between situations where   this may happen one of the situations would be if you have a parent who is the biological parent and you have a boyfriend or girlfriend who is abusing the child and you know that comes   out and there needs to be some change in the the way that children are introduced to new people   or there may need to be some change in another situation and how to indiscipline there are a lot   of variations that may come up but ultimately we need the parent’s full buy-in we need them   to be willing to work with children on emotions identification and cognitive coping and all this   other stuff which ultimately ends up helping them most of the time anyway because I don’t believe   any of these skills can be harmful to a person at At least the initial skills of the trauma narrative if   it’s done inappropriately or incorrectly can be very very harmful but we’ll get there specific   strategies that can be undertaken through perseverance in establishing the therapeutic alliance reach   out to contact and try not to serve as the all-knowing omniscient person but asking them what they need asking them what changed with jr. Asking them for feedback and suggestions about what helps when   jr. gets like this and so you can brainstorm put the parent in the expert role of being the parent imagines that explore past negative interactions with social service agencies or therapy not that   we can undo that but we can make sure not to repeat it and if they start acting disengaged   we can evaluate the situation and come back and say is this reminding you of that prior situation   or you know are you feeling disempowered again or whatever the case may be being fully aware that n   TF CBT you have two very distinct clients plus a the third one is the family so you’ve got a lot   of different things to juggle if you want to explore the parent’s concerns that may make them feel as if they’re not being understood or accepted the lead listens to or is respected and that gets a   little dicey sometimes especially when we start talking about cultural sensitivity about belief about why the trauma occurred or a variety of other things that we’ll talk about   it’s important to be able to hear the parent and come from a culturally sensitive and culturally   informed perspective it’s also important if the parent feels guilty for some reason you   know and sometimes they will be cognizant of any nonverbals or any statements that you make   that might make them feel that way and if it comes out or if there’s no other way to say it you know   talk about any feelings they may have that about being not believed or not respected and how can   you best facilitate making them feel respected and accepted and all that stuff explore and help   them to come overcome barriers to participating in treatment, if it’s transportation if it’s a   job if it’s something else there may be some brainstorming that’s required and a little bit   of case management and I recognize that most of us when we work in private practice or agency   work don’t get any credit for billable hours for case management but it has to be done in the best   interest of the client and emphasize the centrality of the caregiver’s role in the child’s recovery   making sure that they understand that this can’t succeed without their help by using parent sessions   to reduce parent caregiver distress and guide them through structured activities that empower them in   interactions with the child so you’re going to bring them in each week and you’re going to talk   to the parent independently about what’s going on what you’re covering how juniors behaving how you can help them help jr. Etc sometimes you need to delay joint sessions until the parent or caregiver   can offer the child support and sometimes that means not even starting treatment really until   the parent and caregiver parent or caregiver can be on board now you can get started with   psychoeducation emotions identification feelings identification and stress management and coping   skills you know there were not really poking a bunch of bears so you can probably   safely get started on that if it’s sometimes it’s court-ordered and they have to start treatment by   April 1st or something so there are things you can do but you may need to delay the actual beginning   of the trauma narrative until the parent is able to be available to educate everybody on how   therapy works and instill in everyone not just the parent optima optimist that well optimism   about the child’s potential for recovery you know sometimes they’ve been dealing with this   child’s acting out behaviors for so long they’re just like you know we’ve already been to three   other therapists I don’t know what’s going to fix it or I’ve done everything I know how to   do good luck so we can talk about you know a different approach or we can talk about what   they’ve done that’s worked for a short period of time and build on those strengths to instill optimism and hope and empowerment so initially, when we talk about psycho-education   it’s important to provide accurate information about the trauma when children are traumatized   they can be confused and not completely understand what happened they may blame themselves and they   may hold on to myths because they’ve been misled and/or deliberately given incorrect information so   one of the best ways we can help is to correct that information provides information about how   often this happens and whether you know it’s okay to do this that or the other psychoeducation   clarifies inappropriate information children may have obtained directly from the perpetrator or   on their own so the perpetrator may have told them that this is how I express love or this is how you   need to be disciplined because you don’t learn this is how I was disciplined whatever it is or   they could have gotten it on their own they could have gotten it from school from the internet or   just come up with it in their little heads trying to make sense of what happened psychoeducation   also helps them identify safety issues the difference between safe situations and dangerous   situations and as we get through this I really want you to get away from the notion that TF CBT   and childhood trauma are only physical and sexual abuse there are so many other traumas as evidenced   by the adverse childhood experiences survey that I want you to wrap your head around that and there   are things they didn’t cover in the aces such as bullying and natural disasters so we want to help   children whatever the trauma is the trauma made they feel unsafe so we want to identify safety   issues if the trauma was a hurricane then we want to talk about what hurricanes are how often they   hit what to safety plan etc so every time a the thunderstorm comes they don’t freak out and we   want to use psychoeducation to provide another way to target faulty or maladaptive beliefs by   helping to normalize thoughts and feelings about the traumatic experience you know it makes sense   that that was scary and makes sense that you’re angry it makes sense that you feel   this way and we can talk about why that makes sense and why it makes you feel that way through   cycle education you’re getting the child to start talking about the specific trauma that he or she   experienced in a less anxiety-provoking way by talking in Jen wrong about the type of trauma   so you’re talking about natural disasters you’re talking about plane crashes you’re talking about   domestic violence so they start learning about it and then eventually you’re going to move down   to their experience with it so like I said there are a ton of different traumas and the ACE study   even acknowledges that these are just the ten most common ones that they heard however there are many   many many different traumas and types of trauma some of the biggest ones are physical   and sexual abuse physical neglect emotional abuse and neglect and the Aces identified mother treated   violently I would say anyone in the household treated violently it’s not just the mother’s substance misuse within the household and that can be by the parents or by siblings household   mental illness parental separation or divorce and an incarcerated household member so those were   aces but then like I said there’s also bullying the death of a parent or sibling is extremely   traumatic hurricane tornado natural disaster and then I put the fire out separately because sometimes   fire can be man-made sometimes it can be a wiring problem but sometimes it can be Jr was playing with matches now even if jr. Accidentally started the fire does that make it any less traumatic no   it probably makes it more traumatic because then there’s a whole sense of guilt and responsibility   but it’s still a trauma that has to be dealt with so I put a link to the adverse childhood   experiences website if you want to go look more about that but we’re going to move on psycho-education involves specific information about the traumatic events the child has experienced   not the child’s event we’re not going to go into police records or something, we’re just   going to talk about specific information about domestic violence or whatever body awareness   and sex education in cases of physical or sexual maltreatment and there are caveats for getting   parental consent and permission and all that other stuff and Risk Reduction skills to decrease the   risk of future traumatization now going back to those other things it’s not just about physical   or sexual abuse so we want to look at what was the the risk created by you know how can you reduce your   risk of being bullied how can you reduce your risk of being traumatized in a tornado you   know you can’t stop the tornado from coming and they’re everywhere so what do you do and talk about a safety plan the same thing with fire information needs to be tailored to fit a child’s   particularly particular experiences and level of knowledge obviously, you’re going to provide   different information to a seven-year-old than you are to a 17-year-old provide caregivers with   handout materials to reinforce the information discussed in session so this may help educate   the parents about some of it but it lets them know what you talked about and it gets us all   on the literal same page you’re providing them a handout of everything you went over with Junior   and we want to encourage caregivers to discuss this information at home reinforces accurate   information about how safe or unsafe they are and obviously, we’re going towards safe   and reinforced accurate information and develop a safety plan so they feel confident that at   home they’re going to be taken care of when you start psychoeducation you do want to get a sense   of what the child already knows and you can use a question-and-answer game format in which the   child gets points for answering questions which I love this suggestion so you can ask them if you know   what is a hurricane or is a tornado and see if they know and see if they know how much time and much-advanced warning we have for a tornado versus a hurricane or you know whatever situation   you’re talking about you see I did a lot of posts Hurricane Katrina counseling in northern Florida   so that’s one of those things that comes up for I am talking with children about how likely is   it that a category 5 hurricane is going to hit again but encouraging them to give your aunt’s   give answers and if they give the wrong answer you know it’s great to try now you know try to coach them   into a correct answer or provide them the correct one but give them credit for at least making an   effort sample questions might include what is you know and put in the type of trauma what is   bullying how often do you think bullying happens and why does bullying happen you know those are   some questions you can ask to just open a dialogue about bullying, if this child has been a victim of   bullying and is and is traumatized so cultural considerations meet the child and family where   they are by presenting information in a way which they can relate it to their belief system and   you may need to consult with their spiritual guidance guides leaders whether it be a pastor   or you know whatever to get some guidance on how to handle certain aspects of whether it was   the will of God and in the case of sexual abuse how to handle the concept of virginity and how to   handle the concept of bad things happening to bad people and whatever else they think is coming   from or their parents are instilling in them in a belief system we want to make sure that we’re not   necessarily contradicting it and going oh mom dad and the church is wrong but we also want to help   them try to integrate this in a way that can help they have strong self-esteem so reaching out to   those spiritual leaders and the family asking what their belief system about certain things can   be very helpful assess the general beliefs about the trauma if something happened or when something   happens ask the parent or the family that’s there not necessarily the child but you want to get a   sense of what the family stance is on why this happened what it means how it’s going to impact   life hence foreign henceforth and forever more focus on the events they perceive as traumatic to the family but most especially the child if the child’s going back to the Aces you know maybe   the parents got divorced but the child doesn’t see that as traumatic because there was domestic   violence ahead of time the domestic violence was traumatic the divorce was a relief so wherever the   child is with each trauma we want to be respectful of what they perceive is traumatic   and tailor the information so the family can be more receptive to it as supportive as possible and   sometimes you need to make sure that the language you know make sure the language is not jargony about general views of mental health and mental health treatment should also be assessed and addressed in   the psychoeducation piece not only with the child but also with the family, if they are suspicious   of it don’t understand it think that you’re just going to magically fix Junior we want to demystify   the process and talk about what is the purpose of the assessment what is the purpose of each one of   these activities and why am I doing this or why are we doing this as a team and how can it help   and then we also want to provide information to D stigmatize and normalize mental health issues   and seeking treatment some cultures are still resistant to seeking treatment and I use the term   cultures broadly because there’s a stigma associated with it so normalizing for   them how many people go to treatment how common PTSD is or whatever the situation you’re dealing   with it doesn’t mean they have to like it but at At least it will give them a little bit of a nugget   to understand that they’re not the only ones if they are from a cultural group a minority cultural   group of some sort you might want to provide information about how common this particular   issue is in their group I’ve done a lot of work with law enforcement and emergency responders   and they’re kind of their little group so we talk about how common depression is among law   enforcement and emergent emergency responders specifically, because they face so much so many   different stressors than you know Joe Schmo over here so it D stigmatizes and normalizes a little   bit now they still may not talk about it and go well hey you know 37% of us have clinical   depression no that’s probably not going to happen but at least in the back of their mind, they can go   you know what I’m looking around this room and I can bet that at least one other person’s on   antidepressants or something and feel a little less unique and isolated in parent sessions you   want to provide a rationale and overview of the treatment model educates parents about the trauma and talks about the child’s trauma-related symptoms so we’re going to go over what is hyper-vigilance   what is the function it why people become hypervigilant after trauma and what might it   look like in a child because it presents very differently for different children so we might   want to give some ideas and say does this sound like Johnny or does this sound like Johnny and   help them understand why these behaviors may be coming out we want to talk about how early   treatment helps prevent long-term problems okay maybe the trauma happened three years ago but   still, it’s better than waiting ten more years and you know Johnny’s still not having any Ellucian   will want to talk about the importance of talking directly about the trauma to help the children   cope with their experiences and not hedging and this will be on a case-by-case basis but the manual   walks you through handling this discussion with the parents about exactly how much detail do I go   into if Johnny brings it up at home reassure parents that children will first be taught   skills to help them cope with their discomfort and that talking about the trauma will be done   slowly with a great deal of support so we’re not just going to plop them down and go okay and tell   me about the day that all this happened which is what the child has experienced already if   it was reported to law enforcement and/or the child welfare they’ve probably had somebody sit down   and say get right to the nitty-gritty at least once or twice and it’s completely dehumanizing   so we want to reassure parents that we’re not going to do that to the child again will help the   caregiver understand their role in the child’s treatment since this modified since this model   emphasizes working together as a team so I’m not just going to be educating you it’s not going to   be a parallel thing where I go in and I work with Johnny and then I tell you what I did and then I   work with Johnny I’m going to work with Johnny and then we’re going to discuss what Johnny and   I did in session and I’m going to get input from you and we’re going to talk about how you feel   about it and then I’m going to provide you with tools so you can help Johnny outside of the session because   you’re going to be with them for six-and-a-half other days that I’m not and this can’t work   if it’s just one hour once a week and we want to elicit parent input questions and suggestions as   much as possible because they’ve been living with their kid for you know however many years so they   probably have an idea about what works and what doesn’t so we’ll start with both parents and   children in their respective sessions helping them understand what control breathing is and how   it helps slow the heart rate and trigger the wrist and digest sort of reaction in your body   when your breathing slows your heart naturally slows because the stress reaction tells your   brain you’ve got to breathe fast and the heart rates got to go fast well when you override that   then you’re kind of overriding the whole system and we’ll also talk about thought stopping and   this is especially helpful if the trauma is recent or and/or ever-present in the mind of the youth so they   can say I am NOT going to talk about that right now I’m not going to think about that right talk about distraction techniques go back to your DBT stuff talks about improving the moment   and accepts to help the child develop skills to handle and work through when those thoughts pop   up replace unthawed unwanted thoughts with a pleasant one so talk about it in session   when thoughts like that come up what would you prefer to think about and then really get into   the Nitty Gritty the five senses what do you see smell hear taste you know help me get into   that situation or that thought this teaches that thoughts even unexpected and intrusive ones can be   controlled so that gives them hope and again we’re not exacerbating the thoughts right now we’re not bringing up their particular trauma and having them get into detail we are just helping   them deal with what’s happening normally on a day-to-day basis so they feel like they have   more control for the older kids you can have them people log about when this technique is used what   they were thinking about and how effective the thought stopping was and then review it and help   them tune it up if it’s not really effective and give them praise for when they use it effectively   relaxation training persons of Asian or Hispanic origin tend to express stress in more somatic or   physical terms so just be aware of that but that doesn’t mean that Caucasians don’t relaxation   training is good for anyone and the medical school of South Carolina training recommended that relaxation is stress-free and workbook by Davis Schulman and McKay so and   it is still in publication when deciding how to present relaxation techniques are creative have   the child help you to integrate the elements into the technique that makes it more relevant   to them so, what are you thinking about when you relax you know I know I like to go to the woods   but maybe this kid likes to think about a video game or play with their dog whatever it is but helps them make it relevant to them and then have they identify other things they do to relax like   drawing listening to music walking and making a list of those things so they can refer to it when   you’re teaching relaxation training especially if you’re doing something like progressive muscular   relaxation be sensitive to the child’s wishes if they don’t wish to close their eyes or lie down which could trigger memories of the trauma we’re not going there yet so if they feel vulnerable   lying down or taking orders like that because you can imagine how being told to lie down and   close their eyes might be a trigger for certain abuse survivors you know be cognizant of that   and say you know get into a comfortable position or how where would you like to sit while we talk   about this like I said parents can often benefit from the relaxation training as well   so because they’re dealing with their issues about the trauma but they’re also dealing with   trying to figure out how to help Johnny and any of them deal with any of Johnny’s misbehaviors   or problematic behaviors then they move on to feelings identification so it helps the therapist   judge the child’s ability to articulate feelings if you can tell me what makes you happy that’s   great but if you can’t then you know we need to work on figuring out what makes you happy you   also want to help the child rate the intensity of the emotion don’t let them stick with happy   mad sad glad and afraid you know let’s talk about different emotions and use the emotion chart with little faces on it or you can use the emotion thermometer so is it a hot emotion or is   it a cool emotion and helps the child learn how to express feelings appropriately   in different situations I mean sometimes they’re going to be angry but it might not be appropriate   to you know get up and stomp out of the room or whatever however they communicate it so help them   figure out how to articulate that so they can be heard and supported some children have difficulty   discussing or identifying their feelings so you might try stepping back and discussing the   feelings of other children or characters from books or stories so you know think about Puff   the Magic Dragon if they’ve read that you know that dates me a little bit there but you know how   did the little boy feel and talking about things different characters and different stories where there are elements of anger and shame and loss and all of that stuff helps children identify   how they experience emotions if they seem detached from the experience because sometimes they just   they’ve shut it off it was just too overwhelming so we want to talk about you know when you’re   happy what does that feel like or when you’re angry what happens what does your body feel   like when you’re angry and they might be able to tell you they hear their heartbeat in their   ears or everything gets all fuzzy or whatever but help them start tuning in to how they react   and connecting that with an emotional word and then after all, that’s done they can identify feelings   they can identify feeling intensity now we want to differentiate between thoughts and feelings many   children describe thoughts when they’ve been asked about a feeling so if you ask them how they feel they may say I want to run away so you want to say okay well I hear that you want to   run away so I’m wondering if you are bored and you you’re bored and want to get away from it or if   you’re scared can you tell me a little bit more about what it means to you to want to run away during feelings identification the parent sessions normalize what is going on with their   child and help the parent understand that some children may be seemingly in constant distress   or detached from the trauma and that’s okay we all react differently to traumas so again   we’re going to share with the parents what we’re Do let them know any specific difficulties if   any juniors have encouraged the parent to praise the child for appropriate management of difficult motions and I put in parenthesis successive approximations because they’re not going to get   it a hundred percent right every time so if they try to effectively manage their emotions even a   little bit let’s give them praise for that and then help them figure out how to do it a little   bit better the next time so instead of having a complete meltdown maybe they got up and stomped   out of the room well that’s an improvement so then we want to talk about how to shape that   behavior so it’s a more appropriate communication if parents have difficulty identifying their   own emotions provide them with examples so continually ask them questions about how you feel when it’s a rainy day outside and how to do you feel when somebody’s supposed to call you and they   don’t how do you feel when and have about 15 or 20 examples and you can have them on a piece of paper   and even give it to the parent to take home for their homework if parents are overcome with   their own emotions about the trauma validate their feelings and explain how children need to see that their parents can handle talking about the trauma so there the children need to see   the strength and the parents which is what you’re going to work on in parent sessions to make sure   that the parents have the resolve and the skills handle talking about this topic with junior TFC BT can be an effective intervention for children or adolescents whose primary   presenting issue is trauma-related emotional or behavioral dysregulation TF CBT is not appropriate   for clients who are actively suicidal and severely depressed or currently abusing substances we want to make sure they’re clean and sober as much as possible TF CBT starts   with psychoeducation and then teaches stress management and coping skills to aid in the   management of distressing feelings psycho IDI helps to clarify the inappropriate information   children may have and start getting them a little a bit more comfortable talking about the topic in   general before we start going deeper and feelings identification helps participants start   effectively labeling and communicating their feelings so they can receive the support and   nurturance they need from their caregivers and their support system 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 to all CEUs comm slash counselor   toolbox this episode has been brought to you in part by all CEUs calm providing 24/7 multimedia   continuing education and pre-certification training to counselors therapists and nurses   since 2006 use coupon code consular toolbox to get a 20% discount on your order this month.As found on YouTubeAlzheimer’s Dementia Brain Health ➫➬ ꆛシ➫ I was losing my memory, focus – and mind! And then… I got it all back again. Case study: Brian Thompson There’s nothing more terrifying than watching your brain health fail. You can feel it… but you can’t stop it.