PRACTICE components P sychoeducation and parenting skills R elaxation A ffective expression and regulation C ognitive coping T rauma narrative development & processing I n vivo gradual exposure C onjoint parent child sessions E nhancing safety and future development Documenting Trauma: Goals Gradually desensitizes the client to thoughts, feelings and reminders of the trauma Helps client recognize, anticipate and prepare for traumatic reminders of the trauma. Help client develop sense that she is more than her experiences Integrate the event as a part of a larger life experience Help client regain mastery Help clients accept the reality of their experiences without minimizing or exaggerating the significance of what happened. Help clients honor their survival strategies and gently reassess them. 1
Documenting the Trauma Gradual Exposure: Clarify for clients why it is important to slowly l and carefully examine what happened to them. Feelings and thoughts before, during, and after the event(s) will be processed Can start with before the trauma and work forward; or start with today and work backwards. Possible Types of Narratives Create a trauma narrative Straightforward written narrative Book Audiotape or videotape Computer story Poem(s) Song(s) 2
Suggested Steps for Trauma Narratives relaxation as needed Use r Pra aise the child often 1. Introduce rationale 2. Create a neutral narrative 3. Introduce TN by reading a book 4. Determine the format for the child s TN 5. Determine who will write (you or child) 6. Start writing (title page, chapter 1: about child, etc) 7. Re-read the TN as part of Gradual Exposure 8. Expand the TN 9. Add thoughts, feelings and body sensations Documenting the Trauma If multiple episodes, creating a timeline can be helpful as a preliminary step in narrative process Client can choose to write a detailed d narrative about the most salient trauma experience within the timeline Some children may benefit most from a lifebook approach Client will go over the narrative many times in order to get desensitized to it Caregivers will hear the account later and will process it with the child and therapist. Time lines for producing trauma narratives vary considerably (some may take 3-4 weeks; others may take months) 3
Life Book Resource Narrative Start with a neutral narrative that involves asking about all the senses (e.g., a family trip; a birthday party) 4
Clinician s Neutral Narrative Child s Neutral Narrative 5
Narrative Possibly read a book to show example of a narrative e.g., Please Tell!: A child s story about sexual abuse (1991) Hazeldon Foundation (by Jessie) Narrative Work with youngster to set up the chapters that you want to include Title Page-might iht change during process Introduction (about me, my family, my favorite..) Good Memories (before trauma, with family, with abuser) Trauma Details- events of trauma, disclosure, first time, worst time Wrapping Up/Positive Ending (meaning making, what I learned, how to get through it, advice to other kids) Jennifer Wilgocki, LCSW, National TF-CBT Trainer 6
Gradual Exposure Hints Help child re-create the scene: Ask them to visualize the room, something they see in the room, etc. Avoid asking do you remember? Instead, try: I wasn t there and I want to be able to see it just like you did Or, then what happened?; walk me through it Be patient with pauses and silence Narrative Begin narrative and then go back each session to fill in where more detail is needed (sensory, thoughts and feelings) Ask broad, open-ended ended questions What were you thinking? What were you saying to yourself? How were you feeling? What happened next? Make clarifying and reflective statements Tell me more about it I wasn t there, so tell me I want to know all about Repeat the part about So, your uncle began touching your vagina 7
Narrative Rate distress before, during, and after work on narrative (e.g., SUDS- Subjective Units of Distress Scale) My uncle came into my room to kiss me goodnight. He pulled down the covers and touched me down there. I felt scared. I pretended I was asleep. When he was done, he left. The next morning I got up and my uncle said, Good morning, how are you? and I said, Fine. I went to school. 8
My uncle came into my room to kiss me goodnight. I felt good. He pulled down the covers and touched me down there, on my vagina. I felt scared and dirty, and thought why is he doing this, he s my favorite uncle. I pretended I was asleep. When he was done touching my vagina, he left. The next morning I got up and my uncle said, Good morning, how are you? and I said, Fine. Inside I felt scared and I didn t know what to say or do. I went to school. Narrative Delay challenging dysfunctional thoughts until most of narrative (or all) is complete 9
Narrative: Managing Avoidance Praise child for his/her effort Repeat treatment rationale Slow down pace or take a step back Don t over attend to COWs (Crises of the Week) Encourage use of coping skills Be creative Gently persist Sample Narrative 5 year old male Sexually abused at age 4 by grandmother s boyfriend Mark Mark 10
One day there was a grown up named and he touched me on the privates. He touched his pee-pee to my pee-pee. That made me feel sad, really badly sad. I was thinking I said stop and he wouldn t listen. It made me have feelings that upset me. I think he s killing my Mom and Dad because it was really scary and I was really sad. He wouldn t tell anybody but I told Grandma. I felt really happy when I told Grandma but I was still angry. It covered my good dreams when I was asleep. I cover it again with my good dreams powers but I was still angry. 11
It made me feel angry. I screamed into my pillow so I don t hurt anybody. I told my Mom and Dad because I feel sad and then I came here to Dr. Kelly to help me feel my feelings better but I was still angry. And I just love going to see my counselor Dr. Kelly. 12
But when I have hugs it made me feel happy. But I was still angry, though, but it kinda made me feel happy. But I d like kisses too. I like kisses and hugs from Mom and Dad. And I hope you guys have a great day. Bye! Love, your student 13
The OK Rap I m a good person I d like to say; I m a good person, I m special today. But awhile ago it wasn t cool. Tony hurt us, he s such a fool. He might be big, he might be tall; now we know he ain t special at all The thing that happened was sex abuse; we trusted him but it was no use He tried to say we were to blame, but we re not gonna play his game; Not gonna play his game! Uh Unh; Not gonna play his game! We OK. We OK. We OK right now, oh yeah. We OK. We OK. We OK right now! 14
Now we re here with someone else and we are safe you see. You can t touch us anymore; it s in jail you ll be. Oh yeah.. It s in jail you ll be! Sometimes we feel really scared, but that won t stop our mouth. We re gonna tell the world about you and you gonna go way South! Oh yeah. You gonna go way South! Sex abuse feels lonely sometimes and sometimes makes you mad; But it s OK to feel that way; Someday we ll feel glad. Oh, Yeah; Someday we ll feel glad. We OK. We OK. We OK right now, oh yeah,we OK. We OK. We OK right now! Positive Ending (older child example) Therapy After all this happened, the police recommended me to come to therapy and helped me find a therapist. Because of her, now I am doing this story. Me and Mrs. Alanna learned more coping skills, how to keep myself from getting distracted, learned where my feelings are in my body, and talked about my feelings and how big they were. The red car and the man s voice don t pop in my head so much. When I see red cars I don t get so scared anymore. I don t sleep with my mom anymore. I have also gotten a little bit better at school. I have started understanding more math now and I don t get distracted so much. Now my brain is clear because I use my coping skills. While writing this story I have actually felt much better and it actually gets my mind on something. All of my attention is on this story. I feel good doing this story because writing about what had happened actually helps me forget about it a little bit. 15
Positive Ending (older child example) Advice to Other Kids If something like this happens to you, go tell the police, your parent, or a grown up. While this is happening, you should scream, run, and don t accept nothing that they are offering you. You won t be scared forever. You can learn coping skills that will help you. Just remember that there is always somebody that you can talk to when this happens. Sometimes when bad things happen to kids, they don t know what to do and they might act differently. It doesn t mean that they are a different person or that they are mean or bad, just that they are having a hard time adjusting. It doesn t mean that they will remember that for ever. It doesn t mean they will always be scared. Things will get better. Table Group Activity 15 minutes Go over the 13 year old narrative (in binder) and write down what you d still want to know about in order to get it filled out with thoughts, feelings, sensory experiences, and other details Choose one person to record 16
It was a Monday and Mom was at a foster care meeting. It started as a game of tickling. It happened in the living room/computer room and downstairs. I was wearing a T-shirt and some Dark Navy blue stretchy shorts with a Starwars thing on the leg of it. My Dad was wearing a button-up shirt that was dark blue and light blue checkered. He was also wearing some dress-up pants. I was wearing underwear and a bra that day. He went down my shorts and into my underwear and rubbed my private. Then he went up my shirt and in over my bra and rubbed my breast. He asked me if I wanted him to lick me on my private and I said no. Then he asked me if I wanted him to do it all again and I said no. He told me that when I started my period that I could go to him and he would do it again. While he was rubbing my private he asked me if it felt good and I said no. He told me that sometimes Bipolars need to play. 17
He made me promise not to tell anyone and I promised. I finally told because I felt alot of guilt and I felt unclean no matter how many times I took a shower. He told me to go get back to pulling weeds in the driveway to make it look like I had been working because I was supposed to be pulling weeds in the driveway. When my mom got home she made dinner and she would not let me eat until I got a certain amount of driveway pulled, and it was getting dark outside. So my dad told her we wasted a lot of time so she would let me eat. My dad came outside and told me that I could eat and he told me that if my Mom asked what he did to waste time I was to tell her that we were talking about being part of the family. 18
After I had gotten my period about 4 times he tried to do it again. That time I was wearing a skirt and shirt. It was a Friday 7 th and my dad went to get some vitamin C in a tank to clean it and he dropped off {sister} at the church to clean the church. h My mom met my dad d on the road we lived on and mom made me go home with him and she went to go get water in our other tank and pick up {sister}. When we got home he tried to do it again but I would not let him. He said that if I was going to tell on him and that he might as well have fun. I blurted it all out on Monday the 10 th at the Dr s office. Follow up to Trauma Narrative: Cognitive/Affective Processing Goal: To avoid negative behavioral and psychobiological effects through developing appropriate cognitions about the abuse Examine emotional responses to trauma Identify and list underlying thoughts Distinguish functional and dysfunctional thoughts Look for cognitive distortions (remember the 3 Ps- personal, pervasive, and permanent) 19
Common Negative Distortions: Abuse Sexuality I was abused because I was too sexy I must be homosexual It felt good. I must like to be abused Body Concerns I might die of AIDS ; I might be pregnant Interpersonal Concerns No one would ever want to be my friend if they knew No guy will ever want to date me Safety Concerns I will never be safe ; Violence is just a part of life Self Image/ Self Blame I m so stupid ; I am a slut ; It was my fault Step 1 Cognitive Processing Identify cognitions related to the trauma As reported in the trauma documentation Direct inquiry Indirect reports 20
Step 2 Cognitive Processing Explore inaccurate or unhelpful cognitions and the feelings that accompany them Inaccurate attributions Responsibility vs. regret (e.g., can regret a choice like getting g into a car with someone who was drunk, but still not responsible for being raped) bandaids = hurt For younger kids; girls stars = brave smiles = people who know I m not to blame dots = to blame For teens; boys 21
This work depicts a child who sees Mom as most hurt; self, Mom, and therapist as Brave; Self as not yet fully accepting that she was not to blame for the abuse Bees = to blame bandaids = hurt stars = brave smiles = people who know I m not to blame The abuser here is shown as the one to blame Cognitive Processing Step 3 Replace distorted d cognitions i with more accurate, realistic, or helpful ones Progressive logical questioning (Colombo approach) Overgeneralizations Alternate cognitions Best Friend role play Socratic method Weighing of evidence 22
Disclosure puzzle Crisci, Lay, & Lowenstein, Paper Dolls & Paper Airplanes (1998) Review Adolescent s Narrative I came home five minutes after curfew and my dad was mad. When mom told him to stop yelling at me, he went off- calling us both sluts. He started threatening my mom with a knife. I thought I should have told my mom how my dad bothers me every night and maybe she would have left him a long time ago. I kept saying to myself tell her- tell her. I felt angry. My mom yelled at me to call 911 and I did, but I couldn t remember our address. I stayed on the phone and the police came, but by then dad had left. I was really scared, but I told the officer everything and mom cried and cried. 23
Elicit More Feelings, Thoughts, and Other Details I came home five minutes after curfew and my dad was mad. When mom told him to stop yelling at me, he went off- grabbing me telling mom he ll do what he wants -calling us both sluts. He started threatening my mom with a knife. I felt scared and angry. I thought I should have told my mom how my dad sexually abused me every night and maybe she would have left him a long time ago. I kept saying to myself tell her- tell her. I felt angry and stupid, very stupid.. My mom yelled at me to call 911 and I did, but I couldn t remember our address. I stayed on the phone and the police came, but by then dad had left. I was really scared, but I told the officer everything and mom cried and cried. I think she was mad at me too. I only wish I had told him no the first time he did that stuff to me. Elicit and Incorporate Helpful and Productive Thoughts I came home five minutes after curfew and my dad was mad. When mom told him to stop yelling at me, he went off- grabbing me telling mom he ll do what he wants - calling us both sluts. Mom and I are not sluts. Its my dad who had the problem with sexually abusing children. He started threatening my mom with a knife. I felt scared and angry. I thought I should have told my mom how my dad sexually abused me every night and maybe she would have left him a long time ago. I kept saying to myself tell her- tell her. I had been trying to get up the courage for a long time. I felt angry and stupid, very stupid. My mom yelled at me to call 911 and I did, but I couldn t remember our address. I stayed on the phone and the police came, but by then dad had left. I was really scared, but I told the officer everything and mom cried and cried. I thought she was mad at me. I only wish I had told him no the first time he did that stuff to me. I was smart to tell when I thought my mom and I were safe with the officer. Some children never ever tell. My mom was confused and upset at first, but now she is really proud of me and mad at my dad. I m proud of my mom too. 24
Table Group Activity: Pick out the distortions in the 13 year old narrative and record these at your table: be prepared to report out to large group Role Play: Processing Distortions 25