CAT CBT Alliance of Thailand TraumaFocused CBT Amy

CAT CBT Alliance of Thailand Trauma-Focused CBT Amy P. Virutamavongsa, Psy. D

Define Trauma WHAT IS TRAUMA? • A traumatic event is something that threaten someone’s life, safety, or wellbeing • People feel a strong sense of fear, terror, and/or hopelessness • Direct or indirectly experienced • “Something bad or scary that made you worry about your safety” Add a footer 2

Types of Trauma HOW DO YOU ASK QUESTIONS ABOUT TRAUMA? Sexual Abuse or Assault Physical Abuse Witness to Domestic Violence Victim or Witness to Community Violence • Bullying • Travel Accidents, Fires, Medical • Mass Disasters Add a footer • • 3

Prevalence of Trauma APV IN CLINICAL POPULATION Statistics on Trauma • 90% of incarcerated youth in OH has trauma-related diagnosis • Over 1 million children are assaulted, robbed, or raped each year (U. S. Dept of Justice, 1999) • Approx 879, 000 children neglected or abused in 2000 (Children’s Bureau, 2002) Yet there are data that show under-reporting of traumatic experiences Add a footer 4

Effects of Trauma APV BRAIN DEVELOPMENT CT scan of a healthy child with average. VS. CT scan of a child suffer from severe head size neglect Add a footer 5

APV Trauma Symptoms AFFECTIVE, COGNITIVE, BEHAVIORAL Affective • Fear • Anxiety • Sadness • Anger • Affective dysregulations Add a footer Cognitive Behavioral • Irrational, Inaccurate beliefs • Reduced trust • Negative self-image • Accurate but unhelpful cognitions • Avoidance • Maladaptive behaviors (sexualized behaviors, violence, bullying, anger outbursts, selfharm) • Traumatic Bonding 6

For whom is TF-CBT appropriate? APV TF-CBT is appropriate for the following groups: • Children ages 3 -17 • Exposure to single or multiple trauma, any type • Have prominent trauma symptoms • Severe behavior problems that may need alternative interventions • Multiple cultural groups Add a footer 7

APV TF-CBT Components Integration Phase P R A C T I C E Stabilization Phase Add a footer 8

APV Psychoeducation FOR THE CHILD Goals • Normalize child’s and parents’ reactions to severe stress • Provide information about psychological and physiological reactions to stress • Instill hope for child and family recovery • Risk reduction skills Add a footer How? • Provide statistics about trauma • Common reactions to trauma, trauma reminders • Statistics about treatment • Benefits and need for early treatment 9

Multimodal Teaching Method APV VISUAL, AUDITORY, MOVEMENTS Add a footer 10

Relaxation APV GOAL: REDUCE PHYSICAL MANIFESTATION OF STRESS AND PTSD • Yoga stretches • Music – theme song • Stuffed animal – texture, tactile • Peppermint smell • Stress balls (flour, sugar, cornstarch) • Lotion and hand massage • Body scan • Sour candy for dissociation Add a footer 11

Relaxation APV • Mindfulness ü Mindful eating M&M’s • Grounding Scripts • Progressive muscle relaxations üFrozen vegetables üUncooked Pasta Add a footer 12

Relaxation APV • Breathing exercises üSmell the vanilla cake then blow birthday candles üPizza is too hot breathing üStraw breathing for hyperventilation üSnow globe, breathe until the glitter settles üBlow up balloons üBumble bee breathing zzzz üBreath in 4 out 4 üElmo belly breathe on Youtube Add a footer 13

APV Relaxation Positive Self-Talk Coloring Pages Everyday in every way I’m getting better and better Add a footer 14

Feeling Identification and Expression • Accurately identify and express a range of different feelings “Tell me something that make you feel scared” “I don’t feel scared” • Feeling brainstorm, Color my feelings, etc. • Important for child to identify and express feelings when facing trauma reminders APV

Affective Regulation • SUDS Scale of feelings to show that not every situation deserves a 10! • Different feeling words for each scale (2 = annoyed, 10 = engaged) • What is a 10 for you? • What if 10 is inaccurate? • When do we start taking a break? (at a 7!) • How can you tell when you’re moving up the scale? APV

Feelings vs. Thoughts vs. Actions APV • Show they can change how they act and feel by thinking differently • In young children, they cannot process cognitive triangle • “Who made that happen? ”

Examples APV • Joe left his key in the car. His car got stolen. 3 days later, he fell down and broke his leg • What are some thoughts Joe might have about: • Himself: • Others: • The world: • God: • In trauma narrative, have child write own fact statements Add a footer 18

Thought Stopping Skills APV • Use when overwhelmed with trauma reminders • Remote control to “change the channel” • Worry jar to worry later • Snapping rubber band • Imagine a stop sign • Increase distress tolerance • Surfing the wave metaphor – you have to ride the wave down, you can’t just jump off when it gets scary • Pair relaxation with unhelpful thoughts

Thought Stopping Skills Grounding skills (adapted from Seeking Safety handbook) Mental (describe your environment, play categories, read backward, count to 10, citing alphabets slowly, use humor) Physical (run cool water over hand, grab chair tightly, carry grounding object in pocket, breathing) Soothing (kind statements, picture loved ones, coping statement, serenity prayer) APV

Creating Trauma Narrative APV Start with an outline of each chapter • Chapter 1 – general information about child (name, age, school, hobbies, favorite stuff) • Chapter 2 – life “before” trauma • Chapter 3 – what happened – use expressive art techniques • Chapter 4 – life “after” trauma • Chapter 5 – The future Add a footer 21

Trauma Narrative APV Final Chapter • What have you learned? • What would you tell other kids who experienced this? • How are you different now from when it happened or when you started treatment? I came here because I was sexually abused by my uncle. I used to feel scared and dirty. Now I know my body is OK. I don’t know why he did this but he has a problem and it wasn’t my fault Add a footer 22

Rely on Child’s Strengths and Interests APV Alternative Methods for creating Trauma Narrative • Record Talk Show • Cartoon • Poem • Song • Pick 2 songs for each chapter, make album cover, write why clt picked each songs, feelings that come up, etc • Drawings • Sand tray Add a footer 23

Cognitive Processing of Trauma APV Identify inaccurate/unhelpful cognitions about trauma • Inaccurate thought “the sexual abuse was my fault” • Unhelpful thought “this may be the day of the next terrorist attack” • Inaccurate and unhelpful thought “it was my fault my mom was killed in the Tsunami. I should have told her to go to grandma’s house” • Replace distorted cognitions with accurate, realistic, helpful ones • Responsibility vs. Regret Add a footer 24

Challenging Cognitive Distortions APV Joining and Kick it up a Notch Goal: client can argue the difference Eric: “Everyone hates me” Therapist: “You’re right, I guess I do too” “Even your dog hates you” Eric: “No you don’t!” “My dog loves me, he always lick me face” Therapist: “I guess not everyone hates you, huh” Add a footer 25

Challenging Cognitive Distortions APV Socratic Questions • Evidence Why do you think that is true? Does it always hold true? Are there exceptions? What would change your mind? • Assumptions What are your beliefs that make this thought true? Add a footer 26

Challenging Cognitive Distortions Socratic Questions • Different Perspectives What would be an alternative thought? What would your friends tell you? • Consequences When you think that, how do you feel? How can you find out of what you belief is true? • Questions about Questions Why do you think I asked that question? Add a footer APV 27

FR Challenging Cognitive Distortions Responsibility Pie Who's at fault? • Socratic questioning to change inaccurate perceptions such as self-blame Me Add a footer Dad Teacher 28

Challenging Cognitive Distortions APV For Parents • Identify their own cognitive distortions and related feelings “I should have known” “My child’s childhood is ruined” “Our family is destroyed” • Challenge parents’ distortions and replace with more accurate and helpful cognitions • Help parents identify and practice effectively challenging child’s cognitive distortions Add a footer 29

In Vivo Desensitization APV Mastery of Trauma Reminders • Critical for resuming normal developmental trajectory • Hierarchical exposure to innocuous reminders which have been paired with traumatic experiences Ex. Fear of going to grocery store, fear of car ride • Resolve generalized avoidance behaviors Add a footer 30

Conjoint Parent-Child Session APV Goal: To Share Trauma Narrative • Content of session üShare child’s trauma narrative üEncourage open discussion, question/answers between childparent about trauma and other topics üPrepare for future trauma reminders and how child and parent can cope with these üPraise for progress made Add a footer 31

Enhance Safety APV Safety Plan • Practice skills inside and outside of therapy • Being vigilant without being hyper-vigilant Sexually Abused Children • Education about healthy sexuality Children exposed to DV, CV • Education about bullying, conflict resolutions, etc Add a footer 32

Healthy Sexual Boundaries APV PERSONAL SAFETY SPACE, HULAHOOP BOUNDARY, SAY NO TO PERSONAL SPACE INVASION Add a footer 33

Major Barriers to Trauma Treatment APV Fear of Re-traumatizing the child Remember, one of trauma symptoms are re-experiencing Vicarious Traumatization It’s important to maintain adequate self-care “Our clients are different” Laura Murray’s Project in Cambodia with sex trafficked girls Add a footer 34