Advanced TF CBT Level 3: Trauma Narrative. What would you like to gain from our AM sessions on. and Cognitive Processing? 5/9/2016

Transcription

1 Advanced TF CBT Level 3: Trauma Narrative Roy Van Tassell Susan Schmidt What would you like to gain from our AM sessions on Trauma Narrative and Cognitive Processing? 1

2 Trauma Narrative (Gradual Exposure) 4 Why Gradual Exposure before Cognitive Processing? What we can learn from those who study learning and cognition Bloom s Taxonomy and later adaptations find that the first step in understanding is remembering 1. First, people remember facts and details. 2. Then comes understanding: What were my thoughts/feelings then? How did I explain what was happening then? Revised Bloom s Taxonomy 2

3 Gradual Exposure targets the first level, Remembering, and prepares us for Higher Level processing Bloom s Taxonomy in Gradual Exposure The following real narrative demonstrates the way in which youth most commonly recall traumatic events: First, factual details Next, Feelings, thoughts Then attempts to understand and synthesize information. Trauma Narrative Tasks to Accomplish Prior to Cognitive Processing 1. Identify the key trauma memories driving reexperiencing and avoidance symptoms in the youth. 2. Engage in gradual and repeated reviews of trauma memories to reduce the intense negative emotions and physiological sensations that are paired with these memories. 3. During gradual exposure, work with the youth to identify thoughts and feelings experienced during the trauma(s) in an effort to begin connecting to the youth s overarching trauma related beliefs and understandings. 3

4 TN Development Tips for Managing Avoidance 10 First, Establish an In Session Safety Plan Identify level on feelings scale that means a relaxer is needed. Develop list of brief (1 3 minute) relaxers to be used when a break is needed. Reinforce that when relaxers are completed and distress is down, you ll go back to their story development. Develop plan for a grounding activity at the end of the session. Second, Create the Exposure Hierarchy Use a timeline to help identify trauma events and create hierarchy from least to most distressing. Collaborate with the youth to select up to 3 trauma memories to review, with the most distressing being the last trauma chapter to review. Ask the youth to identify a positive memory to start. 4

5 Third, Collaboratively Develop a Plan for Reviewing the Youth s Trauma Memories. Will the standard chapter format work? Or is a more creative way going to better fit for this youth? Examples from past cases: UFC Fighter fighting opponents toward the final match with the toughest competitor Spiderman battling progressively tougher villains Frodo journeying through the dangerous forest and battling specific obstacles along the way Star Wars episodes about the hero s greatest battles against the Dark Side Fourth, Develop a Plan for Structuring GE to the Youth s Individual Trauma Memories Will the standard plan of the child telling the memory and you capturing the memory in writing or on the computer work? If not, what child interests can be incorporated into the exposure process? Examples from past cases: Using a puppet theater Talk show interview format Using a video camera to record repeated takes Place individual questions to support narrative development around the room for the youth to find and answer. This may be paired with something fun like a treasure hunt, solving a mystery, helping a character advance through a story (e.g., helping Anna find Elsa, helping Taylor Swift get to her concert, searching through a jungle to find the treasure, etc.) Questions to support narrative development are assigned a points number. The youth then earns points (e.g., to help the Thunder win the game, etc.) by selecting and answering q s. A q can be returned to answer later in the activity, if desired. TN Development Bridging into Cognitive Processing 15 5

6 Final Chapter Development Consider questions like: What have you learned? How are you different now from when it happened/when you started treatment? What would you tell other children who experienced this? 16 TN Development Working with Caregivers in the TN 17 THE TRAUMA NARRATIVE PROCESS WITH CAREGIVERS Questions to consider: What agreement will be set with child and caregivers to keep TN sharing contained to therapy only for now? How much of the child s trauma story is already known by the caregivers? How much of the child s trauma story will be appropriate to share with caregivers? How to work with the child to select what portions of the TN will be shared with the caregivers? What work needs to be done with the caregivers to prepare them for hearing the story? 18 6

7 Advanced TF CBT Level 3: Cognitive Processing Roy Van Tassell Susan Schmidt Lessons from Adult PTSD Treatment: Cognitive Processing Therapy (CPT) CPT Web: CPT uses the term Stuck Points Conflicting beliefs or strong negative beliefs that create unpleasant emotions and problematic or unhealthy behaviors. Stuck points may be conflicts between prior beliefs and beliefs formed after a traumatic experience. Example: I used to believe that I could protect myself. Now I believe that it s my fault that I got hurt. Stuck points may also be formed if you have prior negative beliefs that seem to be confirmed or reinforced by the traumatic event. Example: Before the trauma, I thought authority couldn t be trusted. Now I know that no authority can be trusted. 7

8 Lessons from Adult PTSD Treatment: Cognitive Processing Therapy (CPT) Five common themes to consider in cognitive processing of traumatic experiences 1. Safety 2. Trust 3. Power/Control 4. Esteem 5. Intimacy 1. Safety Beliefs related to SELF: The belief that you can protect yourself from harm and have some control over events. Beliefs related to OTHERS: The belief about the dangerousness of other people and expectancies about the intent of others to cause harm, injury, or loss. In what ways have you seen or heard issues related to safety in trauma impacted youth? Ideas for addressing these in cognitive processing? 2. Trust Beliefs related to SELF: The belief that one can trust or rely on one s own perceptions or judgments. This belief is an important part of self concept and serves an important self protection function. Beliefs related to OTHERS: The belief that the promises of other people or groups can be relied on with regard to future behavior. One of the earliest tasks of childhood development is trust versus mistrust. A person needs to learn a healthy balance of trust and mistrust and when each is appropriate. In what ways have you see or heard issues related to trust impact traumatized youth? Ideas for addressing these in cognitive processing? 8

9 3. Power/Control Beliefs related to SELF: The belief that you can solve problems and meet challenges. Power is associated with your capacity for self growth. Beliefs related to OTHERS: The belief that you can control future outcomes in interpersonal relationships or that you have some power, even in relation to powerful others. In what ways have you see or heard issues related to power and control impact traumatized youth? Ideas for addressing these in cognitive processing? 4. Esteem Issues Beliefs related to SELF: The belief in your own worth, which is a basic human need. Being understood, respected, and taken seriously is basic to the development of self esteem. Beliefs related to OTHERS: Beliefs about how much you value other people. In addition, a realistic view of others is important to psychology health. In less psychologically healthy people, these beliefs are stereotyped, rigid, and relatively unchanged by new information. In what ways have you see or heard issues related to esteem impact traumatized youth? Ideas for addressing these in cognitive processing? 5. Intimacy Issues Beliefs related to SELF: An important function for stability is the ability to soothe and calm oneself. This selfintimacy is reflected in the ability to be alone without feeling lonely or empty. When a trauma occurs, people react differently depending on their expectancy of how well they will cope. Beliefs related to OTHERS: The longing for intimacy, connection, and closeness is one of the most basic human needs. The capacity to be intimately connected with other people is fragile. It can easily be damaged or destroyed through insensitive, hurtful, or unempathic responses from others. In what ways have you see or heard issues related to intimacy impact traumatized youth? Ideas for addressing these in cognitive processing? 9

10 Thought Ruts, Part 1: Perspective Groundingyoga.com Catastrophizing Imagining the worst possible outcome and thinking that it may be the only possible one. Should s Forming strict rules and unrealistic expectations. Filtering & Magnifying Filtering out the positive and magnifying the negative like looking through tinted binoculars. Emotional Reasoning Polarized Thinking & Labeling Deciding that because something feels true, it must be. Making blanket positive/negative assessments for whatever comes up. Name call to limit perception even further Thought Ruts, Part 2: People Blaming Holding ourselves or another person responsible for every problem. Personalization Self Comparisons Mind Reading Need to be Right Seeing all behaviors around us as responses to ourselves. Measuring ourselves against others, making constant superior/inferior judgments to determine our worth. Feeling we know people s thoughts, the motivations for their behavior and how they feel about us without a word from them. Having to keep proving that we know best in our actions and words, no matter the cost. Cognitive Processing positively shapes and corrects beliefs about self, others and the world that were formed in the storm and aftermath of the trauma. 10

11 Revised Bloom s Taxonomy CRITICAL THINKING Basic Advanced Create Evaluate Analyze Apply Understand Remember What would it be like if? Can you elaborate on the reason? What would happen if? Would it be better if? Why do you think that? What would you recommend? Why do you think? What motive is there? What can you conclude? How would you solve? What would result if? How would you use? Can you explain? Describe what? What does it mean? Give an example? Who? What? Where? When? How? 5 Simple Questions to Start Processing What do you think? Why do you think that? Can you tell me more? How do you know this? What questions do you still have? From Rebecca Alber, edutopia 11

12 Questions to Challenge Stuck Points How might you adapt the questions below for use with children and teens? What is the evidence for and against the stuck point? Is your stuck point a habit or based on facts? In what ways is your stuck pint not including all of the information? Does your stuck point include all or none terms? Does the stuck point include words or phrases that are extreme or exaggerated (i.e., always, forever, never, need, should, must, can t and every time)? In what way is your stuck point focused on just one piece of the story? Where did this stuck point come from? Is this a dependable source of information on this stuck point? How is your stuck point confusing something that is possible with something that is likely? In what ways is your stuck point based on feelings rather than facts? Combine Techniques for Maximum Effectiveness You don t have to use just one cognitive processing technique. Chain them in combinations. Follow through with techniques for best effect. Clarification Questions on the Question Probing Assumptions Socratic Process Probing Consequences Probing Rationale Questioning Tricks #edchat #ukedchat #questioning 12

13 Clarification Probing Assumptions Probing Rationale Questioning Viewpoints Probing Consequences Questions on the Question How can these questions be adapted for use with youth? Why are you stating that? Can you give me an example? How does this related to our discussion? What do we already know about this? What would happen if? How can you verify or disprove? What could we assume instead? How did you choose those assumptions? What do you think causes? How do you know this? What evidence is there that supports? How might it be refuted? What are the strengths and weaknesses of? What are alternative ways of looking at this? Explain why this is necessary or beneficial and who benefits from it? How does fit with what our experience tells us? How does affect? What are the consequences of this assumption? What generalizations can we make? Why do you think I asked the question? What is the point of the question? What does Tricks; #edchat #ukedchat #questioning Caregivers and Cognitive Processing There are multiple reasons caregivers need to know these skills: They often have their own distorted cognitions that need restructuring. They are the KEY person supporting these very new skills for their child. They, themselves, can be a powerful source of challenging cognitions. This is why Conjoint Sessions are so critical. Examples of Internet Resources to Support Cognitive Processing 13

14 How full is your bucket? 14

15 15

16 16

17 Therapeutic dream catchers: 1) Draw/pattern of dream catcher 2) Decorate dream catcher 3) Have the child write out negative emotions, triggers, or experiences. 4) Trap the negative thoughts/triggers/ emotions 5) Have the child circle the dream catcher with strengths, positive traits, activities, and other things/people the client loves. 17

18 18