 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. 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 really 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 actually say you are certified in TFCBT. However, I will provide you resources should you want to go out and pursue those. So we are going to talk about TFCBT as a best practice and implementing it to fidelity, but I'm going to also take a few detours as I always do, and talk about how this might be able to be useful with adults who have 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 TFCBT with adult clients. So TFCBT works for children who've experienced any trauma, including multiple traumas. So what we're really 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, yadda yadda yadda. So it may be a little bit longer. It may be a little 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, it takes them a while to really get the hang of the nuance between the difference between thoughts and feelings. So you might have to do two or three sessions, really helping 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 really 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 it really is important that there is a relationship, that there is a bond, if you will, a rapport between the clinician, the caregiver, which may not be the biological parent, 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 really 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, it gets really intense. TFCBT 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 peer group, may be more related to conduct disorder or FASD or something else, TFCBT may not be appropriate because what we're going to look at with TFCBT is reducing the PTSD symptoms, the hypervigilance, 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 often present as difficulties with affect regulation. We've talked before about how people who have experienced trauma may develop a situation where they are more likely to experience emotional dysregulation, that HPA axis kind of tightens up and holds on to the stress hormones, holds 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 molehills 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 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 worldview of why this trauma happened and make meaning from it. Will it help improve these areas? Will it 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 aleximic. They are very unable to identify their emotions. They're 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 trauma experience that helping them explore how that trauma is impacting them in the present can be really 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 skills 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 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 re-parenting skills. If your parent were here, or if your parent would have responded how you would have wanted, how would they have responded? And 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 you teach here. They prescribe some, but as far as relaxation and stress management, affect expression and modulation, DBT skills seem to fit really 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. They 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 brings up this particular memory, and how do we master that, how do we deal with it. And then finally conjoined parent-child sessions, and these don't come to the end. All along the parents are, or the caregivers, are participating in the process, assuming there is a parent or caregiver, and understanding, 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 TFCBT, reduction in intrusive and upsetting memories, so that's awesome. And if you think about what's the function of these intrusive memories, a lot of times it is because either they A, 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 are 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 vivo desensitization. Avoidance, helping people reduce their avoidance of certain situations, certain activities, so they don't feel like they are confined basically to their own prison. It helps reduce emotional numbing. 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 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 in order 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, 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 of situations that might trigger the trauma memories. So who is this inappropriate for? If the primary issue is defiant or conduct disordered, if you don't believe from a clinical standpoint that this is coming from a root of a trauma history, then addressing a 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, and 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 them, 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 really don't want to start poking the bear, especially in an outpatient setting. But even in residential, and even in 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's a lot of impulse issues. And the next 30 days, there's usually 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 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 TFCBT may not be appropriate. For example, attempting to desensitize to trauma memories is contraindicated when real danger is present. Obviously, I took that verbatim from the TFCBT training or one of them that is cited in your booklet or in 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 actually become certified in TFCBT, it would be an ethical decision at that point, whether or not to implement the program to fidelity. And, you know, obviously we want to make sure that the child is cognizant of any real and present dangers. Challenges, they always come up, especially when you're dealing with families. The 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 hear. Or whether you're dealing with a child right now who is with the 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 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 research of TFCBT as well as other methods if you choose not to use TFCBT. 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 own emotional reactions and is not able to attend to the child's experience. So if the parent feels guilty for what happened, or such as in the cases of domestic violence, the parent themselves is dealing with their own 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 do you have? And if you're trying to survive yourself, you're probably not going to be able to devote your full attention to junior 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 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 virtue of the fact that 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 talk about what's going in into the chart. I don't use subjective judgments. 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 that 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 parent 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 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 way that children are introduced to new people or there may be need to be some change in another situation in how to in disciplining. There's a lot of variations that may come up, but ultimately we need the parents full buy in, we need them to be willing to work with children on emotions identification and cognitive coping and all this other stuff, but 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 least the initial skills. 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 perseverance and establishing the therapeutic alliance reach out contact try not to serve as the all knowing omniscient person, but asking them what they need, asking them what's changed with junior, asking them for feedback and suggestions about what helps when junior gets like this. And so you can brainstorm put the parent in the expert role of being the parent. Imagine 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. So being fully aware that in TF CBT, you have two very distinct clients, plus a third one, which is the family. So you've got a lot of different things to juggle. You want to explore the parents concerns that may make them feel as they're, as though they're not being understood, accepted, believed, listened to or respected. And that gets a little dicey sometimes. Especially when we start talking about cultural sensitivity with regard to 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 so important if the parent feels guilty for some reason, you know, and sometimes they will to 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 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 in 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. 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. 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 junior, 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 psycho education emotions identification feelings identification and stress management and coping skills, you know, obviously, 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 1 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. Educate everybody how therapy works and then still in everyone, not just the parents, 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 in order 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, not completely understand what's 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, provide information about how often this happens, whether, you know, it's okay to do this, that or the other. Psycho education 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. Psycho education 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 TFCBT and childhood trauma is 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 them 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's a safety plan, etc. So every time a thunderstorm comes, they don't freak out. And we want to use psycho education to provide another way to target faulty or maladaptive beliefs by helping to normalize thoughts and feelings about the traumatic experience. It makes sense that that was really scary. It makes sense that you're angry. It totally 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 psycho 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 general 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 10 most common ones that they heard. However, there are many, many, many different traumas and types of trauma. Some of the biggest ones are obviously 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. 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 fire out separately because sometimes fire can be manmade. Sometimes it can be a wiring problem, but sometimes it can be junior was playing with matches. Now, even if junior 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. Psychoeducation 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 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 talking about a safety plan? Same thing with fire. Information needs to be tailored to fit the child's 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 to reinforce accurate information about how safe or unsafe they are. And obviously we're going towards safe and reinforce 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 loved this suggestion. So you can ask them, you know, what is a hurricane or what is a tornado? And see if they know, and see if they know how much time, how much advanced warning we have for a tornado versus a hurricane or, you know, whatever situation you're talking about. Obviously I did a lot of post-hurricane patrina counseling in northern Florida. So that's one of those things that comes up for me is talking with children about how likely is it that a Category 5 hurricane is going to hit again. But encouraging them to give answers. And if they give the wrong answer, you know, it's a great 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 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 own belief system. And you may need to consult with their spiritual guidance, guidance, leaders, whether it be a pastor or, you know, whatever in order 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 happen 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, no, mom, dad and the church are wrong. But we also want to help them try to integrate this in a way that can help them have a strong self-esteem. So reaching out to those spiritual leaders and the family, asking what their belief system is 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, henceforth and forevermore. Focus on the events they perceive as traumatic, the family, but most especially the child. If the child, 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 individual trauma, we want to be respectful of what they perceive as 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. 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 destigmatize and normalize mental health issues and seeking of treatment. Some cultures are still resistant to seeking treatment and I use the term cultures really, really 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 least it'll 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 own little group. So we talk about how common depression is among law enforcement and emergency responders. Specifically because they face so many different stressors than, you know, Joe Schmo over here. So it destigmatizes 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, educate parents about the trauma, talk about the child's trauma related symptoms. So we're going to go over what is hypervigilance? What is the function of it? Why do people become hypervigilant after a 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 10 more years and, you know, Johnny's still not having any resolution. We'll 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 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 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. We'll help the caregiver understand their role in the child's treatment 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 tools so you can help Johnny outside of session because you're going to be with him 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 out 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 rest 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 rate's 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 youth's mind. So they can say, I am not going to talk about that right now. I'm not going to think about that right now. Talk about distraction techniques. Go back to your dbt stuff talk about improving the moment and accepts to help the child develop skills to handle and work through when those thoughts pop up. Replace unthought 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 here taste, you know, really 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 really 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 keep a 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 real 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 actually recommended the relaxation and stress reduction workbook by Davis Eshelman and McKay. So and it is still in publication. When deciding how to present relaxation techniques be creative, have the child help you to integrate elements into the technique that make 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 her dog or whatever it is but help them make it relevant to them. And then have them identify other things they do to relax like drawing listening to music walking and make 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. That 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. And like I said, parents can often benefit from the relaxation training as well. So because they're dealing with their own issues about the trauma, but they're also dealing with trying to figure out how to help Johnny and any of and deal with any of Johnny's behaviors 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 the little faces on it. Or you can use the emotion thermometer. So is it a really hot emotion or is it a really cool emotion and help 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 own 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's elements of anger and shame and loss and all of that stuff. Help 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 emotion 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 do 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're 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 helps 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 doing, let them know any specific difficulties if any juniors having. Encourage the parent to praise the child for appropriate management of difficult emotions. And I put in parentheses successive approximations because they're not going to get it 100% 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 do you feel when it's a rainy day outside? How 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 own homework. If parents are overcome with their own emotions about the trauma, validate their feelings and explain how children really need to see that their parents can handle talking about the trauma. So the children need to see the strength in 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 to handle talking about this topic with junior. TFCBT can be an effective intervention for children or adolescents whose primary presenting issue is trauma related emotional or behavioral dysregulation. TFCBT is not appropriate for clients who are actively suicidal, severely depressed or currently abusing substances. We really want to make sure they're clean and sober as much as possible. TFCBT starts with psychoeducation, then teaches stress management and coping skills to aid in the management of distressing feelings. PsychoEd helps to clarify the inappropriate information children may have and start getting them a little bit more comfortable talking about the topic in general before we start really 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 at allceuse.com slash counselor toolbox. This episode has been brought to you in part by allceuse.com providing 24-7 multimedia continuing education and pre-certification training to counselors, therapists and nurses since 2006. 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