8/12/2011
PRACTICE components
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P sychoeducation
y
and p
parentingg 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
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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.
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Documenting the Trauma
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Gradual Exposure: Clarify for clients why it is
i
important
to slowly
l l andd carefully
f ll examine
i what
h
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
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Create a trauma narrative
Straightforward written narrative
 Book
 Audiotape or videotape
 Computer story
 Poem(s)
P
()
 Song(s)
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Suggested Steps for Trauma Narratives
1.
Praaise the child often
Use rrelaxation as needed
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2.
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Introduce rationale
Create a neutral narrative
Introduce TN by reading a book
Determine the format for the child’s TN
Determine who will write (you or child)
Start writing (title page, chapter 1: about
child, etc)
Re--read the TN as part of Gradual Exposure
Re
Expand the TN
Add thoughts, feelings and body sensations
Documenting the Trauma
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If multiple episodes, creating a timeline can be helpful as
a preliminary step in narrative process
Cli can choose
Client
h
to write
i a ddetailed
il d narrative
i about
b
the
h
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 33-4 weeks; others may take
months)
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Life Book Resource
Narrative
 Start with a neutral narrative that involves
asking about all the senses (e.g., a family trip;
a birthday party)
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Clinician’s Neutral Narrative
Child’s Neutral Narrative
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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
Titl
PagePage
P - might
i ht change
h
dduring
i process
p
 Introduction (about me, my family, my favorite..)
 Good Memories (before trauma, with family, with
abuser)
 Trauma DetailsDetails- events of trauma, disclosure, first
time,
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
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Gradual Exposure Hints
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Help child rere-create the scene: Ask them to
visualize the room,
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)
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Ask broad,
broad open
open--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…
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Narrative
 Rate
distress before, during, and after work on
narrative (e.g., SUDSSUDS- Subjective Units of Distress
S l )
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?”
?” andd I said,
id “Fine”.
“Fi ” I went to
school.
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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,
vagina, he left. The next
morningg I got
g up
p and myy 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
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Narrative: Managing Avoidance
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Praise child for his/her effort
R
Repeat
treatment rationale
i l
Slow down pace or take a step back
Don’t over attend to COWs (Crises of the
Week)
Encourage
g use of coping
p g skills
Be creative
Gently persist
Sample
Narrative
•5 year old male
•Sexually abused
at age 4 by
grandmother’s
boyfriend
Mark
M k
Mark
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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.
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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.
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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
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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
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!
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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.
h
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,
y Me and Mrs. Alanna learned more
now I am doingg this story.
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.
h N
Now my b
brain
i iis clear
l b
because I use my coping
i skills.
kill
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.
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Positive Ending (older child example)
Advice to Other Kids
If somethingg like this happens
pp
to yyou,, go
g tell the police,
p
, your
y
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
doesn’tt 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,
experiences and other details
Choose one person to record
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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
g on the leg
g of it. My
y Dad was wearing
g a button-up
p 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”
play .
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8/12/2011
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.
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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 7th 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
l
th
the church.
h h M
My mom mett my d
dad
d on th
the road
d 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 10th at the Dr’s
Dr s office
office.
Follow up to Trauma Narrative:
Cognitive/Affective Processing
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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 PsPspersonal, pervasive, and permanent)
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Common Negative Distortions: Abuse
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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”
Cognitive Processing
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Step 1
Identify cognitions related to the trauma
As reported in the trauma documentation
 Direct inquiry
 Indirect reports
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Cognitive Processing
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Step 2
Explore inaccurate or unhelpful cognitions and
the feelings that accompany them
Inaccurate attributions
 Responsibility vs. regret (e.g., can regret a choice like
ggettingg into a car with someone who was drunk,, but
still not responsible for being raped)
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bandaids = hurt
For younger kids;
girls
stars = brave
smiles = people who
know I’m not to blame
dots = to blame
F teens;
For
t
boys
b
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bandaids = hurt
stars = brave
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
smiles = people
who know I’m not
to blame
Bees = “to
blame”
The abuser
here is
shown as the
one to blame
Cognitive Processing
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Step 3
R l distorted
Replace
di
d cognitions
ii
with
i h more accurate,
realistic, or helpful ones
Progressive logical questioning (Colombo approach)
 Overgeneralizations
 Alternate cognitions
 “Best Friend” role play
 Socratic method
 Weighing of evidence
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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
off
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
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.
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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
off
wants - calling
lli us both
b h sluts.
l
H
He started
d threatening
h
i 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
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 offoff- grabbing me – telling
mom he’ll do what he wants - calling us both sluts. Mom and I are
not sluts. Its myy dad who had the problem
p
with sexuallyy abusing
g
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 herher- 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 andd mom cried
d andd cried.
d I thought she was madd 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.
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Table Group Activity:
Pick out the distortions in the 13 year old narrative
andd recordd these
h at your table:
bl b
be prepared
d to report
out to large group
Role Play:
y
Processing Distortions
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