Trauma Focused Cognitive Behavioral Interventions: Trauma Informed Care

Trauma Focused Cognitive Behavioral Interventions: Trauma Informed Care



Learn how to use CBT to enhance resilience and safety when addressing trauma.
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Cultural Considerations
~ Meet the child and family where they are by presenting information in a way in which they can relate it to their own belief system.
~ Assess general beliefs about the trauma
~ Focus on the events THEY perceive as traumatic
~ Tailor the psychoeducational information so the family can be more receptive to it.
~ General views of mental health and mental health treatment should be assessed and addressed.
~ Demystify
~ Destigmatize/normalize

Parent Sessions
~ Provide a rationale and overview of the treatment model.
~ Educate parents about the trauma.
~ Talk about:
~ The child's trauma-related symptoms
~ How early treatment helps prevent long-term problems
~ The importance of talking directly about the trauma to help children cope with their experiences.
~ 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 and discussion.
~ Help the caregiver understand their role in the child's treatment, since this treatment model emphasizes working together as a team.
~ Parent input, questions, and suggestions are welcome
Stress Management Techniques
~ Controlled Breathing
~ Helps slow heart rate
~ Triggers “rest and digest”
~ Thought Stopping

Stress Management Techniques
~ Relaxation Training
~ Persons of Asian and Hispanic origin tend express stress responses in more somatic (i.e., physical) terms
~ When deciding how to present relaxation techniques, be creative.
~ Have the child help you to integrate elements into the technique to make it more relevant to them.
~ Have the child identify methods that he/she uses to relax (drawing, listening to music, walking…)
~ Be sensitive to children’s wishes if they do not wish to close their eyes or lie down
~ Parents can often also benefit from relaxation training
Feelings Identification
~ Helps therapist judge child’s ability to identify and articulate feelings
~ Teaches the child how to rate the intensity of the emotion
~ Teaches how to express feelings appropriately in different situations
~ Some children may have difficulty initially identifying and/or discussing their own feelings.
~ Try discussing the feelings of other children or characters from books or stories
~ Help children identify how they experiences emotions if they seem detached from the experience.
~ Introduce the difference between thoughts and feelings.
~ Many children describe thoughts when asked to identify feelings
~ How would you feel? I would want to run away.

Summary
~ TF-CBT can be an effective intervention for children or adolescents whose primary presenting issue is trauma-related emotional or behavioral dysregulation
~ TF-CBT is not appropriate for clients who are actively suicidal, severely depressed or currently abusing substances.
~ TF-CBT starts with psychoeducation, then teaches stress management and coping skills to aid in the management of distressing feelings.
~ Psychoeducation helps to clarify inappropriate information children may have
~ Feelings identification helps participants start effectively labeling and communicating their feelings

tornado, hurricane, kabul, Afghanistan, soldiers, car accidents, paralysis

Unlimited CEUs for $59 available at AllCEUs.com/Trauma-CEU this episode was pre-recorded 
as part of a live continuing  education webinar on demand CEUs are 
still available at   AllCEUs.com/Trauma-CEU 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 TF 
CBT however I will provide your resources should you want to go out and pursue those so we are 
going to talk about TF CBT as a best practice and implementing fidelity but I'm going to 
also also take a few detours and 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 TF CBT with adult 
clients so TF CBT works for children who have 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 yada yada yada 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 a 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 TF CBT 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 thbbt may not be appropriate 
because what we're going to look at with TF CBT is reducing the PTSD symptoms the hyper vigilance 
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 also present as difficulties with   affect regulation we've talked before about how 
people who are experienced 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 hold 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 mole hills 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 world view 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 Alex thymic they are very unable 
to identify their emotions their 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 than 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 skill 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 reap Aron ting 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 that 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 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 conjoint Parent Child sessions and these don't come till 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 TF CBT reduction in intrusive and 
upsetting memory so that's awesome and you know 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 the 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 hyper arousal 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 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 is inappropriate for if the primary issue is defiant or conduct 
disordered if it if you don't believe from a clinical standpoint that this is coming from a 
root of a trauma history and 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 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 TF CBT 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 TF CBT 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 and TF CBT 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 if the carrot 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 here or whether you're dealing 
with a child right now who is with a 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 believe 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 and of TF CBT as well as other methods if you choose not to use TF CBT 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 you 
know 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 
jr. 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 I 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 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 talked about what's 
going in into the chart I don't use subjective judgment 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 
but 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 parents 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 parents 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 maybe need to be some change in another 
situation and how to indiscipline 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 which 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 
in 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 changed with jr. asking them for 
feedback and suggestions about what helps when jr. 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 being fully aware that n 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 their so they're not being understood accepted 
the lead listen 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 also 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 to come 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 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 caregivers 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 jr. 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 psychoeducation 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 1st 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 instill in everyone not just 
the parent optima optimist that well 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 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 psychoeducation 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 TF CBT 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 to safety plan etc so every time a 
thunderstorm comes they don't freak out and we want to use psychoeducation to provide another 
way to target faulty or maladaptive beliefs by helping to normalize thoughts and feelings about 
the traumatic experience you know it makes sense that that was really scary and 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 cycle 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 Jen wrong 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 ten 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 man-made sometimes it can be a wiring 
problem but sometimes it can be Jr was playing with matches now even if jr. 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 psycho education 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 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 a child's particularly particular experiences and level 
of knowledge obviously you're going to provide different information in 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 reinforced 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 
love 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 you see I did a lot of post 
hurricane katrina 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 your aunt's give answers and if they give the wrong answer you 
know it's 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 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 guiders 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 oh 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 hence foreign henceforth and forever more 
focus on the events they perceive as traumatic the family but most especially the child if the 
child's 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 is 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 
D stigmatize 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 will 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 and emergency responders and they're kind of their own little group so 
we talk about how common depression is among law enforcement and emergent emergency responders 
specifically because they face so much so many different stressors than you know Joe Schmo over 
here so it D stigmatizes 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 hyper-vigilance what is the function of it why do people become 
hyper vigilant 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 ten more years and 
you know Johnny's still not having any Ellucian will 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 will help the caregiver understand their role in the child's 
treatment since this modified 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 them 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 in their respective sessions helping 
them understand what control breathing is and how it helps slow the heart rate and trigger the 
wrist 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 
rates 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 youths 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 unthawed 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 hear 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 
people 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 training actually recommended the relaxation is stress-free and 
workbook by Davis a Schulman 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 them 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 their dog 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 them deal with any of Johnny's misbehaviors 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 a 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 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 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 your 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 encouraged the parent to praise 
the child for appropriate management of difficult to motions and I put in parenthesis successive 
approximations because they're not going to get it a hundred percent 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 them 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 there the children need to see the strength and 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 TFC BT can be an effective intervention 
for children or adolescents whose primary presenting issue is trauma related emotional or 
behavioral dysregulation TF CBT is not appropriate for clients who are actively suicidal severely 
depressed or currently abusing substances we really want to make sure they're they're clean 
and sober as much as possible TF CBT starts with psychoeducation then teaches stress 
management and coping skills to aid in the   management of distressing feelings psycho IDI 
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 all CEUs comm slash counselor toolbox this episode has been brought to you in 
part by all CEUs calm providing 24/7 multimedia continuing education and pre certification 
training to counselors therapists and nurses   since 2006 use coupon code consular toolbox to 
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