Completing Trauma Narration in TF-CBT

Hello everyone, welcome to today's webinar to complete a

trauma

narrative on TS cbc. My name is Chad Severs and I will be your moderator today. If this is his first time joining us, explain a little about our program and make some housekeeping announcements. Here and then I'll introduce our speaker and we'll get started, so again my name is Chad Severs. I am the Arkansas project manager building effective

trauma

services or the best of us and we are a state-funded program at UMS Psychiatric Research. Institute and our goal is to improve mental health services for children who have experienced trauma due to events such as diffuse natural disasters or family separation.

We work closely with our state's child advocacy centers and other providers in the state to build a trauma-informed mental health system. system and we're probably best known for providing training to mental health professionals and treatments that are effective in helping children recover from trauma, so I'll briefly go over a couple of internal announcements about all of our speaker's energies. We encourage you to ask questions during the presentation. We'll probably address those questions at the end. We have plenty of content to review for an update, so post your questions as they come in. The question functions are located on the right side. on your screen and if you are interested in earning a CEU, stay until the end of the webinar.

You will be provided a code and then I will send you a survey after the webinar to enter that code. We will receive more instructions at the end. We are recording this webinar and will be uploading this presentation to our website's YouTube channel shortly and be sure to like us on Facebook if it's a topic or if you know of Cu opportunities or other training interests. We post there frequently, so it's a good way to check in and know what's going on in Arkansas and what we're doing with trauma states. Our speaker today, Ben Siegel, is one of our state TS DBT trainers and is also national. trainer at TF CBT and we are very grateful that he is on our best team, so for those of you who are familiar with the TS DBT model, there have been some updates and it is good to have a refresher on trauma storytelling. so without any, I'm just going to hand it to Ben and let him take it.

Hello everyone, dr. This is Benjamin Siegel, associate professor at the Psychiatric Research Institute at the University of Arkansas for Medical Sciences, as Chad said he is a national TF CBT trainer and a licensed psychologist, so I'm happy to provide this webinar on implementing storytelling. of trauma and the cognitive processing of that narrative within TF CBT. trauma-focused cognitive behavioral therapy, so I wanted to start with some warnings about the fine print of this presentation, so it's really designed for both mental health professionals and non-mental health professionals to give an overview of what is the trauma narrative within TF CBT and how it is carried out to educate you to better understand TF CBT if your referral provider prefers the stakeholder victim advocate director just so you are more informed about what it is that part of TF CBT or for mental health professionals, no doubt, and about you about what TF CBT is.

CBT is and specifically the trauma storytelling portion if you are new to TF CBT just gives you a brief overview of what it is or if you have completed formal training like ours in Arkansas for free including online based training in the web. In-person training consultation requires a refresher. There may be some additional tips regarding your current TF CVT cases. I also want to say that this is not a substitute for formal training and TF CBT. At the end of this article, this is not designed for you to be able to do TF CBT, that actually requires

completing

the formal TF CBT training process to be able to do that and of course I am mainly presenting on a component of TF CBT, the trauma narrative and the trauma narrative is specifically and when I am talking about it to be carried out within TF CBT it is not a stand-alone intervention, it is carried out within TF CBT, there is free work, you have to do the stabilization phase before to get to the trauma narrative, but I'll talk more about that in a moment.

The brief overview or the ovary are the goals of this presentation, so let's talk and spend some time on the initial components within TF CBT and the importance of those components in getting the trauma narrative ready for the trauma

narration

goes smoothly, we will talk about what trauma

narration

are steps to

completing

the trauma narration and cognitive processing sharing the trauma narration with the caregiver and then what to do after the trauma narration, so I want to start simply saying that TF CBT is a treatment model that emphasizes proportion and balance, meaning that the skills we do within TF CB teams build on themselves, we have phases, we have components and there is work to be done before going into the trauma narrative and even within the trauma narrative we have to use clinical decision making around what appears to be the level of exposure content and things like that, to give you an overview of TF CBT, remind you what are the phases, what are the components within TF CBT.

I should say that if you are not familiar with TF CBT, it is an evidence-based treatment for children ages 3 to 18 who experience traumatic events and are actively having PTSD symptoms, so in TF CBT you will see on the left the acronym for practice which is typically how a child and their family will progress in TF CBT starting at the top and moving towards At the bottom you will also see that there are phases within TF CBT on the right, so the first day is the stabilization phase that provides the caregiver and child with trauma coping skills education to manage their current trauma symptoms and develop self-efficacy. a sense of control over managing their PTSD symptoms, and as part of that, we are working on trauma storytelling, which is the second phase.

As you'll see, the first phase of stabilization the components were doing cycle education parenting skills relaxation skills effective regulation cognitive processing I'll briefly go over the ones below, but they're designed to be kind of free work for trauma storytelling and, When done well, the stabilization phase will reduce the trauma symptoms, so in the third and second phase, the trauma narrative phase is where we have the child. talks about their traumatic experiences helps them find the meaning behind it explores their thoughts and feelings helps them address any inaccurate or unhelpful thoughts that are getting them on the path to healing and in the final days the integration phase draws on all the Previous work with dramatization based Civilization is to support the child in future events, improve safety, do things like sexual education, prevent communication between parents and children, strengthen the relationship, continue as we clean up the past within the narrative of the trauma so that the child becomes more. focused on the present and focused on the future to help address any future trauma symptoms that may arise or reminders of trauma, so when we talk about TS CBP, we've talked about the phases, let's talk a little about pacing and timing , for typical TS CBT.

In this case, we generally consider 8 to 16 sessions and spend a third of our time on each phase, so if we are doing 15 sessions, that means 5 sessions and the stabilization phase, 5 sessions and the trauma narration phase and 5 sessions of the integration and consolidation phase As you will see, there is a lot of work outside of trauma storytelling in TF CBT and it is vitally important to do so. You will also see on the left that parenting skills occur throughout TS CBT, as well as gradually. exhibition which I'll talk a little more about in a second. I also want to highlight that character participation is fundamental to TF CBT and is very important for caregivers, since we are developing the component skills with the child that we are also doing. the similar skills that are taught to caregivers so that they can support their children, as caregivers have their own emotional thinking, types of symptoms and reactions when their child has experienced trauma, so we are also working with that in a way constant, many children have complex trauma.

The history, meaning they experienced many different traumatic events, sometimes perpetrated, are filled out by those who are supposed to protect them and in those cases we can see PTSD symptoms but also complex trauma PTSD symptoms, which means we have classic PTSD symptoms, such as re-experiencing a hyper intrusion. arousal, negative disturbances and mood, in addition to a kind of serious and effective dysregulation, interpersonal difficulties, we may see some poor coping skills, such as ideation of substance abuse, interpersonal difficulties, etc., it is a type of disorder Post-traumatic stress disorder, in addition to this pattern of trauma throughout your life, often in the first impacts of life. a variety of systems, so it's a little bit more complicated and since you'll notice that with this presentation we're going to take a little bit more time within TF CBT, we might look at sixteen to twenty-five sessions and if By doing that, we'll also you'll know on the right that we're going to spend more time in the stabilization phase, so let's say we have twenty-four sessions.

Duty scpt, that means we're going through twelve sessions and stabilization, which means we're working. more about those coping skills stabilization skills to help with effective regulation improve problem solving related to substance use work on some symptoms of depression in social skills bring more stability so when we have that, we'll move on to trauma storytelling Note that the trauma narrative is not necessarily longer, so even if there is a longer trauma story, we do not necessarily spend more time on the trauma narrative, so in the example above, when we had 15 sessions, we spent about five and the trauma narrative if you have 24 sessions that we are spending, if we are spending twelve and stabilization, we are spending six and trauma narration at six and integration consolidations, well, that's the big picture by TF CBT.

The other thing I want to highlight and this is the importance. of the work that we do in gradual exposure within the stabilization phase, the components above before we get to the trauma narrative because the better you do in gradual exposure and incorporating talking about the trauma into those stabilization skills, those coping skills, those educational skills, the easier it will be The narrative of the plot will be fluid, so I'll go over each component and talk to you about what gradual exposition looks like within each component first, what gradual exposition is so that we know that when Whether children or adults experience trauma, a common reaction is avoidance. a very difficult experience it's hard to think about it it's hard to remember and so there's a natural tendency to avoid not wanting to talk about it not wanting to think about it avoiding people places that remind them of that experience and, for some, that can be a healthy coping mechanism and you know that with the support of other caregivers, the resilience factors that they can talk about can slowly make sense of their events and overcome them, but what we see with PTSD is that The avoidance is so ingrained that the child and the family cannot make sense of what happened, they get stuck in this avoidance that every time something related to the trauma comes up, they put a lot of energy into avoiding doing it and what happens starts the cycle where there is a reminder of the trauma, meaning something reminds them. from the traumatic experience, they try to avoid it and that becomes more and more ingrained, so through TF CBT we know and, you know, trauma research we know that for people who have PTSD symptoms, we have to talk about traumatic events and helping them make sense of it gives them skills for when they have a reminder of trauma helping them to be able to use those skills to reduce that arousal so that we can get to the point where we can do a narrative of the trauma and help them understand make the meaning correct some inaccuracies So what we are doing is that throughout TF CBT we are gradually talking and integrating more about the trauma and the child's traumatic experience with those early components and as we do so, we are helping the child develop self-efficacy andself-confidence. that they can handle those reminders of trauma, those emotions that are related to their traumatic experience and, as we do that, we can slowly get them to talk more about it and they can see that the world is not for that, that they can handle it and that they can work to make sense, understand the processing of your traumatic experience, so this is just a description of the practice acronym, the steps of TF CBT, you will notice that there are two lines, the conclusion is what we are trying to not do, that's not a good job of gradual exposure so practicing stabilization skills is essential a therapist a provider is doing a great job of teaching basic coping skills but never talks about the trauma or has the child identify trauma reminders and use these coping skills for your trauma reminders. and then we get to the T, the trauma narrative, and we have the child start maybe for the first time to talk about their trauma-related experiences, thoughts, feelings, their traumatic events, the arousal level goes through the roof and everyone knows what that means. it means it means the kids aren't coming back it means they may become overwhelmed, they may become, you know, suicidal overwhelmed and without realizing it, you may have pushed them there.

The second line, which is kind of a slow, gradual line throughout the practice, the acronym is what we're filming. because, and you know, in the first few components we're going to talk a little bit more about the trauma and the child's experience, so when we get to the trauma narrative, we've been talking about the trauma the whole time, so it's a natural progression. in the transition to begin the trauma narrative, so it's not something new, it's something that we are simply building on the basis of a lot of things that we do all the time and when done well, the trauma narrative develops seamlessly. problems, so how do we do gradual exposure?

Let's start with the assessment, this is a good model, a good opportunity, start the postgraduate exposure, we are going to ask directly about traumatic events, what the child experienced, ask the caregiver what the child experienced as well and talk about the symptoms that they occur. related to his appearance and as we do this, this gives us the opportunity to identify reminders of trauma that the child is having, which will be very important for the early stages of TF CBT. We always recommend that you know how to conduct a clinical interview. but also using a standardized measure that has been studied and invalidated as cut points where it adds to your clinical assessment and decision making that we are seeing high enough levels of PTSD symptoms that it looks like a trauma-based treatment like TF CBT would be. . appropriate, it's also an opportunity within the assessment, you know, to ask the child a little bit about what happened.

Yeah, we'll call that a reference narrative that you know, it shouldn't go into a lot of detail, you just know, get them talking about it, you know it well. I am here because my uncle touched me, it is a good start for the child and I exemplify that we are going to talk directly about it. He may ask some basic follow-up questions, but just to start, you know, can you talk about it? Are they avoiding aggregates? your clinical decision making, you know, kids avoid, they get angry when this comes up, but this models that we're going to talk directly about this experience, so then moving on to psychoeducation, psychoeducation is providing education about the symptoms of trauma, what are common emotional behavioral physiological responses some basic facts about the specific trauma the child experiences whether it is sexual abuse how often that happens how often who experiences it what causes it who is responsible for it happening and then gradual exposure piece okay one We're talking about trauma in general, but we're going to take our assessment results and we're going to talk about your trauma symptoms, your trauma reminders, and your relentless experience, so again that gradual exposure process, that you know, is part of cycling education. use some analogies like cleaning up the rolled roller coaster, you know how to talk about it, you know it's hard to talk about things at first, but eventually, if you know some people like roller coasters, I'm fine with roller coasters, but you know Some people, kids like roller coasters. you have the experience that you know they were really scared so they were in it and they really enjoyed it and talking about the trauma is going to be difficult but we can do it and get through it.

The same thing happens with cleaning wood when you have a wound. It's like you have to clean it and that might be a little painful, but when you do it with an antiseptic or whatever it helps clean that wound so it doesn't get infected, because unfortunately, when we talk about trauma, if we don't talk directly about those wounds, you know they can have a longer impact, there can be a bigger scar, it can get infected and that's more serious, but it's similar to a filing cabinet, really the filing cabinet analogy. I use it a lot now.

That's what you know, if you think about a filing cabinet, when trauma happens, it's very overwhelming and the brain protects the body. When trauma occurs, we file that memory out of order and that is a coping mechanism that helps at the time when things are very dangerous. The body doesn't allow that person to think about it because they need to focus on the here and now, the safety, but what happens afterwards for many people is that after the trauma, you know it ends, you know the world has become safer, The file cabinet is still out of order and then, when you know, you open the drawer of your file cabinet, only pieces come out, fragments of trauma, reminders of trauma and, what do people do?

They quickly close that file cabinet and don't put it in order. in that file cabinet, etc. What we are doing through TF CBT is slowly giving them skills so that they can slowly open the file drawer, reorganize those files through trauma storytelling, and manage those symptoms so that when they need to get a file, they open the file drawer and they can . look at it, you can remember it, put it back in order, close it and continue with it so that the parenting skills have the TFC, but the gradual exposition piece here is that we are teaching basic parenting skills for behavior management, we are working with the caregiver . teaching them coping skills to help manage the child's emotions or doing things like praise and selective attention and natural and logical reward and consequence charts, the gradual exposition piece is how the trauma has impacted your child's parenting and having a conversation with the caregiver what their response is. have been some common ones I have become too permissive my child has been through a lot I don't love him that much I am not afraid to become structured and consistent and set rules and limits or they become overprotective and the child is a little smothering and therefore When discussing what we really need within parenting, we need a good amount of security, stability and predictability in the structure because traumatic events are the exact opposite of that and therefore we need to help them work with the caregiver to provide an environment that is exactly the opposite and when the child feels safe and the world is predictable and not chaotic, he will begin to feel better and will have fewer symptoms of trauma relaxation teaching basic skills that you know deep breathing progressive muscle relaxation others types of mindfulness activities relaxation strategies to reduce arousal the gradual exposure part is once we teach the basic skills, then we bring out the strong reminder scan by practicing with the child and caregiver what skill what relaxation skill can use when you have those trauma reminders remember that every skill that what we are doing, we are spending time teaching the child and the caregiver so that the caregiver has time to learn about anxiety and apply it to the child's trauma reminders to help them support the child in using these skills to achieve that effective modulation expression. and modulation helped me identify the feelings, the intensity of the feelings, where they feel in their body, additional emotional coping skills, the gradual exposure to this is once they have those basic emotional recognition regulation skills again, we introduce reminders of trauma when you have a trauma. reminder of what feelings are you happy what is the intensity you could suddenly use one to ten or thermometers or gas gauge or battery power well my cell phone battery is full and that means I'm overwhelmed and my phone is about to explode, what skill can I use? be used to reduce that arousal after practicing that skill where is your cell phone battery now? okay well it's the last third of the phones that aren't going to explode don't have that Samsung phone that was supposed to explode so they're fine we're not on the plane etc and so on and so on cognitive coping and processing of the last skill before the trauma narrative, and this is where we help the child understand what thoughts are the difference between thoughts, emotions and behaviors, talk about inaccurate and unhelpful thoughts, thought distortion, common type of thinking, negative type. automatic thinking type of thing that helps them identify alternative thoughts when it's a negative thought, so I'm worthless or I'll never be good at math.

They help them think of some alternative thoughts so that this is really the only exception. to gradual exposure within the tfcd tree we don't have the child explore their trauma related cognitions here we do everyday thoughts to help them practice learning those skills, but for deep rooted trauma related thoughts we postpone them until we get to the cognitive processing part after the trauma narrative and there are a couple of reasons for this, and probably the most important, for many children without doing a trauma narrative and continuing to reduce that avoidance, the hyperarousal, we can't really get to the point . where the child can think of a more useful and accurate alternative thought because for many children there are still high levels of avoidance and arousal and we may need to reduce that through trauma storytelling before we can have the child re-evaluate that thought , then there will be resistance and that is the main reason why you know we are going to delay those that we are going to delay, if they come up, we are going to take note or we will bring them back later.

Of course, if there's a thought, you can provide some education, mention cycling education to ruin some of them, but we're talking more about those deep-seated thoughts about things like the world is unsafe, you can't trust adults, things So, remembering that in the typical case, we only have five sessions to get through all of this before we start the trauma narrative, so we don't have time for that, really the skills that we are teaching in practice, the skills that we don't we are teaching towards the domain that we are teaching them to the point where they understand them they can be successful they can use them when instructed because we need those skills when we move to the trauma narrative they can identify thoughts identify feelings we can direct them to use relaxation skills to cope situations when we have them talk about their traumatic memories I mean remember that the caregivers meet with you alone in each session to teach them skills that we can start and you need to start working with the caregiver on your own inaccurate and unhelpful thoughts related to the trauma , so if You know, you have thoughts that you know my son was damaged and will never be the same.

You can use some strategies here to help them with that so they can move on from their trauma. Alright, that gives us the prosthetic trauma narrative. I know we spent a little. A little bit more time on the initial parts because it's really important to be diligent and pay attention to those components because the more gradual the exposure, the better the process will be, but I want to start with some caveats. I guess the fine print or just some advice on clinical decision making, so the trauma narrative must be a known trauma and the child must have a verbal memory of the trauma and that is part of the reason why the range age for T of CBT is three more that it involves verbal language that the child has to talk about and, in an age-appropriate way, his memory of the trauma can be done through drawings and some questions afterwards, but he has to There may be a verbal memory of the trauma, the other piece is The last one has to do with a significant concern about instability, danger, additional traumatic stress, this is a clinical decision making piece, it doesn't mean you can never make atrauma storytelling, it just means that you might have to think about whether we're going to move toward trauma storytelling. it is appropriate if the child is safe if there is danger if there is a pending major life event that will somehow launch the child into a major life transition and then you know some of those things if you know that major placement decisions will be made very close to everyone's sudden termination of parental rights or about to move to a different foster home or court testimony, we may need to postpone the trauma narrative for a while and help them prepare for those transitions and then return to the trauma narrative afterwards. those transitions because some of them may be part of your trauma story, sorry, just sorry for the noise.

I get a little energetic when I present, so my hands are going crazy even though you can't see them, the other part is significant self-instability. damage active suicidal ideation that despite our best work on instability some children may need additional stability work and that is why we need what we call in some cases stable II unstable there is an instability and you all know the families I am talking about , the children that there are always There will be some instability, but there is some stability in that instability and that is different from an unstable dangerous situation in which we would not want to progress with TFC among many times in other cases of stable, unstable, going through a trauma, narration will help improve stability, but if it is a case where the child is actively suicidal, you know that he still uses drugs and alcohol at high levels and, oh, and he frequently passes out from worry of a overdose, you know there's more stability work, not necessarily going into the trauma narrative, it improves stability, safety, and then.

It goes back to the trauma narrative, you know, and in those cases where there is stability, you know that some of that drug use, suicide, for example, may be related as a trauma and you really want to get there, but we need stability What are we doing with that? in trauma storytelling, so in the first session we are reintroducing why we continue to talk about the child's experience, we can talk about the analogies, review those times for younger children, school-age children and younger will reread a story that we do for psychopaths. education can be an example of a child telling his or her story, for example, probably the best for school-age children and younger children for sexual abuse is please tell a child's story about sexual abuse, the story of Mrs.

Jesse and she talks about basically writing a traumatic narrative about what happened, what happened next, she talks about therapy, that is an example of a traumatic narrative, it is important that in that first session, when we have the child on board, let's start the traumatic narrative in that session and talk about it for a second and what it's going to look like and what you can do but TF CBT works on momentum and if we bring up the idea that this is what we're going to do in the next session and we don't start it, kids can doubt and worry because they don't know what it is and that language may not come back in the next session, so we need to start to build momentum and give the child an idea that this is not a general process, that we can make it fun, we can make it creative and that they can do it even if they are nervous and that's why we need to do some of that during the first session, so in that first session you will work with the child for a while, so you should have some ideas of how we are going to do the trauma narrative .

Be as creative as you want in the typical hang-and-tell trauma narrative. Here it is more of a chapter book because it is easier to explain in less time; However, if you stay true to the main components of that storybook, you can make a trauma narrative. in many different ways, you can do it in a series of drawings, collages, poems, a newspaper story, even text messages back and forth, a teen comic talk show, whatever, but as you go, there is a slow process of building from gradual exposure, etc. Below that I am describing within the chapters, you can do it in different ways, so at this point you should know what your child is interested in and therefore enter the session with some options, you can always use default a chapter book that you know how to write. inside the computer, those are the backup types, but you know the kid really likes comics or is really good at drawing, you might want to incorporate more of that into a trauma narrative, just some important tips that I don't know about. treats. the product, then there will be something and you'll notice I'm saying trauma storytelling versus trauma narrative, the narrative is the product, there will be something that is a physical product after we're done with the storytelling and the trauma processing, but that's not really What Trauma Storytelling and Processing is what happens between the lines between sessions, the conversations that are happening during the process, so don't worry too much about the product because not all the work you've done will focus more on the The process of trauma storytelling and cognitive processing is time-limited, there are specific goals, and I'm going to talk about the level of detail that we're talking about in trauma storytelling.

This is not a detailed step-by-step account of everything that has happened traumatic in a child's life it can take months. This is not TF CBT. You have to be quite structured within TF CBT and you have to control the level of exposure and the content and you have to monitor the symptoms. It's like the idea of ​​a pilot and a co-pilot. the child is the pilot, but if the child strays a little bit he needs to use the bathroom, you take over and this is the piece that is an active process where you were with the child when he does this and you monitor him directly or structure the way that you're going to perceive through TF CBT so that they don't feel overwhelmed and if they start to feel hyperaroused or overwhelmed, you will practice those coping skills and then come back to them so that they feel more or less. four main chapters within TF CBT, if you are making a chapter book, many times what is helpful and if you are making a book, you create a table of contents in that first session to help the child and know exactly what they are going to do and so table of contents you can create your title, you know, usually the table of contents has four chapters, sometimes a little more, so the first chapter is a great extra kind of thing, general, harmless information about me, who I am, my family, school and my Interest may be a little about why I am writing this story.

The second chapter is what it was like before what life was like before my relationship with this person before our house before the tornado. Remember that's just a little more depth of exposure. The third chapter. is the one that could have several chapters is where the child talks about his traumatic experience, what was going on with his thoughts and feelings, so it is possible that that third chapter could have a chapter for a tornado, could have a chapter for domestic violence and you might have a chapter on entering foster care that is perfectly appropriate and we'll talk about those decision-making factors in the second and then the last chapter.

Chapter four is the meaning of contextualization. I've learned? Where I can? Go from here, so that's the big picture, so you have chapter one and chapter two here, so actually chapter one is actually in the Oculus information, just to start the process. I usually add a sentence about the purpose of writing this. I'm writing this because a tornado destroyed part of our house and killed my dogs. It would be good for that first session if you can put that in that sentence. That's a big accomplishment for a younger boy, chapter two, so I'm Kate. You will complete chapter one and chapter two in the first session, just a description of what life was like before the traumatic event.

Have the child you know simply describe what life was like and then you will point out thoughts and feelings, perhaps for a while. More details and content. I'll talk in a moment about how to do that. Chapter three is the "Tell What Happened" chapter. Remember that in this chapter we are only going to have the child describe enough details so that her thoughts and feelings can speak. through our understanding of trauma remember our work with the child in the first third of the model or middle of the model the parts of his story that seemed to be causing the most difficulty we want enough detail to capture thoughts and feelings so that it doesn't happen It has to be a very detailed account of everything that happened in your trauma story.

It could be that if the child suffered sexual abuse over a period of several years, they could talk generally about it or they could talk about the last and the first. the most memorable and you can let them choose because remember it's not about the details, it's enough details for them to talk about it and understand their thoughts and feelings and then you move on to the processing piece, what's behind between the lines so you can add things like revelations of what happened after he was taken out of the house, whatever at this point you know you should have a good understanding of the child and what you think the child thinks is important to tell in this story on the first pass what you are doing. very little in the way of intervening in his story unless it goes too deep, but you allow the child to tell his story, write it down, take notes, however, you are documenting this praise to the child frequently and recommend that he know it before start with this.

In every chapter you're using your child's scale or your cell phone battery to say, "Okay, let's do it," here's what we're going to do. You know, we've outlined this is what we're going to talk about. How do you feel? about it, well, I feel pretty high, I feel pretty anxious, okay, let's talk about it, let's use some coping skills in the middle, if you see them getting a little overwhelmed, you stop them, same thing and on the edge, it's okay, you did it where you now went, okay, I'm okay, I'm less anxious, okay, and you notified them that they built on that success.

I was afraid, but I did it. I'm proud of myself and then what you're going to do after that first pass, depending on how much. The time you have in that session is then you will get more details or request thoughts and feelings. How do you do that? You ask broad, open-ended questions. Well, so you wrote that this happens. What were you thinking? What were you saying? yourself or your feelings or you and we want more details, okay, so you said, tell me a little more about how I wasn't there, I don't understand, repeat that part or something like a trace, okay, so you wrote to yourself I know that you heard the tornado siren and then something like that, just getting them to keep talking about the story, incorporating those thoughts into the feelings I want to talk about and a little bit about what we're doing, we have multiple traumas so we talked before.

The idea of ​​separate chapters that can absolutely work, sometimes we know within the research that if we are able to pick out the primary trauma, the one that is causing the most trauma symptoms, we tend to see a reduction in symptoms in the others. traumas and often as we do. we start with one, we end up talking about processing some of the other traumas because there is a relationship between them, so know that there are options here, use your assessment, use your understanding, go through the practices, work with the caregiver, where are we? Seeing those trauma reminders where the trauma symptoms are coming from, you're going to lean towards the one you're seeing with more symptoms when remembering the assessment, etc., but for some kids it might be this complex trauma story where there's really a lot going on. . of big events and then, in that case, we could do something like a life narrative on our timeline where, instead of making a chapter about each traumatic event because that would be overwhelming, we create a timeline that is just a sheet of paper or a Word document. or you know on a board where first so far the good events, the bad events, you know what periods of life happen, you know what ages it was and then you choose some of you, you know the good events that are particularly important for the child.

I talked about facts, thoughts and feelings and then I went over some of the most difficult ones, the topics that most attract the child's attention and during that process he can do two or three and he doesn't have to do the others. Remember again that it's not about the details. It's about what happens, it's about processing what happens between the lines and for children with multiple traumas, that organization reminds the binder to make like a timeline or put the chapters in order and then helps organize the binder. on a trip, everyone knows those kids where he mentions well when you're in this house, well,when that happened and they can just see that they're confused when this happened and that happened it was in this house and that character when that adult happened this and so we're doing it that process of putting that file cabinet and sorting those cases that complex presentation of trauma to It is often for these children that the underlying thing seems inaccurate unhelpful thoughts about guilt shame betrayal feeling damaged that is what is causing that is what is getting in the way of healing and that is why the important pieces in this may be that processing cognitive that we are going to talk about in a moment is the most important piece for those children that cognitive processing brings us, so remember that we have chapter 1, chapter 2, chapter 3, chapter 3 where We have gone through traumatic events, we have the thoughts and feelings now, once we have those thoughts, there are usually some inaccurate or unhelpful thoughts that get in the way of healing, blame responsibility.

I shouldn't have told my teacher. I'm going to jail Kitty all that kind of stuff I'm not a virgin I'm damaged no one will love me so they are identified through the trauma narrative or come up through your meetings with the caregiver or in the early components of TF CBT , here you have the difference between inaccurate and useless thoughts. We want to analyze them and help them with what we call a guided reconsideration process to help them arrive at a more accurate or useful plot. How do we do this? How do we get these thoughts? We talked about what we do and I'm not going to be able to go into too much detail about all the skills here, but the basic process is that we are trying to gather contradictory evidence or facts by examining the accuracy of thoughts by providing alternatives. explanations alternative evidence that breaks down that thought so you know that a useless but accurate thought is that a tornado could happen at any time is true, it could happen at any time, but for us who live in Arkansas we know that there are warning signs, there are certain Certain times of the year allow for other patterns, but there is a good amount of time when a tornado is more likely not to occur and we can go through an educational process or a process called the Socratic method or role-playing, all of which are designed to come.

Ideally, the child gets some contradictory information that works to change her thoughts. The Socratic question is a progressive logical questioning. Role playing is a way for you to have the child play her best friend or even you and have to take on the role that she is in. We are giving advice about a thought that the child is stuck in and that is why it is difficult for children not to take on that role and then tell you the information you want to hear. Responsibility cake is also very good and we make it often. around responsibility because a lot of kids are at fault so it's just an activity where we assign responsibility within a pie chart of who made that happen and we could do this before doing some processing activities and then after to see if we've made a difference, so in Chapter three you've gone through your processing, you've had improvements in your thoughts, they've become more accurate and useful, how do we know we're done?

Basically, they have described at least one trauma they have suffered. described her worst experience, she is seeing a reduction in symptoms and some mastering of trauma reminders. Now I want to talk briefly about what we are doing with the caregivers, so we are doing the work that we discussed with the children with the caregivers, we are bringing them together. with them in each session and we are working on having caregivers prepare them to listen to the child's trauma narrative. The child will share his narratives with them and we are working with the caregiver on any distortions he has.

I know the world is unsafe, all the men in my life have hurt my children, whatever it is, and we are going through a very similar, you know, through Socratic questioning and examining the evidence as we do with children with caregivers to prepare them. listening to the child's trauma narrative and building that relationship where the caregiver can be present and support that child. Here are some types of cognitive distortions common in families that we'll be working on, so that's the cognitive processing part, so we get to Chapter Three. We changed those thoughts, we've changed them within the written format to make them more accurate.

We prepare the caregivers that you know, many times they listen to drafts or things with them, the narrative of the trauma in each session that the child is creating so that they are prepared to hear what Are we including the lower chapter? This is growth, consolidation, a kind of piece, what have I learned? How am I different? I used to think this, I believe this now, what advice would I give to other kids, this is really the summary of all the work that you have done, this is the beautiful part of tfcg, this is where you see that the kids have healed, that they have actually been paying attention to you and what you have said, and then we prepare and continue to prepare the child and the caregiver to share.

Sharing the narrative is not required but is recommended because we see additional healing and symptom reduction and improvements in the relationship between child and caregiver when we share the narrative when addressing avoidance. I must say that we highly encourage caregiver participation. The caregiver is anyone. that insurance and the adults in the child's life could be, you know Amelia, your staff worker, it could be a child welfare worker and an uncle, foster family member, whoever, as long as they are constantly involved in the child's life and are safe, but not required there. are some of the reasons why the caregiver may not be prepared your own trauma symptoms your own mental health is fine you make clinical decisions based on both Prius but you prepared the child by asking questions about what it could be you know things like you know what you want to ask your caregiver what's the worst thing they could say and then next toe prepare the caregivers and you'll have this slide here and they'll make sure you get the slides you're doing role play asking them what is the worst thing you can say. happened, they are listening to different drafts of the sweat with the child's permission, then you have that shared session where the child reads the trauma narrative to the caregiver and for those of you who have been in those sessions they are just remarkable and we would call it Do you know what? sharing the processing of the trauma narrative may not be what leads to the reduction of all symptoms because stability kill practice works so well to reduce PTSD symptoms?

Processing the trauma narrative exchange is the healing part of TF CBT where you saw the growth, so I'm wrapping up very quickly, we'll address some questions. I want to tell you to remember that there is still a quarter or a third of TF CBT where you can continue to work with the child so that the caregiver builds that communication relationship. You know, it's very similar. process with a trauma narrative that begins more in the present than in the past, then works to consolidate and help the child move from being focused on the past to being focused on the present and the future, that is what we are doing in the final chapter of PFC, the trauma narration that shares the narration and then continue with the last part, so the continuous birthday trauma reminders are seeing this person in the mall you know, he is afraid to drive a car because that's what happened in the car accident.

We're working on those kinds of trauma reminders. The symptoms reduce what we are. work on additional safety safety plans social skills some kind of language sex education things like that characteristics of appropriate partners you know talking to the child and caregiver starting conversations around them knowing who to go to when you have questions about sex what our values ​​are family cultures around sex before marriage, dating, you know, appropriate equalities between couples, things like that fall under this TF CVT piece, working towards a successful graduation, okay, the last thing I want to make sure of remind everyone to practice self-care.

Listening to trauma narratives can be difficult, but I think when you have that healing section to share, it's worth it, so make sure you have your support to make sure you have your own self-care and practice it yourself because the stronger you are, the stronger you are. the stronger you can be for your clients for those of you who have not yet received training, the free online TF CBT training is the first website to list MUSC edu backslash T of CBT on the tfcg org national certification website. It has a couple of really good manuals. resources for T of CBT, we have free TF CBT trainings going on, go to our best website to sign up for one of them and look for ads when they appear, so Chad will help me with some questions in the time we have left.

I thank you dr. Siegel, so we'll look forward to the CD slide here in a moment, but we'll get a question: What are his suggestions, dr. Siegel, when a client may be overindulging, shares during the intake and then explains what happened. What are some strategies for telling people how to deal with that situation? Yeah, that's a great point, so I spent a lot of time on it. in what I think is the most common presentation with children as a kind of avoidance of caregivers who don't want to talk about it, but there are children and there are a good proportion of children where it's exactly the opposite that they just want to let it out, they want say it. get it out, it's on their minds all the time, it's certainly impacting them and they're having symptoms of trauma, but at this point it feels like I need to talk about this, I need to make sense of it, but they're going too far.

The depth isn't great for themselves, so that's a different piece that's a jump to stop them and let them know we're going to have a chance. You know, this is educating about TF CVT. We are looking at 12 to 16 sessions. I can tell you want to talk about it and I want to get basic information about what's happening to you and details now, but I find that when you talk about it it's a little overwhelming, so we're going to spend a lot. At first we just give you skills that, when it's something stable, calm you down, so when you talk about what we're going to tackle very quickly and the harder, the faster we work on these skills, the faster you'll know.

We'll get to the trauma narrative, but we need to do a good job when we talk about it, that it's not overwhelming for you, so we're going to go slow, we're going to get there, so you could use an analogy and a metaphor. Also, like a soda can, a shaken soda can, we have those kids that if you shake a soda can and open the lid, they'll explode, so what do you do? I don't know if it is like that. It makes some difference, but I touch the top for that tab and it's supposed to reduce some of the arousal, but what we do is we slowly open that can to release the pressure and that's what we're doing in practice that might help with some. kids, okay, we have a couple more questions, come on in, I'm just going to move towards the sea, slide over here and give a couple more instructions.

The code for today's webinar is two five zero seven, as I mentioned at the beginning, I'll send them over. Please take a survey which will have a link where you will need to enter this code and also attach the slides to this presentation and if you are watching with a group you could send me an email list of who you watched with and me. I'll go ahead and watch that poll on TV for that, so that'll be helpful. Okay, let's see here and I want to say that I've noticed a lot of good questions, evaluation results and specific cases, type of clinical decision making. about which are really good questions and we won't be able to answer all of them.

I appreciate you writing in the chat box. You can always email Chad or me and we can answer those questions offline. Yeah, so the code again is. two five zero seven go ahead and write that, people finish this and we come to see how it goes, but how does dr. Siegal is used to just bouncing around, you know what precise thoughts versus any kind of precise thinking he wants to keep going, he can still be accurate, but and the grand scheme of things is no yeah, it's nothing, so can you talk a little bit about it?

I know many people struggle with balance, precision, yes we are not looking for perfection, we are looking for improvements and remember that many times children have many different distortions, inaccurate and useless thoughts and a lot of time could be wasted. time within the trauma narrative, so we need to address them, but we don't need them to be one hundred percent accurate, perfect, remember that's enough to see improvement and thatThey will start to think about it. Okay, there could be an alternative explanation. I'm not there yet, but I can start to see that it might be good enough because remember that you still have more time within TF CBT to continue talking about some of them and the last third of the model so you don't completely abandon your thoughts. .

You know, once you're done with the trauma narrative, you can still mention them because we know that when we start to make movement in thought, even if when we're doing that trauma narrative, we process things cognitively, you don't make it. wherever you want, maybe it's enough for now to just put that information that we're giving them to the point where they can start thinking, but okay, I could think about this in a different way that also gains momentum when you don't. talk about it and just so you know, you can always mention it later, but we aim for good enough, we look for improvements knowing we could spend a lot of time and processing, we try to make those bots perfect on many occasions, that's not necessary, thanks.

I know where I want to be respectful of everyone's time, we are on top once again. I'll be sending an email to everyone who attended today, so if you have any additional questions, feel free to respond to that email that I'm dedicating to you and those. who couldn't answer the question, those type of case specific questions we will pass on to dr. Siegel, we also have another experience in the state here, so thanks again everyone. I'll leave the place for about 20 seconds, but have a great rest of your day. Thank you for tuning in, thank you all.