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Advanced

TF-CBT

Level 3: Trauma Narrative

Elizabeth Risch

Amanda Mitten

Melissa Bernstein

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Even at royal engagements,

he said, he had found himself

battling a “flight or fight”

reaction without

understanding why.

“I know there is huge merit in

talking about your issues and

the only thing about keeping it

quiet is that it’s only ever

going to make it worse,” he

said.

“My way of dealing

with it was sticking my

head in the sand,

refusing to ever think

about my mum,

because why would

that help?

https://www.headstogether.org.uk/

How would you like to grow in your Gradual Exposure skills?

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What we can learn from those who study learning and

cognition…

◦ Bloom’s Taxonomy and later adaptations find that the

first step in understanding is remembering

1. First, people remember facts and details.

2. Then comes understanding:

◦ What were my thoughts/feelings then?

◦ How did I explain what was happening then?

Why Gradual Exposure before Cognitive Processing?

Revised Bloom’s Taxonomy

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Trauma Narrative Tasks to Accomplish Prior to Cognitive Processing

1. Identify the key trauma memories driving re-experiencing and avoidance symptoms in the youth.

2. Engage in gradual and repeated reviews of trauma memories to reduce the intense negative emotions and physiological sensations that are paired with these memories.

3. During gradual exposure, work with the youth to identify thoughts and feelings experienced during the trauma(s) in an effort to begin connecting to the youth’s overarching trauma-related beliefs and understandings.

◦ The following real narrative demonstrates the way in which

youth most commonly recall traumatic events:

◦ First, factual details

◦ Next, Feelings, thoughts

◦ Then attempts to understand and synthesize information.

Bloom’s Taxonomy in Gradual Exposure

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Anna, age 15: TN Chapter 4

The whole thing started out late at night. I was asleep and I

heard a loud crash and woke up. -- was still sleeping. I went

downstairs. I only went to the half landing because I didn’t want to

get in trouble if I was downstairs. I sat and looked through the little

crack through the railing and saw all my sisters standing there, and --

and -- were asking dad to cut it out and were crying. Dad was drunk

again and angry. Dad was yelling at them – really explicit bad words.

They were crying and saying stop beating mom.

My dad left the house to go to the backyard. I came

downstairs and dad had pulled mom into the backyard. My sisters

told me to go upstairs. They didn’t want me to see it. I went upstairs to

watch.

-- just pulled into the driveway with her car and eventually

threatened to call the cops. Dad was beating mom with a

wheelchair. The wheelchair had no actual rubber wheels. Our yard

was really big, about two acres.

Anna: TN Chapter 4 – Final Draft

The whole thing started out late at night. I was asleep and I heard a

loud crash and woke up. -- was still sleeping. I went downstairs. I only went to

the half landing because I didn’t want to get in trouble if I was downstairs. I

sat and looked through the little crack through the railing and saw all my

sisters standing there, and -- and -- were asking dad to cut it out and were

crying. Dad was drunk again and angry. Dad was yelling at them – really

explicit bad words. They were crying and saying stop beating mom.

I was scared. That’s when I realized how bad the beatings were. I felt

afraid and angry. I was thinking that you just don’t do that. My dad left the

house to go to the backyard. I came downstairs and dad had pulled mom

into the backyard. My sisters told me to go upstairs. They didn’t want me to

see it. I went upstairs to watch.

-- just pulled into the driveway with her car and eventually

threatened to call the cops. Dad was beating mom with a wheelchair. The

wheelchair had no actual rubber wheels. Our yard was really big, about two

acres. I thought this is the weirdest of all weapons. I felt mad at dad for hurting

mom once again. Mom was hurt and stumbling around the backyard. She

found the wheelchair and sat down. Dad pushed the chair back and it rolled

into a tree. It was dark and hard to see much.

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Anna: TN Chapter 4, cont’d

I remember hearing mom and dad fighting and dad yelled at

mom and mom cried in her little voice to stop it. He kept hitting her. I

remember thinking how weak my mom was and how strong my dad

was.

Dad ended up breaking two of moms ribs and mom went to

her “temple” which is the garage apartment. I remember there was

broken glass everywhere. Some of the glass had blood on it. Mom

refused to go to the hospital.

The next morning dad was crying in his room.

Anna: TN Chapter 4, cont’d – Final Draft

I remember hearing mom and dad fighting and dad yelled at mom

and mom cried in her little voice to stop it. He kept hitting her. I remember

thinking how weak my mom was and how strong my dad was.

Dad ended up breaking two of moms ribs and mom went to her

“temple” which is the garage apartment. I remember there was broken glass

everywhere. Some of the glass had blood on it. Mom refused to go to the

hospital. I thought she was going to get sick or die, or get more hurt. We

didn’t have insurance.

The next morning dad was crying in his room. I had never seen my

dad cry. It was different and scary. I had a really strong feeling that made me

think, wow, my dad’s a real person not just a monster. But part of me thinks he

is a monster. Dad was crying and yelling, thinking about what he did. I

comforted him but was thinking “why would you do this.”

All the computers in the house were broken. Almost all things made of

glass were broken. The computers were symbolic for mom. She would

Frankenstein old computers and make them new for us. When dad destroyed

the computers he was destroying her way of life. He was saying look how

strong I am. Sometimes I feel my mom cared more about the computers then

she did about us. Now I know that’s probably not true. What dad did was

really drastic.

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Anna: TN Chapter 4, cont’d

My Aunt came over that morning around 9am to see mom but

dad wouldn’t let her see mom. My aunt argued that you better let me

see him so she did. My aunt knew that dad was beating her but mom

said she had fallen down the stairs when aunt saw her. She was

protecting dad. Dad wouldn’t let us see mom cause he didn’t want

us to see what he did. He took off the stairs from the garage

apartment. But I was able to crawl out of my sister’s window, onto the

roof. From there I jumped onto the platform that stairs led to.

Anna: TN Chapter 4, cont’d – Final Draft

My Aunt came over that morning around 9am to see mom but

dad wouldn’t let her see mom. My aunt argued that you better let me

see him so she did. My aunt knew that dad was beating her but mom

said she had fallen down the stairs when aunt saw her. She was

protecting dad. Dad wouldn’t let us see mom cause he didn’t want

us to see what he did. He took off the stairs from the garage

apartment. But I was able to crawl out of my sister’s window, onto the

roof. From there I jumped onto the platform that stairs led to. Thinking

about it now I can’t believe I did that. I was thinking that I wanted to

see my mom. Part of me thought that parents just fight, cause this is

always how it was.

I remember thinking how abusive my dad was although I

didn’t want to admit it. Part of you is scared to say it cause it’s all

you’ve ever known. I thought if I tell someone dad is gonna beat me. I

didn’t want to get my dad in trouble. I was just feeling afraid. I can’t

quite describe that feeling.

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TN DevelopmentTips for Managing

Avoidance

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First, Establish an In-Session Safety Plan

◦ Identify level on feelings scale that means a relaxer is

needed.

◦ Develop list of brief (1-3 minute) relaxers to be used

when a break is needed.

◦ Reinforce that when relaxers are completed and

distress is down, you’ll go back to their story

development.

◦ Develop plan for a grounding activity at the end of

the session.

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Second, Create the Exposure Hierarchy

◦ Use a timeline to help identify trauma events and

create hierarchy from least to most distressing.

◦ Collaborate with the youth to select up to 3 trauma

memories to review, with the most distressing being

the last trauma chapter to review.

◦ Ask the youth to identify a positive memory to start.

Third, Collaboratively Develop a Plan for

Reviewing the Youth’s Trauma Memories.

◦ Will the standard chapter format work? Or is a more

creative way going to better fit for this youth?

◦ Examples from past cases:◦ UFC Fighter fighting opponents toward the final match with the

toughest competitor

◦ Spiderman battling progressively tougher villains

◦ Frodo journeying through the dangerous forest and battling

specific obstacles along the way

◦ Star Wars episodes about the hero’s greatest battles against the

Dark Side

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Fourth, Develop a Plan for Structuring GE to the

Youth’s Individual Trauma Memories

◦ Will the standard plan of the child telling the memory and you

capturing the memory in writing or on the computer work?

◦ If not, what child interests can be incorporated into the exposure

process?

◦ Examples from past cases:

◦ Using a puppet theater

◦ Talk show interview format

◦ Using a video camera to record repeated “takes”

◦ Place individual questions to support narrative development around the room for the youth to find and answer. This may be paired with something fun like a treasure hunt, solving a mystery, helping a character advance through a story (e.g., helping Anna find Elsa, helping Taylor Swift get to her concert, searching through a jungle to find the treasure, etc.)

◦ Questions to support narrative development are assigned a points number. The youth then earns points (e.g., to help the Thunder win the game, etc.) by selecting and answering q’s. A q can be returned to answer later in the activity, if desired.

Avoidance

Management

Brainstorm

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TN DevelopmentGlitches, Snags,

Challenges…

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• Narrative isn’t coherent or cohesive

• Youth isn’t reporting or exhibiting distress

• Difficulty determining if youth’s distress is

decreasing

• Questions re: the accuracy or truthfulness of

the narrative

• Chronic or extended session absences

• Youth is experiencing significant distress

between GE sessions

• Others?

What do I do now???

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TN DevelopmentWorking with Caregivers in the TN

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What are common

challenges in Gradual

Exposure with Caregivers?

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THE TRAUMA NARRATIVE PROCESS WITH CAREGIVERS

Questions to consider:

◦ What agreement will be set with child and caregivers to keep TN

sharing contained to therapy only for now?

◦ How much of the child’s trauma story is already known by the

caregivers?

◦ How much of the child’s trauma story will be appropriate to share with

caregivers?

◦ How to work with the child to select what portions of the TN will be

shared with the caregivers?

◦ What work needs to be done with the caregivers to prepare them for

hearing the story?

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◦ Inappropriate self-blame and guilt

◦ Inappropriate child blame

◦ Denial that abuse occurred (or affected child)

◦ Fear of “opening can of worms”

◦ Caregiver’s own PTSD Symptoms

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Caregiver Issues in Trauma-Focused Work

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◦ Chase is an 8 year old boy with a history of sexual abuse from a

peer at his church. Child was very avoidant and resistant to

gradual exposure, but has made great strides and you have

moved onto cognitive processing. In your one on one time with

caregiver, dad continues to report experiencing his own

posttraumatic stress symptoms related to child’s trauma. He

discusses frequent use of avoidant coping skills, and verbalizes

firmly held beliefs around guilt and shame that are tied to his

religious practices. He explicitly states that he is not ready to hear

any details of Chase’s story. He reflects on your desire to help him

through this process, but repeatedly states that he is just trying to

make it through treatment with his head above water.

Case Example

Case Example

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Trauma NarrationYouth with Complex

Trauma

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THE FOLLOWING SLIDES ARE USED WITH

PERMISSION FROM:

Judith Cohen, M.D.

Allegheny Health Network

Matthew Kliethermes, Ph.D.

Children’s Advocacy Services of Greater St.

Louis at University of Missouri, St. Louis

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What is Complex Trauma?

◦Don’t treat CT experiences (early multiple traumas in context of caregiving relationship) but CT OUTCOME

◦PTSD + severe dysregulationICD-11: dysregulated affect, interpersonal problems, negative self-concept

◦ Trauma reminders: often diffuse, not discrete

◦Differential diagnosis is difficult (complex), may coexist with other psychiatric disorders

Symptoms associated with

traumatic events that are

chronic and interpersonal

Difficulty regulating resources

and skills needed for adaptive

functioning

• Interpersonal problems

• Affective instability

• Behavioral instability

Differential diagnosis is difficult

What is Complex Trauma?

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TF-CBT Modifications for Complex Trauma

◦Don’t know if needed—no studies compare

standard vs. modified TF-CBT for complex trauma

◦ Studies HAVE SHOWN that STANDARD TF-CBT

positive outcomes for PTSD and complex trauma

outcomes

◦Modifications for complex trauma were based on

clinical experience, not research

◦ Likely these modifications would better

outcomes for SOME youth with complex trauma

Psychoeducation

Relaxation

Affect

Modulation

Cognitive Coping

Trauma Narrative

and Processing

In vivo

Conjoint sessions

Enhancing safety

Trauma

Narrative

Phase

Integration/

Consolidation

Phase

Stabilization

Phase

Pa

ren

tin

g S

kill

s

Gra

du

al E

xp

osu

re

Tim

e: 8

-16 s

ess

ion

s

1/3

1/3

1/3

TF-CBT Proportionality

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Enhancing Safety

Psychoeducation

Relaxation

Affect Modulation

Cognitive Coping

Trauma Narrative

and Processing

In vivo

Conjoint Sessions

Enhancing Safety

Trauma

Narrative

Phase

Integration/

Consolidation

Phase

Stabilization

Phase

Pa

ren

tin

g S

kill

s

Gra

du

al E

xp

osu

re

Tim

e: 1

6-2

5 s

ess

ion

s 1/2

1/4

1/4

TF-CBT Proportionality – Complex Trauma

TF-CBT Implementation Challenges for Complex Trauma

Common challenges:

1) Taking too long for TF-CBT– front end engagement in trauma treatment

2) Recognizing when TF-CBT ends and other treatment may be needed

3) Identifying unifying themes

4) Processing of pervasive and persistent challenging cognitions

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Challenge #1: Engaging Youth in TF-CBT

◦ Gradual exposure occurs on 2 levels

◦ Direct exposure (explicit memories)

◦ Relational (implicit trauma memories)

◦ Due to a history of betrayal and lack of trust, therapeutic strategies focused on interpersonal engagement is key

◦ Normalizing and validating thoughts and feelings

◦ Motivational interviewing

◦ Interpersonal relational activities (e.g., making a playlist for grounding together)

Challenge #2: Need Longer Treatment

◦ Transition from TF-CBT to trauma-informed care

◦Many youth need ongoing treatment after TF-CBT

◦ Trauma-specific outcomes vs. comorbidities/

outcomes related to other adversities, challenges

◦After TF-CBT: graduate; redo treatment plan to

conceptualize new goals and ID new EBT

◦ Recognizes insurance requirements, youth needs,

also youth’s accomplishments and mastery

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CHALLENGE #3:IDENTIFYING UNIFYING THEMES

“What the

heck is a

THEME?”

View from the Literary World

◦ Definition:

◦ The underlying message of a story

◦ Critical belief about life conveyed in the

story

◦ What the story means

◦ Stories often have more than one theme.

◦ Function:

◦ Bind together essential elements of a story

◦ Provide understanding of the “character’s” experiences

◦ Give key insight into how the author views the world/life

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View from Trauma-Focused Therapy

◦ A “stable and coherent framework for understanding one’s

experience” is an important psychological need for trauma

survivors (McCann & Pearlman, 1990)

◦ Processing themes is an attempt to help meet that need

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Processing Themes: Moving Away from “TN Tunnel Vision”

◦ Processing themes requires looking for meaning across traumas

rather than within one trauma

◦ The meaning ascribed to a trauma often changes following

exposure to subsequent traumas

◦ Themes are patterns that form over time in a child’s life. They

often pop up as thinking errors

◦ Common themes include:

◦ Safety

◦ Trust

◦ Power/Control

◦ Esteem Issues

◦ Intimacy Issues 42

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◦ I can’t tell anybody that I’m hurting

◦ I don’t care about anyone

◦ Why even try I’m just going to fail

◦

Activity: Catch the theme for Narrative Work

Identify, Organize, and Process Complex Trauma Themes: Useful Strategies

Events◦ Desensitization

◦ Behavioral/Emotional

◦ Trees

◦ Who, what, when, where, how?

Themes◦ Meaning Making

◦ Cognitive/Emotional

◦ Forest

◦ Why?

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• Visualize trauma narration and processing as a

continuum

• Adjust your location on this continuum based on

the session-to-session needs of the client

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TN Continuum

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Identify, Organize, and Process Complex Trauma Themes: Useful Strategies

◦ TIMELINES

◦ Can be used in assessment and all PRACTICE components

◦ Facilitate “forest level” processing…,

◦ …but also allow “tree level” processing

◦ Visual nature of timeline seems to make themes more

accessible for youth

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Sample Timeline

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◦ “My history of trusting people”

◦ “Period of no control”

◦ “ How I lost respect for others”

Examples of thematic narrative chapters