HUD

TRAUMA
HANDBOOK
A Guide for Helping
~— Trauma-Exposed Children
~ and Adolescents

RICKY GREENNALD
 Digitized by the Internet Archive
In 2022 with funding trom
Kahle/Austin Foundation

https://archive.org/details/childtraumahandb0000gree
Pre-publication REVIEWS, COMMENTARIES, EVALUATIONS . .

rT|ee timely text argues that exposure to traumatic events can both precipitate and exacerbate
many common childhood disorders and manifest in adolescence in a variety of conduct
problems. Without taking a proper trauma history and directly addressing the effects of such
trauma, most contemporary therapy approaches are doomed to fail. Children and adolescents de-
serve effective, evidence-based interventions, and this text blends findings from motivational inter-
viewing, trauma-focused cognitive-behavior therapy, and EMDR in a practical, sensitive, and cli-
ent-acceptable way.
The text results from many years of creative clinical work with children and adolescents. The ac-
tive style developed with children is replicated in the workshops devised for therapist, and the text
can be used as a basis for peer-group learning. It is strongly recommended for all child mental
health therapists who are truly dedicated to making a difference to the lives of young people.”

—William Yule, PhD, FBPsS

Professor of Applied Child Psychology, Institute of Psychiatry, King’s College, London;
Consultant Clinical Psychologist, South London and Maudsley NHS Trust

Mf | Fs Child Trauma Handbook is a practical guide to trauma-informed therapy with children and
teens and the families who care for them (who may be traumatized themselves). Written to
accompany training on the topic, all practitioners will find this book easy to read and apply imme-
diately.”

—Charles Figley, PhD

Director, Florida State University Traumatology Institute

TI 1 [as is a fascinating book on how to respectfully approach and treat traumatized children. But
it is so much more; it shows how to build on underlying health and strengths in both children
and their caretakers. It is a well of clinical wisdom presented in a user-friendly step-by-step frame. It
is an empowering book!”

—Atle Dyregrov, PhD

Founder, Center for Crisis Psychology, Bergen, Norway

Mf pe past three decades have seen dramatic changes in our understanding of child develop-
ment and our conceptual and methodological tools for dealing with childhood problems.
One of the most important of these changes is our growing appreciation for the central role played
by trauma in the lives of troubled kids. Dr. Greenwald’s Child Trauma Handbook is a major con-
tribution to these efforts. In language that is clear and accessible to a wide range of clinician-
practitioners, he has translated research and theory into comprehensible and pragmatic tactics for
recognizing and dealing with the developmental consequences of trauma in the lives of children.
He exposes the gaps in traditional therapeutic approaches as well as in ‘common sense’ when it
comes to an effective response to child trauma. His approach is respectful, both toward the child
client and the adults in that child’s life. Grounded in his understanding of the research on trauma
and his clinical experience, he offers up a powerful learning experience for the reader.”
—James Garbarino, PhD
E. L. Vincent Professor of Human Development, Cornell University
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Child Trauma Handbook
A Guide for Helping
Trauma-Exposed Children
and Adolescents
Child Trauma Handbook
A Guide for Helping
Trauma-Exposed Children
and Adolescents

Ricky Greenwald, PsyD

CONCORDIA COLLEGE LIBRARY

BRONXVILLE, NY 10708

Routledge
Taylor & Francis Group
New York London
© 2005 by Ricky Greenwald. All rights reserved. No part of this work may be reproduced or utilized in any form or by any means,
electronic or mechanical, including photocopying, microfilm, and recording, or by any information storage and retrieval system,
without permission in writing from the publisher. Printed in the United States of America.

PUBLISHER’S NOTE
Identities and circumstances of individuals discussed in this book have been changed to protect confidentiality.

AUTHOR’S NOTE
The author gives permission for forms and exercises to be copied and used freely by the reader in his or her practice setting.

Original ink illustrations that appear throughout this book are © Sarah Douglas 2005. All rights reserved.

Cover design by Jennifer M. Gaska.

TR: 8.9.05; 3.22.07

Library of Congress Cataloging-in-Publication Data

Greenwald, Ricky.
Child trauma handbook : a guide for helping trauma-exposed children and adolescents / Ricky Greenwald.
p. cm.
Includes bibliographical references and index.
ISBN-13: 978-0-7890-2793-1 (pbk. : alk. paper)
ISBN-10: 0-7890-2793-3 (pbk. : alk. paper)
1. Psychic trauma in children—Treatment—Handbooks, manuals, etc. 2. Psychic trauma in adolescence—Treatment—
Handbooks, manuals, etc. 3. Post-traumatic stress disorder in children—Treatment—Handbooks, manuals, etc. 4. Post-traumatic
stress disorder in adolescence—Treatment—Handbooks, manuals, etc. I. Title.
[DNLM: 1. Stress Disorders, Post-Traumatic—therapy—Adolescent. 2. Stress Disorders, Post-Traumatic—therapy—Child.
WM 170 G816c 2005]

RJ506.P66G74 2005
618.92'8521—dc22
2005001042
 CONTENTS

Acknowledgments xi

Introduction _
How Trauma-Informed Treatment Is Different wm
How to Use the Book

SECTION I: UNDERSTANDING TRAUMA—A FRAMEWORK

FOR ORGANIZING EXISTING SKILLS

Chapter 1. Understanding Trauma

Why Trauma Matters

A Useful Definition of Trauma
What Makes an Event Traumatic?
The “Trauma Wall”
Resiliency and Vulnerability
Survival Orientation
Posttraumatic Symptoms
A Note on Exercises/Activities in This Book
Exercise: Float-Back

Chapter 2. The Structure of Trauma Treatment

Meaning of Behavior
Exercise: Meaning of Behavior
Selecting a Trauma Treatment Structure
The Fairy Tale Model of Trauma-Informed Child Treatment

Chapter 3. The Trauma-Informed Therapeutic Relationship

Child Trauma Treatment—Basic Principles

What It Takes to Be a Person Who Helps Traumatized Kids
The Therapeutic Relationship
The RICH Relationship Model
Exercise: Who Helped You and How?

Chapter 4. Taking Care of Yourself

Exercise: How Has Working with Traumatized Kids Affected You?

Exercise: Your Most Upsetting Case
Exercise: How Do You Know When It’s Happened to You?
Exercise: Self-Care Check-In
Exercise: Self-Care Plans
Exercise: Peer Support
SECTION I: EVALUATION AND TREATMENT PLANNING

Chapter 5. The Initial Interview—From “Hello” Up to History

Acculturation
Therapist Style
Introducing Treatment
The Rules
Starting with a Parent Present
Meeting Alone with the Parent
Meeting Alone with the Child
Exercise: Practice the Initial Interview
Obtaining More History While Focusing on Strengths

Chapter 6. Taking a Trauma History

Exercise: Take a Trauma/Loss History

Chapter 7. Trauma-Informed Case Formulation

Exercise: Do It Yourself

Chapter 8. Making a Treatment Contract

Motivation Enhancement
Motivational Interviewing
Finding the Princess
Future Movies Script
Treatment Planning and Contracting
Obstacles to Following Through with the Contract

SECTION II: SAFETY AND STRENGTH BUILDING

Chapter 9. Case Management

Exercise: Convince the Assistant Principal (AP) or the Parent

Case Management Pitfalls and Remedies

Chapter 10. Parent Training

Did I Hear You Say “Yes, But’?

Working the Case Formulation
Practicing Respect and Empowerment
Parent Training Interventions
The Therapist As the Parents’ Personal Trainer

Chapter 11. Self-Control Skills Training

Avoiding High Risk

Self-Management of Anxiety Symptoms
Self-Control of Behavioral Choices
 Choices Have Consequences 161
Exercise: Map Out a Problem 163
Exercise: Choices Have Consequences 165

Chapter 12. Getting Stronger 169

A Strength-Building Approach 169

Risks of Strength Building 174
Addressing the Problem 175
Containment Procedures es)
Exercise: Safe Place 176

SECTION IV: TRAUMA RESOLUTION 179

Chapter 13. Trauma Resolution Methods 181

Exposure 182
EMDR 185
Other Validated Trauma Resolution Methods 188
Discussion 188

Chapter 14. Preparation for Exposure 191

Target Selection and Memory Breakdown 191

Exercise: Breaking Down the Memory LF
The Container 198

Chapter 15. Conducting an Exposure Session 201

A Chunk at a Time 201

Making a Book to Tell the Trauma Story 202
On the Way to Exposure 203
Exposure Procedure 207
Exercise: Practice with Exposure 210
Selecting the Target Memory for Exposure Z11

Chapter 16. Problem Solving in an Exposure Session 215

Problem: One Part of the Story Is Especially Difficult 215

Problem: The Client Seems Overwhelmed 216
Problem-Blocking Beliefs 218
Exercise: Practice with Exposure Pap

SECTION V: MAKING THE MOST OF IT 225

Chapter 17. Reevaluation and Consolidation of Gains 227

In Vivo Exposure 227

Family Strengthening Interventions 229
Other Interventions 232
Chapter 18. Relapse Prevention and Harm Reduction 233

What Can You Do to Keep Bad Things from Happening? 234

Harm Reduction 236
Ending Treatment When Trauma Resolution Has Not Been Completed Zo
Ending Treatment 240

Chapter 19. Challenging Cases: Applying the Fairy Tale Model 241

The Fairy Tale Revisited 241

Exercise: Apply the Model 246
The Importance of Using the Model 249
Exercise: Case Consultation Using the Fairy Tale Model Zo

SECTION VI: 24/7—HELPING THE CHILD IN DAILY LIFE Det

Chapter 20. Creating a Safe Environment 257

Things Are Okay Now 2)

Adults Are Okay Now 258
Things Can Get Better 258
Physical Safety 258
Emotional Safety ESS)
Threats to Safety 209
Exercise: How Safe Is Your Home or Workplace? 262
The Safety Theme Approach 262
Exercise: Make the Child’s Environment Safer 268

Chapter 21. Discipline Is Love 271

Accentuate the Positive Zi2

Eliminate the Negative 2A
Don’t Mess with Mr. In Between 274
Principles for Implementing Discipline Using a Positive Discipline Approach 276
Time-Out Paty)
Exercise: When We Don’t Come Through 283
Handling Our Own Emotions 284

Chapter 22. Using Incentives for Success 287

Sources of Motivation 287

Point Systems 289
Individual Behavior Contracts 291
Designing a More Complex Contract 294
Exercise: Develop an Individual Behavior Contract 291
Implementing the Contract 302
Problem Solving the Individual Behavior Contract 302
Popcorn Points: Another Strategy Using Incentives 304
Chapter 23. The Magic Words: Cognitive Interventions

Stance of the Adult

The Labeling Methods
Exercise: Find the Magic Words

Appendix A. Trauma-Informed Psychological Assessment

Appendix B. Child Trauma Resources Online

References

Index
 ABOUT THE AUTHOR

Ricky Greenwald, PsyD, is the founder and Executive Director of the Child Trauma Institute.
He was previously Assistant Clinical Professor of Psychiatry and Director of Training for the
child trauma program at Mount Sinai School of Medicine in New York City. Dr. Greenwald is
the author of numerous professional articles as well as several books, including EMDR in Child
& Adolescent Psychotherapy (1999) and Trauma and Juvenile Delinquency (Haworth, 2002).
His work has been translated into over a dozen languages. Dr. Greenwald, a clinical psycholo-
gist, has been working with children, adolescents, and their families since 1985.
 Acknowledgments

I first acknowledge those who have taught me, mentored me, and invested in my professional
development as a therapist and child trauma specialist. In chronological order: Tod Rossi,
Deborah Roose, Cheryl Keen, Larry Allman, Jim Bibb, Claude Chemtob, and Nancy Smyth.
Thanks to each of you for your friendship and guidance. You may not be able to tell, but some-
thing I learned from each of you is in here.
Thanks to Karen Johnston, who was such a strong source of personal support while this book
was being developed and written. Thanks also to Hannah Greenwald, who provided encourage-
ment and food in the final stretch.
Thanks to Esther Giller of the Sidran Institute. She approached me with the idea for this
book—it’s changed by now, of course!—and told me that I was the person to write it. If not for
Esther’s initiative, this book would probably not have been written.
Thanks also to the following individuals, who each reviewed a draft of the book and provided
helpful feedback: Margaret Blaustein, Cristina Casanova, Susan Etkind, Denise Houston,
Rebecca Hubbard, Nancy Knudsen, Naomi Kramer, Noemi Levi, Veronica Picone Matuk,
Karen Nash, Angela O’ Rawe, Lori Rockmore, Bart Rubin, Oliver Schubbe, and Beth Venart.
Thanks of course to all of the kids and families ’ ve worked with over the years. Gotta learn
somehow! I hope you’ve gotten as much out of it as I have.
Finally, thanks to my supervisees and to those who attended the workshops, seminars, and
training programs on which this book is based. All those detailed evaluations I asked you to
complete really did make a difference.

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 Introduction

Many sincere, hardworking people out there really care about kids. I hope you’re one of them.
A great deal of knowledge has been developed about kids who have been exposed to trauma
and/or loss—knowledge about what kids experience, how they can heal, and how to help them
do it. These methods have been tested and proven effective. Unfortunately, most of this knowl-
edge has been the province of specialists. The problem is, those specialists don’t have your job.
The purpose of this book is to get this information to you, because you’re the one who needs it
to better help the kids you work with. I hope you will gain depth, specific skills, and grounding
in your understanding of what to do with your kids, how to do it, when to do it, and why.
This book was designed as the text for a five-day course for mental health professionals, as
well as for a two-day course for others who work with kids, including paraprofessionals, child
care workers, foster parents, and others. Although the book can stand alone, you would get
much more from the supervised practice of a live training experience. If you are on your own, I
suggest that you act as if you’re in a workshop and actually practice the exercises, ideally with
one or more colleagues who are going through the book with you.
The book is based on programs I gave for widely divergent groups: open workshops attended
by mental health professionals from around the world; weekly seminars for child psychiatry res-
idents at Mount Sinai School of Medicine in New York City; workshops for school-based mental
health professionals working for the New York City Department of Education after September
11; a course for undergraduate students at Hampshire College (Amherst, Massachusetts); and
workshops for professional and direct care staff at Queen’s Medical Center (Honolulu, Hawai1)
Pediatric Department, Covenant Children’s Home and Family Services (Princeton, Illinois),
and Edgewood Children’s Center (St. Louis, Missouri). On each occasion I asked for detailed
feedback, and here’s what I learned:

¢ All helping professionals want and need the big picture, even if they are not going to be
personally responsible for each of the steps in treatment.
¢ When it comes to practical skills, people appreciate being given scripts for what to say and
do. The next step is to actually use the scripts. This helps in the learning.
¢ Many participants already have considerable knowledge and skill. This training pro-
gram/book does not negate that. Rather, it empowers individuals to use their skills more ef-
fectively, by providing a user-friendly model for knowing when to do what.
¢ This model applies to most distressed kids, even when trauma or loss is not identified as the
presenting issue.
¢ This training program really works. Over and over I have seen people take this material and
use it. Problem behaviors go down; grades go up. Kids get better. Not all of them, of course,
but it seems to improve the odds.

I have also been working with colleagues to conduct research on this approach to training
people in child/adolescent trauma treatment. So far, we have found the following:
a CHILD TRAUMA HANDBOOK

¢ Following completion of the training, participants reported feeling better about their work
and reported improved trauma treatment knowledge and competency (Greenwald, Stamm,
Larsen, & Griffel, 2003).
¢ Following completion of a certain module of the training, participants reported feeling re-
duced distress when imagining themselves in a challenging work-related situation (Green-
wald, Johnston, & Smyth, 2004).
* This finding has now been replicated and extended. We have gathered new data that shows
that, following completion of a certain module of training, mental health professionals feel
more caring and empathy when imagining a challenging acting-out client, and feel more
comfort and confidence in their role as this client’s therapist (Greenwald, Greenwald, &
Smyth, 2005). .
¢ By two months after a related training and consultation in an adolescent residential treat-
ment facility, the monthly incident count (including assault, property destruction, and run-
ning away) decreased by at least 50 percent in every category, on all five units, compared to
any of the six months prior to the training (Greenwald, 2003).

The model and methods seem to apply across class, ethnicity, culture, and language. Small
glitches do occur when it comes to translation. People do sometimes tell me, “I had to change
the script in one place to make it fit for the kids I work with.” But they also consistently say,
“This is working with my kids.” In my mind, this is two kinds of good news. First, these com-
ments suggest that these therapists have the sense and the skills to adapt the material to the cul-
ture of the kids and families with whom they’re working. I don’t teach this adaptability, but it’s
important to do it! Second, the comments suggest that the phase model of trauma-informed
treatment, with emphases on safety, relationship, and empowerment, can be effective with
trauma-exposed kids in any setting. I have already fielded requests to help start treatment and/or
training centers based on this model in locations as diverse as Bangladesh, Burundi, California,
Guatemala, India, Israel, and Northern Ireland.

HOW TRAUMA-INFORMED TREATMENT IS DIFFERENT

To do trauma-informed therapy well, it helps to already be a good therapist. Many of the skills
and interventions are the same. Trauma-informed treatment is distinguished in part by the way
standard interventions are informed by, and organized around, trauma theory. When we under-
stand the way that past trauma may contribute to present-day problems, the treatment model
guides us to specific strategies, specific ways of using our clinical skills, and sequencing our
repertoire of interventions.
For example, parent training for consistent discipline is widely used in the treatment of chil-
dren with disruptive behavior, typically with a learning theory rationale so that parents are
taught to punish or disregard unwanted behaviors and reinforce wanted ones. In trauma-
informed treatment, parent training is also used, with essentially the same techniques and ratio-
nale. However, additional rationale is also provided. The parent is told that the child’s problem
behavior is related to feeling unsafe and upset because of past trauma and that the acting-out be-
havior is a way of seeking external (parental) control, such discipline being interpreted by the
child as reassurance that the parent is strong, in charge, and able to protect the child. Therefore,
the parent can be an agent of healing by doing special things to help the child feel safe and se-
cure. Thus, rather than implying that the “untrained” parent was the cause of the child’s behavior
problems (a risk in other treatment approaches), the parent is told that the child has a wound, en-
tailing a special need that the parent can address. This rationale leads to increased sympathy for
the child and to an active healing role for the parent. Both of these enhance the attachment that
 Introduction 5

may have been disrupted not only by the trauma but by the child’s rejection-inviting behavior
problems.
Furthermore, this theory-driven treatment approach systematically utilizes parent training at
a specific point in the course of treatment, in preparation for later treatment tasks. Other stan-
dard interventions are similarly incorporated, being implemented at specified points and using
trauma-related rationale, to further the goals of the trauma treatment.
Finally, the “stance” of the therapist is authoritative and directive while also being collabora-
tive, respectful, and, within certain limits, permissive, taking into account the special needs of
the traumatized child. This differs from other therapy models in a variety of ways, for example:

* A psychiatrist might conduct an evaluation by reviewing a comprehensive list of possible

symptoms, making a diagnosis, and then saying, “I can help you with your problem.” This
is based on the medical model of determining the diagnosis and offering treatment, with
the implication that the “patient” is ill and the powerful doctor can effect a cure. The
trauma therapist will not ask about the list of problems until first learning about the client
and family’s strengths. Then, after making a diagnosis, he or she will say, “I can help you
help yourself.’ This conveys the belief that the client may be wounded but has underlying
health and strength that can be enhanced and utilized for recovery, setting the stage for later
strength-building treatment activities.
¢ A psychodynamic therapist might ask open-ended questions, be willing to sit with si-
lences, and refuse to grant requests for judgment-laden opinions. The trauma therapist rec-
ognizes that each of these practices can tend to increase the child’s anxiety in ways that are
counterproductive for trauma treatment. The trauma therapist will help the child to feel
successful by offering a menu of types of appropriate responses rather than allow the child
to sit in silence, feel like a failure, or act out with a “don’t know—don’t care”’ attitude. The
trauma therapist will provide frequent feedback and impressions so that the child does not
have to wonder—and be afraid of—what the therapist might be thinking.
¢ A humanistic (or psychodynamic) therapist might encourage the child to disclose the de-
tails of the trauma memory and express related thoughts and feelings. A good session is
characterized by the child’s “opening up.” The trauma therapist will actively prevent such
opening up until the child has completed the preparatory tasks and is likely to be able to
manage and contain the experience. Furthermore, the trauma therapist will make efforts to
help the child “close down” and regain composure before ending the session, to assist with
containment and self-control.
¢ A play (or art, psychodynamic, or humanistic) therapist might wait for the child to initiate
disclosure and/or discussion of the trauma memory, on the principle that the child will
bring it up when he or she is “ready.” The trauma therapist will make the goal of trauma res-
olution explicit in the treatment contract and will lead the child to engage in a number of
activities with the explicit goal of helping the child become ready to face the trauma. Later
in treatment, the trauma therapist will help the child face the trauma in manageable doses.
Even so, the child always retains the prerogative to stop; the trauma therapist is directive
but not coercive.
¢ A cognitive-behavioral therapist might develop a functional/behavioral diagnosis and then
offer a task-oriented treatment plan to help the child manage or overcome the symptoms. If
the diagnosis is trauma related, the symptom-management activities may be followed by
activities specific to desensitizing the trauma memory. The trauma therapist will do all of
this too, but will first work on developing a supportive and empowering relationship, as
well as mobilizing parents and others to engage in specific behaviors to support the child’s
recovery.
4 CHILD TRAUMA HANDBOOK

These therapy approaches were just presented in their traditional “pure” formats for the sake
of contrast, whereas in practice many therapists integrate elements from a variety of therapy ap-
proaches. Indeed, the trauma therapy approach represents one such integration. Specific to the
trauma therapy approach are the rationale and the theory-driven system, including a sequence of
interventions that are borrowed from a variety of traditions. One workshop participant described
this approach as “cognitive-behavioral with a relationship base and family systems interven-
tions.”
As you progress through the book learning the stages of trauma-informed treatment, many in-
terventions will be familiar, but some may seem novel or even counterintuitive. For example,
many therapists feel some initial discomfort with asking the child directly, as early as the second
session, to disclose trauma/loss history. Many of the same therapists feel even more. discomfort
with asking the child not to disclose too much detail at that time, for those children who seem to
be trying to tell the whole story on the spot. There are good reasons (that I'll explain along the
way) for sticking to the trauma-informed treatment approach. So please keep your mind open
and give it a try. Most therapists have reported that even interventions which they initially balked
at worked out well with their clients. Remember, the goal is not merely to practice a favorite
technique but to help the kids. Learning something new can be awkward at first, but that’s what
this book is for.
You’ll be learning, step by step, a phase model of trauma treatment. That means that treatment
tasks are done in a specific order for a specific reason. Don’t let this step-by-step approach fool
you. In real life, kids don’t always go in order! In our work we are constantly reassessing, to fig-
ure out if our clients are still where we thought they were last week or even five minutes ago.
Even so, having the phase model as a framework will help you know what to do at any given mo-
ment, providing that you are able to determine where your client is (within the phase model) in
that moment.

HOW TO USE THE BOOK

This book is designed to teach you understanding, self-care practices, and intervention skills
in a systematic way. The chapters are in their present order for a reason: each builds on what
came before. Here’s how I hope you’ll use the book.

Mental Health Professionals

Those providing regular psychotherapy or counseling sessions to kids should read the whole
book in order. The first five sections will take you through theory, therapeutic relationship, self-
care, and the entire course of treatment. Section VI, “24/7,” is focused on milieu treatment, so
you may not be using skills from this section in your daily work. Still, you should be very famil-
iar with the material in that section so that you can help parents, teachers, child care workers,
youth counselors, and others to do their jobs as effectively as possible.

Others Who Work with Kids

These individuals, including child care workers/line staff, counselors, paraprofessionals, case
workers, court personnel, shelter workers, and parents, should definitely read Section I and Sec-
tion VI. Section I will help you understand the kids you work with, and will also explain the
healing relationship, as well as self-care issues and skills for those who work with kids. Section I
also provides an overview of how child trauma treatment helps kids recover from trauma and get
their lives back on track, one step at a time. The more you understand about what the child’s
 Introduction 5

therapist is doing, the better you can work as a team. Section VI, “24/7,” is focused on what to do
with kids whom you are working or living with. It will help you understand how to create a safe
and supportive environment; how to provide compassionate, effective discipline; how to moti-
vate kids to try their hardest; and what to say to them when tricky situations arise. You might
choose to read the rest of the book as well; it will give you more detail on what goes on during
the therapy meetings.
Most chapters include at least one experiential exercise. If you came to learn skills, these ex-
ercises are a chance to try them out in a format carefully structured to help you learn. These exer-
cises generally work best when you do them with others; many of the exercises that are focused
on practicing an intervention can only be done with others. If you are going through the book on
your own, you'll be able to do some of the exercises by yourself. Still, for the best learning, you
should make an effort to try the interventions with kids or colleagues.
Some of the exercises involve using worksheets or forms. If you don’t want to write in the
book, take the trouble to make a good copy of the worksheets or forms. These forms have been
used, and refined, with hundreds of workshop participants. Using the given format will help you
to do well.
For easier reading, I have avoided cluttering the text with citations except where absolutely
necessary. Still, it’s important that you understand that the theories and methods taught in this
book are solidly grounded in the scientific literature and that you know where to find this litera-
ture if you want to pursue it. At the end of each book section I’ve included a brief annotated bib-
liography. This provides the primary sources—or sometimes the classic sources—for the main
topics covered in that section. The goal is not to provide an exhaustive literature review but only
to give what I believe are the best examples of the sources of interest.
We still have not found a good pronoun that refers to both boys and girls. I just don’t want to
say “it” when I really mean “he or she”! So I’ve done my best to alternate pronouns, because the
material in this book applies equally to both genders.
Finally, acomment about our professional community: Those of us who care about kids share
both sadness and hope. It’s important, for ourselves and for the kids, that the hope is paramount,
it sustains us and allows us to persevere. So how can we keep hope alive and thriving? One way
is to become more effective in our work, so that we achieve better results and have more reason
to hope. This book can be one of your strategies. Another way is to share—the sadness, the
hope, and the sense of mission—with one another. The sharing, the connection we have with
one another, also sustains us and allows us to persevere.
You are here, and I take this as a gift. Thank you for joining me, for allowing me to share with
you. I hope that your experience with this book will help you to become more effective and to
find opportunities to share and connect with your colleagues as well.
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 SECTION I:
UNDERSTANDING TRAUMA—A FRAMEWORK
FOR ORGANIZING EXISTING SKILLS

To talk about helping trauma-exposed kids, we start with the basics: What is trauma? How
does exposure to trauma affect kids? How can kids recover, heal, even grow, through dealing
with their traumatic experiences? What does it take to be a person who can help kids through this
process?
Section I lays the foundation for how to approach understanding and helping trauma-exposed
kids. Perhaps some of the material in this section—and throughout the book—will be familiar to
you. I hope you’ll be learning new things here too, but the more you already know, the better.
The goal here is to provide a framework, a systematic approach, through which you can use both
existing and new skills. The trauma-informed treatment approach does not replace the activities
and interventions you’re already doing. Rather, it helps you to organize and sequence them for
maximum effectiveness.
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 Chapter 1

Understanding Trauma

WHY TRAUMA MATTERS

If you are working with kids, chances are that you are trying to help them do better in some
way: get in less trouble, do better at school, feel less angry or sad, not hurt people. So why not
just focus on the problem? Why should we care about trauma?
Following is a partial listing of the kinds of problems kids might have that are potentially
trauma related:

Disruptive behaviors
Poor frustration tolerance
Depression
Anxiety
Poor concentration
Loss of interest in activities/goals
“Don’t care” attitude
Anger
Fighting
School absences
Substance abuse
Criminal behaviors
Noncompliance with medical treatment
Suicidal behaviors

This is not to suggest that trauma is the only reason kids have problems. But trauma can find the
child’s weak spot. Trauma is a powerful stressor that can either cause new problems or make ex-
isting problems worse. If we try to help kids but don’t take trauma into account, we risk ignoring
a driving force behind the problems. We risk being less effective.

A USEFUL DEFINITION OF TRAUMA

Trauma was previously defined as a horrific event “beyond the scope of normal human expe-
rience” (American Psychiatric Association, 1980). To qualify as traumatic, an event should be
subjectively perceived as threatening to a person’s life or physical integrity, and should include a
sense of helplessness along with fear, horror, or disgust. Such events might include being in a car
accident, house fire, or natural disaster; being raped; or being assaulted. Through research we
have learned to identify a wider range of events as being possibly traumatic—for example, wit-
nessing a parent or sibling being beaten; being diagnosed with a life-threatening illness.
The bad news is that traumatic events are not beyond the scope of normal human experience.
Although not every child will be exposed to one or more traumatic events, most will. This is not
just true for kids growing up in high-crime urban areas. Even our (presumably) best-protected
9
10 CHILD TRAUMA HANDBOOK

kids experience trauma. For example, a study of second-year college students (modal age of
nineteen) found that 84 percent had experienced at least one major trauma (Vrana & Lauterbach,
1994). Among disadvantaged urban populations, very few escape exposure to major trauma
events (see Greenwald, 2002b). Trauma during childhood and adolescence is now so common
as to be normative. When working with a child or adolescent with any kind of problem, we can’t
afford to assume that trauma is not a factor.
Although the focus here is on trauma, it is important to note that other adverse life events can
have a traumalike impact on kids. For example, a child’s response to a significant loss can be vir-
tually identical to a posttraumatic response, except that following loss, hyperarousal may not be
present (Pynoos, 1990). Indeed, the research on adjustment disorder shows that many children
do not adjust to or recover from a range of adverse events (Newcorn & Strain, 1992) but main-
tain some symptoms indefinitely.
When working with a distressed child, we do not ask if the event qualifies as a trauma before
offering help. We will offer essentially the same treatment regardless of whether the source of
the distress is an earthquake, a sexual assault, or a death in the family. In this book, the term
trauma is intended to apply to major trauma as well as loss and other adverse life events, as long
as the event has had a traumalike impact on the child.

WHAT MAKES AN EVENT TRAUMATIC?

Not every upsetting event is so intense and overwhelming that it is experienced as traumatic.
The biggest factor pushing an event into the traumatic range is, not surprisingly, how bad it is.
Several factors determine the severity of the exposure to trauma:

¢ The nature of the event itself

¢ Direct experience versus witnessing versus hearing about it or seeing it on TV
¢ Personal impact versus impact on a known person versus impact on a stranger
¢ After-event impact (e.g., lifestyle disruption)

Severity of the Event

Some events are clearly worse than others. For example, an open-hand spanking is not as bad
as being whipped with a belt, which is not as bad as being beaten to the point of broken bones. In
most cases, once the event has been described, its severity is readily apparent. However, children
with special vulnerabilities may experience certain insults especially severely. For example, be-
ing punched in the arm will hurt a child who has hemophilia more than it will hurt a child who
does not have this condition. Also, how the event is perceived contributes to its severity. For ex-
ample, a child who does not understand the danger she was in may not experience a nearly fatal
near-miss event as traumatic.

Proximity of the Experience

The more directly the child is involved in the event, the higher the risk of posttraumatic stress
symptoms. For example, in a school shooting, children witnessing the event had the most se-
vere symptoms, followed by children nearby who heard the shots but did not see the event, fol-
lowed by children farther away who neither saw nor heard (Pynoos et al., 1987). However, even
distant exposure can have impact, especially when children can personally relate or feel directly
affected in some way. For example, younger children who saw the World Trade Center towers
collapse on television, and who saw this multiple times, were exposed repeatedly to this event
 Understanding Trauma Il

because they did not understand that it was only the same event being replayed. They thought
that many buildings had been hit and were coming down, and they felt more vulnerable.

Personal Impact

Something that happens to the child or to someone he cares about is likely to have a greater
impact than something that happens to a stranger. Children take it very personally when a parent
or sibling is victimized or hurt. On the other hand, it is important not to underestimate the impact
that an apparently distant event can have on a child.

¢ A ten-year-old boy’s classmate drowned during a school outing. He did not even like the
drowned girl, but felt guilty that he had not been friendlier toward her and irrationally
blamed himself for her death.
* A five-year-old boy looked out the window and saw a neighborhood man getting beaten up.
After that he was afraid to go outside; he feared someone might beat him up too.
¢ A nine-year-old girl’s best friend’s father died of cancer. She became obsessed with the
fear that her own parents might have cancer.

After-Event Impact

This is a critical element of severity of exposure that is often overlooked. Imagine that two
identical bombs are dropped. One explodes and makes a crater in the ground. The other ex-
plodes somewhere else and also makes a similar crater in the ground, but then some nearby
buildings collapse into the second crater. Although both bombs had the same strength, the sec-
ond bomb has had more impact and thus can be considered more severe. Life experiences can be
like this too. A traumatic event is more than just the single terrible moment.

¢ A fourteen-year-old girl was in a car accident. After the crash, she did not know for a few
minutes whether her aunt (the driver) was dead or alive. In the hospital, she had to wait by
herself in a small room for almost an hour. The attendants cut off and discarded the bloody
jacket she had been wearing in order to tend to her wounds; her boyfriend had given her
this jacket and she treasured it. She was left with a scar on her lower arm and felt that she
could no longer wear short-sleeved shirts or bathing suits.
¢ A four-year-old boy’s father died in a work-related accident. His mother became depressed
and withdrawn. Spring came around and the boy’s father was not there to teach him how to
catch a baseball. He’d already received a baseball glove for Christmas. Father’s Day came.
His birthday. His first day of school. (This could go on indefinitely, as major losses can
have fresh impact at every developmental milestone.)
¢ An eleven-year-old girl lost an uncle in the World Trade Center disaster. Even a month
later, her parents were upset all the time and couldn’t seem to talk about anything else.
Also, her school wasn’t any good anymore; everyone there was angry now because
hundreds of kids from some other school were all crammed in there too, until they could go
back to their own school again.

In other words, it’s not just the event itself but the circumstances surrounding and following
the event that may make it traumatic rather than merely upsetting. Personality, social support,
and other factors (discussed later in this chapter) also help to determine whether a child can han-
dle an event or will be overwhelmed.
Ve: CHILD TRAUMA HANDBOOK

THE “TRAUMA WALL”

A popular saying is that “What doesn’t kill you makes you stronger,” or, less colloquially, that
we grow from adversity. Although this certainly can be true, it is not always the case. Sometimes
what doesn’t kill you may still hurt you or cause damage. So how does this work—why does it
go one way rather than the other?
Here a food analogy is helpful. Usually, we chew food, swallow it, and digest it. It becomes
part of our nutrition, something we can grow from. Ideally, we do something similar with an up-
setting experience. Kiibler-Ross (1969) described a similar process in the stages of processing
Orlels
For example, let’s say your dog dies. Maybe you don’t think about it or process it every min-
ute of the day, but now and then you do think about it, remember different aspects: how frisky
she was when you first got her, how she liked to have her belly scratched, how badly you feel
about having let her out the day she got hit by a car. You remember, you talk to others, you take a
walk, you write, you cry, you laugh. Little by little—or bite by bite—the hurt becomes smaller
as more gets processed, integrated, “digested.” When an upsetting experience is digested, it be-
comes your nutrition, something you grow from. Then it becomes part of long-term memory,
part of the past. It is not as fresh or upsetting anymore. Along with the emotional processing, we
have organized the elements of the experience into a coherent story, including a perspective that
allows us to move on. For example, you might say to yourself, “Well, she loved to play outside. I
guess there was always the risk of an accident, but she would have been miserable tied up,” and
“She was a great dog. I'll always love her.”
However, sometimes upsetting experiences do not get processed in this ideal way. Sometimes
it’s just too much to face, to take bites out of. Maybe the event was too upsetting and overwhelm-
ing; maybe you try to talk about it and are punished for that (perhaps by parents getting upset or
peers teasing); maybe just when you are ready to take a bite out of this upsetting memory, an-
other one comes along. It can be so difficult to face this upsetting memory, to tolerate it, that
many people try to push it aside, push it behind a wall. That brings quick relief, so the strategy is
experienced as helpful. Unfortunately, it provides only a temporary solution.
Back to the food metaphor: Imagine that you have eaten some food that is bad for you or poi-
sonous. Ideally you will be able to get rid of it somehow. Maybe you'll be shaky or sick for a lit-
tle while, but it’Il be gone from your system. Unfortunately, with an upsetting experience, you
can’t just reject it and flush it down the toilet. The only way out is to go through—through the
memory processing system into long-term memory. Until the memory is processed, or digested,
it stays behind the wall.
Although the wall may provide some relief, this system has problems. First, the memory
stays fresh and keeps its power indefinitely, until it is digested. I have worked with people
months, years, and even decades after the trauma, and the quality of the undigested memory is
the same. When asked to concentrate on the memory, they say things like, “It’s so vivid it’s like it
just happened yesterday,” or, even more telling, “I’m there.”
Also, although the memory retains its freshness and power, it is still behind the wall, so we
can’t get at it with the rest of our psychological resources the way we can with processed memo-
ries. This means that the memory, or parts of the memory, can negatively influence us and we
may feel helpless to stop it. For example, many rape victims will say, “I know in my head that it
wasn’t my fault, that I didn’t do anything wrong, that I didn’t deserve that. But I can’t help feel-
ing ashamed, dirty, to blame.” In other words, the healthy part that knows better can’t manage to
influence the powerful beliefs and feelings that are shielded behind the wall.
Furthermore, the memories stored behind the wall are not content to stay there. They are al-
ways waiting for a chance to come out, go through the system to be digested, and become part of
the past. It is as if the memory is seeing its chance and saying, “Me too! Can I finally be treated
 Understanding Trauma Is

like a normal memory and get processed already?” When this happens, we say that the memory
was “triggered” or activated by a reminder, something thematically related. Another way of ex-
plaining this is that the stuff piled up behind the wall is like a “sore spot,’ and when some kind of
reminder hits that sore spot, the reaction is stronger than others might expect. This is because the
person is not just reacting to what’s happening right now; the old stuff is kicking in, too.

* Most of us who drive are at least a little nervous about driving. This is reasonable and in-
spires us to put on our seat belts and watch out for bad drivers. However, we are still able to
enjoy conversations with our passengers, listen to the radio, and think about where we are
going. Now think about the woman who experienced a car accident because she couldn’t
stop on a snowy road. Afterward, whenever she got into the driver’s seat, she had the usual
amount of nervousness, plus all the extra fear from behind the wall. You’ve probably seen
people like her on the road, clutching the wheel and gritting their teeth as if they are expect-
ing an accident to occur at any second. On rainy or snowy days, so much of the fear piled on
that she could not manage to drive herself to work.
* Most of us, when accidentally bumped in the hallway, will be slightly irritated, perhaps
make a comment, but forget about it five minutes later. Now think about the twelve-year-
old boy who has been routinely physically abused at home. Behind the wall is piled-up fear
of being attacked, a sense of helplessness, and rage. When he is bumped in the hallway, the
“sore spot” reaction from the stuff piled up behind the wall is so strong that he believes he
is being attacked. Naturally, being angry and not wanting to feel helpless anymore, he de-
fends himself. When he is sent to the assistant principal’s office for “punching a peer with
no provocation,” he insists that the other kid started it.

Note that it is not necessary to be aware that an unprocessed memory is being triggered for it
to be happening. Sometimes the person will be acutely aware of it, as unwanted images from the
memory itself come back. For example, one thirteen-year-old girl said, “Every time my boy-
friend tries to kiss me, I freak out. I see the face of that guy who messed with me when I was lit-
tle.’ However, often the person is unaware of the impact of the behind-the-wall memory and just
subjectively experiences a strong reaction to the present situation. For example, a sixth-grade
boy who has experienced several events involving helplessness may give up too quickly when
he does not immediately grasp how to do his math homework. He may say, “It’s too hard—I
can’t do it” when he probably could do it with a little effort—if he weren’t overwhelmed by the
“sore spot” helplessness from behind the wall.
We all understand this phenomenon. We understand that people have their wounds, their sen-
sitive areas, their sore spots. We say, “Don’t mention John around her, unless you want her to
start crying,” or “Don’t joke like that with him—he’II go ballistic.” What we mean is that there
are unprocessed memories piled up behind the wall that can get triggered by thematically related
events in the present. We understand that people can be more reactive than the current situation
warrants when they are hit on their sore spot. This is one of the consequences of carrying trauma
memories that are not fully processed.

RESILIENCY AND VULNERABILITY

Beyond the objective severity of the event itself, several factors contribute to determining
whether a given upsetting experience is ultimately processed or pushed behind the wall.
14 CHILD TRAUMA HANDBOOK

Social Support

The choice to face and digest an upsetting event versus pushing it behind the wall occurs in a
social context. Children may not want to talk about upsetting thoughts and feelings around their
peers for fear of being rejected and isolated. At home, kids may not want to worry their parents
or other family members. When a parent says, “Don’t talk about that. It'll only upset you!” the
child learns, ““Wow—this is so bad and scary that even Mom/Dad can’t handle it!” So unless
kids are in an accepting and supportive environment, they may be getting messages that do not
provide support for talking about the trauma and that discourage processing.

Temperament

Pain threshold is a familiar concept that can be applied to emotional pain as well. People are
unique in the ways they experience events. The same event with the same severity will bother
one person more than another. Extending an earlier analogy, two identical bombs might make
different size craters for each person. Furthermore, even if the same size bomb is making the
same size crater for two people, it might bother one person more than the other. For example, on
a 0-10 scale of severity of emotional upset, two kids might each report the same event as being a
6. However, one child might experience that 6 as no big deal, and the other might find it intolera-
ble. Obviously, the more difficulty a child has with tolerating pain, the more tempted that child
will be to push the memory behind the wall.

New and/or Repeated Insult/Wound

Suppose a child has experienced a minor everyday type of upsetting event, such as a peer in-
sult or a school-related frustration. She is on track to digest it and is just getting ready to take a
bite when some new stressor comes along, and then another, and another, and another. Eventu-
ally so many of these small events pile up that the pile is experienced as “too much” and pushed
behind the wall. This pileup of minor events commonly occurs in kids who have an untreated
learning disability or attention deficit/hyperactivity disorder (ADHD); kids who are bullied; and
kids who are subject to emotional abuse.
You might have noticed that we just expanded our definition of trauma. If it’s behind the wall,
it counts. If it’s behind the wall, it’s creating sore spot reactivity, whether the sore spot comes
from one big event or a hundred smaller ones.

Attachment Status

Some preliminary research suggests that attachment status can, to some extent, predict the
child’s preferred coping style. This also makes sense. How do you become someone with a se-
cure attachment? You do this by having a “good-enough mother” (Winnicott, 1965). This parent
figure actually doesn’t need to be a mother, but he or she does need to be good enough! When
you have a good-enough mother, you learn, through repeated experiences over time, that if
you’re cold, soon you’ll get warm again; if you’re hungry, soon you’ll get fed; and if you get so
angry that you want to kill, your mother will survive and so will you; she will not retaliate or re-
ject you. In other words, in the process of developing a secure attachment, kids learn that al-
though they may not like to feel bad, they can handle it and things will come out okay.
When securely attached kids have to deal with a trauma memory, they have an experience
base and coping style that favors facing it and getting through it. Incidentally, kids with secure
attachment are also more likely to have good social support, because they are probably still in
 Understanding Trauma us)

the family in which the attachment was formed, and because they are more capable of forming
other supportive relationships.
On the other hand, how do you form anxious, insecure, or disorganized attachment? You do
so by having a (subjectively experienced) not-good-enough mother, or a good-enough-some-
times-but-not-other-times mother. Kids with problematic attachments have learned, through re-
peated experiences over time, that feeling bad can be disastrous and overwhelming. If you are
cold, you might get warm, or you might stay cold and miserable. If you are hungry, you might
get fed, or you might just get hungrier. If you get so angry that you want to kill, you might get re-
jected or attacked. In other words, in the process of developing a problematic attachment, kids
learn that feeling bad is a danger sign, to be avoided if possible. When such kids have to deal
with a trauma memory, they have an experience base and coping style that favors trying to push
it out of the way, to get rid of the threat.
The more severely problematic type of attachment status is known as failed attachment or re-
active attachment disorder. Unattached kids may experience trauma in a qualitatively different
way than other kids do; they also have some unique ways of responding to various interventions.
The treatment of kids with the most severe attachment problems is beyond the scope of this
book. The treatment approach presented in this book is still necessary in their treatment, but it is
not sufficient; an additional specialized treatment component is needed.

Safety and Attachment

There are also other consequences of traumatization. In Erikson’s (1963) developmental the-
ory, the first stage of development is trust versus mistrust. With a good-enough mother, the in-
fant learns through repeated experience that he or she will be taken care of, that the world is a
safe place. Trauma can alter that perspective, reverse that lesson.
We have understood this since the beginning of the modern era of trauma study. In the World
War I literature on post-traumatic stress disorder (PTSD, which was called “shell shock” then),
it was reported that soldiers under bomb attack would frequently call out either for God or their
mothers. What is the significance of this? The first promise was being broken: “The world is no
longer a safe place. I am not being taken care of. Mother, God, you lied to me.”
Attachment and safety are inherently related, and when children feel unsafe they seek the
comfort and protection of their primary attachment figures. The toddler at the zoo is not fright-
ened by the tiger; he is safe with his mommy. However, trauma can disrupt attachment, in part
because the attachment figures have, by definition, failed to protect and an unimaginably bad
thing happened.
Some kids may react to this trauma-related attachment challenge by withdrawing, whereas
others may seek out new attachment figures who are perceived as more likely to protect. For ex-
ample, although there are practical reasons for affiliating with street gangs, the explanations
kids offer are revealing: “We watch each other’s backs,” and “This is my family.”

SURVIVAL ORIENTATION

When children are exposed to trauma, they learn that parents and others cannot be relied upon
for protection; they learn that bad things can happen. They then make a profound shift in their
worldviews, in their orientations to daily living. Instead of focusing on normal concerns and ac-
tivities, the primary focus becomes keeping the bad thing (or other bad things) from happening
again. When we say someone has “Jost her childhood,’ this is what we mean. The child ex-
changes the healthy (if irrational or naive) optimism for a survival orientation.
16 CHILD TRAUMA HANDBOOK

POSTTRAUMATIC SYMPTOMS

Many posttraumatic stress symptoms can be understood from the perspective of the sore-spot
reactivity, plus the survival orientation.

Reexperiencing

Reexperiencing, one of the primary posttraumatic symptoms, refers to instances in which the
memory itself recurs or intrudes into awareness. The child might complain that he thinks of the
memory “all the time” or that it comes to mind at random moments, without warning. However,
on analysis, it turns out that such intrusions generally occur when they have been triggered by
something in the present. Most people find these intrusions disturbing and disruptive. Flash-
backs are an extreme and relatively rare reexperiencing symptom; nightmares and waking
memories are much more common.

Avoidance

Avoidance, another of the primary posttraumatic symptoms, relates to both the sore-spot re-
activity and to the survival orientation, the wish to keep any more bad things from happening.
For example, a traumatized child might avoid walking down a certain street where she had been
hit by a car, both to avoid a recurrence of the accident and to avoid being reminded of the mem-
ory. Avoidance can have significant impact on many areas of life:

¢ A fourteen-year-old boy, whose best friend had abandoned him during a street fight, says,
“T don’t have friends, only associates. Friends let you down.” He is avoiding the possibility
of being let down again by not trusting anyone anymore.
¢ A fifteen-year-old girl with exposure to multiple traumas is not doing much in the way of
schoolwork, and she is having unprotected sex. She says, “What does it matter? Nothing’s
going to work out for me anyway. Why bother making the effort?” She is avoiding the pos-
sibility of feeling disappointed again by not getting her hopes up, not feeling optimistic,
not setting goals for herself (the technical term for this is pessimistic future).
¢ A nine-year-old boy, who had been hit by a car while on his bicycle, has quit his baseball
team. He says, “I just don’t feel like going anymore.” In fact, he’s not going anywhere ex-
cept school and home, because he doesn’t feel safe anywhere else. He’s learned that bad
things can happen out in the world, and he doesn’t want any more bad things to happen to
him.

Hyperarousal and Hypervigilance

Hyperarousal and hypervigilance are also common outcomes of traumatization. Many chil-
dren are in a constant state of alert, on the lookout for possible signs of danger. When kids are
primed to expect the worst, they can be jumpy when startled or threatened. The problem is, when
you think you’re a nail, everything looks like a hammer. So many kids will interpret neutral or
ambiguous social cues as being threatening (the technical term for this is hostile attribution
bias; see Dodge & Coie, 1987). For example, a boy may notice a peer looking his way and as-
sume that the peer is showing disrespect and trying to start a fight. Of course, this kind of
assumption leads to problems!
 Understanding Trauma 17

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Numbness

Many traumatized kids find themselves “numb” or unable to feel certain (or most) emotions.
This may be a “freeze” response to being overwhelmed or it may be a special kind of avoidance.
Some kids will say, for example, “I can’t let myself feel anything or I’l feel everything; it’l] all
come back. And that’s too much,” or, “I’m afraid that if I start crying, I'll never stop.” The numb-
ness solution is to block it all out.

Substance Abuse and Other Avoidance Strategies

Many traumatized kids are unable to effect that numbness and so seek activities that will help
them “forget about” the memory or related affect. For example, some kids become thrill seekers,
troublemakers, or workaholics to stay busy and distracted with attention-compelling activities.
Many youth turn to substance abuse to keep the trauma memories away, if only for a while. One
nineteen-year-old boy who had been brutally assaulted by peers said, “I think about it every
night. It keeps me awake for hours. I have to catch a buzz [smoke marijuana] to get myself to
sleepy

Affect Dysregulation

The technical term for sore-spot reactivity is affect dysregulation. We should not use this term
in front of our clients, but it’s important to understand it. Breaking it down, affect is emotion, and
dysregulation means unregulated, out of control, or volatile. Emotions may become out of con-
trol when traumatized kids react very strongly to minor stressors because they are already sensi-
tized. This in-the-moment reaction, perhaps of anger, fear, sadness, shame, or helplessness, can
18 CHILD TRAUMA HANDBOOK

¢ BUTT HARDLY 4
(TOUCHED HIM!?
=
5 é
Sauce Play. Pruanr food
Her eral

be very intense and uncomfortable, even intolerable. The fear of these reactions drives many of
the avoidance behaviors.
Also, kids who react very strongly to minor stressors are at a high risk of impulsive acting out
behavior (van der Kolk et al., 1996). The impulsive acting out provides quick relief from the in-
tolerable feeling, but often leads to other problems. It is likely that unprocessed trauma plays a
significant role in the acting-out problems of many kids with oppositional/defiant and conduct
disorders (Ford, 2002; Greenwald, 2002b).

Posttraumatic Symptoms over Time

Unfortunately, kids don’t just “get over” their traumatization. The memory (and associated
symptoms) doesn’t just fade away with time. It stays fresh as long as it’s behind the wall. It stays
fresh until it’s digested. But what does it take for digestion to be possible? What needs to happen?
Going back to the food analogy. Suppose you’ve just had a nice lunch and you’re back at
work. Someone bursts into your office and announces that there’s a bomb scare in the building,
so you have to rush out and go somewhere else. Meanwhile, your nervous system is shifting
from parasympathetic to sympathetic, and the blood is going away from the stomach to supply
the brain, arms, and legs. This allows you to escape and survive. Twenty minutes later you hear
an announcement that the whole thing was a hoax—there’s no bomb. You go back to work and
gradually your nervous system shifts back to parasympathetic. The blood goes back to your
stomach, and you can proceed with digestion.
This return to relaxation does not happen with posttraumatic stress symptoms because they
are self-perpetuating. The need for survival mode is repeatedly reinforced, with no shift to safety
and relaxation, no opportunity for digestion:
 Understanding Trauma 19

* A young girl who had been assaulted on a certain street walks the long way home from
school to avoid going down that street. She may say to herself every day that she does this,
“Phew! I escaped another assault.”
* A girl who was raped by the babysitter—who is now in jail—is bullied by her big brother in
minor ways on a daily basis. She learns, over and over again, that males who are bigger and
more powerful than she is can have their way with her. Her “psychological truth” is that she
is in constant danger.
* A previously victimized teenaged boy believes that he is being stared at by a peer and inter-
prets this as a hostile affront. If he
—quickly leaves the situation, he may say to himself, “Phew! I got away! I’m glad I’ve
stayed so alert.”
—challenges the peer, who then backs down, he may say to himself, “I defended myself
well.”
—challenges the peer, who responds by fighting, he may say to himself, “I was right: he
was hostile.”

Regardless of specific outcome, these posttraumatic symptoms serve to reinforce the percep-
tion that the world is still dangerous. Every avoidant behavior—such as walking the long way
around—only provides relief from fear, and reinforces the perceived need for avoidance. The
defensive-intent aggressive behaviors also are self-reinforcing: by forcing the other’s with-
drawal or hostility, the need for the defensiveness is confirmed. Since traumatized kids tend to
be hypervigilant and to overinterpret neutral cues, these types of situations may occur fre-
quently. As long as kids remain in survival mode, they do not feel safe and are not prepared to
relax or to digest their trauma memories.
Posttraumatic stress symptoms can also make it more difficult for kids to handle new chal-
lenges in a healthy way. A new upsetting experience may be hard enough to manage already.
However, when this new experience triggers trauma-related reactivity from something that’s al-
ready behind the wall, the reaction to the new experience can be much stronger than is appar-
ently warranted. This extra-strong reaction can make it even more difficult to manage the new
experience effectively, and the child is more likely to push the memory behind the wall rather
than attempt to digest it. Thus, previously traumatized kids are at a higher risk for being over-
whelmed, and traumatized, by new upsetting experiences.
The more trauma memories (and associated thoughts and feelings) are piled up behind the
wall, the more likely this “trauma burden” (Greenwald, 1997) will affect the child’s daily life. A
single memory might be well contained, at least until the child is faced with a very closely re-
lated reminder. For example, after an initial period of adjustment, children of divorce tend to
look and act like other kids, with no special problems—at least until they get old enough to at-
tempt their own intimate/romantic relationships (Wallerstein, Corbin, & Lewis, 1988). Because
kids can be good at containing or hiding their distress, many parents come to believe that the
child has “gotten over” the trauma.
As unprocessed trauma accumulates behind the wall, two things happen. First, the strength of
the reactivity to a current stressor is likely to be greater, so others are more likely to notice that
the child is overreacting to things. Second, the child is more likely to overgeneralize and practice
a wider avoidance. This is because humans are good at recognizing patterns and can use this
ability to avoid repeating the same mistake. However, a traumatized child’s interest in avoiding
further trauma can be so powerful that she may take avoidance to an extreme.
Following is an example of how avoidance might be generalized from a specific identified
high-risk situation to other less high-risk situations:
20 CHILD TRAUMA HANDBOOK

¢ I won’t be alone in a room with Uncle Matt anymore. He messed with me last time.
¢ Uncle Matt has a beard—that must be it. I guess I can’t trust men with beards.
¢ I can’t trust men.
¢ I can’t trust.

Pessimistic future can develop in a similar way:

¢ Wow—something bad happened. I didn’t know that could happen.

¢ Something bad might happen again. I'd better be careful.
I know bad things are going to happen.
Only bad things will happen, and good things will turn bad, so why get my hopes up?

In summary, posttraumatic stress symptoms can persist indefinitely and can lead kids to react
very strongly to minor stressors. In fact, sometimes others don’t see any stressor at all, because
we don’t know what might be a trauma reminder to the child. When the triggers are not apparent
to others, we are prone to forming opinions about the child’s behavior that are not based on un-
derstanding. For example, we may be likely to assume that a child is gratuitously aggressive
when, from his point of view, he is only defending himself.

A NOTE ON EXERCISES/ACTIVITIES IN THIS BOOK

The exercises and activities are included because they are likely to help you to learn the mate-
rial. People tend to learn best when engaging personal experience is part of the lesson. Because
this book is focused on trauma, the experiential component sometimes focuses on trauma as
well. Participation in such experiences might hurt your feelings or at least bring up hurt feelings
that were otherwise dormant. In live workshops, most people find that they can handle this and
they are glad they participated. However, occasional exceptions do occur.
Although in general the value of the learning will outweigh the potential for discomfort, it
will be up to you to make that determination for yourself at each instance. You will want to con-
sider not only the value of the lesson but the possible impact of participation on your emotional
status and functioning, in light of your current situation/surroundings and your plans for later in
the day. You always have several options:

¢ Participate fully in the activity.

¢ Participate until you determine that your distress level is as high as you are willing to allow
it to go; then stop.
* Participate but carefully select the content (e.g., which memory to focus on) to avoid an un-
wanted level of distress.
¢ Decline to participate.

Bear in mind that sometimes you get more than you bargained for. If you choose to participate
and then find that it is too much for you, it is important to take care of yourself and make sure
that you’re okay. Here are some suggestions in this regard:

* Do the deep breathing or another of the calming exercises that are presented at various
points in the book.
* Use any of your usual coping skills/methods as long as they are constructive (e.g., thinking
of something else, taking a walk, listening to music, etc.).
* Discuss your concerns with the workshop leader if you are attending a workshop.
 Understanding Trauma 21

* Discuss your concerns with a trusted family member, friend, colleague, or supervisor.
* Discuss your concerns with a mental health professional.

EXERCISE: FLOAT-BACK

The main purpose of this exercise is to see how trauma-related triggers may be active in your
own life. When you see how a principle applies to you, you can use your experience to better un-
derstand others. Another purpose of the exercise is to directly experience an activity that you
might ask a client to do. For this exercise, you’Il need a pencil or pen and paper.

Float-Back

1. Think of a situation that happened within the past couple of days in which you were some-
how distressed: upset, mad, worried, hurt, sad, frustrated, etc. It doesn’t have to be any-
thing major. The first thing that pops into your head is probably the right one.
2. On a scale of 0-10, 0 is no bad feeling at all, 10 is the worst a feeling could possibly be.
Concentrate on the worst part of the recent event. Notice the picture in your mind, what you
are saying to yourself, and what you are feeling. On a scale of 0-10, how bad is the feeling
right now as you are concentrating on it? (Not how bad it was then.) Write that number
down.
3. Now as you are concentrating on this recent memory, again notice the image, what you are
saying to yourself, what you are feeling, where you feel this in your body. Now try to make
the feeling even more intense.
4. Let your mind float back in time, maybe a long way back, to when you first learned to feel
this way. If something pops into your head, maybe that’s it.
5. Now ona scale of 0—10, with 10 being the worst the feeling could be, how bad is the feeling
from the old memory right now as you are concentrating on it? (Not how bad it was then.)
Write that number down.

Deep Breathing

Because I asked you to think about something that might be upsetting, now I will ask you to
do a deep-breathing exercise that might help you to feel better, to relax again. You might not
need this, but please do it anyway for the experience. You will be taking a very deep, slow breath
in, to a count of three, then hold for three, then breathe out slowly to a count of three. Ready?
Breathe in 1, 2, 3; hold 1, 2, 3; out slow 1, 2, 3. Again, breathe in 1, 2, 3; hold 1, 2, 3; out slow
ia:
This time, when you breathe out, look for any bad stuff—tension in your body, upsetting
thoughts or pictures—and when you breathe out, imagine the air coming from that place and the
bad stuff going out with the exhale. Ready?
Breathe in 1, 2, 3; hold 1, 2, 3; breathe out the bad stuff, 1, 2,3. Once more, breathe in 1, 2, 3;
hold 1, 2, 3; breathe out the bad, 1, 2, 3.

Discussion Questions

How many (ina group, raise hands) had a higher number—a worse feeling—for the old mem-
ory than for the recent one? (Normally about three-fourths of the group will raise hands here.)
What might this mean?
22 CHILD TRAUMA HANDBOOK

¢ What was once significant may maintain its influence, even over a long time period.
¢ Do you think that, for you, your reaction to the current event was at least in part due to hit-
ting the sore spot from the old one?

How many (in a group, raise hands) had a higher number—a worse feeling—for the recent
memory than for the old one? (Normally about one-fourth of the group will raise hands here.)
What might this mean?

¢ Perhaps the recent event was actually a major trauma, although the odds are against this.
¢ What’s fresh may feel more relevant than something that happened a long time ago.
¢ Will kids believe you when you say that the recent event is not relevant?

The trick here is that both answers are the right answer, and with kids we must somehow ad-
dress both the past and the present if we are going to be helpful.

A twelve-year-old boy had been doing pretty well until his mother died suddenly, when he was seven.
Since then, he has done worse in school, had a short temper, and gotten into a lot of fights. You are abso-
lutely sure that his problems are directly related to the death of his mother (and you’re right). But when you
bring this up, he storms at you, “Everybody wants to talk about my mother all the time! I’m sick of talking
about my mother! That’s not what’s bothering me! My problem is that my teacher picks on me. I’m the one
that gets in trouble even though the other kid started it!”

If you insist on talking with him about his mother, what will probably happen? He will feel
disrespected. He is trying to tell you what is important to him and you are ignoring him. He will
then discount you and become uncooperative. This is especially tempting for him because then
he can avoid talking about his mother! And you lose your chance to be of service.
But if you do it his way and talk only about the problem of the day, what will probably hap-
pen? He will feel respected, he will work with you, and he might even learn a few problem-solv-
ing or other coping skills. But the core problem will remain because the source of his reactivity
never gets addressed. He might go from one counselor to the next for years and never solve his
problem.
So what do we do about this? How do we address the past as well as the present? I’ll tell you
later! This is the part of the book in which we try to understand what’s going on with traumatized
kids. Later on step-by-step guidance is available for what to do and how to help them. In the next
chapter we take the first step, by learning how to analyze a presenting problem to take into ac-
count both past and present-day contributing factors.
 Chapter 2

The Structure of Trauma Treatment

An understanding of traumatized kids’ experience is a good first step. However, to know what
to do about it, we must also understand exactly how the child’s posttraumatic stress symptoms
might relate to the current presenting problem. The next step will be to use that understanding to
determine a course of action.

MEANING OF BEHAVIOR

Just about half of all child/adolescent mental health referrals are for problem behaviors
(Kazdin, 1987), so problem behavior is a good example to use for the present focus on under-
standing the child’s presenting problem. However, the same principles will apply to kids’ pre-
senting problems and symptoms more widely, whether or not problem behaviors are part of the
picture. Based on this discussion, following is a summary of the possible role of trauma in prob-
lem behaviors:

¢ Kids learn from experience. Trauma can be an intense experience that teaches powerful,
long-lasting lessons. These lessons—or negative beliefs about the self and the world—are
protected behind the wall and may not be amenable to rational intervention.
¢ Unprocessed trauma creates a pileup of unprocessed feelings, possibly including shame,
guilt, anger, fear, hurt, helplessness, and sadness.
¢ Thematically related reminders of the trauma may trigger a heightened response, or over-
reaction, to the present situation. This happens when the new stressor hits the sore spot;
then the negative beliefs and the piled-up feelings kick in.
¢ When a child is experiencing an intense reaction which includes a distorted interpretation
of what is happening and which feels intolerable, the child is at high risk of impulsively
acting out.

In sum, problem behaviors may be set in motion by present-day minor stressors that trigger a
trauma-related overreaction. How often are kids’ problem behaviors related to their overreaction
to a trauma-related trigger? How do we figure this out for a given child? What kind of informa-
tion do we need?
Following are the suggested steps (again, details on how to accomplish these steps are pro-
vided later):

1. Get a good trauma/loss history.

2. What would someone learn from this (trauma/loss) experience? What negative beliefs
might the child develop?
3. What kinds of feelings might be piled up behind the wall?
4. Learn details about the context in which the problem behavior occurs. What is the apparent
precipitating event? In what way might that be a trauma-related trigger?
23
24 CHILD TRAUMA HANDBOOK

5. What is the problem behavior? How does it relate to the trigger? Why has this problem be-
havior become the child’s solution to this situation? Does it serve to make the child feel
safer or better in some way? Does it get rid of the bad feelings?

When we meet a child, often we are only told what “the problem” is. We need to know more.
We need to know what the problem means to the child, how it serves the child’s needs. To be-
come proficient at conducting a trauma-informed “meaning of behavior” analysis, it is useful to
practice by breaking down the analysis into these steps.
Provided in this chapter is a Meaning of Behavior Worksheet for you to use in practicing
these steps. Make photocopies of the worksheet to have on hand for your own future use. Shortly
you'll have the opportunity to practice completing the worksheet using some case examples.
Following is an illustration of how this might be done.

Meaning of Behavior Worksheet Example

Casey

Casey is an eight-year-old boy who is referred for frequent fighting in school and in his neighborhood.
He has a history of witnessing domestic violence—seeing his father push his mother and hit her—and
has tried unsuccessfully to protect his mother from his father. Casey tells you that he does not pick fights
but only defends himself when other kids gang up on him and call him names.

Here is an abbreviated example of how you might fill out the worksheet:

1. Trauma/loss event: Saw father push and hit mother.

2. Lesson learned (negative belief): 1am powerless.
3. Piled-up feelings: Anger, fear, shame.
4. Trigger situation: Theme: feeling threatened or attacked; example: being teased by other
kids.
5. Problem behavior: Fighting.

Here is the story (the explanation) you might tell. Notice that the order of events in the story is
the same as the order of steps on the worksheet.

1. There were times that Casey saw his father hurting his mother. Casey tried to stop it from
happening, but he couldn’t. He was too small.
2. Kids learn from experience. Kids who have had this kind of experience often learn to be-
lieve that they are powerless, that they can’t protect themselves or those they love, that they
are not good enough.
3. Also, when something like this happens, kids often have very strong feelings, like being
afraid that someone will get hurt, being mad, and being ashamed that they can’t stop it
from happening. These feelings can be so big that they just pile up inside and leave a big
sore spot.
4. Now, no one likes to be teased; it bothers everyone at least a little. But when Casey is
teased, I can’t help but wonder if it might be hitting that sore spot from the old thoughts and
feelings that are piled up inside. Then his reaction is much stronger than other people think
it should be. Then the bad feelings might be so strong that he can’t stand it, and he has to
get rid of them somehow.
5. So his solution is to attack the kids who are teasing him. When he hits them, this gets rid of
the bad feelings. It gets out his anger. Also, he doesn’t feel powerless anymore; he feels
like he is able to protect himself.
 The Structure of Trauma Treatment 25

Here are some tips on how to complete each of the sections on the form:

I. Trauma/loss events. Include any specific past events that might be stuck behind the wall
and contributing to the current sore spot reactivity. These must be actual events, specific mo-
ments in time when specific incidents occurred. List the actual event (saw father push mother),
not a label for the event (witness domestic violence). If you believe that the trauma actually con-
sists of many small events, still be specific (told she was stupid by father many times) rather than
general (emotional abuse). Note that even if the recent trigger situation was traumatic, it does
not go here on the form.
2. Negative beliefs. Ask yourself: What kinds of lessons would a child tend to learn from
those kinds of events? What would the negative beliefs be? The concept of negative beliefs is a
bit complicated but worth getting right. Two kinds of beliefs come into play here. The first is
about “who I am” and can be expressed as a negative self-statement such as “I am a bad person,”
“Tam not safe,” or “I’m not good enough.” This is the type of negative belief that we use in Step
2 of this worksheet. The other is a belief about cause and effect, what works in the world, such as
“Tf Iam stubborn, Pll get my way,” or “IfIfight, I'll feel big and powerful instead of small and
helpless.” This type of belief comes from modeling as well as direct experience—what is rein-
forced. This type of belief is what informs the child’s choice of a “solution” or problem behavior
and is considered (but not necessarily spelled out) in Step 5 of the worksheet.
3. Piled-up feelings. Ask yourself: What kinds of feelings might kids tend to have with those
kinds of events, along with those negative beliefs? Most people find this step fairly straight-
forward. Watch out for one thing, however: In everyday talk we often confuse the language of
thoughts and feelings. For example, someone might say, “Boy, do I feel stupid!” Technically,
though, the negative beliefs might be “I am stupid” and “I’m inadequate,” whereas the piled-up
feelings might be shame, frustration, and anger. Try to keep beliefs and emotions in their proper
sections.
4. Trigger situation. This section has two parts. First we need a theme. What kinds of things
hit the sore spot and set this kid off? How would these situations be characterized? What do they
have in common? Then we need specific examples, typically recent and/or common specific in-
stances that the child can easily recall which represent the theme in action. An example is spe-
cific when it includes time, place, and action.
5. Problem behavior(s). These should really be called solution behaviors. They are used ha-
bitually because the child has learned that they solve the problem; they make the trigger situa-
tion’s intolerable feelings go away. Again we are looking for very specific behaviors (not gener-
alizations or labels), what the child actually does to manage the trigger situations.

EXERCISE: MEANING OF BEHAVIOR

The following are some vignettes that you can practice with. In a group, talk together at each
step before individuals write in their worksheets. For each vignette, complete the worksheet in
order, starting at the first step (trauma/loss), filling in as many items as you can, then moving on
to the next step. It is okay to fill in things that you can guess may be true, even if they are not
specified in the vignette; use your experience and judgment here. Of course, we won't be sure
about these things, but they are worth noting and then exploring with the child and family.
You may find yourself tempted to simply tell the story and give the explanation, without do-
ing all of the steps. My experience as a trainer is that if you yield to this temptation, you'll be do-
ing what you already know instead of trying something new; and you won’t learn as much. Ten-
courage you to go step by step. Just fill out the form. Telling the story will be addressed in a later
chapter.
26 CHILD TRAUMA HANDBOOK

A sample response is included for the first vignette, but the point is to try it out for yourself
and then use the sample response to check your work. If you are confused by a discrepancy,
check back to the tips for completing each of the sections.

Damian

Damian is a thirteen-year-old boy who has a history of witnessing domestic violence as well as direct
physical abuse, until his parents divorced when he was seven. His mother reports that he is respectful to
her and helps out with the younger children when he is at home. He is a friendly, outgoing boy who seems
to be popular with both boys and girls. However, his gregariousness has been escalating into verbal ag-
gression: teasing peers, rudeness with teachers. The current referral follows an incident in which he phys-
ically intimidated a small female teacher by “getting in her face” without actually touching her or verbally
threatening harm. You learn from Damian that (1) he did not intend to hurt her and (2) she asked for it, i.e.,
she criticized him for not knowing an answer and made him feel stupid in front of the class.

Jody

Jody is a seven-year-old girl, previously high functioning, who began wetting her bed and having night-
mares following the anniversary of the World Trade Center attack. Her house burned down three years
ago (she was not home at the time). She has also been picking on her younger sister more recently. The
event precipitating the referral was a crying jag at school that occurred after a teacher asked Jody why
she hadn’t completed a quiz.

Michael

Michael is a ten-year-old boy who was diagnosed with ADHD at age nine after two years of school-
related problems including impulsive/disruptive behavior, interpersonal conflicts, and poor work habits.
Medication at age nine seemed to help at first, but after a few good weeks, his school performance deteri-
orated again. Trauma/loss history includes a minor auto accident at age five and the death of an uncle at
age six.

Jessie

Jessie is a fourteen-year-old girl who was recently arrested for harassing peers (Swearing at them,
threatening, and throwing rocks) along with other girls. This precipitated the referral. She claimed that the
harassed peers started it, were telling lies about her and her friends, and were threatening them as well.
She was molested between age six and seven by her mother’s live-in boyfriend. When this was discov-
ered, her mother kicked the boyfriend out of the house.

Exercise Follow-Up

Note that although the examples in the vignettes focused on active problem behavior, the
same trauma-informed model can be applied to kids with emotional problems such as depres-
sion and anxiety. These kids also may overreact to trauma-related triggers, leading to increased
symptoms. Again, this does not mean that trauma is the only cause of any problem. However,
when the trauma component is recognized, a more complete understanding of the problem is
possible.
Many people comment that they have not looked at “presenting problem” behaviors in quite
this way before. It is one thing to be aware that a child has been traumatized and that this might
somehow relate to her problems; it is another to show exactly how the trauma and related issues
might drive the problem, step by step.
When you understand a problem from this perspective, many more options are available for
addressing it. For example, with the vignette of Casey, if we look only at the problem behavior,
we are likely to punish him for hitting. We are also likely to conclude that he needs better “anger
 The Structure of Trauma Treatment ate

Meaning of Behavior Worksheet

© Ricky Greenwald 2004.

1. Trauma/loss event (all events):

2. Negative beliefs (negative self-statements):

3. Piled-up feelings:

4. Trigger situation (what sets off the reactivity):

Theme:

Example(s):

5. Problem behavior(s):
28 CHILD TRAUMA HANDBOOK

Meaning of Behavior Worksheet Sample:

Responses to the Damian Vignette
© Ricky Greenwald 2004.

Note that not all “right” answers are included.

1. Trauma/loss event (all events):

Saw father hurting mother
Beaten by father and verbally put down
Heard parents in loud arguments
More or less lost father (Damian hardly sees him since his parents split up.)
. Negative beliefs (negative self-statements):
Bad things are my fault.
I’m a bad person.
I’m helpless.
There’s something wrong with me.
I’m not safe.
. Piled-up feelings:
Fear, shame, anger, sadness, guilt, confusion
. Trigger situation (what sets off the reactivity):
Theme: Someone putting him down or making him feel small
Example(s): Corrected by teacher in front of the class; left out/ignored by peers
. Problem behavior(s):
Getting in the teacher's face, teasing peers

management” or self-control skills, or perhaps better social skills so that he can make friends
with kids who tease him. However, from his perspective, he doesn’t need better self-control
skills. He was controlling himself just fine: he was defending himself.
Once we develop a fuller understanding of why he hits the kids who tease him, there are more
angles to work with, more possible solutions. Cover up the next paragraph so you can’t read it.
Done? Okay. Now, based on this fuller understanding, what other interventions can you sug-
gest?
We will probably still punish him because we don’t want to condone his hitting. We might
still help him develop better self-control skills as part of a broader approach. We might also help
him distinguish between being teased and being physically attacked. We might help him recog-
nize when he is overreacting because of trauma-related triggers and how to calm himself down.
We might intervene in his environment to help him feel safer and less vulnerable to attack. Fi-
nally, we might help him face the trauma memories and work through them or “digest” them so
that less junk is piled up behind the wall. Then he is less likely to overreact in these situations,
and it will be easier for him to handle it in a better way.
 The Structure of Trauma Treatment 29

apr eisniitramaen
eremttliae HARB imag,
ere

( I'lt FIX YOU! win

A

Many people comment that you must know a lot about a child to be able to complete the
Meaning of Behavior Worksheet. That’s true. You are generally told about the presenting prob-
lem up front. Then you must find out about the trauma history and the context of the problem be-
haviors. It takes a lot of time and effort to learn these things. In many work settings, it’s difficult
to find the time to get this information.
But if you can’t fill out the Meaning of Behaviors form, maybe you don’t really know enough
about what’s going on, about why the child is acting out. If you don’t understand what’s behind
it, how can you be effective when you try to help?
This argues against the casual catch-as-catch-can “pep talk,” “check-in,” or “crisis response”
approaches to counseling that are common in settings such as schools, where counselors are
overburdened. The casual approach may be helpful for kids who need only the occasional sup-
port, encouragement, and advice of a friendly adult. However, for many kids with persistent
problems, casual counseling is unlikely to get to the root of the problem. In many cases, the ca-
sual approach may offer little more than a few feel-good minutes for the child.
30 CHILD TRAUMA HANDBOOK

It is worth the investment of finding out what the problem really is so that you can respond in
a way that has a better chance of making a difference. Once you understand, once you can com-
plete the Meaning of Behavior form, you are in a better position to offer a systematic approach to
trauma-informed treatment that is targeted to the individual child’s needs.

SELECTING A TRAUMA TREATMENT STRUCTURE

The mental health field has been strongly influenced by physicians and psychiatrists, who
have advocated for the medical model of diagnosis and treatment. In the medical model, the doc-
tor determines what’s wrong and, based on the diagnosis, prescribes the designated treatment.
The medical model is ideal for broken bones, diseases that respond to a particular medicine, and
many other medical conditions. In many instances, the correct diagnosis does lead to the correct
treatment, which leads in turn to cure. Another benefit of the medical model is the placebo ef-
fect, in which the fact that treatment is being offered can itself be beneficial, regardless of the in-
dependent medical effect of the treatment. To perhaps oversimplify, the placebo effect reflects
the psychological impact of being treated by someone with a doctor’s authority and power.
However, when treating someone for posttraumatic stress-related problems, the medical
model is not appropriate. Traumatized people already feel helpless and damaged; that’s part of
the problem. What happens when a helping professional takes an authoritarian role with a trau-
matized person and says, “I know your diagnosis and I will cure you”? The traumatized person
feels damaged, controlled, small, and helpless. This only reinforces the problem. It doesn’t
solve it.
Trauma treatment requires a different attitude on the part of the helping professional. An em-
powerment model is needed that can allow and encourage the child to take initiative, to actively
participate in each stage of the treatment, to recover from the trauma, and to grow from it. In
fact, quite a bit of research has been conducted on which types of interventions help traumatized
kids the most. I’ve organized these interventions into a systematic approach which I call the
fairy tale model of trauma treatment. In this model, the fairy tale is used (loosely) as an analogy,
with elements of the story representing treatment components. First we need the story.

The Fairy Tale

Once upon a time there was a small kingdom, about the size of a small town. Things were
pretty regular there. People did their jobs; kids went to school. Some people went to church or
temple and some didn’t. Some people would go to a friend’s house on the weekend, get together
for a barbecue, play games, or have a party. Most people got along, but not everyone. And that’s
how things were: pretty regular.
Until one day...
The dragon came. One day the dragon ate a cow right out of a farmer’s pasture. Another day
the dragon ate a dog right out of someone’s front yard. People got pretty scared! The parents told
their kids that they weren’t allowed to go outside anymore. The thing is, kids aren’t very good at
not going outside. So the parents stayed home to guard their kids, to keep them safe from the
dragon.
Soon no one was going to school anymore, and not so many people were going to work, ei-
ther. Everyone was so afraid of the dragon that they mostly just stayed inside their houses. And
people started wondering, “How come our kingdom has a dragon, anyway? The other kingdoms
don’t have one.” No one knew why, but they wanted to know, so they started making guesses.
One group of people blamed another group of people; that group of people blamed some others
... and pretty soon, everyone was blaming someone and they were all mad at each other.
 The Structure of Trauma Treatment 31

It didn’t take long until this kingdom got a bad reputation. People from the other kingdoms,
well, they didn’t know about the dragon, but they sure knew what was going on. They would say,
“That kingdom’s messed up. The people don’t go to work, the kids don’t go to school, nobody
gets along, they’re all mad at one another. All they do is stay inside all the time. They’re messed
up.
And that’s how things were. Until one day...
A knight in shining armor came along. Well, he wasn’t really a knight, and he didn’t have any
armor. He was just some guy who happened to be passing through. But the people in the town
saw something in him.
“You!” they said. “You can slay the dragon; you’re just the one to do it!”
The guy said, “No, sorry, I’m not a dragon slayer. You have the wrong guy. I’ve been walking
a long way. I’m looking for this certain princess I’m in love with. But I don’t know what king-
dom she lives in.” He pulled a picture out and showed it around. “Have you seen this princess?
Do you know where I can find her?”
The people said, “Yes, she’s our princess. She lives here. And what a coincidence: she really
wants to get married—to whoever slays the dragon!”
When the guy heard this, he said, “Well, in that case, ’m your man. Take me to your dragon!”
So they took him to the dark place where the dragon was sleeping. The guy saw the dragon
and said, “Whoa, this is a bad idea! I can’t handle this dragon! No way! It’s huge; it looks really
strong. It’s covered with scales—it breathes fire. Let’s just forget the whole thing!”
The people said, “No, you can do it. We know you can! You can work out, do exercises, build
yourself up. We’ll help. We’ll get you a personal trainer. And remember the princess!”
The guy said, “Oh yeah, the princess!” He was in love with this princess and he really wanted
to marry her. “Okay, I don’t know about this, but I’ll give it a try and see how it goes.”
So they gave him a personal trainer and took him to the schoolyard to start on his exercises.
But he couldn’t stay focused! Every time he got started on some exercise, he would suddenly
stop and look all around. He was afraid the dragon would get him while he was out there, ex-
posed. So he wasn’t making any progress. This clearly was not working.
So they took him to a clearing at the edge of the forest where there were high trees on one side.
Then they worked to build a high fence around the rest of the clearing. Everybody pitched in:
cutting lumber, putting it up, securing it, cooking for the workers. . . . Even the little kids helped
by bringing water to people, carrying messages, doing whatever they could. It wasn’t long until
they had a high fence around the rest of the clearing. Then the guy could concentrate on his
exercises.
Things went better after that. Every day he worked hard with his personal trainer: he did
push-ups, sit-ups, lifted weights, ran laps, did all kinds of exercises. Every day the trainer added
a pound or two to the various weights. Every day the guy became a little stronger, a little faster, a
little more agile. Eventually they got an athletic teenager to dress up in a dragon costume, and
they did role-plays so the guy could practice his dragon-fighting moves.
Finally, the day came: he was ready. He went to the dark place where the dragon was, faced
the dragon, fought it, and slew it.
He did marry the princess, but things didn’t just go back to the same old way that the kingdom
used to be.
For one thing, they now had a hero in their midst. People from the other kingdoms were say-
ing, “That kingdom has a dragon slayer. I wish ours had one.” And everyone in the kingdom felt
proud, walked a little taller; they knew they’d all helped out and been a part of it.
But they were still asking each other, “How come our kingdom had a dragon, anyway? I won-
der if we’ll get another one?” They still didn’t know. They were worried about this, and they re-
ally wanted to know. So they hired a consultant.
oP CHILD TRAUMA HANDBOOK

The consultant took a good look around. Then she called everyone together for a big meeting
to tell them her findings. “You have two problems here. First of all, you throw all your garbage in
the dump. It’s this huge pile of garbage that stinks for miles around. That smell attracts dragons.”
So they decided that everyone would put their garbage in a compost pile in their own yard. No
big smell to attract dragons, and compost is good for the gardens anyway.
The consultant also told them, “Here’s your other problem. On the edge of the kingdom
where the farms are, there are all these low fields. It’s flat, flat, flat for miles! Dragons are lazy,
and this place, it’s just too easy for a dragon to cruise right in.” So they decided to plant clusters
of apple trees here and there in the fields. They liked apples anyway, and this way it wouldn’t be
such smooth sailing for any dragon that was wandering by.
Well, it didn’t take long before they had so many apples that they didn’t know what to do with
them. So every year in the fall, they had a big apple festival, and people would come from all the
kingdoms for miles around. There were all kinds of contests for the tastiest apples, the biggest
apples, the best apple pies. They also had plenty of food, games, and music—everything a festi-
val should have.
The highlight of the festival, on the Saturday night—the event that everyone would go to—
was the dragon-slaying contest. Of course, they didn’t have a real dragon, so whoever had won
the year before got to play the dragon. All year long, teenagers from all the kingdoms were prac-
ticing, training, hoping that they’d be the one to win the big contest at the next year’s festival.
Not only was this great fun, but if another dragon ever did show up, they would be ready!
Then, they did live happily ever after—more or less. The end.

THE FAIRY TALE MODEL OF TRAUMA-INFORMED

CHILD TREATMENT

The fairy tale was presented as the metaphorical basis of a model for an effective, comprehen-
sive approach to trauma-informed child treatment. Each step in treatment is illustrated by the
corresponding portion of the fairy tale. Here are the steps:

1. Evaluation—This includes the history of trauma/loss, strengths/successes, and circum-

stances in which the problem symptoms/behaviors occur.
2. Motivational interviewing/goal setting—lt takes a lot of work, persistence, and courage to
overcome trauma-related problems. Kids are not likely to commit to this unless we can
help them identify their own goals—what they want for themselves—and understand how
doing these treatment activities can help them to achieve their goals. This is the motiva-
tional component; most kids won’t do all this work just because someone else says they
should.
In the fairy tale, without the princess, nothing would happen. With the princess in the
picture, it’s still a daunting task, but the guy says, “I guess I’ll give it a try and see how it
goes.”
3. Trauma-informed case formulation and psychoeducation—Based on the evaluation, we
communicate our understanding to our clients. The core of the case formulation is the
Meaning of Behavior form. It is important to convey our findings in a sympathetic way that
focuses not on blame but on deeper understanding. This opens the door to possible solu-
tions.
In the fairy tale, that kingdom just seemed “messed up” from the outside. If you knew
about the dragon, what people were doing was still unfortunate, but at least it made sense.
It is also important to focus on the child’s strengths and resources, also an integral com-
ponent of the case formulation. These become the foundation for success in treatment.
 The Structure of Trauma Treatment 33

In the fairy tale, some guy came along who eventually became the dragon slayer. In real
life, the client is his or her own knight in shining armor and becomes the dragon slayer
himself or herself. We need hard facts so that when we say to the client, “You—you’re the
one who can do it,’ we have good reasons for believing this.
Remember that it takes a kingdom to slay a dragon. The guy in the story didn’t do it by
himself. So part of the evaluation is to learn about the resources available in the kingdom,
or the family and community.
. Treatment contracting—The treatment contracting involves coming to an agreement to
pursue specific activities in service of the client’s goals, in light of the strengths and chal-
lenges highlighted in the case formulation. The treatment plan typically includes doing ac-
tivities to become more safe and stable, gain better self-control skills and emotional
strength, and face and work through the trauma memories.
In other words, create a safe fenced-in area, get stronger, build up skills, and slay the
dragon.
. Case management and parent training for safety and other needs—It is very difficult to fo-
cus on building up strength and skills when an ongoing threat exists. If we want to help
kids to get over their trauma memories, we must first make sure that the trauma is not ongo-
ing. We also must ensure, to the best of our ability, that their basic needs are being met.
Otherwise, they will be too distracted by survival to focus on trauma recovery. We often
work with parents and other caregivers to help them provide a more consistent and sup-
portive environment, for example, by becoming more consistent in their discipline style.
This helps kids feel more safe and secure so they can relax and concentrate on their tasks.
In the fairy tale, the people had to find a safe place and build a fence around it so the guy
could focus on his personal training tasks.
. Self-management skills training—This training contributes to physical and psychological
safety as well as improved affect regulation. We often train kids in various self-manage-
ment and self-control skills. This also enhances their sense of safety and security, because
the more they are able to control themselves, the better they are treated by others and the
more supportive their environment becomes. At the same time, kids become more compe-
tent and confident, as well as emotionally stronger, and are able to handle progressively
greater challenges.
Once the fence is up, the guy can work with the personal trainer to become stronger and
faster, and (in role-plays) practice fighting the dragon. It takes more than strength and skill
to slay a dragon. If you’re going to fight a dragon, you’d better be able to take a punch or
two.
. Trauma resolution—Remember the digestion metaphor? Digestion cannot happen while
we are in survival mode. We need to feel safe and relaxed first. That’s partly what all that
preparation was about. Then it’s a matter of facing the memory, taking a bite at a time,
chewing it up—even if it tastes bad!—and digesting it. In treatment, this typically involves
thinking and talking about it over and over again in a structured, systematic way.
The guy in the fairy tale faced the dragon, fought it, and slew it. Actually, in treatment
we’llprobably start with a snake or two, and then a baby dragon or two before we go for the
big one. Remember, we’re the personal trainers here! We want to build on successes, not
overwhelm our clients.
. Consolidation of gains—Once the trauma is resolved, or digested, the other problems may
melt away, but sometimes they don’t. The child may have some bad habits or be missing
some skills. Now that the trauma is no longer driving the problem, the child is in a position
to respond positively to other interventions, to solve remaining problems, and to get firmly
on a better track toward his goals.
Now that the dragon is out of the way, the guy can marry the princess.
34 CHILD TRAUMA HANDBOOK

9. Relapse prevention and harm reduction—It’s not enough just to recover from the trauma
and get on a better track in life. Better to also learn from this experience and take measures
to prevent a trauma recurrence. This is the time to work with the child and others in her life
to identify potential risks and take specific actions to mitigate those risks. This makes other
bad things less likely to happen in the future.
Stop using that dump; compost instead, so that dragons are not attracted by the stink.
Plant clusters of apple trees to make it harder for dragons to just cruise in.
Since you can’t guarantee that trauma will never recur, this is also the time to anticipate
a possible recurrence and to make specific plans to recognize that and to minimize the
damage.
And if a dragon should ever come again, be ready with a bunch of teenagers who have
been in training as dragon fighters.
 The Structure of Trauma Treatment 3d

The Fairy Tale Model of Trauma Treatment

© Ricky Greenwald 2003.

Stage of treatment Corresponding element of the fairy tale

Evaluation including | see your strengths; you’re the one who

can slay the dragon.
Strengths/resources
We need to know about the dragon to make
Trauma/loss history sense of the problems.

Motivational interviewing, goal Without the princess, nothing will happen.

setting

Trauma-informed case formu- Identify the strengths/resources as reason

lation and psychoeducation to hope for a chance of success.
Take the dragon into account; then the
problems make sense.

Trauma-relevant treatment Recommend fence-around, personal train-

contracting ing to get stronger, and slay the dragon.

Case management for safety Build the fence around so you’re not wor-
and other needs; parent train- ried about being attacked at any moment.
ing for safety and security Then you can concentrate on your tasks.

Self-management skills train- The personal training approach to build

ing for physical and psycho- skill and strength.
logical safety as well as im-
proved affect regulation

Trauma resolution Slay the dragon.

Relapse prevention and harm Compost instead of using the dump, to stop
reduction attracting dragons; stands of apple trees so
it's harder for dragons to come along.
Teens training for the dragon-slaying con-
test, so if another one does come along,
we'll be ready.
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 Chapter 3

The Trauma-Informed Therapeutic Relationship

CHILD TRAUMA TREATMENT—BASIC PRINCIPLES

Each of the steps in treatment is made up of a number of specific interventions. These steps
will be taught in detail in the following chapters. For now, I wish to introduce a few key princi-
ples that pervade the child trauma treatment approach. These principles are intentionally intro-
duced in this chapter because relationships are created with attitudes and actions. By following
these principles, the therapist can help the child feel safe enough and trust the therapist enough
that she will be willing to engage in the necessary treatment activities.
It’s important to recognize that you do not have to be a therapist to create a therapeutic or
healing relationship with a child. Parents, counselors, teachers, coaches, direct care workers,
case managers, and others are all in a position to help a child heal. The quality of your relation-
ship is the vehicle for the healing. This is because when kids feel safe, respected, and cared for,
they are more likely to “let you in” and benefit from what you have to offer. So please read this
chapter with your own work in mind.

Safety First

The traumatized child’s primary concern is safety. Kids feel safe when they know what to ex-
pect and what to do—when they feel that things are under control.

¢ Therapists can do many things to help kids feel safe in therapy. For example, at the begin-
ning of the first session, the therapist can introduce “the rules” including the schedule for
meeting, the purpose/goals of meeting, conditions of confidentiality, and what is expected
of the child in sessions.
¢ Case managers can do many things to help kids feel safe, even when kids must be placed or
moved. Case managers can tell kids what is going to happen, when it will happen, what the
child is supposed to do, and specifically how the child will maintain important relation-
ships after the move (e.g., “There will be supervised visits with your mom every Thursday
after school”). Case managers can make life disruptions feel more under control, for exam-
ple, by helping kids keep and carry their personal belongings from one placement to the
next.
¢ Parents, teachers, and direct care workers can help make kids feel safe by preventing vio-
lence, by maintaining a daily routine, and by enforcing their rules consistently. If the adult
enforces rules inconsistently, the child does not know what to expect—and when the rule
finally is enforced, it’s often done out of anger and the enforcement may be overly harsh
and frightening. When the adult enforces the rule at the first violation, the consequence can
be small and reasonable, and the adult is more likely to be calm and supportive.

EG
38 CHILD TRAUMA HANDBOOK

Safety Last

When we are working our way through the treatment steps in the fairy tale model, we are ask-
ing our clients to face progressively greater emotional challenges. For example, as early as the
second meeting, we are asking the child to tell us about the worst things that ever happened to
him. Most children habitually avoid talking about such events because it upsets them. So after
they answer our questions, get upset, and then the session ends, what then?
In many circles, child therapists have a bad reputation because this issue is managed poorly.
Many therapists are trained to believe that their job is to help the child to “open up”—to express
feelings, work on issues—whether through talk, art, or play. This opening up activates the
trauma memory, which upsets the child. Then the session is over and she is sent’on her way.
Many teachers have complained, “It’s bad enough that she gets taken out of my class—my class
is important; she comes to school to learn—but then when she comes back after a meeting with
the counselor, she’s all upset. She can’t concentrate. She’s a mess!” Similarly, many parents
have complained that the child is “a mess” in one way or another for some period after therapy.
Although some therapists believe that this is just the inevitable fallout that comes from doing
therapy, these therapists are wrong. They are not trained in trauma treatment. Remember, as do
the rest of us, kids learn from experience. What do kids learn from the experience of being a
mess after their therapy session? They learn that bad things happen if they open up with you.
One fourteen-year-old boy said, “Last time, after I left here, I was still heated. I ended up getting
into a fight and I got in trouble. I don’t want to talk about that [upsetting personal] stuff
anymore.”
When kids and their caregivers regularly experience bad outcomes from therapy sessions, it
gives therapy (and the therapist) a bad reputation. Parents, teachers, and other adults feel that
therapy is an imposition, a disruption to the day. They see it as harming rather than helping the
child. So the adults are more likely to terminate the child’s therapy or at least not support it as ac-
tively as the therapist would prefer. Also, the kids in this situation are likely to become more re-
sistant and more reserved. Why trust the therapist who keeps setting you up for problems? Why
open up if it only gets you upset and gets you in trouble?
The wise trauma therapist minimizes the risk of bad outcomes to sessions by using the fol-
lowing strategies:

¢ Carefully control what is discussed in a session so that the challenge (level of distress) is
consistent with what the child can be expected to tolerate/handle. Using the personal
trainer metaphor, if a client lifted fifteen pounds last meeting, don’t give her fifty pounds
this time. Give her fifteen again, or maybe eighteen or twenty if you think she’s ready. With
this approach, the child experiences repeated successes with progressively greater chal-
lenges, and is unlikely to become overwhelmed.
¢ Use the “cognitive-affective-cognitive sandwich.” Make the sandwich by surrounding the
emotional/expressive component of your session with more structured components grounded
in rational thinking. For example, you might start out by reminding the child of the reason
he is going to talk about the hard thing, how this relates to his goals. In the middle you do
work with the emotion, at whatever level the child is ready to handle. The emotional com-
ponent is finished with calming activities so that the level of upset/arousal is diminished.
Then you move back to the cognitive, perhaps by discussing what was learned, perhaps by
reorienting to what’s next in the child’s day. This helps the child to contain the emotion and
to regain composure. Although there is no guarantee, therapists who make a practice of us-
ing the sandwich tend to have far fewer problems with their kids being a mess later on.
—One example of this sandwich approach is the Float-Back exercise in Chapter 1. Re-
member what happened? First was the cognitive piece, about how kids are affected by
 The Trauma-Informed Therapeutic Relationship 39

trauma and why it’s worthwhile for you to feel bad, briefly, to gain insight into this dy-
namic. Then the emotional piece, where you explored your own upsetting memories, the
recent one and one from the past. This part was finished with the calming activity—in
this case, deep breathing. Then back to the cognitive, with a discussion about what this
might mean for kids and what to do about it.

Safety in Between

No matter how carefully we follow the fairy tale model, no matter how well we plan, surprises
always occur. We are working with humans! So it’s important to continually monitor how your
clients are doing and what is going on with them. Frequently, when things are not going accord-
ing to plan, it’s because the child no longer feels safe. If we are paying attention, we can catch
this and address it.

¢ A fifteen-year-old girl has been doing well in treatment, and is ready for trauma resolution.
The therapist prepares her for this, and they plan to start on it at the next meeting. Then for
the next two meetings something comes up and the girl cancels at the last minute. The ther-
apist telephones her and asks her to please come to the next scheduled meeting and tells her
that the plan to talk about the trauma is off for now. When the girl arrives at the next meet-
ing, she eventually explains that she does not feel ready to talk about the trauma yet and
was afraid to come to sessions for that reason.
¢ An eleven-year-old girl has been very cooperative in treatment for the first four sessions
with her school guidance counselor. Today she seems angry, refuses to answer questions in
any detail, and keeps looking at her watch. The counselor asks her if she is in a hurry today.
The girl says, “Yes, my group is presenting our project at ten o’clock and I’m supposed to
be there!” The counselor thanks the girl for saying that, and they agree to reschedule their
meeting so the girl can leave now and meet her classroom obligation.
¢ A six-year-old boy appears to be engaged in his rather new treatment and to like his thera-
pist. However, when the therapist asks about the worst things that ever happened (the
trauma/loss history), the boy clams up. The therapist switches to play with stuffed animals,
and points out one small animal who wants to tell about the bad thing that happened, but is
afraid to. After some discussion, the boy suggests that the animal is afraid that if it tells, its
parents will get in trouble.
¢ A ten-year-old boy has been working well in treatment and has completed several sessions
of trauma resolution work. However, in this session, he refuses to talk about the memory
that is already partly resolved. The therapist is stumped and is unable to get a decent expla-
nation from the boy. Later, the therapist mentions to the boy’s mother that he seemed dif-
ferent today and did not accomplish as much as usual. The mother reports that she had
blown up at her son a couple of days earlier and threatened to send him to live with his fa-
ther if he didn’t get a better attitude.

In each of these cases, some pressing concern prevented the child from moving forward ac-
cording to the therapist’s plan. If the therapist just barges ahead, the child’s concern is not ad-
dressed. The child might then feel disrespected and/or pressured, and take protective action.
On the other hand, when the therapist notices when things are not going smoothly and shows
respect and concern, the child learns that the therapist cares and wants what is best for the child.
In general, the more the therapist can do to help the child feel safe and supported, the more work
the child will be able to accomplish in therapy. Our goal is to create a “fenced-in” safe area in the
room, in the therapy relationship itself.
40 CHILD TRAUMA HANDBOOK

Security Is Love

Therapists, like parents, can convey love and caring for the child by helping the child feel se-
cure. The more the child knows what will happen in therapy and what to expect, the more secure
and cared for he or she will feel. The therapist can do many more things to help the therapy situa-
tion be predictable and supportive for the child, including the following:

* Keep your promises. Be ready and start the session on time. (If you can’t do this reliably,
don’t make the promise.)
¢ Start each session the same way. Routines are reassuring. The starting routine can be as
simple as a check-in. For example, many therapists start by saying, “Tell me something
good and something bad that happened since last time we met.” In addition to the value of
having a routine, this is also a good way to find out what’s happening in the child’s life. Of-
ten this material can be used in support of the treatment plan. For example, if the child re-
ports having handled a peer confrontation poorly, this event can be used for practicing self-
control skills.
¢ End each session the same way. Establish routines for putting toys or materials away, talk-
ing about what’s next in the child’s day, or asking the child to say something he or she liked
and something he or she didn’t like about the meeting. Again, part of the value is the fact of
the routine, and part of the value is helping the child to gain closure on the session, regain
composure, and be ready for what’s next in his day.

Success

Remember the princess? The entire therapy enterprise is to serve the child’s goals. In the
trauma treatment approach, we may be part of the kingdom (providing safety and support); we
are also the personal trainer. As the personal trainer, our job is to help the child make progress to-
ward winning the princess. Remember, nothing succeeds like success. So one of our primary
strategies is to help kids build a track record of success by achieving smaller goals one step at a
time. This track record helps build confidence that the next steps will also be worthwhile and
successful and nurtures hope that the larger goals can be attained.

WHAT IT TAKES TO BE A PERSON WHO HELPS TRAUMATIZED KIDS

If you’ve made it this far, you’ve got a pretty good understanding of what it means to be a trau-
matized child, and you have a good overview of the steps involved in treatment. However, it
takes more than understanding and skills to be able to help traumatized kids. It takes a certain
kind of person. It takes someone who cares enough to make the effort to understand, learn, and
use the skills. It takes someone who cares enough, and who is strong and resilient enough, to
persevere through the child’s sometimes painful steps toward healing. It takes someone who can
help children feel that they are with a person who cares about them and will care for them; they
are in a Safe place with a fence around it.
Being a person who is able to help traumatized kids is a big deal; it’s not to be taken lightly. It
entails a specific set of interpersonal skills and practices as well as self-care skills and practices.
Not everyone can do this, and not everyone would choose to. There are inherent challenges and
even risks or occupational hazards.
Having what it takes to do this work is not a categorical trait, such as being nice enough or
smart enough. It’s more about being able to come through for kids in certain ways, to maintain
certain kinds of awareness, to self-monitor, and to use the information you obtain in constructive
 The Trauma-Informed Therapeutic Relationship 41

ways. It’s also about taking good enough care of yourself (see Chapter 4) that you are able to
focus on kids’ needs when you’re on the job.

THE THERAPEUTIC RELATIONSHIP

_ Special problems are inherent in trying to help traumatized kids. Each of the following makes
it particularly challenging to form a therapeutic relationship with such a child, and to get the
child to do anything productive:

¢ Traumatized kids by definition have had their primary attachment disrupted (the promise
of safety having been broken) and they are cautious about trusting others and about form-
ing relationships.
* Traumatized kids have been profoundly disappointed, and they are reluctant to be hopeful.
They are afraid to hope because they don’t want to be disappointed again. They are afraid
to invest in therapy because that implies hope and invites disappointment.
¢ They are skeptical about the possibility that anything good will happen. Why work toward
a goal that’s “not gonna work out anyway’?
¢ Some of the trauma therapy activities involve talking about upsetting events. Traumatized
kids often have poor affect tolerance and are uncomfortable with distress. It feels like “too
much.” They don’t want to talk about it.

Traumatized kids have special needs from you in terms of how you behave toward them and
how you relate to them. You need to be the person who helps kids feel safe and secure, to under-
stand themselves and how to be successful in overcoming their problems. What kind of person
would be able to help kids in this way? What would such a person be doing? How can you ad-
dress the child’s fears to the point that he or she is willing to trust you, invest in therapy, and do
the work?

THE RICH RELATIONSHIP MODEL

The RICH model—Respect, Information, Connection, Hope—is one approach to therapeutic

relationship that is well suited to trauma treatment (Saakvitne, Gamble, Pearlman, & Lev,
2000). It is an empowerment approach that encompasses the therapist’s attitude and also implies
specific behaviors that contribute to a safe, supportive, and therapeutic environment.
Note that although the focus here is on how to treat kids, the same principles can apply for
how to treat parents, teachers, and co-workers. When we treat one another this way, we all feel
safer, more supported, and more related/connected. This allows us to feel better, to work well to-
gether, and to focus more effectively on helping the kids.

Respect

This aspect encourages individual attention and respect for each child: “I can treat you like a
person, not a number or a problem. I can treat you the way I would want (my own child) to be
treated.”
Many kids who are referred for treatment have learned to feel that something is wrong with
them—that they are a problem. They may have experience with overburdened workers who can-
not devote adequate attention to individual children, who are burned out and just not very nice,
or who take out their own sense of frustration and helplessness on the kids they are supposed to
42 CHILD TRAUMA HANDBOOK

help. Many kids have been treated impersonally or have been treated as if they are a problem.
Actually, these kids often are a problem! They may behave in ways that elicit anger, frustration,
and rejection from their parents, teachers, and others. That’s why they are being sent for help.
When the helper responds in the same way that others have responded, it doesn’t help. It just
adds to the problem and reinforces it.
When the helper treats the child with respect, this may break a pattern and open the door for
something different to happen—perhaps something good. Treating a child with respect means
listening as well as talking; respecting the child’s autonomy and right to make his or her own
choices (of course, choices have consequences); telling the truth; keeping promises; and seri-
ously addressing the child’s own concerns. Specific ways of doing these things will be detailed
throughout the book. When children feel respected, they are more likely to respond positively.

Information

This aspect encourages honesty and creativity in providing children with information: “This
is what you need to know to understand the situation.”
When we tell kids what will happen and what to expect from us, they feel respected and safe.
They know what’s going on. They know what’s coming. When we tell kids what we expect from
them and how to do it, then they know what to do and have a better chance of being successful in
their work with us. Being successful feels good, and is good, for all of us.
Another kind of information is particularly meaningful to traumatized kids. Many times, kids
who have developed symptoms following a trauma or loss don’t really understand what has hap-
pened to them or why they are not the way they used to be. Many such kids believe that they are
bad, crazy, or damaged in some way. They may have been told, repeatedly, that they are “messed
up” by people who didn’t know about the dragon. We can tell the story a different way, using the
fairy tale model, to explain that their symptoms are a reasonable (if unfortunate) response to the
bad things that happened.
When we can help kids (and others) see themselves as hurt instead of bad, they have more em-
pathy for themselves. Also, they understand, finally, what’s been happening to them. Many kids
have said, “No one’s ever explained this to me before.” This is often accompanied by consider-
able relief. The therapist also gains a certain credibility and status that can be helpful in the treat-
ment contracting phase. If the therapist does have a map of this territory, maybe that map shows
the way out, too.

Connection

This aspect encourages creating an emotional bond with the child: “I can imagine what it
might feel like to be you. I’m here with you now.”
This is perhaps both the simplest and most complicated aspect of the therapeutic relationship.
You can have all the understanding and techniques in the world, but if kids feel that you don’t
care about them, they will not work with you. Kids understand that people who don’t care about
them may not have their best interests in mind and cannot be trusted.
When you care about a child, to some extent you open your heart. You forma relationship. A
caring adult with good boundaries and a focus on the child’s needs may create a unique and heal-
ing relationship for the child. Many traumatized kids have been victimized by people who were
expected to care for them. For such children, your relationship might serve as a more positive
model of an adult-child relationship. This paves the way for other successful relationships in the
future.
 The Trauma-Informed Therapeutic Relationship 43

Even kids whose parents have been appropriately protective and supportive will often with-
draw from their attachment relationships to some extent following trauma. For these kids, the
therapy relationship can serve as a step toward trusting adults again and reestablishing the pri-
mary attachment relationships.
Connection is also important in trauma therapy because we will eventually ask the kids we
work with to face their pain. Of course, often the reason they need our help is because they can’t
stand to face their pain, but instead choose the quick-relief behaviors that others call a problem.
Yet somehow the emotional support provided by the therapist can help. When a young child
skins a knee and it must be washed, she may cry but will tolerate the washing if it is her mother
doing it. Even as adults, when a friend or loved one is in some kind of pain, we offer a shoulder,
an ear, a hug. Connection helps kids to tolerate their pain while they are learning to deal with it in
healthier ways.
Many ways to convey caring to a child are detailed throughout the book. They might include
actions to show respect and help the child feel safe; keeping the therapeutic frame (e.g., being on
time, avoiding undue focus on the therapist, avoiding sexual contact), and focusing on the
child’s own interests and concerns. Empathy is a key means of showing caring; this involves be-
ing able to feel what the child feels while also maintaining the adult’s sense of responsibility and
objectivity. The caring adult (therapist or otherwise) feels and shows concern for the child’s wel-
fare, and expresses pleasure in his growth and achievements.
Risks are also inherent in opening your heart to a child. To care about the child and feel what
he feels is to open yourself to his pain and to your own pain. This can be very difficult to manage,
and will be discussed in more detail in Chapter 4.
44 CHILD TRAUMA HANDBOOK

Hope

This aspect focuses on providing experiences that will lead the child to develop a more posi-
tive outlook. “This process can lead to good outcomes.”
For kids to engage in the hard work of treatment, there must be some sense of possibility that
the work will be worthwhile. There must be hope for things to get better. The therapist can help
the child develop hope in three ways:

iB As the relationship develops, the child may learn to trust more, by experimenting with trust
and being rewarded. As the child comes to feel that the therapy relationship is successful,
he may develop hope that other interpersonal relationships can work in the future.
. When the therapist offers a case formulation that helps the child understand herself, and
feel understood for perhaps the first time, the child is likely to take the therapist very seri-
ously. When the therapist then explains that certain treatment activities are likely to help,
the child may become hopeful. After all, the therapist seems to know.
. As the child, step-by-step, makes progress through the treatment program, he is building a
track record of progressively more substantial achievements. Each time the child takes an-
other step forward, he becomes more confident and more hopeful that he can heal more
fully and achieve his goals.

EXERCISE: WHO HELPED YOU AND HOW?

— . Think back to your own childhood/adolescence. Think of one person who stands out who
really helped you in some way—someone who made a positive difference in your life, in
your development. Maybe this person helped you overcome a problem, get a better atti-
tude, feel better about yourself, or try to succeed at something. This person might be a ther-
apist, a teacher, a coach, a relative, or someone else. Write down who the person was and
what impact the person had on your development.
N . Now think about what actions this person took that made him or her have such a positive
influence on you. Write down what the person did that made such a difference.
. Now write down, for each of the following categories, a specific thing this person did that
pertains to that category. In what ways were this person’s actions consistent with the RICH
model? In what ways were the person’s actions inconsistent with the model?
Respect:

Information:
Connection:

Hope:

Share if in a group.

Discussion Questions

ik. What did you notice by doing this?

Ds What do you learn from this?
38 What qualities/behaviors seem to be most essential to helping a child?
 The Trauma-Informed Therapeutic Relationship 45

The essence of this relationship approach is to come from the heart, to find some way of loving
each child we work with. Considerable research indicates that the nonspecific components of
therapy—empathy and positive regard—make a substantial contribution to the client’s progress.
However, just having and emanating the positive feeling is not enough. Many well-meaning
therapists truly care for the children they work with but do not help them recover from trauma.
The rabbi at my grandmother’s grave said, “Love is taking responsibility.” The rabbi meant
that my grandmother did more than merely say “I love you.” She showed her love by putting
food on the table and ensuring that her kids had clean clothes to wear to school. Therapists ought
to care enough to take responsibility too: to learn what it takes to help children heal and to offer
this to the kids they work with. It takes specific actions to recover from trauma. It is the thera-
pist’s job not merely to care, but to do something about it. The therapist’s trauma-informed inter-
ventions help build the therapeutic relationship and convey the therapist’s caring, while also
helping the child take the actions essential to healing.
In other words, the therapeutic relationship is fundamental to the child’s healing. However, a
repertoire of specific practices, skills, and interventions is integral not only to the child’s healing
but to the development of the therapeutic relationship itself. Throughout this book, the tech-
nique and relationship aspects of the trauma treatment approach will be intertwined.
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 Chapter 4

Taking Care of Yourself

Mental health professionals and others who work with kids have a special interest in self-
care. In every field from surgery to farming, it’s important to keep the tools and equipment in
good working order. For those who work with kids, our person is the primary tool. We use our-
selves to form therapeutic relationships and to provide understanding, emotional support, and
guidance. We use ourselves to bear witness, to share the burden of the child’s pain. It is essential
to ne this tool—ourselves—in good condition. If we can’t handle it, how can we help the kids
to do so?
Kids learn from experience. Many kids have learned that it’s not okay to talk about the bad
things that happened: “If I talk about it, people get upset: parents get sad or angry, other kids
tease, people change the subject. It’s better not to talk about it”” When you encourage the child to
talk about it, what will she learn from you? That depends on how you react. Hopefully, the child
will learn that it’s okay to talk about it, that you can handle it and won’t freak out, fall apart, or
reject her.

An eight-year-old boy was in his second session of treatment with a new therapist, after having been in
weekly therapy with someone else for two years following a major trauma. The new therapist, wanting to
know how much had already been accomplished, asked, “So how much did you talk about [the trauma]
with your other therapist?” The boy replied, “Oh, we never brought it up. [The other therapist] wasn’t ready
yet.” (As far as | know, this is a true story. It was told to me by the person who is the new therapist in the
story.)

If we are impaired, we bring less to a relationship. When we are preoccupied with our own
concerns, we are unlikely to “show up” at 100 percent capacity. We have less energy. When our
own needs are unmet, we may have a hard time staying focused on what the kids need. Kids will
pick up on this. They will feel less respected and less important to us. They will feel less secure
and more likely to act out with us, to test us. When we are not at our best, we are at a higher risk
of falling into traps instead of being helpful.
If we try to help others at our own expense, we cannot sustain this. Many extremely dedicated
professionals correctly recognize that a great deal urgently needs to be done. It can be tempting
to try to do it all or at least to routinely work to exhaustion. We may feel that we are saving lives,
or something close to that, and that this justifies pushing ourselves. Although this kind of per-
ception regarding the value and urgency of the work may be accurate, it does not mean that we
have to destroy ourselves doing it.
Working to exhaustion is the pony express model. The pony express was an early mail deliv-
ery system in the United States (1860-1861). Because speed of delivery was highly valued, the
strategy was to ride a horse to its limit. Then a new horse would pick up where the other left off,
while the exhausted horse would be rested and cared for. If you are not part of a tag team—if no
one is available to take over your job for you when you get tired and need a month off—you must
pace yourself, otherwise you’lIwear yourself out and nothing will be left for the kids you care so
much about.
To care for ourselves properly, it is important to understand the challenges. What is the impact
of doing what we do? How does it affect us?
47
48 CHILD TRAUMA HANDBOOK

EXERCISE: HOW HAS WORKING WITH TRAUMATIZED KIDS

AFFECTED YOU?

Write down how working with traumatized/hurt kids has affected you in each of the following
categories (from Saakvitne et al., 2000):

Beliefs about the world

Spiritual beliefs
Sense of self, groundedness, emotional stability
Sense of personal safety or family’s safety
Trust of yourself or others
The way you judge people
Sense of control
Ability to be alone, to be with others
Relationship to your body

If you are working with a group, once everyone is finished please feel free to share something
that you wrote down. However, please also feel free not to share. It is important for people to feel
that it is okay to either talk or be silent.
Then in a group discussion or on your own, answer these questions:

What surprised you about your own responses?

What surprised you about others’ responses?
Did you notice any common themes?
Did you notice areas of divergence?

Following are some examples shared by others:

¢ “T used to always be heartbroken to see children being mistreated in public places. You
know, like some mother slapping her kid and saying, “Shut up or I'll really give you some-
thing to cry about.’ After a few years in this field, I started to notice how good I felt when I
was around kids who are being treated well. I used to just take that for granted. Now it re-
ally strikes me, makes my day better.”
¢ “When my girlfriend’s little daughter climbed on my lap, I kind of froze. Iknow I’m not a
child abuser, but I’ve been exposed to so much of it I actually felt as if Iwas doing some-
thing bad with her. I had to catch myself, tell myself that this was normal, friendly physical
contact and it was okay.”
* “T’ve seen too much, the things people can do to each other. I’ve developed a cop’s-eye
view of the world. I am so ready to assume the worst about people I barely know.”
¢ “Tve learned that I often underestimate people. I can’t tell you how many times these really
pathetic-looking parents surprised me and came through for their kids, in one way or an-
other. I think I’ve learned to have more respect. Even when people don’t look so good, I’ve
learned that maybe they really are trying, doing their best. And that when I give them the
tools, maybe they can do even better. So I guess I don’t just write people off the way I used
to.”
¢ “Tlost my faith in God.”
* “Working in this field has made me rely more on my faith, become a more spiritual per-
son.”
 Taking Care of Yourself 49

Clearly, this work has potential for personal impact. Just as self-care is particularly important
for those who work with kids because the self is the primary tool, so is the self also at particular
risk—especially when working with hurt children.
Why should working with hurt kids have so much impact? More specifically, why is there so
much potential for negative impact? The following are some reasons why we may be particu-
larly vulnerable:

We are exposed to horrible stories of things that happened to kids we care about.
When we do good work, we are empathetic. We open our hearts.
We feel responsible for these kids’ well-being.
We feel angry and helpless about what happened.
We may also feel angry and helpless about what is continuing to happen.
The stories we hear might remind us of our own stories.

In many ways, working with traumatized children can be similar to exposing ourselves to a
traumatic experience. Many mental health professionals and others who work with traumatized
kids suffer from what has been called “secondary traumatic stress syndrome” or “vicarious
traumatization.’ When we are exposed to someone else’s trauma story and situation, we can
be traumatized from that; it can hurt us. We are then vulnerable to developing symptoms our-
selves.

EXERCISE: YOUR MOST UPSETTING CASE

Think about the most disturbing or upsetting case that you have had. Write down what aspect
caused you the most distress. In a group, share this if you wish to. In a group, what do you notice
about differences and/or common themes?

What Gets to Us?

Just as not every upsetting experience is traumatic, not every session with a traumatized child
causes vicarious traumatization. Therapists tend to agree that certain key features of a case can
make it especially difficult to handle: caring about the child, feeling helpless, and getting trig-
gered by the child’s story or behavior.

Caring

Many who work with children attempt to shield themselves from risk by trying to avoid car-
ing. If you don’t care, it doesn’t have to hurt so much. Unfortunately, if you don’t care, by defini-
tion you cannot do good work because children will not trust you or engage with you. If you do
care, then what hurts the child has a better chance of hurting you too.

Feeling Helpless

The child with the most horrific story can be a “great case” if the therapist is able to be help-
ful. When therapists are asked to describe their most disturbing/distressing case, they typically
tell about one in which the therapist, for whatever reason, is powerless to help or to make any-
thing better. It is difficult to tolerate being helpless when a child you care about is hurting.
50 CHILD TRAUMA HANDBOOK

Getting Triggered

Just as children can experience some minor stressor as a trigger (a reminder of past trauma)
and then overreact on that account, so too can therapists. We have sore spots too! Sometimes it is
the child’s trauma story that serves as a reminder of the therapist’s own trauma history. Some-
times it is the child’s behavior or situation that makes the therapist feel angry, frustrated, re-
jected, or helpless; and it is this feeling that serves as the therapist’s trigger. When triggered, the
therapist is at a higher risk of overreaction, of experiencing these strong feelings as intolerable.
In any of these situations (or a combination of them), the risk of vicarious traumatization 1s
heightened, but it is still not automatic. It depends on how the therapist handles it. Vicarious
traumatization occurs when the challenging/upsetting material is not processed but gets stuck
somehow, maybe even pushed behind the wall.
When this happens, the therapist may be in trouble and some of those symptoms and prob-
lems might show up. Therapists may react inappropriately to certain kids, with the therapist’s
own distress interfering with a therapeutic focus on the child’s experience and needs. The thera-
pist may become preoccupied, sad, withdrawn, stressed, or irritable, possibly impacting the
therapist’s personal life as well. The therapist may develop a more impersonal style on the job to
try to avoid further hurt or trauma-related triggers. The therapist may become cynical, ex-
hausted, burned out.

EXERCISE: HOW DO YOU KNOW WHEN IT’S HAPPENED TO YOU?

Think of a time when you were hurt in some way by your work. Write down

1. what happened,
2. what your symptoms were,
3. how you noticed what was wrong, and
4. what you did about it.

In a group, share this if you wish to. In a group, what do you notice about differences and/or
common themes?
Working with hurt kids is an occupational hazard. To do good work, we open our hearts. Thus
we risk being hurt ourselves.
Think about the phrase occupational hazard. What comes to mind? In many other fields, the
occupational hazards are recognized and addressed. On a construction site, people are required
to wear hard hats. In a hospital, used needles are safely sequestered. Airplane crews are required
to rest after a certain number of hours. What do we do to protect ourselves? What can we do?

EXERCISE: SELF-CARE CHECK-IN

Write down your answers to the following questions.

When is the last time that you...

* got what you consider a good night’s sleep?

* spent quality time with a friend?
¢ did your favorite kind of exercise?
* had time to yourself when you didn’t have to take care of others?
* put food into your body that you consider nutritious?
 Taking Care of Yourself ol

spent quality time with your romantic partner or a family member?

left work on time or early, even though there was more to do?
took time for a meal without doing something else at the same time?
talked to a supportive colleague about challenges in your work?
did something you really enjoy doing when you have the time?

Follow-Up Questions

What did you notice about what you just did?

What did you learn about yourself?
What did you learn about your life situation?
How does that feel?
What are you saying to yourself about this now?

Self-Care Strategies

Each of us can do a number of things to minimize the impact of our occupational hazard. Not
surprisingly, some of these are the same things that we might recommend to a stressed-out par-
ent or friend. These self-care approaches are likely to keep us more healthy, balanced, and able
to handle whatever comes our way:

1. Nutrition. It’s easy to believe that you’re too busy for lunch so you just grab a candy bar or
bag of chips on the fly. However, this does not take care of you. It will only add stress and
wear you down. Remember that you are the only pony doing your job. Treat yourself as
you would treat your only pony, one who must be good for the long haul. Drink enough wa-
ter. Eat foods that really nourish you.
. Exercise. The typical obstacles to exercise are time, convenience, depression, and fatigue.
However, you probably know from experience that regular exercise will help you feel
better, less fatigued, more alert, and thus make better use of your time. Exercise gives more
than it takes; it improves health and promotes longevity. If some obstacle prevents you
from getting regular exercise, itis worth your while to find a way to overcome the obstacle.
. Sleep. Those who don’t get enough sleep incur a chronic burden of stress related to sleep
deprivation. This can lead to health problems, bad moods, and underfunctioning. Typical
obstacles to sleep are time and worry. Again, it’s worth addressing these; would you rather
have good excuses or good health?
. Substance avoidance. When people feel stressed or upset, it is tempting to want to push the
bad feelings out of the way, behind the wall. One of the more popular ways to do this is by
drinking alcoholic beverages or using other so-called recreational drugs. The problem with
this strategy is that pushing it out of the way only provides short-term relief but does not
solve the problem—and substance use can bring new problems. If you find yourself
stressed and tempted to increase your normal level of substance use, you would probably
be better off finding a more productive way of dealing with the stress.
. Stress management. What works for you? Many options are available for coping with
stress, whether you do this as a daily routine or only when you notice that you are feeling
stressed. Many people benefit from activities such as exercise, competitive sports, medita-
tion, yoga, listening to music, reading, taking a bath, taking a walk, dancing, doing art-
work, or even cleaning the house. It is important to figure out what works for you, and do it.
. Social support. People with good social support networks tend to feel more positively
about their life situation and to handle stress and challenges more effectively. It is impor-
De CHILD TRAUMA HANDBOOK

tant to have people in your life who you can talk to, who can help you when you need it,
who you can do things with, and feel close to.
7. Time away/refreshing activities. Everyone needs a break or a respite. Isn’t this what you
would tell a parent or a friend? If it’s good advice for them, it’s good advice for you. What
do you enjoy doing? What’s a good change of pace for you? If you build this into your life
on a regular basis, it will help you to feel fresher and more content.

Many of us are in jobs in which it is literally impossible to get everything done or even to get
all the important tasks done. We may feel that kids’ well-being and even their lives are on the
line, and we may be right about this. The temptations to engage in long work hours and heroic
self-neglect can be powerful. This is why it’s so important to step back and make conscious deci-
sions about how we operate. It’s fine to be dedicated to helping children and their families, but
it’s not fine to do this in an unsustainable way that hurts you and your family—and possibly the
kids you’re trying to help as well.
The self-care decision can involve real sacrifices. You might find yourself taking a break dur-
ing the day to go to the bathroom, to call home, or to have a real lunch. You might find yourself
leaving work at a reasonable time, even though there’s more to do. You might find that you are
doing less than you used to, which can be difficult to accept. It’s important to understand the al-
ternative.
Those who fail to take care of themselves are at high risk of developing stress-related prob-
lems such as underperformance, job burnout, health problems, bad moods, and damaged per-
sonal relationships. Most people with this understanding choose to do only what they can on the
job, not what they wish they could do. With this choice, you have a better chance of being able to
do good work tomorrow as well as today.
Which self-care practices are you currently using on a regular basis?

EXERCISE: SELF-CARE PLANS

This excercise can be done individually or in pairs. If you’re in a pair, ask your partner each of
the following questions, and don’t quit until you get answers that are both realistic and very spe-
cific. Then switch to do the same exercise in the other role. If you’re by yourself, it’s more diffi-
cult to be hard on yourself and not let yourself squirm out of being specific. Do your best.

Questions

* What one self-care practice do you feel that you should be doing, and that, realistically, you
can actually do?
What’s your next step? Start small, with one realistic example of the desired behavior.
How will you do it? What day, what time, what place, what action?
What are the obstacles? What could keep you from doing it?
How will you handle this to keep yourself on track?

Discussion

Will you be able to find out if your partner followed through? Make a specific plan (you
know, date, time, place, action—the whole thing!) for checking in. If you’re doing this alone, put
your plan in an envelope that you will open the day after you were to have done your planned
action.
 Taking Care of Yourself 53

Special Self-Care Issues for Trauma Therapists

The self-care strategies just described can apply to anyone. There are also some self-care
strategies that are specific to those who work with traumatized kids (or adults, for that matter).
These relate directly to the challenges inherent in hearing about what has happened to the kids
and to interacting with them and experiencing some of their problem behaviors firsthand. How
is the mental health professional expected to avoid being traumatized by the kids’ stories or be-
ing triggered by the frustration and helplessness that may be a natural response to the kids’
problem behaviors?
This issue is often referred to as countertransference—the therapist’s personal/emotional re-
action to the client—and is considered perhaps the greatest challenge to doing good work. This
is potentially an issue in any type of treatment, but when the treatment focus is trauma, the con-
tent can be particularly challenging for the therapist. Although having an emotional response to
clients is unavoidable, ideally we use this to learn more about our clients. It becomes a problem
when our emotional response takes over; then we are focused primarily on our own feelings and
are at risk of acting out. Here are some of the more common counter-transference reactions to
working with traumatized kids:

¢ Playing the rescuer

¢ Helping the client to avoid the painful material
¢ Being angry at the parent(s)
e Disliking the client
e Disconnecting: becoming bored, distracted, distant, disengaged

Several strategies together comprise an overall approach to this challenge. These are not mere
techniques that can be mastered with an hour’s practice. Rather, this approach represents a ma-
jor commitment to personal development, self-awareness, self-care, and responsibility/integrity
in relationships. How many times has someone said to you, “I don’t see how you can do the
work you do!’””? Many people are not willing to make such a commitment, to be able to manage
the pain and the challenges and remain effective. But this is what it takes.

Self-Care

The self-care strategies previously described help us be at our best. Then when our own
trauma-related triggers come up while we are working with kids, we will have the best chance of
handling this the way we would like to.

Personal Therapy

If we can’t go to certain places within ourselves, how can we take a child there? To help the
child work through his trauma, we should have worked through ours—or at least be working on
it and know our way around. Then when the child tells his story, we will have a better chance of
being able to focus on how he is doing and what he needs. Otherwise we risk being distracted
and even overwhelmed by our own emotions or memories when they are triggered. Also, a ther-
apist who has been a therapy client usually has a deeper understanding of the process.

Self-Monitoring

Self-awareness and self-monitoring allow the therapist to notice emotional reactions and to
consider them, rather than merely acting out. Clinical supervision is essential to developing this
54. CHILD TRAUMA HANDBOOK

skill; we may not be automatically good at seeing our own blind places, at seeing ways that we,
not the client, might be the problem. When we are able to notice that we are feeling angry, frus-
trated, helpless, or rejected, we have a chance to reflect on this and make a decision rather than
just acting on impulse.

¢ What does this mean about the client? Is she feeling helpless too? Is this how others usually
feel when they are with her? I wonder if they do what I feel like doing? What would be a
more helpful response right now?
¢ Also, what does this mean about me? Why is it always these sullen, silent kids who make
me so mad? Do I have a sore spot that he is finding? How can I figure this out and take care
of it? :
¢ What’s going on here? Am I really being hurtful the way she says I am? Or is she just reen-
acting her trauma, assuming that everyone victimizes her? Is it her or me? How can I sort it
out?

More Supervision, More Therapy

What? Again? Just when we think we’re in pretty good shape, some client comes along who
surprises us. We find ourselves having a problematic emotional reaction and we know that we
are not doing our best work with this client. The first step is to discuss the situation with a super-
visor (senior therapists who no longer require weekly supervision often arrange for mutual peer
supervision on a regular basis). Sometimes this consultation is sufficient for the therapist to get a
better understanding of the situation and to then manage it effectively. Other times, the therapist
may conclude that further personal therapy is needed to become less reactive and more capable
of handling this particular type of challenge.
Self-care helps us to be at our best. Self-monitoring helps us take our own emotional re-
sponses as useful information, rather than allowing our emotions to take us over, lead us to act-
ing out. Following are a few additional strategies we can use to keep our heads above water so
that we can keep doing the work we care about.

Don’t Be Helpless

Remember that feeling helpless can really get to us. This may seem like simplistic advice, but
it is offered in all seriousness. Following are several ways to reduce the sense of helplessness
that many helpers can feel:

¢ Improve your skills. The better you are at what you do, the more effective you will be, and
the better your results are likely to be, on average. Part of this strategy is not merely to get
better at some skill or another, but to get better at the skills that are most likely to make a
difference for your clients. There is a myth that all therapy styles/approaches are equal, and
that therapists can resonably and responsibily choose according to personal preference. In
fact, considerable research exists on various approaches to trauma treatment. It is clear that
some approaches are more equal than others! Our job is not merely to learn techniques that
seem interesting, but to help our kids. The fact that you are here is an indication that this is
one of your strategies.
* Improve your work environment. As you develop a more sophisticated understanding of
your own needs and the needs of the kids you are helping, you may become aware of sys-
temic problems in your work setting. For example, if the staff are being frequently as-
saulted, they are unlikely to feel safe enough to be able to concentrate on the kids’ needs.
Or if your kids and their families are being given a new worker every time they get to anew
 Taking Care of Yourself ys)

phase of your program, their repeated experiences of disrupted relationships may detract
from the benefits that any given worker may be attempting to offer. To the extent that you
can educate and advocate for improvements in your work setting, these factors can then
support rather than undermine your work. Other strategies may include reporting unethical
practices and encouraging others in your setting to obtain trauma-related training.
* Compensate for your work environment. You may work in a setting that falls short of ideal
when it comes to supporting the self-care and supervision needs of its staff. You can find
creative ways of making sure that you get what you need. This might involve self-disci-
pline for taking lunch breaks or leaving work at a reasonable time. It might involve devel-
oping a professional peer support group on your own, on or off the clock. It might involve
obtaining supervision on your own (or with co-workers), if you are not receiving what you
consider adequate supervision otherwise. Self-care is important both for you and your job,
whatever it takes to do it.
* Work where you belong. This applies to the work setting itself, as well as the type of work
and clientele. Does your workplace support your ability to do work that you feel good
about, or are you constantly undersupported, undermined, and sabotaged? Will success
with this type of person/problem make you feel successful? Is your personality and life sit-
uation suited to the work? There is enough work to go around! So we might as well find the
kind of work that is right for us. We will be happier doing it and in the long run will have
more to offer.

A case manager stayed in an “impossible” job for many years because she kept telling herself
that the client families needed her there. However, she was always frustrated and stressed because
her caseload was far too large to be able to do good work with anyone. Finally, when the stress
threatened her marriage, she found another job that had more reasonable demands.
Oné woman moved from direct clinical service to administration when she adopted two children;
she said that her kids took all of “that kind of emotional energy” and that she needed a little more
emotional distance in her workday.
One man left a good job working with mentally retarded kids. He said, “My co-workers love it
here; it’s a good place, and the kids are making real progress. But for me, it’s no good. | can’t get past
the fact that no matter how hard | work, they’ll always be mentally retarded.”

Rationalize

It is easy enough to beat ourselves up over every failure, because we care and we want to help
every child, not just some of them or even most of them. But it’s not fair to hold ourselves up to
unrealistic standards. This only exposes us to unreasonable self-criticism, which is destructive.
We usually think of rationalizing as a bad thing, a defense mechanism, a way to avoid. But
coming up with a fresh rationale, another way of looking at something, can also be constructive.
Especially when it’s a more accurate perspective than the way we have been thinking. It works
better to be rational and fair, even with ourselves.
Sometimes when it is hard to get a perspective on our own situation, it can be helpful to imag-
ine that the situation belongs to someone else. Probably you would say one or more of the fol-
lowing to a friend or colleague who, despite good effort, was unable to help a certain child:

¢ You did your best.

¢ Can’t win ’em all.
¢ Look at your success rate. Do you expect perfection?
¢ The child knows you tried. That counts for something.
* You don’t know what impact you may have had on that child, in the long run. Maybe you
planted a seed.
56 CHILD TRAUMA HANDBOOK

Many of us work in such challenging circumstances that progress is often slow and uncertain,
and “success” is relatively rare. As you learn to apply the model and the interventions in this
book, your success rate might improve. Even so, more discouraging circumstances require more
sophisticated rationalizations, to allow us to maintain our morale while continuing to fight the
good fight.

¢ Aclinician working with juvenile delinquents said, “The literature says that I'll be lucky to
help maybe one out of ten of these kids. If Ican help two or three out of ten, I’m beating the
odds! Then I think I must be doing something right.”
« A caseworker responsible for a large caseload of abused and neglected children said, “If I
think about all the kids I can’t save, it gets depressing. But when I think about giving up, I
don’t think the next person in my job would care as much as I do or try as hard. Realisti-
cally, I think I’m probably helping more kids than someone else would.”

Process/Express the Feelings

Sometimes we absorb the pain of our clients and then carry it around with us. Sometimes we
have our own feelings of sorrow, anger, or helplessness that stay with us long after the session 1s
over. Then we may feel as if we are “taking our work home” with us, in a way that is unwelcome
but difficult to shake. It is important to identify and then do something with these feelings so
they don’t just stay stuck inside and color the rest of our day or week. Many methods are avail-
able for processing or expressing these feelings, such as exercise, competitive sports, dancing,
walking, writing, doing artwork, or talking to someone. Figure out what works best for you, and
then do it.

Buddy System

Mental health professionals have a unique, somewhat priestlike role. Others bring their pain
and suffering to the mental health professional, who is expected to absorb it, assist in its man-
agement and digestion, and keep the whole thing a secret. In some systems (e.g., schools, disas-
ter response), the mental health professional may serve in this role not only for the child/family
clients, but for the other staff members. Where does all this pain and suffering go? Who counsels
the counselor?
We cannot unburden ourselves on our clients, nor on our nonclinician co-workers—this
would compromise our role and our ability to do good work. Although some of us may discuss
an occasional case (disguised, of course) with a significant other, in general we want to avoid
this, too. We don’t want to make a habit out of dumping the horrors of the day on our spouse. To
do this would be to inflict secondary trauma, and to what purpose? War veterans and police offi-
cers tend to have a similar reticence about polluting their family environment with “war stories.”
Fortunately, we can turn to one another. Professional peer support can be invaluable in many
ways. When we meet regularly with professional peers, we can do the following:

¢ Obtain and provide consultation on challenging cases.

* Teach one another new ideas and skills we have learned at workshops or from books.
* Offer support and alternative perspectives to colleagues who are having difficulty with a
client, co-worker, or boss.
* Identify and express work-related thoughts and feelings that might otherwise stay stuck in-
side us and do harm.
* Identify and problem solve systemic problems that undermine the clinical work.
¢ Discuss self-care strategies.
* Hold one another accountable to actually use the self-care strategies on a regular basis.
 Taking Care of Yourself at

In short, the buddy system is what makes everything else work. We don’t always have the dis-
tance or perspective to help ourselves, but we can help one another to learn, stay focused, self-
monitor, solve problems, and maintain good habits.
In some work settings, once you have your professional license you may be told that “you
don’t need supervision anymore.” This is wrong. We all need a regular opportunity to meet with
professional peers to discuss our work in depth. Even after you are more experienced and don’t
require a senior supervisor, you can still benefit from peer supervision. Work settings that don’t
allot time and space for supervision (individual or peer-group) are being penny-wise and pound-
foolish. They are likely to pay many times over in lower quality of work, worse morale, and
higher turnover.
The buddy system—professional peer support—is the hard hat of our profession. If your
work setting does not provide you with an opportunity for regular peer support, then it has failed
58 CHILD TRAUMA HANDBOOK

to address your occupational hazard. This is irresponsible. However, the failure is often the re-
sult of ignorance rather than bad intent, and so may be responsive to education. If you are unable
to obtain this essential support within your workplace, as a responsible professional you are still
obliged to build it into your professional life. You owe it to your clients, your family, and your-
self.

Connecting with One Another

We get something else from interacting with professional peers: the interaction itself. When
we connect with one another, we are not alone in our work. We interact with others who know
what we know, who do what we do, who care about what we care about. We can communicate
with one another in a special way because of these shared experiences and understandings.

EXERCISE: PEER SUPPORT

Write down your answers to each of the following questions:

1. Do you have any regular meeting/interaction with your professional peers? Describe it.
Does it serve you?
2. When and where do you have a chance to learn new skills that can help you be more
effective?
3. When and where do you have a chance to freely discuss issues (including systems and in-
terventions as well as emotions) that come up in your work with kids?
4. When and where do you have a chance to feel a sense of camaraderie or closeness with
your professional peers?
5. What would it take to develop a peer support system in your workplace? How, specifically,
might you go about accomplishing this?
6. What would it take to develop a peer support system independently? How, specifically,
might you go about accomplishing this?

For many of us, the work to help hurt kids is more than a job; it’s a calling. And although it
may be a noble calling, at times it can make us feel lonely, frustrated, and profoundly sad. It can
be a great comfort to share this sadness with others who also share our commitment and our mis-
sion to help hurt kids. Of course, we do more than share sadness; we also share hope. This shar-
ing of knowledge, skills, support, sadness, and hope might take place in our work setting, in our
peer supervision group, and in professional conferences and meetings. We are enriched by being
part of this community; it can sustain us.
Self-care is an ongoing obligation of the helping professional working with traumatized kids,
and for many of us, an ongoing challenge. The challenge increases at times of stress, whether
that stress is related to our personal lives, work settings, or what is going on within the treatment
of a particular child. At times of stress it may be very difficult to focus on caring for ourselves,
yet that’s when it’s most important that our “tools of the trade” are in good condition. As we
progress through this training/book, self-monitoring and self-care issues will be raised on a reg-
ular basis. At each phase of treatment, we should check in with ourselves, and with one another,
to support one another and keep ourselves in shape and on track.
 Taking Care of Yourself 59

SECTION I BIBLIOGRAPHY

Campbell, J. (1968). The hero with a thousand faces. Princeton, NJ: Princeton University Press. The classic work on
the quest of the hero as a metaphor for personal growth and transformation. The quest of the hero has the same ba-
sic structure as the fairy tale presented in this book.
Chemtob, C. M., Roitblat, H. L., Hamada, R. S., Carlson, J., & Twentyman, C. (1988). A cognitive action theory of
posttraumatic stress disorder. Journal of Anxiety Disorders, 2, 253-275. The classic paper on survival mode as a
post-traumatic symptom.
Cohen, J. A., Berliner, L., & March, J. S. (2000). Treatment of children and adolescents. In E. B. Foa, T. M. Keane,
& M. J. Friedman (Eds.), Effective treatments for PTSD: Practice guidelines from the International Society for
Traumatic Stress Studies (pp. 106-138). New York: Guilford Press. An authoritative review of effective child
trauma treatments and what components the effective treatments tend to have in common.
Figley, C. R. (1995). Compassion fatigue. New York: Brunner/Mazel. An early classic.
Fletcher, K. E. (1996). Childhood posttraumatic stress disorder. In E. Mash & R. Barkley (Eds.), Child psycho-
pathology (pp. 242-276). New York: Guilford Press. This chapter provides a good overview of child and adoles-
cent post-traumatic stress disorder and posttraumatic stress.
Giaconia, R. M., Reinherz, H. Z., Silverman, A. B., Pakiz, B., Frost, A. K., & Cohen, E. (1995). Traumas and
posttraumatic stress disorder in a community population of older adolescents. Journal of the American Academy
of Child and Adolescent Psychiatry, 34, 1369-1380. Documents the wide range of clinically significant non-
PSTD outcomes that trauma exposure can entail.
Greenwald, R. (2002). The role of trauma in conduct disorder. Journal of Aggression, Maltreatment, and Trauma, 6,
5-23. This article synthesizes research and theory on how exposure to trauma and loss can contribute to the devel-
opment and persistence of problem behaviors. It lays the foundation for the Meaning of Behavior analysis.
Herman, J. L. (1992). Trauma and recovery. New York: Basic Books. A classic example of a phase model of trauma
treatment; also provides a nice history of the treatment of PTSD.
Kendall-Tackett, K.A., Williams, L. M., & Finkelhor, D. (1993). Impact of sexual abuse on children: A review and
synthesis of recent empirical studies. Psychological Bulletin, 113, 164-180. A classic paper showing the wide
range of possible outcomes of exposure to sexual abuse.
Pearlman, L. A. & Saakvitne, K. W. (1995). Trauma and the therapist: Counter-transference and vicarious
traumatization in psychotherapy with incest survivors. New York: W. W. Norton & Co. Good integration and
treatment of the issues.
Perry, B. D., Pollard, R. A., Blakley, T. L., Baker, W. L., & Vigilante, D. (1995). Childhood trauma, the
neurobiology of adaptation and use-dependent development of the brain: How states become traits. Infant Men-
tal Health Journal, 16, 271-291. This classic paper describes the impact of early trauma on the child’s neurologi-
cal and personality development.
Saakvitne, K. W., Gamble, S., Pearlman, L. A., & Lev, B. T. (2000). Risking connection: A training curriculum for
working with survivors of childhood abuse. Baltimore: Sidran. This is the source of the RICH relationship model.
The book focuses on working with adults, but the relationship principles are essentially the same.
Stamm, B.H. (Ed.) (1995). Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators.
Lutherville, MD: Sidran. Another classic.
Terr, L. (1991). Childhood traumas: An outline and overview. American Journal of Psychiatry, 148, 10-20. This
classic paper provides a good overview of trauma and explains the important distinction between discrete (Type
1) trauma and chronic (Type 2) trauma, and the effect that these types of trauma exposure can have on the child’s
development.
Tokayer, N. (2001). A brief note on the research support for the Risking Connection approach. In K. W. Saakvitne
(Ed.), Relational teaching, experiential learning: The teaching manual for the Risking Connection curriculum
(pp. 175-177). Baltimore: Sidran. Reviews the empirical and theoretical support for the RICH model, focusing
on psychoeducation, empowerment, and therapeutic alliance.
van der Kolk, B. A., Pelcovitz, D., Roth, S., Mandel, F. S., McFarlane, A., & Herman, J. L. (1996). Dissociation,
somatization, and affect dysregulation: The complexity of adaptation to trauma. American Journal of Psychiatry,
153, Festschrift Supplement, 83-93. This classic paper does address the impact of childhood trauma, even though
the focus is on those traumatized kids as adults. A good explanation of affect dysregulation and more generally
how trauma exposure can lead to a wide range of symptoms and psychopathologies.
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 SECTION II:
EVALUATION AND TREATMENT PLANNING

The evaluation phase begins with the first meeting (actually with the first contact) and ends
when feedback on the evaluation has been provided, recommendations have been offered, and
the child and family have decided, with the therapist’s guidance, how to respond to these. Typi-
cally this involves a treatment contract, that is, an agreement for the child and family to engage
in treatment to address the issues raised in the evaluation. The evaluation should normally be
scheduled to be completed as soon as possible, even within a single day, because of the follow-
ing:

¢ Families tend to bring children for treatment in times of crisis.

¢ Children and families in crisis are most willing to engage in treatment; when the situation
has quieted down, they may be less interested (until the next crisis).
¢ Even though many beneficial things should be occurring during the evaluation, it is not
called treatment. Families in crisis should not be made to feel that they are being kept wait-
ing for the official treatment to start.

In short, a rapid evaluation process will help families to feel that their pressing concerns are
being taken seriously and responded to quickly, and will increase the chances of families choos-
ing to engage in the recommended treatment.
Trauma-informed treatment—or any treatment—really starts with the first contact. It should
go without saying that the person making the phone call or other initial contact should be treated
with courtesy and respect, given all necessary information in an understandable form, that some
connection should be made even in a limited first contact, and that hope should be conveyed.
The RICH approach will maximize the likelihood that the family will show up for the first meet-
ing.
It should also go without saying that every effort should be made to honor the relationships
that the child and family form with the helping professional(s). Treatment does not arbitrarily
begin after the “evaluation” has been completed and “treatment” starts. Treatment starts at the
first contact. This is when the child and family begin to form a relationship with whomever they
are interacting with.

A thirteen-year-old girl who had been sexually assaulted went through the three-session assessment
with the intake worker at the community mental health clinic. Her case was discussed at a staff meeting
and then assigned to a therapist. The girl never showed for her therapy appointment. She told her mother,
“| already talked to that one lady. | practically told her my life story. She’s the one I'll talk to. I’m not going to
start all over again with a stranger.”
61
62 CHILD TRAUMA HANDBOOK

Also, as the evaluation phase of treatment progresses, the child and family are telling their
story, the therapist is giving feedback—a lot is happening. We may be tempted to underestimate
how much treatment is really taking place even before we agree on a treatment plan and “begin.”

An eleven-year-old boy went through a two-hour evaluation following a school referral for disruptive be-
haviors and failing grades. The evaluator provided a trauma-informed case formulation and treatment rec-
ommendations to the boy and his parents. However, implementation of the recommendations (for treat-
ment) was delayed by four weeks until after the plan was approved at his individual educational plan
meeting. When he returned to the same clinician to commence treatment, he said, “I don’t need to be
here. |don’t have a problem anymore.” Indeed he was doing much better with his behaviors and his school
performance. He explained, “Once you explained everything to me [at the end of the evaluation], | knew
what to do about it.”

That so much may be accomplished during the initial intake/assessment phase of treatment is
not accidental. We have much to accomplish at every phase of treatment. Following are the pri-
mary goals of the evaluation phase:

¢ Establish a sense of safety and predictability in the therapy.

¢ Enhance/reestablish primary attachment relationships.
¢ Provide trauma-related psychoeducation.
¢ Develop a case formulation.
¢ Identify goals and enhance hope in achieving them.
¢ Develop a trauma treatment contract.

The stated purpose of the evaluation phase is to learn about the child in order to understand
what is wrong and how to fix it. However, the therapist can accomplish the remaining goals
along the way by behaving in a manner designed to instill a sense of safety and predictability,
and by presenting information in a manner designed to increase understanding of the child, em-
pathy toward the child, and hope for healing.
Remember, we can’t just say “trust me” or “you can feel safe now.” We must do the work to
give kids and families experiences with us that will allow them to learn to trust us and to feel safe
with us.
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 Chapter 5

The Initial Interview—

From “Hello” Up to History

How does a trauma therapist say Hello?

Actually, much goes into how we introduce ourselves and kick off the treatment relationship.
The first goal is to establish a sense of safety and predictability in the therapy. We can do this by
telling our clients what’s going on and what to expect. The trick here is to tell them the truth, and
to offer a truth that is reasonably enticing.
Psychotherapy was initially considered only suitable for intelligent, articulate, psychologi-
cally oriented clients, but now we try to treat a much wider range of people. This brings special
challenges. The psychotherapy literature tells us that clients from minority groups are more
likely than others to drop out of therapy so quickly that treatment never gets a chance to work
(Wierzbicki & Pekarik, 1993). The same is true for individuals who are not so intelligent or ver-
bal. This does not imply that these groups are similar, but both groups tend not to understand the
appeal of the traditional unstructured talk-therapy approach. Children in treatment have many
similarities to these groups, in that kids may not understand the purpose of unstructured talk,
and they may not be particularly psychologically minded or verbal. So it’s important to under-
stand that kids as a group may be difficult to engage.
The literature also tells us that certain therapist practices can mitigate this problem and help
these people to stay in treatment (Sue, 1998; Nader, Dubrow, Stamm, & Hudnall, 1999). The
therapist can “acculturate” the client by explaining what therapy is, what the procedures are,
how it works (and why these procedures might help), and what is expected of the client. It is also
helpful when the therapist’s style is directive, goal-oriented, and activity-focused rather than un-
structured.

You are here.

Knight, kingdom, Fence around Personal Slay the dragon Apple trees,
dragon, princess (case management, training (trauma resolution) compost, contest
(evaluation and parent train) (skills and (relapse prevention)
treatment plan) strength
building)

FIGURE 5.1. Steps in the fairy tale model.

65
66 CHILD TRAUMA HANDBOOK

ACCULTURATION

Clients who are not “therapy-wise” do not generally understand why an undirected “talking
about whatever you want” is supposed to help them. As one incarcerated fifteen-year-old boy
said, “They’ve been giving me counselors for years, but all that talking doesn’t make a differ-
ence. I still do what I do.” They want to know what to do to solve their problem, and they don’t
see how this kind of talk will get results. When the therapist explains the therapy procedures and
why these procedures can be expected to help the client, clients are more likely to engage and to
stick around. Therapists can also tell the clients what to do—how to behave in order to be suc-
cessful in treatment. Then clients know, and have a better chance of doing it.

THERAPIST STYLE

The other issue here is what actually happens in therapy. Just “talking about your feelings”
doesn’t necessarily help (and might actually do harm if the feelings are overwhelming). The
trauma-informed treatment approach consists of a series of tasks, and relies on a directive thera-
pist to guide treatment accordingly, while also being sensitive and responsive to the client.
When the client is helped to recognize the impact of his trauma (the dragon), to identify his goals
(the princess), and to understand how the treatment plan might help him to overcome his prob-
lems and achieve his goals (personal training to slay the dragon and marry the princess), then he
is more likely to engage and to stick around.

INTRODUCING TREATMENT

The therapist can start, then, by explaining what treatment is for and what is expected to hap-
pen in treatment. Here’s an example of what a therapist might say at the beginning of the first
session:

THERAPIST: Did your father tell you why you are here?
CLIENT: No.
THERAPIST: Usually kids come here because someone is worried about them, someone thinks
that they could be feeling better, acting better, doing better in some way. My job is to learn a
lot about you: what you care about, what you want for yourself, and what might be getting in
your way. So I'll be asking you a lot of questions. Then I’Il tell you what I learned. Then I’ll
give you some suggestions for how to get what you want, what to do about the things that are
in your way. Did you know that this is what we’d be talking about?
CLIENT: Sort of. Not really.

Note that we are not talking about the child’s problems at this point. We are acknowledging
that problems exist and suggesting the possibility of solutions. However, the first focus is on ac-
culturation, on what we’re doing here, why, and how we are going to do it. This continues with
an explanation of the rules. This word is chosen intentionally; children understand what rules
are.
 The Initial Interview—From “Hello” Up to History 67

THE RULES

Here the therapist is primarily addressing the child, although the parent(s) may also be present.

THERAPIST: Before we get started with the questions, I want to tell you what the rules are for our
meetings together. The first rule is about your privacy. That rule is that I don’t tell other kids
what you say. And I don’t tell other grown-ups, either. What you say here is private. But there
are exceptions. One exception is if you give me permission to tell someone about a certain
thing. Also, if I’m afraid someone’s in danger, the law says that I have to tell. So if you tell me
that you have a gun and want to shoot someone, I have to tell your dad or the police or some-
one who can stop you and keep everyone safe. Also if you or some other kid is getting
neglected—like they don’t get fed meals at home—the law says I have to tell so that they can
be taken care of and be safe. So here’s a quiz. What would I do if you told me that you stole a
pack of gum from the store, but don’t tell anyone?
CHILD: You'd tell.
THERAPIST: Why?
CHILD: ’Cause I broke the law; it was wrong.
THERAPIST: Did you give me permission to tell?
CHILD: No.
THERAPIST: Is someone in danger, about to get hurt?
CHILD: Oh, you wouldn’t tell, then.
THERAPIST: I might tell you that you did something stupid, but you’re right, I would have to keep
your privacy. [Therapist discloses any additional exceptions to confidentiality, e.g., disclo-
sures to third-party payor, records kept for the agency, etc.]
THERAPIST: Okay, so that covers the rule about what I can say to other people. The next rule is
about what you say. The rule is you are not allowed to say anything in here unless you decide
you want to. So what if I ask you a question that you don’t want to answer? How do you fol-
low this rule? What can you do?
CHILD: Say I don’t want to answer?
THERAPIST: That would be good. Can I count on you to do that?
CHILD: Okay.
THERAPIST: Let’s practice. I’m going to ask a question that you don’t want to answer, then you
try that. What’s four hundred fifty-four times sixty-eight?
CHILD: I don’t want to answer.
THERAPIST: Good job! Should we practice again or are you good enough at that already?
CHILD: I’m good enough already.

The previous script is intended as an example of how to explain the rules. The point is that
whatever your rules are, you should make sure to explain them. What information will you tell
parents and what will remain between you and the child? If you are working in a juvenile justice
setting, are you required to report instances of law-breaking? This is your chance to spell it all
out.
Stating the rules makes them explicit. Therapy is a new setting for most children, and know-
ing the rules up front helps them to feel secure because then they know what to do and what will
happen. The contents of the rules also convey safety and control for the child. This is reinforced
by quizzing the child on the first rule and practicing with the second. The child can feel actively
in charge of what she will say and what will be said about her. Finally, the quiz, and especially
68 CHILD TRAUMA HANDBOOK

the practice, make the rules feel more true, more real. It’s one thing to be told that a rule exists;
it’s another thing to experience it.
Note that the second rule is not phrased as “You don’t have to answer a question if you don’t
want to.” That’s not a bad rule, but it carries the implication that the child can choose not to par-
ticipate by refusing to answer a question. That sets up both the child and the therapist to feel as if
they have failed. This rule, “You may not speak unless you decide you want to,” carries the im-
plication that the child is participating fully regardless of the choice. Later, when the child re-
fuses to answer a question, the therapist can say, “I’m so glad you remembered my rule!” Thus
both the child and the therapist remain successful.
Helping the child remain successful is a core element of trauma-informed treatment for a cou-
ple of reasons. First, in the fairy tale model, we are focused on personal training to help the child
develop strength and skills. When failure becomes habitual, it’s difficult to keep up the morale
necessary to persevere. Also—and this is related—even a small failure may hit a sore spot and
trigger a trauma-related overreaction. If kids are getting habitually triggered in therapy, they will
learn that therapy is not a safe place and they need to protect themselves. Then they are more
likely to be resistant and withdrawn, and less likely to get the job done. The more we can do to
help kids feel successful when they are with us, the better chance we have of being successful
with them.
After the rules we will ask questions. Consistent with the fairy tale model, it’s very important
to get the “once upon a time” information before we start focusing on the dragon and the prob-
lems it created. When we meet a child and focus immediately on his problems, he feels as if he is
a problem and that is how we see him. On the other hand, if we focus on the positives—the his-
tory of successful relationships and achievements—the child feels as if we are getting to know
him, not just what’s wrong with him. Also, because the child is expected to be his own knight in
shining armor, we need to be able to see this potential in the child and to know his strengths. We
get this information by asking, by learning much about him, not just the problems.

STARTING WITH A PARENT PRESENT

Treatment is normally more effective when parents are involved; however, in certain settings
parents may be unavailable. Even in such settings, it’s worth making a creative effort to include
parents whenever possible. Assuming we have one or more parents present when we start treat-
ment, there are special procedures for the first meeting.
The therapist still explains the purpose and activities of treatment as well as the rules. The
therapist then announces that after meeting all together for a while, time will be made for the
parent alone, and for the child alone. The parent is then less likely to raise issues that should not
be discussed in front of the child; if the parent does so anyway, this sets the stage for the therapist
to tell the parent, “We can talk about that later.’
We try to ask about “normal” things before asking about problems; this makes people feel
more comfortable and respected. When the parent(s) and child are present together, a good start-
ing point is to ask about the family. The therapist can ask a little about each family member, and
create a genogram (diagram/map of the family).
Next, we make an exception to the typical first-session focus on the “once upon a time” mate-
rial. We ask the parent about the presenting problem. First, most parents would feel that some-
thing was not quite right if, during the first meeting, they did not get to discuss the problem and
why they are bringing their child for help. They might feel disrespected or that the therapist was
not interested in the problem.
Also, one of the goals is to begin to enhance/reestablish primary attachment relationships.
One way to do this is by asking parents what they most like about the child. However, if you ask
 The Initial Interview—From “Hello” Up to History 69

this now, many parents will “spoil” their own answers by making such statements as, “Well, he
gets along well with his siblings—when he’s not fighting with them,” or “She’s good at doing
her chores—if she’s ever home.” Many parents have such an urge to tell the therapist about the
problem that it’s best to invite this early and let them get it out of their system.
When a child is brought for treatment, she often feels like this is part of “being in trouble.” By
this time, the ongoing parent-child interaction may be fraught with anger, frustration, and rejec-
tion. Hearing the parent tell the therapist what’s wrong is probably not big news to the child. On
the other hand, the child may not have heard much lately about the ways she is positively viewed
by the parent.
Once the parents have dumped their load of complaints, they are more able and willing to
recall and discuss good things about their child. This reminder of positive attachment is a won-
derful way to end the family portion of the initial evaluation session. If only briefly, it helps the
family to feel close in a way they may not have for some time. This experience provides encour-
agement to all parties and makes them hopeful about the treatment.
Here is an example of how this part of the session might be conducted.

THERAPIST: Remember I said that parents bring their kids to me ’cause they’re worried about
them? Who’s the most worried about you? And what is he or she worried about?
CHILD: I don’t know. Ask her.
THERAPIST: I will. But I’m asking you first. If you’re not sure, it’s okay to guess. I want to see
what you think she’s worried about.

(Once the child has said as much as he will, ask the parent to confirm and elaborate if neces-
sary regarding the primary concerns/complaints. If the parent starts to make a comment that is
inappropriate or unnecessarily embarrassing to the child, remind the parent that he or she will
have an opportunity to speak with you in private as well.)

THERAPIST: Now I'd like you to tell me the things you like most about [your child].

(Therapist writes these down in the list by the child’s figure in the genogram. If parent quali-
fies these items with complaints, therapist ignores and redirects to focus on positives. Often the
positives are remembered items that were more prominent before the presenting problem
started/escalated.)

THERAPIST: I can see that there are a lot of things you really appreciate about your child. It must
be frustrating to care so much for him and see him having such a hard time.

The therapist’s summary statement (before transitioning to the parent-only meeting) conveys
the impression/implication that the essence of the family is positive attachment and the essence
of the child is the positive qualities. The presenting problem is seen as a disruption that is upset-
ting but can be dealt with. This type of subtle intervention is repeated frequently to enhance at-
tachment and empathy and to convey that we are building on strengths to overcome problems.

MEETING ALONE WITH THE PARENT

The parent interview should cover the following:

¢ developmental history including temperament, attachment, medical, social, educational,

legal (don’t forget to ask about head injury and about prior treatment);
¢ detailed trauma/loss history;
70 CHILD TRAUMA HANDBOOK

¢ details of the presenting problem, including the situations in which the problem occurs,
and the parent’s typical response (or range of responses);
* the parents’ discipline style including details of how and when it is implemented; and
* anything else the parent wishes to disclose without the child present (save this for last).

When asking about the child’s trauma/loss history, it’s best to give multiple specific examples
of possible events, rather than asking the open-ended question. Recognition is easier than recall.
Also, this can be a sensitive topic. Parents often express guilt feelings when discussing their
child’s trauma/loss history. The therapist can point out that although it’s natural for parents to
feel that way, in fact most children do get exposed to significant trauma or loss. The important
thing is to protect them as much as possible, and then to help them recover from the negative ef-
fects—which the parent is clearly making an effort to do.
This is a good opportunity for the therapist to start piecing together any possible connection
between the child’s trauma/loss experiences and onset or escalation of problems. Therefore it’s
important to question the parent with some specificity regarding observed changes following re-
ported events. Then later when the therapist provides the case formulation, many of its compo-
nents have been “field tested” with the parent ahead of time. Thus, rather than the therapist pull-
ing a rabbit out of a hat, the case formulation arises naturally from the previous conversation,
and the parent is more likely to accept the therapist’s views.
There are several important reasons to learn a lot about the presenting problem, the context in
which it occurs, and what happens when/after it occurs:

¢ This kind of attention shows respect to the parents, who have sought your help because of
this problem.
¢ You want to be able to complete that Meaning of Behavior form, so you need to be able to
identify the triggers that seem to set off the child.
¢ You want to learn the details of how the child is reinforced for the problem behavior. Re-
member, the problem behavior is the child’s solution to the earlier problem of facing a
trauma-related intolerable overreaction that was triggered by some minor stressor. How
does the solution solve the problem? The better you understand how the problem behavior
is working for the child, the better you’ll be able to offer solutions.
¢ You want to learn about the parents’ discipline approach because you want to know what
solutions they’ve already tried. Also, many parents’ discipline approaches actually contrib-
ute to the child’s problem by reinforcing her problem behavior and/or by increasing her
sense of insecurity. For example, many parents use an ineffective, inconsistent discipline
style in which they first let things slide and then get so frustrated that they overpunish.

The parent training issues and methods can be gently introduced or anticipated here to help
the parents become familiar with the concepts. It is important for the therapist to convey respect
for the parents’ intentions, e.g., not wanting to be hard on the child after all he’s been through.
Then later the parent training will be easier to sell because it will not be about contradicting the
parent, but about helping him or her express his or her good intentions more effectively.

MEETING ALONE WITH THE CHILD

Kids can feel pretty nervous when a strange adult starts asking them personal questions. The
more we can do to help kids feel safe and in control, the more comfortable and more likely to co-
operate they will be. Also, the more we can help them to feel safe and in control, the more they
will learn to trust us and to believe that we care for them and have their best interests as a priority.
 The Initial Interview—From “Hello” Up to History 71

A number of specific things can be done to foster the development of this therapeutic relation-
ship and to help kids to feel safe with us.

Allow Certain Choices

Some children feel more comfortable when they are able to draw or play with a toy while talk-
ing. Although it is very important to get through the evaluation, we can allow kids to keep their
hands occupied as long as they are also able to fully participate in the evaluation. Upon seeing
the child begin to play with a toy, the therapist might say something like, “I don’t know you very
well. Will you be able to play with that toy and concentrate on our conversation at the same
time?” This gives the child the option of playing with the toy, while also making clear that the
conversation is a priority.

Help the Child Prepare

Before diving into the questions, remind the child about saying “I don’t want to answer that.”
Think about driving a car, fast. This can be a little scary, but fun too. Now think about how fast
you'd be willing to drive if you weren’t sure if your brakes worked! Whenever we ask a child to
“drive fast” or to take a new risk, it’s nice to say, “Let’s check and make sure your brakes still
work.” This reminder of how to “not answer” can help kids to feel in control, and then more will-
ing to take the risk and answer questions.

Start Small

After the big buildup of “here come the questions,” kids are relieved to be asked about their
favorite color, favorite food, favorite activities, etc. The questions only gradually become more
personal as kids become more comfortable. Children find these innocuous questions relevant—
it’s what they might want to know about one another—and like to be seen as a whole person and
not just as a problem. Most kids will answer most or all of the questions, and will feel good at
having expressed themselves—even if no apparent emotionally laden disclosure has occurred.

Warn Before Any Potentially Challenging Shift

The trauma therapist avoids surprising children with sudden shifts or potentially objection-
able (personal and/or upsetting) questions. Thus the warning, “Here comes a different kind of
question,” or “Here comes a question that some kids don’t like. Do you remember what to say if
you don’t want to answer?” The goal is not to surprise kids but to help them feel that we are
looking out for them. In general, the more kids feel that they are in control and can say No, the
more they are willing to go ahead.

Give a Menu

When the child has trouble answering an open-ended question or some other question, the
therapist quickly (after about two seconds) intervenes with a “menu” of possible choices—types
of appropriate answers. This helps the child be successful and can preclude the tendency for an-
gry acting out (e.g., “Don’t know, don’t care”) in the interview. The two-second rule is a good
guide, but you can use your judgment or even ask about the silence. For example, “This seems to
be a hard question to answer. Should I just give you more time or ask it in a different way?”
There are important differences between giving a menu and asking a leading question. Giving
a menu is a way of showing what a right answer might look like, orienting the child to the possi-
72 CHILD TRAUMA HANDBOOK

bilities, but clearly asking for the child’s own answer. A leading question, on the other hand,
pushes the child to give the particular answer that the therapist seems to be demanding. Here is
an example, as a follow-up when the child did not adequately answer the question, “How do you
know when you’re angry? What are the signals?” A menu might be, “Well, some kids say they
get swear words in their head, or fighting words, or their mind goes blank. . . Some kids say that
their face gets hot, or their heart starts pounding, or they fidget, or their hands turn into fists. . . .
What happens with you? What are your signals?” A leading question might be, “Then you want
to kill him, right?” A leading question can feel coercive to the child, and yields limited informa-
tion of dubious value. Use the menu.

Provide Frequent Feedback

Therapy can feel safer for kids when the therapist offers frequent feedback. Many kids have
been exposed to adults who, due to mental illness, substance abuse, or trauma-related reactivity,
have been volatile. Kids in this type of environment learn to (try to) read minds, read signs, to
figure out when the bad thing might happen, so that it can be avoided or at least prepared for.
When a therapist plays the “blank slate” game, kids don’t know what the therapist is thinking,
and they are liable to fear the worst. Then they will feel unsafe, afraid to say certain things for
fear that you’ll get angry or not like them anymore.
On the other hand, if you provide frequent feedback, kids will feel that they know what’s go-
ing on with you, and they won’t have to worry about it. This doesn’t mean that you make a habit
of self-disclosure. Rather, it means that you let them know, selectively, what you think you are
learning. For example, you might say, “So I’m getting the impression that you’re smart enough
to do well in school, if you decided to do the work. Do you think that’s true?”
This gives you a chance to convey a positive impression, focusing on the child’s strengths
even while acknowledging the problems. Another advantage of providing frequent feedback
along the way is that you get a chance to field-test the building blocks of your case formulation
so that by the time you formally offer the case formulation, the child has already become famil-
iar with many of its elements.

Offer Information

The therapist can share a couple of specific kinds of information during the initial interview.
This strategy amounts to an informal psychoeducation regarding the impact of trauma. The goal
here is to help kids understand themselves and their symptoms as within the range of normal re-
sponses to stressful past events. This also helps to build the case for the case formulation.

¢ Why you are asking that question. The therapist can simply explain this to provide infor-
mation. For example, “The reason I was asking is that some kids, after they get a concus-
sion like you did, they notice that some things are different, like they might get headaches,
or have more trouble concentrating than they did before, or have a shorter temper. Did you
notice anything like that for you, after the concussion?”
* What other kids say. At various points (e.g., when offering a menu or framing a question
with multiple options) the therapist refers to what “other kids” say. Traumatized children
often feel strange, alien, isolated, different. This type of questioning effects some of the
universality normally available in group therapy: that the things that have made the child
feel different are actually things in common with other children. Kids feel relieved to dis-
cover that they are “normal.”
 The Initial Interview—From “Hello” Up to History 73

Honest Praise for Self-Advocacy

Kids may be hesitant to tell you that they have to go to the bathroom, that they don’t want to
talk about a certain thing that you’ve asked about, or that they are in a hurry to get out of the ses-
sion because of some other high-priority commitment or activity. They may feel that advocating
for their own needs would somehow be disrespectful to you or to the treatment. Although this
consideration may be admirable in some way, the risk is that the child ends up taking care of the
therapist instead of the other way around. If the child believes that her needs are not as important
as yours, then in that way the therapy relationship may be replicating a prior victimization or ex-
ploitation and will not feel safe to the child.
This does not mean that there should be no rules in therapy; to the contrary, rules exist in large
part to help the therapist maintain the focus on the child’s needs. Traumatized kids respond well
to structure and predictability; this helps them to feel safe. However, the therapist should be sen-
sitive to the child’s apparent discomfort and supportive of the child’s needs, which hopefully the
child will learn to assert with more comfort and confidence over time. For example, the therapist
might say, “Of course you can go to the bathroom now. How could I expect you to sit there and
concentrate when you have to go to the bathroom? I’m so glad you said something!”
What do kids learn when the therapist supports their needs being met? They learn that “This
therapist cares about me and wants to make sure that I’m okay. This is not someone I need to de-
fend myself against; this is someone who looks out for me, is on my side.” Of course, the thera-
pist will have to be alert for possible abuse of this flexibility, but in general it pays off nicely.

EXERCISE: PRACTICE THE INITIAL INTERVIEW

Using the following script, practice this portion of the initial interview with a colleague; then
change roles and have the colleague practice with you. If you are on your own, just go ahead and
try this with a new client, bearing in mind that you don’t use this script until after you’ve done
the acculturation, rules, and other activities that come first.

If You Are the Client

¢ Role-play a child of any age (old enough to talk in full sentences!). Tell the therapist your
name and age.
¢ Do not look at the script. Don’t do the therapist’s job. Just respond as you would in the role
you are playing. However, please don’t give the therapist too much trouble, either! This is
not the time to role-play your hardest case; give this therapist a break while he or she is try-
ing to learn a new procedure.
¢ In an actual session, this portion of the interview comes after the rules. So when you are
asked, “What do you do if there’s a question you don’t want to answer?” you can say, “No
comment” as if you had just worked this out a few minutes before.

If You Are the Therapist

* Use the script verbatim, except that you may not need to ask all the questions (e.g., regard-
ing drug use) to younger children who do not endorse the first questions along that line.
¢ If you don’t get the answer you want/need, optional follow-up questions are provided in
parentheses. For example, if you ask, “What’s your favorite color?” and the child says
“Blue,” then you’ve got your answer and you can move on. If the child says, “I don’t really
74 CHILD TRAUMA HANDBOOK

have one favorite,” then you can use the parenthesized question and say, “Okay, what are
your two or three favorites?”
* Ifthe child declines to answer a question, thank her for remembering your rule, and move
on to the next question.
* Do not ask extra questions to learn more about the child’s responses. This might feel
counterintuitive, but trust me for now and later you’ll decide for yourself. The following
are two exceptions:
—It’s okay to ask a clarifying question if you really don’t know what the child means. For
example, if she says she smokes “a lot” of cigarettes, you might ask, “Like how many
cigarettes in a day?” | '
—It’s okay to ask brief follow-up questions on the positives that come up. For example, if
he says he likes to draw, you might ask, “What kind of stuff do you draw?” This contrib-
utes to the focus on strengths.
¢ Write down what the “child” says. You would do this in a real session. This is your assess-
ment data. It also shows respect: “What you say is important.”
¢ Use the script verbatim. Say it word for word. Do not wing it. You have the rest of your ca-
reer to do as you please. Right now, take this opportunity to learn as much as you can from
this. This script is as carefully crafted as a sales pitch, and pulls for the responses you want.
Please give it a try.

Exercise Follow-Up Questions

For the clients: What was that like? How did it go for you? Can you describe what worked
with you and what didn’t?
For the therapists: What was that like? How did it go for you? Can you describe what
worked with you and what didn’t?

Many therapists balk at using a script or indeed at doing anything with which they’re not pro-
ficient or comfortable. It’s important to recognize that when you are trying to learn a new skill,
you are likely to feel de-skilled for an initial learning period. The phases of learning are observa-
tion, imitation, and then integration. If you skip the imitation stage, you will have less to inte-
grate. If you are willing to experience the growing pains of actually learning the new method,
you are more likely to improve your skills, as eventually you integrate the new skills with your
current level of competence and comfort. It will happen!
For at least the first several kids, I encourage you to use the script in the session. If kids ask
what you’re doing with that book or piece of paper, you can just say, “I use this to make sure I
don’t forget to ask any of the questions.” You are the professional here. Kids don’t know how
you’re supposed to do your job, and they’Ilaccept this answer. Some therapists continue to use
the script as a regular practice.
Many therapists find it uncomfortable to just accept some short answer and move on; they say
it feels mechanistic and uncaring. But what did your clients say? What is their experience?
Many kids report, “I felt comfortable answering the questions because I knew you weren’t going
to pry.” This is an important precedent to set, because in the next session we will be asking about
trauma/loss history, and want the kids to feel safe to answer those much more difficult questions
without fear of prying. We want to keep the treatment carefully contained so that kids feel safe
and are not overwhelmed by being asked to handle more than they’re ready for.
Many kids, even the ones who gave one-word answers down the line, also say, “I liked being
able to express myself, tell you how I feel about things.’ When we ask these kinds of questions,
kids feel that we want to know them. Even if they don’t elaborate on their answers, they may feel
that they are expressing themselves and being understood.
 The Initial Interview—From “Hello” Up to History 75

Child Interview Script

© Ricky Greenwald 2004.

You remember | said | was going to ask a lot of questions to try to learn a lot about
you? And do you remember not to say anything unless you decide you want to? And
what do you do if there’s a question you don’t want to answer?

So here come the questions, ready?

ae favorite color? (Possible follow-up: Okay, what are your two or three fa-
vorites?

What's your favorite food?

What's your favorite music?

What's your favorite TV show?

What do you like in school? (Possible follow-up: Nothing? Not even recess?)

What don't you like in school? (What else?)

Some kids like to keep to themselves, some like to mostly be with one or two good
friends, some like to hang with a crowd. Which way are you? (If “crowd,” then: Would
you say there are certain kids who are better friends to you? Or is everyone the
same?)

You remember what to do if | ask you something that you don’t want to talk about,
right? I’m going to ask you some questions about your friends. Do your friends smoke
cigarettes or not? Do they smoke weed? Drink? Other drugs? Would you say that
your friends do pretty well in school, just get by, or are having trouble? Do your
friends get in trouble with the law or not?

Now some of the same questions about you. You smoke cigarettes? Weed? Drink?
Other drugs? How do you do in school? Do you get in trouble with the law?

What do you like to do with your friends? (Possible follow-up to “hang out”: So if |was
watching you guys hanging out and having a good time, what would | see you doing?)
What else do you do with your friends?

What else do you like to do? What else?

What have people told you that you’re good at?

I’m going to ask you a different kind of question now. If you could be any animal, who
would you be? What would be good about being a [ ]?

If you could have three wishes, what would they be?

If you could wave a magic wand right now and all your problems would disappear,
what would be different tomorrow? (Possible follow-up: If I’m watching on TV, what
would | notice was different?) (Possible follow-up: Okay, so you’d be doing better in
school. What would be different that would allow you to do better? Would the change
be something inside you or outside you?)
76 CHILD TRAUMA HANDBOOK

Clearly this script is designed to start off slow, build rapport, and help kids to feel comfort-
able. However, we are also learning what we need to know. For example, it is critical to obtain as
much information as possible about the child’s strengths and achievements. Later, these will be
used as a basis for hope.
The three wishes and especially the magic wand questions are good for identifying not only
treatment goals, but also obstacles. It’s also a good way to learn how the child perceives the
problem. Does it come from inside or outside the self? For example, a boy who sees his tendency
to fight as an internal problem might say, “I wouldn’t get so mad anymore.” A boy who sees the
same problem as external might say, “People wouldn’t act so stupid [make me so mad] any-
more.” When we know how this child sees his own situation, then we know how to talk about it
in a way that is consistent with his viewpoint. Then our case formulation is more likely to be
accepted.

OBTAINING MORE HISTORY WHILE FOCUSING ON STRENGTHS

The previous script, plus the acculturation preliminaries, can generally be covered in the first
hour. The entire intake interview may require several sessions, depending on the length of the
sessions. Following the portion of the interview detailed previously, the therapist can ask about
the family and about the child’s developmental history—although if a parent is available, then
the family information is obtained first, and the developmental history directly from the parent,
who will be a better informant. Then the therapist can ask about medical history (including head
injury) and current status, educational history and current status, and legal history and current
status.
You’ll need a sufficiently detailed history so you will later be able to tie together any trauma/
loss history with possible onset or escalation of problems. It is also important to continue to
learn about strengths, abilities, positive relationships, and successes, since these will be the
foundation for the child’s work in treatment. For example, the therapist might ask about educa-
tional history as follows:

¢ When you were in the first grade, did you feel like you were about as smart as other kids, a
little smarter, or a little slower? How were your grades in first grade?
¢ Did you get in trouble in school more than other kids, less than other kids, about average?
Would you say you had more friends than other kids then, less friends, about average?

Once the baseline of school-related functioning is established, the therapist can go forward
from there and develop a time line of changes that may have occurred.

THERAPIST: So how long did things stay this way in school until something changed?
CHILD: Until about fourth grade.
THERAPIST: Oh. What happened in fourth grade? What was different?
CHILD: I started getting into fights more, and my grades weren’t so good anymore.
THERAPIST: Like how much more? How many fights in a week?
CHILD: Not every day, but at least once or twice a week.
THERAPIST: How come you were fighting so much more than before? What was different?
CHILD: I just was more mad.
THERAPIST: And were you still passing your classes? What were your grades like then?
CHILD: I was still passing but it was mostly Cs and Ds, and I failed one or two classes.
 The Initial Intervilew—From “Hello” Up to History 77

THERAPIST: And how long did things stay this way until they changed again?
CHILD: When I went to the middle school in sixth grade, I got with a new group of kids and
started skipping classes a lot. ...

The same type of interviewing can be practiced for the other topics (medical, legal). This re-
sults in a good time line of the child’s history of functioning in multiple areas. We also know
how well she was doing before the problems started. Later, we can point to those times as proof
that she has the capacity to do well if it were not for the impact of the trauma/loss history.
Incidentally, by the time you finish this part of the interview, you have learned quite a bit
about the presenting problems, but you haven’t done it by asking “What’s your problem?” or
making the child feel as if she is a problem. Rather, you got to know the child and in the course of
telling her story, information about her problems were revealed. This child is likely to feel that
you see the good in her, that you see her as a normal kid—if with some problems—and that you
care about her. That’s a good start.
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 Chapter 6

Taking a Trauma History

By the second or third session, it’s time to ask the big question: “What are the worst things
that ever happened to you?” If we are going to conduct trauma-informed treatment, we need to
get the trauma on the table so we can incorporate it into the case formulation and treatment plan.
Therefore, the history must be done during the evaluation. Fortunately, it can be done in a care-
ful, intentional way that helps the child to feel safe and able to make progress in treatment.
Even the order of the different topics in the intake interview supports the fairy tale model.
First we ask about the good things, the strengths, the track record of achievements and positive
relationships—the “Once upon a time” stuff from when circumstances were better. (Hopefully
there was such a time! If not, we still do the best we can in terms of identifying strengths and re-
sources.) Then we ask about history up to the present, in various areas of life, and start to learn
about the impact that the dragon might have made in terms of problem development. Only then
do we ask about the dragon.
When we do ask about the dragon, we do it in a specific, limited way. Remember, the personal
trainer does not ask the knight to go from five pounds to a hundred all at once. The strategy is to
provide progressively greater challenges, one step at a time, each one manageable with the ther-
apist’s help. You may have already taken the child through several challenges up to this point,
for example:

¢ Trusting an adult enough to cooperate and answer questions.

¢ Telling the three wishes and the magic wand changes—these responses often reflect an
awareness of the child’s wounds and current problems. (“I wish my family had a nice house
and never had to worry about rent.” “I wish my brother never died.”)
¢ Talking about the family (some problems may be found here).
¢ Talking about the problem history (as part of education and legal history).

That’s a good start, but there’s a long way to go before the child can be expected to slay the
dragon, or to talk about the trauma and face the emotions. To invite this too soon is to risk failure.
So when we get the trauma history, we are careful to ask for, and allow, only disclosure of the
most basic facts, the bare minimum that will allow us to proceed with the case formulation.
Even though we are not asking for the whole story for each trauma event, the disclosure can
be difficult for the child. It is probably the most challenging thing we have asked the child to do
so far in treatment. So we continue to use the principles and practices of trauma treatment, to
help the child to manage this experience, to feel successful, and to come out in reasonably good
shape. Here are the steps we take:

1. Warn. Here comes a hill. Why don’t you check your brakes again, just to make sure they
work? In other words, we remind the child again about the rule: Do you remember what to do
if there’s something you don’t want to answer?
2. Make a “list.” We say, “I need to make a list of the worst things that ever happened to you.”
What does the word list imply? Brevity. This is going to be quick and easy, perhaps even im-

i
80 CHILD TRAUMA HANDBOOK

personal. We’re not going to get into details. This establishes a limit, defines what will be hap-
pening. The child knows that he will not be expected, or allowed, to provide a lot of detail.
_ What other kids say. This is a crucial opportunity for psychoeducation. When it comes to the
trauma history, which is often a secret, kids feel at their most strange, damaged, and vulnera-
ble. Here, the therapist offers the menu of possible trauma/loss events without even waiting
for the child to be silent for two seconds first. This accomplishes several purposes:
¢ If you just ask the child to list the worst things that ever happened to her, you will get some
answers. If you first give many examples of items that might be on her list, you will get
more answers. This is the difference between multiple choice and fill in the blanks: recog-
nition is easier than recall.
« When you give these examples by saying, “Let me tell you the kind of things that other kids
say,” you are normalizing the part of the child’s experience that may feel most abnormal.
You have transformed this question from “How are you damaged and different?” to “In
what ways are you like other kids?” This takes some of the pressure and stigma away.
¢ Children often keep these experiences private and may be worried—for good reason—
about how others might respond to a disclosure. When you describe what other kids have
said, and you are calm and businesslike, you give the message that you can handle what-
ever this child will tell you. You’ve heard it before. You can talk about it; you will not freak
out. This provides permission and safety.
. Get the list. Once you have prepared the child, ask for the list of worst things. It is up to the
child to determine what might belong on the list. The child may include items that surprise
you, yet fail to include items that you are sure should be included. It’s okay to suggest addi-
tional events that you may be aware of from the earlier interviewing (including the parent in-
terview).
Nn . Age for each item. You also want to know at what age (or what grade) each event occurred.
This can usually be done as the child is reporting each event, or it can be done just afterward.
You need to know when events occurred to determine if the trauma/loss history can help ac-
count for problem onset or escalation.
SUDS for each item. SUDS stands for subjective units of distress scale and is technical jar-
gon, not a term you should be using with kids. This is the 0 to 10 scale for how bad it feels
when you concentrate on it right now. Some tricks are involved in getting the SUDS scores:
¢ Some kids will claim that “It doesn’t bother me anymore.” Although they are not exactly
lying, what they often really mean is something such as, “I don’t let it bother me anymore. I
try not to think about it.” You don’t need to argue about this. Just ask your question in a way
that will get you the answer you want, e.g., “When you make yourself concentrate on it
now, just for a second, how bad is it from zero to ten?”
* Don’t ask “How do you feel?” That’s not exactly the question. We are trying to help the
child to keep some distance, keep it a little less personal. So the question is “How bad is
the feeling?” which is more objective, less intrusive. Or better yet, once they get used to the
routine, ““What’s the number on this one?”
* Asking for the SUDS is, in a way, doing exactly what we have been trying to avoid: having
the child get into the feelings associated with the trauma memory. When therapists ask for
the SUDS as they are asking about each event, they risk getting the child mired in the mem-
ory and unable to shake it. We do need to ask for the SUDS, so the best we can do is get it
over with as quickly as possible. This is why we save it for last and do all of the events at
once—well, one after another.
What if the child refuses? Sometimes the child will refuse to disclose one or more of her
trauma memories. This is good. It means that she is following your rules. So what can you do
about that? How can you get the information you want/need while still respecting her deci-
sion (and keeping your own promise about the rules)?
 Taking a Trauma History 81

Here’s an interesting point: when you are talking about not talking about the trauma, you
are in fact talking about the trauma. So when the child says she doesn’t want to talk about it,
you have already accomplished one of your goals, which is to have her talk about it, at least a
little, but not more than she can handle just now.
Another of your goals, though, is to get a time line of when the bad things happened, so that
you can develop a case formulation. You can’t just ask her, “How old were you?” because that
would be talking about it, and she just told you that she doesn’t want to talk about it. But you
can ask her, “Is it okay to ask you how old you were?” Most children will readily disclose the
age of the event they don’t want to talk about. Later you can ask for the SUDS for that mem-
ory the same way you ask for the SUDS on the other memories on the list.
If the child will not even allow you to ask about the age of the event, don’t worry; you can
still do your job. Just write a question mark down on your list for the trauma and again for the
age and SUDS. The fact that she is not telling you more is itself important information. She is
letting you know that it would be too much for her to handle today. Does this mean that you
have not established the trusting relationship that you were hoping for? Does it mean she’s
testing you? Does it mean that she’s having a bad day but will have an easier time talking
about the hard stuff next time? Does it mean that she is more fragile than other kids and will
need that much more preparation before she is ready to slay the dragon? These are questions
you will want to keep in mind.
. What if there’s nothing on the list? Sometimes a child who believes he is cooperating just
doesn’t have anything to put on the list. This can happen for several reasons. Sometimes even
though you have provided the menu of common trauma/loss events, for some reason that
doesn’t jog the kid’s mind regarding his own similar experiences, and he can’t think of any.
Some kids have a personal style that does not allow or acknowledge extremes, and so they are
unable to respond to your question about “worst things” or things that “really hit you hard.”
Finally, some kids do not consider the upsetting events in their own history to be severe or bad
enough to merit being put on this list.
Just because there might be some good reasons why your list is empty (or nearly empty),
don’t stop there. In general, for reasons that will become clear later, it’s good to have at least
two or three items on a younger child’s list, and at least four or five items on a teenager’s list.
More is fine too; less will often be a problem.
So what to do? We definitely don’t want to tell the kid, “No, I know you have more stuff to
put on the list. Come on, give it up!” Fortunately, your clients don’t know what your next
question will be. So when you have a client who doesn’t give enough events for the list, here
are your next questions:
¢ How old were you for the worst thing that ever happened at school?
¢ How old were you for the worst thing that ever happened with other kids?
¢ How old were you for the worst time you ever lost someone you cared about?
¢ How old were you for the worst time you ever got disciplined or punished?
¢ How old were you for the worst time you ever saw parents or other grown-ups arguing or
fighting?
These questions seem to help complete the list. Occasionally the child will still say, “Nothing
like that ever happened,” and we can accept that, as long as it’s not the consistent answer for
each question. Usually he will give the age that the event happened and explain a bit about it.
Notice that we do not ask, “Did this ever happen to you?” We already asked that, and came
up empty. This time we ask, “How old were you when this happened?” Now we get an answer
we can use.
_ Finish the sandwich. Remember, whenever we expose a child to challenging emotional con-
tent, we follow it up with some calming activity, then with something more thought-oriented
to help with recomposure. Following the trauma history we have the child do a deep breathing
exercise. This helps the child relax. Then we ask about the best things that ever happened.
82 CHILD TRAUMA HANDBOOK

This helps the child to refocus on something more positive, rather than staying stuck in the
trauma. Although we avoid asking probing details about the trauma, it is okay to ask more
about the good events; this helps to accomplish its purpose. Finally, we end the session with
conversation about more casual issues, such as what the child will be doing later in the day or
the week.
It is important to write down the details of the child’s trauma history; you will need to refer to
it on several occasions later in the treatment. Your notes on the trauma history might look like
the “Worst Things” box that follows. Please review that box now. Perhaps you noticed the com-
ment in parentheses after the “Breathing” notation. As a therapist, you may have a repertoire of
interventions that can help kids calm down. Not every intervention works for every child. It’s not
the child’s fault and it’s not a problem. We just want to keep track of what works and what
doesn’t with a given child so that we can proceed accordingly. With the girl in the example, we
are unlikely to attempt deep breathing again, and this note will remind us to try something else
next time.

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 Taking a Trauma History 83

“Worst Things” Example

Worst things

Age Event
10 Uncle RJ died
3) Car accident
a v 10+
13 Boyfriend broke up with me ite
Breathing (went through the motions but did not appear to relax)

Best things

Age Event
All My birthdays
14 Roller skating
Re Beach vacation

EXERCISE: TAKE A TRAUMA/LOSS HISTORY

Work with a colleague. When you have finished, change roles and do it again. If you’re on
your own it is worthwhile to complete the form for yourself, but you’1l be missing much of the
learning experience.

If You Are the Client

¢ This is not a role-play; be yourself. It is up to you to decide which events you wish to dis-
close. Disclose only to the extent that it feels comfortable and appropriate to do so.
¢ Do not use or look at the script; that’s the therapist’s job. Just be yourself.

If You Are the Therapist

¢ Use the Trauma/Loss History form provided, or duplicate the form on another piece of pa-
per that you can write on. As you receive answers, write them into the form.
¢ Use the trauma history script. In the script, the words in brackets are instructions for you.
The rest is to be spoken aloud. Do it verbatim—word for word.
* Remember to go in order. First, do the preparation, followed by the trauma/loss events and
ages. When you have all of those, get the SUDS for each event. Then practice the deep
breathing. Next, proceed to the best things. The script will guide you.
¢ Just because you will not be asking probing questions about the bad things that happened,
this does not mean that you must shut off your humanity or your caring. You still can—and
should—use your clinical skills to convey your compassion, your concern, and your com-
fort and ability to tolerate hearing what you are being told. How do you accomplish this?
Different people have different styles, but the basic requirement is empathy, that combina-
tion of being both emotionally present and objective/composed. Good luck.
84 CHILD TRAUMA HANDBOOK

Form for Trauma/Loss History Exercise

© Ricky Greenwald 2004.

Worst Things

Age SUDS (0-10)

(Breathe)

Best Things

Age
 Taking a Trauma History 85

Trauma/Loss History Script

© Ricky Greenwald 2004.

Now I’m going to ask you about something that some kids don’t like to talk about. You
remember what to do if you don’t want to say something?
Good. | wantto make a list of the worst things that ever happened to you. Things that
made you really sad or mad or scared, things that really kind of hit you hard. Maybe you al-
ready have something in mind, but let me tell you the kinds of things that other kids say, so
you know what I’m asking about.
Some kids, it would be maybe a car accident, or another kind of accident, or seeing
someone else get hurt really bad. Some kids, it’s that someone in their family, or someone
else they care about, got really sick or died. Or being taken away from their family. Or if
someone hurt you, or made you do sex things, or threatened you, told you they would do
something bad. Or seeing parents having really bad arguments or fights.
So what would be on your list? Okay, how old were you then? What else would be on
your list? [Etc. until there are no more events to list.]
[Note: If the child denies any trauma/loss, then ask the following questions to fill out the
list:

How old were you for the worst thing that ever happened in school?
How old were you for the worst thing that ever happened with other kids?
How old were you for the worst time you lost someone you cared about?
How old were you for worst time you ever got punished or disciplined?
How old were you for the worst time you saw parents or other grown-ups arguing or
fighting?]

Now I’m going to ask you how bad the feeling is for these, on 0 to 10, where 10 is the
worst feeling in the world, and 0 is no bad feeling at all. ’m not asking about how bad it was
at the time, but when you make yourself think about it right now, how bad the feeling is right
now. So for [that car accident], how bad is that feeling right now on 0 to 10? [Ask about
SUDS—the 0 to 10 subjective units of distress scale—for each memory on the list.]
Did anyone ever show you how to do deep breathing, like to relax? I’m going to ask you
to try my way of doing it for a couple of minutes, then you'll tell me whether we should ever
do it again, or not. You will be taking a very deep, slow breath in, to my count of 3, then hold
for 3, then breathe out slowly to a count of 3. Ready?
Breathe in 1, 2, 3; hold 1, 2, 3; out slow 1, 2, 3. Again, breathe in 1, 2, 3; hold 1, 2, 3; out
slow 1, 2, 3.
This time, when you breathe out, look for any bad stuff—tension in your body, upsetting
thoughts or pictures—and when you breathe out, imagine the air coming from that place,
and the bad stuff going out with the exhale. Ready?
Breathe in 1, 2, 3; hold 1, 2, 3; breathe out the bad stuff, 1, 2, 3. Once more, breathe in 1,
2, 3; hold 1, 2, 3; breathe out the bad, 1, 2, 3.
How did that go? Would you say you feel better than before, worse, about the same?
Now | want to know about the best things that ever happened to you, or times that you
felt really good. For some kids it would be a really good birthday, or they did something
they’re proud of, or they went someplace special, or were having a really good time doing
something. What are the best times you can remember?
86 CHILD TRAUMA HANDBOOK

Exercise Follow-Up Questions

If You Were the Client

How did this go for you? Please describe your experience if you are willing. Since people
have a range of experiences, we can begin to learn from one another about the variety of possible
responses. What did your therapist do that made you feel more or less comfortable than you
might have expected? Did talking about the bad memories upset you? Did the breathing or talk-
ing about the good memories have any effect?

If You Were the Therapist

How did this go for you? Please describe your experience if you are willing. Were you
tempted to encourage your client to talk more? How did you handle that?

For the Group

As a therapist in that exercise, please raise your hand if you found something your client said
personally challenging to listen to, or upsetting or hard to tolerate in some way. What did you tell
yourself about that while it was happening? How did you handle it? Do you feel any remaining
distress? How do you want to handle this distress now?
Many therapists who are new to trauma treatment struggle with the constraint of the list.
When you ask kids about their trauma/loss history, some of them will try to tell you the whole
story on the spot. It can be tempting to permit this. Many of us were trained to believe that when
a client “opens up,” that’s a good session. He is choosing to open up; he obviously wants to talk
about it, right? Wouldn’t it be disrespectful to shut him up once he has started? What kind of
message would he get from that?
Despite this temptation and these arguments, it is usually a bad idea to allow the child to dis-
close too much so early in treatment. The following several reasons suggest the therapist should
exercise restraint on the child’s behalf:

¢ Kids tend to be ambivalent about disclosing their trauma/loss history. They want to express
it, yet they don’t want to face it or expose themselves in that way. Just because the child is
showing you one side or the other does not mean that she is not ambivalent. You must al-
ways take both sides into account. If you tell her, “This is important. We don’t have time
now, but I hope we can talk about it in more detail when it’s the right time,” you have ad-
dressed both sides of the ambivalence. If you just allow her to spill her guts, you have only
addressed one side. The other side is likely to come out later. There is a risk that the child
will feel overexposed and even tricked by the therapist into overdisclosure. Then the child is
likely to feel unsafe and withdraw.
* If you allow the child to discuss the trauma in too much detail too soon, you are inviting
fallout after the therapy session is over. You haven’t yet had a chance to do the self-man-
agement training to help the child learn to cope better with upsetting feelings. So a higher
risk exists that the child may become upset later on, and perhaps act out or underfunction.
This is bad for the child and gives you, and treatment, a bad reputation.
* Ifyou allow the child to talk too much about the trauma, you are less likely to have time to
complete the follow-up activities in the session. The follow-up activities are critical to help
the child manage and contain the emotion that may have been activated by recalling the
trauma memories. This further increases the risk of after-session problems.
 Taking a Trauma History 87

¢ If you allow the child to talk too much about the trauma, you are less likely to have time to
complete the trauma/loss history in this session, and you’ll have to do it again next time to
get it done. The history is essential to making a case formulation. Once you have a case for-
mulation and a treatment contract, things go much better, so you want to get to that point as
soon as you can.
¢ You are the mental health professional with the specialized knowledge of how to conduct a
trauma-informed treatment. You are the adult who is supposed to be providing a secure,
supportive, and predictable environment, so the child can learn to feel safe. Chances are,
the child is coming to you at least in part for impulse control problems. So whose judgment
do you want to trust—yours, or the child’s? If you allow the child’s overdisclosure impulse
to spoil your session and your treatment program, you have failed the child; you have not
kept your own implied promise.

If this session has gone well, the child may have had a rather profound experience. He may
have told you about something that he has never talked about before. Perhaps he was afraid of
how someone would react; perhaps he was afraid that he himself couldn’t handle it. Hopefully
you reacted in a calm and supportive manner; and hopefully he was able to handle it well enough
too, with your guidance. This is a great step! He has learned some important facts about himself,
about you, and about what he might be capable of in treatment. He is stronger now than before,
and he has more reason to hope.
It doesn’t really take very long to ask the child about the trauma/loss history, but there’s
clearly a lot to it! The follow-up activities—deep breathing, list of good things, and the less in-
tense final conversation—are all very important to help the child regain composure and come
away with a good experience. These take time. So here’s some advice: don’t start on the trauma
history with only ten or fifteen minutes left in your session! You might not make it through all
the follow-up activities; it’s too risky. If you have long sessions (close to an hour) then you can
start partway through the session. If you have shorter sessions (closer to half an hour) it is best to
start on the trauma history near the beginning of the session.
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 Chapter 7

Trauma-Informed Case Formulation

If all you get out of evaluation is a diagnosis, you don’t have much to work with. If the inter-
vention of choice was simply a pill or medical procedure, little understanding would be re-
quired, and a mere diagnosis might suffice. Keep in mind, though, that in child trauma treat-
ment, both the child and the parents will be asked to perform a series of challenging tasks that
require both energy and persistence. Also, many of your kids and families have probably already
been through counseling, perhaps more than once, and the problems keep getting worse. So
your explanation must be extremely good. It should demonstrate your knowledge and credibil-
ity while also providing a persuasive rationale for the treatment activities you’ll recommend.
This is accomplished with a trauma-informed case formulation. The case formulation is the
product, or outcome, of the evaluation. It’s the therapist’s explanation of what’s going on with
the child. The case formulation becomes the cornerstone of the entire course of treatment—it’s
the road map. In fact, when I provide consultation and the therapist isn’t sure what to do, the
problem is almost always the absence of case formulation to guide the treatment. With a good
case formulation, you will have a deep, detailed understanding about who the child is, how the
problem developed, which factors keep the problem going, and what to do about it.
Although the case formulation is formally offered following the interview portion of the
Evaluation, in fact it begins much earlier. The therapist should be testing hypotheses all the way
along, by providing mini-formulations with both the child and the parent, and requesting feed-
back. This helps the therapist correct misimpressions early on, and to pursue fruitful areas in
more depth. It also allows the child and parents to gradually try on the therapist’s perspective
and give input into the formulation’s development. In other words, the evaluation should be an
interactive learning experience for the family. By the time the full case formulation is offered,
the family should feel as if they are being told something they basically already know and under-
stand—even if they did not know, and could not have articulated it that way, prior to the evalua-
tion.
This type of interactive process of mini-formulations also gives the therapist an opportunity
to zero in on specific details related to the formulation, and on the client’s language. Later, when
the full formulation is offered, the therapist can use the client’s language and fill it in with the
specific examples most relevant to the client. This enhances both the understandability and cred-
ibility of the formulation.
The case formulation is an opportunity to teach the child and family about the problem and
how the child’s trauma/loss history contributes to the problem. This accomplishes several pur-
poses, as follows:

¢ It transforms the child from “bad” to sad, mad, or scared. It’s tempting for a parent or other
caregiver to be angry with a bad child, to reject him, give up on him. But what if the child
isn’t really bad, just wounded? How do you react to a wounded child? You want to help.
Helping the parents see the child as wounded rather than bad opens the door for more em-
pathy and for enhanced attachment.
¢ It externalizes the child’s problem while internalizing the child’s goodness. Like their par-
ents do, many children also believe that they themselves have become bad, damaged,
89
90 CHILD TRAUMA HANDBOOK

tainted in some way. The case formulation helps them to see themselves as basically good,
with some problems that have intruded but do not represent their core being. In other
words, the dragon is the problem, not the kingdom itself.
It normalizes (and depathologizes) both the problem and the solution. Kids suffering from
posttraumatic symptoms and labeled as “problems” tend to feel that they are not normal,
that they are stigmatized, broken, sick. The case formulation helps them to see themselves
as having normal and reasonable reactions to unfortunate events. The case formulation also
calls for simple and normative actions (such as becoming stronger and talking through the
bad memory) to effect a cure.
It emphasizes strengths and resources. The case formulation does not start with the dragon
or the problems/symptoms. It starts with Once upon a time; with the kingdom’s pre-dragon
level of functioning, and with the knight in shining armor. It is the kingdom and the knight,
together (or, the family/community and the child) who will work together to slay the
dragon. The therapist must identify the child’s strengths and resources because these will
be the foundation of the child’s success in treatment.
It mobilizes people to productive treatment-related activities. When the child, parents, and
others can understand where the problem comes from, when they can feel empathy, con-
nection, and protectiveness toward the child (instead of anger and rejection), when they can
feel capable and empowered to solve the problem, and when they have reason to hope for
improvement . . . watch out!

The trauma-informed case formulation is essentially a story of the child’s life, which shows
how the child learned specific lessons (leading to the presenting symptoms) from specific expe-
riences (the trauma). The story is presented in plain language in a way that makes good sense to

|at,0 ONE EVER-R EXPLANED)

\ THIS TO ME BEFORE!
 Trauma-Informed Case Formulation 9]

parents and children who may not be psychologically oriented. The structure is the same as the
“meaning of behavior” form, but with “Once upon a time”—the child’s strengths and re-
sources—added at the beginning. Although the contents are individualized, all trauma-based
case formulations should include the following elements:

1. Begin with available evidence of positive attachments, healthy development, successful

functioning, good qualities, prosocial goals, supportive others, and other strengths and re-
sources.
2. Call attention to specific traumatic experiences in the child’s history.
3. Describe how other kids tend to react to such experiences:
* Negative beliefs: They may learn that the world is unsafe—bad things might happen—
and they better watch out. They may learn to believe that they are helpless, unworthy, or
bad.
¢ Pile-up offeelings: The bad feelings from the event (e.g., sadness, anger, worry) are so
big that it’s kind of too much. The feelings get stuck inside, and just pile up.
4. Describe how when something happens now that’s a reminder (trigger) of the old event, it
hits a sore spot, and the pile-up of bad feelings is so strong that kids get overwhelmed,
bogged down, caught in their symptoms. Sometimes they end up doing things to get rid of
the bad feelings, that later they wish they hadn’t done.

Here is the same case example that was used to illustrate the Meaning of Behavior form. To
make this a trauma-informed case formulation, the “Once upon a time” part (strengths, suc-
cesses, resources) is added at the beginning. Remember that the child’s identified problem be-
havior is actually a solution, from his perspective, to some other more pressing problem.

Casey is an eight-year-old boy who is referred for frequent fighting in school and in his neighborhood.
He has a history of witnessing domestic violence—seeing his father push his mother and hit her—and
had tried unsuccessfully to protect his mother from his father. Casey tells you that he does not pick fights
but only defends himself when other kids gang up on him and call him names.

Here is an abbreviated example of how you might fill out the worksheet:

1. Strengths/successes/resources: Will stand up for himself and his family. Does not pick
fights. Wants friends.
. Trauma/loss event: Saw father push and hit mother.
. Lesson learned (negative belief): | am powerless.
. Piled-up feelings: Anger, fear, shame.
A . Trigger situation: Theme: feeling threatened or attacked; example: being teased by other
BWN
kids.
6. Problem behavior: Fighting.

Here is the story (the explanation) you might provide. Notice that the order of events in the
story is the same as the order of steps on the worksheet.

1. Casey really cares about his family. He is brave and willing to stand up for himself and his
family even when others are bigger and stronger. He tries hard in school. He is a friendly
boy and is nice to other kids. He told me that he really wants to get along with kids better
and have more friends.
2. There were times that Casey saw his father hurting his mother. Casey tried to stop it from
happening, but he couldn’t. He was too small.
92 CHILD TRAUMA HANDBOOK

_ Kids learn from experience. Kids who have had this kind of experience often learn to be-
lieve that they are powerless, that they can’t protect themselves or those they love, that they
are not good enough.
_ Also, when something like this happens, kids often have very strong feelings, like being
afraid that someone will get hurt, being mad, and being ashamed that they can’t stop it
from happening. These feelings can be so big that they just pile up inside and leave a big
sore spot.
_ Now no one likes to be teased, it bothers everyone at least a little. But when Casey is teased,
I can’t help but wonder if it might be hitting that sore spot from the old thoughts and feel-
ings that are piled up inside. Then his reaction is much stronger than other people think it
should be. Then the bad feelings might be so strong that he can’t stand it, and he has to get
rid of it somehow.
. So his solution is to attack the kids who are teasing him. When he hits them, this gets rid of
the bad feelings. It gets out his anger. Also, he doesn’t feel powerless anymore; he feels
like he is able to protect himself.

Notice that the child’s goals were included in the “Once upon a time” section. He wants more
friends. Positive prosocial goals make kids feel normal. This boy is not “bad” or one who “just
doesn’t care.” It’s important to point this out. Also, this is his Princess; this is the thing that will
motivate him to work hard with us. When we follow the case formulation with treatment recom-
mendations, we will refer to his goals as the reason it is worth his while to follow our advice.

EXERCISE: DO IT YOURSELF

Try this exercise by yourself or, better yet, in a small group (three or four is ideal). Using the
following vignette, do the following, in order:

— . Complete the Trauma-Informed Case Formulation worksheet (included in this chapter).

Do this in order. Fill in everything you can for the first section, then the next, etc.
. Tell the story (give the case formulation) out loud to others in your group. Follow along
with the order used in the worksheet. Do your best but don’t worry if it’s not so smooth. It
takes practice.
. Have others give feedback: What one thing worked really well in that story and should be
done the same way next time? What one thing could be done better, and how?
. Have another person take a turn telling the story and receiving feedback. Repeat the pro-
cess until everyone has had a turn.
. Here are some tips to make the story work. It can be helpful to review these tips before each
attempt at telling the story. You won’t get these all at once; it takes practice.
¢ Go in order. Follow the worksheet. It works.
¢ Use py language that the child, teacher, or high-school-educated parent can under-
stand.
* Use actual experiences rather than labels, for example, “he saw his father hit his mother”
is preferable to “he witnessed domestic violence.” This way you are conveying the facts,
not making up labels. (On the other hand, sometimes it is more appropriate to be
vague—*“some bad things happened”—rather than disclose confidential information in
a group that includes people who may not have a right to hear the details. You’ll have to
use your judgment in the situation.)
 Trauma-Informed Case Formulation 93

* Try to avoid accusing the child of having certain thoughts or feelings. It’s better to talk
about the thoughts or feelings of other kids in similar situations. If the shoe fits, wear it.
This approach is experienced as less intrusive. Also, when you talk about other kids hav-
ing similar experiences, the child in question feels more “normal,” less like a freak, and
may feel more comfortable listening to what you have to say.
* Explain that when the trigger event causes the same negative beliefs and feelings as
those piled-up from the trauma memory, it’can hit the sore spot, leading to an extra-
strong reaction. Try to use the phrase “hits the sore spot” because people understand
that. Explain how the problem behavior gets rid of the bad feelings and has become a so-
lution for the child.

Following are some additional examples of case formulations.

Example 1: John

Presenting Information

John is a ten-year-old boy in the fourth grade. He has dyslexia that was only diagnosed a few months
ago and he is receiving special help with reading now. His grades and his disruptive behavior have been
progressively worsening for several years. The request for evaluation followed a suspension for dumping
his desk and walking out of a class during a quiz, as well as failing grades in several classes.

Formulation

Introduction: “Let me tell you what I’ve learned about John, and what I think can be done for
him. Then we can talk about it and you can decide what you want to do.”
Once upon a time: “One thing I’ve found out is that everyone I talk to really likes him! He
watches out for his little sister, helps around the house sometimes, wants to do well at school,
and has friends who like to play with him.
“But I know he has a lot of trouble with his reading, and that makes schoolwork hard to do.
And the reason you’re talking with me is because he also gets into a lot of trouble at school, not
doing his work, making noise, and getting into fights. And you told me that sometimes at home
he doesn’t listen, either. So let me tell you why I think he is the way he is.”
Then the dragon came: “Any kid who has this much trouble reading is bound to have a hard
time in school—to have things go wrong, over and over again.”
Negative beliefs: “Other kids in this situation have told me that when they see other kids do-
ing stuff they can’t do, they start to think that maybe they’re stupid, even if that’s not really true.”
Piled-up bad feelings: “Other kids have told me that it can be pretty frustrating to hit that wall
again and again. And when it’s hard to read, it’s hard to do almost any subject in school; even
math has word problems this year.”
The trigger: “So now, when he does try and something is hard, I wonder if it reminds him of
all those other times, hits the sore spot where all the years of frustration are piled up. That much
frustration can be hard to handle; it can feel like too much.”
The problem behavior and how it’s a solution for him: “So sometimes I think he decides right
away he can’t do it, and just gives up. And one thing I think is happening is that he’s so sick of
getting frustrated that sometimes he’d rather not even try, so he doesn’t have to get frustrated
again.”
94. CHILD TRAUMA HANDBOOK

Exercise: Trauma-Informed Case Formulation

© Ricky Greenwald 2007.

Marcus is a fourteen-year-old boy who was referred following his second suspension (for
fighting) in a month, this time for beating someone rather severely. Testing from second
grade showed an estimated IQ of 95 (the average range is 90-110) with better perfor-
mance than verbal scores. At that time he was having some reading difficulties—dyslexia
was suspected but never formally diagnosed—and responded well to a brief stint of tutor-
ing. However, by fourth grade he was no longer earning academic grades higher than a C.
He is generally quiet and attracts little attention in his classes, where he has been getting
by with barely passing grades and minimal work. He typically gets suspended once or
twice a year for fighting, and will not tell the vice principal (but will tell you) that he only
fights when someone disrespects him or his family. He is quiet and respectful at home,
with occasional temper outbursts. History of exposure to harsh physical discipline and wit-
nessing domestic violence, steadily escalating until Marcus was eleven when parents
separated and divorced. He is no longer in contact with father and says that’s the way he
wants it.
Let me tell you what | think I’ve learned about you.

1. [Once upon a time] First of all, lve learned some good things (introduce positive im-
pression of strengths and resources, including relationships, competencies, suc-
cesses, goals)...

. [Then the dragon] | also learned that you’ve been through some hard times (refer in
a general way to the trauma/loss history) .. .

. [Negative beliefs] Other kids I’ve talked with, who have had experiences like that,
have told me they’ve learned to believe bad things about themselves, which aren’t
actually true but they can’t help feeling that way...

. [Piled-up feelings] Also when bad things happen, other kids have told me that they
end up with some strong feelings, like. ... These can stay stuck inside, in a big pile,
and make a sore spot.

. [Trigger/high-risk situation] Now, whenever (describe the trigger situation theme) oc-
curs, | can’t help but wonder if that might be hitting the sore spot. No one likes (re-
cent example); it would bother anyone this much (show small amount with hands)
But if it hits the sore spot, it could feel like this (show large amount with hands)

. [Solution behavior] Most kids | know, if they feel that bad, they’ll do anything to get
rid of that. (Name the “solution behavior’ that followed the example above.)
 Trauma-Informed Case Formulation 95

Exercise: Trauma-Informed Case Formulation

© Ricky Greenwald 2007.

Michael is a ten-year-old boy who was diagnosed with ADHD at age nine after two years of
school-related problems including impulsive/disruptive behavior, interpersonal conflicts,
and poor work habits. Medication at age nine seemed to help at first, but after a couple of
good months, his school performance has been steadily deteriorating. At home he does
his chores after repeated prompting, and gets along with his siblings, though with a fair bit
of squabbling. His parents are currently separated; he lives with his mother, and sees his
father several times per week. Trauma history includes a minor auto accident at age five,
and the death of an uncle at age six.

Let me tell you what | think I’ve learned about you.

alt [Once upon a time] First of all, I’ve learned some good things (introduce positive im-
pression of strengths and resources, including relationships, competencies, suc-
cesses, goals)...

. [Then the dragon] | also learned that you’ve been through some hard times (refer in
a general way to the trauma/loss history) . . .

. [Negative beliefs] Other kids I’ve talked with, who have had experiences like that,
have told me they’ve learned to believe bad things about themselves, which aren't
actually true but they can’t help feeling that way...

. [Piled-up feelings] Also when bad things happen, other kids have told me that they
end up with some strong feelings, like. ... These can stay stuck inside, in a big pile,
and make a sore spot.

. [Trigger/high-risk situation] Now, whenever (describe the trigger situation theme) oc-
curs, | can’t help but wonder if that might be hitting the sore spot. No one likes (re-
cent example); it would bother anyone this much (show small amount with hands).
But if it hits the sore spot, it could feel like this (show large amount with hands).

. [Solution behavior] Most kids | know, if they feel that bad, they’ll do anything to get
rid of that. (Name the “solution behavior” that followed the example above.)
96 CHILD TRAUMA HANDBOOK

Example 2: Jody

Presenting Information

Jody is a seven-year-old girl in the second grade, previously high functioning, who began wetting her
bed and having nightmares following the anniversary of the World Trade Center attack. She has also been
picking on her younger sister more recently. Her house burned down three years ago (she was not home
at the time). The event precipitating the referral was a crying jag at school when the teacher asked Jody
why she hadn’t completed a quiz.

Formulation

Introduction: “Let me tell you what I think I’ve learned about Jody, and you can tell me if this
makes sense to you or not.”
Once upon a time: “First of all, I’ve learned that Jody is basically a normal girl who likes to
play, gets along with other children, does well in school, and listens to her parents.
“But you came for help because it seems that in some ways, she’s not herself lately.”
The dragons: “I think it’s probably related to what happened when the World Trade Center
was destroyed. Let me tell you the kinds of reactions that some other children are having; maybe
Jody’s going through something like this too.
“When something very scary happens, like a house burning down or a big building being de-
stroyed, children can take this a lot of different ways.”
Negative beliefs: “Kids with good parents grow up feeling safe and protected, and then some-
thing happens to show them that maybe things aren’t so safe. Sometimes they become very wor-
ried that something else bad will happen. And also, this might not seem to make sense, but some
kids will feel guilty when something bad happens, even though we know they could not have
caused it. But kids get mad about something, and then something bad happens, and part of them
might believe that their anger caused it.”
Adding in a little psychoeducation regarding other posttraumatic symptoms: “When kids
have been badly scared, sometimes they have bad dreams; sometimes they start wetting their
bed again.”
Piled-up feelings: “This type of event can also make a child feel helpless, sad, or angry. These
feelings—the fear, worry, helplessness, sadness, anger, guilt—can just pile up, get stuck inside.”
Trigger: “Then when something else happens to remind her of one of these feelings, even
something small, the pile-up of feelings can kick in and she can have a strong reaction. So
maybe something goes a little wrong at school, she feels a little mad or helpless, and instead of
handling it like she used to, now it hits that sore spot, and it’s so strong that it’s too much to han-
dle anymore.”
The problem behavior and how it’s a solution for her: “So then she just gives up and cries.
This gets out some of the bad feelings for her, also when she gives up that takes the pressure off
because she’s not getting frustrated anymore, and people try to comfort her.”

Example 3: Carla

A case formulation can take multiple traumas into account as well. Here is an example of the
portion of the case formulation (the trauma, negative beliefs, and piled-up feelings) that per-
tains:

Carlaisa ten-year-old girl in the fourth grade. She has a history of exposure to domestic violence at
ages three to five, death of a cousin by auto accident at age six, and dyslexia that was only diagnosed two
months ago. She was referred for failing grades and for refusing to do her schoolwork.
 Trauma-Informed Case Formulation 97

“When kids see one parent hurting the other one [like your child did], they often learn to
believe that they are not safe, that bad things can happen, and that they are helpless, what
they do doesn’t matter. Also, sometimes the bad feelings that kids have are so strong that
they just pile up, and stay stuck inside. Kids might feel mad about what happened, sad
about it, and even ashamed that they couldn’t stop it. Iwouldn’t be surprised if [your child]
had some of this kind of reaction to what she saw a few years ago when things were bad at
home. -
“Then when her cousin died, that’s another trauma piled on the first one. More helpless-
ness, more belief that bad things are going to happen, more anger, sadness, shame. The pile
just gets bigger.
“We also just found out a couple of months ago that Carla has dyslexia. Kids that have
dyslexia and don’t know it have lots of experiences at school, maybe many times every day,
where they are trying as hard as the other kids, but they can’t do it. Kids in this situation of-
ten learn to believe that there’s something wrong with them, and that they’re helpless, try-
ing doesn’t make any difference, bad things will happen no matter what you do.
“So Carla has been learning the same lessons over and over again. And the bad feelings
have just been piling up. And now, when [a trigger] happens . . .”

When you were practicing your case formulations, you might have noticed a strong tempta-
tion to go right into what the child and family should do about all this. Good! That’s what comes
next, in the same session—but here, it’s in the next chapter.
You might have also noticed that the focus, in these case formulations, was on the trauma-
related issues. This is not to say that trauma is the only issue or the only reason that the problems
develop or persist. There may be many other reasons; for example, the parents’ habitual ways of
responding might be repeatedly reinforcing the problem. However, the case formulation is not
the time to be passing around blame. The purpose of the case formulation is to increase under-
standing of the trauma contribution to the problem. This helps people access their caring for the
child, and to mobilize to improve the situation. Later on, we will use this understanding, caring,
and determination to address the other issues as well.
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 Chapter 8

Making a Treatment Contract

Once the trauma-informed case formulation has been accepted, treatment recommendations
can be made, and hopefully accepted by the child and family. Following the themes of the case
formulation, recommendations will focus on helping the child feel more safe and secure, and be-
come stronger and more effective, so that he will be able not only to manage the trauma-related
symptoms, but to face the trauma memory directly and gain mastery and resolution. Specific
treatment recommendations will most likely include

¢ Interventions specific to unique problems, symptoms, or situations;

¢ Parent (and other caregiver) activities to help the child feel more safe and secure;
¢ Child activities to help the child feel safer, stronger, and in control; and
¢ Child activities (later in the treatment) to help the child face and master the trauma memory.

Before trying to “close the deal” on the treatment contract, however, we must ensure that the
child’s (and family’s) motivation is being effectively developed and tapped. Remember, without
the princess to work toward, nothing else will happen.

MOTIVATION ENHANCEMENT

The case formulation is not only about the past and the present; it is also about the future. Mo-
tivation is an essential component, because without it, nothing else will happen. There are two
main ways to enhance motivation during the case formulation:

1. Don’t forget the princess! It is critically important to identify not only the parent’s goals for
the child, but the child’s goals for herself. What kind of person do you hope your child be-
comes? What kind of life do you want to have when you are older? What kind of day do
you want to have now, next week, next month?
2. It’s not enough to yearn for the princess if it’s only a fantasy. The child and the family must
believe, at least tentatively, that success is possible. Remember hope? Many things should
have already been happening that contribute to hope:

¢ The development of the therapeutic relationship might already make the child feel more
hopeful that safety is possible and that attachment is possible.
¢ The therapist’s obvious depth of knowledge about the presenting problem gives the ther-
apist credibility, and makes the proposed solution seem plausible.
¢ When the therapist talks about “what other kids say,” and then indicates that other kids
have been successful in treatment, the child might believe that he can do it too.
¢ The family’s increased sense of attachment as a result of the evaluation sessions shows
them that their former closeness may not be altogether lost.
* The child’s ability to tolerate the disclosure of trauma/loss history provides the begin-
ning of a track record for success with greater challenges.

99
100 CHILD TRAUMA HANDBOOK

* The therapist’s recommendation of a series of practical steps toward problem resolution

can bridge the gap between the problematic present and the desired future. Seeing how
it’s possible to achieve goals, step by step, makes the prospect of this achievement more
plausible.

In other words, nearly everything you are doing contributes to a growing sense of hope. The
child and family have been learning to feel better about themselves and one another through
their work with you. They have also been learning to respect both your knowledge and your ex-
pertise. Hopefully, with the case formulation and treatment recommendations, you'll have them
ready to work!

MOTIVATIONAL INTERVIEWING

Motivational Interviewing (MI) is a well-established counseling style/approach to conduct-

ing an evaluation and providing feedback that can be helpful for getting kids to identify their
own goals and then to commit to a treatment plan in the service of those goals. Although MI has
been used primarily with adults with substance abuse problems, in recent years it’s been applied
more widely, including use with people with post-traumatic stress disorder, and with teens. Sev-
eral studies of MI with teens found that a single MI session led to the following outcomes (in the
different studies):

¢ Ten percent had quit smoking cigarettes by six-month follow-up.

¢ Thirty-seven percent more in the MI group attended their treatment sessions (compared to
the control group).

This approach recognizes that people with problematic behaviors are generally ambivalent
about these behaviors. On one hand, the problem behaviors solve some other problem for them
(e.g., help to get rid of a bad feeling); that’s why they persist. On the other hand, these behaviors
cause other problems!
When others complain about why these behaviors are a problem, it’s natural for an ambiva-
lent kid to respond by resisting, perhaps by saying, “I like it. ll do it if I want to. It’s none of
your business!” On the other hand, when the other person supports his right to keep his behavior
and acknowledges that some value must be found in persisting with that behavior, it’s natural for
an ambivalent kid to respond by filling in the other side of the ambivalence, perhaps by saying,
“Yeah, but I’m sick of getting in trouble because of what I do. It’s getting old.”
When we tell kids what’s right, then even if they accept this, they are accepting what we said.
When we can guide kids to tell us what’s right (for them), then they feel more ownership; it’s
what they said—it’s theirs. In this empowerment model of treatment, we want kids to take the
initiative as much as possible. We want them to feel that they are participating in treatment activ-
ities because of their own determination to achieve their own goals. We may be the guide or the
coach, but we can’t do the work; so it’s got to be the kid’s princess.
Here are the essential principles and procedures in the MI approach.

Free Will: What You Do Is Up to You

The therapist is explicit about the fact that the child is making her own choices. The therapist
might say, “It’s your life; what you choose to do is up to you.” This respects the child’s auton-
omy while stating the truth—the child does make choices, not only of behaviors but of their con-
sequences. It’s important for the therapist to be supportive of the child while also keeping some
 Making a Treatment Contract 101

distance or neutrality, to avoid being sucked into a conflict about what the child should choose.
For example, the therapist might say (or at least say internally), “I hope you make the choice that
will help you get to your goal. But whatever choice you make, you know what happens at six-
thirty tonight? I have dinner.” In other words, root for your team, but don’t bet your savings on
what the team does. Another way of thinking about this is that we are supportive of the client but
we are not invested in the behavioral choices she makes at any given time. When kids can’t use
their choices as weapons in a fight with the therapist, they are left fighting with themselves, and
sometimes this leads to good things.

Empathy: Embrace the Client’s Worldview

Empathy has been identified as one of the key components of effective psychotherapy, and
it’s central to this approach, too. When we embrace the client’s worldview, he feels supported
and respected; he feels that we are with him. This doesn’t mean that we necessarily believe ev-
erything he says, or that we only see it the way he does. But we do convey understanding and ac-
ceptance. This is often accomplished with an active/reflective listening approach. For example,
the therapist might respond to the child’s explanation of what happened by saying, “So you were
just kidding around, but then he started really fighting with you?” The alternative, to say, “It
sounds like you started it,” is nothing new; this is what others have been telling this child already.
It hasn’t helped; that’s why they sent him to you. When you show empathy and acceptance for
your client’s worldview, then at least you are in the same conversation, and he feels that
someone cares and understands.

Be Nonconfrontational

Getting in the kid’s face and telling her what’s wrong with her might work in the movies, but
nowhere else. All you really get with the confrontational style is another free hour in your week.
The research indicates that the in-your-face approach only leads to worse treatment compliance
and increased dropout (Sommers-Flanagan & Sommers-Flanagan, 1995). Kids don’t like to be
“yelled at,’ so they block you out and write you off. The motivational interviewing style is non-
confrontational. We leave it up to the client to confront herself.

Identify Goals and Enhance Investment in Goals

The therapist guides the client toward identifying goals, things he cares about, wants for him-
self. Even this can be challenging for a child with trauma-related avoidance of hope; the child
may habitually deny having goals to preclude disappointment. The therapist also guides the cli-
ent to increasing his investment and commitment to these goals. This is done by helping the
child get in touch with how much he wants these goals, and also by helping the child to believe
that it’s not just some fantasy; we can figure out practical steps that can make the goals seem
more realistic and attainable.

Highlight Conflict Between Goals and Behaviors

The climax, or punch line, of the motivational interviewing approach is to highlight the con-
flict between the client’s goals and her current behaviors. This is done, of course, in an empa-
thetic and nonconfrontational manner. The therapist might say, “I’m confused. You told me that
you want those good things to happen for you, and I believe you. I think you really do want that.
But you’re also doing this stuff that you told me can get in your way, keep you from getting what
102 CHILD TRAUMA HANDBOOK

you really want. So it’s hard to tell what you really do care about.” When this dilemma is high-
lighted and given back to the client, it can have a strong impact.

Offer Specific (Concrete Actions) Advice

Once the client has endorsed the positive goals and claimed them for her own, the therapist
can offer advice, specific actions the client can take to help her to achieve her goals. Even now,
it’s important to maintain the stance of supportive neutrality, so that the client can retain owner-
ship of her goals and her initiative. The therapist might say, “Well, if that’s really what you want,
let me tell you what other kids have done in your situation to get to the kinds of goals that you're
talking about .. .” Then the treatment plan is offered in service of the child’s goals.

Arrange for Some Quick Successes

It is important that the treatment plan include some early treatment activities that will lead to
quick, if small, successes. What happens when the child quickly sees that he is actually accom-
plishing the first things on the list? He believes, more than before, that this can really happen,
and that he is already on the road to success. He becomes more confident, more hopeful, and
more committed to treatment.

FINDING THE PRINCESS

A number of strategies are available for guiding kids to identify and invest in their own goals.
Your strategy will be determined in part by the child’s age and developmental status. Kids at dif-
ferent ages have different concerns, different concepts of future, and different perspectives on
how much of the future might be relevant.
Preschoolers are very present focused; they just want to feel safe and happy. Most kids this
young will do what their parents tell them to do, as long as their parents are effective authorities
and as long as the child does not feel afraid. The parents are so influential that most of the moti-
vational focus is with the parent. Motivational approaches for parents are addressed in Chap-
ter 10.
School-aged children want to have a good day, but also are able to look forward to the near fu-
ture. Kids this age want to stop wetting their bed so they can sleep over at a friend’s house; they
want to get a better report card so their parents will take them to the video arcade; they want to
earn money to buy a special toy; they want to get better at a sport so they can get picked earlier
for a team, and so they can help their team win. This does not mean that they would choose to be
in treatment, even if the treatment can help them to get what they want. We must still count on
the adults to make sure that the child shows up.
Even so, it’s the child who will either work with us, or throw obstacles in the way. It’s impor-
tant first to identify what the child cares about, wants for herself, and then to make those goals
the explicit focus of the treatment. Note that one goal she may have is to not come to treatment
anymore. This is a legitimate goal to work toward and, of course, working hard on the other
treatment goals will get the whole thing over with more quickly. It’s also important to help the
child believe that her parents really want her to work toward her goals. In case the child believes
that her symptoms help her parents in some way, this intervention helps her to feel that her par-
ents will be okay and that she has their permission to get better. Also, when the child and parents
work together, this supports and enhances the relationship that may have been disrupted. Here
are the steps in a relatively straightforward intervention to accomplish this motivational piece:
 Making a Treatment Contract 103

1. Acknowledge that it may not be the child’s choice to come to treatment. “Your parents told
me that you’re going to have to come here every week for a while. Does that sound good to
you, or would you rather be doing other stuff?”
2. Identify goals by using a “greatest hits” menu of other kids’ goals. Make sure to include the
goals you suspect this client might have. “Here are some things that other kids have told me
they wished for. You tell me if you wish for any of these things, too.
* Some kids wish they didn’t have bad dreams anymore.
* Some kids wish they got better grades in school.
¢ Some kids wish they had more friends.
¢ Some kids wish they didn’t get picked on so much.
* Some kids wish their parents didn’t yell at them so much.
¢ Some kids wish they didn’t wet their bed anymore.
¢ Some kids wish they didn’t get in so much trouble.”
3. Align the child’s goals with the parents’ goals for the child. “So you wish that you had
better grades, and that your mom didn’t yell at you so much? You know, when I was talking
with your mom before, that’s what she said she wanted for you, too. Did you know that?”
4. Mutually commit to these goals. “So while you are stuck coming here, is it okay if that’s
what we work on? Doing things to help you get better grades, and to get your mom to yell
at you less?”

By the time most kids are twelve or thirteen, they are also interested in the long-term future, in
what kind of person they will become, and what kind of life they will have as an adult. However,
teens are also still very interested in the immediate as well as the near future, and in fact may be
choosing instant gratification at the expense of long-term goals. This is especially likely for
traumatized kids, who may say, in effect, “Nothing good’s going to happen for me anyway.
Nothing’s going to work out, so I might as well just do what I want right now.” The problem is
that the bigger (or longer term) the goal, the more likely that the trauma-related “pessimistic fu-
ture” will keep the child from feeling hopeful about it, or even admitting to having the goal at all.
Of course, the more actively the child avoids plans, hopes, and dreams, the more difficult it is to
get the child to invest in the future, and the more such a future focus is needed.

FUTURE MOVIES SCRIPT

The following “future movies” intervention (Greenwald, 2004, pp. 8-11) is one example of a
way to help teens to identify their goals and to elicit increased investment as well as commitment
to working toward these goals. It has been successful in extensive clinical experience as well as
preliminary studies. It follows the motivational interviewing principles, and it is structured and
scripted as carefully as a sales pitch to address the anticipated objections and obtain the desired
responses. For example, the movie metaphor is used to allow kids to maintain some initial dis-
tance while discussing their hopes and dreams; this lowers the perceived risk. Later, the practical
steps from today to the desired goal turn the goal from a fantasy into a realistic possibility.

I’ve asked about your past and about how things are now. Now I want to know about your
future. Let’s say that ten years from now—how old will you be?—I stop at the video store
on my way home from work, and pick up a movie called The [client’s name] Story. It’s
about this kid who grows up in a city, starts out okay. Seems like a good kid but then some
things go wrong for him, and he gets more angry, more stressed, the bad feelings piling up
inside. He gets so stressed he ends up doing some things he doesn’t really feel good about.
He gets himself into some trouble, and I’m saying to myself, “This is a bummer. I used to
work with kids like this. Looks like another good one going down the drain.” But then
104 CHILD TRAUMA HANDBOOK

things start to change. First one good thing, then another, then another . .. till finally, by the
end of the movie—you know that last picture, when the music’s playing and the credits are
rolling?—I’m smiling, and saying, “Way to go! You made it!” So tell me: If this was your
story and things go the way you wish they would, what would your life be like? ;
(Note: With a real client, the therapist uses that client’s history as the filler for this story.
So it will have a little more detail and will directly relate the client’s trauma/loss history to
the onset or escalation of his problem behaviors. Then it will relate the “stress pileup” to
the client’s current reactivity and acting-out behaviors. This follows the fairy tale model,
and is one way to present the trauma-informed case formulation.)
Follow-up questions, if called for: “What would you be doing for a living? Where do
you think you’ll be living? In the neighborhood you’re in now, or someplace else in the
city, or where? Your own house or an apartment? By yourself, with a buddy, with a girl-
friend? Maybe married by then? What’s she like? Will you have your own car? What kind?
What color?”

Sample Movie Script Dialogue

THERAPIST: Okay, so if this is your life, what would be in that last picture, to let me know how
good you’re doing?
CLIENT: I’m in front of my house with my wife and my kid.
THERAPIST: When you have this picture, what kind of feeling goes with it?
CLIENT: Good, happy.
THERAPIST: Where do you feel that? Where in your body?
CLIENT: All over.
THERAPIST: And what could you say to encourage yourself toward this goal? Something like, “T
can do it,’ or “I’m gonna make it”?
CLIENT: “Go for it.”
THERAPIST: Okay. Now I want you to concentrate on this picture. Maybe it’ll work better if you
close your eyes. Concentrate on the picture, the feeling, where you feel it, and what you’re
saying to yourself.
THERAPIST: The thing is, the movie didn’t just jump from the middle to the end; there were all
these things that happened along the way to get there. So tell me, if this was your story, what
happens in this movie? What would we see you doing tomorrow, next week, next month, next
year?
CLIENT: You mean if this was me?
THERAPIST: Yes, if this was your story, the way you’re hoping it would happen.
CLIENT: Well, I wouldn’t get in trouble anymore.
THERAPIST: Okay. What would you do?
CLIENT: First Pd do good in school and graduate and make my mom proud.
THERAPIST: So what do you have to do to do good in school?
CLIENT: Have to go every day, pay attention, do my homework.
THERAPIST: And when trouble comes?
CLIENT: Just walk away.
THERAPIST: And after you graduate, do you see yourself getting a job, joining the service, going
to college, what?
CLIENT: Pl probably work with my uncle, detailing cars, and go to college at night. Then learn
about computers. There’s good money in computers.
 Making a Treatment Contract OS

THERAPIST: So now I want you to imagine watching the whole movie in your mind, not from the
beginning but from today all the way to that good end you were telling me about. All the
things you were saying would happen to get there. You can do this with your eyes open, or
closed. So start from today, and tell me when you’re done.
How did it go? What happened in the movie?
[hope it goes the way you want it to, but what if it doesn’t go the good way we’ve been talk-
ing about? What if you kept on doing the same old stuff, and things got worse and worse?
What would that last picture be?
THERAPIST: Okay, so in the bad ending you see yourself behind bars?
CLIENT: Yeah. In a concrete room, like at the lockup.
THERAPIST: And what kind of feeling goes with this picture?
CLIENT: Bad. Sad.
THERAPIST: Where do you feel that?
CLIENT: In my mind.
THERAPIST: With this picture, would itfeel true to say to yourself, “It’s not worth it” to go that
way?
CLIENT: It’s not worth it. That’s for sure.
THERAPIST: Okay, so just for a few seconds, I want you to concentrate on this bad ending, the
bad feeling, where you feel it, “It’s not worth it.’ Okay. Did that “It’s not worth it” feel more
true, less true, about the same? Okay, let’s do this one more time. Concentrate on this bad end-
ing, the bad feeling, where you feel it, “It’s not worth it.’ Okay. Is it more true, less true, about
the same?

Commitment to Goals

THERAPIST: So on zero to ten, zero is nothing, ten is all the way, how much of you really wants to
go for that good ending you were telling me about?
CLIENT: Almost all of me, maybe eight or nine.
THERAPIST: Okay, and on zero to ten, how much of you still feels like doing the same old thing?
CLIENT: Maybe half. About five.
THERAPIST: So most of you really wants to go the good way?
CLIENT: Yeah.
THERAPIST: But sometimes that smaller part takes over and messes it up for all of you?
CLIENT: You could say that. I guess so.

Strengths and Obstacles

THERAPIST: If you were going to make a bet on a sports team, on who would win the game, how
would you decide which team to bet on?
Right, you have the idea. Okay, so let’s say I’m going to put a hundred dollars down on you
making it to the good end. What would make me think this was a smart bet?
Well, I have some ideas about why this might be a smart bet. See if you think these ideas
are right or wrong.
106 CHILD TRAUMA HANDBOOK

Well, you said you want to graduate high school and then get a basketball scholarship to
college. Are you a good basketball player?
CLIENT: Yes. I was the best one in my high school before I got kicked off the team.
THERAPIST: Okay, I’ll write down “good basketball player.” See, that’s something that will help
you get to your goals. What else is there?
CLIENT: If I decide to do something, I don’t give up.
THERAPIST: Okay, Ill write that down too. Also, you tell me that you have a close family?
CLIENT: Yeah, we’ll do anything for each other.
THERAPIST: I’ll write down, “close family,’ because it’s easier to get to your goal when your
family is behind you. What else?
Now, I bet there’Il be someone else who’s gonna say, “I’ll bet you” and they’ll think that
they’re gonna make some easy money. What would make them think that they have a smart
bet?
What could stop you from getting to your goals? What could get in your way?
So it sounds like there are some good reasons to believe that you really could make it on the
good track. And also some real challenges, some things that could get in your way.
On zero to ten, how confident are you right now that you’ll be able to make it in the good
direction?
And what would it take for you to feel a little more confident, for that six to be a seven?
What would have to happen? (Follow up-questions/reflections as needed.)

In the previous intervention, following the Motivational Interviewing principles, after the
goals were identified, the conflict is highlighted by focusing on the possible outcome of doing
the same old (problem behavior) stuff. This conflict is further developed by focusing on
strengths and obstacles. At each step, while the conflict is being highlighted, the client is guided
to identify with the positive goals, while seeing the problem behaviors as a problem for himself
(and not just for others). And at each step, the client is gaining a better understanding of what to
do to get to his goals, and why he might really be able to be successful. By the end of this ses-
sion, many kids will feel so capable and confident that they don’t notice that they have shifted
from talking about a movie to talking about their own plans.
There’s another reason that it’s important to include the component of identifying possible
obstacles to achieving the goals. If obstacles are not part of the conversation, some kids will not
perceive them. If kids don’t perceive any obstacles to their goals, then they don’t need your help!
They’re fine on their own, thanks anyway. When you can agree on significant obstacles or chal-
lenges, then you have something to offer, a strategy to help them to become stronger and to mas-
ter the challenges. Don’t think you can skip this part and get away with it—you’ll pay later!
Many teens, at the end of the entire course of treatment, will say that the future movies session
was their favorite part of the treatment. We are helping kids to identify their goals and to recog-
nize their own strengths and resources. This feels good, and it often inspires kids and mobilizes
them. This is the session they thank you for.
Clearly the motivational interviewing approach supports the fairy tale model. It focuses on
empowering the client, helping her to identify “the princess” and then encouraging her to be-
come more confident and to do what it takes to get ready to slay the dragon. Once the case for-
mulation has been provided and the motivation has been identified and developed/enhanced as
much as possible, it’s time to offer the specific advice.
 Making a Treatment Contract 107

TREATMENT PLANNING AND CONTRACTING

The case formulation provides a detailed understanding. This leads directly to “What do we
do about it?” The therapist can then recommend a treatment plan: build a fence around the child
for safety and security, then help the child to become stronger, then to slay the dragon. The treat-
ment plan also accomplishes several purposes:

* It extends the road map of the case formulation from the past and the problem into the fu-
ture and the solution. The therapist may have been the first one to ever really explain the
problem. This capitalizes on the therapist’s credibility and improves the chances of accep-
tance of the proposed solution.
* It gives everyone a role. This is especially important for parents, who may feel guilty, inad-
equate, and disempowered. Parents can build the fence around the child by maintaining
household routines, implementing a consistent discipline approach, and taking other mea-
sures to help the child feel more safe and secure. Teachers or others can do their part in
some situations. The child can work on becoming stronger, in anticipation of facing and
working through the trauma memories.
* People feel better when they can take an action that is expected to make a difference. In
many types of psychotherapy, parents are just told to bring the kids, and the kids are just
told to do or say whatever they feel like doing or saying. This can make people feel help-
less. With a clear treatment plan, including specific actions at each step, people can feel
that they are doing something that matters.
¢ It enhances faith in the treatment. When people can perform specific actions that are ex-
pected to directly help them in achieving specific goals, they understand why they are do-
ing the actions. When people know why they’re doing a treatment activity, they are more
likely to believe in it, and to keep coming to therapy. Chances of engagement and success
are increased, and risk of dropout is reduced.

With Older Kids/Teens

In the session after Future Movies (Greenwald, 2004), with older kids it can be helpful to cre-
ate a graphic representation of the problem—including the trauma component—and the solu-
tion. This approach anticipates and addresses one of the major problems in treatment: that once
kids get better at self-control and things calm down, they—and others—think that treatment was
successful and it’s done. The graphic, illustrating the trauma’s ongoing impact on reactivity, can
serve as a reminder that there’s more work to be done (Nancy Smyth, personal communication,
September 2002). The following transcript (Greenwald, 2004) shows how this might be set up.
In that session, the therapist started out with a blank piece of paper, then drew the circles and
filled them in during the conversation.
Note that, as in all of the scripts presented in this book, the words are chosen very carefully.
This does not mean that you can’t modify the words to fit your situation. However, the modifica-
tions should be done intentionally and not casually. For example, at one point in this dialogue,
the therapist asks, “Can I touch your shoulder lightly?” It would be unwise to skip that or to say,
“Now I’m going to touch your shoulder lightly.” Asking permission is essential. On the other
hand, you might choose to be even more careful with a given client, by asking, “Can I touch your
shoulder lightly with this book?”
108 CHILD TRAUMA HANDBOOK

Problem Behavior Cycle and Treatment Recommendations

© Ricky Greenwald 2003.

. Past experience
Suggestions:
1. Avoid high risk.
2. Build self-control skills.
3. Reduce stress:
* every day
¢ from the old stuff
4. Track record of
small successes.

High-risk
situations

Negative Thoughts
consequences (adds stress) & feelings

Quick-relief
behavior
 Making a Treatment Contract 109

Sample Dialogue

THERAPIST: Last time we met, we talked about your goals, the kind of life you want for yourself.
We talked about your strengths, things that will help you get what you want, and also about
some things that could get in your way. You said that the main thing that could get in your way
bi
ies temper. So are you losing your temper every minute of every day, or just at certain

CLIENT: Just once in a while, only if someone makes me mad.

THERAPIST: Like what would someone have to do to make you mad?
CLIENT: If they say something about my family, or if they stare at me or talk stupid.
THERAPIST: Oh, so there are only certain situations that could lead to you losing your temper.
I’m going to write these down as your “High-Risk Situations.” So when’s the last time that
one of these things happened?
CLIENT: Just yesterday.
THERAPIST: What happened yesterday?
CLIENT: On the bus, this guy bumped into me and then stared at me like it was my fault, like I
was supposed to apologize to him.
THERAPIST: So when that happens, what are your thoughts and feelings?
CLIENT: I’m mad.
THERAPIST: What are you saying to yourself? What are the words in your head?
CLIENT: I want to hurt him.
THERAPIST: And what’s happening in your body? What are the signals that you’re mad?
CLIENT: My heart is beating and my hands are fists.
THERAPIST: So this is a pretty strong reaction. When you’re like this, what do you feel like do-
ing?
CLIENT: Feel like hitting the guy.
THERAPIST: Okay. But you told me that this kind of thing would get you bad consequences. Like
what kind of bad thing might happen to you if you hit people?
CLIENT: Suspended from school, maybe get locked up again. The guy might try for revenge...
THERAPIST: So let me ask you another question. These high-risk situations you were telling me
about—would you say that you mess up every time someone does one of those things?
CLIENT: No, usually I can control myself.
THERAPIST: Would you say that you have a better chance of controlling yourself when you are
feeling good, relaxed? Or when you’re already stressed?
CLIENT: If I’m already stressed, that’s when the trouble happens.
THERAPIST: So when you get these bad consequences, like being suspended from school, or
wondering if someone will try for revenge, does that make you more relaxed or more
stressed?
CLIENT: Definitely more stressed.
THERAPIST: So the more you handle these high-risk situations by fighting, the more you end up
getting stressed from the consequences?
CLIENT: Yeah, I guess so. Oh, I see. This is a cycle!
THERAPIST: Right, it can be. Now here’s an interesting thing: You know how you told me the
things that were your high-risk situations? Other kids, some of them don’t mind that stuff, but
other things bother them, things that are no big deal to you. I have an idea why these are the
high-risk situations for you. Can I tell you?
nO CHILD TRAUMA HANDBOOK

CLIENT: Sure, go ahead.

THERAPIST: Okay. To explain this, can I touch your shoulder lightly?
CLIENT: Okay.
THERAPIST: Okay, pay attention, and tell me how much this hurts, on zero to ten. (Punches cli-
ent’s shoulder lightly.) How much?
CLIENT: Nothing. Zero.
THERAPIST: Now I’m going to ask you to imagine something that I would never do, and you
would never let me do. Imagine that I have a baseball bat, and that I swing this bat as hard as I
can, right to that spot on your shoulder. Not just once, but over and over again for ten minutes.
And then tomorrow, the same thing, over and over again. Every day like that for two weeks.
And then, you’re walking down the hall, and someone bumps you in the shoulder—can I
touch you there again?
CLIENT: Okay.
THERAPIST: Okay, now tell me how much this would hurt if someone bumped you like this, after
that two weeks with the baseball bat (punches lightly as before).
CLIENT: A ten!
THERAPIST: How come?
CLIENT: ’Cause it’s already all banged up and sore.
THERAPIST: That’s what I think might be happening with your high-risk situations. Remember
when I asked you about the worst things that ever happened to you, and I asked you on zero to
ten how much those things still hurt inside? Some of the things on your list had pretty high
numbers. I’m wondering if those things make a sore spot inside you, so when something else
comes along that maybe feels like that in some way, it hits the sore spot and you react extra
strong.
CLIENT: I think so; I think that’s what’s happening.
THERAPIST: So this makes sense to you?
CLIENT: Yeah.
THERAPIST: Okay, then we have a pretty good idea of what could get in your way, keep you from
getting to your goals. So let me give you some suggestions for how to handle this stuff, so you
can be in charge of yourself and get your life to go the way you want it to.
CLIENT: Okay.
THERAPIST: First of all, let’s say you have a friend. He’s twenty-one. He’s an alcoholic but he’s
trying to stay sober. He’s doing good so far. He needs a job, and he says to you, “That bar
down the street needs a bartender. Think I should try for that?”” What will you tell him?
CLIENT: No, don’t do it.
THERAPIST: Why not?
CLIENT: ’Cause there’s gonna be beer all around. Sooner or later he’s gonna drink some.
THERAPIST: Good answer. So you already understand the first thing I’m going to suggest for
you: Avoid high risk. If you know where the trouble is, sometimes you can just decide to stay
away from it. Thing is, your friend took your advice; he got a job at the clothing store. But
then he went to a birthday party and guess what?
CLIENT: They’re drinking.
THERAPIST: Right. So even when you do everything right, sometimes you just can’t avoid the
high-risk situation. So here comes my next suggestion, and it’s something you’re already do-
ing—my suggestion is to get even better at this: self-control skills.
CLIENT: Yup.
 Making a Treatment Contract Ill

THERAPIST: Now you told me that if you’re stressed, it’s harder to use your self-control skills. So
my next recommendation is to reduce stress. Now this one has two parts. One part is to get
better at living a less stressful life, and at bringing your stress down once you are stressed. The
other part is to bring stress down from the old stuff, those old memories that make that sore
spot inside. There are special ways of talking about those old memories. It doesn’t make them
disappear, but it can help to make the sore spot smaller. This isn’t something we would do
right away, but maybe down the line.
My final suggestion probably won’t be a surprise either: Success. The more you succeed at
doing the things you said you cared about, the more strong you’ll feel, the more confident
you'll feel, and the harder you’ll be willing to work on it.
So what do you think of these suggestions? Do they make sense to you?
CLIENT: Yeah, they make sense; some of it I’ve been trying to do already.
THERAPIST: So is this something you think you might want to work on together, when we meet?
CLIENT: I guess so.

With Younger Kids and Their Parents

At this stage parents almost always accept the formulation and embrace the plan. The really
critical element at this point is to insist on the importance of the parents’ role, so they don’t think
that they can just leave all the work to the therapist.

THERAPIST: There are several things that we usually do for kids in your son’s situation. The first
thing is to keep up the special help in reading that he’s getting at school. Then there are things
that you can do at home, that can help him to feel more secure and less worried. That will help
him to calm down. Also, I can work with him to help him get over the old bad feelings that he
still carries around. Down the line, we might want to do a behavior chart to help him get better
habits, but we might not need it.
PARENT: That sounds good. I really think he needs that individual counseling, have someone to
talk to.
THERAPIST: Yes, I think it should help. But the biggest job will be yours. If you can make him
feel more secure at home, then my job will go much better. I can get a lot more done. You’re
much more important than I am. I’m just some guy he talks to once in a while. You’re his
mom.
PARENT: So what should I be doing?
THERAPIST: There are a few things, we talked a little about them before. When you told me that
your husband is kind of hard on the kids, and you give in to them a lot? That kind of makes a
kid feel insecure, ’cause the rules are always changing. Also you said that sometimes you get
really mad and end up yelling at him, or making some big punishment you know you won't
keep later. So you kind of lose control, doing things you don’t really want to do. When you
lose control, that can also make him feel insecure. He really needs you to be in charge, so you
can protect him and keep him safe and under control.
PARENT: It’s not easy. These kids, they do make me mad sometimes.
THERAPIST: I know it’s not easy. I can give you some things to try. Then you try them, see how it
works for you and where there’s problems. I’ll help you figure it out. It’s a lot of work for you,
but most parents find that once they get into it, their kids really do calm down and things are
better.
2 CHILD TRAUMA HANDBOOK

Some parents may already feel like failures because they couldn’t handle the child’s problem
on their own. When the therapist sets the parents up as active partners in the child’s treatment,
the parents are likely to become more confident and effective. The therapist should also be vigi-
lant in pointing out the parents’ contributions at every opportunity. Even when the child re-
sponds dramatically to an individual session, the therapist can accurately say that the parental
support made it possible. The therapist’s goal is not to get the glory but to help the family.

THERAPIST: So if your child skins his knee, gets a cut, what do you do?
PARENT: Wash it up; put on a Band-Aid.
THERAPIST: Okay. What if he breaks his leg? Do you put on a splint, or what?
PARENT: No, take him to the emergency room, to the hospital.
THERAPIST: Of course you do. The everyday things you can handle yourself, but sometimes a
problem gets too big and you go to a professional for help. This is the same thing. This is what
good parents do when it gets too big to handle on their own.

The last part of the agenda for the treatment contracting session is to have the parents give the
child explicit permission to engage in treatment, and to make progress. Parental support can
be conveyed simply by the parents, with the child present, reviewing the child’s goals, for exam-
ple, doing better in school and getting in less trouble, and encouraging the child to cooperate with
the therapist. Feared negative outcomes associated with progress should be addressed as needed.

THERAPIST: Your dad was telling me that he wants you to learn to control yourself better, so you
can do better in school and not get in so much trouble. You were saying you wanted that too,
when we talked last week, remember? So you and | are going to work together to help you get
better at controlling yourself. Do you think that when you’re older, more strong, you can con-
trol yourself better?
CHILD: Yeah, when I’m bigger.
THERAPIST: So what we’ll be working on is helping you get bigger and stronger so that you can
handle things better, things that are hard now like when someone makes you mad. Okay?
CHILD: Okay.
THERAPIST: So here’s what we’ll be doing. Your dad told me that he might be getting more strict
at home, to help you learn to do what you’re supposed to do. And you and I will meet once a
week. I can kind of coach you in some tricks to help you control yourself better. Also, remem-
ber what we talked about, how those bad feelings could be stuck inside from old things that
happened, like from the hurricane and from seeing your parents fight?
CHILD: Yeah.
THERAPIST: Another thing we can do is talk about those old things, and try to make the bad feel-
ings be smaller so they don’t mess you up so much.

You might have noticed that no mention has been made in the treatment contracting of the fi-
nal phases of treatment, relapse prevention, and harm reduction. This is intentional. At this
stage, kids and parents are trying to figure out how to get rid of the current problem, so that’s
what we talk about. Once we’ve gotten through trauma resolution, though, and helped kids to
get their lives back on track, then we can talk about the future in more detail. At that stage, kids
and families are generally quite willing to talk about what they can do—anticipating future chal-
lenges and making strategies to handle these—to stay on track. Right now, though, it’s just not
the issue at hand.
 Making a Treatment Contract ids

OBSTACLES TO FOLLOWING THROUGH WITH THE CONTRACT

Finally, it is worthwhile to anticipate treatment obstacles and prepare coping methods in col-
laboration with the family. There are several common obstacles to treatment (Greenwald, 1999).
Kids who believe that their symptoms are helping their parents may feel that family loyalty is
more important than symptom relinquishment. Sometimes the logistics of getting the child to
treatment regularly may prove challenging to a family. Paradoxically, sometimes the fact that
the child has become so much better takes the pressure off in terms of follow-through. Each of
these obstacles are addressed in the following text.

Obstacle: “Treatment Might Be Risky”

Some children believe that their symptoms serve an essential function in the family. For ex-
ample, the child may believe that the focus on the problem protects the family by keeping them
from focusing on something else that is more upsetting. Kids often fear that if they give up the
problem they will be giving up the attention and closeness that they are used to having with their
parents. If the child believes any of these kinds of things, then she may not be willing to really
engage in treatment despite apparently agreeing to it.
To address this, the therapist can express concern regarding possible risks of successful treat-
ment. The child may then acknowledge concern that “getting better” might lead to unwanted
consequences. Once the child admits to this—sometimes only following specific questioning—
it can be seriously discussed. Typical outcomes include contradiction by amazed parents, who
assert that relationships will actually improve; discussion of specific ways of tracking possible
114 CHILD TRAUMA HANDBOOK

changes in relationships; and a family commitment to exploring this issue in therapy following
individual treatment.

Script

THERAPIST: Before we get too far, I just want to check and make sure that going ahead will be
okay. (To child) If you get better, what would be the worst thing about that?
CHILD: Nothing. I don’t know.
THERAPIST: Let me tell you what other kids worry about, and you tell me if any of these is true
for you. Some kids worry that if they don’t have the problem anymore for their parents to
worry about, their parents might have more problems with each other. Some kids worry that if
their parents don’t have to worry about the problem anymore, the kid might not get as much
attention, and they might not be as close to each other anymore.
CHILD: That one.
THERAPIST (to parent): Is that a worry for you too?
PARENT: Of course not. If we didn’t have to deal with all this, we could spend time doing nice
things instead.
THERAPIST: Like what kinds of things?
PARENT: Oh, watching movies, going to the park, playing games...
THERAPIST: You mean that if he didn’t have this problem, he’d get just as much time with you,
but doing more fun things?
PARENT: That’s right.
THERAPIST: (to child) Would that be okay with you?
CHILD: That would be better.
THERAPIST: Well, it sounds good to me too, but I’m still just a little worried. Can we make a
deal? After the problem is gone, can we get back together and make sure that things are going
well in the family? That you’re really doing those fun things? Then if something went wrong,
we can fix it.
CHILD: Okay.
PARENT: Okay.
THERAPIST: (to child) So what would be the best thing about getting better?

Comments

* It is important for the therapist to deliver this intervention with a straight face, and to in-
clude a brief menu of possible risks that are most likely to be plausible to the child.
* This intervention helps the child to feel permission, support, and safety in attempting to re-
linquish symptoms. It also may serve to “hype” the treatment, with the therapist’s paradox-
ical worry about success leading to increased motivation. The awareness of family dynamics
ee ae by this discussion may also help the family to reorganize in support of the child’s
changes.
* This is also a good time to point out that the parents and child each independently identified
treatment goals that they share.

Sometimes even this intervention will not be sufficient, for example, when the parent has
given ambivalent messages regarding support of the treatment, or when the child’s symptoms
reflect concern about the parent’s safety or well-being. For example, in the case of so-called
school phobia, quite often the child is actually staying home to protect a parent froma perceived
 Making a Treatment Contract 115

risk of loneliness, suicide attempt, sudden health emergency, or violence. Then the therapist can
ask the parents to demonstrate their support of the treatment with concrete behaviors that can re-
alistically allay the child’s fears. For example:

Script

THERAPIST: Your daughter really needs to know that you will be okay even if she leaves you to
go to school. Supposing that you get depressed while she’s at school, who can you call?
PARENT: I can call my sister.
THERAPIST: Is she available during the day?
PARENT: Oh yes. We talk to each other all the time.
THERAPIST: Because your daughter will try to watch out for you until she really believes that the
grown-ups are taking care of it. So if she comes home from school and she finds you drinking,
or lying in bed crying, what will she think?
PARENT: That I’m a mess.
THERAPIST: Yes, she’ll be thinking that you really do need her to stay home and take care of you.
Supposing she comes home from school and finds the house looking good—maybe you’ve
gotten a snack ready for her—what will she think then?
PARENT: That I can take care of myself.
THERAPIST: Yes. And that she can go to school knowing that you’Il be okay.

Comments

¢ This type of intervention can assist parents in accomplishing a variety of self-care and
safety behaviors, including calling on an adult for assistance, locking the door of the apart-
ment to keep out intruders, etc. The therapist helps to identify a behavior that the parent can
actually accomplish, and then defines this behavior as having a specific meaning, as dem-
onstrating that the parent is okay, and that the parent supports the child’s treatment.
¢ This intervention can also be more directly related to the treatment itself. For example, the
therapist can define the parent’s bringing the child to treatment sessions on time as proof of
parental support for treatment.
¢ This is consistent with the therapist’s overall approach with the parent: to create shared un-
derstandings of the impact of the parent’s behavior, and putting the parent in the position of
healing his child by doing things the parent is capable of doing. The capability is developed
by helping the parent understand the value of the behavior, and by problem solving to help
the parent overcome obstacles to implementing it.

Obstacle: “Something Came Up at the Last Minute”

Especially with multiproblem families, things tend to come up that prevent the families from
coming on time—or at all—to their scheduled appointments. The trauma therapist views this
disorganization and lack of predictability as a target of treatment, since consistency and routine
tends to be part of the treatment plan.
The therapist can manage this treatment obstacle by explaining that consistency in attendance
is important to treatment effectiveness, and asking about what kinds of things might prevent the
family from achieving regular attendance. Obstacles may include child care issues, forgetting,
transportation difficulties, etc. These should be problem solved in sufficient detail that the par-
ent has a specific and realistic plan to surmount each identified obstacle.
116 CHILD TRAUMA HANDBOOK

Obstacle: “I Don’t Have a Problem Anymore”

Paradoxically, the success of the Evaluation and Preparation phases of treatment may tempt
the family to end treatment prematurely. Many families do not appreciate the extent to which
healing from trauma is possible. When the family understands the child’s problem better, and
the child has made good progress with symptom management, the crisis has passed and the child
has regained at least some of his former level of functioning. At this point kids often claim to be
“better,” and it can be difficult for the parents to know how to disagree with that claim. Avoid-
ance may also be an issue; not only do children often prefer to avoid talking about the bad thing
that happened, but their parents often wish to spare them that experience. Kids often say, “I’m
doing fine now, so I don’t need to talk about that [trauma memory].”
This obstacle can be addressed by predicting it and discussing it. It’s important to explain that
the trauma memory, if left untouched, can remain as an ongoing source of stress and vulnerabil-
ity. Even if the child seems to be doing better in the moment, if he does not work through the
trauma memory, the sore spot remains, and he will be more vulnerable to future stressors. Be-
cause of this obstacle, it is particularly important to have presented a persuasive case formula-
tion that makes clear the central role of trauma in the child’s presenting problem.
It is also important to establish that the parental role includes making decisions about the
child’s treatment. For some reason, otherwise responsible parents may tend to consider mental
health treatment something that the child should do only if he wants to. Here it can be helpful to
equate mental health treatment to medical treatment—the parent would not neglect the child’s
medical care just because the child complained about it. Of course, the child will not have to talk
about anything he doesn’t want to, but he should be made to attend treatment if such treatment is
warranted.

SECTION II BIBLIOGRAPHY

Colby, S. M., Monti, P., Barnett, N. P., Rohsenow, D. J., Weissman, K., Spirito, A., Woolard, R. H., & Lewander,
W. J. (1998). Brief motivational interviewing in a hospital setting for adolescent smoking: A preliminary study.
Journal of Consulting and Clinical Psychology, 66, 574-578.
Greenwald, R. (2000). A trauma-focused individual therapy approach for adolescents with conduct disorder. Inter-
national Journal of Offender Therapy and Comparative Criminology, 44, 146-163. The future movies interven-
tion is introduced here.
Greenwald, R. (2002). Motivation—Adaptive Skills—Trauma Resolution (MASTR) therapy for adolescents with
conduct problems: An open trial. Journal of Aggression, Maltreatment, and Trauma, 6, 237-261.
James, B. (1989). Treating traumatized children: New insights and creative interventions. Lexington, MA:
Lexington Books. Nice example of therapeutic style in beginning treatment.
Lawendowski, L. A. (1998). Motivational interviewing with adolescents presenting for outpatient substance abuse
treatment. Dissertation Abstracts International, 59-03B, 1357.
Miller, W. R. & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York:
Guilford Press. The classic text on motivational interviewing.
Monti, P. M., Colby, S. M., Barnett, N. P., Spirito, A., Rohsenow, D. J., Myers, M., Woolard, R., & Lewander, W.
(1999). Brief intervention for harm reduction with alcohol-positive older adolescents in a hospital emergency de-
partment. Journal of Consulting and Clinical Psychology, 67, 989-994.
Newman, E. (2002). Assessment of PTSD and trauma exposure in adolescents. Journal of Aggression, Maltreat-
ment & Trauma, 6, 59-77. Overview of more formal trauma assessment strategies.
 SECTION III:
SAFETY AND STRENGTH BUILDING

Once we have developed a case formulation and have the child’s and the family’s agreement
to work on the recommended treatment activities, we can move forward with the recommenda-
tions. In this section we focus on safety, skill development, and strength development (increas-
ing affect tolerance), in preparation for facing and working through the trauma.
In the fairy tale model, the tasks at hand are to build a fence around the child so that she can
feel safe and secure enough to concentrate on the other tasks, then to help her become stronger
and more skilled in preparation for slaying the dragon.This entails the following:

¢ Case management for safety and problem resolution

¢ Parent (and other adult) training for safety and security
* Self-control skills training for safety and competence
¢ Progressive mastery of affective challenges—‘“getting stronger”

There are several reasons to go through these steps rather than going directly to the trauma
resolution work. When we get to the Trauma Resolution phase of treatment we want the child to
be able to say about the trauma, “That was bad, but it’s over, and things are okay now.” This is
not achievable unless the trauma actually is over and things actually are okay now. Therefore, in
preparation for trauma resolution, everything possible should be done to ensure that the child
is—and feels—as safe and supported as possible.
Threats to safety and threats to sense of safety often, but not always, coincide. For example,
ongoing exposure to a perpetrator of continuing physical abuse will make the child be unsafe
and feel unsafe, whereas ongoing exposure to threats of a jailed perpetrator may not affect the
child’s actual safety but will probably make her feel unsafe. More rarely, a child may be unsafe
without feeling unsafe, for example, if the parent is secretly abusing drugs while responsible for
the child’s care, or leaving the child with potentially irresponsible caregivers.
Perhaps the most common ongoing safety-related problems entail repeated exposure to trig-
gers. For example:

A girl, whose father no longer hit her, would shrink away and instinctively put an arm in front of her face
whenever the father yelled. Presumably she interpreted the yelling as a danger signal, a warning that the
slap would soon follow, as it used to. When the therapist explained to the father that his daughter felt un-
safe when he yelled, the father made more of an effort to avoid yelling, so that the girl would feel safer.
A girl who suffered with a reading disability for some years before it was diagnosed was repeatedly trig-
gered every time she found her schoolwork too difficult. Whenever an assignment seemed challenging
she would say to herself, “This is too hard; I’m sick of being given things | can’t do. I’m not going to try any-
more.” As part of treatment, arrangements were made for the teacher's aide to respond extra quickly to
this child’s requests for help in school, to help her to begin to feel that she could manage frustration and
succeed with school-related challenges. This intervention was provided in addition to the special instruc-
tion that had been instituted to help her with reading.

LG
118 CHILD TRAUMA HANDBOOK

Another goal in this phase of treatment is to help parents and other caregivers “rehabilitate”
themselves by reestablishing their roles as protectors and helpers in the child’s life. When a
child is hurt, the child’s parent almost always feels like a failure. Whether the child’s hurt came
from actual irresponsibility on the parent’s part, or whether it was just the bad luck that comes
with living, parents typically feel that they are to blame, that they should have protected better.
Then bad things can happen, for example:

The parent may be traumatized by what happened to the child, and by the parent’s own per-
ceived contribution to that. This could lead to a range of posttraumatic symptoms and
might add weight to any of the other problems on this list.
The parent, overburdened with guilt, may try to “make up for” the child’s hardships by al-
lowing him to slide, overindulging, and not being strict or consistent anymore with rules or
expectations.
The parent, feeling inadequate or even depressed, may become more withdrawn and less
active in parenting activities such as discipline, supervision of homework and chores, and
doing enjoyable things with the child.
When the child acts out—perhaps due to the sore spot trauma-related overreaction—the
parent may then have a sore spot trauma-related overreaction to the child’s behavior, which
is a reminder of the parent’s guilt and failure. Then the parent might react with loss of con-
trol and act out against the child, instead of responding appropriately.

When the child heals, the parent finds some relief. When we can give parents an active and
constructive role in the child’s healing, the parent heals, too. When the previous parenting ca-
 Safety and Strength Building 119

pacities are restored or even enhanced, the child benefits. The parent becomes more effective in
protecting, guiding, and nurturing the child, and the primary attachment relationship is reestab-
lished on firmer ground.
Finally, it takes a great deal of strength, skill, and determination to slay the dragon. If we ask
the child to attempt to face the trauma before she is ready, she is likely to feel overwhelmed and
even retraumatized. Then she learns that facing the trauma—and trusting the therapist—is a bad
idea. On the other hand, when we help her to gradually build up her strength and skill in facing
emotional challenges, then she learns that she can in fact become progressively stronger and
better able to handle things. While building capacity she is also building her track record of suc-
cesses. This gives her more hope for success in the future, and increases her investment in her
goals, and her determination to continue her efforts.
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 Chapter 9

Case Management

One of the first things we want to do is build a fence around the child, to help him to feel more
safe and secure. Although many issues will be addressed with parent training and self-control
skills training, certain issues can be addressed very early on, with case management. The case
management may be done directly by the therapist, or by anyone in the family’s system that can
get the job done. These case management interventions can often have a significant impact on
the child’s ability to recover from past trauma, and should be effected as soon as possible.
What kinds of issues need managing?

1. Continued exposure to an abuser

2. Acute/pressing needs (e.g., medical, housing)
3. Parent at risk of being hurt (e.g., involvement with an abusive partner; suicide threats)
4. Continued exposure to an unwarranted trigger
¢ Learning disability without special help
¢ Bullying
¢ Inadequate supervision
¢ Erratic or absent discipline

The purpose of case management is to actually solve problems that are currently forcing the
child to remain focused on survival and other pressing concerns, instead of being able to focus
on activities that will lead toward healing. Case management involves intervening in such a way
that the child’s life situation has been altered. For example:

A mother brought in her teenaged girl who was showing apparent posttraumatic stress symptoms after
having been bitten by a rat while asleep one night in their apartment. The girl was anxious, jumpy, and
afraid to fall asleep. Rats had long been a problem in their apartment building and they had been unsuc-
cessful in their efforts to get their landlord to solve the problem. The clinician who evaluated this girl said,
“Of course you're afraid to go to sleep; you must be worried that another rat will get you. What you need is

You are here.

Knight, kingdom, Fence around Personal Slay the dragon Apple trees,
dragon, princess (case training (trauma resolution) compost, contest
(evaluation and management, (skills and (relapse prevention)
treatment plan) parent train) strength
building)

FIGURE 9.1. Steps in the fairy tale model.

12]
L22 CHILD TRAUMA HANDBOOK

a safer place to live. Let's work on that first, then we’ll see how you're doing.’ The mother was then con-
nected with a housing advocate who helped her to find a new apartment. When she brought her daughter
back afterward, the posttraumatic stress symptoms were still present but much less pronounced.
A sixth-grade boy was referred for school-related problems: he gave up on assignments very quickly,
was disruptive in class, and was rude to peers and teacher. His history included witnessing domestic vio-
lence (until his parents divorced) as well as the death of an aunt with whom he had been very close. A
comprehensive evaluation found that the boy liked his teacher and really wanted to do well in school.
However, he had ADHD, which made it difficult for him to stay focused and on task with his schoolwork.
Schoolwork-related frustration hit his sore spot and became a trigger for his trauma/loss-related helpless-
ness and hurt. Then he used his problem behaviors to make himself feel less helpless and less hurt. Once
he was given medication, he was better able to focus on his schoolwork. He was still a hurt, angry boy with
bad study habits. But he was being triggered much less often, and for the first time was able to say,
proudly, “I can do it. |can be good in school.”

Although the goal of case management is straightforward (solve the problem), getting it done
is not always so simple. Ideally the change is accomplished by convincing those involved to sup-
port the change. In the previous example, the mother of the rat-bitten girl was immediately en-
thusiastic about finding a safer place to live, and followed through with everything she was
asked to do. However, the parents of the boy with ADHD were reluctant to try medication for
him, and this took some persuading. This persuading can be tricky, and might not happen all at
once.
If the first persuasion attempt is not successful, then you may have to just go ahead without as
sturdy a fence around the child as you might wish for. However, you may be able to negotiate for
another chance later on. For example:

In avery similar case, the parents of the boy with ADHD refused to try medication for him at all. Even af-
ter hearing the recommendations and the reasons for same, they said, “We just don’t want to give our boy
medication. We don’t like the side effects we heard about. We want to try to solve the problem some other
way.” Then the therapist said, “Il understand; a lot of parents feel that way. They want to try everything they
can before just giving their kid a pill. |gave you my recommendations, but you’re the parents and it’s your
decision. So we can still go ahead with the other things. It will mean that we’ll all have to put in extra effort
because the medicine won’t be there to help. And you never know, sometimes when kids feel better, some
of the other problems fade away. Let’s give it our best shot.”
In this case, treatment proceeded on several fronts. The mother worked on a more consistent disci-
pline approach at home and the father committed to more regular scheduled contact with the boy. The
teacher used an incentive system for good behavior and academic achievement. In individual therapy, the
boy worked to develop self-control skills, problem-solving skills re classroom challenges, and eventually
worked through the trauma and loss memories.
After about four months, the therapist approached the parents again, and said, “You know, we’ve tried
everything, and it’s worked. He’s happier, he tries hard, and the bad memories don’t hurt him anymore.
He’s not an angry person anymore; he feels good inside. He’s doing a little better at school, but he still has
a lot of trouble with his schoolwork. After all of the things we did, the ADHD is still giving him the same
trouble. Would you consider trying the medicine now?”
This time, the parents agreed, and medication was tried. The boy immediately did much better in
school, to the point where he was no longer a behavior problem and was routinely completing his assign-
ments. Of course, this dramatic improvement would almost certainly not have happened had the medi-
cine been tried sooner; the improvement was partly because the other issues were no longer in the way.
The point here is that case management can happen at any point, although it is generally preferable to
take care of it right away.

The key to getting cooperation for the case management task is the trauma-informed case for-
mulation. With rare exception, parents, teachers, and others who work with kids truly care about
them and want to do what is right. However, what they are actually doing might not be the best
thing for the child. The case formulation can help them to understand the child and what he re-
 Case Management £23

ally needs, and then the recommendations will give parents and caregivers a role in helping the
child. For example:

The mother of an eleven-year-old boy did not want to discipline the boy because she wanted to make
up for all that he had been through with an abusive father. The mother said, “I don’t like to be hard on him”
With the case formulation, the therapist was able to help the mother understand that her son acted out
when he felt unsafe and that he escalated the problem behavior until she was finally forced to discipline
him. When she understood that her discipline provided reassurance—and that when she disciplined for
smaller offenses, she was less harsh—she willingly became more strict with her son.

_ The assistant principal (school disciplinarian) did not want to discipline a fourteen-year-old girl for bul-
lying her peers, because he thought it would be more helpful to talk with her, as he had done several other
times in the past year for similar offenses. The case formulation helped him to understand that the girl
used bullying as a solution to feeling uncomfortable in challenging social situations, and that she repeated
the bullying behavior because it worked for her; it provided relief, with minimal negative consequences.
With this understanding, the assistant principal made a new response: he punished her (to make the bul-
lying behavior less rewarding) and also contacted the parents and recommended treatment to help the
girl to find a more acceptable way of managing the challenging situations.

EXERCISE: CONVINCE THE ASSISTANT PRINCIPAL (AP)

OR THE PARENT

If you’re on your own, just complete the worksheets as instructed. If you’re with others, then
in small groups (four is best), for each of the following vignettes, complete the worksheet to pro-
vide a case formulation and treatment recommendations using the fairy tale model. Then role-
play the conversation you would have with the identified parties. Use what you’ve put on the
worksheet to convince them to do what is best for the child. Repeat each role play until everyone
in your group has been in each role.
You will notice that much of this is the same as you’ve done before; it’s building on the case
formulation. Here, though, you’ll be taking it the next step, using the formulation as leverage to
get some action. Here are some tips:

¢ Remember to use plain language, avoid jargon, and tell a story.

¢ Emphasize that kids learn from experience, and that they will learn from new experiences
as well. What do you (the AP or parent) want the child to learn?
¢ Avoid criticizing the caregiver, even by implication, for not being perfect already. If you
put down or disrespect the caregiver, he or she will block you out. Better to acknowledge
that he or she does care and to recognize the efforts already made on the child’s behalf. Ac-
knowledge the good intentions that even the caregiver’s wrong position represents. When
you offer to help the caregiver do what he or she is already doing for the child, but more ef-
fectively, your suggestions are more likely to be accepted.
¢ This is a complex intervention. You have a better chance of being understood if you keep it
simple. One way to keep it simple is to go in order—do your talking by following the form
from beginning to end.

Damian

Damian is a thirteen-year-old boy who has a history of exposure to witnessing domestic violence as
well as direct physical abuse, until his parents divorced when he was seven. His mother reports that he is
respectful to her and helps out with the younger children when he is at home. He is a friendly, outgoing boy
who seems to be popular with both boys and girls. However, his gregariousness has been escalating into
124 CHILD TRAUMA HANDBOOK

Exercise: Case Formulation for Case Management

© Ricky Greenwald 2004.

. Once upon a time (introduce positive impression of strengths, including relation-

ships, competencies, successes, resources):

. Then the bad thing(s) happened:

. Leading to (for each possible trauma event, describe how other kids have reacted:
negative beliefs, piled-up feelings):

. Now, whenever the trigger (or “high risk”) situation occurs (describe the trigger situa-
tions—theme and examples—and how that leads to reactivity):

. Then the bad thoughts and feelings are so strong that (describe the urgency of the
reaction, and how the problem behavior provides relief for the child):

. This is what helps kids in this situation (outline the phases of treatment and what is
accomplished in each phase):

: Here is what you can do (explain what impact the current situation is having on the
child, and what impact your recommended action would have, in relation to the fairy
tale model):
 Case Management 125

verbal aggression: teasing peers, rudeness with teachers. The current referral follows an incident in which
he physically intimidated a small female teacher by “getting in her face” without actually touching her or
verbally threatening harm. You learn from Damian that (1) he did not intend to hurt her and (2) that she
asked for it by criticizing him for not knowing an answer and making him feel stupid in front of the class.
The AP (school disciplinarian) likes this boy—Damian “is a good kid, has a heart’—and wants to give him
a break this one time. You're now having a meeting with the AP, mother, and Damian.

For this exercise, keep it simple and just focus on trigger situations related to the recent teacher
situation. When you have finished with that, repeat with the second vignette, working with the
parent to establish some strategy to reduce the impact of the biological mother’s unreliability.

Angela

Angela is a nine-year-old girl who is in treatment for emotional and behavioral problems. She is bossy
with peers and does not easily tolerate waiting for her turn or losing a game; you have seen her cheat, and
even dump the game board. You know that she was sexually abused on several occasions by her step-
father during ages five and six until Child Protection intervened. Then mother refused to kick out her hus-
band, so Angela went to live with her maternal aunt, who helped to raise her and who is currently in the
process of adopting her. Visits with her biological mother are scheduled for two hours every Thursday af-
ter school. When the visits are accomplished as planned, Angela’s behavior is rather stormy at home for
the rest of the day: crying, yelling, stomping, disobeying. When her biological mother fails to show for the
visit—this happens about half the time—Angela’s behavior at home is even more stormy and lasts
through the following day as well. Two months into treatment, you have formed a good relationship with
Angela and are planning to work toward trauma resolution activities with her. You also have a good rela-
tionship with her aunt, who is an excellent parent. You’re now having a meeting with the aunt.

For this exercise, keep it simple and just focus on trigger situations related to the biological mom
visiting situation.

Follow-Up Group Discussion

For those on the receiving end (as the AP or parent), what kinds of statements made you feel
confused, put down, or put off? What kinds of statements helped you to get the picture? What
kinds of statements led you to feel empowered or enthusiastic about what the therapist wanted
you to do? For those acting as the therapist, what specific behaviors contributed to you having
done a good job? What did it take, what did you have to say to yourself, to get yourself to do
those things?

Sample Responses

Here are examples of how the previous forms might have been completed. If you did not
come up with exactly the same results, that doesn’t mean that you were wrong. But you can use
these examples as a guide to see what was intended.

Damian

1. Strengths/resources: Good heart, has friends, helps his mother, respectful at home, does
well in school, has mother who makes many efforts on his behalf (including getting time
off from her job to attend this meeting), school disciplinarian who wants what's best for
Damian.
126 CHILD TRAUMA HANDBOOK

. Trauma/loss history: Saw father hit mother many times; heard loud fights; was beaten by
father several times; abandoned by father following parents’ separation.
. Negative beliefs: ’'m unsafe; I can’t protect myself; I’m inadequate; there’s something
wrong with me; piled-up feelings: shame, fear, anger, sadness.
. Trigger situations: Theme: feeling put down in some way; example: teacher correcting in
front of others.
. Problem behaviors and why it’s a solution: Threatening or intimidating another person can
make him feel powerful and that he can protect himself.
. Overview of treatment recommendations/plan: External controls that can make him feel
extra safe and secure so he can relax a little and be able to focus on recovering from what
has hurt him. Motivation for change, figure out what he wants and why current behaviors
won’t help. Then he’!l be more willing and able to work on these issues in his meetings
with me.
. How you can help right now: Has to learn that “crime doesn’t pay” so that it will be worth
his while to choose another type of solution behavior. The more he gets away with this kind
of thing, the more he learns that it works for him. Punishment can teach him that choosing
aggression has a high cost. Punishment will also give a message to him, as well as others
(students and teachers), that threatening behavior is not tolerated here; that makes every-
one feel safer. Also can reduce frequency of triggering; perhaps speak to teacher about cor-
recting him in private?

Angela

. Strengths/resources: Wants friends, wants to please adults, capable of recruiting adults to

care about her, capable of forming attachments/relationships, tries hard in school, does
well in school, many interests, is not secretive, shows how she’s feeling, is outgoing, can be
a leader, has an aunt who is like a mother to her, who is dedicated to her care and who is
generally effective as well, has a therapist who cares about her.
. Trauma/loss history: Sexual abuse by stepfather, rejection/abandonment by biological
mother.
. Negative beliefs: ’m helpless; I’m worthless; I don’t deserve to be loved; there’s some-
thing wrong with me; I can’t tolerate bad feelings; piled-up feelings: grief, anger, shame,
despair, confusion.
. Trigger situations: Theme: being abandoned or rejected; examples: When biological
mother does visit but then says good-bye, and also when biological mother fails to show
for the visit.
. Problem behaviors and why it’s a solution: Relief from intolerable feelings by expressing
them in temper tantrums. The punishments give her containment and reassurance.
. Overview of treatment recommendations/plan: I want to work with her on self-control
skills and then on recovering from the trauma memories, not only the abuse but being re-
jected/abandoned by her biological mother. But first she needs to feel safe and secure, as if
things are more or less okay right now, so that she doesn’t have to be constantly focused on
trying to make sure that more bad things aren’t going to keep happening.
. How you can help right now: She won’t be able to concentrate on any of her treatment
tasks while she’s being freshly abandoned and rejected by her biological mother every
week! She’ll stay distracted by her repeated upsets and her fear of more to come. Can we
try to figure out how to keep her from getting hurt the same way every week like this?
 Case Management 12%

Standing Your Ground

Sometimes a case management intervention can be challenging or controversial. Remember

that your first obligation is to do your best for the child, according to your skills, understanding,
and professional standards. You want to be able to stand by your actions—to avoid legal liability
for substandard practice, and to live with yourself.

A clinician evaluated a five-year-old girl who had been molested by a man, and who was somewhat
nervous around men. The clinician prepared a written evaluation that included a recommendation for a fe-
male therapist. However, before the evaluation was turned in, he happened to speak with a male therapist
in the same clinic, who had somehow already had a couple of sessions with the little girl, which he said
were going well. To avoid “rocking the boat,” against his better judgment the evaluator turned in a report
with no reference to the gender of the therapist. A week later, the girl suddenly refused to work with the
male therapist anymore.
A clinician was hired by the public school to evaluate a ten-year-old boy with mild mental retardation
and emotional disturbance. The boy was being repeatedly frustrated because he was in classes with con-
tent too abstract for him to relate to; then he would start acting out and getting into trouble. The clinician
recommended that the boy be provided an educational curriculum suited to his abilities and needs. The
principal said, “You can’t recommend that. We don’t offer that kind of program here anymore,’ but the rec-
ommendation stood, and became part of the child’s educational record. Within a few weeks, a new class-
room was created for this purpose—and several other children with similar needs joined the class as well.
A child protection worker in a small town investigated an abuse allegation and found that the child had
indeed been physically abused by the father, who was the custodial parent and a local police officer. The
usual action in this situation would be to require the father to participate in an anger management pro-
gram for parents. As a “professional courtesy” the worker did not require this but only recommended it.
The father never attended, and the abuse continued.

When the Case Doesn’t Get Managed

In many situations, you will be able to elicit cooperation and accomplish the case manage-
ment tasks that you believe will help the child. Sometimes this will fail, and then you’ll have to
consider your options.

Accept Defeat Gracefully

One option is to just keep on working, and accept that not everything you want for the child
will happen as you wish it would. This option is preferred when you really have no choice any-
way. Even so, it can still be worthwhile to make the recommendation and the attempt; this plants
the seed. Sometimes you’ll have another chance later on.

A fourth-grade boy was referred for problem behaviors and loss of interest in former activities. Interac-
tions in his family had also deteriorated. Recommendations included specified family activities, a class-
room-based incentive program, and psychotherapy. The parents refused psychotherapy because of a
prior experience in which they felt that a therapist had been intrusive. The evaluator was clearly not wel-
come to even discuss their position, but instead asked whether it would be okay for some of the same
goals to be addressed by the school counselor. This was acceptable to the family, who also allowed the
evaluator to provide consultation to the counselor and to the teacher.
Aconcerned teacher noticed that a certain child often came to school with dirty clothes and sometimes
fell asleep in class. She contacted the school counselor, who contacted the parents, who refused to talk
about it. The counselor made a report of suspected neglect to the local child protection agency, which re-
fused to investigate. The counselor and the teacher decided to make an extra effort to make the parents
feel welcome in the school, to be supportive of the child, and to be alert for other opportunities either to
make some headway with the family, or to file another report for child neglect.
128 CHILD TRAUMA HANDBOOK

Advocate for the Child

Sometimes even if you are not immediately successful in effecting a change, you can do
more. Perhaps your advocacy will lead to a resolution. Even if it doesn’t, there is still value in the
child and family knowing that you made the effort on their behalf. You may be the only person
giving them the message that the child deserves to be safe and to be treated with respect.

A twelve-year-old boy was afraid at school because he was being repeatedly bullied by an older boy,
who had severely beaten him on one occasion. The school did not discipline the offender and did nothing
to protect the younger boy. Repeated requests for action made by the parents and by the boy's therapist
got no results. The therapist then wrote a letter to the school principal detailing the events that had taken
place, including the interactions between the boys, as well as the parent and therapist requests for the
school to do something about it. In this letter, the therapist stated that the school has an obligation to pro-
tect its students, and that this is particularly true when a specific known danger exists. A copy of this letter
was sent to the parents, the police, and the child protection agency. Perhaps due to the increased aware-
ness of the school’s legal liability that this “paper trail” engendered, the older boy’s schedule was modified
so that the boys would not meet each other at school anymore.

A nine-year-old girl was referred for treatment for posttraumatic stress symptoms after having seen her
mother severely stabbed by mother’s ex-boyfriend. The symptoms of anxiety and intrusive imagery were
most severe in the evenings, when mother was not home because she was out with her current boyfriend,
who was controlling and emotionally abusive. The therapist did not know the mother well enough to tell
her who her boyfriend should be. However, the therapist was able to help the mother understand that her
daughter was afraid for her mother’s safety, especially when mother was with someone like the one who
had hurt her. Mother agreed to call her daughter before bedtime to reassure her that everything was all
right. Within a couple of weeks, mother spontaneously began to limit her late nights to two per week, ona
schedule. Two months later, mother left the boyfriend.

Following is the intervention that led to the initial change in the behavior of the mother whose
daughter worried when mother was out at night. Notice how the therapist focuses on the case for-
mulation and the child’s safety concerns. Notice also how respectful the therapist is of the
mother’s accomplishments and of the way she does care for her child. With this foundation, when
the therapist makes a new suggestion, the mother does not take this as a slight; rather, she is able to
hear it as helping her do what she is already doing, but better.

THERAPIST: Since you were attacked last year, your daughter has been really worried that some-
thing else bad might happen. We’ve been talking about how important it is for her to start feel-
ing like things are safe now, so she can start to get over what happened before. What kinds of
things have you been doing to make sure that things are safe now?
PARENT: He’s in jail now, the guy who attacked me. I don’t have to worry about that anymore.
THERAPIST: That’s good to know. But we can see that your child is still worried, and I’m sure
that you do other things to make sure that everyone’s safe. What kinds of things do you do?
PARENT: Well, I always make sure the door’s locked when we go out and when we’re home. And
I don’t let her answer the door or the phone. She knows she has to let me do that. And I don’t
let her roam the streets like some parents do. She comes right home from school.
THERAPIST: That’s good. You do a lot of the things already that I would have suggested. And
what about you? What do you do to let her know that you’re safe, that she doesn’t have to
worry about whether you’re okay or not? I know that she says that the nights you don’t come
home, she’s still pretty worried.
 Case Management 129

PARENT: Well, the problem is that my boyfriend doesn’t have a telephone. But she’s okay at
home with her (older teenaged) sister there. I know she’s safe.
THERAPIST: Yes, but she says that she doesn’t know that you’re safe. She doesn’t really know
when she gets home from school if you’re going to be home that night or gone away, and
when you don’t call at night, I bet her imagination gets going.
PARENT: Maybe I could call her from a phone booth before she goes to bed, just to tell her good
night so she knows I’m okay.
THERAPIST: I think that’s a really good idea. And another thing: is there any way that you can tell
her ahead of time if you’re going to be out that night? Kids usually feel a lot better when they
know what to expect.

The more the therapist works with the family on issues that are clearly related to being safe
and to feeling safe, the more the trauma-based case formulation is reinforced. This lays a good
foundation for the later focus on more abstract safety issues such as the parent setting consistent
limits or avoiding yelling.

Force the Change

In extreme situations, change is necessary whether the parents (or other caregivers) like it or
not. Many of these situations are covered by mandated reporting laws to protect the child’s
safety. Even in such extreme situations, there are opportunities to show respect and to empower
the parents to come through for their kids.

A second-grade boy had so many school absences that soon a mandated report would have to be filed
for educational neglect. The school principal said to the parent, “If your son misses two more days of
school this term, the law requires me to report you for neglect. | don’t want to have to do that, and | hope
it's not necessary. | Know you care about your son, so I’m sure that there’s a good reason he’s missed so
many days. What is the reason? Is there anything we can do to help him get to school?”
A seventh-grade girl disclosed to her therapist that her stepfather had been “messing” with her. The
therapist asked if it would be okay to invite the girl’s mother into the session; the girl said yes. Several is-
sues were addressed, including immediate actions to protect the girl, as well as the therapist's obligation
to make a report to the child protection office. They decided to make the report together, which they pro-
ceeded to do, taking turns on the phone to talk with the worker. They were able to tell the worker about the
actions they were already planning to take to protect the girl.

CASE MANAGEMENT PITFALLS AND REMEDIES

It can be heartbreaking to witness major disruption in the child’s life (e.g., removal from the
home), especially when it seems that the situation is being mismanaged by the authorities. Many
children do in fact describe the intervention as being more traumatic than the original situa-
tion—even in retrospect, years later. Although sometimes disruption is unavoidable, it is often
made worse than it needs to be.
When we are involved in making changes to a child’s life situation, there are many things that
we can do—and can encourage the allied professionals to do—to minimize the disruptive im-
pact. Underlying these suggestions is the RICH relationship—that kids (and parents and col-
leagues) deserve to be treated with respect, to be given information, to maintain their connec-
tions as much as possible, and to have reason to hope for a better future. When kids and others
are treated this way, there is less chance that we are adding new trauma to the old, and more
chance that we are actually helping.
130 CHILD TRAUMA HANDBOOK

Here are some true stories of situations that kids have experienced at the hands of those who
were supposed to be helping them. Unfortunately, those who work with abused children will be
all too familiar with stories like these; this reflects common practice. Following the vignettes are
specific suggestions for the various professionals involved.

Law Enforcement/Detective/Police Officer

A thirteen-year-old girl had truthfully disclosed to her basketball coach that her mother had allowed
mother’s friend to rape the girl. Later that night a police officer went to the girl’s home, unannounced, and
barraged the girl with antagonistic questions, in front of her mother. The girl was stunned, and felt that she
was being “treated like a criminal,” especially when the police officer threatened to arrest her if she lied.
The girl said very little and disavowed the rape.

Suggestions

¢ Vary interview technique according to the individual you’re talking to—not everyone is a
criminal.
* Nonoffending parents already feel bad; they want to help. Be respectful.
¢ Make the victim feel safe to tell you what happened by interviewing her privately, or with a
nonoffending parent.
¢ Victims are more likely to tell the truth if they’re not afraid of you. An aggressive tone is
aggressive! If they feel as if you’re victimizing them, too, their primary goal will be to pro-
tect themselves from you.
¢ Use simpler language for younger children.
¢ Understand that kids may not feel comfortable with you right away, or tell the whole story
the first time. Have patience.

Child Protection/Child Welfare Worker

Three weeks after an allegation of sexual abuse had been made, a twelve-year-old girl was awakened
after midnight and taken by the child protection worker to the hospital emergency room for a medical
exam.
A group of three siblings were removed from their home following substantiation that they were being
abused by their mother’s live-in boyfriend. Mother kicked out the boyfriend immediately and obtained a re-
straining order. The caseworker was on vacation and the supervisor did not return the mother’s calls.
When the caseworker returned two weeks later, she was backed up with work. She was slow in returning
phone calls, slow in getting to the home to make a visit, and slow in getting the paperwork done. Although
it took inemother only two days to make the home safe for her children, it took the children eight weeks to
return home.
A ten-year-old boy in foster care was met at school by his caseworker, who took him to a new foster
placement. He did not know to expect this, and did not know why it was happening. (It was because the
current foster parent had lost patience with him.) His few belongings were in a plastic trash bag in the
worker's car. His pet turtle, the only possession he cared about, was also in the worker's car, but it had
been there all day and had died in the heat.

Suggestions

¢ Getting things taken care of in a timely manner can minimize the extension of the trauma.
For example, an out-of-home placement can take days or weeks instead of months.
* Communication and coordination among the various players can avoid replication of
exams, interviews, and services.
* Avoid the dramatic/urgent approach except when it is truly called for.
* Let kids know what to expect as much as possible.
 Case Management 13]

* Help kids to keep their possessions and their existing relationships as much as possible.
* Keep the same worker on the case whenever possible. Kids and families learn to count on
you. You are not interchangeable. You know them, and they know you.

Prosecutor/District Attorney

A nine-year-old girl was molested by a neighbor. The girl was interviewed about the molestation in
great detail by the police detective, then by the hospital social worker (where she had her physical exam),
and then by her new therapist. But after all that, it seemed for months that no one was going to do anything
about it. Finally the prosecutor showed up, and asked her the same questions all over again.

Suggestions

¢ Talk to the victims and witnesses as soon as possible. Then they’1l have a better memory
for details, and will feel that you (and “the system’’) care and take this seriously. Also, ex-
pediting this process can minimize the duration of the trauma—many kids dread this meet-
ing.
* Joint process with allied professionals can preclude the need for repeated interviews.

MD/Pediatrician/Emergency Room

A six-year-old boy was referred to child protective services when his teacher noticed bruising on his
legs. The emergency room doctor, not an abuse specialist, diagnosed physical abuse without obtaining a
second opinion. The child was placed in foster care for six months before the bruising, which continued to
occur, was correctly diagnosed as a blood disorder.
A pediatrician noticed a number of old bruises on a five-year-old girl during her regular physical exam.
The doctor did not want to “open a can of worms” and so said nothing. A month later, the girl was in the
emergency room with several broken ribs.

Suggestions

¢ Don’t fake it. If you’re out of your area of expertise, refer the case, at least for a consulta-
tion or second opinion.
¢ Don’t hide it. If you don’t want to deal with child protection services, don’t just drop the
ball. Actively pass it to someone who will deal with it.

Mental Health/Counselor/Therapist

A thirteen-year-old boy told his therapist that his father (the custodial parent) had emotionally and
physically abused him on a number of occasions. The therapist, assuming that child protective services
would just make matters worse, took care of it by talking to the father herself. The abuse continued for an-
other year until the boy began doing so much worse in school that he drew more attention to himself.
A four-year-old girl had been molested and was now in therapy. Her mother asked the therapist what
was happening in therapy, and if she (the mother) could do anything to help her daughter. The therapist
explained that it was important for the little girl to have privacy, so the therapist couldn’t discuss it. No ad-
vice was given to the mother, except to keep bringing her child. This continued for more than a year with
no great improvement in the girl’s posttraumatic stress symptoms. Even then, it was the mother who fi-
nally stopped this and got a new therapist for her daughter.
Anine-year-old boy was referred to a therapist working in a specialty program for sexually abused kids.
The boy had been sexually abused on two occasions by a neighbor; however, he was more concerned
with the death of a grandparent two years earlier, and with his peer interactions. The therapist put the boy
through the standard six-month group and individual treatment program, entirely focused on the sex
abuse.
132 CHILD TRAUMA HANDBOOK

A ten-year-old girl disclosed that she had been molested by her older brother. The therapist thanked
her for the disclosure, and later reported it to the authorities. Later that day, strange adults came to the
girl’s house, frightened her and her parents with questions and threats, and took the girl away! The girl
had no idea that anything such as this might happen, and the “safety” intervention ultimately proved to be
more traumatic than the molestation had been.

Suggestions

¢ Ask more questions before drawing conclusions. Really listen. Use a systems model of the
child in the family/social context. Individual treatment can be important but is rarely suffi-
cient to help this child become safer.
° Take responsibility and initiative to help allied professionals see the child the way you do.
When others understand the case formulation, they are more likely to give support in a way
that is good for the child.
¢ Facilitate communication among various players to avoid replication and ensure that criti-
cal needs are being addressed.
¢ Monitor yourself, practice self-care, and seek consultation to keep yourself on track.
¢ Use effective methods for trauma treatment.
¢ Share information with clients so they know what’s going on and have a chance to prepare.

Many of these suggestions may require innovative approaches to providing services to children.
It may take some effort to change the way your system works, or works with others. Remember,
though, that the primary goal is not to make things convenient for ourselves, but to help the kids.
Here are some examples of ways that agencies and organizations have made changes so that
case management and related interventions are more helpful for kids:

¢ A child welfare agency used to have one worker to investigate child abuse cases, another
worker to manage the child’s case once the investigation was completed and the abuse
charges proved valid, another worker to conduct home studies for potential foster and
adoptive families, another worker to manage the cases of kids in foster placements, and yet
another worker for kids in adoptive placements. After learning of the literature that showed
that families are more likely to seek help sooner—before a problem gets out of hand—
when they have a long-term relationship with their worker, the agency reorganized. Now,
once the investigation is founded, a worker is assigned to a child (or sibling group) all the
way through, no matter what happens to the child. This has required some additional train-
ing; however, it has reduced employee turnover, and also reduced the frequency of failed
foster and adoptive placements.
¢ A hospital that received many referrals for suspected child abuse started a “one-stop”
multidisciplinary child advocacy center where most of the required activities could take
place. The staff includes a pediatrician, nurse, social worker, and psychologist, all with
specialized training. This clinic works with designated allied professionals from child pro-
tection and law enforcement. When forensic interviews are conducted by the staff member,
the child protection worker and the police detective can observe behind the one-way mir-
ror. Subsequent treatment for medical as well as mental health needs is provided by the
staff. This program requires regular meetings and good communication, as well as occa-
sional multidisciplinary training events, to help the various professionals coordinate their
efforts. However, the families feel taken care of, and the professionals believe that they are
providing better service, reducing redundancy, improving treatment compliance, and im-
proving chances for successful prosecution.
¢ A regular feature at the staff meetings of a community mental health center involved relat-
ing the latest horror stories regarding how their kids and families were being mismanaged
by child welfare workers, probation officers, teachers, and others. They decided to stop
complaining and try to solve the problem. After that, early in the treatment of a new child/
 Case Management 133

family, a meeting would be called of all involved (including the child, parents, and allied
professionals). The case formulation would be presented as a basis for the treatment plan.
Then each person at the meeting could define his or her role as part of this team effort. This
approach did not always work because it was difficult to get everyone to show up or coop-
erate, but it did at least improve the situation.
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 Chapter 10

Parent Training

This chapter focuses on working with parents. However, many of the same principles and
methods apply to foster parents, teachers, residential workers, and others who spend their day in
the child’s life space.
There is some overlap between parent training and case management, in terms of building a
fence around the child. However, parents (and other caregivers) are also unique due to their re-
sponsibility for the child, their importance to the child, and their daily interaction with the child.
Parents have a critical role in helping the child to be safe and to feel safe, and in encouraging and
supporting the child on the path to healing. The many things that we wish parents would do in-
clude the following:

* Keep the child safe.

* Help to make sure the child can be reasonably successful at school and elsewhere.
¢ Bring the child to appointments regularly and on time, until we say that treatment is com-
pleted.
Do not give up on the child.
Enjoy the child more; reinforce positive behaviors.
Stop hitting the child or blowing up at him.
Use calm, reasonable, firm, and consistent discipline.

Although parents will generally recognize the importance of our wish list for their behavior,
they are not always willing or able to come through for their children. This does not mean that
they don’t care about their kids. It means that something is in their way. Here is a list of the “Yes,
but. . .” greatest hits:

1. I tried it (e.g., time out for discipline, instead of spanking) but it didn’t work.
2. I don’t want to bring it (the trauma memory) up; it will only upset her.
3. I don’t want to be hard on him (enforce the rules); he’s been through enough already.
4. She makes me so mad I can’t help it (yelling, hitting).
5. He just doesn’t care anymore, it’s no use trying to help him.
6. I’m just so tired I don’t have the energy.

Parent training is fine for teaching good parenting skills and practices, but it doesn’t take care
of the “yes-but” problem. If there’s a yes-but, then the parents won’t be using the skills they
learned. We address this issue by using the fairy tale model as the foundation for the parent train-
ing approach.
Parent training for supportive behaviors, including calm and consistent discipline practices, is
part of many child therapy approaches, and is a key component of trauma-informed treatment.
One key distinction in trauma-informed treatment is the emphasis on the child’s sense of safety,
following from the trauma-based case formulation and recommendations. The other key distinc-
135
136 CHILD TRAUMA HANDBOOK

tion is the emphasis on respect and empowerment of the parent. Building on the parent’s track
record of caring about, and for, the child, the parent training is offered as a way to help the par-
ents do even more of what they are already doing, or trying to do.
This is an important point because parents can be pretty touchy about being told that they
need “training” to do what they have already been doing. Parents can also be touchy about re-
ceiving advice from someone who is different from the parent in terms of parental status, educa-
tional level, socioeconomic status, ethnicity, and/or gender. Parents who have experienced dis-
respect or even coercion from “the system” can be touchier still.
In short, the risk that your parenting advice will be rejected is high. You can make rejection al-
most certain by emphasizing that you know best and that the parent is the real problem. We con-
vey this message when it is what we actually believe. This message is actually conveyed quite
often by well-meaning professionals, even when effort is made to hide the true message within
the jargon.
Although it is important to recognize problems, with the fairy tale model we work with the
parent’s strengths, so that’s where we need to focus. The case formulation can help us do this.
When we see the child as wounded, we can help the parent see the child that way too. The par-
ents are not told—even by implication—“Your bad parenting practices have caused this prob-
lem.” Rather, they are told, sometimes explicitly, “If it weren’t for your child’s particular
problem, your discipline style would be of little interest to me. However, because of the trauma/
loss experiences, your child is wounded, and there are special things that you can do, at least for
a while, to help her to get better.” Thus, instead of being blamed for the child’s problems (parents
tend to blame themselves already), parents are given an opportunity to be agents of their child’s
healing.

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 Parent Training 137

DID I HEAR YOU SAY “YES, BUT”?

At this point, many in a training audience roll their eyes, and say, “Yes, that’s all very nice, but
you don’t know the parents I work with!” When we see a parent behaving inappropriately, in a
way that only reinforces the child’s problems, it is easy to feel justified in believing the worst
about the parent. It is yet easier to believe bad things when the parent has other problems as well.
But ask yourself: how would you respond to a misbehaving child if you truly believed that she
was bad, did it on purpose, and just didn’t care anyway?
On the other hand, think about some of the parents whom you see as problematic, uncoopera-
tive, incompetent. Imagine that the daughter of one of these parents breaks her arm. The parent
takes her to the emergency room, where a cast is put on. Three weeks later the cast comes off and
the physical therapist tells the parent, “Do this exercise with your daughter at home. Here, I’ll
show you how. Do it every day, ten times in the morning, and then ten times at night. Bring her
back in a week and I'll see how she’s doing.” Most or all of your “problem parents” will follow
through with this, right? Maybe not perfectly, but pretty well.
When parents feel blamed, disrespected, or otherwise attacked by the therapist, they are
likely to protect themselves and reject the therapist. When parents see their child as bad, behav-
ing badly on purpose, and not valuing the parent-child relationship, they are likely to protect
themselves and reject the child. On the other hand, when parents feel respected and supported,
they are able to be more open to your advice. And when parents can see their child as hurt, not
“bad,” they are more likely to come through with what the child needs to recover. Of course, no
matter what we do right, not every parent will come through. But we can’t know ahead of time
which parents will surprise us and come through for their kids, when we give them a way to un-
derstand and a way to do something about it.

WORKING THE CASE FORMULATION

The key to eliciting parent cooperation is the case formulation and the fairy tale model. This
helps parents see their child as still good, but wounded. It helps them to understand why the
treatment recommendations make sense and will lead to healing. And it helps them to under-
stand how important their own role is. With the case formulation, you can:

1. Advise parents to do things differently, not because they were doing it “wrong” before, but
because their child has a special need.
2. Help parents to embrace a rationale that overcomes their “blocking beliefs.” For example:
¢ When the parent says, “I don’t want to be hard on him (enforce the rules); he’s been
through enough already,” the therapist can say, “Enforcing the rules makes him feel
more secure. Then he knows what to expect, knows he can count on you.”
¢ When the parent says, “I don’t want to bring it (the trauma memory) up; it will only up-
set her,” the therapist can say, “If she sees that you can handle talking about it, then she
can talk about it with you and get your help. Right now, because she doesn’t want to up-
set you, she just keeps it inside, has to face it all alone.”
3. Help parents become active agents in the child’s healing and recovery.
4. Help parents identify personal obstacles to helping their kids, and what to do about them.

Sometimes parents really do need their own treatment. But if we just say this up front, we
have overstepped our mandate (which is typically child-focused) and the suggestion may be per-
ceived as offensive. On the other hand, if we work with the parent to gain an understanding of
what to do and why, and then the parent still says, “I try to do it right, like we talked about, but I
138 CHILD TRAUMA HANDBOOK

just get too angry and lose control,” then we have an opening. Then we can say, “Is it okay to talk
about what keeps you from coming through for your child the way you want to?” Then, without
even knowing the details of the parent’s history, we can offer a trauma-informed case formula-
tion to explain the parent’s own sore-spot reactivity regarding the child’s behavior, and present
options for taking care of it. At this point, many parents will engage in self-control skills train-
ing, and some will be willing to work toward trauma resolution as well.

PRACTICING RESPECT AND EMPOWERMENT

The fairy tale model’s trauma-informed case formulation includes an emphasis on the “king-
dom’s” strengths and resources. This supports the empowerment approach. To make this fly, we
must be able to identify and acknowledge the parents’ strengths. Remember, the parents are the
ones building the fence. The therapist should do as much as possible to convey support and re-
spect for the parent, and to enlist the parent’s active cooperation.
As the therapist learns about current discipline practices, even inappropriate and/or ineffec-
tive ones, the therapist can convey an understanding of the parent’s positive underlying intent.
For example, if the parent spanks the child for lying, the therapist might say, “It sounds like you
really want your child to learn to tell the truth.” Then when the therapist offers suggestions for
modifying the parent’s approach, the parent does not experience it as a put-down, but rather as a
tip to help the parent do what he or she is already trying to do, but better.

PARENT TRAINING INTERVENTIONS

The following handout is an example of a way to build on the case formulation—work the
fairy tale model—in a parent training approach. Typically this handout is not just passed to a
parent, but is accompanied by a full session discussing each portion, step by step.
The core principles of the positive parenting form (and the parent training approach) are as
follows:

Problem behavior is a way children ask for reassurance. Reassurance calms kids down.
You are the parent. You are the child’s rock of security.
If you are in charge, you are strong and can protect.
Keep your promises.
Only make promises that you can keep.
When you stop a problem quickly, it’s smaller and easier to handle.
Minimize negatives; reinforce positives.

The following repertoire of interventions (Greenwald, 1999) can help parents understand the
issues involved, overcome the obstacles, and acquire the specific behaviors necessary for effec-
tive discipline. The therapist needs to judge which interventions to use and which to skip, ac-
cording to the demands of each case. (These interventions from Greenwald, 1999, Eye Move-
ment Desensitization and Reprocessing are reprinted by permission of Jason Aronson, an
Imprint of Rowman & Littlefield Publishers, Inc.)
 Parent Training 139

Positive Parenting
© Ricky Greenwald, PsyD 1997

Children who misbehave often feel scared, nervous, and insecure. They need gentle,
but firm, consistent discipline. Then they will know that they can count on their parents.
This will make them feel more secure, and they will calm down. Here are some ways to
provide this sense of security to your children:

1. Keep Your Promises

Avoid making promises you can’t keep. Then your kids will learn that they can count on
you. This goes whether your promise is for a treat or for a punishment.
Don’t promise good things unless you are sure that you can come through. And stick with
small punishments so that you can follow through on those, too.

Train your children to learn that Yes means Yes and No means No.

2. Stop a Problem Quickly

Don’t get into arguments with your child. You are not equals; you are in charge. You also
want to avoid losing your temper. When you lose your temper, your child has pushed your
buttons, and you have lost control. But your child needs you to be in control, to be in
charge. Also, when you lose your temper, you may be tempted to yell, hit, or make prom-
ises that you can’t keep (like a punishment that is too big). All these things will just make
your child more scared and insecure.
You can avoid losing your temper by stopping a problem quickly, before it gets out of hand.
Just tell your child one time what you want. Next, give one warning. Next, give a short time-
out. After the time-out is done, the child still has to do what you say. That’s it. No messing
around.
When you stop a problem quickly like this, you don’t have a chance to get frustrated and
angry. Then you can handle it in a way you can feel good about.

3. Enjoy Your Child

Some children do bad things because they like to get attention from you. Why not give at-
tention for good behavior instead?

As you become quicker and more effective with your discipline, your child will probably
calm down and give you less trouble. Then you will have more time and energy to enjoy
your child. Find things to do together that make your child feel special. It could be big things
like going to the park or the beach for the day. It could be something small like fixing some-
thing together or cooking a meal together.

Remember, discipline and fun all come from the same place: your love and concern for
your child.
140 CHILD TRAUMA HANDBOOK

Problem Behavior Is a Request for Reassurance

This is really just a reminder of the case formulation, as it applies to the child’s problem be-
haviors.

THERAPIST: Sounds like your daughter can get pretty hard to handle sometimes.
MOTHER: Oh ya, she gets me going. It’s like she’s just asking to get smacked, until finally some-
times I do it, just to shut her up.
THERAPIST: Remember how we were talking about when she had to see you and her father fight-
ing those times, and then he left? When kids go through that kind of thing, they get really
scared inside. Like the world’s not safe anymore, anything can happen. And then, even much
later, they’re still worried that something else bad might happen anytime.
MOTHER: Yes, she is worried like that, I know.
THERAPIST: So when she gets nervous, wonders if things are still safe, she asks you, by acting
bad. Then if you can show you’re in charge—in control—she feels safe again.

A Safe Child Has a Strong Parent

With parents of younger children, this intervention can help illustrate how, when the parent is
in charge, the child can feel safe. This is most appropriate when the child has taken on a parental
role, perhaps as the confidante, caretaker, or boss (if the parent is not in charge, the child is the
boss). The therapist highlights this role confusion to the point of absurdity, which may jar family
members into a new perspective on their interactions. First the confusion itself is presented, and
then elements of resolution are addressed sequentially. Once parents demonstrate that they are
bigger, older, and stronger, they are qualified to be in charge. Once they can prove that they
are really in charge, they can use this parental role to help their child feel more safe and secure.

THERAPIST: You might think I’m stupid, but I’m getting confused here. Which one of you is the
real mother?
CHILD: She is!
THERAPIST: I’m not so sure. When Mom tells you her troubles, then you’re the Mom. (Then to
the mother:) Do you have any adult friends you can tell your troubles to, so that Sara doesn’t
have to be your mother?
MOTHER: Yes, I talk to my neighbor sometimes, and to my sister .. .
THERAPIST: That’s good. You want to keep grown-up talk with the grown-ups, so that your
daughter can be a kid. But I’m still confused about who the mom is. Remember a little while
ago, when you (to mother) told her to put the markers away, and she kept on using them? She
was the boss then. I always know who the real mom is by seeing who’s in charge. So I’m still
reyeun (To the child:) Are you in charge sometimes, when maybe your mom is supposed
to be?
CHILD: Sometimes I don’t listen good.
THERAPIST: Oh, so you might be confused sometimes too. No wonder I’m confused now.
MOTHER: Well I tell her, but she doesn’t always listen.
THERAPIST: Right, that’s why we’re all so confused. But it’s really important to know who the
mom is, to know who’s in charge. Let’s see, a mom should be bigger, older, stronger... (to
child:) Mom, stand up.
 Parent Training 14]

CHILD: I’m Sara!

THERAPIST: Oh, I’m sorry! Got confused. Okay, Mom—no, I mean Sara—stand up. And (to
mother) Mom, you stand up too. Okay, good. Now which one of you is bigger?
CHILD: She is!
THERAPIST: Hmm. Let’s see, you go up to here (puts hand by the top of child’s head), and you go
up to here, yup, she is bigger. Now, who’s older? |
CHILD: She is!
THERAPIST: Are you sure? How old are you?
CHILI Lmnisix:
THERAPIST: And how old are you?
MOTHER: Twenty-seven.
THERAPIST: Bigger, and older. Well, maybe you are the real mom. But let’s see who’s stronger.
(To child:) Go over and lift her up off the ground.
CHILD: I can’t.
THERAPIST: Well, you never know. If you were the mom you could. Go give it a try.
CHILD: (tries) I can’t.
THERAPIST: Okay, good try. Now (to mother) you lift her off the ground. (Mother does so.) Oh,
bigger, older, and stronger too! Well, she might really be the real mom. But let’s find out who
the boss is! (To child:) What I want you to do is tell her to jump up and down. See if you can
make her do it. (To mother, whispers:) Don’t do it.
CHILD: Jump up and down.
MOTHER: No (smiles and does not move).
THERAPIST: (to mother:) Good job. Now, how does she get her way sometimes? I know! (To
child:) Tell her again, maybe she’ll change her mind. (To mother, whispers:) Don’t do it.
CHILD: Jump up and down.
MOTHER: No (smiles and does not move).
THERAPIST: You’re both doing a good job. (To child:) Keep telling her again and again. I bet you
can get her to change her mind. (To mother, whispers:) Don’t do it.

This role-play provides an excellent opportunity to emphasize the appropriate parental au-
thority role. Children do tend to enjoy this activity even if they are unable to articulate that they
feel more secure when their parents take charge. The parent can become somewhat inoculated to
the child’s coercive strategies, simply by going through each one systematically, with the child’s
playful participation.

THERAPIST: Hmm, I guess that’s not working. What can we do? I know! Make that face that you
make, you know (makes face). No, you do it better. Go ahead, make that face and tell her
again.
CHILD: (makes face) Mom, jump up and down.
THERAPIST: Boy, she’s tough, isn’t she? Can you think of anything that might get her to do what
you say?
CHILD: Maybe if I cry?
THERAPIST: Good idea, try that (by now, mother understands her role and does not need continu-
ous prompting to stand her ground).
CHIED 1 carrti
THERAPIST: That’s okay. Just do your best, make believe.
142 CHILD TRAUMA HANDBOOK

CHILD: (moans) Mom, jump up and down.

THERAPIST: That was pretty good, but she’s still not doing it. How about yelling? Will that work?
CHILD: I don’t think so.
THERAPIST: Well, let’s try one last thing. This time, yell at her to do it, and stomp your feet too.
(Child stomps and yells.) Well, I guess this is the real mom after all. She’s older, bigger, stron-
ger, and it turns out that she’s in charge, too. You can’t boss her around. That’s good news.

Once the parent is established as the more powerful person in the parent-child relationship,
this should be tied immediately to the protective function. This can be accomplished through
discussion or role-play, and can be modified to reflect any identified fears the child may have.
The therapist can say something like, “Well, your mom seems pretty tough to me. Do you think
she’s tough enough to handle monsters?” Then the therapist may direct a role-play in which the
parent is able to successfully protect the child from the feared object.
 Parent Training 143

THERAPIST (raising arms and baring teeth): Here comes the monster! I like to eat little children. I
ans I see one! (walks slowly toward the child). (Whispers: “You think your mom can save
you?’’)
MOTHER: Go away or I’ll shoot!
THERAPIST: Ha ha! Here I come!
MOTHER: Bang! Bang!
THERAPIST (falls down): I’m dead.

If the therapist is uncomfortable in playing the monster role, a puppet or other prop can be
used. Props can also be used for weapons or other means of protection. This role-play may be re-
peated a number of times, with variations, e.g., “Oh no, now two monsters are coming!”
Although the child is the most direct beneficiary of this game, the parent is also learning how
important the strong parental role appears to be to the child. This can help to overcome parental
ambivalence about taking charge.

Keep Your Promises

One of the most important concepts for parents to understand is that routines and rules are like
the parent’s promises to the child. This helps the parents realize how much their own behavior
has been compromising the child’s sense of security. It can be introduced gently, however, by
conveying the assumption that the parent has positive intent but just didn’t know better.

THERAPIST: Let me ask you something. If you tell your kid, “If you clean up your room in ten
minutes, I’ll give you some ice cream,” and then in nine minutes, she shows you her room,
and it’s nice and clean, are you going to say, “That’s nice, but I was just kidding about that ice
cream’?
PARENT: Oh, I would never do that. Of course I would give her the ice cream like I said.
THERAPIST: I thought so. If you make a promise, you wouldn’t let her down. But what about
this: What if she doesn’t do what you say, some little thing, and finally you get so mad that
you say, “Okay, you can’t go to the park tomorrow.” And then tomorrow comes and you’re
not mad anymore, and you realize that the punishment was too big, and it’s a nice day...
PARENT: Oh, I let her go. Usually I do give in later on.
THERAPIST: So you do break your promise in that situation?
PARENT: I guess so. I never thought of it that way.
THERAPIST: When you don’t do what you say, you let her down. A lot of parents don’t realize
that. But when you say what’s going to happen, she’s counting on you to make it happen. She
needs you to be a rock that she can always count on. You know how it is when you can’t count
on someone. It feels pretty shaky. Also, you have rules for good reasons, right?
PARENT: I like to think so.
THERAPIST: So let’s say that she’s not allowed to play in the street, and—
PARENT: That’s a good example. A lot of fast cars go by our house.
THERAPIST: So let’s say you tell her, “Don’t play in the street or you’IIhave to come inside.” And
then she plays in the street, and she says, “Please, give me another chance?” and you let her
stay out. What will she be thinking about that?
PARENT: Be happy she can keep on playing, think she got away with it.
THERAPIST: Part of her might be happy, but part of her is going to wonder, going to feel all shaky
and nervous inside . . .
144 CHILD TRAUMA HANDBOOK

PARENT: Oh, like maybe I don’t care about her.

THERAPIST: That’s exactly right. Like maybe you don’t care if she’s safe or not. If you have a
tule, to keep her safe, to help her learn to be a good person, whatever, you show you care by
keeping your rules. And by doing what you say, so she knows she can always count on you.
That will help her feel safer and she can start to calm down.

What Are Rules For?

This intervention helps parents to focus on their good intentions and how these can be com-
promised when they get too angry and lose control. This sets the parent up for the following in-
tervention, which offers a specific method for disciplining without anger.

THERAPIST: This might seem like a stupid question but I’m going to ask anyway. Why do you
have rules for your child? Is it to protect him, keep him safe, and to help him to learn to bea
good person? Or is it so that when he breaks the rule, you can punish him and get revenge?
PARENT: My rules are to keep him safe, and to teach him right from wrong.
THERAPIST: So your rules come from love, from being a good parent.
PARENT: Of course.
THERAPIST: That’s what I thought. Would you say that it’s easier to be the kind of parent you like
to be—coming from love like that—when you’re calm? Or when you’re angry?
PARENT: When I’m calm.
THERAPIST: So if you get mad enough, sometimes the revenge thing takes over?
PARENT: Well, sometimes, if I get mad enough, yeah, I might yell or come up with some punish-
ment that’s really too much.

Stop a Problem Quickly

This strategy serves multiple functions. It provides parents with practical steps with which to
implement effective discipline. It helps parents keep their promises by using such small punish-
ments that follow-through is less problematic. It helps parents to avoid losing their tempers by
intervening before a problem situation gets out of hand. When parents can learn to intervene
very quickly, with very small consequences, the child is reassured without having to escalate,
and the discipline problem becomes much smaller.

THERAPIST: One of the biggest problems parents have in keeping their promises is that they get
so angry that they make punishments that seem too big later when they’re not mad anymore.
PARENT: Yes, I do that.
THERAPIST: One way to fix this is to decide ahead of time what punishments you will use, so you
don’t have to think up something when you’re mad.
PARENT: That makes sense.
THERAPIST: Do you ever use time-out?
PARENT: Yes, sometimes I send her to her room, if I get mad and don’t want her around. She can
come back later, maybe in half an hour, if she wants to be good.
THERAPIST: I want to teach you a kind of time-out that you can use. You just pick a spot wher-
ever you are, like in a chair or against the wall in the room you’re in. And when she’s in a time-
 Parent Training 145

out she can’t talk, or play with anything, or kick the wall, or really do much of anything. And
the time-out should last a minute.
PARENT: A minute? That doesn’t seem like much.
THERAPIST: Maybe it should just be half a minute. I’m looking for a consequence that’s so small
that it won’t break your heart to follow through on it. Can you stand it to keep her in a time-out
fora minute?
PARENT: (laughs) That won’t be a problem.
THERAPIST: Good. Because now I’m going to tell you to do this every chance you get, and to
look for chances. You know how we were talking about one of the problems being that she
can get you mad?
PARENT: That’s for sure.
THERAPIST: Do you get mad right away, or only after a long time?
PARENT: No, it’s just when I tell her and she keeps on doing it, won’t stop, won’t listen. Finally I
get frustrated with her.
THERAPIST: That’s what I thought. So here’s what I want you to do: Tell her the first time. Then
if she doesn’t do it, tell her one more time, and count to three, not one, two, two and a half, two
and three-quarters, just a straight, one, two, three. Then pow! it’s time-out, one minute. Then
she still has to do what you say. No arguing, that’s just the way it is.
PARENT: That’s it? That seems simple enough.
THERAPIST: The trick to this is that you don’t have a chance to get angry, because you’re not let-
ting it drag on and on. And you can keep your punishment small because she hasn’t done
much. And the time-out isn’t really even a punishment. It’s just like, well, you don’t follow
the rules, so you’re on the bench a little while; then you can come out and try again.
PARENT: I think I can do that.
THERAPIST: This week I want you to practice every chance you get. If you’re not sure, go for it.
And if you ever catch yourself starting to get frustrated or angry, you’ve probably let it go too
far already, but you can still give a time-out right away. The funny thing about this is, the more
strict you try to be, the less you end up giving those really big punishments.

If the child is hanging around, or can be brought into the session, I like to role-play the time-
out procedure several times, first with me playing the parent, then with the parent playing her-
self. Sometimes the child likes to have a crack at the parent role as well. This exercise has several
benefits. First, the parent gets to observe and then practice under observation. The child has a
positive, even playful, first experience of this intervention, perhaps making it feel nonpunitive.
Also, by role-playing obedient and disobedient behavior, the child may develop a stronger sense
of control over her symptomatic behavior. Finally, the therapist can put a therapeutic “spin” on
the whole enterprise.

THERAPIST: Your mom and I were talking, and she decided that she’s going to be in charge more,
so that you can feel safer at home. So now we want to practice something, will you help us?
CHILD: Okay.
THERAPIST: Okay, I’m going to tell you to put away the toys, but you keep playing with them.
Ready? Put those toys away. (To the child: “Don’t do it.”)
CHILD: (keeps playing)
146 CHILD TRAUMA HANDBOOK

THERAPIST: I told you to put those toys away (To the child: “Still don’t do it”). One, two, three.
Now you have to do a time-out. Stand up over there in that corner. Yeah, right over there. No,
you can’t play with that during a time-out. Here, I’ll hold it for you. Okay, good, just stand
there. I’Il time you for a minute and tell you when you’re done. That’s good, you're done now.
Good job! This time it’s your mom’s turn. Do you think she can do that like I did? Will you
help her practice it?

Slot Machine

The importance of keeping one’s word consistently can be illustrated with the slot machine
metaphor. This intervention also helps to prepare parents for the challenge of standing their
ground, and highlights the value of sticking with it.

THERAPIST: So you understand now that whatever you say is like a promise to your kid. In the
same way, it’s really important to stick with what you say. You know how at the checkout
counter at the store, there’s always some kid who says, “Please, Mommy, please please
please?”
PARENT: Right, and she finally says, “Okay, here. Just shut up already!”
THERAPIST: Oh, you’ve seen that too? The funny thing is, that parent is actually training her kid
to be a pest, to act that way.
PARENT: What do you mean?
THERAPIST: Well, I’m gonna tell you how Las Vegas works, why they make so much money. It’s
the same principle; it’s something you can use at home. Let’s say I’m putting quarters in a ma-
chine, and every time I put a quarter in, I get four quarters back. What am I gonna do?
PARENT: Keep putting quarters in.
THERAPIST: That’s right. And then what happens if one day I put in a quarter, and nothing comes
back?
PARENT: You quit.
THERAPIST: Soon I quit. First, though, maybe I put in a bunch more quarters, say, ““What’s
wrong with this machine?” maybe bang it a couple of times. But you’re right, eventually I say,
“I guess this machine just doesn’t work anymore” and I quit, go try some other game. But
what about this: what if I’m putting quarters in a machine, and mostly nothing happens, but
every once in a while I get a jackpot?
PARENT: That’s like the slot machines.
THERAPIST: That’s right. The real ones, they work this way for a reason. Because what’s going
to happen if I put in a quarter and nothing comes back?
PARENT: You keep on trying.
THERAPIST: That’s right. Maybe put in ten more quarters, maybe a hundred, and each time, I’m
saying to myself, “Keep trying, the next one could be the jackpot.”
PARENT: And then you’re a millionaire and you quit your job.
THERAPIST: And that’s just the same thing that the kid at the checkout counter is doing, when
she says, “Please, Mommy?” and she says, “No,” and it’s “Please?” “No.” “Please?” “No.”
“Please?” “No,” ten times. She’s saying to herself, “Keep trying; the next one could be the
jackpot.”
PARENT: So when she bugs me and I give in...
THERAPIST: That’s right. Jackpot.
PARENT: I see what you’re saying.
 Parent Training 147

THERAPIST: So the trick is to just remember, yes means yes and no means no. Once you say it,
Just stick with it. Otherwise, you’re training her to keep on bugging you, go for that jackpot.
PARENT: I’ve got it.
THERAPIST: I want to warn you, though, that this might get harder at first. Remember what hap-
pens when the machine doesn’t work anymore?
PARENT: She might try harder.
THERAPIST: Right, she might put in all those extra quarters, hit the machine... which means that
she might really try to push you, see if she really can count on you now, or if you’re just kid-
ding. And what happens if you just get tired, finally give in?
PARENT: Jackpot.
THERAPIST: Right. So if you’re going to make this work, you really have to stick with it. Once
she learns, though, that you mean what you say, well, why bother putting in all those quar-
ters? Have to find a different game.

The Damn-Shit-Fuck Progression

If the principle of early intervention needs to be further emphasized, this should do the trick.
The dramatic language can help parents to remember the point. Also, it ties the child’s misbe-
havior to his insecurity, hopefully eliciting the parent’s desire to reassure, rather than the par-
ent’s aversion to punish. Of course, this particular expression should be used only when it would
not be too uncomfortable or otherwise inappropriate.

THERAPIST: When your kid does something wrong, I think he’s asking for help. He’s asking you
to set him straight so that he feels safe. When he feels out of control, he needs you to help him,
until he can control himself again. But if he messes up and you just let it go, he gets more and
more nervous. Then what do you think happens?
PARENT: Well, he just keeps going.
THERAPIST: That’s right. There’s something I call the Damn-Shit-Fuck Progression which I
think happens with your child. When he says Damn and nothing happens, he gets more ner-
vous, and asks for help even louder. Then he tries Shit to see if you’ll help him. If you don’t
come through then, he’ll go to the next step.
PARENT: I’ve seen that before. He just gets out of hand.
THERAPIST: When he’s nervous, he really needs you to take charge, to show him that you’re in
control. When you give the time-out, he’s reassured, and he can calm down. Otherwise, he’ll
just go to the next level, until you finally come through.

Physical Restraint

Occasionally, a parent will say, “But she won’t stay in the time-out.” Then the therapist says,
“Make her stay. You’re in charge.” Then the “how” must be addressed in some detail. In most
cases, the parent can simply insist, or even stand in front of the child to block escape. Sometimes
it is necessary to teach physical restraint techniques, which requires being able to count on the
parent to implement this complex intervention effectively and safely. The parent must be able to
proceed in a caring, authoritative and nonreactive manner, so the child feels safe rather than at-
tacked. Physical restraint should only be taught by a therapist with formal training in a trauma-
informed physical restraint method, which, though occasionally essential to child trauma
treatment, is beyond the scope of this book.
148 CHILD TRAUMA HANDBOOK

Alternate Time-Out System

The standard approach to time-out, as previously described, may be too difficult for some re-
active parents to manage effectively. Sometimes kids in time-out argue, make faces, tap their
feet, or do other objectionable or distracting things. If the parent can’t help arguing or yelling at
the child, the problem behavior is being reinforced even within the time-out, which is counter to
the time- out’s purpose. The following alternative time-out system offers parents increased
physical control of the child, while keeping the parents away so they are less tempted to
reinforce the negative behaviors (Dutton, 2004).
The parents must designate a time-out room, such as the child’s bedroom, in which there is
nothing, including the walls and the furniture, which the parents are not willing to risk. The
room should probably not contain a TV or electronic game system, but other toys are okay. If the
child does not go immediately when given the time-out, she is physically transported by the par-
ent. If she does not stay in the room voluntarily, the closed door forces her to do so. The child
completes this time-out by being quiet for the specified period, perhaps five minutes, or one
minute for each year of her age.
During a time-out, the parent goes about her business, regardless of what happens in the
room. The child may be screaming and destroying everything within reach, for minutes or even
hours; the parent ignores her. Only after the child has been quiet for the designated period does
the parent make contact. Then, the parent is to only praise the child for behaving well for the past
few minutes and thus completing the designated time-out. Note that the child is not required to
sit silent and motionless, but merely to occupy herself quietly in her room.
This system relies on the principle that the child will do whatever is reinforced by the parent’s
attention. When the child misbehaves, the parent immediately sends her to the time-out room so
that no reinforcement is available. When the child behaves properly by successfully completing
the time-out, the parent does reinforce that positive behavior. Negative behavior diminishes
when the child learns that it will not be reinforced. If the parent can stick it out, this system can
be effective even with very challenging children.

Beyond Time-Out: Natural Consequences

Beyond time-out for annoying or disobedient behavior, the therapist can help the parents to
apply the principles of trauma treatment to the variety of discipline challenges that may arise.
The goal is to support the child’s sense of safety and security while providing appropriate limits
as well as learning opportunities. These principles include the following:

* Keep your promises. Be willing to follow through on the consequences you select.
* Avoid retaliation or revenge. By definition, these represent parental loss of control.
¢ Avoid depriving the child of meals, sleep, school, or (if possible) other worthwhile activi-
ties.
* Use consequences that are fair, make sense, and offer opportunities for a positive outcome.

These principles can guide parents in evaluating disciplinary options. For example, physical
discipline (e.g., spanking) is generally problematic because it represents retaliation—loss of
control—by the parents, and because it gives the child something else to be afraid about. The
restitution approach has the advantage of being rehabilitative rather than punitive: it is clearly
fair, and the child may actually make up for his misdeed, thereby repairing damaged relation-
ships as well as self-esteem.
The concept of “natural consequences” helps many parents grasp the constructive intent of
this approach to discipline. The parent’s role is not exactly to punish, but to ensure that the child
 Parent Training 149

has an opportunity to learn from his mistakes by taking responsibility for them. Examples of
natural consequences include the following:

¢ Make a mess, clean it up.

* Break something, fix it or replace it. Replacement can be done with cash or labor (e.g., ex-
tra chores).
* Break my trust, you lose it until you earn it back. For example: You didn’t come back home
by dark tonight, so you can’t go out after dinner tomorrow. And I lost half an hour worrying
while you were late, so you owe me a half hour of chores.
* Work before play, especially if the work isn’t getting done. Poor grades? No TV until your
homework’s done.

Although such consequences are often necessary, a positive emphasis is a preferable means
of eliciting wanted behavior. If parents seem to be getting bogged down around a particular
problem behavior, the therapist can suggest a focused incentive program to encourage the child
to do better. Sometimes the carrot-and-stick approach works: having both positive and negative
consequences for the same events. For example, if the child doesn’t get ready for school on time,
he may have to go to bed fifteen minutes early that night. On the other hand, if he is ready every
morning, he may get a treat Friday after school.
One of the important components in either a formal behavioral program or a more general ap-
proach to discipline is the parent’s attitude of supportive neutrality. When the child is facing
known consequences for a behavioral choice, the parent can help him see that he has chosen the
consequence with his own actions. This takes the parent off the hook and helps her feel less
mean. When the parent can see the child as struggling with the consequences of his own choices,
the parent is in a position to be less personally reactive, and more able to focus on the child’s
needs.

THERAPIST: So when he tells you that you’re mean because he has to go to bed early, how do you
react to that?
PARENT: I get mad. I feel like 1am mean, and I’m sick of his grumbling.
THERAPIST: Try saying this: “You told me you wanted to go to bed early; you told me this morn-
ing with your actions. It’s not my choice; it’s yours.” Say that.
PARENT: You chose that yourself. You were late this morning and that was the deal.
THERAPIST: How does it feel when you say that?
PARENT: Like it’s not my problem.
THERAPIST: That’s right. You’re being a good parent. You’re keeping your promises, and you’re
letting him learn from his mistakes so he can do better.
PARENT: But I know him. He’ll just grumble some more.
THERAPIST: That’s not your problem either! In fact, it’s his job to grumble. He’s trying to find
out if he can really count on you or not. He’! push your buttons. What are they? The “guilt”
button, the ““mean’” button. What else?
PARENT: Oh, he knows them all.
THERAPIST: So your first job is to come through, keep your promise. Then you can help him
learn by telling him that it’s his choice. He can be happier if he makes better choices. And if
he still is grumbling, if you want you can help him with his feelings. Try saying this: “You
don’t sound very happy about going to bed early.”
PARENT: You don’t sound happy about going to bed early.
THERAPIST: That’s it. You can help him learn to handle things he doesn’t like. But it’s not your
problem.
150 CHILD TRAUMA HANDBOOK

You’re in Charge

Parents must understand that out-of-control children need someone else to be in control, and
to help contain them, until they can control themselves again. This concept can be conveyed in
many ways, and is a recurring theme in the parenting sessions. First, the parents must grasp that
the child’s sense of security rests on the adult being in charge. Then parents must learn to iden-
tify specific situations in which they may be relinquishing their authority, and learn how to
recover it.

THERAPIST: We talked before about how your child feels scared inside, how every time some lit-
tle thing makes her nervous, all those old scared feelings kick in.
PARENT: Right. You said, from the hurricane. I didn’t realize that before. And the fighting, I
know they didn’t like that, but I didn’t know it was still bothering her.
THERAPIST: Sometimes it’s hard to know what kids are thinking. What happens with kids is that
those old feelings can get stuck inside, and now any little thing can hit that sore spot and make
her start feeling scared again. But you know how you can tell when she’s scared?
PARENT: No, she never talks about that stuff.
THERAPIST: Kids don’t know much about how to talk about stuff. She shows you she’s scared,
she shows you by doing something she’s not supposed to do. Then when you put her in her
place, she feels safe because you’re in charge. She can count on you.
PARENT: Right, we talked about that, the time-outs.
THERAPIST: But there’s more to it. If you argue with her, or if you yell, you’ve lost control, and
that can spoil the help you’re giving her.
PARENT: Just from yelling at her?
THERAPIST: Sure. When you’re in charge, acting like the parent, what you say goes—no fuss
about it. But if she can get you going, get you to argue with her, negotiate points, then you’re
just like another kid—just like her, instead of in charge. Or if she can push your buttons, get
you mad, well, you’ve given her control again. She’s gotten you to yell and fight with her, just
like you were another kid. When you’re the parent, you don’t have to do that. When she’s out
of control, she needs you to be the parent, to be in control.

Parents may have difficulty maintaining their own self-control and avoiding the arguing, yell-
ing, or hitting which may have been habitual. The following strategies can contribute to success
in this effort:

* Viewing the child’s misbehavior as reflecting fear can help the parent feel sympathy for the
child instead of feeling personally affronted.
¢ Using the quick, small punishments can preclude opportunities for parental frustration.
¢ The “not my problem” approach can further depersonalize parent-child conflict.

When this child-focused approach is insufficient for parental self-control, individual work
with the parent may be required. Self-control and anger management techniques can be helpful.
Another approach is to view the child’s misbehavior as triggering a traumatic memory for the
parent; in other words, the child’s behavior may be hitting the parent’s trauma-related sore spot.
The therapist can then do a case formulation with the parent, with a limited focus on how this
might be happening, and then work with the parent on resolving his or her own trauma.
 Parent Training IS!

The Stepfamily Trap

In many families, one parent—typically the father—plays the role of the overly harsh disci-
plinarian, while the other parent—typically the mother—plays the overindulgent role. This is
most common when the mother has custody of her children and the father is actually a step-
father who has married into the family; however, many intact families, and same-sex-parent
families, have a similar dynamic. The problem is, the more the father disciplines harshly, the
more indulgent and protective the mother becomes; and the more the mother neglects to disci-
pline, the more the father feels obliged to step in. This creates a positive feedback cycle of in-
creasing polarization, resulting in considerable family tension. When the father is punitive and
the mother indulgent, the child cannot really count on either parent for appropriate guidance and
support.
The therapist can explain these dynamics to the parents, and tell them how to resolve it: by
having the mother (or the one who has been “‘soft’”’) take the lead as the disciplinarian. Her rela-
tionship with her children will not be damaged by exerting her authority—it will actually be
strengthened. When she becomes the primary disciplinarian, this gives her husband the opportu-
nity to back off, and to develop a more positive relationship with the children.

Preventing the Parent Split

Some kids will try to play one parent against another in a different way: by going to the parent
who is more likely to give them their way. This could be a different parent depending on the oc-
casion. For example, one parent may be more permissive regarding privileges, whereas the other
may be more generous with money. The problem is that when a child is allowed to split his par-
ents, rules are not rules and parents are not in charge. Although the child may persist in attempt-
ing to split because of the immediate reinforcements, the more significant outcome is that the
child will feel insecure and unprotected. Another outcome is that the parents are likely to resent
each other, and may even feel that they must “outbid” the other parent for the child’s affection.
The therapist can explain these dynamics and work with the parents to develop a system of
teamwork. This system is specific to each family, but typically involves the following:

1. Parents agree on certain rules up front, and agree to stick to them even if only one parent is
present.
2. Parents agree to check with each other when the child makes certain types of requests, to
make sure that the other parent hasn’t already given an answer!
3. Parents make a rule that if the child has already received an answer from one parent, that’s
the answer. If the child then tries to get a more favorable answer from the other parent, the
child faces a predetermined consequence.

When parents use the same rules, they are not in the position of competing for the child’s af-
fection, and they are not in the position of undermining each other’s authority. Also, the child
can have parents who are in charge and who keep their promises.

Focus on the Positive

Parents can be encouraged to give frequent praise for their children’s positive behavior, rather
than only giving attention in response to misbehavior. In some situations the parent can learn to
ignore negative behaviors and focus on positive behaviors of other children, perhaps thereby en-
couraging the problem child to join in. The therapist can also suggest that the parent regularly
152 CHILD TRAUMA HANDBOOK

devotes some time to doing an enjoyable activity with the child. In conjunction with the effective
discipline approach, this can help shift the family’s energy to more positive interactions. Also,
as noted previously, specific behaviors can be developed and encouraged through the use of
incentives.

THE THERAPIST AS THE PARENTS’ PERSONAL TRAINER

In the initial session focused on the parenting approach, the therapist is likely to focus on the
Positive Parenting handout and perhaps a few of the other interventions described previously,
according to what seems most on target. Don’t try to get everything done at once. It’s better to
focus on a small number of tasks that can realistically be accomplished, and then later build on
success. Parents should have sufficient opportunity to discuss and rehearse this discipline ap-
proach in session until they feel prepared to implement it at home. A caution against overly high
expectations can help parents feel successful with even small progress.

THERAPIST: In this meeting, I just gave you the ten-week course! So I don’t expect you to get it
all at once. Habits take time to change. Also, kids are good at finding the loopholes! What I
would like you to do is try this out, do your best, and then come back and tell me which parts
worked, and which parts didn’t work for you. Then we can try to solve the problems and you
can do even better after that. We’re not expecting any dramatic changes right now. We’re just
getting started.
 Chapter 11

Self-Control Skills Training

Kids can do several things for themselves that will help them to feel more safe and secure and
strong. These fall under several categories:

¢ Avoiding high-risk situations

¢ Self-management regarding anxiety symptoms
¢ Self-control regarding behavioral choices

AVOIDING HIGH RISK

There are two types of high-risk situations. One type is when kids are at high risk of being
triggered to acting-out behavior. The other type is more literally a high risk in that kids are in
some special kind of danger. When kids avoid the latter type of high-risk situations, they can feel
safer because they are safer. In each case, helping kids to get better at avoiding high risk is an ex-
cellent step. And in each case, this is done by specifically identifying the high-risk situations,
and then planning, and practicing, how these situations can be anticipated and avoided. Some-
times this can involve family members and making practical changes in lifestyle. For example:

¢ A certain babysitter does not provide adequate supervision; the parent agrees to use a dif-
ferent one.
¢ The child is afraid on the night the parent stays out late going to classes; the parent agrees
to phone the child just before bedtime.
¢ The mother’s ex-boyfriend, who assaulted her, has not been found/arrested; the mother
gets the lock on her door changed, and tells several neighbors to be on the lookout for the
man and to call the police if they see him.
¢ The father, who has had health problems, agrees to have an adult family member check up
on him during the day while the child is in school.
¢ The child’s “high-risk” time for getting into trouble and/or danger is during school, when
he cuts classes and goes places with his friends. The child, parents, and teachers set up a
system in which the teacher signs a card every time the child goes to class, and the child
shows the signed card to the parent every day after school. This monitoring helps to keep
the child in class.

Often the child’s exposure to high risk situations is under her own control. Then the therapist
can work with her directly, by helping her to identify the situation and come up with effective

153
154 CHILD TRAUMA HANDBOOK

You are here.

Knight, kingdom, Fence around Personal Slay the dragon Apple trees,
dragon, princess (case training (trauma resolution) compost, contest
(evaluation and management, (skills and (relapse prevention)
treatment plan) parent train) strength
building)

FIGURE 11.1. Steps in the fairy tale model.

ways of avoiding it. The next step is to have the child practice the coping strategy, first in imagi-
nation and then in real life. Here’s an example of how this might go.

THERAPIST: We’ve been talking about why you’re here, so that we can help you to be safer and to
feel safer. So tell me, where is it that you feel the most unsafe?
CHILD: I don’t know.
THERAPIST: Do you feel the most unsafe at school, at home, on the street, somewhere else?
CHILD: At school.
THERAPIST: In class, at recess, at lunch, when do you feel most unsafe?
CHILD: On the way to school and then in the hallways and at recess, that’s when those boys
bother me the most. I eat lunch in the art room; they don’t bother me there.
THERAPIST: Good. Are there times at recess or in the hallways or on your way to school that you
feel more safe than other times?
CHILD: Only if I’m with my friends.
THERAPIST: Are you usually with your friends, or usually by yourself?
CHILD: I’m usually by myself, but not always.
THERAPIST: If you decided that you wanted to feel more safe at school, do you think it might be a
good idea to go with your friends more instead of by yourself?
CHILD: I think so.
THERAPIST: Do you think you might really do this, or will something be in your way?
CHILD: I like to go with my friends but sometimes I forget, or sometimes they get started, like
they’ve already left the classroom, before I’m ready.
THERAPIST: So what could you do if you decided that you wanted to go with them?
CHILD: Get ready faster?
THERAPIST: So you mean, get ready faster when it’s time to leave class?
CHILD: Yes.
THERAPIST: So what do you have to do to get ready to go?
CHILD: I have to get stuff ready for the homework, take the papers and book that I need, put my
pencils and notebook in my pack...
THERAPIST: And you usually wait until the bell rings to do that?
CHILD: I guess I can start getting ready earlier, so when the bell rings I can just go.
 Self-Control Skills Training US$)

Comments

Several interventions were demonstrated that are consistent with the overall trauma-informed
approach:

* When the child did not immediately say where. she felt most unsafe, the therapist did not
merely repeat the question—that could make the child feel stupid and unsuccessful in the
therapy. The “menu” restated the question to include helpful examples.
* There may be other problem-solving options as well, for example, turning to adults for as-
sistance in controlling a bully (or prior assailant). This particular script assumes that such
options have already been pursued in prior sessions as part of initial case management.
* The therapist has not told the child what to do. Rather, the therapist reminded the child of
the child’s (and parents’) own goals, and then asked a series of questions to help the child
find her own solution.
* Ifthe child does not come up with a solution, the therapist can offer a menu, e. io Let me
tell you the kinds of things that work for other kids in this situation, and see if you think that
any of these might work for you.”

Script Continued

THERAPIST: So if you did this, you could walk with your friends, and you might feel safer in the
hallway going to your next class?
CHILD: Definitely.
THERAPIST: I’m going to ask you to imagine doing this; let’s just see how it goes. What class
would you be leaving?
CHILD: Math.
THERAPIST: And what time does math get out? When does the bell ring?
CHILD: At ten past ten.
THERAPIST: What time would you need to start getting ready, to get out right when the bell
rings?
CHILD: Maybe five minutes ahead of time.
THERAPIST: Okay, so I’m going to ask you to imagine watching a little movie, in your mind. In
this movie, you’re in math class, and you’re checking the clock now and then, and at five past
ten you start getting ready to go. Then when the bell rings, you’re ready to go. You go with
your friends, walking to your next class, feeling safe. So you can do this with your eyes open
or closed, whatever will help you concentrate. Start at the beginning, you’re in class looking
at the clock, keep going until the end where you’re walking down the hall with your friends.
Tell me when you’re done. Ready?
CHILD: Done.
THERAPIST: What happened? How did it go?
CHILD: I just saw what time it was, put my things in my pack, and I was out the door with every-
one else.
THERAPIST: Then what? How was the hallway?
CHILD: Oh, I just walked with my friends, and no one bothered me.
THERAPIST: Way to go.
156 CHILD TRAUMA HANDBOOK

Comments

1. Many children already have a general idea about what they should be doing differently.
However, they’re not doing it. Practice makes a difference—it improves competence and
confidence, and these in turn improve motivation and likelihood of actually doing it.
2. To practice it, there needs to be an “it”—not just some general idea. Considerable specific-
ity and concrete detail is necessary for the child to imaginally rehearse (visualize) the cop-
ing behavior. As a rule, if the therapist can’t easily visualize the “movie” that the child is
watching, more detail is needed.
3. If the child is having difficulty producing the needed detail, the therapist can ask, “If ’m
watching you on TV, what do I see you doing?” This orients the child to the request for de-
scription of concrete, observable (and repeatable) behaviors.
4, There are several steps to follow in directing an imaginal rehearsal:
¢ Interview for the details of the problem/situation, solution/coping behavior, and rein-
forcer/outcome.
¢ Describe the contents of the movie in detail, and in sequence.
¢ Summarize the movie to orient the child to the beginning, the steps along the way, and
the ending.
¢ Instruct to start at the beginning, go through to the end, and tell the therapist when it’s
over.
5. It’s important to practice not only the behavior itself, but the preceding situation as well as
the outcome. The details of the preceding situation (e.g., math class, five past ten) become
reminders to initiate the behavior. The outcome is the reinforcer; rehearsing a behavior that
is reinforced makes real-life repetition more likely.

SELF-MANAGEMENT OF ANXIETY SYMPTOMS

Even when kids are good at avoiding the high-risk situations, there are still other situations
that are not actually high risk, but that trigger a trauma-related reaction such as anxiety or fear.
Kids can learn to control their own emotional and physiological responses to these situations, so
that they are not so vulnerable to the triggers, and not as likely to need to avoid a range of actu-
ally safe situations.
Again, this self-management training is accomplished by specifically identifying the triggers
and by helping the child to identify, and practice, effective coping skills. Here’s an example
(continuing from the previous vignette) of how this might be done.

THERAPIST: Where else do you feel unsafe?

CHILD: Sometimes, like, riding a bus with my mother, I see teenaged boys and I get nervous, like
maybe they’ll do something to me.
THERAPIST: Could they really do anything to you there on the bus?
CHILD: No.
THERAPIST: But it still feels unsafe to you. You get that feeling?
CHILD: Yeah, I know nothing’s gonna happen but I can’t help it; I still get scared.
THERAPIST: Okay. How can you tell when you’re feeling scared? What words are in your head?
What’s going on in your body?
CHILD: I don’t know.
THERAPIST: Like, are you saying to yourself, “Here comes trouble,” or “I’m scared,” or “Watch
out,” or “[’m doomed,” or what?
 Self-Control Skills Training 157

CHILD: I just say “Oh no, oh no” over and over in my head.
THERAPIST: And let me tell you some things that other kids notice in their bodies; you can tell
me if anything like this happens to you. Some kids say that their heart starts beating faster or
pounding, or they get sweaty, or they get all tense, or their stomach feels funny .. .
CHILD: My heart beats faster, and I get a kind of sick feeling in my stomach, and all over my
body I kind of feel weaker, and kind of tense and still, like I’m afraid to move.
THERAPIST: Let me tell you something about how your body and your mind work together.
When you're in danger, your mind tells your body, and then your body does all these things to
take care of the danger. Like maybe once when you were in danger, you learned to keep still to
keep from making things worse, and now that’s how your body reacts, to try to keep you safe.
The thing is, when your body does all that stuff—heart beating fast and all—your brain no-
tices. Then your mind says, “Wow, look what my body’s doing! I must be in big trouble!” So
your mind gets your body going, and then your body gets your mind going even more. Do you
follow that?
CHILD: Yes:
THERAPIST: The thing is, this can happen even on the bus, when you know in your head that you
really are safe, that nothing bad will happen there. But once your body gets going, it makes
you believe that you’re in danger and you feel worse than you have to. See how that works?
CHILD: You mean when my heart’s beating that makes me think I’m scared?
THERAPIST: Yes, that’s it. Even when you know better. But you know what? You can make your-
self feel safe then, if you decide to. You can control your body, get your body to give your
mind a different message.
CHILD: How?
THERAPIST: Do you remember that deep breathing thing we did last week?
CHILD: Yes.
THERAPIST: Well, when you do that, you calm your body down. And when your body calms
down, your mind starts to think that things are really okay. And you know what happens then?
CHILD: What?
THERAPIST: When your mind thinks things are okay, your body calms down even more. Here,
I’ll show you. Let’s find an example. When was the last time that you were on the bus and felt
scared?
CHILD: Just yesterday.
THERAPIST: Okay, I want you to remember being on the bus yesterday. Look for the time on the
bus when you were the most scared; get a picture of that in your mind. Notice what you're
seeing, what words are in your head, what you’re feeling, what’s going on in your body.
Got it?
CHILD: (Nods.)
THERAPIST: Concentrate on this. Now I’m going to ask you how bad the feeling is, on zero to
ten. Ten is the worst the feeling could be; zero is no bad feeling at all. How bad is the feeling
right now?
CHILD: Five or six.
THERAPIST: Okay. Now I’m going to ask you to do that deep breathing, like last week. Ready?
Deep breath in, one, two, three. Hold it, one, two, three. Out slow, one, two, three. Deep
breath in, one, two, three. Hold it, one, two, three. Out slow, one, two, three. Deep breath in,
one, two, three. Hold it, one, two, three. Out slow, one, two, three. Good. Now, on zero to ten,
where are you now?
CHILD: About a three.
158 CHILD TRAUMA HANDBOOK

THERAPIST: All right! We’re going to do a little more of the breathing. This time, when you
breathe out, look for any bad pictures in your mind, or bad thoughts or feelings, or any place
where your body doesn’t feel good, and when you breathe out, you can breathe out from there
and let it go with your breath...

Comments

¢ After the therapist acknowledges and seriously addresses the child’s realistic fears, the
child is more likely to be open to acknowledging that some of her fears are not realistic. If
the therapist skips the first step, the child will likely feel discounted and perceive the thera-
pist as not credible.
« Awareness of the signals of (in this case) fear are essential. There would be no point in
learning coping behaviors without knowing when to use them. As in the previous imaginal
rehearsal, the components of the fear response are used as a signal to initiate the coping be-
haviors. In fact, following the above, the therapist might well direct an imaginal rehearsal
in which the child practices using the deep breathing in the feared situation.
¢ The therapist can also use self-talk, visualization, progressive relaxation, or other methods
to help the child with self-calming. Such skills should be practiced repeatedly so that the
child becomes competent and accustomed to practicing self-calming in specified situa-
tions.

For those kids for whom the fear and anxiety symptoms are particularly distressing, the thera-
pist can guide the child to repeatedly concentrate on a distressing situation/image until the
SUDS gets to a designated “maximum tolerance” level, and then use distraction, self-talk, and
relaxation methods to bring the SUDS down. When this is done over and over within a session,
the child learns to feel that she can handle any anxiety that comes her way.

THERAPIST: We’re going to practice you handling getting anxious at those times when you really
are safe. On zero to ten, what’s the most you are willing to be upset right now?
CHILD: I could handle a six; I don’t want to go higher than that.
THERAPIST: Okay. So ina little while ’m going to ask you to think of something upsetting, like
being on the bus yesterday, and then calm yourself down. What ideas do you have about how
you can calm yourself down?
CHILD: Well, I can breathe like that again.
THERAPIST: That’s a good idea; it worked for you before. Any other ideas?
CHILD: Well, I know that I’m not really in danger on the bus.
THERAPIST: Right. So one thing you can do is just tell yourself something like that. What would
you say to yourself?
CHILD: I feel scared but I’m really safe.
THERAPIST: That might help; I think that’s a good idea. Something else that works for some kids
is to think of something else instead, something that makes them feel good. Like the Safe
Place we practiced with before, or playing with your dog, something like that.
CHILD: I can think of my dog.
THERAPIST: So you have a lot of strategies now, ways to calm yourself down. So here’s what
we're going to do. I’m going to ask you to think about when you were on the bus yesterday.
When the picture is in your mind, tell me.
CHILD: Got it.
THERAPIST: Where is it now on zero to ten?
 Self-Control Skills Training 159

CHILD: Maybe a four or five.

THERAPIST: Okay, I want you to keep concentrating on it until it’s a six, then stop. Think about
the picture, the bad thoughts and feelings, make it more intense until it’s a six, tell me when
you’re there.
CHILD: It’s a six now.
THERAPIST: Okay, now use your strategies to calm yourself down. Tell me when it’s a two.

This is repeated several times—up and down, up and down—until the child is clearly good at
bringing down the distress level. It can also be practiced using different images and scenarios.
After this session, many kids have a new sense of confidence that they can handle whatever anx-
1ety comes their way.

SELF-CONTROL OF BEHAVIORAL CHOICES

Self-control skills training is frequently offered as a stand-alone intervention. The relatively

limited impact of anger management training programs for antisocial youth (Kazdin, 1997) may
be explained by the failure to incorporate this as a component of trauma-informed treatment,
and implemented in the proper order of interventions (Greenwald, 2002a). The odds are better
when kids first identify and invest in their own goals, making the skills work meaningful to them,
and when this intervention is eventually followed by trauma resolution work to reduce the
trauma burden and related sore-spot reactivity.
Even so, self-control skills training can itself reduce posttraumatic stress symptoms. For ex-
ample, in a randomized study of war veterans with PTSD and severe anger management prob-
lems, those receiving standard PTSD treatment plus anger management training reported re-
duced intrusive imagery, whereas the standard care control group did not (Chemtob, Novaco,
Hamada, & Gross, 1997). Prior to treatment, when these men were perceiving threats and acting
out (in defensive aggression), their fears would tend to be confirmed, because their own behay-
ior engendered hostility in others. This repeated experience would tend to reinforce their per-
ception of the world as a dangerous place where such defensive aggression is required. Once
they began to control their responses, they probably experienced much more favorable re-
sponses from others. Thus, they had repeated opportunities to learn that the world was not so
dangerous after all, anymore. Perhaps, once they felt they were out of the “war zone,” their
trauma memories did not seem quite so salient, leading to a reduction of intrusive images.
These findings can also be applied to kids. One of the ways that kids learn to feel safer is by
having their environment actually become more favorable—more predictable and supportive,
less hostile. Kids learn to feel stronger by getting better at successfully coping with challenging
situations that used to overwhelm them because of the trauma-related reactivity. When kids with
impulsive/acting-out problems improve their self-control, they will probably also feel safer and
stronger.
The following method of teaching self-control skills training to kids integrates the effective
components of several approaches. It builds on the preceding steps in the treatment approach
that has been presented already. When self-control skills training is presented as part of an
agreed-upon treatment plan in the service of the child’s identified goals, he is likely to be in-
vested in trying hard to master the skills. Also, it integrates the child’s long-term goals with cur-
rent issues and pressing concerns. This is accomplished by:

* doing a check-in at the beginning of the session, and asking for something good and some-
thing bad that happened since the prior meeting;
160 CHILD TRAUMA HANDBOOK

* choosing one of those things—good or bad—as an example of the child’s everyday chal-
lenges regarding self-control (the event can be used whether the child was successful or
not);
¢ reminding the child that this challenge is a good example of the kind of thing that could get
in his way; that mastering this challenge will help him to achieve the goals he has identi-
fied. You are then working on present and future concerns at the same time.

To help a child change a long habit of impulsive acting out, it’s important to understand not
only the trauma-related reactivity driving the impulse, but the reinforcement that the child re-
ceives following the acting-out behavior.
Imagine that your dog has gotten into the garbage and made a mess. Three days later you
scold the dog. What does the dog learn from this? First, getting into the garbage is great fun!
Second, the dog’s owner is mostly okay, but every once in a while gets upset out of the blue. Oh
well.
Kids with problem behaviors have this experience over and over again. The relief is experi-
enced right away, and the negative consequences happen so much later that they don’t seem rele-
vant. What happens some other time doesn’t matter because it does not feel connected to the
problem situation or to the behavior. Learning occurs best when the consequence—whether re-
inforcement or punishment—is close to the behavior.
With kids, the problem behavior is being repeated because it works in some way: it provides
relief from the intolerable thoughts and feelings. Negative consequences somewhere down the
line do not feel very relevant to the child in the moment. To make matters worse, the child often
experiences the so-called appropriate behavior as a punishment, because the frustration is im-
mediate, and the reward is too far in the future to be reinforcing. Thus, the problem behavior is
 Self-Control Skills Training 161

reinforced by the immediate relief it provides, and the appropriate behavior is punished by the
lack of relief. The long-term consequences are too distant to be influential.
In order to help kids to change their habits, we must find a way to flip the reinforcement
schedule. We must find a way to make the problem behavior less appealing, and the wanted be-
havior more appealing. This can be done by rehearsing the challenging situations, along with the
different behavioral choices, and pairing these choices with their long-term consequences. Our
first goal is to “spit in the soup”—to make the problem behavior less appealing, because now it
is more closely associated with an unwanted consequence. Our second goal is to “sweeten the
pot’’—to make the desired behavior more appealing, because now it is more closely associated
with the wanted consequence.
With younger kids this rehearsal can be done with role-plays. With older kids (teens and pre-
teens) it can be done with imaginal rehearsal. Either way, it is essential to have the child practice
the behaviors, and to immediately follow this with the experience of the long-term conse-
quences, so that the association of choices and consequences can be reinforced.

CHOICES HAVE CONSEQUENCES

“Choices Have Consequences” is an imaginal rehearsal intervention used with older kids
(and sometimes their parents), to help them to get better at handling challenging situations the
way they would like to. It occurs at the point in treatment where self-control skills training is
called for. In the fairy tale model, that’s after the case formulation, treatment contract, and case
management has been taken care of. The child, and the caregivers, have already done their best
to make things safe, supportive, and secure, and to reduce high-risk situations. Now it’s time to
manage those situations that cannot easily be avoided. As with any intervention, it should be
directly tied to the child’s stated goals.
The child’s high-risk situations, or challenging situations, have already been identified on the
“circles and arrows” page that includes the treatment plan. This gives the general idea, but to
practice self-control skills, a specific situation/example has to be used. This can often be ob-
tained just by asking the routine question at the beginning of the session: “Tell me something
good and something bad that happened since we last met.” Often, the child will report some
event in which either she failed to exert self-control, or succeeded. Either way, that event can be
used as the example. The therapist might say, “We’ve been talking about the things you wanted
for yourself, how you want your life to go. You told me that if you keep on getting into fights,
that could keep you from getting to your goals. Is this a good example of the kind of thing that
can happen, that could get you into a fight?”
If such an example is not provided, the therapist can ask for one. “We’ve been talking about
the things you wanted for yourself, how you want your life to go. You told me that if you keep on
getting into fights, that could keep you from getting to your goals. When’s the last time that
something like that happened, when you did get into a fight?” If the child says, “Not for a long
time,” the therapist can say, “When’s the last time that something happened that got you mad,
where you could have gotten into a fight if you didn’t control yourself?”
The goal here is to get a typical, everyday example of the challenging situation. We don't
want to get some major trauma event here, nor do we want to get a minor event that might be too
closely related to a major trauma. Using the personal trainer strategy, we want to add only a few
pounds at a time. We don’t want these examples to be overwhelming; we want the child to have a
good chance of handling it, to be successful. Therefore, it’s generally more effective to use ex-
amples related to peer provocation or to authority figures such as teachers; avoid examples tied
to family, especially to parents.
162 CHILD TRAUMA HANDBOOK

Once the example situation has been identified, the therapist follows the structure of the cir-
cles and arrows diagram. The child is asked to imaginally view a “movie” including the
following:

1. The provocation or challenging situation—a specific, concrete image of what is happening

in a specific moment in time—the moment just before the choice is made.
2. The thoughts, feelings, and physical sensations that follow this. These are the signals that a
choice is about to be made.
3. The “bad” (acting-out) behavioral choice.
4. The “bad ending” or negative consequence, paired with the words, “It’s not worth it.”

Then the child is asked to identify a coping strategy that would get him to the good ending in-
stead of the bad one. “What could you do, in this situation, that would take you toward the good
ending?” Many kids do know what to do here. However, if not, the therapist can always offer a
“menu” of “what other kids have done” in this situation. Then the child is asked to imaginally
view a movie similar to the first one, except that the good behavioral choice is made, leading to
the good ending.
Finally, the child is told to start the movie the same way, but the ending will be determined by
the behavioral choice: ““Good choice goes to the good ending; bad choice goes to the bad end-
ing.” This “surprise ending” is repeated until the child chooses the good ending twice in a row.
Here is an example of how this intervention might be set up:

Choices Have Consequences Sample Script

THERAPIST: You told me last time that getting into fights was in your way, keeps you from get-
ting what you want in your life. And you said that you get into fights when someone makes
trouble for you, like when someone stares at you or says something disrespectful. Give me an
example of when that’s happened lately, even something little.
YOUTH: Well just this morning this kid got into my face. I was ready to whack him good.
THERAPIST: How come you didn’t?
YOUTH: There was a teacher there, and I didn’t really want to get in any more trouble.
THERAPIST: So what did you do? How did you control yourself?
YOUTH: I just tried to ignore him and concentrate on something else.
THERAPIST: So it sounds like you’re doing things to get to that good ending we were talking
about.
YOUTH: I guess so.
THERAPIST: Okay, good. I said Iwould give you some stuff you could practice to get stronger to-
ward your goals. Today we’re going to start on something to help you get even better at how
you handled that thing this morning. I’m going to ask you to watch a little movie in your
mind. It starts out with—what was this kid’s name?
YOUTH: Jeff.
THERAPIST: When he was getting in your face, what was he doing? What did he say?
YOUTH: He was bragging, and then telling me I didn’t know what I was talking about. But he
was the one with no clue; he was just talking stupid.
THERAPIST: Okay. At the beginning of this movie, Jeff is in your face like he was this morning.
The next thing in the movie is the signals inside, the thoughts and feelings. What was going
on inside you?
YOUTH: Mad.
 Self-Control Skills Training 163

THERAPIST: How can you tell you’re mad? What are the signals? What words are in your head?
What’s going on in your body?
YOUTH: My arms are tight, my hands are making fists, and no words really; my mind’s kind of
blank. And really mad. It builds up until I can’t stand it sometimes.
THERAPIST: Okay. In this movie, it starts out with Jeff in your face. Then you notice yourself
getting more and more mad. Then in this movie, you do the thing you might feel like doing—
you whack him good. Then the ending of this movie is that bad ending you told me last time,
with you behind bars saying, “It’s not worth it.” So start at the beginning, and when you get to
that ending, tell me when you’re done.

This is a real “workhorse” of self-control skills training and can be used with any number of
challenging situations. A few of the following tips will help it to go smoothly and work well:

* Itis essential to use a specific situation. If the therapist can’t visualize it as if seeing it on
TY, it’s probably not specific enough yet. You need to know who’s saying what, etc.
¢ This intervention is designed to change only the client’s behavior. Only use this when the
client’s own coping behavior is identified as a problem to be improved.
* Before “running the movie,” make sure that the statement “It’s not worth it” feels true to the
child, for the bad ending that’s been selected. If not, extend the bad consequences farther
into the future until “It’s not worth it” does feel true. For example, the child may not feel
bad about losing a privilege following some misbehavior; but he may indeed feel bad about
where this habit might lead: to prison.
¢ The therapist should present a neutral response to the child’s selected outcome. Many kids
will experiment with the bad choice before ending up with the good one. The therapist
shouldn’t become excited either way. That way, the child is deciding for himself, and not to
please the therapist.
¢ This is a rather quick intervention, with a very concrete focus. This is not the time or place
to ask probing questions about feelings or to work for insight into the source of the prob-
lems. We already did that in the case formulation. Now we are focusing on practical coping
skills. So don’t go therapizing; just help your kid to get the job done.

The following two exercises will help you learn, step by step, how to set up and conduct the
Choices Have Consequences intervention. The setup is the more complicated part. Once you be-
come proficient, it only takes a few minutes, but getting used to it does take some practice.

EXERCISE: MAP OUT A PROBLEM

Pair up with a colleague (or try this with a friend or client). This is not a role-play. You will
each be yourselves, and you will each get a turn as therapist and client. If you are working alone,
complete the form for yourself. (Cynthia Cushman contributed to the development of represent-
ing problems with this type of graphic representation.)

If You Are the Therapist

This can be a challenging exercise because it requires skill and practice to get it right. You
may have to say more than you see in the script to elicit all the details you need. Also, this exer-
cise will probably be harder than actually doing the intervention with kids—it just tends to
happen that way!
Here are some tips that will clarify what you’re trying to get in each of the circles. Before you
decide that you’ve finished the job, I suggest that you check back here and review these tips
164 CHILD TRAUMA HANDBOOK

again. People often find that they need to do a few more things to make it right, and it’s important
to make it right.

© The high-risk situation is often, but not always, the same as the trigger situation that we
have used in previous exercises. The high-risk situation is the moment in time just before
the decision is made to either do the quick-relief behavior or the behavior that will lead to
the good ending. For example, if the problem behavior is yelling at mother on the tele-
phone, the high-risk situation is the specific thing that mother says, e.g., “You really should
have come by last Sunday,” just before your client is tempted to yell. If the desired behavior
is going outside to take a walk, the high-risk situation is the moment that the client would
be going outside, or might otherwise decide to sit down and read the paper. Get specific
here, e.g., “In the kitchen, it’s seven a.m., just finished my cup of coffee and put the empty
cup in the sink.”
* The thoughts and feelings and physical sensations are the signals that a choice is about to
be made. These might be the same as some of the negative beliefs and piled-up feelings
from the earlier exercises, but they might be different, too. The focus here is on the client’s
subjective experience in the moment. Your goal is to identify the thoughts, feelings, and
sensations that push the client toward the quick-relief behavior.
¢ The quick-relief behavior is the behavior that your client is tempted to do instead of what
he wishes he would do. This should be a specific action in the moment that the choice is
made, not the whole series of steps that leads to the bad end.
¢ The effective behavior is the behavior that the client wants to do in that challenging situa-
tion to advance toward his goals. Again, it’s not a whole series of behaviors, just one thing
in that moment. The quick-relief behavior and the effective behavior should be mutually
incompatible choices—the client must do one or the other. For example, do you yell,
“Mom, would you please get off my case already?” or do you say, “Mom, I’ve got to go
now. Talk to you soon”? Do you walk out the door to start on your walk, or do you pick up
the newspaper? In these examples, one choice goes to the quick-relief circle, the other
choice goes to the effective behavior circle.
¢ The negative consequence (the “bad ending” of the movie to come) should represent the
worst-case scenario, the definitely unwanted extreme. Make sure that once your client de-
scribes the general situation, you ask the next question in the script and get a visual image
that represents this. If you can’t easily visualize it like you’re watching it in a movie, it’s
probably not specific enough yet. The image should represent a moment in time when your
client can see herself in an unwanted situation.
Also, you want to make sure that “it’s not worth it” feels true for the client. If that state-
ment does not feel true, then have the client project the problem farther into the future, to a
more extreme bad ending. Until “it’s not worth it” feels true for the client, he has no reason
to change his behavior.
* The positive consequence (the “good ending” of the movie to come) should represent the
best-case scenario, the definitely wanted extreme. Make sure that once your client de-
scribes the general situation, you ask the next question in the script and get a visual image
that represents this. If you can’t easily visualize it like you’re watching it in a movie, it’s
probably not specific enough yet. You can ask questions such as, ““Where are you? What
are you doing? What are you wearing? Who else is there?” and “What time is it?” You
won’t need to ask all questions to all clients; the point is to get an image that’s specific.
* The thoughts and feelings circle is filled in with internal signals, the red flags that a choice
is about to be made. Each of the other circles are filled in with a specific image. An image is
specific when the therapist can easily visualize it as if watching it on TV. An image is spe-
cific when it includes a (day and) time, a place, and an action.
 Self-Control Skills Training 165

If You Are the Client

Think of a problem that you would like to work on right now. It must be a behavior that is, in
theory, within your power to change. Here are some examples of behaviors that people often
choose to work on for this exercise:

* Controlling an-angry reaction

* Being more assertive in a certain type of situation
* Getting more exercise; controlling overeating
¢ Procrastinating less
* Getting certain chores done more efficiently
* Doing the things that are a higher priority in your life

EXERCISE: CHOICES HAVE CONSEQUENCES

(GREENWALD, 2004)

This is a continuation of the setup that you did with Map Out a Problem. In an actual session
the setup would only take a few minutes, and you’d just go right into this. If you are working
with a partner, continue with that partner. If you are on your own, be your own therapist and take
yourself through the client’s experience.

If You Are the Therapist

You should be working from the already-completed Map Out a Problem form. Use the fol-
lowing script. Say the words in italics out loud; the rest are instructions for you.

If You Are the Client

Think of a problem behavior of your own that you would like to get better at doing in a more
positive/constructive way. This can be an “acting-out” behavior such as losing temper, overeat-
ing, etc., or it can be a less visible problem behavior such as failing to be assertive, procrastinat-
ing, etc. Don’t read the script—that’s the therapist’s job. Just be yourself and cooperate as best
you can.

Script

Run the movie (in imagination, eyes open or closed); say, “Now I want you to watch this in
your mind like it’s a movie. Start with [the provocation/situation], then notice [the thoughts and
feelings], then [the bad behavior], then the bad ending with ‘it’s not worth it.’ Start at the begin-
ning, tell me when it’s done. Ready?” Then ask what happened; make sure it was run properly
and ended with “‘it’s not worth it.”
Set up the good movie same way, using the challenging situation, the thoughts and feelings as
signals, then with the good choice and good ending. “This time the movie starts the same way,
with [the situation] and [the thoughts and feelings]. This time, do what it takes to get to the good
end. Start at the beginning; tell me when it’s done. Ready?”
166 CHILD TRAUMA HANDBOOK

Map Out a Problem—For Behaviors to Be Improved

© Ricky Greenwald 2004.

. So are you always doing this, or just in certain situations? Like what’s a recent ex-
ample, the last time that happened? Doesn’t have to be anything big. (Or: When’s
the next time this could happen?)

. When you’re in this situation, what are the thoughts, the words in your head? Your
emotional reaction? The signals in your body?

. If you let this take you over, what do you do next? (This is, or leads to, the problem
behavior.)

. If the problem habit continues, gets even worse, how bad could things get? What
picture could represent that? Does “it’s not worth it” feel true? To go that way, |
mean.

. What if you got a handle on this, got it under control, what would you be doing in-
stead (of the problem behavior)?

. SO if this effective behavior got to be a habit, what good things would that lead to?
What picture could represent that?

4. Negative 1. High-risk 6. Positive

consequences situations consequences
(“It's not worth it.”)

3. Quick-relief 2. Thoughts 5. Effective

behavior & feelings behavior
 Self-Control Skills Training 167

Run the movie; ask what happened; make sure it was run properly.
Set up the surprise ending the same way: bad choice, bad ending; good choice, good ending.
“This time, the movie starts the same way, with [the situation] and [the thoughts and feelings].
This time, I don’t know what’s going to happen; it depends on you. The rules are, ‘Bad choice
goes to bad ending and It’s not worth it. Good choice goes to good ending.’ Ready?”
Run the movie; ask what happened; make sure it was run properly.
Repeat the surprise ending movie routine (the previous script) until the client chooses the
positive end two times in a row. Every time, remind: “Bad choice, bad ending; good choice,
good ending.”
Repeat the entire routine with other challenging situations.

Follow-Up Questions

How did this go for the clients? What was your experience like? How did it go for the thera-
pists? Raise your hand if, as the client, you are now less likely than before to handle this situation
the way you want to? No more likely and no less likely? More likely than before?
Many people (not all) feel encouraged by this exercise, and believe that they are now more
likely to handle the target situation the way they want to. This may be true, but ask your client (or
yourself): How long did it take you to develop the habit you’re trying to change now? How long
do you think it might take to get the new habit? What does it take to get a new habit? Practice!
If you find that change is coming very slowly, that can still be counted as progress. Habits take
time to change. But the more you practice, the more you'll get it.
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 Chapter 12

Getting Stronger

Getting stronger is an ongoing theme in this treatment approach, so this chapter could easily
have come earlier. Getting-stronger interventions appear all along the way. For example, during
the treatment planning conversation, the therapist might ask a younger child, “Do you think that
when you get bigger and stronger, you’ll be able to handle this stuff better?’ When the child
agrees (the common response), the therapist can say, “So one of our goals is to help you to get
bigger and stronger.” There are several advantages to focusing on getting stronger:

* Itis consistent with the fairy tale model. It emphasizes empowerment and helps to justify a
variety of treatment activities.
* It offers a normative and positive “‘spin’” to the treatment: we are just trying to help you to
get through this developmental challenge.
* Ittakes advantage of kids’ natural desire to become bigger and stronger, and to show this to
parents and others (“Look, Ma, no hands!”’).

A STRENGTH-BUILDING APPROACH

Getting stronger involves the ability to tolerate upsetting things (the technical term is “affect
tolerance”). When kids can’t stand the bad feeling even for a moment, they are likely to do just
about anything to avoid it or get rid of it. This leads to pervasive avoidance, impulsive acting out,
and other problems. When kids are better able to tolerate feeling bad for a little while, then they
have a better chance of handling the situation the way they would like to.
Of course, success feeds on itself: as kids become more able to handle challenges the way
they would like to, the stronger they feel. This paves the way for the next challenge. This is the
“personal trainer” strategy in the fairy tale model. We give kids progressively greater challenges
while also helping them learn to manage each challenge as it comes. Eventually, the child will be
ready to slay the dragon.
Several principles guide the strength-building approach:

. Focus on the natural desire to become bigger and stronger.

. Offer challenges: can you do this?
. Build on strengths and successes.
. Take one step at a time.
Re. Downplay expectations to preclude sense of failure:
ABWN
¢ Poor/limited performance was expected.
* Good performance surpasses expectation.

169
170 CHILD TRAUMA HANDBOOK

With Older Kids

So for example, immediately following Choices Have Consequences (the self-control train-
ing activity described in the previous chapter) the therapist might downplay expectations as fol-
lows.

THERAPIST: It seems like you have this down, you know what to do now in that situation?
CLIENT: Yup, I’ve got it.
THERAPIST: So how long did it take you to get that bad habit that you’re trying to change now?
CLIENT: I don’t know, years I guess.
THERAPIST: So how long do you think it’II take to change to the new habit you’ve been practic-
ing?
CLIENT: I don’t know.
THERAPIST: You think it’ll happen overnight? Or you think it might take a lot of practice over
time?
CLIENT: Practice.
THERAPIST: I think so too. So don’t worry if you’re not perfect all of a sudden. But the more you
remember to practice this, the sooner you’ll get the new habit down.

Following this conversation, it is very hard for the client to fail. If he comes back the next
week with no progress, the therapist can say that this was expected. Usually at least some prog-
ress is noticeable, though. For example, if the problem behavior is still happening sometimes but
not as often, the therapist can again say that this was expected and that the progress is encourag-
ing. If, as sometimes happens, the problem behavior has not recurred despite repeated opportu-
nity, the therapist can say, “Well, it wasn’t supposed to happen that fast. I’m glad to hear that you
did so well this week, but I’m not sure it’s a habit yet. If things don’t go perfect next week, that
just means that it takes a long time to make a new habit.” This way the client gets credit for out-
performing expectations, and if he backslides, it’s still not a failure, only par for the course.

With Younger Kids

The specifics of the strength-building approach are different with younger kids. With youn-
ger kids, the therapist can encourage the confusion of physical and inner strength, which chil-
dren seem to readily accept. Then the child’s sense of physical strength can give her the confi-
dence to face difficult emotional material. This is done as follows:

1. Discuss what she or he does to get stronger, e.g., walking, sports, eating well, sleeping, etc.
2. Imaginally rehearse “I’m getting stronger” while doing these activities; end with strength
image.
3. Have the child perform exercises, e.g., push-ups. Keep a count. It’ll be higher next time!
4. After the exercise, say, “I wonder if you’re strong enough to...”
¢ Act like a good sport if I beat you at this game.
¢ Talk about the bad thing for three minutes.

Here is an example of how the therapist might work this theme with a child.

THERAPIST: We were talking about you getting stronger. How strong are you? Make a muscle,
let me see.
CHILD: (makes a muscle)
THERAPIST: Oh, you're already pretty strong. How many push-ups can you do?
 Getting Stronger 171

CHILD: Maybe five.

THERAPIST: Let’s see. Go ahead.
CHILD: (does eight push-ups while therapist counts out loud)
THERAPIST: Eight, that’s pretty good! What kinds of things do you do to make yourself strong?
CHILD: I don’t lift weights or anything.
THERAPIST: Do you-only eat potato chips all day, or do you eat good meals?
CHILD: I get potato chips sometimes, but I have to eat the regular meal first.
THERAPIST: Well, eating nutritious food helps you grow and get stronger. Do you stay up all
night long, or do you go to bed and get some sleep?
CHILD: I go to bed at nine o’clock; that’s my bedtime.
THERAPIST: Good; sleeping helps you grow and get stronger too. Does someone pick you up and
carry you around everywhere you go, or do you walk around with your own feet?
CHILD: I walk! I walk to school and to the store.
THERAPIST: Well, exercise makes you get stronger. Do you ride a bike, or get any other exercise?
CHILD: I ride bikes with my friend, I play tag at recess, and play some basketball in the park.
THERAPIST: Good, so you do a lot of things to make yourself strong. No wonder you can already
do so many push-ups. The more exercise you get, the stronger you get. When you think of
yourself getting stronger, what is the picture you have?
CHILD: Me lifting up a house.
THERAPIST: I’m going to ask you to do two things at once; see if you can do it. Think of yourself
lifting up a house. You have the picture now? Good. Think of that picture, and take a really
slow, deep breath. Was that easy, or hard?
CHILD: Easy.
THERAPIST: Well, let me try to make it even harder. Think of that picture again, of lifting up a
house, and say to yourself, “I’m getting stronger,’ and take another slow, deep breath. How
did that go? Were you able to concentrate on all that?
CHILD: Yes.
THERAPIST: Wow, you did that too! No matter how hard I make it, you can do it. What were
those things you do to make yourself stronger?
CHILD: Eating, riding my bike, playing basketball.
THERAPIST: Okay, think of those things now, and say to yourself, “I’m getting stronger.” Deep
breath. Okay. Now say that again, out loud: “I’m getting stronger.”
CHILD: I’m getting stronger.

It is important to mix imagery and statements about getting stronger with actual proof of this.
The direct experience of getting stronger makes the statement credible. Thus the push-ups.
Jumping jacks also work, or sit-ups, or how fast the child can make it from here to that tree. The
point is for the child to feel, and show off, how strong she is. Then we can build on this strength
to help the child to face the next challenge. For example:

THERAPIST: It sounds like those kids are still picking on you. But I’m glad to hear how well you
did in school this week. You remember what you and your dad said, that you come here be-
cause you want to do things to get better at getting along with other kids.
CHILD: Can we play now? (holds up a board game)
LZ, CHILD TRAUMA HANDBOOK

THERAPIST: Yes, Ill play this game with you. But first, Iwant to check on something. Last week
you did eight push-ups. Can I see how many you can do today?
CHILD: (does ten)
THERAPIST: Ten! Well, it looks like you’re getting stronger.
CHILD: I am getting stronger. I ate my vegetables every day at dinner; my dad says they give me
vitamins. And I race my dad to the car and I can beat him sometimes.
THERAPIST: Last week when we played this game, do you remember what happened when I got
ahead?
CHILD: Huh?
THERAPIST: Last week, when I got ahead you didn’t like it, and you started taking extra turns to
make sure that you would win.
CHILD: Oh, yeah.
THERAPIST: But remember what you told me? How other kids wouldn’t want to play with a bad
sport?
CHILD: Kids like to play with someone who follows the rules, who takes their turn.
THERAPIST: I think that’s true. And I see that you’re getting stronger. So here’s my question for
you: Are you strong enough now that if I get ahead in this game, you can handle it and be a
good sport?
CHILD: I think so.

Later in treatment, the challenge is to get the child to be willing to face the trauma memories.
This tends to be a greater challenge with older kids, who may be less “compliant,” and with kids

oO
(TIME ME!)
 Getting Stronger 173

who have poor affect tolerance. Persuading kids to take the next step can be especially challeng-
ing when, paradoxically, the other phases of treatment have been successful. In that case, the
child may doing pretty well by now. So why bring that bad stuff up?
If you have been using the circles and arrows diagram and the treatment plan with the differ-
ent steps, then “reducing stress from old memories” will sooner or later be the next task on the
list. Even some kids who have been going along with the program until now are reluctant to face
the trauma memories. So it’s worthwhile to make an extra pitch at this point, going back to the
diagram and reminding the child of how this work can help her get to her goals. Again, working
the strength-building theme can be useful. Here’s a typical conversation to get a kid to agree to
try the trauma resolution work, including a sports metaphor that can be helpful.

THERAPIST: Okay, so the next thing on the list is to go after those old memories, to bring down
the stress from those, so that you don’t react so strong to the high-risk situations anymore.
CLIENT: I don’t think I really need to do that. I’m doing pretty good now. And I don’t want to talk
about that stuff anyway.
THERAPIST: So let me ask you something. Say you’re on the basketball team and your coach
wants everyone to come to the practices. Are you going to say, “I don’t need to come to the
practices. Maybe if we start losing games I’Il come.” Or are you going to go to the practices?
CLIENT: Go to the practices.
THERAPIST: How come?
CLIENT: Gotta do what he says to stay on the team. Also, practice makes perfect, the more we
practice, the more we’re gonna win.
THERAPIST: I thought you’d say that, because you’ve been showing me with all the practice
you’ve been doing here, and with how much better you’re handling things. So now, say you’re
winning all your games, and then your coach says, “I want you to start coming early to prac-
tice, to do all these extra exercises.” And you say, “What for? We’re already winning all our
games?” And the coach says, “Yeah, but so are the other teams that we’re gonna face in the
play-offs!” So do you do the extra exercises, or do you say no?
CLIENT: I guess I’I] do them. I want to win the play-offs too.
THERAPIST: Well, this is why I’m suggesting that you work with me on the old memories. Be-
cause you’ve told me that you want to be successful tomorrow too, and not just today; because
you have a lot of plans for yourself. Let me tell you what I’ve seen happen to other kids. I’ve
seen a lot of kids who got better at self-control, things were going pretty well, and they said
they didn’t want to work on the old memories. So they did fine for a while, maybe a month or
two, maybe a year or two. They were handling all the regular high-risk situations fine. But
then some big problem comes along, maybe they lose a girlfriend they really care about, or
someone in their family dies, some big stress. And that’s too much for them, and they go
downhill again. So that’s why I’m suggesting that you take care of this stuff now, while you’re
doing well, while you’re strong already. So you can get even stronger and be able to handle
the really hard stuff whenever it comes.
CLIENT: Okay, I guess I'll give it a try.
THERAPIST: When you’ve done this, I think you’ll be glad. Other kids that have done this,
they’ve told me afterwards that things don’t get to them as much as they used to, like they
don’t get so mad anymore. But it’s the same rules as always. So if we’re talking about some-
thing and you don’t want to anymore, you can always say that it’s time to stop.
174 CHILD TRAUMA HANDBOOK

RISKS OF STRENGTH BUILDING

With the personal trainer strategy, we are always pushing kids to do their best, to take the next
step, the next challenge. Hopefully we are also providing adequate support so that when kids
agree to take these steps, they will be successful. However, despite our best efforts, there is
plenty of room for things to go wrong. Sometimes kids will refuse to take the next step; some-
times they will take that step, but it will be too much for them to handle. So we want to be pre-
pared for the problems so that we can handle them successfully when they come.
One common challenge occurs when the child says that she is discouraged, tired, or “doesn’t
care” about this work. It’s the therapist’s job, on one hand, to encourage the child—without be-
ing pushy—and on the other, to allow her to make her own decisions. This is best done by focus-
ing the child on her own goals, her own reasons for doing the work, so that the issue does not be-
come a confrontation between the child and the therapist. Then the therapist can maintain the
position of ally, regardless of the child’s choice in a given session. Here are the steps in this
approach:

1. After the beginning-of-the-session check-in, the therapist can remind the child of her stated
goals. Then the task is being introduced in service of the child’s goals. “We were talking before
about the things you wanted for yourself, and what you could do to help you achieve your goals.
Last time we talked about avoiding high risk, so today we were going to work on self-control
skills.”
2. Then if the child declines to participate in the planned task, the therapist can accept this and
move on, keeping the focus on the child. “Usually you work hard with me, so I’m wondering
what’s different today. Maybe you're tired? Or there’s something else on your mind that makes it
hard to concentrate?”
The other common challenge occurs when the child overexposes to upsetting material. We
are most focused on this risk when we get to the trauma resolution work, but it can happen at any
point along the way. Here are points of particular risk for this:

¢ Answering the question about three wishes or the magic wand

¢ Answering the question about who is in the family
¢ Answering the question about something good and something bad that happened since the
prior meeting
¢ Answering the question about trauma/loss history
¢ Talking about (and visualizing) good ending to the “future movie” (this challenges the
avoidance strategy of not getting one’s hopes up)
¢ Talking about (and visualizing) the bad endings to the “future movie”
¢ Talking about (and visualizing) the bad ending to the “choices have consequences” movie
* Talking about any current concern (e.g., peer conflict, love problems, the health of a family
member)
¢ Talking about an upsetting memory

How can you tell if the child has gone too far for comfort? There are a number of signals, and
it’s important to be alert to these. If you fail to catch this, it will probably keep going, maybe get
worse, until you do finally figure out what’s going on. Here are some of the ways that kids can let
you know that they’re in over their heads:

¢ Saying, “I don’t want to talk about this anymore”

¢ Crying
¢ Changing the subject
 Getting Stronger 175

° Overtalking about a tangential detail, or about something else altogether

* Fidgeting, moving around, finding things in your office to mess with
° teen or other “incongruent” emotion that does not fit the content of what’s being talked
about
Getting angry
Silence
Looking down or away
e
Suddenly being done with the session, even though it wasn’t time to be done

ADDRESSING THE PROBLEM

So you’re noticing that something might be wrong. What to do about it?

The first thing is to make sure you are correct about what you think is happening. This is done
simply enough by asking. However, you want to avoid asking in a way that is intrusive or that
further opens the wound. The wrong way to ask: “I notice that you’re having some trouble talk-
ing about this. What’s the worst thing about it?” Here’s a better approach that will get you your
answer while feeling respectful and supportive to the child: “I notice that you’re looking down at
the ground and not saying anything. Are you just trying to think of what to say next? Or is it get-
ting to be hard to talk about?”
Sometimes you can problem solve and help the child to keep on going. This does not neces-
sarily mean just giving a pep talk (although sometimes it may). It means really figuring out
what’s going on and trying to solve the problem. Only then might you make a decision, together,
that it’s okay to push on. Some problem-solving strategies:

1. If the child says that it is hard: “You told me that you really cared about your goals. Now
that I see you doing the work, sticking with it when it gets hard, Iam taking you more seri-
ously.”
2. If the child says that it’s too boring:
¢ Consider that the child might be feeling overwhelmed, and trying to manage this by feel-
ing less, or trying to avoid continuing. The child may also be angry about being in this
position. The child may also simply be bored.
¢ For self-control skills training: “Good, this is what we want. We want you to practice so
much that it’s like instinct. Because in the moment, you might not have a lot of time to
think. The more you practice, the better chance you have of being ready.”
¢ For talking about the trauma/loss memory: “Good, this is what we want. The more bor-
ing it is, the less it can hurt you. Let’s do it [tell the story] again!”
3. If, despite the therapist’s attempts, the child still says that he’s had enough: The therapist
accepts this and moves on to the next part of the session, containment procedures.

CONTAINMENT PROCEDURES

A number of interventions can be used to help the child “put the bad stuff away” and regain
composure:

* Say that the hard part is over now.

¢ Have the child visualize putting the bad memory in a secure container (script for this in
Chapter 14).
¢ Teach deep breathing (script for this in Chapter 1).
¢ Teach “safe place” (script follows).
176 CHILD TRAUMA HANDBOOK

¢ Put toys/materials away.

¢ Talk about plans for improved behavior (including utilization of coping skills).
¢ Talk about plans for later in the day or for the weekend.

When we ask about trauma/loss history, we do some of this ina planned, systematic way: we
follow with deep breathing, then talking about the best things that ever happened. In practice, we
should be doing these things in a systematic way at the end of every session. Even sessions that
don’t seem “heavy” or intense may still be different from the rest of the child’s day. You may be
the only person with whom he feels so safe and comfortable, the only person to whom he shows
a certain side of himself. So every session should have some kind of ending routine that helps the
child put the session away, regain composure, and reorient to what’s next for him.
After a particularly challenging or emotional session, some of the extra containment/relax-
ation interventions should be used, as a lead-up to the usual ending routine. One such interven-
tion is the Safe Place guided visualization.

EXERCISE: SAFE PLACE

In pairs, take turns leading one another through the Safe Place visualization. When one per-
son has done it, switch roles and do it again.

If You Are the Therapist

Use the following script. Say aloud the parts in italics. The rest is to guide you. Only use the
prompts if you need them. If you are already getting a good answer, accept it and move on. This
is a conversation, So once you’ve said something, wait for a response before you move on.

If You Are the Client

Be yourself and cooperate.

Safe Place Script

Think of a place where you feel good, safe, relaxed, where nothing bad can happen. (Prompt:
Could be a place you know, a place from a long time ago, a place you make up; maybe from
when you were a kid, being with a certain person, or in a certain room or house.)
Got it? What is it?
So get a picture in your mind, who’s there, what it looks like, how you feel to be there...
What kind offeeling goes with that? Where (in your body) do you feel it?
Would itfeel true to say, “I’m safe,” or “I’m okay,” or what would be the right words (to go
with this picture)?
Now I want you to concentrate on the picture, what you’re saying to yourself, the feelings... .
Concentrate, and take a couple of slow, deep breaths.

Discussion

Clients share your experiences. Therapists share your experiences.

Problem Solving the Safe Place Intervention

The Safe Place is a popular visualization for calming and self-soothing. It can be used in ses-
sion to help calm down, and it can be practiced elsewhere as well. Most kids (and adults) can
 Getting Stronger 1Th

learn it easily, and they like it. Sometimes kids will teach other kids how to do it too. However,
the Safe Place has a couple of tricky aspects, things that can go wrong and need to be caught and
corrected.
Occasionally, the child can’t come up with a safe place. An alternative is to think of an activ-
ity that feels good, comfortable. Clients have chosen a range of activities, from roller skating to
making a cup of coffee in the morning. The goal is to find a visualization that feels good, com-
fortable, relaxing, safe.
A more common problem is that the safe place isn’t so safe after all. Supposing that one of the
child’s problems is that he gets bullied, and the safe place he picks is playing football in the park.
When he starts concentrating on the safe place image, what do you think is going to happen?
Sooner or later, the bully will show up. Then the safe place is spoiled. A similar situation can
occur with abused kids who choose their home or bedroom as the safe place.
The safe place is no use if it’s not really safe and spoil proof. This is why the therapist must
ask what the safe place is. Then use your own judgment—asking more questions if necessary—
to determine whether this safe place is really good enough. If not, then it’s okay to say, “I don’t
think this one will work for what we’re doing. Can you think of another one?”
A final point: when we are helping people to calm down, put the hard stuff aside, and regain
composure, how do we know when it’s finished? We know by asking, and by observing. Don’t
ask the client to concentrate on the upsetting situation again; that will just bring it back. You can
ask, “Where are you now on zero to ten?” If you observe continued signs of distress, that’s an
answer, too. The goal is not merely to go through the motions, but to make sure that your clients
leave the session in good shape. This will help them feel that they are on a good track in their
work with you, and they will be ready to try again next time.

SECTION HI BIBLIOGRAPHY

Child Welfare League of America. (2004, February). Creating parenting rich communities. Available online at
<http://www.cwla.org/programs/r2p/biblioparenting.pdf>. Annotated bibliography including general parenting
research and parent training research and information.
Kazdin, A. E. (1987). Treatment of antisocial behavior in children: Current status and future directions. Psychologi-
cal Bulletin, 102, 187-203. Review of the literature on training in self-management skills for kids with problem
behaviors.
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 SECTION IV:
TRAUMA RESOLUTION

The goals and tasks of the trauma resolution phase of treatment include the following:

¢ Select an order for memories to be addressed.

* Identify upsetting elements of the trauma memory.
¢ Face and master the upsetting elements of the memory.
¢ Repeat with other trauma/loss memories.
¢ Identify trauma-related triggers—reminders that trigger a trauma-related reaction.
¢ Face and master the triggers.

One way of describing the goal of trauma resolution is that after successful resolution, the
child will say, “That was bad, but it’s over, and things are okay now.” Therefore, it’s very impor-
tant that things are okay now, or as close to that as possible, before attempting trauma resolution.
Another way of stating this is that the child must have reason to believe that he is no longer in the
“war zone” if he is to relinquish survival-mode as a primary orientation. Therefore trauma reso-
lution should not be attempted until the following has occurred:

¢ The most significant case management tasks have been implemented.

¢ The parents are doing their part to help the child to feel more safe, secure, and supported.
¢ The child has developed adequate self-management skills to be prepared to handle the po-
tentially highly challenging trauma material.

There may or may not be a clear line between the previous phase of treatment and this one.
Many of the same methods may be used. For example, following the check-in at the beginning
of the session, the therapist may ask for a demonstration of strength (“I want to see how strong
you are. How many jumping jacks do you think you can do today?) and then say, “Do you think
you’re strong enough now to talk about the car accident for two minutes?” Or the exposure
methods (that will be described in the following text) may first be applied, as a sort of trial run,
with the recent upsetting event (e.g., getting in trouble that day in school) that the child may have
reported. Thus, the child will feel that her continuing progress in becoming stronger and more
competent allows her to master progressively greater challenges.
When you hear people talk about “trauma treatment” or “trauma work,” they are usually re-
ferring to the trauma resolution portion of the trauma-informed treatment approach. Of course,
you wouldn’t want to try trauma resolution until you’ve done all the other stuff to get ready for it.
There are a number of trauma resolution methods available, which will be reviewed in the fol-
lowing text. Then one method—exposure—will be presented in much more detail in the follow-
ing chapters.

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 Chapter 13

Trauma Resolution Methods

Quite a bit of controlled research has been conducted on the various methods of helping kids
to work their trauma memories through to resolution. The clear result is that not all methods are
equal. Some tend to be slow and haphazard whereas others work relatively quickly and thor-
oughly. The big dividing line is between the so-called “traditional” child therapy methods such
as play, art, and talk, and the so-called “structured, focused” trauma resolution methods such as
prolonged exposure (PE) (Foa & Rothbaum, 1997), cognitive processing therapy (CPT) (Resick
& Schnicke, 1993), and eye movement desensitization and reprocessing (EMDR) (Shapiro,
2001). The structured, focused treatments win hands down (Chemtob & Taylor, 2002). They are
faster—often by months or even years—and more effective.
The mental health field has an odd and untenable tradition of being practitioner centered
rather than client centered. It is not unusual to hear a therapist say, “I’m a play therapist” or “I’m
a family therapist,’ or “I use a psychodynamic approach.” However, in my opinion this is inap-
propriate when it is a rigid position, and it represents a serious problem with the field. Would
you want to go to a physician who only prescribes certain treatments and not others, regardless
of what might be proven effective, or what might be best for you? Therapists should be saying—
as some do—‘“I work with children with problem behaviors,” or “I work with kids with anxiety
problems.” Therapists should not merely use their own favorite methods and hope that their cli-
ents will happen to be a good match for the methods; therapists should use whatever works best
to help our clients. This does not mean that we cannot have a primary orientation or way of un-
derstanding our work. However, it does mean that we should not eschew tools that may be help-
ful to our clients, unless we have something truly equivalent to offer.
You need a good sword to slay a dragon. Given our current knowledge, it is no longer ethical
to attempt trauma resolution with an unstructured approach. That’s like trying to slay the dragon
with a stick. It’s just not fair to the client, because it doesn’t get the job done. This does not mean
that we cannot use play, art, and talk modalities with children. However, for trauma resolution,
these methods should be used in a carefully structured and focused way (as discussed in the fol-
lowing text).
You are here.

Knight, kingdom, Fence around Personal Slay the dragon Apple trees,
dragon, princess (case training (trauma resolution) compost, contest
(evaluation and management, (skills and (relapse prevention)
treatment plan) parent train) strength
building)

FIGURE 13.1. Steps in the fairy tale model.

181
182 CHILD TRAUMA HANDBOOK

Choosing which structured, focused trauma resolution method to use is another question.
Several methods have proved effective, and as yet there is no method of choice, no clear front-
runner. The two major trauma resolution methods, and a couple of others, are described andre-
viewed following. This chapter has more of a scholarly focus than the others, because selection
of a trauma resolution method should be based on actual evidence of effectiveness, efficiency,
and acceptability to clients.
First, the structured focused methods all benefit from the preparatory work that has been de-
tailed previously in this book. Some of the trauma resolution methods explicitly include some of
the preparatory steps, but that is not the focus of this chapter. No matter which trauma resolution
method you use, you should still do all the other steps presented in this book, including the prep-
aration as well as the follow-up. The focus here is on what distinguishes the methods from one
another during the trauma resolution phase of treatment.

EXPOSURE

Exposure is a long-established method that has many years of study supporting its efficacy.
Although there are a number of variants of exposure, the core of this method involves having the
client tell the trauma story in detail, over and over again. “Start at the beginning, talk in the pres-
ent tense as if it’s happening right now, and along with each thing that happens, say what you're
thinking and what you’re feeling. Then when you get to the end, we’ll do it again. And again.
And again.” Many of the exposure variants involve homework as well, for example, listening
each day to the cassette tape recording of the story told in the exposure session, or writing down
the whole story again each day.
One of the theories about why exposure works focuses on the “information processing” as-
pect (Foa, Steketee, & Olasov, 1989). This model articulates the processes underlying what I
have referred to eariler as “digesting” the trauma memory.
Another theory about why exposure works involves habituation, or desensitization. The idea
is that somehow by facing the trauma memory over and over again, it gradually loses its sting.
This theory underlies a key component of the exposure approach, which is to guide the client to
face the memory for a prolonged period. By facing the memory, avoidance is prevented, so that a
new lesson can be learned. Remember that as long as the memory is being avoided, the avoid-
ance is being reinforced and the memory keeps its threatening aura. However, when the memory
can be faced while in a safe environment, the client has a chance to learn that the memory is no
longer dangerous. Habituation/desensitization and avoidance prevention are the main principles
guiding the structure of the exposure treatment approach.
The idea of “getting back on the horse that threw you” shows that we have a commonsense
understanding of the problems associated with avoidance. We know that if you are thrown by a
horse and then don’t get back on soon, you are likely to continue to be afraid of riding. On the
other hand, if you get back on the horse again and have more good experiences riding, the bad
experience will be put in perspective and won’t have the power to limit your activities.
Exposure works when it lasts long enough. If the client only faces the memory for a minute,
gets anxious and upset, and then stops, the avoidance is reinforced by the relief of not thinking
about the memory anymore. He got off the horse before the horse even took a step. The problem
is that people want to avoid these trauma memories for a good reason: because facing the mem-
ory is so uncomfortable and hard to tolerate. It’s important to find a way to help the client toler-
ate the memory long enough to get past the avoidance, to the new lesson.
Some exposure principles and strategies are nicely exemplified in “in vivo exposure,” in
which the client faces the feared thing “‘in life” rather than in imagination only. The following is
an example case study.
 Trauma Resolution Methods 183

Jamie

Jamie is a nine-year-old boy who has been bitten by a dog. Every time he even thinks about dogs, he
becomes anxious. He now refuses to go near any dog, even his cousin’s dog with whom he used to al-
ways like to play.

The therapist asks Jamie to list all the dog-related things that can make him anxious or fear-
ful—everything from being near a big, scary dog, to seeing a picture of a dog. Then Jamie is
asked to rate on zero to ten how much it bothers him to imagine each of the items. Then the list is
ordered from least distressing to most. His list looks like this:

Seeing a picture of a puppy (1)

Seeing a picture of a scary dog (3)
Seeing the cute dog behind the window at the pet store (4)
My cousin’s dog on a leash (4)
Playing with my cousin’s dog (6)
A scary dog on a leash (8)
A scary dog not on a leash (10)

The therapist has Jamie practice various coping skills such as have been described in previous
chapters. Jamie learns to distinguish between his body’s “danger signals” (e.g., rapid heartbeat)
and actual danger. He learns to calm himself with deep breathing, thinking about something that
makes him feel safe (being tucked in at night by his mother), and telling himself, “I’m safe.”
Next, they work with the first item on the list. The therapist shows Jamie a picture of a puppy.
The goal is for Jamie to use his coping skills as needed, in order to keep on looking at the picture
until it doesn’t bother him anymore. This takes about ten minutes. He is able to look at it, touch
it, etc., while reporting that it’s a zero and doesn’t upset him at all.
The next challenge is to do the same thing with the picture of the scary dog. This time Jamie’s
imagination starts to run, his heart starts to pound, and he says, “Can’t we do this some other
day?” The therapist reminds him that quitting now will only reinforce the avoidance and give the
fear more power. The therapist also prompts him to be resourceful, by saying, “What can you
tell yourself?” Jamie says, “It’s only a picture; it can’t hurt me.” Jamie does stick with it, and af-
ter about fifteen minutes of staring at the picture and making himself feel calm, he is just as com-
fortable with this picture as with the other one.
This is how the in vivo exposure works. At each step, Jamie faces the thing that he is afraid of.
He does not stop too soon, because that would only reinforce the avoidance (by giving him re-
lief). Instead, he uses his coping skills to stick with it. Finally, in each case, he learns that the
feared thing is not actually dangerous, and he doesn’t have to be afraid anymore. Of course, this
only applies to things that are actually safe. The therapist does not send him to face a scary dog
that is unleashed!
In vivo exposure works. However, the therapist must be aware of several potential pitfalls, as
follows:

¢ It’s important to prepare the client properly in terms of motivation, coping skills, and un-
derstanding the rationale and method of the treatment itself. Otherwise, the risk is greater
that the client will quit part way through an in vivo exposure session. This just reinforces
the avoidance and doesn’t help the client.
¢ It’s important to start small and progress gradually. If you start with too great a challenge
(an item with a high distress rating) or make too great a leap in distress level from one item
to the next, it might be too overwhelming; the coping skills may not be adequate. Then the
184 CHILD TRAUMA HANDBOOK

client is more likely to quit before having achieved the elimination of the distress, and this,
again, reinforces the avoidance.
¢ It’s very important that the client not be bitten by the dog! Then the client would learn that
he was right to be afraid. This reinforces the avoidance too!

Imaginal exposure is similar to in vivo exposure in many ways. Imaginal exposure is done in the
therapist’s office, using imagination and memory, rather than facing the actual “thing” such as a
picture of a dog, or the dog itself. However, many of the principles are the same. The client is en-
couraged to use coping skills in tolerating the feared memory. The client is encouraged to not
give in to the urge for avoidance, but to stick with the memory until it doesn’t bother him any-
more. The therapist’s job is to prepare, guide, support, and monitor the client so that he can use
his coping skills effectively and handle the memory, so that he does not become overwhelmed,
or “bitten by the dog.” This imaginal exposure method will be described in detail in the follow-
ing chapters. It is primarily appropriate for adolescents (and adults).
For younger children, the structured, focused trauma resolution methods must often be modi-
fied in ways that incorporate other child therapy techniques. For example, play therapy can be
used in a structured, focused way to assist in trauma resolution (Gil, 1991; James, 1989). When
imaginal exposure is used with younger children, it may entail creating a “book” with the child,
using pictures and words to tell (and retell, work through) the story of the trauma memory
(Deblinger & Heflin, 1996). The research on this modified exposure for kids shows that it works
pretty well, especially when the other treatment components (parent training, self-management
skills, etc.) are included (Cohen, Berliner, & March, 2000). These modifications will also be de-
scribed in the following chapters.
 Trauma Resolution Methods 185

EMDR

The other leading trauma resolution method is eye movement desensitization and reprocess-
ing (EMDR). EMDR will be discussed in some detail here, because it will not be taught in this
book, and because knowledge of this method is important. EMDR began in 1987, when a psy-
chology graduate student named Francine Shapiro noticed that her own upsetting thoughts
faded when her eyes spontaneously moved rapidly from side to side. Over the next several years,
she and her colleagues developed and refined this discovery into a systematic therapeutic ap-
proach.
EMDR is a complex method that combines elements of behavioral and client-centered ap-
proaches. To oversimplify, the client is asked to concentrate intensely on the most distressing
segment of a traumatic memory while moving the eyes rapidly from side to side (by following
the therapist’s fingers moving across the visual field). Following the initial focus on the memory
segment, after each set of eye movements (of about thirty seconds), the client is asked to report
anything that “came up,” whether an image, thought, emotion, or physical sensation (all are
common). The focus of the next set is determined by the client’s changing status. For example, if
the client reports, “Now I’m feeling more anger,” the therapist may suggest concentrating on the
anger in the next set. The procedure is repeated until the client reports no further distress and can
fully embrace a positive perspective. Shapiro (1995, 2001) has presented this method in detail.
Similar to other methods, EMDR can be modified in various ways to work with children at
different developmental levels (Greenwald, 1999).
Shapiro has proposed an information processing model as the theoretical basis for EMDR.
Others (Hyer & Brandsma, 1997; Sweet, 1995) have pointed out that the components of EMDR
are very similar to the components of other structured focused trauma treatments, suggesting
that the effective methods may share common factors underlying their effect. The debate about
whether the eye movements actually contribute to treatment effect is far from settled; but avail-
able data suggest that they do (e.g., van den Hout, Muris, Salemink, & Kindt, 2001). Other than
the eye movements, EMDR is very different from exposure because the client is not required to
stay with the upsetting part of the memory for an extended period. In fact, free association is en-
couraged, and (within limits set by the therapist) clients will go wherever their mind takes them.
If exposure works by preventing avoidance, then EMDR works in some different way (see Rog-
ers & Silver, 2002; Smyth & Poole, 2002). If exposure works because of information process-
ing, then it’s possible that exposure and EMDR share the mechanism of effect, even if this mech-
anism is activated differently in the different treatments.
A review of randomized treatment studies, published as part of the International Society for
Traumatic Stress Studies’ Treatment Guidelines, found EMDR to be an empirically supported
efficacious trauma treatment (Chemtob, Tolin, van der Kolk, & Pitman, 2000), with the reserva-
tion that EMDR had not yet been directly compared to other validated focused PTSD treatments
such as prolonged exposure. Since the publication of that review, several studies meeting most
of Foa & Meadows’ (1997) “gold standard” criteria have directly compared EMDR to validated
cognitive-behavioral therapy (CBT) treatments (including an exposure component) for PTSD.
Findings across studies indicate that both treatments were, in general, comparably efficacious
(Ironson, Freund, Strauss, & Williams, 2002; Lee, Gavriel, Drummond, Richards, & Green-
wald, 2002; Power et al., 2002; Taylor et al., 2003). One study (Taylor et al., 2003) found a
greater effect for prolonged exposure; the others slightly favored EMDR. Two of the studies
(Ironson et al., 2002; Power et al., 2002) suggested that the therapeutic effect may have occurred
more quickly for EMDR than for CBT. One study (Ironson et al., 2002) found that the level of
distress both during and between sessions was lower for EMDR; this study also found a lower
dropout rate in the EMDR group.
186 CHILD TRAUMA HANDBOOK

A recent meta-analysis that used a “change per therapy hour” statistic found that, in con-
trolled comparison studies, EMDR was consistently more efficient than CBT (Rogers & Silver,
2003). These findings suggest that EMDR may be at least equal to other CBT approaches in effi-
cacy and acceptability while being more efficient, in that with EMDR, much less homework is
required, and the treatment effect may be achieved in fewer sessions.
Less research on EMDR has occurred for children and adolescents as compared to adults, but
several controlled studies of varying quality testing EMDR for kids have been reported. Puffer,
Greenwald, and Elrod (1998) reported on a wait-list design study of twenty children and adoles-
cents who were assigned according to convenience of scheduling to EMDR treatment or
delayed treatment groups. Treatment was a single session; the focus was a single trauma or loss.
The first author conducted all treatment and assessment, using several measures, at pre, post,
and 1-2 m follow-up. No change occurred during the 1 m no-treatment delay, and significant im-
provement was recorded between the first and last scores on all measures. On the best measure
of trauma symptoms (Impact of Events Scale), of the seventeen participants starting in the clini-
cal range, eleven moved to normal levels, and three others dropped twelve or more points, while
the other three stayed the same. Problematic design features include lack of randomization, lack
of independent assessment (although no subjective scoring was involved), and use of a therapist
with only partial EMDR training. Also, three participants had ongoing sources of distress, mak-
ing recovery unlikely. Still, the results were quite positive, although somewhat more variable
than in other studies.
Several studies have compared EMDR to “standard care” or to a nonspecific treatment. For
example, Soberman, Greenwald, and Rule (2002) compared standard care plus three sessions of
EMDR to standard care for twenty-nine boys ages ten to sixteen with serious conduct problems
who were either in residential or day treatment care. They found that EMDR led to significant
reductions in both reactivity to the targeted memories and severity of the primary identified
problem behaviors. Limitations include use of a single therapist and lack of independent assess-
ment.
Scheck, Schaeffer, and Gillette (1998) compared two sessions of EMDR with two sessions of
active listening (AL), treating sixty females between the ages of sixteen and twenty-four, who
were actively pursuing high-risk behaviors (substance abuse, unsafe sex, criminal acts, suicide
attempts, etc.) and who had histories of trauma. This study included random assignment,
twenty-four well-trained therapists, independent blind assessment, and multiple standardized
measures. Although both groups improved posttreatment, EMDR outperformed AL on all five
measures, with significant differences on four of the five. The EMDR group’s posttreatment
gains were also clinically significant, with mean scores falling within one standard deviation of
the nonclinical norms on all measures, whereas for the AL group, only one of the measures was
in the normal range. Two measures readministered at ninety-day follow-up showed mainte-
nance of gains for the EMDR group. This study found no differences in the responses of the
young adults compared to the older adolescents (J. Schaeffer, personal communication, Novem-
ber 1996), in that EMDR was equally effective. This study was limited by failure to assess
behavioral outcomes.
Rubin and colleagues (2001) reported only nonsignificant trends favoring EMDR with a
challenging child guidance center population (N = 39, ages six to fifteen). Participants in each
treatment group had the same therapists, and randomization determined which children would
have EMDR included in their otherwise similar eclectic treatment. Reasonable efforts were
made to ensure treatment fidelity for EMDR. Unfortunately, the researchers relied on a single
outcome measure (the Child Behavior Checklist) that does not assess posttraumatic stress, and
that is known to be relatively insensitive to change.
There are only three EMDR/child studies in which EMDR has been compared to a credible
alternative trauma treatment. Chemtob, Nakashima, Hamada, and Carlson (2002) reported very
 Trauma Resolution Methods 187

positive results in using EMDR with thirty-two children and adolescents traumatized by Hurri-
cane Iniki in Kauai. Only those who did not respond to a generally effective previous cognitive-
behavioral small-group treatment program were offered EMDR. The design featured a delayed-
treatment control group, independent assessment with several standardized measures, and five
therapists with varying levels of EMDR training and experience. The treatment protocol was
clearly specified, and a number of efforts were made to ensure treatment fidelity. The partici-
pants averaged a 58 percent reduction on the primary trauma measure following three sessions,
with results holding several months later. The primary limitation was the lack of an alternative-
treatment control group at the time that EMDR was being delivered. Thus, although EMDR did
work for these nonresponders to the prior treatment, we still don’t know how the participants
might have responded to additional sessions of the other treatment.
Jaberghaderi, Greenwald, Rubin, Zand, and Dolatabadi (2004) compared EMDR to CBT for
fourteen sixth-grade girls in Iran who had been sexually abused and who suffered from clini-
cally significant posttraumatic stress symptoms. Participants were randomly assigned and re-
ceived up to twelve sessions of either CBT or EMDR treatment. Assessment of posttraumatic
stress symptoms and problem behaviors was completed at pretreatment and two weeks post-
treatment. Both treatments showed large effect sizes on the posttraumatic symptom outcomes,
and a medium effect size on the behavior outcome, all statistically significant. A nonsignificant
trend on self-reported posttraumatic stress symptoms favored EMDR over CBT. Treatment effi-
ciency was calculated by dividing change scores by number of sessions; EMDR was signifi-
cantly more efficient, with large effect sizes on each outcome. Limitations include small N, sin-
gle therapist for each treatment condition, no independent verification of treatment fidelity, and
no long-term follow-up.
Finally, de Roos, Greenwald, de Jongh, and Noorthoorn (2005) compared EMDR to CBT ina
community mental health center for thirty-eight children and adolescents who had been exposed
to the Enschede (Netherlands) fireworks disaster. The study included eight therapists each using
both methods, training and supervision by an expert in both methods; manualized treatments;
session checklists reviewed for treatment fidelity; blind independent assessment with multiple
standardized measures; and random assignment to treatment condition. Both treatment condi-
tions also included parent sessions. Both treatments showed large effects, with clinically signifi-
cant reductions on all outcomes, including PTSD diagnosis, posttraumatic stress and related
symptoms, and problem behaviors. EMDR was significantly more efficient, with greater change
per session on most measures, and termination criteria achieved in an average 3.17 sessions
compared to an average of four sessions for CBT.
In sum, the child/adolescent literature on EMDR is basically consistent with the adult litera-
ture. It’s clear that EMDR works well, probably about as well as the other proven-effective
trauma resolution methods. It’s possible that EMDR works better than other trauma resolution
methods, and it’s likely that EMDR works more quickly. However, the literature is only sugges-
tive on these latter points, and more research needs to be done.
Meanwhile, no evidence supports any reason to avoid using EMDR for the trauma resolution
portion of treatment. Negative “side effects” (e.g., clients becoming more upset) have been re-
ported, but mainly by those attempting to use EMDR in ways that were clearly inappropriate
(see Greenwald, 1996). Clinicians formally trained in EMDR generally agree that EMDR is less
risky than alternative trauma resolution methods (Lipke, 1994), perhaps because clients can
more easily tolerate EMDR as compared to exposure, and/or because with EMDR, so much
resolution occurs within the session.
Perhaps the main drawback—and the reason it is not taught in this book—is that EMDR isa
relatively complex treatment approach that requires considerable training and supervised prac-
tice to master (Greenwald, 1996). Evidence suggests that even those with the basic training in
188 CHILD TRAUMA HANDBOOK

EMDR don’t always perform it properly (e.g., Jensen, 1994) and that when EMDR is done
properly, it yields better results (Maxfield & Hyer, 2002).
Many clinicians have chosen to obtain EMDR training because of the word-of-mouth reports
as well as personal experience. Many therapists and clients will describe their experiences with
EMDR as being qualitatively different and more effective than other therapy experiences they
have had. Although the research literature has not yet established EMDR as the trauma/loss
treatment of choice, it has at least established EMDR as a responsible choice.

OTHER VALIDATED TRAUMA RESOLUTION METHODS

Cognitive processing therapy (CPT) is another validated trauma treatment method with many
similarities both to the preparatory methods described previously in this book, and to imaginal
exposure. Most of the research supporting CPT with adults has been conducted with rape vic-
tims; however, it has been applied more widely. To date only one controlled study supports
CPT’s use with adolescents with PTSD (Ahrens & Rexford, 2002).
Of note is the unique trauma resolution procedure used within CPT. Rather than having the
client tell the trauma story to the therapist, she is asked to write it down for homework. Then in
therapy, she may talk about her experience of writing it down, and the therapist can provide sup-
port and guidance. Then she writes the trauma story again for homework. In the Ahrens and
Rexford study, this procedure was tolerated by juvenile delinquents who may be expected to
have very limited willingness to tolerate the upsetting feelings associated with their trauma
memories. Perhaps the writing provides a sense of distance and control that the standard imag-
inal exposure does not.
Traumatic Incident Reduction (TIR) (Gerbode, 1989) is not yet considered a primary treat-
ment option because so few controlled studies have been reported, and none (that I know of)
with kids. Of note is the unique trauma resolution method used within TIR. Rather than telling
the trauma story out loud to the therapist, the client is asked to visualize it, step by step, as if he
were watching it in a movie. Then the therapist asks what stood out for the client most during
that viewing; the client responds, and the therapist practices “active listening.’ Then the entire
process is repeated multiple times until the memory is no longer distressing.
Many other trauma resolution methods are available; however, these either have not been ap-
plied to children, or no controlled research supports their efficacy, and therefore they are not in-
cluded in this review. This does not mean that they don’t work—only that at this time I do not
have a basis to recommend them.

DISCUSSION

Although all of the reviewed methods involve some element of exposure to the memory, some
methods are more similar than others. The standard imaginal exposure and the modified-for-
kids exposure are very similar in structure, although the technique is modified to be develop-
mentally appropriate. The exposure component of cognitive processing therapy is also fairly
similar, in that it is also highly structured around telling, and repeating, the trauma story, al-
though in CPT this is done by writing it rather than speaking it.
The structure of EMDR is substantially different. The client is asked to start with the worst
moment in the trauma, and then follow where this leads—a kind of free association procedure.
Sometimes the whole story gets reviewed; sometimes it doesn’t. The client does not necessarily
go over and over the same material, but rather focuses on some parts and not others, and for rela-
tively brief periods. According to the primary theories and practices underlying imaginal expo-
 Trauma Resolution Methods 189

sure, this should not work. Since EMDR does work, a different theory is needed to explain it.
This theory would be closer to the information processing or digestion model, which is of course
a metaphor for brain processes that are not yet well understood. Even so, the result is that the
memory is no longer distressing, and the client is able to tell the story in a coherent way.
TIR seems to fall somewhere between imaginal exposure and EMDR. The client is asked to
go through the entire story from beginning to end by visualizing it rather than saying it or writ-
ing it down. Then she-is asked to report on what stood out for her, and to discuss that as she sees
fit. Thus it has a variant of the storytelling component common to imaginal exposure, as well as
a variant of the free-association component common to EMDR.
All of these methods have certain factors in common:

1. Each requires careful preparation so that the client will be willing to do the procedure, and
be able to tolerate it.
2. Each involves directly facing the trauma memory in a systematic way.
3. Each continues until the distress is reduced or eliminated.
4. Each results in the client being able to tell the story (often, previously fragmented) in a co-
herent and comfortable way.
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 Chapter 14

Preparation for Exposure

TARGET SELECTION AND MEMORY BREAKDOWN

The focus in this book will be on using exposure as a trauma resolution method, whether stan-
dard exposure for teens, or modified exposure for younger kids. However, in general, the same
strategies and principles will apply when other trauma exposure methods (e.g., EMDR, CPT)
are used instead of exposure.

Selection of Memories for Exposure

Several strategies may be used to decide which trauma memory (assuming, as in most cases,
that there are more than one) to address first. Most exposure traditions focus only on the primary
identified trauma, that is, the one that apparently precipitated the referral. Another approach,
more common with clinicians who use EMDR, is to go in chronological order, starting with the
earliest memory and moving forward. A third strategy, which can also be combined with either
of the first two, is to go in order from lower to higher SUDS ratings, that is, from least to most
anticipated difficulty.

Go for “the Big One”

This strategy is often used in the exposure tradition. This may be the best choice for children
who were previously high functioning and who had not been exposed to major trauma or loss
prior to the primary identified trauma event. One advantage to this strategy is that—if 1t works—
by focusing on only one trauma memory, the trauma resolution phase of treatment can be com-
pleted relatively quickly. Another advantage to working with the “precipitating event” memory
is that this strategy is relatively easy for kids to understand. If their case formulation story indi-
cates their problems from this event, then it makes sense to them to go after the memory of this
event.
However, problems can occur with this approach. For many kids, starting with “the big one”
may prove overwhelming—too much too soon—and backfire by giving the child an upsetting
experience that does not even lead to feeling better. Also, sometimes when the child starts with a
later trauma memory, the trauma resolution work does not go very smoothly because of the in-
fluence of untreated earlier memories.
This is a tricky concept but important to understand. When a child has earlier unprocessed
trauma memories, the unprocessed material is kept “behind the wall” and sometimes comes out
when triggered by a thematically related stressor. This is the “sore spot” reaction. When a new
trauma event occurs, part of the child’s response to the new event will be an overreaction, be-
cause of the material behind the wall kicking in. The child doesn’t know that she is overreacting;
her subjective experience is that the current event warrants her reaction. Later, it works the same
way. When we ask for the SUDS on that trauma event, some of the reported distress will really
be from the sore spot reaction from earlier memories, even though it feels to the child as if it’s all
related to the identified event.
19]
192 CHILD TRAUMA HANDBOOK

This is important because when you are trying to help a child process a trauma memory, you
want to have a good chance of being successful. When some of the distress attached to the mem-
ory is actually from earlier memories that you’re not talking about, it’s more difficult to get reso-
lution on the memory you are talking about. You can find yourself going through the identified
memory over and over, not getting anywhere with it, and not knowing why. On the other hand, if
the earlier memory is resolved first, the work with the identified memory is likely to go more
smoothly.

Dave was a thirty-four-year-old man who came to treatment complaining of stress on the job for the
past three years. However, nothing at his work site had changed; everything had been the same for eight
years. What did happen three years ago was that his aunt had died. Dave said, “She was like a mother to
me, since my own mother died when | was six.” He gave the rating for the memory of his aunt’s death as a
“ten plus” and the memory of his mother’s death as a “four.”
 Preparation for Exposure 193

Although he didn’t quite understand why the therapist wanted him to work through the earlier memory
(mother’s death) first—“that one doesn’t bother me’—he agreed to do so on the therapist's suggestion.
Working through this memory took three full sessions using EMDR and included considerable intensity of
emotion at several points, far more than the four of the initial distress rating. Dave said, “I had no idea that |
was still carrying so much pain from that.”
Then he faced the more recent memory (aunt’s death), which had initially been identified as the pri-
mary source of distress. It was still a sad memory, but it only took one session to resolve. There was just
not that much left of it once the earlier memory’s sore-spot reaction had been removed.

Go in Order

This strategy is often used in the EMDR tradition. When more than one significant trauma/
loss memory is on the list, often the preferred option is to address each memory in chronological
order, starting from age zero and moving forward. By addressing trauma memories in chrono-
logical order, each trauma only carries its own distress burden—no sore-spot reaction piled
on—and can be more readily resolved. Then when addressing later trauma, the prior traumas
have already been resolved, so less distress remains.

Personal Trainer Modifications

Finally, with either strategy, you must also consider whether your client is ready to handle the
memory you want to target first. It is often preferable to start with a less distressing trauma
memory as a way to help the child become more competent in the method and gain a track re-
cord of success, prior to addressing the more challenging one you might have in mind. For ex-
ample, what if you want to go in chronological order, but the earliest memory on the trauma his-
tory list is rated as a ten? Perhaps you’ll decide to start with a later memory on the list that has a
lower rating, as a stepping-stone to facing the more difficult one. Remember, as a “personal
trainer” you want to give your clients challenges that they can handle. You don’t want to offer
too great a challenge and invite failure. Better to go a step at a time.
Selecting the order of trauma memories for exposure is guided by clinical judgment. Go for
the big one and the hope of quick relief? Use a systematic approach and go chronological? Start
small and build up, slower but safer? Fortunately, order selection is not a single make-or-break
decision. The therapist is constantly presenting just-manageable challenges to the child and sup-
porting the child’s capacity to manage them. If the challenges seem too easy, the therapist can in-
troduce greater challenges; conversely, if the challenges seem too difficult, the therapist can help
the child to contain the memory, relax, and back off. Then the therapist will know to go slower
for a while so the child can be successful and make progress.

Breaking Down the Memory

The goal of exposure is to help the client gradually face and process—or “digest”—the vari-
ous components of the trauma memory, with the result being desensitization to the memory,
along with a more mature and adaptive perspective on the event and on his own part in it. In this
process, the discrete fragments of the memory (and associated thoughts and feelings) tend to be-
come better organized and ordered, to form a coherent narrative. The narrative includes the de-
tails of the memory but does not end there; it ends now, with the client accepting the pain and
loss, learning and growing from it, and moving on to a new and more satisfactory state of being.
Exposure with adults typically involves having the client describe the memory in great detail,
including actions, thoughts, and feelings, and in the present tense to further encourage emo-
tional engagement. This is repeated multiple times in the presence of a supportive but directive
therapist who keeps the client on task. However, even with adults this can be extremely chal-
lenging, and many therapists who practice exposure report a high dropout rate. With kids, it is
194 CHILD TRAUMA HANDBOOK

even more important to conduct the exposure in a manner that is not overwhelming, so that it can
be tolerated.
One way to do this is to “titrate” exposure to the memory by having the child face only a por-
tion at a time, rather than the whole memory at once. Breaking down the memory is a procedure
that entails making a list of components of the memory prior to doing the standard exposure rou-
tine. This intervention helps to titrate exposure in two ways. By asking first for a “list” of com-
ponent events for the memory, rather than asking for the whole story with thoughts and feelings,
the client may be able to discuss the memory with relatively less emotional content the first time
around. The list approach can be a nicely contained step. Also, once the list is made, the trauma
memory may be broken down into more manageable portions. Then the client might only work
on a certain portion of the memory at one time, rather than the entire memory. These steps are
not always required, but they’re good options to have available.
Breaking down the memory is a fairly simple procedure. It is similar in many ways to the
method for obtaining a full trauma history, except that now the list is focused on components of
a single memory. Once the trauma memory has been selected for exposure, the therapist helps
the child to identify discrete portions of the memory, put them in the order they occurred, and
rank each portion with a SUDS score from zero to ten. The SUDS ratings are used in several
ways:

¢ They help the child learn more about how she feels in relation to the memory.
¢ They help the therapist plan a strategy for approaching the exposure work (see Chapter 15).
¢ Finally, they serve as a baseline, so that later on, the therapist can say, for example, “you
started out as an eight on this part and now you Say it’s only a three. Would you say you’re
making some progress?” Without this baseline measurement, it’s easy for kids to forget
where they were, and then it’s harder for them to tell how much they’ve accomplished.

The therapist and child together also identify posttrauma information and events that relate in
some way. For example, if the perpetrator of an assault is in jail, or if the child is no longer in
physical pain, this is an important component of the narrative even if it did not occur at the exact
time of the index event.

Get to the Good Ending

It is critical to success in this method to make sure that the child’s story goes all the way to a
good ending. This is true both for the memory breakdown and for the exposure itself. Even if
there is no ending that is really happy, it’s essential to find an ending point in which at least the
bad part is really over.

Bryson was an eight-year-old boy who complained in session one day about having missed recess
that morning because he pushed a boy who had insulted him. He gave this a SUDS rating of eight. The
session was interrupted and then picked up again the next day. The counselor reminded him of what
they'd been talking about the day before, and asked again for a SUDS rating. This time it was a zero. Why?
Bryson explained, “Oh, we’re friends again!”

Remember, one of our goals with exposure is for the child to be able to say, “That was bad, but
at least it’s over now, and things are okay.” Really understanding—on a gut level—that the bad
part is over helps people to let it go and move on. One reason traumatized people stay stuck is
because some part of them doesn’t realize that the bad part is over now. The memory isn’t orga-
nized into a story; it’s still in fragments. The fragments that include the worst parts of the mem-
ory don’t know that it’s over now.
 Preparation for Exposure 195

So when we help someone to organize the story, we must make sure the story goes all the way
to a good end, to when the bad part is really over. This can be tricky; it can be hard to finda good
end to many stories. For our purposes, a “good ending” doesn’t necessarily mean that what hap-
pened was good, or even that the ending was good. The goal is to get the client past the distress-
ing fragments of the memory to a felt sense that it’s really over. Here are some examples of good
endings to bad memories, which the therapist helped the client to identify:

A fourteen-year-old girl had been teased mercilessly by her peers throughout elementary school. Al-
though only two teasing-related memories were on her trauma history list, smaller but similar events were
a daily occurrence for some years. So at the end of the event in her memory, she also knew that she faced
the same kind of thing the next day. The therapist asked her, “Do you get teased now?” Fortunately, she
was no longer getting teased, but got along well with her peers. The ending to her teasing memory story
was in the present: the last event in this memory was seeing herself having lunch with her friends at
school, the day before this therapy session.
A ten-year-old boy’s older brother's fiancée had died two years ago in a car accident. The boy missed
her then and now; she had been like part of the family and they had been close. The good ending was see-
ing himself return to school and other normal activities the week after the funeral.
A seven-year-old girl had been injured the year before in a fall from a friend’s apartment window. She
had broken bones and many cuts, and had to return to the hospital for treatment on multiple occasions
over several months. The story of the trauma memory included those hospital visits. The good end was
saying good-bye to the last doctor, and then seeing herself playing jump rope with her friends.
A five-year-old boy was severely beaten on several occasions by his grandmother when he stayed with
her for the summer. He still has to see her at family events, but his parents have told him that grandmother
is not allowed to babysit him anymore. The good ending was when his parents told him that, and then see-
ing him safe with them at their home.
A twelve-year-old girl had been near a building that got bombed. Although her daily life routine is unre-
markable, she lives in an area where bombs or other attacks could happen again. Her good end was that
no one she cared about had been hurt in the bombing; she visualized eating dinner with her family mem-
bers all present that evening.

These examples illustrate several possible strategies for identifying the good ending. Ideally,
the good ending can represent a true resolution of the event. Sometimes this resolution can be
found soon after the event, and sometimes it needs to be found much later. Unfortunately, some
events do not have true resolutions, for example when there is lasting damage (e.g., the loss of a
family member; a permanent physical injury) or when the event seems especially likely to recur
(e.g., in an area regularly targeted by criminals or terrorists). In such instances the best we can do
for a good ending is identify a time when the bad event and its aftermath was as finished as pos-
sible, and things were as much back to normal as possible.
It’s important that the good ending be represented in an image of an actual event, an actual
moment in time, when a particular thing happened. Many people will describe a status as their
good end; then it’s up to the therapist to help the client convert the status into a representative im-
age. For example, if the client describes her good ending as, “I wasn’t afraid to ride on the bus
anymore,” then the therapist might ask, “What picture represents that for you; what do you re-
member doing that let you know that you weren’t afraid anymore?” For another example, if the
client describes his good ending as, “I didn’t feel bad; I wasn’t worried about it anymore,” the
therapist might ask, “So when you didn’t feel bad, and weren’t worried about it anymore, what
were you doing?” The point is, this is a story. Ina story, things happen. So for the good ending, it
must be an actual event that happens. An event has a time, a place, and an action. If the therapist
cannot visualize the good ending as clearly as if seeing it on TY, it’s not specific enough yet.
196 CHILD TRAUMA HANDBOOK

Sample script

Here is an example of how a breaking down the memory session might go.

THERAPIST: Today we’re going to talk a little about the memory, just enough to make a list of the
different things that happened. Let’s see, what are the different parts of the memory? What
was the first thing, like if this whole thing was a movie, what would be the beginning?
CHILD: Getting into the car.
THERAPIST: Okay, getting into the car. Who was getting into the car?
CHILD: Me and my brother and my mother; we were going to the store.
THERAPIST: Okay, and what’s the next thing?
CHILD: We’re driving along and then we stop at the stop sign but the car behind us didn’t stop; it
crashed into us.
THERAPIST: Okay. Driving along. Stop at the stop sign. Car crashed into us. What happened af-
ter that?
CHILD: Then the ambulance came and took me to the hospital, and then they put on the cast and
the bandages and then we went home.
THERAPIST: Okay. Ambulance came and took me to the hospital. Put on the cast and the ban-
dages. Went home. Then what?
CHILD: Then I didn’t go to school the next day but Iwent after that. And then the cast came off a
few weeks later. That’s all.
THERAPIST: Got it. And what about your mother and your brother? What happened to them?
 Preparation for Exposure 197

CHILD: They came to the hospital with me and they got some bandages too but they weren’t hurt
bad.
THERAPIST. Okay, P’Il put that down too. Now after the cast came off, is there any more to the
story, to the movie about this car accident?
CHILD: I don’t think so.
THERAPIST: What about how you kept having the bad dreams and being nervous about getting
into a car, and then you came here and got stronger and able to handle it, and getting back to
normal?
CHILD: Oh, yeah.
THERAPIST: So what happened that really let you know that you were back to normal again?
CHILD: I didn’t need the light on when I went to bed. And I could get in a car to go someplace
without feeling worried.
THERAPIST: Like when did you get in the car without feeling worried, where were you going?
CHILD: To the store with my mom.
THERAPIST: Okay, now I have a list of all the things you told me, that would be part of the story.
Now I’m going to go through the list, one at a time, and ask you to give me a number to tell me
how bad the feeling is now when you concentrate on it. On zero to ten, ten is the worst that the
feeling can be, and zero is no bad feeling at all. So just for a minute, concentrate on getting
into the car that day, and notice how you're reacting inside right now. How bad is that feeling
right now, if ten is the worst and zero is nothing?
CHILD: Maybe a three.
THERAPIST: Okay, and how about when you stop at the stop sign?
CHILD: That’s an eight.
THERAPIST: And when the car crashes into you?
CHILD: Ten. Ten plus!
THERAPIST: And when the ambulance comes?

EXERCISE: BREAKING DOWN THE MEMORY

If You Are on Your Own

Follow the therapist instructions with someone who will let you practice on him or her, or
with a client who you are sure can handle this and for whom it is an appropriate intervention at
this time.

If You Are the Client

¢ This is not a role-play, be yourself.

* Choose a memory (from your trauma history list or otherwise) that you rate six or lower on
the zero to ten scale, and that you are willing to talk about today.
¢ Do not look at the script; that’s the therapist’s job.
* Remember what to do if you feel that you need a break or if there’s something you don’t
want to talk about. Just because you agree at the beginning does not mean that you will feel
the same way later on. Take care of yourself.
198 CHILD TRAUMA HANDBOOK

If You Are the Therapist

¢ Use the form in this chapter, including the script that’s on it. Verbatim, of course!
¢ You’ll be making a list of each event that happened in the memory. You don’t need or want
a lot of detail here, just the bare bones of the event. Write each event down on its own line,
in the open space of the form. Write the next event on the next line. Use another page if you
need more space.
¢ Remember, this is only a list. Don’t pester your client with questions about thoughts or
feelings. Don’t pester your client with questions about minute details. Just get the thing
that happened, write it down, and go on to the next thing that happened.
* Make sure you go all the way to a good end that is a specific event, just like the rest of the
things on the list.
¢ When the list is done, follow the script to get the SUDS on each item. Write that down on
the edge of the line for that item.
¢ Ina session, you might decide to just continue with the standard exposure. In this exercise,
finish with a calming activity. Try the “Container” intervention (the script is included in the
following text). Then see if your client would like to do some deep breathing or a safe place
visualization.

THE CONTAINER

The Container is yet another intervention that can be used to help calm the client. The best
time to use a container is after you’ve been talking about a memory that may have been upsetting
(even if the client does not show upset). The goal is to help the client feel as if the memory is put
away again. In the script below, this is a conversation. You must wait for answers to your ques-
tions before you go on to the next one. You don’t want to give your client too many ideas; it’s
better if she comes up with her own imagery. The questions are designed to help her to make it
specific enough that it works:

What kind of container can you think of that could hold this memory until you need to get to
it again?
What would it be made of? How big would it be? How would you close it (keep it secure)?
Where would you keep it?
What I want you to do is imagine packing this memory away in [the container]. When it’s
all put away, let me know.
How did that go? Does itfeel all put away?

Problem Solving

Once ina while, the container doesn’t really work. You will know this because when you ask,
“Does it feel all put away?” your client will say, “No.” Then you must help your client improve
the container so it will work. You can do this by asking questions, for example, “What kept it
from being all put away?” Then your client will probably tell you that the container was too
small, too weak, or not adequately secured. Then you can ask for solutions, for example, “What
would it take to make the container work better?” Again, your job is to guide the client to come
up with her own imagry. Once the client has improved the container to solve the problem, you
try the visualization again.
Once the memory is put away in the container, check with your client. How’s he doing now?
If he’s not all the way relaxed, follow this with deep breathing or safe place. Then, finish up with
 Preparation for Exposure 199

Breaking Down the Memory

© Ricky Greenwald 2004.

Today we're going to talk a little about the memory, just enough to make a /istofthe dif-
ferent things that happened. Let's see, what are the different parts of the memory? What
Bes inefirst thing, like if this whole thing was a movie, what would be the beginning? Then
what’

” ata would you say it felt like this was really over? What event or picture represents
at?

Make a list of the different parts of the memory, in chronological order. Go all the way to
the end, to where things are okay again.

Event segment

Okay, now | have a list of all the things you told me, that would be part of the story. Now
I’m going to go through the list, one at a time, and ask you to give me a number to tell me
how bad the feeling is now when you concentrate on it. On zero to ten, ten is the worst that
the feeling can be, and zero is no bad feeling at all. So just for a minute, concentrate on [the
first part of the story], and notice how you’re reacting inside right now. How bad is that feel-
ing right now, if ten is the worst and zero is nothing?

(Put the current SUDS next to each item on the list, above. Then either go directly into
exposure [on the whole memory or a selected section], or do some containment/closure
activities.)
200 CHILD TRAUMA HANDBOOK

any debriefing or even small talk, whatever is needed to help your client regain composure and
be ready for whatever’s next in his day.

Discussion Questions

Clients should describe their experiences. Therapists should describe their experiences. How
many therapists had their own emotional reaction to the client’s story? What did you do with it;
how did you handle it? Is there more you need to do? Clients, how many had a higher SUDS in
the memory than what you had expected? What can we learn from this to help us understand our
clients? Clients, raise your hand if you feel worse off than before? Same as before? Better off
than before? ,
 Chapter 15

Conducting an Exposure Session

Once you have selected a memory to target for exposure, and broken down the memory (see
previous chapter), you’ll need to decide on an exposure strategy. Should you work with the story
a chunk at a time, or all at once?

A CHUNK
AT A TIME

You choose this strategy when you have to, when in your opinion the child will not be able to
handle the whole story all at once. The younger the child, and/or the more emotionally fragile,
the more often this strategy is used. For example, you might judge that the child is not ready to
face the most upsetting portions of the memory right away, but can get started on some other
portions and so build strength. Or you might judge that the child does not have the attention span
or ability to tolerate staying with the entire story long enough to get much accomplished. You
want to help the child be successful, so you aim for a smaller bite.
If you are going to do exposure a chunk at a time, you can’t skip the step of breaking down the
memory. You need to know what the components of the memory are so that you can make an in-
formed decision about where to start and how to proceed. The two main ways to implement this
strategy are by going in order of what seems manageable, or by going in the sequential order of
the event.

In Order of What Seems Manageable

This is a good strategy when you feel that the child is ready to handle the memory, but isn’t
quite ready to face the worst part yet. So in the first exposure session, you have him focus not on
the whole memory, but on a chunk that you agree to start on. Typically, this chunk will include
more than one line on the memory breakdown form; itll be a portion of the memory that in-
cludes several of those lines in sequence. Once you work through that chunk (using the exposure
procedure described in detail in this chapter), you go on to another chunk. You might continue
this strategy for some time, or at some point you might switch to working with the entire mem-
ory all at once.
So where do you start? One approach is to select the chunk that seems easiest to handle. You
can determine this by looking at your memory breakdown form, which will list the SUDS rat-
ings next to each event. This is the personal trainer style again, going one step at a time, starting
small and working your way up. Another approach is to start with the last part of the memory,
perhaps from some time after the worst part is over, all the way through to the good ending. This
may be tolerated relatively well because the child keeps on encountering a reminder that it really
is over now. It is important to work this ending chunk at some point before you have the child
face the worst part of the memory. Later, when the child is facing that worst part, it will be easier
for her to tolerate because she will be more able to remember, and truly believe, that it’s over
now.
201
202 CHILD TRAUMA HANDBOOK

In the Sequential Order of the Event

This is a particularly good strategy for younger children (pre-teen to much younger) who may
be better suited developmentally to working with an art, play, or drama focus rather than straight
talking. Although many strategies exist for working with younger children using these symbolic
modalities (e.g., see Gil, 1991; James, 1989), the focus here will be on the sequential approach
(Deblinger & Heflin, 1996) that has been subjected to extensive research (Cohen, Deblinger, &
Mannarino, 2004).

MAKING A BOOK TO TELL THE TRAUMA STORY

In this approach, the child and the therapist work together to make a book of the story of the
trauma memory. In this book, perhaps each item on the Breaking Down the Memory form will
have its own page. For each page, the child draws a picture to represent the portion of the mem-
ory being depicted. While he is drawing the picture, the therapist may be prompting the child by
asking what the characters in the picture are doing, thinking, and feeling. Either the child or the
therapist (using the child’s words) might write a caption or a narrative to go along with each of
the pages. This approach has the following advantages:

1. Prompting for actions, thoughts, and feelings helps the child to fully engage with that por-
tion of the memory so it can be digested.
2. The fact that it’s a picture allows the child to maintain a certain distance, which may make
the memory easier to tolerate while it is being faced.
3. The act of drawing keeps the child active and engaged. This gives her something to do,
which counters restlessness.
4. The drawing itself provides a way to manage and express any distress related to the mem-
ory.
5. The time it takes to draw the picture allows the child to stay with that portion of the mem-
ory long enough to overcome the avoidance and to acheive some digestion.
6. Only one portion of the memory is being focused on at a time. This may keep it from be-
coming overwhelming for the child.

Even in the sequential approach, it’s okay to skip the most difficult pages if the child is not yet
ready for those. However, eventually those should also be completed, and then put in their place
in the sequence. Usually, once the child has progressed to the good ending, she will feel more
able to go back to the hard parts and get through those as well. Sometimes additional strategies
can also be helpful, for example, using additional strength-building interventions such as those
described earlier in the book.
Many therapists also routinely use incentives to help children to get through exposure. This
can be as simple as, “Once we get our work done, we’ll have time to play,’ or it can involve an
agreement for the child to earn a certain reward or prize for accomplishing a specified task in
treatment. Although incentives can be useful, it is important not to use such large incentives that
the child would ultimately feel coerced. It’s also important to do all the preparatory steps to gain
the child’s understanding, motivation, and cooperation, and to help her to build her coping skills
and affect tolerance. If incentives are attempted as a shortcut for skipping those steps, it won’t
work.
Once the pages of the book are completed, including the title page, the book can be bound,
perhaps with tape or staples. The final task in this exposure procedure is for the child, in the ther-
 Conducting an Exposure Session 203

apist’s presence, to show the book to her parents and tell them the story from start to end. Many
children are proud of their work and look forward to this session.
We want the parents to be proud of their child as well, and to show their compassion and pride
while the child is showing the book and telling the story. However, if parents are seeing this
book and hearing the story from the child for the first time, they are likely to feel overcome with
their own emotions. Then the focus would be on the parents and not on the child. Worse yet, the
child might feel thatthe parents need her care. To help parents to come through for their chil-
dren, the therapist meets with them alone and prepares them for the “‘show-and-tell” session by
going over the story with the parents in detail. This gives the parents a chance to have their own
reaction to the story in private. Then when their child shows the book and tells the story, the par-
ents are more prepared to support the child the way they want to.
After the story has been presented, the therapist works with the child to prepare questions for
the parent, and also works with the parent to prepare questions for the child. The ensuing struc-
tured conversation about the trauma helps to further reestablish the parent-child bond and com-
munication. This facilitates the transition toward the end of therapy and helps the parent take
over some of the therapist’s role.
The rest of this chapter will focus on the “talk” format for exposure, assuming that the entire
memory will be used. However, the same method can be applied to the talk format for working
on a chunk at a time, and the principles apply to the sequential drawing method as well.

ON THE WAY TO EXPOSURE

Several last-minute things need to be done on your way into the exposure session. These will
help your client understand why you are asking him to do this and how it relates to his goals, and
will also help him feel that he has ready access to whatever makes him feel safe, secure, and in
control.

Restate Rationale

You need to remind your client about why you are asking her to do this activity. Don’t think
that just because you talked about it last week, she still knows! Kids tend to shy away from talk-
ing about their trauma memories and can easily forget why it seemed like a good idea when you
talked about it before. Kids may feel that bringing up the trauma memory will only make them
upset and make things worse for them. Also, kids who are doing better in various ways, often be-
cause of your help and guidance, may feel they don’t need to talk about the trauma because
they’re already doing well. Here’s an example of what you might say to reorient your client to
the reason for doing exposure today:

You told me that you wanted to [restate child’s treatment goals here, e.g., do better in
school, have more friends, stop having bad dreams, have a good job someday]. We were
talking before about how the bad memories on your list make stress pile up inside you, give
you that sore spot, and get in the way of the things you want. So we’ve been doing these dif-
ferent things to help you get stronger and more in charge of what happens to you. We've
talked about avoiding high risk and staying safer, you’ve done a lot of work to get stronger
and better at handling things, and you’ve figured out ways to keep your stress down.
The next thing we said we would do is to talk about the bad memories on the list, one by
one. The reason I’m thinking that this is a good time is that you are getting stronger, I think
you can handle this now. I’ll be asking you to tell what happened in [the selected memory]
over and over. It might be hard; it might hurt your feelings while you’re doing it. Remem-
204 CHILD TRAUMA HANDBOOK

ber, though, that the more you do it, the stronger you get, and the smaller your sore spot
gets, the less power the memory has to mess you up.

The rationale may be presented in different ways, according to developmental level and ac-
cording to the way the therapist understands what exposure actually accomplishes. For example,
you may wish to use the “digestion” metaphor, or you may wish to focus on how facing the
memory over and over again interferes with avoidance and allows desensitization to occur.
Whatever rationale you give for exposure, it is always important to tie it to the child’s stated
goals, and to present it as the next step in a series of treatment activities in which she has so far
been successful.
Sometimes even after you give this rationale, kids will object to doing exposure because they
are so much better now that they “don’t have a problem anymore.” Then you'll need to offer an
additional rationale that will hopefully be persuasive. Normally this will focus on remaining
symptoms and on future challenges. For example:

Years ago, when I was working with someone who is doing as well as you’re doing now, I
would think that we were all done. So if this was a few years ago, I might shake your hand,
say “good work,” and send you on your way. But here’s what happened. Those kids mostly
did pretty well as long as things in their life stayed the same. But when some new challenge
came along, some new stress, like maybe their girlfriend broke up with them, or someone
in their family died, then things would go downhill and they’d end up with the same kinds
of problems they had before. So maybe a couple of months later or a couple of years later,
I’d see them again. The reason is that we hadn’t helped them to digest the trauma memo-
ries, so they still had the same sore spots. When something big came along, it hit that sore
spot and it was just too much. So I’ve learned the hard way. Now I always suggest that
while you’re doing well and feeling strong right now, you take care of the sore spots. Then
when some new challenge comes along down the line, you’ll have all your strength and
you'll have a better chance of handling that, too.

Here’s another way of conveying essentially the same message.

THERAPIST: Supposing you’re on a basketball team, and your coach tells you, “You can’t just
come to the games. You have to come to the practices, too, and do push-ups, run laps, every-
thing. You don’t really like doing push-ups or running laps. What are you going to do?
CLIENT: Come to practice; do what the coach says.
THERAPIST: Why? You don’t really like doing some of that stuff.
CLIENT: Have to, to stay on the team. Also, it makes me stronger so I can play better, help the
team win.
THERAPIST: I thought you’d say that. Okay, so the season is going along, and your team is win-
ning every game. Now your coach says, “I want you to start coming in for extra practices;
we're going to be doing more different exercises and drills from now on.” Why do you think
your coach would say that? You’re already winning every game.
CLIENT: I don’t know.
THERAPIST: I think it’s because the coach wants your team to win the play-offs, too. You know
who you’re going to face in the play-offs?
CLIENT: The other teams that have been winning all their games!
THERAPIST: Right. So are you going to tell your coach, “Forget it; we’re already doing fine. I’m
not going to those extra practices’’?
CLIENT: No, I want to win the play-offs too.
 Conducting an Exposure Session 205

THERAPIST: Well, that’s where I think we are right now. You’ve done a lot of work with me, to be
safer, get stronger, better at handling things, and it’s really paid off. You’re stronger now and
you're doing pretty well, wouldn’t you say?
CLIENT: Well, I’m not getting in trouble much anymore.
THERAPIST: So it’s like the team that’s winning the games, and now it’s time to get ready for the
play-offs. So if I just wanted you to win today’s game, I’d say that you were all set, and I
wouldn’t ask you to do any more work. But I want you to win tomorrow’s game, too. I want
you to win the play-offs. Remember the things you told me you wanted for yourself? To get
through school, learn a trade, get a good job, have your own family?
CLIENTAYES:
THERAPIST: Well, sooner or later, some big challenge is going to come your way. Maybe break
up with a girlfriend you care about, maybe lose a good job, maybe someone in your family
dies. You know how life is; things happen.
CLIENT: It’s always something.
THERAPIST: So now that you’re doing well and feeling strong, it’s a good time to get ready for
the big challenges that’1l come your way down the line. The stronger you get now, the smaller
you can make those sore spots, the better chance you’ll have of handling even the big things.
Then you'll have a better chance of staying on your track to your goals.

If even this isn’t enough, and your client still resists, perhaps you are asking for more than the
client believes she can handle. Then it may be wise to back down just a bit, perhaps by suggest-
ing that you start with an easier (lower SUDS) memory than you may have initially had in mind.
You are still holding your ground in terms of recommending that your client complete the
trauma resolution work, but you can offer a way for her to get into it more cautiously.

THERAPIST: Even though I can see that what I’m saying makes sense to you, a lot of kids are still
not really sure that they want to talk about those memories that still hurt inside. Some kids
think it might be too hard, more than they can handle. And some kids just don’t believe that it
would work for them, that they could really feel better about the memory than they do now.
Do you have any of these questions about doing it?
CLIENT: I just don’t see how talking about it is going to help. It'll just stir things up.
THERAPIST: Must be kind of confusing for you. Because you know me pretty well by now,
you’ve had pretty good luck with my suggestions so far. But you’re not sure about this one.
CLIENT: Yeah, nothing against you. I’m just not sure about this.
THERAPIST: Well, if it’s not going to work for you, of course you shouldn’t do it. But if itis going
to work for you, you’d probably end up being really glad that you did do it. So I have an idea
for you. My suggestion is that you kind of check it out, but not with one of the really bad
memories. My suggestion is to pick out something that happened in the last few days that
maybe bothers you some now, but that you know is really no big deal. Kind of like sticking
your toe in the water to see how it is before you decide whether you're going to go swimming
or not. How does that sound to you?

Reminder of Strength Resources

Before expecting the child to face the challenge entailed in talking about the trauma memory,
it’s good to remind her of the things that make her feel strong and secure. The client might get
206 CHILD TRAUMA HANDBOOK

GOT YOUR
SWORD? =

this from being reminded of her goals and of all the success she has already achieved on the path
to her goals; this was shown previously in presenting the rationale. Another strategy, particu-
larly for younger children with whom the same approach has been used all along, is to refer di-
rectly to physical strength. The therapist might say, “Let’s see how many push-ups you can do
today,” as preparation for saying, “Okay, I think you’re strong enough to talk about this now.”
Some therapists also like to use a variety of “helpers,” which can symbolically represent
strength, attachment, safety, or other resources to help the child face the trauma memory. Help-
ers are a standard element of trauma processing for kids within the EMDR tradition, and more
detail on how to develop such helpers is available from other sources (Greenwald, 1999). These
helpers can be toys, imagined weapons, celebrities or fantasy characters from the mass media,
or people that the child knows personally, such as family members. By this time in the treatment,
the therapist is likely to know the child fairly well, and may suggest, “Would you like to hold
that [toy] sword while we talk?” or “Would it help to imagine that your father is here with you
now?”
If you are using a helper, sometimes the child will incorporate the helper into a fantasy ver-
sion of the story being told. That is, instead of telling the story as it actually happened, the child
may tell it the way he wishes it would have happened had the helper been available. If this oc-
curs, don’t worry, just keep going. Sometimes kids need to tell it the “wishful” way one or more
times; this helps them gain the strength to tell it the harder way. However, if the child only tells it
the fantasy way over and over, the therapist can actively encourage the next step, for example, by
saying, “This time, can you imagine that your father is here with you while you tell the story the
way it actually happened?”
 Conducting an Exposure Session 207

Practice with Stopping

By now itis your habit to remind your clients of how to follow your rule if there is something
they don’t want to talk about. Every time you are about to do something that might be touchy,
you remind them again. It’s like a friendly warning: there’s a hill up ahead, remember how to use
the brakes if you need to? When it’s time to do exposure, we go a little farther, in effect saying,
“Here comes a very steep hill. It’s time to check out the emergency brakes, too!” One way to do
this is by practicing a new way to stop.

THERAPIST: We're going to be talking about something that might be hard for you sometimes.
So you might need to take a break. That doesn’t mean that you can’t handle it, just that you
need to take a break. So if you want a break, what can you do?
CHILD: I can say I want a break?
THERAPIST: Right. Let’s practice that right now, I’m going to be talking and you interrupt to tell
me you want a break, okay? Bla bla bla bla...
CHILD: Stop! I want a break!
THERAPIST: Good, you can do it. I want to show you another way, too, that you can do it without
even telling me. Remember the safe place image that you use here sometimes?
CHILD: Yes.
THERAPIST: Okay. What did you have for breakfast this morning?
CLIENT: Cereal.
THERAPIST: Here’s what we’re going to do. You start out by concentrating on what you had for
breakfast. Then [ll call out “Switch” and you go as fast as you can to the safe place. When
you get there, let me know. Okay, think about breakfast . . . Switch.
CLIENT: I’m there.
THERAPIST: Good. What did you have for dinner last night?
CLIENT: Chicken and potatoes.
THERAPIST. Okay, think about the chicken and potatoes . . . Switch.
CLIENT: I’m there.
THERAPIST: That was fast. Do you think you’re pretty good at this, or do you want more prac-
tice?
CLIENT: I’m good at it.
THERAPIST: Okay, so if you decide you want a little break, you can go any time to your safe
place. You don’t have to ask first.

As with the initial “rule” about what to do if there’s something you don’t want to talk about,
we give the clients practice with this new method of putting on the brakes. Telling them about it
is nice, but not really enough. Clients develop belief in these brakes when they’ve had the expe-
rience of using them. The more kids feel that they are in control, the more willing they are to at-
tempt a challenge such as exposure.

EXPOSURE PROCEDURE

Here are the instructions we give to an older child or adolescent who is about to do exposure:

1. Tell the story (or the selected part of the story) from beginning to end.
2. Tell it in the present tense, as if it’s happening right now.
208 CHILD TRAUMA HANDBOOK

3. Say what’s happening, also what you’re thinking and feeling. :

4. Now and then1’ll ask a question to help me understand something, or to see how you’re do-
ing. ' '
5. When you finish, I’ll ask you to do it again, and then again. This is how you'll get stronger.

When the child is telling the story of the trauma memory, he will probably not be following
your instructions exactly. That’s okay. This is a process. It can take many retellings, over one or
even several sessions, for the work to get done. Your goals, meanwhile, are (1) for the child to
make at least a little progress each time, to digest at least one or two more bites, and (2) for the
child not to get bitten by the dog, not to get overwhelmed. As long as you are achieving your
goals, you can just let him tell it the way he is telling it. ;
Then when he’s through, you give the instructions all over again, and he tells it again. This
time, you’ll probably notice that some parts of the story are different—a little more detail here, a
little more emotion there. This is your signal that the work is getting done. If this is happening,
trust the process. Don’t pester him with questions; just let him talk. Trust the process; it works.
Your goal is to keep a balance, to help the child stay feeling strong enough to handle it, but
also engaged enough with the memory that there is something to handle—too much and he gets
overwhelmed, too little and nothing is being digested. In the middle ground, as long as some-
thing is moving, the therapist mostly witnesses and stays out of the way. The therapist should
keep several strategies in mind during an exposure session, to keep the child on track.

Structure First

If you notice that the story is being told without much emotion or detail, that can be a good
thing. In the previous session, we did this on purpose when we broke down the memory with the
“list” approach. We accept a superficial narrative, especially early in the procedure. This allows
the child to build the structure of the story before filling it in. Remember, until now the memory
may have been a jumble of unorganized fragments. Giving the story order and structure helps
the child to feel more secure and grounded. In particular, we want her to be secure in knowing,
and feeling, that the good end is connected to the difficult middle, before she gets too involved in
the emotions related to the difficult part.

Be Permissive

You might also notice that in telling the story, the child suddenly shifts from present tense to
past tense. What does that mean? What just happened there? It probably means that she reached
a more emotionally difficult part of the memory and felt the need for more distance. You might
also notice that the child is telling lots of detail, thoughts, feelings, and then suddenly skims
through one portion of the memory very quickly. This is probably another strategy for managing
something difficult. Your job is to be glad that your client knows how to manage the intensity of
the exposure to this memory. This saves you the trouble! So when you notice these things, espe-
cially early in the story, be permissive. Just accept what is said and let your client keep going.
Later, when she is feeling stronger, she will probably dig in more.

Repeat

When the story has been told, give the first three instructions again, verbatim. As the child
gets used to hearing these instructions, he may start to prompt himself, for example, “Oh, I went
to the past tense. Okay, now I’m walking in. . .” This is fine, but don’t think that’s a reason for
you to start doing it. Stay out of the way. The next time the story is finished, give the instructions
 Conducting an Exposure Session 209

again. By now you can probably use a shorthand version: “Okay, start again from beginning to
end, present tense, and what you’re thinking and feeling.”
You might notice that your client thinks that this is enough already. He’s already told it (once,
twice, three times). Okay, some interesting things came out, but that’s enough. Nothing else is
going to happen. You might also notice that you're feeling the same way! That’s okay. Have
your client tell the story again anyway. And again. And again. And again. You will probably no-
tice that each time, more progress is made.
Regardless of my assurances that you should keep going, chances are that when you’re on the
spot, you will still be skeptical and unsure about this. I don’t know why this should be, but Iam
predicting it because it’s so typical. The problem is, if you don’t believe in your heart that there’s
value in persevering, it’s going to be difficult for you to convince the client to keep going when
he’s telling you he’s sure he should be stopping now. You need to experience this for yourself, as
a client, with someone who will encourage you to keep going long enough to fully resolve the
memory. Even then, it'll take practice and experience as a therapist for you to become accus-
tomed to this. Ideally, while you’re learning and practicing these methods, you are also being su-
pervised by someone who is already good at trauma treatment.

Monitor

I’ve just been telling you over and over again to trust the process and stay out of the way. Now
I'll tell you when to jump in. It comes down to monitoring your client. Remember in the instruc-
tions, you said, “Now and then I’ll be asking you a question”? You were preparing for this
eventuality.

remrineecttaiaener 0060089 =

(AGAIN? THIS 1S .
ETTING BORING!
210 CHILD TRAUMA HANDBOOK

Remember, you want her to be engaged but not overwhelmed. How can you tell if she is in-
deed in that middle ground where good things can happen? Or in the danger zone? Or in com-
fortable avoidance? You do this by observing and, if necessary, by asking.

Too much? If you are concerned that too much exposure is happening, your job is to help
the client to gain a little more distance and composure. You can check in, ask for SUDS, see
if the client is okay or feeling overwhelmed. Note that some clients can tolerate a very high
SUDS and still be okay. If needed, you might suggest deep breathing, taking a break, or
skipping the hard part of the memory for now and going to an easier part.
Too little? If you are concerned that too little exposure is happening, you can start gently
prompting your client to report all details, to stay in the present tense, ando describe what
she is thinking and feeling. Remember that the client may have many good reasons to avoid
greater engagement, so you don’t want to push too hard at the wrong time. Use your clini-
cal judgment. If you are confident that your client really can handle this with some encour-
agement, then go ahead and push a little.

EXERCISE: PRACTICE WITH EXPOSURE

If You Are the Client

This is not a role-play. Be yourself.

Choose a memory (from your trauma history list or otherwise) that you rate six or lower on
the zero to ten scale, and that you are willing to talk about today. If you participated in the
Breaking Down the Memory exercise, you might want to continue with the same memory.
Do not look at the script; that’s the therapist’s job.
Remember what to do if you feel that you need a break or if there’s something you don’t
want to talk about. Just because you agree at the beginning does not mean that you will feel
the same way later on. Take care of yourself.

If You Are the Therapist

When your client tells you what memory she’!] be working on, help her to identify a good
end that’s a specific event.
Use the following instructions, one through five, the first time. Verbatim, of course!
Do your best to restrain yourself and allow your client to do her work. Don’t pester her with
questions about details, present tense, thoughts or feelings. Don’t tell her your own insights
or interpretations. Just be present and let her tell her story.
Make sure the story goes all the way to the good end.
Repeat the first three instructions, again verbatim. Have the client tell the story again.
Do this as many times as you have time for and as your client will tolerate.
When you have finished with the exposure portion of the exercise, use the “Container” to
put the memory away. Then see if your client would like to do some deep breathing or a
safe place visualization.

Exposure Instructions

1. Tell the story from beginning to end.

2. Tell it in the present tense, as if it’s happening right now.
3. Say what’s happening, also what you’re thinking and feeling.
 Conducting an Exposure Session 241

4, Now and then I'll ask a question to help me understand something, or to see how you're do-
ing.
5. When you finish, I’ll ask you to do it again, and then again. This is how you'll get stronger.

Discussion Questions

* Ina group, clients, please share your comments and experiences.

* How many (clients) found that the SUDS turned out to be higher than you had initially
rated it?
° or: many (clients) feel that you are worse off than before? The same as before? Better
off?
¢ Therapists, please share your comments and experiences.
* How many therapists had some difficulty restraining yourself from making comments or
other interventions?
* How many clients felt that the therapist cared about you? What did you notice that made
you think that?
* How many therapists had a personal emotional reaction while conducting this session?
How did you handle this? How do you feel now? Do you need to do anything else to take
care of yourself?

SELECTING THE TARGET MEMORY FOR EXPOSURE

Here’s a reminder about the difference between workshop practice and clinical practice. In a
workshop setting, we count on participants to decide for themselves what memory they want
to work on today. In clinical practice, we do not ask our clients, “What memory do you want to
work on today?” That would be an abdication of our professional responsibility. Imagine going
to a physician and being asked, “What examination methods would you like me to use today?”
or “What medication or treatment would you like me to prescribe today?”
As therapists, we are the ones with the professional training and knowledge. It’s up to us to
develop a case formulation and treatment plan. It’s up to us to develop, in collaboration with the
client, of course, a strategy for selecting the order of memories to target with exposure. Our cli-
ents don’t know what we know about how treatment works or how to make these choices. That’s
our job.
I’m making this point for two reasons. First, when something is practiced in a workshop set-
ting, it can feel natural to do it the same way in clinical practice. So it’s important to alert you to
any differences. Also, many therapists have been previously trained to believe that it’s good clin-
ical practice to let the client determine what is discussed, so the way you practiced this in a
workshop setting might also be consistent with some of your clinical practice habits. Although
trauma therapists do try to take the client’s current concerns into account, and if possible inte-
grate these into the treatment session, trauma therapists do much more than follow the clients.
Trauma therapists guide clients through a carefully structured series of tasks, designed to help
them gradually become safer and stronger, digest the trauma memories, and prepare for future
challenges.

When Have You Done Enough Exposure?

Are we done yet? How do you know when you have finished with exposure for the memory
you’ve been working with? Although this question has no definitive answer—practices differ
among the various trauma resolution traditions—there are some useful guidelines.
zi2 CHILD TRAUMA HANDBOOK

No More Changes

You notice that the story is the same, again and again. (When the child first complains that it’s
getting boring, the therapist says, “Good, that’s what we want. That means that it’s losing its
power. Now tell it again”) No new detail is forthcoming, the emotional issues have been worked
out and no longer seem to have any charge, and the client has an easy time telling the story fully.

No Irrational Negative Self-Statements

In an unprocessed memory, often negative beliefs exist about the self, such as “It was my
fault,’ “I’m bad,” “I’m not safe,” etc. These are the kinds of beliefs that hurt your client—they’re
part of his sore spot. When your client has really digested the memory, he will have a healthier
way of seeing the memory and his part in it. Now he will make statements such as, “I did the best
I could,’ “I’m safer now,” and “I learned from this.”

Low SUDS

You don’t need to get toa SUDS of zero to be done (unless you’re using EMDR). With expo-
sure, even when you’ve done all the work, sometimes the SUDS level stays at a low or moderate
level for days or even weeks afterward. As long as you’ve really worked the memory into the
ground, and the other criteria are met, you’re probably okay. However, if any portion of the
memory is still highly distressing, it can probably use more work.

Symptom Reduction

If you are doing exposure on one memory of many on the trauma list, you are not likely to see
much in the way of quick symptom reduction, because so many other memories remain that are
also driving the symptoms. However, if you are doing exposure with the primary identified
trauma, you should expect to see some symptom reduction within days or weeks. You are most
likely to see reduction of symptoms that are most closely related to posttraumatic stress, such as
nightmares, bed-wetting, and intrusive imagery. However, other symptoms may also diminish.
Ideally the SUDS should be no higher than about a three, and lower is even better. Ultimately
the child should feel strong, in control, and bored with discussing the trauma.

The Session After Exposure

When you are working with a child in the trauma resolution phase of treatment, and you have
been doing exposure, you should be doing specific things in the session after the exposure ses-
sion.

Regular Check-In

It’s important to do your regular beginning-of-the-session check-in, for several reasons. The
check-in maintains the routine that is part of the structure and predictability of your treatment. It
also serves a purpose, which is to find out what’s happening. If there is some crisis or pressing
concern, you will want to know that right away, so you can take it into account and perhaps ad-
dress it. It can be very frustrating to go ahead with your own agenda only to find out that your cli-
ent can’t concentrate because of some other concern that you weren’t aware of. Finally, the
check-in might give you some clues about the child’s response to the work done in the previous
session.
 Conducting an Exposure Session Peal)

Ask About the Memory

You want to know how the previous session’s work might have affected your client during the
week, and you want to know the current status of the memory. So you might say something like,
“We talked about a hard thing last week. In the last few days, did you think about that more than
usual, less than usual, or about the same? And on zero to ten, where is it now?” After an expo-
sure session it is fairly common for the client to think more about the event than usual, at least
for a while, and then to feel more relief and leave it alone. But don’t be surprised if the memory
is worse than when you left it, better, or the same. Anything can happen.

Finish Work on the Memory

If the memory is still unresolved, then you can do more work with it. Does a blocking belief
need to be challenged and corrected? Does a hot spot exist that can be worked over? Or is it just a
matter of having your client tell the story more times?

Do Exposure with the Next Memory

If the memory you’ve been working on has been fully digested, it’s time to do exposure with
any remaining memories that are still disturbing to the client. You’Ilwant to use the same kind of
judgment and strategies that you’ve been using already, to select the next memory to target with
exposure, and to help your client get through it. Of course, now that your client has made it
through exposure successfully with one memory, she is stronger and more experienced, so she
will be able to handle a little more challenge in the next one.
The trauma resolution phase continues until all the significant trauma/loss memories have
been resolved and are no longer a source of distress.
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 Chapter 16

Problem Solving in an Exposure Session

Doing exposure well takes practice, and even though it may seem pretty simple, there’s a lot
to it. It will be difficult to do exposure well, and to fully use the suggestions here, without super-
vised practice. Much of deciding if, when, and how to intervene during an exposure session is
clinical judgment. The practice and supervision will help you learn where the judgments fall.
Many sessions will go smoothly, and then the basic procedures and principles described in
the previous chapter will get you through nicely. Other sessions will not go so smoothly. This
chapter will give you ideas on what to do in response to some of the most typical problems that
come up during exposure. Actually, these typical problems are all variants of the same basic
problem: that the memory is difficult to get through. However, the memory can be difficult for
various reasons, each calling for a different problem-solving strategy.
When the exposure session is going smoothly, meaning that movement (change) occurs from
one time to the next, then at the end of one telling of the story, the therapist can simply repeat the
instructions and have the client tell the story again. On the other hand, if the therapist has con-
cerns about how the session is going, the end of a telling of the story can be a good time to check
in, ask questions, and try to figure out what’s going on. This doesn’t mean that it’s okay to ask
pointed or intrusive questions that will push the client to open up again to the difficult part of the
memory! The goal of the questioning is to learn whether the client is still in the productive mid-
dle ground, or if not, what the nature of the problem might be. Understanding the problem al-
lows the therapist to choose the best intervention to solve the problem.

PROBLEM: ONE PART OF THE STORYIS ESPECIALLY DIFFICULT

Sometimes most of the story is going smoothly, seems easy to tell, but one place in the mem-
ory is areal sticking point (or maybe a couple of places). You might have a feeling that much of
the memory is too easy and nothing’s happening there, while the part that’s difficult is not really
getting much airtime.

Signals That This Might Be Happening

¢ One or two places in the memory seem much more difficult than the rest.
¢ The difficult places do not move or change from one telling to the next.
¢ Therapist is wondering what to do about this (this really is one of the signals!).

Questions the Therapist Can Ask at the End of a Telling

¢ How did it go for you this time? What struck you the most?
¢ What’s the worst part of the memory right now? Where is that on zero to ten?
215
216 CHILD TRAUMA HANDBOOK

Intervention Strategy

¢ Work the “hot spot.” Go through the portion of the memory that includes the hot spot—per-
haps from just before that part to just after it. Do this over and over again. It’s okay to leave
the rest of the memory alone for a little while.
¢ After you’ve made some headway on the hot spot, go back to working with the story of the
whole memory again. Hopefully things will keep on moving now.
¢ The hot-spot strategy can be repeated if necessary, and/or tried with other spots in the
memory.

PROBLEM: THE CLIENT SEEMS OVERWHELMED

If the client is feeling overwhelmed, he cannot digest anything. Also, there is a risk that he
will experience the exposure session itself as a new trauma. In the early days of exposure, a large
percentage of clients dropped out of treatment for this reason. Now that we are better at catching
this problem and helping clients stay in that productive middle ground, we don’t lose so many of
them. It’s a bit tricky to achieve this balance, though. On the one hand, we are asking our clients
to talk about an upsetting thing that happened to them, in the present tense, along with details,
thoughts, and feelings. Surely we are expecting some anguish and tears! Yet we don’t want them
to get bitten by the dog. We want them to face only what they can handle and digest. So it’s im-
portant to remain sensitive to the client’s status, and to try to keep them from trying to take too
many bites at a time.

AFRAID OF GETTING BIT AGAIN?

 Problem Solving in an Exposure Session Ze

Signals That This Might Be Happening

* Expression of distress. The child may say that he is feeling bad or is having a difficult time.
Body language. This can include crying, tearfulness, changes in breathing or posture, etc.
It can also include restlessness or fidgeting.
Shift to past tense. Going from present to past tense is a distancing strategy. It is used fre-
quently in exposure sessions that are going well, so it’s not automatically a problem. But it
is an indication that the client is trying to back off. You can take this into consideration
along with the rest of what’s happening, and see if you think there’s a problem.
* Shift to superficial. Again, at times a superficial account is appropriate within an exposure
session that’s going well. Early on, many kids will lay down the structure of the story with
one or more rounds of a relatively superficial recounting. Much later, after the details have
been told and worked through, the story might again become relatively superficial because
the details are no longer interesting. However, when you see your client telling the story in
some detail, and then getting to a difficult part and skimming over it in a superficial man-
ner, the client is probably practicing an avoidance strategy. This is not automatically a
problem if progress is being made, but should be taken into consideration.
¢ Humor. If your client makes a joke about something that’s really painful, usually it’s best if
the therapist can respond both to the underlying pain and to the fact that the client is at-
tempting to gain some distance from the pain. It’s okay not to laugh.
¢ Boredom. When the memory is really worked into the ground, boredom is a goal, a sign of
success—it means that the memory has lost its charge. However, sometimes a client will
complain of boredom prematurely, before the work is even close to being completed. Al-
though sometimes this can be a sign of actual boredom, often it is an indication of avoid-
ance.
¢ Overtalking. Beware of clients who give way too much detail about things that don’t mat-
ter, such as what she ate for breakfast the week before the event. You’!] know this when you
hear it. Another method of overtalking is when clients seem to spend all their time talking
about the exposure session in one way or another, rather than doing it. Think, “Avoidance.”
¢ Wanting to be done (for any of a variety of “reasons’’). I’m all better now; this is boring; this
is stupid; this isn’t doing anything; can we play now?

Questions the Therapist Can Ask in the Moment of Concern

¢ Where are you now on zero to ten? Is this okay for you, or does it feel like too much?
¢ Are you telling me that it might be too hard to talk about this part right now? Should we go
to another part that’s not so hard?
¢ Do you feel like you want to just keep going? Or should we take a little break?

Intervention Strategies

¢ Allow some avoidance (e.g., a shift to past tense, a superficial telling of a certain part).
Then just give the regular instructions the next time through, and let the client set her own
degree of closeness or distance to the memory.
* Bring the SUDS down. This can be done with deep breathing, safe place visualization, or
other strategies.
¢ Shift to another less challenging focus.
¢ Go to the good end; focus on things being okay now.

CONCORDIA COLLEGE LIB

RARY
3RONXVILLE, NY 10708
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218 CHILD TRAUMA HANDBOOK

PROBLEM-BLOCKING BELIEFS

Sometimes the “sticking point” in a distressing memory is a child’s negative belief, for exam-
ple, that she was at fault in some way. Such beliefs are not always rational, and even the rational
ones are generally not objectively true, even if they may work within a child’s logic and limited
fund of information. These are called “blocking beliefs” because they block further progress in
digesting and resolving the memory.
Some beliefs are directly related to the exposure process itself. For example, a child may be-
lieve that she can’t handle the emotion associated with the memory, and so remains at a superfi-
cial level in each telling. Another example would be a child who believes that if she talks about
the memory, she will get so angry at her parent that their relationship will be destroyed. This
type of blocking belief prevents the child from being willing to fully participate in the exposure.
Sometimes the problem beliefs work themselves out over repeated exposure. If this does not
seem to be happening, the therapist can try cognitive restructuring interventions, including So-
cratic style questioning as well as psychoeducation. In other words, we give bits of information
and ask questions to lead the child to a different and more useful way of looking at it. Here is an
example of how a therapist might introduce information to shake loose a blocking belief, while
allowing the child himself to generate as much of his own understanding as possible.

CHILD: I should have told her to watch out for that car; it’s my fault.
THERAPIST: Did you know the car was coming?
CHILD: No, but I should have known. I should have been watching.
THERAPIST: Did your mother give you that job, to watch for cars behind her?
GHILDANG)
THERAPIST: Did you know that if you were always twisted around to look behind you, you could
get more hurt than you did?
CHILD: No.
THERAPIST: Your mother told me about this accident, too. Did you know that even if you had
seen that car and said, “Watch out!” your mother still couldn’t have gotten out of the way?
CHILD: No, I didn’t know that.
THERAPIST: The rule is, it’s the driver’s job to watch for other cars, and it’s the kids job to sit with
a seat belt on, and not to mess around, so that the driver can concentrate on driving. Did you
have your seat belt on?
CHILD ayes:
THERAPIST: And were you screaming and jumping around so your mother couldn’t concentrate
on driving?
CHILD: No, we were just talking.
THERAPIST: So you were doing your job. Were you driving that other car, the one that crashed
into your car?
CHILD: No!
THERAPIST: So whose fault do you really think it was, your fault for doing your job just the way
you were supposed to? Or the other driver who wasn’t paying attention and crashed into you
guys?
CHILD: The other driver.
THERAPIST: That’s what I think, too. Now go back to when you’re sitting at the stop sign, and tell
the story again.
 Problem Solving in an Exposure Session 219

Signals That This Might Be Happening

* The client seems stuck, not making progress.

* The client states a blocking belief, either spontaneously or in response to questioning.

Questions the Therapist Can Ask at the End of a Telling

1. What was the hardest part this time? Where is that now on zero to ten?
2. What keeps that part from getting better?
3. What are you saying to yourself about that?

Although the general approach to blocking beliefs is the same regardless of the specific be-
lief, specific interventions seem to work best in response to particular blocking beliefs. Some of
the most common types of blocking beliefs, along with suggested interventions, are listed in the
following:

Blocking belief: 1 m still in danger.

Suggested intervention: Is that true? Please explain. Can he hurt you from jail? Etc. (Note
that if the client really is still in danger, this should be addressed as much as possible
prior to trying exposure.)
Blocking belief: It was my fault/I should have done X (when this is irrational/incorrect).
Suggested intervention: Provide information; ask clarifying questions.
Example: An eleven-year-old girl had come home from school at age five to see her grand-
father on the floor, having a heart attack. In the exposure session, she is stuck on, “I
should have called nine-one-one.” Even though she has been told previously that it was
already too late, that an ambulance could not have saved him, she is not thinking of that
right now. She’s stuck on blaming herself.

THERAPIST: Do you remember what the doctor told your mother about that?
CHILD: What?
THERAPIST: That he would have died anyway, even if someone did call nine-one-one.
CHILD: Oh, yeah.
THERAPIST: So how old were you when this happened?
CHILD: Five.
THERAPIST: Did you know nine-one-one when you were five? Had someone taught you that?
CHILD: No, I just learned it maybe last year.
THERAPIST: Yeah, I think most kids learn nine-one-one when they’re maybe nine or ten years
old. So you weren’t old enough to know nine-one-one then?
CHILD: I guess not.
THERAPIST: And the doctor said it wouldn’t have helped anyway?
CHILD: I guess not.

Blocking belief: It was my fault (when this is true).

Suggested intervention: What have you learned from this? What do you know now that you
didn’t know then? What would you do (in that situation) now? Is there anything you can
do to make up for what happened?
220 CHILD TRAUMA HANDBOOK

This is a particularly tricky situation, because when the child actually did cause the bad event,
it’s not an irrational belief that can be refuted. Still, there’s no point in living a miserable life just
because you did something bad. The goal here is not to relieve the child of legitimate guilt, but to
help her figure out how to learn to live with this and move on in a productive way. Kids can often
recognize that they have learned and grown, that they are different now, and that they would do
something different in that situation now. It can also be helpful for the child to find some way to
help others, as a way to make amends for the earlier wrong.

Blocking belief: ’'m a bad person because of this.

Suggested intervention: Who did the bad thing? Did you deserve this? What would you say
if it happened to someone else?
Example: A ten-year-old girl had been molested by her uncle a few months earlier. At that
time her uncle had blamed her for his behavior, saying that the dress she was wearing,
and the way she looked, made him do it. In the exposure session, she is stuck on the idea
that she is a bad person because if she caused it, she must have wanted it to happen.

THERAPIST: So when you put that nice dress on, what were you thinking about?
CHILD: Just that it was a nice dress. I like to wear it; it’s pretty. My parents gave it to me for my
birthday.
THERAPIST: You weren’t saying to yourself, “I think I’1l wear my nice dress today so that my un-
cle will mess with me’?
CHILD: No! I never thought of that.
THERAPIST: I didn’t think so. So how old is your uncle?
CHILD: I don’t know, maybe thirty?
THERAPIST: And how old are you?
CHILD: len:
THERAPIST: And who’s bigger?
CHILD: Ee 1s:
THERAPIST: So who usually decides what happens, the bigger older person who’s in charge, or
the smaller younger kid?
CHILD: The big person. But he said that if I hadn’t worn that dress—he said I made him do it.
THERAPIST: Do you think that when you grow up, you’ll have a family of your own?
CHILD: I think so.
THERAPIST: What if you give your daughter a really nice dress for her birthday? And then some
big grown-up man messes with your daughter—and he says it’s her fault because she was
wearing that nice dress. Whose fault would it really be?
CHILD: The man’s.
THERAPIST: It wouldn’t be your daughter’s fault for wearing that nice dress you gave her?
CHILD: No, she can wear a nice dress; there’s nothing wrong with that.

Blocking belief: If 1 feel better (about the person’s death) that would mean that I didn’t
care. Alternately: If lam no longer in mourning, that would mean that I am no longer in
a relationship with this person.
Suggested intervention: What would [the dead person] want for you to do?

This is a very common blocking belief in exposure sessions focused on bereavement. The es-
sence of this blocking belief is that the child’s primary goal is to maintain a relationship with the
 Problem Solving in an Exposure Session Zak

dead person. That’s more important to the child than getting rid of sadness. The problem is, right
now, the only way the child can see how to maintain the relationship is to keep the sadness.
In this situation, telling the child to go ahead with the exposure—in other words, let’s get to
work on getting rid of the sadness—risks giving the message that the therapist does not care
about helping the child to maintain the relationship. But that’s the child’s primary concern. This
creates an impasse, and nothing gets done.
It’s better to work with the child on the child’s goals. Although you can simply ask, “What
would [the dead person] want for you to do?” it’s even better to have the child ask the dead per-
son directly. Then instead of giving her own opinion of what the dead person would say, she can
get the actual statement. Since most people have some experience in talking with dead people,
this is usually not too hard to accomplish. For example:

THERAPIST: So how would you talk with your grandmother? Some people would go to the
graveyard; some people would go outside at night; some people would do it while they’re
sleeping, in their dreams; some people would write a letter and then burn the letter so the
smoke goes up... What would work best for you?
CHILD: I would go outside at night and talk to her in the sky.
THERAPIST: Okay, now what I want you to do is imagine going outside at night and talking to her
in the sky. You can do this with your eyes closed, if you want. Imagine telling her how much
you still care about her, and how you are staying sad to show her that. Ask her if that’s okay
with her, if that’s what she wants you to do. And notice how she answers...

This is not an exhaustive list of blocking beliefs or problem-solving strategies, but it gives
you the general idea. Notice that although the therapist does introduce information in certain cir-
cumstances, in general the therapist avoids telling the child what to think or believe. Rather, the
information and questions are designed to guide the child to reach his own conclusions. Then
they are his and there is a better chance that he’Il integrate these conclusions into his story.
After the blocking belief has been addressed and possibly resolved with this cognitive inter-
vention, you can go back to working on the memory as before. Perhaps the first time, you might
want to work just on the hot spot related to the blocking belief. Normally when the blocking be-
lief has been addressed, you will see renewed progress when you return to the regular exposure
procedure.

EXERCISE: PRACTICE WITH EXPOSURE

This is the same exercise as in Chapter 15. It’s a good exercise to practice, and this time
around you know more about how to do it than you did before.

If You Are the Client

¢ This is not a role-play; be yourself.

¢ Choose a memory (from your trauma history list or otherwise) that you rate six or lower on
the zero to ten scale, and that you are willing to talk about today. If you participated in the
Breaking Down the Memory exercise, you might want to continue with the same memory.
¢ Do not look at the script; that’s the therapist’s job.
¢ Remember what to do if you feel that you need a break or if there’s something you don’t
want to talk about. Just because you agree at the beginning does not mean that you will feel
the same way later on. Take care of yourself.
222 CHILD TRAUMA HANDBOOK

If You Are the Therapist

When your client tells you what memory she’ll be working on, help her identify a good end
that’s a specific event.
Use the following instructions, one through five, the first time. Verbatim, of course!
Do your best to restrain yourself and allow your client to do her work. Don’t pester her with
questions about details, present tense, thoughts or feelings. Don’t tell her your own insights
or interpretations. Just be present and let her tell her story.
Make sure the story goes all the way to the good end. :
Repeat the first three instructions, again verbatim. Have the client tell the story again.
Do this as many times as you have time for and as your client will tolerate.
When you’re done with the exposure portion of the exercise, use the “Container” to put the
memory away. Then see if your client would like to do some deep breathing or a safe place
visualization.

Exposure Instructions

1. Tell the story from beginning to end.

2. Tell it in the present tense, as if it’s happening right now.
3. Say what’s happening, also what you’re thinking and feeling.
4, Now and thenI’1l ask a question to help me understand something, or to see how you're do-
ing.
5. When you finish, Ill ask you to do it again, and then again. This is how you’|l get stronger.

Discussion Questions

In a group, clients, please share your comments and experiences.

How many (clients) found that the SUDS turned out to be higher than you had initially
rated it?
How many (clients) feel that you are worse off than before? The same as before? Better
off?
Therapists, please share your comments and experiences.
How many therapists had some difficulty restraining yourself from making comments or
other interventions?
How many clients felt that the therapist cared about you? What did you notice that made
you think that?
How many therapists had a personal emotional reaction while conducting this session?
How did you handle this? How do you feel now? Do you need to do anything else to take
care of yourself?

SECTION IV BIBLIOGRAPHY

Ahrens, J. & Rexford, L. (2002). Cognitive processing therapy for incarcerated adolescents with PTSD. Journal of
Aggression, Maltreatment & Trauma, 6, 201-216. The first report of CPT being used successfully with adoles-
cents.
Deblinger, E. & Heflin, A. H. (1996). Treating sexually abused children and their nonoffending parents: A cognitive
behavioral approach. Thousand Oaks, CA: Sage Publications. This is the classic text/manual on doing modified
exposure with kids, using the strategy of making a book to tell the story of the trauma memory. Much of the re-
search showing that exposure works with trauma-exposed kids has used this manual as the basis for their treat-
ment.
 Problem Solving in an Exposure Session 223

Gil, E. (1991). The healing power of play: Working with abused children. New York: Guilford Press. An alternative
structured/focused approach to trauma resolution using play.
Greenwald, R. (1999). Eye movement desensitization and reprocessing (EMDR) in child and adolescent psycho-
therapy. Northvale, NJ: Jason Aronson. A thorough presentation of EMDR for kids, within a trauma-informed
treatment approach. Plenty of vignettes and session transcripts to see how it really goes.
James, B. (1989). Treating traumatized children: New insights and creative interventions. Lexington, MA:
Lexington Books. Another example of both traditional and innovative child therapy methods applied to trauma
treatment.
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 SECTION V:
MAKING THE MOST OF IT

When you’ve finished the trauma resolution phase of treatment, the child is much closer to re-
gaining a developmentally appropriate level of functioning. Sometimes this just happens—once
the trauma is cleaned up, symptoms seem to just melt away, and more normal functioning takes
over. Sometimes, though, problems remain. These can be taken care of more easily now that the
unprocessed trauma is no longer driving the symptoms. For example, this might be an excellent
time to revisit skill development. Now that the trauma is out of the way, kids will have a much
better chance of learning better study habits, self-management skills, and other things they may
have been working on.
Some of the persisting symptoms might be clearly trauma related. For example, a child may
avoid a certain type of activity or place that reminds her of the trauma, even after the trauma it-
self is no longer particularly distressing. Another example is related to the “hyperarousal”
symptom—the child might still have an unreasonably strong reaction to something that is, in
some way, a reminder of the trauma:
A fourteen-year-old girl who had been abducted by men driving a red car continued to become anxious
whenever she saw a red car.
A twelve-year-old boy who had been overly reactive to his frustration in math class, perhaps initially be-
cause this reminded him of his trauma-related helplessness, continued to be overly reactive and to give
up too easily.

Family relationships should also be reevaluated, since these may have been modified as a
function of the parent training and/or the child treatment. For example, a child who has been
overprotected may start to be given more responsibilities. Also, some children believe that their
symptom serves an important function in the family; once the symptoms are reduced or elimi-
nated, the therapist has an obligation to check and make sure that the family is okay, and has
found another way to take care of what the symptom was being used for:
An eleven-year-old girl had “school phobia” because she was afraid to leave her mother alone during
the day. Her mother had a medical condition and this fear was somewhat realistic. In a family meeting fol-
lowing the trauma resolution work, the therapist checked to make sure that there was still a trusted adult
checking in with mother during the day.
A seven-year-old boy, at the beginning of treatment, had been reluctant to participate. Then in a family
meeting, in response to the therapist's questions, he had expressed concern that if his mother didn’t have
to worry about him and yell at him any more, they wouldn't be as close. The family made an agreement
that as his behavior improved and his mother didn’t have to discipline him so much, they would find other
things to do together, such as play games and watch movies. After the trauma resolution was completed,
in a family meeting the therapist asked how often they were doing things together such as playing games
and watching movies.

The issue of the child’s vulnerability should also be addressed at this time. Before, the focus
was on safety and stability in the present. Now the focus can be on the future. What can be done
225
226 CHILD TRAUMA HANDBOOK

to limit vulnerability to further trauma exposure? If something bad happens anyway, what can
be done to limit deterioration and facilitate recovery? Also, for kids who have been unwilling or
unable to complete the trauma resolution work, how can remaining trauma-related vulnerabili-
ties be managed in the future, especially in times of increased stress?
The following chapters focus on how to follow up on trauma resolution work, how to consoli-
date the gains made in the prior treatment phases, addressing the issues described previously. A
range of interventions may be used, including family systems interventions, in vivo exposure,
and relapse prevention. The concepts and procedures directly build on previous interventions.
 Chapter 17

Reevaluation and Consolidation of Gains

After trauma resolution has been completed, some of the easiest remaining problems to take
care of are those that are trauma-related. Often these problems or symptoms will melt away, but
sometimes they have taken on a life of their own. Then they tend to be very responsive to cogni-
tive and behavioral interventions, because the driving force behind the problems is no longer
present.
There are a number of effective strategies for overcoming leftover trauma-related symptoms,
including in vivo exposure as well as the use of incentives; these can also be combined. Use of
incentives is discussed in more detail in the final section of the book.

IN VIVO EXPOSURE

The central principle of in vivo exposure is that the fear underlying the avoidant behavior is
disproved, and “extinguished,” by persistently engaging in the avoided behavior. It’s only by
facing the situation that you’
ve been avoiding that you can find out that the feared thing isn’t go-
ing to happen. Of course, for this to be successful, it’s important for the child to be able to toler-
ate the thing she has been avoiding. The therapist helps her to prepare for this by breaking it
down into manageable steps and then rehearsing coping skills to address any anxiety associated
with doing it.

THERAPIST: I want to check with you again this week, how much has that thing been on your
mind, the memory we’ve been talking about so much?
CHILD: I don’t really think about it anymore.
THERAPIST: That must be nice. If you make yourself concentrate on it right now, how bad is the
feeling right now, from zero to ten?
CHILD: It’s the same as last time, maybe a one or two. It doesn’t really bother me.
THERAPIST: And are you back to sleeping in your own bed again, or still sleeping in your Mom’s
bed?
CHILD: Oh, I still sleep in my Mom’s bed; I’d be too scared to sleep in my own room anymore.
THERAPIST: You know, after all the brave things I’ve seen you do, I bet you could handle sleep-
ing in your own room, too. Your mom told me that when you’re good at sleeping by yourself
again, she’ll let you do a sleepover at your cousin’s house. Is that something you want to be
able to do?
CHILD: I’ve been asking her for months when can I sleep over at their house.
THERAPIST: Okay, so let’s help you get ready for sleeping by yourself, so that you’ll be more
confident that you’ll be able to handle it. We’re going to think about each step of this, from
thinking about going to bed, to going to your room, to your mother saying good night to you,
to you getting into bed, staying there, falling asleep. . . . 1want you to imagine a movie in your
mind, with each of these steps. It starts when you are thinking about going to bed, and it ends

PAGE
228 CHILD TRAUMA HANDBOOK

when you wake up in the morning. Go ahead, start the movie, and then tell me when you're
done.
CHILD: I didn’t get all the way through, I started hearing noises and got nervous and went to my
mother’s bed.
THERAPIST: In this movie, about how long did you last in your own bed?
CHILD: Maybe ten or fifteen minutes.
THERAPIST: That’s not bad for a start. Do you remember how before, we were talking about the
difference between actually being unsafe, and actually being safe but feeling unsafe?
CHILD: Yeah.
THERAPIST: Do you think that in your bed at night you are really unsafe, or aré you really sate
but maybe feel unsafe?
CHILD: I’m safe but I don’t feel safe.
THERAPIST: Do you remember what to do when you know you’re safe, to help yourself calm
down and feel safe?
CHILD: Like the breathing and stuff?
THERAPIST: Right, it’s the same thing we were doing before. The deep breathing, saying to
yourself, “I’m safe,’ thinking about your Safe Place, thinking about doing something fun. .. .
Which of these do you think would work best for you while you’re lying in bed?
CHILD: Maybe the safe place.
THERAPIST: Okay, let’s try that. Iwant you to do that movie in your mind again. This time, when
you’re in your bed and the noises start, what can you say to yourself?
CHILD: That I know I’m really safe.
THERAPIST: Okay, so when the noises start, you say to yourself, “I know I’m really safe,” and
then concentrate on your Safe Place. In this movie, stay in your bed for half an hour, then if
you want, you can go to your mother’s bed. Okay? So start at the beginning, think about going
to bed, and tell me when the movie’s over.
CHILD: Done.
THERAPIST: How did it go this time, how long did you stay in your own bed?
CHILD: I stayed for a half an hour, and whenever I got nervous I did that stuff you said.
THERAPIST: And how bad would you say it got, on zero to ten, what was the worst it got?
CHILD: Maybe a four or five.
THERAPIST: How long do you think you could stay in your bed, for real, without it getting too
hard?
CHILD: I think I could do it for half an hour, as long as I knew it was going to be over soon.
THERAPIST: |think that’s a good way to start. Every night this week, I want you to stay in your
own bed for half an hour before you go to your mother’s bed. Is there a clock near your bed so
you can check how much time you have?
CHILD: Yes, it has glow-in-the-dark hands so I can see what time it is at night.
THERAPIST: Okay, let’s try the movie one more time. You’!I go to your own bed, when you hear
noises or get nervous you tell yourself it’s really safe, think of your safe place. And after half
an hour you can leave, go to your mother’s bed. Ready?
CHILD: Done.
THERAPIST: How did it go that time?
CHILD: Easy.
 Reevaluation and Consolidation of Gains 229

THERAPIST: Okay, good. I’m going to talk to your mom about this too, so you both remember.
So every night this week, you go to your own bed for half an hour, right?
CHILD: Right.
THERAPIST: And after all the ways that I’ve seen you be brave, seen you get stronger and stron-
ger, my bet is that you’re going to be able to do this. What do you think?
CHILD: I think I can, too.

As with imaginal exposure, the ideal for in vivo exposure is a moderate level of distress. Too
low is too easy and little is accomplished; too high is too difficult, too great a risk of failure and
feeling overwhelmed. Challenges close toa SUDS of five are preferred. If the SUDS attached to
an avoided situation or behavior is much higher than five, the challenge can be broken down into
more manageable components.
With an older child, it may be more important to present a rationale, e.g., “It’s important for
you to stay in bed for at least X minutes, to prove to yourself that it really is safe there. If you
keep leaving the bed after only a minute or two, you’ll never really be sure. But if you stay there
a long time and nothing bad happens, you can learn to feel safer and safer.”
As with many interventions, in vivo exposure can be supported by incentives, such as the an-
ticipated overnight at the cousin’s house used in the above example. It is important for the thera-
pist to work closely with the parent to guide the parent in encouraging and reinforcing desired
behaviors. Just as important, though, is to build on the child’s own growing sense of strength and
self-efficacy.
In the previous example, the child is likely to overstay in her own bed, even fall asleep there,
on one or more occasions. This is not assigned, so that if it does not happen, the child does not
feel that she has failed; but if it does happen, the child feels extra successful for having surpassed
the assignment.

FAMILY STRENGTHENING INTERVENTIONS

Near the beginning of treatment, the therapist may have raised issues regarding how the pre-
senting symptoms may have been affecting the family’s sense of closeness, and/or the child’s
normal development. As treatment comes to a close, it is worth revisiting these issues. Now that
the child is no longer so disruptive, is the family really less close? Or are they (as they had pre-
dicted) just as close, but focused on more enjoyable activities? Now that the child is no longer
impaired by his fears, do his parents treat him like a normal child his age? Do they let him walk
to the corner store? Do they expect him to do chores? Or are they still extraprotective, such as
had been appropriate when he required special care?
There is no single way to approach these issues. In general, the therapist may directly inquire,
with the child, the parents, and the family together, as seems most fitting. Most commonly,
the parents can be guided to correct any remaining problems with a combination of awareness,
psychoeducation, and sometimes specific suggestions or assignments.

THERAPIST: Do you remember when we first decided we were going to work together? Do you
remember that I was worried about whether you and your parents would be less close if they
didn’t have to be busy yelling at you and punishing you all the time? But you all said that the
family would still be close, but that you would have more fun together instead of just arguing.
So I wrote down the kinds of things you thought you would be doing. Let’s see, here itis. You
said that you would watch movies together, play cards together, but also just enjoy each other
more just doing regular things like going to the store or maybe helping to cook a meal or
230 CHILD TRAUMA HANDBOOK

something. So let me ask you first: Do you think that you are more close with your parents
than before, having more good times together? Or is it worse than before, or about the same?
CHILD: I think we’re more close because I act better. I’m more good now, and they don’t have to
yell at me so much anymore.
THERAPIST: And if I was watching your family on TV, what would I see you doing together?
What would I notice that would make me think that things were better?
CHILD: When Dad asks me to take out the garbage I don’t argue with him. I just do it—well,
most of the time, anyway—and you would see us watching a movie together.
THERAPIST: What about you? How do you see it? Better than before, worse, about the same?
PARENT: Things are a lot more peaceful at home. I think it’s nicer for everyone.
THERAPIST: And would you say that when you don’t have to yell at your child, you can ignore
her now, or are there things you still do together?
PARENT: Oh, we do plenty of things together. We go to the store, errands, we do things at home,
she helps me with chores, we watch TV or movies. It’s just nicer now.
THERAPIST: You told me that that’s how it would happen, I guess you were right. That’s good, I
didn’t know if I should be worried about that or not.

As always, it’s important to learn each person’s perspective, and to obtain specific, concrete
information. The therapist asks for specifics, gives examples, and persists. In this example, the
problem had been resolved, and the therapist was just checking up to be thorough before termi-
nating. On the other hand, if problems are uncovered, the therapist would explore the nature of
the problem and work with the family to correct it.

THERAPIST: I’ve been pleased to see how well your son has done in talking about the bad memo-
ries. [know he feels a lot better now and he’s not having the bad dreams anymore. You’ve also
told me that he seems happier in general, and more interested in things again.
PARENT: Yes, you really helped my son; I’m so thankful.
THERAPIST: I’m glad he’s doing so much better. You really came through for him, too: you
brought him here, you gave him all that extra attention while he was so clingy and wanting to
be near you all the time. You really helped him to feel secure so he could get back on his feet.
PARENT: Well, he’s my baby.
THERAPIST: You know, that’s what he told me too! But now that he’s feeling better, he says he
doesn’t want to be treated like a baby anymore. Isn’t that good news?
PARENT: I know. He doesn’t want to have a bedtime anymore, wants to watch anything he wants
OngliVes..:
THERAPIST: Fortunately, you have the good sense to know that you’re in charge, and that he still
needs that from a parent. But I think there are some things you can do, to kind of push him a
little, help him feel more grown-up and responsible, like other kids his age.
PARENT: Like what?
THERAPIST: Well, you know how you were walking him to the bus stop? For a while, that was
just the right thing to do, made him feel really safe. It was just what he needed. But now—
PARENT: Oh yeah, I can see how that would be embarrassing. And I can see the bus stop from my
window anyway. I guess I don’t have to be right there where the other kids can see me.
THERAPIST: I think that’s a really good idea. You can still see that he’s safe, he can still know that
you're watching. But when you let him go by himself, you’re giving him the message that he
can handle it, that he’s okay, that he can do things that other kids his age can do. If he thinks
you believe in him, he’ll believe in himself even more.
 Reevaluation and Consolidation of Gains Psi

As with the earlier parent training, the preferred approach iis to identify the parent’s positive
intent, give credit for ways that they are already successful in expressing that intent, and then
find other things they can do to express the intent even more effectively.
This intervention often involves helping the parent make a shift from a previously appropriate
parenting role to a current role that involves giving the child more responsibility. This shift may
be difficult for a parent who is in a habit of providing an extra level of protection for a child that
has been especially vulnerable. The therapist does not accomplish this by saying that the parent
was wrong, but by saying that, to be a parent to a growing child, the parent must occasionally
make shifts to respond to the growing child’s changing parent-related needs. Parents know this;
the therapist’s job is to help the parent recognize this as one of those moments when a shift is
needed.
In the previous example, only one parental behavior change was mentioned. In an actual ses-
sion, the therapist might say, “I wonder what other ways you can show him that you believe he
can handle things that other kids his age can do?” And if this does not yield a good response, the
therapist can suggest examples of normative levels of responsibility for a child that age—for ex-
ample, doing chores, or going places with friends—and ask where the child is relative to the
norm.
Ideally, a small number (two or three) of parent behaviors are targeted for change in this inter-
vention. A single change might not be sufficient to encourage generalization; too many changes
might be hard to remember to do, leading to failure to implement the planned changes. A small
number of changes, selected according to a guiding principle (e.g., showing that we believe in
him), are likely to be implemented successfully, and can be built upon.

(See‘You AFTER ScH001 *

1)
LEV CHILD TRAUMA HANDBOOK

OTHER INTERVENTIONS

After trauma resolution, the therapist should take a good look at the child’s overall situation, a
sort of reevaluation. Check for case management and safety issues, skills and habits, and family
dynamics. Anything that still needs work, this is the time to do it. At this point, the intervention
strategy should be appropriate to the problem; it’s not a trauma issue anymore. Fortunately, at
this point, non-trauma-related intervention strategies have an excellent chance of working, since
the trauma is not in the way anymore.
 Chapter 18

Relapse Prevention and Harm Reduction

Let’s go back to the fairy tale model. Once the dragon is slain and the guy has married the
princess, well, that’s nice, but we’re not done yet. What can we do to keep more dragons from
coming along? And if one should come, what can we do to be ready for it? Now that we’ve
worked out the problems that were bothering the child and family in the moment, it’s time to fo-
cus on the future.
Relapse prevention refers to a range of interventions designed to keep a vulnerable person on
track despite the challenges and adversities that may arise. It can help to prevent recurrence of an
unwanted event; prepare coping strategies for a stressful situation; and if/when the bad thing
happens anyway, relapse prevention and harm reduction strategies can minimize damage and
speed recovery. In child trauma treatment, the goals are (1) to prevent recurrence of trauma;
(2) to prepare coping strategies for anticipated challenges; and (3) in the event of a new trauma,
to develop response behaviors including rapid recognition of the traumatization, along with
Symptom management and help seeking. Some of the same concepts and methods that have
been used throughout the treatment can be used here.
The approach to relapse prevention is very similar to the approach to self-management skills
training that was used earlier in the treatment. In fact, the Choices Have Consequences interven-
tion can be used here as well. The strategies in relapse prevention are to

1. Emphasize the child’s goals, strengths, and positive intent. Blaming the child only knocks
her down and makes her weaker and less capable of handling challenges.
2. Externalize the problem. If the problem is personality or temperament, the client is stuck
with who she is, and thus powerless to cope. If the problem is situational, the client can do
something to avoid or manage situations.
. Identify future high risks and strategies to avoid these.
. Identify specific signals as cues to specific actions.
OW
&
Nn . Identify the signals as early in the risky situation as possible, so that the client gets better at
managing the situation before it goes too far.
6. Label failures as “expected” and not as signifying total failure. If one slip means total fail-
ure, the child is more likely to give up. If a slip is expected, the child can still feel that she is
on track, and can maintain her efforts.
7. Utilize all available resources to help the child implement her coping strategies. For example:
¢ Pair behaviors with their consequences.
¢ Invoke “the rules,” “what Mommy says,” or other external authorities that may strengthen
the child’s stance.
¢ Involve parents and others in the planning of coping strategies; for example, mother
agrees to take the child’s statements seriously if she reports being assaulted again.
8. Rehearse/practice the coping strategies.

It can be very tempting to end treatment when the child seems to be “all better now.” The ther-
apist and the child are feeling satisfied and successful, and for good reason. Everyone did their
job. The child is feeling better and acting better; nothing’s wrong now. So why not quit? Because
if you don’t prepare for the future, you could be in for some nasty surprises.
233
234 CHILD TRAUMA HANDBOOK

You are here.

Knight, kingdom, Fence around Personal Slay the dragon Apple trees,
dragon, princess (case training (trauma resolution) compost, contest
(evaluation and management, (skills and (relapse prevention)
treatment plan) parent train) strength
building)

FIGURE 18.1. Steps in the fairy tale model.

prncpan seins ast han

riba el DRAGONS IN YOUR

Ce pect

|\
THROW YoU OF

WHAT CAN YOU DO TO KEEP BAD THINGS FROM HAPPENING?

The child as well as family members should be involved in making plans for avoiding poten-
tial problem situations. This will probably involve continuing to use safety-oriented practices
that were hopefully initiated much earlier in the treatment. The latter part of the treatment is also
an opportune time for the therapist to prepare the child and parents for upcoming developmental
challenges—and related safety concerns—that can reasonably be anticipated.
 Relapse Prevention and Harm Reduction 280:

Coping Skills in Challenging Situations

Of course, it is impossible to prevent every potentially risky situation, so it’s also important to
prepare the client for challenges that are likely to be faced. In the following case, the therapist
hadn’t yet made the effort to identify and address the client’s vulnerabilities.
Martha was a nine-year-old girl who was in treatment for having been molested on multiple
occasions by an uncle, some years before. She had been in treatment for six months and had
completed the trauma resolution work. The current focus of treatment was on her remaining bad
habits such as interpersonal problems related to her bossiness with peers.
One day at about noon, the therapist got a call from Martha’s mother: “Do you know where
she is?” The therapist said, “No, isn’t she in school?” Martha’s mother called back an hour later
to report that Martha had been found, in the home of another girl in her class. When found, they
were in the living room, eating popcorn and watching TV. The other girl’s mother was there, too.
It seemed likely that Martha’s earlier experiences of having been molested had predisposed
her to doubt herself in the face of authority and to allow herself to be coerced. When the therapist
heard this story, it became apparent that addressing Martha’s vulnerability could not wait! Mar-
tha came to treatment later that day, and the therapist then initiated some relapse prevention
strategies.

THERAPIST: Your mom told me that you weren’t in school today. She got pretty worried about
you.
CHILD: Yes, I was at my friend’s house.
THERAPIST: I heard about that. How did that happen?
CHILD: Well, I was at the bus stop to go to school, and my friend was there, and her mother said
we could come inside, so we did, and we watched TV and ate popcorn.
THERAPIST: I’m wondering what was happening inside you while your friend and her mother
were inviting you to their house, but you knew you were supposed to be waiting for the school
bus. What were you saying to yourself then? What kinds of feelings were you having?
CHILD: Well, I had kind of a funny feeling and I knew I wasn’t supposed to go. But I sort of
thought that because it was her mother, it must be okay. And I thought we were just going in-
side for a minute, like until the bus came, but then when I said, “Aren’t we supposed to be go-
ing to school?” the mother said it was okay and I didn’t really know what else to say.
THERAPIST: So it sounds like you knew it was wrong and you were kind of uncomfortable, but
you weren’t really sure what to do.
CHILD: Yeah.
THERAPIST: And then your mom got so worried she called the police, and now you got into big
trouble with your mom.
CHILD: Yeah.
THERAPIST: So would you say that this whole thing was your idea? Or would you say that you
were really just trying to go to school but that someone tricked you?
CHILD: Well, kind of, I guess they did trick me. I thought it was just going to be for a minute.
THERAPIST: Did you know that that’s how a lot of bad things happen? There’s a lot of tricky peo-
ple out there trying to get other people into trouble.
CHILD: No, I didn’t know that.
THERAPIST: Do you want to get tricked anymore? Or do you think you’ve had enough of that?
CHILD: I don’t want to get tricked anymore.
THERAPIST: Should I tell you the secret so you know how to keep people from tricking you?
236 CHILD TRAUMA HANDBOOK

CHILD: Okay.
THERAPIST: Well, when someone tries to get you to do something, you can ask yourself, Is this
something I’m allowed to do or not? and you can notice if you have an uncomfortable feeling
or a funny feeling. And if it seems like maybe there’s something wrong with it, like maybe
someone’s trying to trick you, you know what you can do?
CHILD: What?
THERAPIST: You can say no, and you can get away. Do you think you can say no?
CHILD: Yes.
THERAPIST: Let me hear you. Say it strong.
CHILD: No! ‘
THERAPIST: That’s not bad. Now let me see if I can trick you. I know! I’m going to be a guy
who’s walking along while you’re playing in your front yard. Ready?
CHILD: Okay.
THERAPIST: Hello little girl. Can you tell me which way is the McDonald’s from here?
CHILD: It’s over that way.
THERAPIST: Can you show me? If you come with me, I’Il buy you some ice cream.
CHILD: Um. no!
THERAPIST: You did it! I tried to trick you but it didn’t work. Let me see, maybe I can trick you
this time. Okay, we’re on the school playground, kind of away from other people, and I’m an-
other girl who you want to be friends with but don’t know very well. Hey, come here. I have a
cigarette. Want to smoke it with me?
CHILD: My mommy says I’m not allowed to smoke.
THERAPIST: ll be your best friend.
CHILD: No, thank you!
THERAPIST: You did it again! You’re pretty good at this!

HARM REDUCTION

What if something bad does happen in the future? What can you do to keep yourself on track?
Another part of relapse prevention is called harm reduction. The focus of harm reduction is to
help your client anticipate and identify signals that the bad thing has happened, that things are
aes wrong for him, and to catch himself. In the following case example, this preparation was
not done.

Kevin

Kevin was a thirteen-year-old boy who was brought in for treatment because of depression, social with-
drawal, and loss of interest in former activities. With a trauma-informed evaluation and case formulation,
the problem seemed to have come from a single trauma memory of having been molested by a stranger a
few years before. Following the trauma resolution phase of treatment, the boy showed a rapid and re-
markable transformation: his posture improved, he got a haircut, he smiled, he became more talkative
with his family, and he became reinvolved in baseball, which had previously been a passion of his. Treat-
ment was ended with congratulations all around.
Three months later, Kevin was brought back into treatment, having just been arrested for breaking a
large number of windows at his school by throwing rocks at them one evening. Kevin was a “good kid” and
not the type to do anything destructive, but he had in fact done this. Here’s the story.
Since treatment, Kevin had been doing quite well for two months. Then one day the neighborhood
bully, who was about Kevin’s age, took Kevin’s younger brother’s skateboard. Kevin found the bully, fought
him, and was able to take the skateboard back. In this neighborhood, that was not such an unusual en-
 Relapse Prevention and Harm Reduction 23h

counter, and Kevin thought little more about it. Until the next day, when Kevin was hanging out on the cor-
ner with a few of his friends. The bully’s father walked up and, without words or warning, punched Kevin,
pushed him down, kicked him a couple of times, and walked away.
_ Then Kevin went into a tailspin. He hid out in his room most of the time, telling himself bad things about
himself and the world. He stopped going to baseball practice. He was unable to concentrate well in school,
and did little of his assigned homework. Every day he became more confused and more depressed. Fi-
nally one evening, not knowing what to do with his tortured emotions, he found himself in the schoolyard.
Feeling moments of relief by throwing rocks at windows, he kept on doing it until the whole wall of windows
was broken. i

Harm reduction can be taught in about the same way as other relapse prevention strategies.
It’s just that the focus is on a different point in the anticipated challenging situation. The goal
here is to anticipate and identify signals that something has gone wrong, so that it can be ad-
dressed before more damage is done. Had this procedure been done with Kevin, there is a good
chance that he would have asked his mother to bring him back to the therapist long before he was
at the point of throwing rocks at windows. Here is an example—with a different child—of a
harm reduction intervention.

THERAPIST: You know how, after that kid at school showed you the knife and made you do all
that stuff, you kept it a secret for a long time?
CHILD: Yeah, he said he’d kill me if I told.
THERAPIST: Right. And so you kept it a secret a long time. Remember how bad that felt? And
how you were doing worse in school, and getting in trouble and stuff?
CHILD: Yeah.
THERAPIST: How long was it before you told? Maybe a year?
CHILD: About that; I guess so.
THERAPIST: And once you told, your mom brought you here, and we talked about it a lot, and
you got so strong that it doesn’t mess you up anymore.
CHILD: Plus, that kid didn’t kill me, cause they kicked him out of school and he’s not allowed to
go near me or I can call the police.
THERAPIST: So if you have a friend someday that this kind of thing happens to, what would you
tell your friend to do?
CHILD: Tell her mother or her father or her aunt or something.
THERAPIST: I think that’s a good idea. Cause then she can get the kid in trouble, and she can start
to feel better, like you did.
CHILD: Yeah.
THERAPIST: What if something else really bad happens to you someday? I hope it doesn’t, but
what if it does? What could you do?
CHILD: Tell.
THERAPIST: Who would you tell?
CHILD: My mother.
THERAPIST: What if your mother’s on vacation and she’s gone away for a few days?
CHILD: I can tell my auntie.
THERAPIST: Would you have to wait a while or can you tell her right away?
CHILD: Right away as soon as I get home from school.
THERAPIST: I think that’s a good idea. But let me ask you a question. What if you’re not sure if
you should tell or not, and you decide to keep it a secret? But then you notice that you’re start-
ing to feel bad. Then what can you do?
238 CHILD TRAUMA HANDBOOK

CHILD: I can tell. If I feel bad, I should do something, right?

THERAPIST: I think you’re right. Feeling bad is a good signal that you should tell. How can you
tell that you feel bad? What are the signs?
CHILD: I stay in my room a lot and cry.
THERAPIST: And then you can tell your mom or your auntie?
CHILD: Yeah.
THERAPIST: You remember when we talked about this with your mom? She really wants you to
tell her if anything else bad ever happens. Remember she said that?

As with the self-management training interventions, it’s always important to transform con-
cepts into concrete behaviors and events. In the previous example, “feeling bad” was trans-
formed into a concrete indicator of distress, “stay in my room and cry.” Then two years later,
when she is staying in her room a lot and crying, there is a better chance that she will recognize
this, catch herself, and do something about it. This chance is further improved when the distress
signals, and the corrective behaviors, are practiced in role-plays or imagination.

ENDING TREATMENT WHEN TRAUMA RESOLUTION

HAS NOT BEEN COMPLETED

Relapse prevention and harm reduction strategies should be used at the end of every treat-
ment, regardless of how much has been accomplished already. Treatment may end for a variety
of reasons, perhaps because the child is moving, or the insurance policy will not pay for more
sessions and the family cannot afford to pay out of pocket. Sometimes treatment ends because
the child absolutely refuses to engage in trauma resolution activities, despite the therapist’s best
efforts—so there’s nothing left to work on. No matter why treatment is ending, the therapist
should prepare the child as well as possible for the challenges to come.

Julio was a fifteen-year-old boy who came to the United States as a refugee from the Guatemalan civil
war at age eleven. He had average to high-average intelligence and an accent so good that he sounded
native to the United States. He was in treatment while in a three-month program at a residential facility op-
erated by the juvenile corrections system in his state. Within the facility, Julio’s behavior was excellent. He
did well in school, got along with others, did not lose his temper, and did not break rules. The concern was
very specific: When he was released, would he go back to stealing cars, or not?
Julio was cooperative in therapy, in part because he was so interested in figuring out what he could do
to make sure that he was never incarcerated again. He was able to identify long-term goals that he cared
about and was willing to work for. He declined to identify the events on his trauma history list, but consider-
ing where he had come from, itis likely that his trauma history included witnessing of assault, torture, and
murder, as well as the loss of significant family members, possibly including parents and siblings. How-
ever, as noted in the chapter on trauma history, the specific details are not absolutely necessary in order
to provide a trauma-informed case formulation. The real treatment impasse arose a little later, when the
“personal training” phase of treatment was over, and the therapist suggested that it was time to start slay-
ing the dragons.

JULIO: No, I don’t need to talk about all that stuff [the trauma].
THERAPIST: What do you mean? You told me about the goals you have for yourself, things you
really care about. I thought that you would want to give yourself the best chance of getting
there.
JULIO: I do care, I’m going to make sure I get there. But now that you explained to me about the
traumas behind the wall, and the sore spots, I know what to do.
THERAPIST: What?
 Relapse Prevention and Harm Reduction 252

JULIO: I'll just make the wall stronger so those things don’t mess me up anymore.
THERAPIST: How will you do that?
JULIO: I know how.
THERAPIST: So it sounds like you really don’t want to talk about the bad things that happened.
You really want to kind of keep them behind the wall and keep them from bothering you.
JULIO: That’s right._
THERAPIST: And you a60 really want to get to your goals, to live the kind of life you were telling
me about.
JULIO: That’s right.
THERAPIST: And you're feeling pretty confident that you can do both: make the wall stronger,
keep those memories out of the way, and get to your goals.
JULIO: Yup.
THERAPIST: Well, my job is to make suggestions and your job is to make decisions. It’s your life.
So I’m going to explain a little more about my suggestion, and then it’s up to you to make
your decision. I’ve seen other kids try your strategy, and sometimes it works. The problem is,
sometimes it only works for a while. Then some new stress comes along and adds to the pile-
up. Then even the stronger wall just isn’t enough, and the trauma messes them up again, and
they end up doing things that get them in trouble all over again. I’d hate for that to happen to
you. That’s why I’m suggesting that you do the work now, to take care of the trauma memo-
ries so they can’t hurt you anymore.
JULIO: I get what you’re saying, but I’m going to do it my way.
THERAPIST: Okay. I hope that sooner or later you do take care of that stuff behind the wall; when
you do it, I think you’ll be glad you did. But no one can tell you when it’s your time. It could
be next year or twenty years from now. You’ll have to decide that for yourself.
JULIO: Maybe never.
THERAPIST: Maybe never. Now you’re making a decision that I’m kind of worried about, I’m
afraid that your way, things might go bad. But I hope you prove me wrong. Supposing that it
turns out you’re right, say, one year from now, what will you be doing? What will be happen-
ing in your life?
JULIO: I’1l be going to school every day, keeping my grades up. I’ll have a job after school. I can
walk by nice cars without needing to drive them away. . .
THERAPIST: In other words, you’ll be doing the things you said you would be doing, to get to-
ward your goals.
JULIO: Yup.
THERAPIST: And I hope it doesn’t happen this way, but what if it turns out that I was right to be
worried? What if your wall isn’t strong enough, and you’re getting off track? What would be
going on a year from today?
JULIO: I’d be stealing cars again, cutting school sometimes. My aunt would be on my case all the
time. .
THERAPIST: And if you noticed these things happening, what could you do to get yourself on
track again?
JULIO: Talk to a counselor. Do what you said.
THERAPIST: How do you find a counselor?
JULIO: Ask my aunt, or ask the guidance counselor at school.
240 CHILD TRAUMA HANDBOOK

Another therapist might have kept Julio in treatment for longer and tried to work on building
affect tolerance to the point where Julio might have been more willing to consider trying the
trauma resolution work. That might have been a better strategy. Also, unfortunately, we can’t be
sure that the counselor whom Julio might find a year from now will know how to help him with
trauma resolution. The point of this example was not to second guess the therapist, but to show
how a therapist might help a client to prepare for future challenges even when treatment was not
completed according to the therapist’s agenda.
In many ways, this final part of treatment replicates what was done earlier, but this time with a
focus on the future rather than the present. The earlier focus was on being safe today; now we are
focusing on being safe tomorrow, next month, and next year. The earlier focus was on avoiding
high-risk situations this week; now the focus is on avoiding high-risk situations-farther in the fu-
ture. The earlier focus was on managing everyday problem situations in a way that led to a good
ending; now the focus is on anticipating more significant and challenging problem situations in
the future, and managing those.

ENDING TREATMENT

When is it finally time to end treatment? It may be so if the following occur:

¢ Presenting problems are resolved.

¢ The child reports little or no distress when recalling the trauma memories.
* The child reports little or no difficulty in managing trauma-related triggers.
* The family has made a positive adjustment to the child’s improved functioning.
¢ The child is oriented toward a positive future and is behaving in ways that will make sucha
future likely to occur.
* The child and family can anticipate future challenges and stressors, and are prepared to re-
spond to these effectively.
 Chapter 19

Challenging Cases: Applying the Fairy Tale Model

Early in the book, the fairy tale was presented, with elements of the fairy tale then related to
corresponding steps in a comprehensive trauma-informed treatment approach. Since then,
you've been learning how to do various interventions in each of these steps in the treatment ap-
proach. Now that you’ve been through each of the steps, it’s time to pull it all together again, to
work with the model as a whole.
Here is a retelling of the fairy tale. Please don’t skip this even though you remember it from
before. People consistently tell me that they were glad for getting the story the second time.
Read it carefully. As you read it this time, notice what’s the same as before and what’s different
or new.

THE FAIRY TALE REVISITED

Once upon a time there was a small kingdom, about the size of a small town. Things were
pretty regular there. People did their jobs; kids went to school. Some people went to church or
temple and some didn’t. Some people would go to a friend’s house on the weekend, get together
for a barbecue, play games, or have a party. Most people got along, but not everyone. And that’s
how things were: pretty regular.
Until one day...
The dragon came. One day the dragon ate a cow right out of a farmer’s pasture. Another day
the dragon ate a dog right out of someone’s front yard. People got pretty scared! The parents told
their kids that they weren’t allowed to go outside anymore. The thing is, kids aren’t very good at
not going outside. So the parents stayed home to guard their kids, to keep them safe from the
dragon.
Soon no one was going to school anymore, and not so many people were going to work, ei-
ther. Everyone was so afraid of the dragon that they mostly just stayed inside their houses. And
people started wondering, “How come our kingdom has a dragon, anyway? The other kingdoms
don’t have one.” No one knew why, but they wanted to know, so they started making guesses.
One group of people blamed another group of people; that group of people blamed some others
... and pretty soon, everyone was blaming someone and they were all mad at each other.
It didn’t take long until this kingdom got a bad reputation. People from the other kingdoms,
well, they didn’t know about the dragon, but they sure knew what was going on. They would say,
“That kingdom’s messed up. The people don’t go to work, the kids don’t go to school, nobody
gets along, they’re all mad at one another. All they do is stay inside all the time. They’re messed
up.”
Ag that’s how things were. Until one day...
A knight in shining armor came along. Well, he wasn’t really a knight, and he didn’t have any
armor. He was just some guy who happened to be passing through. But the people in the town
saw something in him.
“You!” they said. “You can slay the dragon; you’re just the one to do it!”

241
242 CHILD TRAUMA HANDBOOK

The guy said, “No, sorry, I’m not a dragon slayer. You have the wrong guy. I’ve been walking
a long way. I’m looking for this certain princess I’m in love with. But I don’t know what king-
dom she lives in.” He pulled a picture out and showed it around. “Have you seen this princess?
Do you know where I can find her?”
The people said, “Yes, she’s our princess. She lives here. And what a coincidence: she really
wants to get married—to whoever slays the dragon!”
When the guy heard this, he said, “Well, in that case, I’m your man. Take me to your dragon!”
So they took him to the dark place where the dragon was sleeping. The guy saw the dragon
and said, “Whoa, this is a bad idea! I can’t handle this dragon! No way! It’s huge; it looks really
strong. It’s covered with scales—it breathes fire. Let’s just forget the whole thing!”
The people said, “No, you can do it. We know you can! You can work out, do exercises, build
yourself up. We’ll help. We’ll get you a personal trainer. And remember the princess!”
The guy said, “Oh yeah, the princess!” He was in love with this princess and he really wanted
to marry her. “Okay, I don’t know about this, but I'll give it a try and see how it goes.”
So they gave him a personal trainer and took him to the schoolyard to start on his exercises.
But he couldn’t stay focused! Every time he got started on some exercise, he would suddenly
stop and look all around. He was afraid the dragon would get him while he was out there, ex-
posed. So he wasn’t making any progress. This clearly was not working.
So they took him to a clearing at the edge of the forest where there were high trees on one side.
Then they worked to build a high fence around the rest of the clearing. Everybody pitched in:
cutting lumber, putting it up, securing it, cooking for the workers. . . . Even the little kids helped
by bringing water to people, carrying messages, doing whatever they could. It wasn’t long until
they had a high fence around the rest of the clearing. Then the guy could concentrate on his exer-
cises.
Things went better after that. Every day he worked hard with his personal trainer: he did
push-ups, sit-ups, lifted weights, ran laps, did all kinds of exercises. Every day the trainer added
a pound or two to the various weights. Every day the guy became a little stronger, a little faster, a
little more agile. Eventually they got an athletic teenager to dress up in a dragon costume, and
they did role-plays so the guy could practice his dragon-fighting moves.
Finally, the day came: he was ready. He went to the dark place where the dragon was, faced
the dragon, fought it, and slew it.
He did marry the princess, but things didn’t just go back to the same old way that the kingdom
used to be.
For one thing, they now had a hero in their midst. People from the other kingdoms were say-
ing, “That kingdom has a dragon slayer. I wish ours had one.” And everyone in the kingdom felt
proud, walked a little taller; they knew they’d all helped out and been a part of it.
But they were still asking each other, “How come our kingdom had a dragon, anyway? I won-
der if we’ll get another one?” They still didn’t know. They were worried about this, and they re-
ally wanted to know. So they hired a consultant.
The consultant took a good look around. Then she called everyone together for a big meeting
to tell them her findings. “You have two problems here. First of all, you throw all your garbage in
the dump. It’s this huge pile of garbage that stinks for miles around. That smell attracts dragons.”
So they decided that everyone would put their garbage in a compost pile in their own yard. No
big smell to attract dragons, and compost is good for the gardens anyway.
The consultant also told them, “Here’s your other problem. On the edge of the kingdom
where the farms are, there are all these low fields. It’s flat, flat, flat for miles! Dragons are lazy,
and this place, it’s just too easy for a dragon to cruise right in.” So they decided to plant clusters
of apple trees here and there in the fields. They liked apples anyway, and this way it wouldn’t be
such smooth sailing for any dragon that was wandering by.
 Challenging Cases: Applying the Fairy Tale Model 243

Well, it didn’t take long before they had so many apples that they didn’t know what to do with
them. So every year in the fall, they had a big apple festival, and people would come from all the
kingdoms for miles around. There were all kinds of contests for the tastiest apples, the biggest
apples, the best apple pies. They also had plenty of food, games, and music—everything a festi-
val should have.
The highlight of the festival, on the Saturday night—the event that everyone would go to—
was the dragon-slaying contest. Of course, they didn’t have a real dragon, so whoever had won
the year before got to play the dragon. All year long, teenagers from all the kingdoms were prac-
ticing, training, hoping that they’d be the one to win the big contest at the next year’s festival.
Not only was this great fun, but if another dragon ever did show up, they would be ready!
Then, they did live happily ever after—more or less. The end.

So what did you notice in the fairy tale this time that was different from the first time?
Give yourself credit for that. The story is exactly the same as before. What’s different is you.
You know more now, so you are able to notice more elements of the story. You are able to see
how these relate to the trauma treatment approach.
For much of this book, you have been working with one step at a time. The new task, for this
chapter, is to work with the model as a whole. On the following page is a summary of the fairy
tale model and the corresponding component in the trauma-informed treatment approach. In
case you’re wondering, this also is exactly the same as when it appeared earlier in the book.

Applying the Model

You probably figured out some time ago that this treatment approach is not just for kids with
PTSD, or just for kids with presenting problems clearly related to trauma. Most therapists who
learn and practice this system end up saying, “This is just good therapy. I’ve been using this with
all my clients.” They are still doing many of the things they used to do, with kids, families, and
any others involved, but now they are doing it in a way, and in an order, that takes trauma into
account.
Even so, any theory or model has an area of “best fit” and other areas where the fit may not be
so good. One of the goals of this chapter is to help you to test the fairy tale model with your own
challenging cases, to see if, and how well, it might fit your cases and provide you with useful
guidance.
Another goal of this chapter is to give you more practice in using the model and internalizing
it. When you learn a new way of thinking about how to do your work, at first your focus is on
what’s new. In the long run, though, you don’t want to be focused on the fairy tale model; you
want to be focused on the kids you’re working with. So it’s important to practice the model until
you get used to it. Eventually, instead of focusing on the fairy tale model, you’re focusing with
it—it’ll become your perspective, the way you see a case. This takes practice.
When you are working with the fairy tale model, of course it’s great if you’ve started your
case that way, and done all the steps in order. But you may have many ongoing cases that you’ve
started some other way, or picked up from someone else. You may also have cases that you are
trying to do according to the fairy tale model, but they are especially confusing or challenging in
some way. And even within the fairy tale model, kids don’t sit still for us to go along according
to our own agenda. Sometimes events happen in their lives that throw off the course of treat-
ment, and when we next see them, they’re not in the same place we left them.
Because we can’t force kids to be where we think they should be, the best we can do is figure
out where they actually are. When you know where the child is in the treatment model, you will
have a much better idea of what’s needed, and what you should be doing. Here is a more detailed
summary of the goals and tasks for each phase of treatment.
 CHILD TRAUMA HANDBOOK

The Fairy Tale Model of Trauma Treatment

© Ricky Greenwald 2003.

Stage of treatment Corresponding element of the fairy tale

Evaluation including | see your strengths; you’re the one who

can slay the dragon.
Strengths/resources
We need to know about the dragon to make
Trauma/loss history sense of the problems.

Motivational interviewing, goal Without the princess, nothing will happen.

setting

Trauma-informed case formu- Identify the strengths/resources as reason

lation and psychoeducation to hope for a chance of success.
Take the dragon into account; then the
problems make sense.

Trauma-relevant treatment Recommend fence-around, personal train-

contracting ing to get stronger, and slay the dragon.

Case management for safety Build the fence around so you’re not wor-
and other needs; parent train- ried about being attacked at any moment.
ing for safety and security Then you can concentrate on your tasks.

Self-management skills train- The personal training approach to build

ing for physical and psycho- skill and strength.
logical safety as well as im-
proved affect regulation

Trauma resolution Slay the dragon.

Relapse prevention and harm Compost instead of using the dump, to stop
reduction attracting dragons; stands of apple trees so
it's harder for dragons to come along.
Teens training for the dragon-slaying con-
test, so if another one does come along,
we'll be ready.
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246 CHILD TRAUMA HANDBOOK

EXERCISE: APPLY THE MODEL

For each of the vignettes below, speculate about where the child is, which phase of trauma
treatment. Then make a suggestion as to what the therapist might do to help the child progress.
It’s okay to refer to the Phases of Trauma Treatment page for ideas. Remember that until the
tasks of one phase have been completed, the child is unlikely to be successful in a later phase of
treatment. Also, sometimes a child may leap forward or backslide for one reason or another. Al-
though there is rarely a single “right answer” in this field, some suggested responses are in-
cluded following the vignettes. So if you want to formulate your own answers first, don’t look
ahead.

1. A ten-year-old girl has had two trauma resolution sessions and has done well in each.
When she comes for the next session, although she does not report anything special in the
beginning-of-the-session check-in, she seems angry and abrupt. When the therapist re-
minds her of how well she has been doing in treatment, and suggests picking up where they
left off, the girl refuses. The therapist reminds her of her goals and how this work is helping
her to achieve them. The girl responds, “I don’t want to do it. I just don’t care about that
anymore.” What is the phase of treatment? Based on that, what should the therapist do?
2. A nine-year-old boy is in treatment for disruptive behavior in school, and for peer prob-
lems such as teasing and fighting. The first two sessions were focused on rapport building
and seemed to go well. In the third session, the therapist is trying to teach him some self-
control skills, but the boy is barely cooperative and will only agree to participate half-
heartedly for a few minutes at a time, in exchange for time playing games. The therapist
complains to the boy, “This is supposed to be for you. Why does it feel like I care about it
more than you do?” What is the phase of treatment (or what’s missing)? Based on that,
what should the therapist do?
3. A seventeen-year-old boy with a history of conduct problems is in treatment because it is
required by the alternatives-to-incarceration program to which he has been adjudicated. He
has been cooperative in the first several sessions, and appears to be sincerely invested in
achieving positive long-term goals. But when the therapist offers him the treatment plan,
he rejects it, saying, “I don’t need to do that stuff. I don’t need counseling.” The therapist
reminds him of his goals, and the boy says, “Yeah, but I’m going to do all that. I don’t have
any problems.” What is the phase of treatment (or what’s missing)? Based on that, what
should the therapist do?
4. A distraught grandmother calls the clinic to arrange treatment for her thirteen-year-old
grandson, for whom she is the custodial parent. She describes a number of possible post-
traumatic symptoms, including low energy, nervousness, heightened startle response, and
being afraid to go to sleep. The precipitating event was that the boy had been bitten by a rat
while asleep. The grandmother professes her own guilt: usually she stays up and scares the
rats away by swatting at them with newspapers, but on the night in question, she fell asleep
by accident, leaving her grandson vulnerable. She has been complaining about the rat
problem for some years, but neither her landlord nor the city has done anything for her.
Now her grandson has posttraumatic stress. What is the phase of treatment (or what’s miss-
ing)? Based on that, what should the therapist do?
5. A fifteen-year-old girl is brought to the in-school therapist because when she took off her
sweatshirt earlier in the day, a peer noticed fresh cut marks on the girl’s arm and reported it
to a counselor. By now the school principal has notified the parents, and the therapist is ex-
pected to do whatever is necessary to make sure that the girl is safe and taken care of. What
is the phase of treatment (or what’s missing)? Based on that, what should the therapist do?
 Challenging Cases: Applying the Fairy Tale Model 247

6. A fourteen-year-old girl has been doing well in treatment, and in the last session worked
her most significant trauma through to resolution. That trauma was also the first one, chro-
nologically, on her list, which includes four other traumas rated at a SUDS of eight or
higher. In the next session, the girl reports that the treated memory doesn’t bother her any-
more. The therapist suggests proceeding with the next trauma on the list, but the girl says
that that memory doesn’t bother her anymore either, that it’s a zero. The therapist checks to
make sure that she’s really concentrating on it (some kids claim zero when they really
mean that they are making sure not to think about it) and she still reports no distress. They
go through the same routine with all the other untreated trauma memories on the list, with
the same results. What is the phase of treatment (or what’s missing)? Based on that, what
should the therapist do?

Suggested Answers

Case 1

Phase of treatment: The girl is clearly not in the trauma resolution phase today. Since it ap-
pears from the vignette that the case formulation, motivational component, and treat-
ment contracting were done already, the issue probably lies elsewhere. She says she
doesn’t care about her goals, but the therapist knows she does. So what’s going on?
Chances are that something has happened to make the girl feel unsafe or insecure in
some way, and the phase of treatment would be Safety and Strength Building.
Intervention: The therapist must find out what’s on the girl’s mind and help her address it
somehow.
The story: In this case, the girl’s mother had become upset with her for a minor offense a
couple of days prior to the session, and threatened to send her into foster care if she mis-
behaved again. The therapist was able to talk with the mother and the mother agreed to
explain to her daughter that she had spoken in a moment of anger but did not mean it.
Once the “fence around” the girl had been repaired and she felt secure again, she was
able to continue with the trauma resolution work in the following session.

Case 2

Phase of treatment: In the fairy tale model, they are still in the first phase of treatment. The
therapist is wishing that the child is ready for Strength Building, but the foundation is
not there. Whenever the therapist is trying harder than the child, wants it more than the
child does, it is probable that the princess hasn’t been identified. Right now the child’s
only goals are to have a good time, to play games. That’s not adequate. If he doesn’t have
treatment-related goals, some personally meaningful reason to work with the therapist,
not much will happen in treatment.
Intervention: If the beginning of the Evaluation has already been completed, then the ther-
apist can work with the child on identifying what he would like to improve in his life and
making a treatment contract to include treatment activities that will help the boy to
achieve his goals. However, in this case, it appears that the therapist has not been follow-
ing the model at all. He’d best start from scratch and do it right, otherwise he will con-
tinue to encounter problems.
248 CHILD TRAUMA HANDBOOK

Case 3

Phase of treatment: One small but important thing seems to be missing here. The boy does
not seem to perceive that any challenges or obstacles stand between him and his goals. If
the boy believes that he is on track to his goals and nothing is in his way, why would he
need the therapist?
Intervention: The therapist should find ways of highlighting potential obstacles. Two ways
of doing this are described in Chapter 8. First there is the listing of strengths and obsta-
cles, including the gambling metaphor and the question, “Why would that other person
bet that you’re not going to make it?” Later comes the Problem Behavior Cycle, which
has the advantages of being visual and of incorporating the trauma history as the source
of the vulnerability. Once there is agreement about possible obstacles, the boy might de-
cide that it’s worth working with the therapist to become more capable of mastering the
challenges he faces.

Case 4

Phase of treatment: This was a trick question. In this case, we’re in a pre-evaluation phase,
because something urgent must be taken care of before evaluation is even appropriate. If
we do an evaluation now, all we will learn is that the boy is afraid to go to sleep, and that he
has symptoms appropriate to someone who is living with fear and without sleep. The prin-
ciple is “‘safety first,’ and urgent safety and survival needs come before anything else.
Intervention: Safety first. In this case, the therapist connected the grandmother with a
housing advocate, and stayed in touch with her over the following weeks while she went
through various steps to obtain a safer place to live. Once that was accomplished, the
therapist invited the grandmother to bring her boy in for an evaluation. At that time, liv-
ing in a new rat-free apartment, the symptoms were mostly gone. This is a common is-
sue in critical incident and disaster response. Naive mental health professionals may ask
people how they are feeling or if they want to talk about it, when what’s really needed is
something more practical. When people are in crisis they need to know what’s going on,
where their loved ones are, what they will eat, where they will sleep, how they will get
home. Safety and survival come first. Often the best “mental health” intervention is giv-
ing someone a blanket, a sandwich, or crucial information.

Case 5

Phase of treatment: In this type of situation, most therapists are trained to conduct a safety
assessment for risk of suicide. This might include questions about suicidal ideas, intent,
plan, and means to achieve it. If this was your response, don’t feel too badly, you’re not
the only one. But I would argue that these are overly intrusive questions, coming from a
stranger. And bullets are not whizzing by. The knife is not in her hand right now. Yes, we
are concerned, but this concern allows us to take all the time we need to do the job right. I
would say that because this is the first meeting, we are at the beginning of the evaluation
phase. So there is a presenting problem, everyone has one. This particular presenting
problem does have sufficient urgency to require that much of the evaluation is done in
the first meeting.
Intervention: Introduction to treatment, rules, favorite color, etc. In this particular case, the
therapist spent an hour and a half with the girl, and they got all the way through the ini-
tial interview, family, developmental, medical, school, trauma/loss, and best things his-
tory. By this time, the girl felt so comfortable with the therapist that she was glad to ex-
 Challenging Cases: Applying the Fairy Tale Model 249

plain about the problem with her boyfriend over the weekend and how that made her so
upset that she cut her arm. When she contracted for safety, the therapist trusted her be-
cause they had a relationship; the girl was not just making a frivolous promise to get
some strange adult off her back. The girl did keep her promises, and also continued with
treatment to a good conclusion.

Case 6 f

Phase of treatment: Yes, this does happen sometimes, and it’s real. It appears that the
trauma resolution phase is complete before the therapist expected it to be. So how can
this be? What happened? Three main possibilities exist, which are not mutually exclu-
sive. First, the high SUDS ratings for the later traumas on the list could have been
mainly “sore spot” reactions, overreactions that had more to do with the earlier memory
than with the identified later event. When the earlier event was digested and no longer a
source of distress, the discrete reactions of the later events (the reaction not related to the
“sore spot’) just didn’t amount to much, weren’t significant on their own. Also, when
the client works through one trauma memory, the new lessons can somehow generalize
to other trauma memories as well. You can’t count on this happening, but sometimes
you find that it did. Even when this does occur, you often still must treat the other trauma
memories, but maybe it’Il go easier because of the work that’s been done on the first one.
Finally, the client’s life situation may have changed in a way that makes the later trauma
memory less relevant. For example, a teenaged boy had “getting locked up” at age four-
teen as a SUDS of ten. However, by the time he got around to being ready to work on
that memory, it was only a two. The therapist told him that it had been a ten before and
asked why it was so much lower. The boy said, “Well, look how well I’m doing now. I
know I’m not gonna get locked up again!”
Intervention: It looks as if it’s time to move on to the posttrauma resolution reassessment,
to see what symptoms and problems have disappeared on their own, and what might
need to be actively addressed. However, if I’m the therapist for this girl, I'll probably
keep checking the SUDS levels for those untreated trauma memories, at least for a cou-
ple of weeks, just to be sure.

THE IMPORTANCE OF USING THE MODEL

Hopefully what you are getting from these examples is the idea that kids will show us where
they are by what they say and what they do. They are not always where we think they are or
where we wish they would be. But at least they give us clues that we can track down to learn
what’s going on, and from there we can use the model to figure out what needs to be done.
Sometimes a pressing concern or change in life situation causes progress or setback. Sometimes
the therapist has skipped one or more steps and ends up paying for this later when the child is un-
able or unwilling to do what the therapist wants.
I have been providing supervision and consultation to therapists for many years, and I’ve
learned that certain therapy impasses occur with some frequency. One of the reasons I wrote this
book is that I got tired of trying to teach the whole system over and over again to therapists
within the one-hour conversations we were having. Although the system is not so hard to learn,
it can’t be done on the fly. Here are some of the more typical problems that therapists report,
along with my fairy tale model response.
250 CHILD TRAUMA HANDBOOK

THERAPIST: So that’s what’s going on. I’m just not sure what to do, where to go from here.
CONSULTANT: What’s the case formulation? What’s the treatment plan?

THERAPIST: I’m trying to get him to work with me, but it feels like ’m pulling teeth.
CONSULTANT: What are his goals that he believes treatment will help him to achieve?
THERAPIST: This feels like a good case for [EMDR, exposure], but I don’t know if she’s ready
yet.
CONSULTANT: Have you done skill building to develop coping skills and affect management?
Have you tried the trauma resolution method with a recent minor event? Do you have a
trauma/loss history? What about starting with an earlier (or a lower SUDS) trauma from the
list?

THERAPIST: I just don’t see how I’m going to get anywhere with this kid, the way the home envi-
ronment is.
CONSULTANT: You’re probably right. So the first thing to do is work with the parents to make
things more predictable and supportive.

In these cases and many others, because therapists skipped steps, they got in trouble or got
lost. You can’t make a treatment plan without a case formulation. You can’t get the child to work
on the treatment plan unless she has her own goals that she believes the treatment is supporting.
You can’t expect a child to focus on goal-oriented treatment activities while she is feeling threat-
ened or unsafe in her daily life. You can’t do trauma resolution without having done the strength
building.
 Challenging Cases: Applying the Fairy Tale Model Zol

The fairy tale model is a comprehensive system; it covers the bases. When you do the steps in
order and you don’t skip any, the child tends to be ready and able to do the next one. Of course,
some kids can go through the steps faster than others. And because life happens, kids don’t al-
ways stay in order. Still, proceeding in order and doing all the steps gives you a good chance of
getting the job done. When the situation isn’t what you thought it was, you can use the model to
figure it out and get your bearings.

EXERCISE: CASE CONSULTATION USING THE FAIRY TALE MODEL

Think of a challenging case, something current, that’s on your mind for whatever reason. It
doesn’t have to be a “trauma case.” If you are doing this by yourself, use a copy of the following
form and fill in each of the sections. If you are with a group, have one person present the case and
then the group members can serve as consultants to complete the form together.
It is essential in this exercise that you proceed in order, and restrain yourself from jumping in
with questions or suggestions that are out of order. One goal of this exercise is to test the model
on your case: if you stick to the fairy tale model, can you provide a good consultation? Will all of
your questions be asked? Will all of your suggestions for interventions have a place in the
model?
Another goal of the exercise is to practice using the model in a systematic way that will help
you integrate it into your way of thinking about your work. If you just jump in with questions
and suggestions as you think of them, you are not doing anything you don’t already know how to
do, so it’s less likely for learning to happen. By going in order, you are, in fact, using the model.
It takes discipline to wait for the right moment for your questions and suggestions. It can be
helpful to make a note when you think of something, so that you have it for the right moment.

Discussion Questions

For the Presenter

How did this go for you? Did you feel respected and supported? Did this consultation have
any impact on your understanding of the case? Did this consultation give you any ideas for what
to do? Did the fairy tale model seem to fit this case?

For the Consultant(s)

How did this go for you? Did you get a chance to ask all your questions? Did you get a chance
to make all your suggestions? Was there a place for them?

SECTION V BIBLIOGRAPHY

Marlatt, G. A. & Gordon, J. R. (1985). Relapse prevention: Strategies in the treatment of addictive behaviors. New
York: Guilford Press. The classic text.
202 CHILD TRAUMA HANDBOOK

Case Consultation Form

© Ricky Greenwald 2004.

Summary

iF Presenter summarizes (in about two minutes):

* Client’s age, gender, family status/situation, school/work/living status/situation
¢ Presenting problem/symptoms including some details
¢ History of treatment: How many sessions so far? What was done in each session?

. Consultant asks clarifying questions, in order, to the extent needed to complete the
case formulation:
Once upon a time—Strengths/resources:

Then the dragon—Trauma/loss history:

Leading to
Negative beliefs:

Piled-up feelings:

Now when the trigger happens (theme and example):

it hits the sore spot. This brings back the negative beliefs and piled-up feelings,
which are intolerable. Then the person tries to get rid of that by using this solution
behavior:

. Consultant asks, in order, about what has already been done at each phase of treat-
ment. Here is where suggestions can be included, also in order.
 Challenging Cases: Applying the Fairy Tale Model Ps)

Trauma-Informed Treatment—Sequence of Interventions

© Ricky Greenwald 2004.

Fairy Tale Model Stage of Treatment

Evaluation
¢ Acculturation: purpose of treatment, treatment activities.
¢ Rules/expectations/agreements.
¢ Rapport/trust-building.
Once upon atime...

* Strengths/resources, internal and external (the knight and the kingdom).

¢ History of functioning and problem development.
The dragon

¢ Trauma/loss history (then deep breathing, then best things).

The princess

¢ Motivational interviewing/goal setting.

—Long-term goals (for teens especially); shorter-term goals too.
—Practical steps to get from here to there.
—What the bad ending would look like.
—Strengths/resources in support of goals.
—Obstacles to achieving the good ending.
¢ Trauma-informed case formulation and psychoeducation.
*Remember: Case Formulation + Princess = Treatment Contract*
¢ Trauma-relevant treatment contracting:
—Fence around, personal training, and slay the dragon; or
—Enhance safety and security, avoid high-risk/trigger situations, stabilize, self-man-
agement skills, trauma resolution.

Safety, stabilization
Fence around
e Case management regarding safe housing, reliable medical care, appropriate educa-
tional placement, etc.
Parent training for increased household routine, consistent/supportive discipline, etc.
Avoiding/preventing dangerous situations.
Controlling/limiting bullying and other abuse.
Avoiding “high-risk” situations including trigger/sore-spot situations when possible.
Skill-building, strength-building
Personal trainin

Safe Place, deep breathing, etc. for self-soothing/calming.

Self-management training for anxiety.
In vivo exposure to overcome fears.
Choices Have Consequences (set this up with Map Out a Problem) for control of behav-
iors.
Incentive system for habit improvement.
(continued)
254 CHILD TRAUMA HANDBOOK

(continued)

Trauma resolution

Slay the dragon

¢ Introduce Exposure (or EMDR, CPT, or other trauma resolution activity).
¢ Decide the order for targeting memories (start small!).
¢ Break down the memory (if you need to, as a step).
¢ Do the exposure (or other method).
End of session:
¢ Container with any incompletely processed memory.
¢ Debrief, calming activities, assist in regaining composure.
Next session:
¢ Continue with same memory;
* or if it's done, go to the next one; or if all done, move on.

Consolidation of gains
Marry the princess

¢ Revisit case management and self-management practices now that the sore spot is
smaller. Get daily functioning as good as it can be.
Relapse prevention and harm reduction.
Compost; Plant apple trees; Dragon-slayers in training

¢ Revisit case management and self-management practices, now focused on anticipated

future challenges. In particular:
—Avoid/prevent high-risk situations.
—Prepare to cope with challenging situations.
aittangs should go badly, how to recognize the signs and catch yourself before it gets
00 bad.
 SECTION VI:
24/7—HELPING THE CHILD IN DAILY LIFE

To get the most out of this section of the book, it’s essential that you have read the first section
already; that’s Chapters | through 4. This section is especially for those who spend “daily liv-
ing” time with kids. You might be a parent (perhaps foster and adoptive) or a worker in residen-
tial treatment, day treatment, school, camp, shelter, corrections facility, or another kind of pro-
gram. You have a critical role to play in the child’s treatment.
What kids experience and learn in their daily life is very important. Not all the healing takes
place in the therapy hour. In fact, the healing that will occur in the therapy hour depends to a
large extent on what happens in the rest of the child’s life. Kids whose life experiences allow
them to feel ever more safe, secure, strong, and successful will have the best chance of being
able to do the work in therapy, recover from their wounds, and move forward with their lives.
You have special opportunities to influence kids because of your personal relationship and
because of the time you spend with them. You also have special challenges for the same reason;
personal relationships and time together can lead to emotional investment—and sometimes
emotional reactivity—on the part of the adult. This section of the book will provide guidance on
how to help kids to feel safer and more secure, and to become more strong and successful. The
same methods you will be using to help your kids can also help you to keep yourself from over-
reacting, so that you can focus on the job you are trying to do.
Ideally, you are working closely with the child’s therapist, who is also (ideally) using the fairy
tale model of trauma-informed treatment, or something similar. The therapy will go better when
you are actively supporting the child’s participation and when you are telling the therapist about
what’s going on in the child’s life. The therapy will also go better when you are helping the child
feel more safe and secure and to become more successful in daily life. You should also be talking
with the therapist about the efforts you are making with the child. The therapist can give you
suggestions and help you to problem solve when things are not working out as planned.
In the fairy tale model, there are many points in treatment when the adults in the child’s life
play an especially important role:

I. Evaluation and Treatment Planning

A. Goals: Understanding, hope, commitment to action
1. Bringing kids to treatment.
2. Providing information to the therapist.
3. Participating in the child’s reestablishment of attachment to parents and parent fig-
ures.
4. Demonstrating support for the child’s participation in treatment.
5. Committing to adult participation in the treatment.

oe
256 CHILD TRAUMA HANDBOOK

II. Safety and Strength-Building

A. Goals: Safety, skills, success, courage
1. Helping to create a supportive environment so the child can feel more safe and se-
cure.
2. Helping the child to develop effective coping skills and other good habits and behav-
iors.
Il. Trauma Resolution
A. Goals: Work through trauma
1. Keeping up the supportive environment so the child can concentrate on the work in
therapy.
IV. Consolidation and Relapse Prevention
A. Goals: Resolve symptoms, prepare for challenges
1. Work with the child and the therapist to help the child solve any remaining problems
and further improve good habits and skills.
2. Work with the child and the therapist to anticipate future challenges and to plan and
prepare accordingly.

In sum, the adults in the child’s life are active in every stage of the child’s treatment and recov-
ery from trauma and loss. The adults can directly support the treatment, for example, by bring-
ing the child to the therapist. However, the primary role of the adults is to create a safe, support-
ive environment for the child, and to help the child learn and practice self-management skills.
This will be the focus of the chapters in this section.
 Chapter 20

Creating a Safe Environment

One of the early, and ongoing, steps in treatment is to create a safe environment for the child.
This is important because we want kids to be able to feel that although bad things have happened
in the past, things are okay now. We want kids to be able to feel that although adults allowed bad
things to happen in the past, it might make sense to start trusting adults again. Finally, we want
kids to be able to feel that because things are getting better now, there’s reason to hope for fur-
ther improvement, and to work for it.

THINGS ARE OKAY NOW

If we expect the child to “get over’ the bad events that happened, she must have some reason
to believe that the bad events really are over, and in the past. Is it true to say, “At least things are
okay now’’? Only then can she start to separate the present from the past and feel that she can
move on. Are things really okay now? Or are the old problems being “‘reenacted,” replayed over
and over again, in some other way? Until kids can really believe that things are different (and
better) now, they will not let down their guard enough to do their work in therapy. As long as
kids perceive that they are still in the war zone, in constant danger, they’ll stay defensive, fo-
cused on survival.

A ten-year-old girl had been raped by her babysitter (who was now in jail). Her older brother constantly
bullied her and took her toys, and her parents allowed this without comment. She was learning the lesson
of the rape over and over again every day: that she was helpless against stronger people who would do
whatever they wanted to her.

A five-year-old boy whose father had abandoned the family believed that it was because his father
didn’t like him, that there was something wrong with him. On the playground, the other children teased
him mercilessly; they told him that they didn’t want to play with him because he was clumsy and stupid. He
was learning the lesson of the abandonment over and over again every day; that something was wrong
with him.

A twelve-year-old boy had been molested by a neighbor when he was nine. He had attention deficit/
hyperactivity disorder that was not being treated, and he kept on getting frustrated in school when seeing
that other kids were getting their work done but he was not, even though he was trying. He was learning
over and over again that he was helpless and that there was something wrong with him.

A fifteen-year-old girl grew up being neglected and poorly supervised, which led to a number of unfor-
tunate events. Now, in the residential facility, she’s figured out which staff members will let her get away
with not doing her chores properly, and even with sneaking off to meet with other residents who smoke to-
gether. She is learning, over and over again, that she is not important and that adults don't care enough to
take good care of her or protect her.

Zot.
258 CHILD TRAUMA HANDBOOK

ADULTS ARE OKAY NOW

One of the unfortunate lessons that kids learn from having experienced trauma or loss is that
the adults did not protect them or keep the bad event from happening. Adults become “spoiled”
as a source of protection and guidance. Many kids will then lose faith in adults, and rely only
upon themselves—and sometimes their peers. Although this may be understandable, it’s not
good! In fact, kids still need the love, protection, and guidance that adults can provide.
When we can take control and help kids to feel safe again, something good happens. When
we can help kids to feel safe, we are rehabilitating ourselves in kids’ eyes. Then kids can start to
trust adults again, start to look to adults for love, protection, and guidance. Kids become willing
to attach again. When kids are open to the good adults have to offer, they have a better chance of
getting back on a healthy track in their development.

THINGS CAN GET BETTER

Kids learn from experience. When the bad events happened, they learned from experience to
expect more bad things to happen. After that, many kids train themselves not to expect good, be-
cause when you don’t get your hopes up, you don’t get disappointed. The problem is, when you
don’t get your hopes up, and you’re not expecting anything good to happen, it’s hard to get your-
self to work hard in school or therapy. Why should you? Maybe it’s boring or hard, and nothing
good’s going to come of it, anyway.
When kids start to feel safe and secure, something good happens. That’s just it: something
good has happened. Now they have a new kind of experience to learn from. When kids start to
see that things have gotten better—that things can get better—it’s harder to stay pessimistic.
Hope starts to grow.
When kids feel hope, they are more willing to work on getting better at handling challenges,
and on getting stronger. The more progress kids make, the more successes they experience, the
more confident and hopeful they become.
The “personal trainer’ approach helps kids become stronger, more capable, and more confi-
dent, one step at a time. Meanwhile, the child is working on similar goals during his meetings
with the therapist. When he becomes strong enough and brave enough, he will be ready to slay
the dragon, to face and work through the trauma memories. Then he will be able to do even
better with daily life challenges. This is our goal.
So how do we help kids feel safer? What does it mean to create a safe environment?
When kids feel safe and secure, and do not need to focus on survival or self-protection, they
are more able to focus on healing and on healthy development. We want kids to know, to believe,
that their basic needs are being met. We must give kids experiences that will help them learn this.
Here, the concepts of physical safety and emotional safety will be presented separately for
convenience. However, they actually overlap, because when kids are safe, they also have more
of a chance to feel safe. In general, the principle is that we want to go beyond merely meeting
kids’ needs, to also teaching them—through experience—that they can count on this.

PHYSICAL SAFETY

° Protection from attack. For kids to be safe, they must be protected from being attacked.
This means that they are not being sexually abused by family members or anyone else.
 Creating a Safe Environment 209

They are not being bullied and beaten by peers. They are not being assaulted or beaten by
parents or other caregivers.
* Protection from other dangers. For kids to be safe, they cannot be exposed to dangerous
risks or experiences. This means that they are not exposed to dangerous weapons that could
be used by them or against them. They are not being transported by drunk drivers: they are
not being supervised by someone who is too depressed, irresponsible, drunk, or high to
take care of them. They are not allowed to ride in a car without wearing a seat belt. When
they are sick, they receive medical care.
* Other basic needs. For kids to be safe, they must live in a safe place. It should be dry
enough and warm (or cool) enough that they can be healthy. They should be able to sleep
without worrying that rats will bite them or that neighbors will sneak in and do harm. They
should have enough to eat, of food that is nutritious.

EMOTIONAL SAFETY

Protection from attack. For kids to feel safe, protection from attack must be much more ex-
tensive. Kids can feel safe when they are not being verbally attacked by being yelled at, in-
sulted, disrespected, or put down in some way. Kids can feel safe when they are not being
threatened with violence or disrespect. This means that no one else is being hurt or threat-
ened either. Remember, when an adult punches a wall or kicks an animal, a child sees this
(correctly) as a threat.
¢ Predictable routines. Kids who have been exposed to trauma have learned that bad things
can happen, so they are prone to assume the worst. When they don’t know what’s going to
happen, they worry! Adults can help with this by structuring the day, and various activities,
into predictable routines. For example, if food is served at set mealtimes, kids can learn to
count on that. Many activities can be routinized, including waking up, getting dressed, get-
ting ready for meals, eating meals, going to school, coming home from school, doing
homework, getting ready for bed, and going to sleep. The more kids know what to expect,
and what is expected of them, the more safe and secure they can feel.
* Consistency by adults. If kids are to regain trust in adults, they need to be able to count on
us to do what we say we will do. That means that we enforce our rules, every time, the same
way. That means that we keep our routines up. That means that we keep our other “prom-
ises’” too, so that kids know that we mean what we say and they can count on us.

THREATS TO SAFETY

Threats to safety and to sense of safety will make kids feel unsafe. Then they will be focused
on survival, self-protection, and worry about the bad things that might happen rather than on the
work we want them to do, or on healing.

Adult Loss of Control

Kids’ trust in adults is based on the foundation of adults being in charge, strong, and protec-
tive. If adults are not in charge, if adults lose control, the foundation crumbles. This is because if
adults are not in charge of kids, the adult is not strong, not able to protect. Also, if adults lose
control of themselves, they might lose more control and hurt the child. Adults can show loss of
control in several ways:
260 CHILD TRAUMA HANDBOOK

Repeating a command. “Put that down. I said put that down. I said put that down. I said put
that down.” An adult who is in charge only says it once, then gives a warning, then enforces
the consequence. Only an adult who is not in charge resorts to whining, begging, or ha-
ranguing.
Arguing with a child. “Yes.” “No.” “Yes.” “No.” “Yes.” “No.” An adult who is in charge
may give a command, make a request, or give an explanation. An adult may be willing to
discuss. When adults argue with children, they are on the child’s level; they have lost their
authority.
Yelling. An adult who is in charge does not need to yell. An adult who is in charge can state
feelings or expectations calmly, and this will be enough. People yell when they are feeling
helpless and frustrated. Yelling may also be a danger signal for some children, that some-
thing even worse is coming.
Threatening. When an adult threatens to hurt a child or reject a child, the adult is losing
control, by being unable to manage the child using the established rules, and by being on
the way to doing something very bad. When the adult says, “If you do that, the bogeyman
will get you,” or “One more time and I’ll send you to foster care,” the child will live in fear,
focused on survival. Threat of an unrealistically severe punishment brings a similar prob-
lem. When the adult threatens, “If you do that again, I’I] ground you for the next year,” the
child knows that the adult is feeling out of control and is threatening a consequence that
will not happen; the adult is preparing to break a promise.
Hitting, throwing, breaking. Sometimes an adult loses control to the point of physically at-
tacking the child or making some other physically threatening gesture. When the adult hits
the child, in some situations this can become a new trauma. Even with less severity, it can
still become a sign of ongoing danger. Similarly, if an adult throws an object in anger, or
breaks something, or even slams the door loudly in anger, this signals to the child that the
adult is not in control, and that worse may be coming.

Broken Promises

Kids need to be able to count on us to do what we say we’ll do. Promises can be broken in
many ways, and some of them aren’t so obvious:

Not coming through with a wanted consequence. If you say, “If your room’s clean in ten
minutes, I'll give you a popsicle,” and then, even though the room is cleaned within the
time limit, you say, “Oh, the room looks good, but there’s no popsicle for you,” then you’ve
broken a promise. Most of the time we don’t do that. However, when the child “‘spoils” the
anticipated reward by breaking some other rule, we may be tempted to say, “Well, you
earned your popsicle but you can’t have it because you hit your sister.” No matter how we
might justify this to ourselves, that’s a broken promise.
Not coming through with an unwanted consequence. If you say, “Stay out of the street or
you'll have to go inside for half an hour,” and then the child goes into the street again, but
then says, “Oh, I forgot. Please give me another chance; I’ll try,’ what will you do? If you
give the child another chance, you’ve broken the promise! All the child can learn from this
is (1) that you don’t care what happens to him (you told him to stay out of the street for
safety, right?) and (2) that you can’t be counted on to keep your promises. Maybe you
thought you were doing him a favor, but all you were really doing is making him feel inse-
cure.
Not sticking to rules or routines. Kids count on us to do what we say. When we say that you
have to do your homework before playing, you have to do your homework before playing.
When we say that dinner is at six, dinner is at six. Rules and routines allow kids to know
 Creating a Safe Environment 261

what is going to happen. This helps them to feel secure. Being loose with these rules and
routines, even to do kids a favor, really does the opposite; it makes them feel insecure. Of
course, occasionally rules or routines need to be changed, for example when someone is
sick. In such situations, the adult should explain why the rule or routine has been changed,
and explain that in normal circumstances, it will be the same as usual.
* Allowing adults to be “split.” When one adult makes a rule or a promise and the child
works with another adult to undo that or go around it, then the first adult’s promise is bro-
ken. Splitting can be a serious problem when adults work as a team with a child, such as in
a family, school, or treatment facility. When the child is able to split the adults, then the
adults are not in charge and cannot keep their promises, and the child cannot feel safe or se-
cure. An additional problem with splitting is that the adults become distracted by anger
with each other and toward the child, which makes it harder to help the child the way they
want to.

Allowing Attacks or Threats

When we allow kids to be attacked or threatened, they will not feel safe. Even if we are not
doing this ourselves, or not doing it intentionally, the effect is the same. Here are some common
types of attacks or threats that kids may experience:

* Bullying. Bullying used to be termed unfortunate but acceptable, “normal,” and just part of
life—along with drunk driving, sexual harassment, and racial discrimination. However,
when we decide that such behavior is not acceptable, and we make rules to express this de-
cision, things change. Drunk driving still occurs, but to a lesser degree. Our society is in a
transitional stage regarding acceptance of bullying. In some schools and facilities, bullying
is no longer tolerated, and thus much less occurs. In facilities where it is still tolerated, it
occurs more often. If your facility chooses to tolerate bullying, many of your kids are living
in fear because of that choice.
¢ Threats and put-downs by peers. The slightest comment or look from a peer can be a put-
down or a threat. When this is allowed by the adults, then kids learn that no one will protect
them and they have to protect themselves. This leads to fear and fighting.
¢ Put-downs by adults. For better or worse, adults who work with kids are as human and var-
ied as everyone else. In some families and some facilities, the adults who are supposed to
be helping kids are instead meeting their own needs in a twisted way, feeling important by
putting kids down or making kids feel small or helpless. I know of one instance in which
certain counselors in a residential facility engaged in a daily contest to see who could get
more kids “off program” that day, by getting the kids so upset that they would misbehave.
Although hopefully this is an unusual extreme, it is not so unusual to abuse power in
smaller ways, even with kids that we care about. We are especially vulnerable to doing this
when we are feeling helpless or frustrated ourselves, whether in our personal lives or in the
work situation.
¢ Aggressive physical restraint. In some situations, physical restraint is necessary to keep
kids safe. During a tantrum, while being restrained, many kids state that they are being mis-
treated or hurt, when in fact they are being carefully and lovingly handled. However, in
some treatment facilities, an outmoded style of physical restraint is used. In one facility, the
physical restraint method was described by kids and staff alike as an aggressive, fighting
type of maneuver. In another facility, a staff member explained that the good thing about
his restraint method was that “the more the kid wiggles and squirms, the more it hurts.”
Again, although this is an extreme (and the man was later fired for hitting a child), the
262 CHILD TRAUMA HANDBOOK

“fighting move” type of restraint is all too common. Kids know when they are being pro-
tected and when they are being assaulted, no matter what we say we are doing.
* Continued exposure to an unwarranted trigger. We cannot protect kids so well that they are
never upset. Trauma-exposed kids tend to be extrasensitive to daily stressors, and to react
to small challenges that would not affect another child. However, when kids are repeatedly
exposed to situations that should not have occurred, they will become focused on their fear
of that situation. Examples of unwarranted triggers include bullying, continued exposure
to an abuser, and untreated learning disabilities or medical problems. When kids face such
situations, their experience is of being constantly exposed to bad things happening to them.

EXERCISE: HOW SAFE IS YOUR HOME OR WORKPLACE?

Think about the place where you work with distressed kids—your home or your work setting.
Answer the following questions:

¢ What procedures or situations are already in place that help kids to be safe and feel safe?
¢ What procedures or situations are in place that make kids be unsafe or feel unsafe?
¢ What ideas do you have about how to improve the safety of your setting?

THE SAFETY THEME APPROACH

The safety theme approach is a good way to tie all the safety strategies together. This ap-
proach is more than the sum of its parts—it is a philosophy, a way of seeing children and work-
 Creating a Safe Environment 263

ing with them. It requires coming from a place of love and understanding (not anger or fear). It
requires an understanding that a child’s “bad” behavior comes from fear, not malice. A cornered
animal is the most dangerous, and people are no different. If we can see past the fangs to the fear,
ve en help the child feel safe and able to trust us. Safety is the foundation of learning and
ealing.

Words

Safe should be the most-used word in the day. Every intervention should be explained in
terms of its safety value. For example, a child may be disciplined for calling another child a
name, not because it’s “not nice” or even that it “hurt his feelings,” but because “he doesn’t feel
safe when you call him names; he feels attacked.” Starting a fight is against the rules. This ap-
proach does take practice.

Rules

Rules should be relatively few and simple so they can be overlearned. Before certain activities
(or every activity), rules should be recited by the children, as their “ticket” to participation. A
rule should reflect safety concerns explicitly, or it should probably be dropped. Rules should be
followed inflexibly so that children learn to take them seriously and to count on the adults to
keep them safe. (Adults must enforce safety rules consistently. Otherwise, children will get the
message that the adults don’t care about their safety.)
It’s helpful to frame rules in a positive manner: what to do. The following are examples of
helpful rules:

¢ Follow directions (a catchall).

¢ Let teachers teach; let students learn (addresses potentially disruptive behavior).
¢ Respect others, yourself, and property (addresses threatening, aggressive, and destructive
behavior).
¢ Additional rules can be made for specific activities.

Adult Vigilance

The adults should be highly vigilant to intervene in potentially unsafe situations before they
get out of hand. Examples of unsafe activities include rock-throwing, play-fighting, insulting
another child, taking another child’s possession, or failing to follow directions. Early interven-
tion has many benefits. When a problem is addressed quickly, unsafe situations will rarely pro-
gress to the point of actual physical damage to person or property. Also, early intervention tends
to prevent adults from becoming frustrated or angry—thus they are more able to respond with
appropriate concern. Finally, because kids do unsafe things to express their own insecurity, a
quick response by adults is very reassuring and precludes the need for escalation. Adult vigi-
lance, although it may seem too strict initially, will go a long way toward creating a safe place
and helping the kids to feel more calm and secure.

Daily Routine

The daily schedule should be adhered to strictly and consistently. When we tell a child what
to expect, we are making a promise. If we want kids to feel secure, we have to keep our promises
to them. They also need to know that what they expect to happen at school will actually happen.
Keeping to the daily routine is extremely important to children’s sense of security.
264 CHILD TRAUMA HANDBOOK

If a child should lose control at any point in the day, becoming unsafe and/or disruptive, it is
critical that he not be allowed to alter the routine. Even if he needs to be removed, the activity
should continue. If he is very loud or disruptive, he should be moved far enough away so that his
behavior does not disturb others. The other kids must be able to count on the routine and to count
on the adults to be in charge. If acting-out kids are able to destroy the plans and promises of the
adults, the adults are not as powerful as the children, a notion that frightens children.
The adults should be deployed so that sufficient staff is available to support kids in need of as-
sistance with self-control (e.g., by monitoring time-out or implementing a physical restraint)
while other staff are available to carry on the scheduled activity.

Physical Environment

The physical environment should also be carefully structured and defined such that each
space has a specified function—schoolwork, cooling off/regaining control, recreation, etc. This
should be carefully designed to avoid possible disruption of one activity by another. Ideally, a
separate space will be available relatively nearby when a child is so disruptive that she must be
removed from the group.

Positive Focus

Criticism, scolding, and punishments have already been tried with your kids. A focus on the
negative only feeds it; this risks escalation, does not solve the problem, and teaches the child to
live in fear of attack (criticism, punishment). Although some consequences for misbehavior are
inevitable, a positive focus works better. This includes a focus on what the child is doing right, a
focus on incentives/rewards, and a focus on the pleasure of participating in group activities and
being successful.

Discipline

Discipline comes from love, not from anger. The purpose of discipline is to keep the kids safe
so they are able to pursue their daily activities. There is no role here for punishment, which chil-
dren may perceive as an angry attack on them. Since many children are accustomed to angry dis-
cipline, it may take them a while to learn the difference, but they will. Note that if the child can
get the adult angry enough to yell or argue, the adult has lost control and the child is no longer
safe. Adults must be in charge.
“Consequences” occur naturally as a result of the child’s choices. The child constantly earns
the opportunity to continue participation in the group activity, and also earns points toward some
reward on a behavioral plan. These are seen as positive consequences. If a child is not behaving
safely, he is removed until he is ready to return and behave safely. This may be seen as a negative
consequence and he may be upset about missing an activity. However, it is also a positive conse-
quence in that he—and others—are being kept safe.
Our job is to keep the kids safe until they learn to keep themselves safe. When a child loses
control we provide it externally. Eventually the child will internalize control through this experi-
ence. A “bad” behavior is just the child’s way of asking for our help. The child deserves help, not
punishment.
The disciplinary rules should be well defined and adhered to consistently. This way the child
will know what to expect, the adults will know what to do, anda safe, secure setting is provided.
The specific tools and methods that support the safety theme will be the focus of Chapters 21,
22eange2ss
 Creating a Safe Environment 265

Physical Restraint

Physical restraint is a good example of a safety theme tool. It is the safety theme “‘bottom
line.” In essence, we are saying to kids, ““We will do whatever it takes to keep you safe. Even if
you are out of control, I will hold you until you can control yourself again.” This is not a punish-
ment; it is a gift. We do this without a second thought for a two-year-old who is having a tan-
trum. If an older child needs to be held until she can regain self-control, then we do this for the
older child too.
There are many “brand names” of physical restraint methods on the market. Competent prac-
tice of physical restraint requires special training. If you’re not already trained but need to be,
you might need to shop around for the method that meets your needs. If you are already trained,
perhaps you can take a second look at your procedures. Here are some of the essential features of
physical restraint, when it is done in support of the safety theme approach.

Kids (and Parents) Know What to Expect

If physical restraint is part of your repertoire, and any possibility exists that you might use it
with, or near, a certain child, then you’d need to inform the child ahead of time. Then you can ex-
plain it the way you would like him to understand it, while he is calm. “Part of my job is to keep
kids safe, no matter what happens. If someday you get out of control and your body starts doing
something that’s not safe, I will do my best to hold you and keep you safe until you get control of
yourself again. I can show you now how I would hold you. Do you want me to show you with
you, or with this doll here?” Then the therapist can demonstrate the hold, the child can ask ques-
tions, and it’s no big deal. When (or if) the restraint occurs, the child already understands what
will happen and why.
This preparation is also important for kids who will see or hear other kids being restrained. If
they have not been prepared, they are likely to be frightened and may believe that the restrained
child is being assaulted because restrained children often struggle, scream, cry, and claim that
they are being hurt. When kids understand what they are seeing and hearing, then being exposed
to a restraint only confirms their impression that here, the adults keep the kids safe.
It’s also important to inform parents and other caregivers about physical restraint, if restraint
is a possibility, and to discuss it with them. This makes them part of the treatment planning.
Then when you do restrain the child and he threatens to tell his parents, you can say that his par-
ents have agreed that you should do this to keep him safe. Also, if the child tells his parents that
you “attacked” him, his parents can probably figure out what he’s talking about.

Restraint Is Used Only to Enforce Safety

When you use physical restraint in support of the safety theme approach, you use it only to
keep kids safe. Using it just to enforce rules or to get kids to do what you want is coercion. Use
other consequences for that, and let kids make their own choices and learn from their experi-
ences:
Restraint is the obvious choice when a child is actively harming or threatening herself or
someone else and refuses to stop. For example, if a child refuses to stop hitting her head against
the wall, or swinging a chair around with peers nearby, she clearly requires restraint.
With the safety theme approach, many problem behaviors can be viewed as a threat to safety,
possibly requiring physical intervention. For example, if a child strays so far from the group that
the adult cannot see her to supervise adequately, that is a safety issue. The adult might say, “I
promised your mom that I would keep you safe. I have to be able to see you to keep you safe. If
you leave my sight again, you will have to hold my hand after that to make sure you’re close
266 CHILD TRAUMA HANDBOOK

enough that I can keep you safe.” For another example, if a child disrupts the classroom and re-
fuses to leave on his own, the adult might say, “This classroom is a safe place, and the other kids
need to feel safe here so they can concentrate on their schoolwork. For kids to feel safe here, they
need to be able to count on doing their schoolwork, and they need to be able to count on the
rules. When you make so much noise, you’re keeping them from doing their work, so you have
to go to your time-out for a few minutes. If you don’t go on your own, I will help you.” Of
course, the adult would not make this whole speech in the moment, but the building blocks
would all be in place from earlier discussions with the individual and with the group.
Note that neither of these examples will automatically result in a restraint. However, if the
child does not maintain self-control by following the safety instruction, the adult will heip,
physically. Even then, often children will cooperate when they are given a helping hand. How-
ever, if the child resists at that point, a restraint may be required.

The Safety Words Are Used

When physical restraint is used in support of the safety theme approach, it’s always clearly
about safety. Safety words are used before, during, and after the restraint. First of all, physical
restraint is introduced to the child as a last resort to keep kids safe. Then right before the re-
straint, the adult typically gives safety-related instructions (e.g., “You have to hold my hand so I
can keep my eye on you. To keep you safe, I need to be able to see you.” or “Put that chair down
right now! That’s not safe.’”), so the child knows that she is being restrained for continuing to be
unsafe. During the restraint, the adult continues to repeat statements such as, “I’ve got you. I’m
keeping you safe.” Afterward, the restraint is discussed in the same vein—as something the
adult did to keep the child (and/or others) safe.

The Holds Are Not Hurtful

The goal here is safety, not attack. If you learn the proper method of physical restraint, and if
you keep yourself calm and in control, this won’t be a problem. The physical restraint “holds”
are designed to protect and contain children, not hurt them, no matter how much the child might
struggle.

Adults Keep Themselves Calm

Restraining a child can be an intense experience, both physically and emotionally. With this
intensity, we risk becoming overly emotional and squeezing too hard, hurting the child, or per-
haps arguing with the child instead of comforting him. Special precautions should be taken dur-
ing a restraint to remain calm. We use the safety words, because while we remind the child of the
reason for holding him, we also remind ourselves. When we remember that we are helping the
child and keeping him safe, we operate from a sense of love and protectiveness. Deep, slow
breathing should be practiced during the restraint in order to stay calm and keep focus and con-
trol.

This Is Help, Not Punishment

A restraint is not used to punish, but to protect. Punishing may hurt the child and may occur
because we feel angry at the child. Protecting the child involves feeling loving. If we are punish-
ing, then when we have punished enough, we can let the child go; if we are protecting, then we
don’t let go until we are sure that the child is safe and able to self-control. If we are punishing,
then restraint makes the child feel ashamed; if we are protecting, then we give needed support
until the child grows enough to keep herself safe.
 Creating a Safe Environment 267

Hold Until the Child Can Self-Control

Because this is not punishment but help, we don’t release the child just because the restraint
has lasted “long enough already.” The restraint ends when the child is calm and can keep herself
safe, which she demonstrates by keeping control of her arms and her legs while still being held
by the adult. If you end a restraint too soon, the child will let you know by quickly acting up
again and requiring further restraint. It is better to end slowly and cautiously, so that you can be
confident that the child is really in control and doesn’t need your help anymore.

A Story About Physical Restraint

Here’s a true story from my own experience that highlights the difference between good and
not-so-good methods of physical restraint. Many years ago I worked as a part-time therapist ina
fairly good residential facility for boys with severe behavior problems. Unfortunately, in this fa-
cility the physical restraint method was aggressive. I told the director of my concerns, and he ac-
tually agreed with me, but explained that because of all the staff retraining involved, he would
not be able to make the change for a few months. I told the director that meanwhile, I would do
restraints my own way. Since I was a therapist and not a direct care worker, my stance did not
seem to be a problem because I was not expected to be involved in a restraint anyway.
One day I was meeting with a ten-year-old boy who seemed particularly distressed, though he
did not tell me why (I did ask!). We had met several times previously and things had gone pretty
well. But this time, he insisted on hitting his hand against a wooden table. I asked him not to do
that, because I didn’t want his hand to get hurt. He did it again. We went through the routine
several times, until I finally told him that if he did it again, I would hold his hand to keep it safe.
To make a long story short, he essentially forced a physical restraint, had a tantrum (while being
held), and then eventually calmed down and regained his composure.
The next day I learned more about how that physical restraint had fit into the boy’s day. He
had known that following his meeting with me, he was to be interviewed by child protection in-
vestigators regarding his experience of having been physically abused in a foster placement. My
understanding, with hindsight, is that he was anxious about this interview and made me hold
him so that he could feel protected and reassured. Apparently, this worked for him. Not only did
he handle the interview smoothly, but later that night, when everyone else on his unit acted out
and got into trouble, he was the only one who did not misbehave. Since he was not typically
better behaved than his peers, I am guessing that he had gained a sense of calmness from his
experience of being held and contained.
I thought that was the end of the story, but I was wrong. A couple of weeks later, his mother
came for a visit. The boy took his mother’s hand and was showing her around the facility, intro-
ducing her to people (including me) and telling her stories about his experiences there. I had
some opportunity to observe them together when he did not know I was nearby. By and by, he
pointed to another staff member, who had apparently restrained him some days before, accord-
ing to the aggressive method required by the facility. “There!” he said to his mother, “That’s the
one who attacked me!”
This boy was clearly able to distinguish between a loving, protective restraint and an aggres-
sive one. He experienced reassurance from mine, and violence from the other. I am not saying I
was a better person than the other staff member, only that my method of physical restraint better
expressed my intentions than his did.
Physical restraint is a complex intervention that does require specialized training and supervi-
sion to do well. It’s also an important intervention to have in your repertoire for those kids who
may need it. If kids can’t keep themselves safe, and you can’t keep them safe, you can’t do much
to help them. If you are working with kids who need physical restraint, take the trouble to learn
how to do it well.
268 CHILD TRAUMA HANDBOOK

EXERCISE: MAKE THE CHILD’S ENVIRONMENT SAFER

Complete the Meaning of Behaviors form for each of the vignettes.

¢ Identify the main thing that is challenging the child’s sense of safety.
¢ Decide what needs to be in place to reinforce safety and a sense of safety.
Role-play getting this done; include all involved parties.

Jesse and Mischa

Jesse, eleven, and Mischa, seven, are siblings in foster placement because their biological father is
long gone and their biological mother was neglectful. The children had been returned to their mother on
several occasions, but although she tried to keep them, she was a drug addict and was not successful in
making her kids a priority. The last time the judge sent them back to their biological mother, the judge said
it was “against my better judgment” and described it as a last chance. The last chance lasted for five
months. Now, parental rights are in the process of being terminated, the kids are back again in the same
home where they had stayed for three years prior to the last stint with their biological mom, and the foster
parents are in the process of adopting them. Although the foster parents have a good relationship with
Jesse and Mischa, the kids are sensitive regarding their biological mom, and the foster parents don't re-
ally know what happened while the kids were with her.
The adoptive parents have a friendly, open home. Plenty of food is always available, and friends often
show up to visit or share a meal. The parents are loving and permissive, letting the kids eat what they want
and where they want; the kids often avoid vegetables, and sometimes eat while watching TV. Bedtime is
the same; kids are allowed to go to bed when they are tired, and sometimes end up falling asleep in the liv-
ing room or wherever they were when they got tired. The kids each have their own room, and although
they are not allowed to leave messes in the rest of the house, are allowed to keep their own rooms as they
wish.
The kids, though ambivalent about losing their biological mom again, seem relieved and happy to re-
turn to this home and family. Within a week they seem settled in, and they are trying hard and doing well in
school. Their behavior at home varies. Sometimes they are okay, but often they fight with each other,
throw and break objects, and on occasion run out of the house and stay away for half an hour or more.

Exercise: You are one of the adoptive parents, or you are their social worker/case manager.
Choose one.

Lisa

Lisa is a sixteen-year-old girl currently living in a girls-only group home. She was molested for several
years by her stepfather before disclosing to her school counselor at age thirteen. She has had a number
of serious behavior problems including cutting classes, smoking cigarettes and marijuana, drinking, lying,
stealing, fighting, running away, and going out (and having sex) with much older boys/men. Chances are
good that she'll be in this home, or a similar placement, until she turns eighteen.
Although she gets along with many of the residents and staff members in the group home, she is also a
disruptive influence. For example, she will make up a story about one of the girls and tell others that this
girl said something mean about another one. She is particularly close to one of the staff members, who
acknowledges that they have a special relationship. He feels that he has a chance of really reaching her
and helping her. In general, Lisa gets in a lot of trouble in the group home because she breaks so many
rules. However, when her favorite staff member is working, he often gives her a break and will talk to her
instead of making her pay the set price for her rule violation.

Exercise: You are on the staff.

Discussion Questions

1. What were your solutions?

2. How did it feel to be in each part in the role-play?
3. What can we learn from that?
 Creating a Safe Environment 269

Meaning of Behavior Worksheet

© Ricky Greenwald 2004.

. Trauma/loss event (all events):

. Negative beliefs (negative self-statements):

. Piled-up feelings:

. Trigger situation (what sets off the reactivity):

Theme:

Example:

. Problem behavior(s):
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 Chapter 21

Discipline Is Love

Many caring adults are hesitant to discipline children. Why should this be? Many of us grew
up learning to associate discipline with anger, yelling, and even revengeful punishment. If we
believe that discipline is inherently hurtful, naturally we don’t want to inflict it on kids we care
about. The problem is that when we don’t discipline kids, they keep misbehaving, and we be-
come more angry and frustrated. When the discipline finally does occur, it’s just as we feared:
it’s done with anger. No wonder so many adults try to avoid disciplining kids!
Because kids do need discipline, we might as well do it in a way that works, and in a way that
also communicates our true intentions. Your approach to discipline depends on your answers to
the following questions:

¢ Why do kids act out? Because they’re bad and want to spread their badness around? Or be-
cause they have been “triggered’”—something hit their sore spot—and they are feeling
anxious and unsafe?
¢ Why do you have rules? To help kids to be safe, to heal, and to learn to do right? Or to get
revenge when kids break the rules?

If you believe that kids break rules because they are bad, then you will probably want to use
discipline to punish them and get revenge. Unfortunately, that approach to discipline does not
really make kids feel safe, nor does it teach them to do right. It only adds more pain to the pile,
and teaches them to fear the punishing adult.
If, on the other hand, you believe that kids break rules because they are trying to make them-
selves feel okay when they are feeling unsafe or insecure, then you will probably want to use
discipline to help kids to feel safe, to heal, and to learn to do right. This approach to discipline
takes considerable effort, especially at first. The good news is that this compassionate approach
to discipline is also the effective one.
This positive, compassionate approach to discipline is based on several assumptions:

1. When kids act out, that means that they feel unsafe or insecure. They use their actions to let
us know that they need our help.
2. We want to do what we can to reassure kids, so that they can feel safe and secure again. We
can reassure them with discipline.
3. We want kids to learn good things from their experience of our discipline. We want them to
learn:
¢ They are safe.
¢ They can count on us.
¢ What they do matters. Good actions get rewarded; bad actions do not get rewarded, and
may require discipline.

An effective discipline approach is best offered within the context of a safe, supportive environ-
ment (see Chapter 20), in which kids work toward goals they care about (see Chapter 22). We’ll
be focusing here on several components to the positive discipline approach: focusing on the pos-
itive, using a time-out system, and using natural consequences.
atl
242 CHILD TRAUMA HANDBOOK

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ACCENTUATE THE POSITIVE

The first principle in positive discipline is to focus on the positive. This is not just to be “nice,”
but because it works. Here are some keys to this approach.

Kids Will Try to Meet Your Expectations

A famous study was conducted in a public school system some years ago. Researchers came
into a few classrooms and gave each child an assessment. After the assessments were com-
pleted, the researchers gave each teacher a list of several children in their class who, based on the
test results, would be “late bloomers” and do especially well as the year progressed. The kids
heard nothing about the lists; only the teachers knew. The tests turned out to be highly predic-
tive, and the kids on the list did do better and better at school as the year progressed. The teachers
were very impressed and wanted to be able to use the tests with their future classes.
 Discipline Is Love Zio

Maybe you already know the punch line: the tests were phony and the kids were selected for
the lists at random! So if the whole thing was a hoax, why did the kids all do so much better? We
can only draw one conclusion. The only special thing about the kids on the list was that their
teachers believed that they would do better over time. Somehow, the teachers’ beliefs and expec-
tations toward these kids were communicated, and the kids responded by coming through, by
meeting the expectations they perceived.
Since kids do tend to respond to how people view them, why not use that to their benefit?
When we find ways of communicating that we see kids positively and that we expect them to do
good things, many kids will naturally respond by proving us right.

Attention Is Reinforcing

Kids learn from experience. When they have a repeated experience of being rewarded, or “re-
inforced,” for doing a certain thing, they learn that doing that certain thing brings rewards. Then
they’re more likely to do that thing again. So you might as well focus your reinforcements on the
behaviors that you hope kids will do again and again.
Give positive attention whenever you “catch” the child doing something right. Your noticing
is itself reinforcing. And if the child is also working with a formal incentive system, your notic-
ing will also serve as encouragement that she is on track toward her goals.
You can give positive attention not only for obviously good actions, but for neutral ones, as
long as you can find some way to call it a positive action. For example, a boy who sometimes
punched other children with no provocation was praised simply for walking down the hall: “I
see you walking down the hall keeping your hands to yourself. This makes other kids feel safe
around you, so they’ll be more likely to want to play with you.” Again, he is seen as practicing
friendly behaviors, he is reinforced for these, and thus is more likely to continue them.

Reinforcement Builds Relationship

You may know of a family in which the new stepparent attempts to discipline a child before
establishing much of a relationship. The child correctly says, “I don’t have to listen to you!
You’re not my [mother/father]!”’ This highlights an important principle in discipline: we earn the
authority to discipline a child by becoming someone he cares about. We become someone he
cares about, in part, by providing for his needs and by helping him feel good.
When we focus on the positive aspects of a child, we are building the relationship. Whenever
possible, we want to get to know a child in a way that makes her feel that she is seen in a positive
light. We can accomplish this by engaging in enjoyable activities together, and by letting her
know that we see the good things about her. When she feels that you like her and that you are no-
ticing her positive behavior, she will feel safe and comfortable with you. When you develop a
positive relationship with a child, the child is likely to try to please you. The more she cares
about you, the more she will value your comments, and the more reinforcing they will be. Fi-
nally, if you do need to discipline the child later on, you will have earned the authority to do so.

ELIMINATE THE NEGATIVE

Ignore the Negative

When we ignore behavior that we don’t like, we are not reinforcing it with our attention. Ifthe
goal of the bad behavior was to get our attention, this strategy will be discouraging. (Certain be-
274 CHILD TRAUMA HANDBOOK

haviors, such as when one child physically attacks another cannot be ignored. We are obliged to
intervene to keep kids safe. Other times, we may have more leeway.)

Notice Someone Else’s Positive

While we are ignoring one child’s problem behavior, we can actively give our attention to an-
other child’s more appropriate behavior. Often, the first child will join the other child in an at-
tempt to get a share of the reinforcing attention.

Distract or Rechannel

Another way to stop a child from doing something you don’t want her to do is to engage her in
something else instead. With this strategy, you are not reinforcing the bad behavior, and you are
giving the child another option to earn your attention and reinforcement. As kids become in-
volved in positive behaviors, we can reinforce them for doing something we approve of.

Explain Why the Behavior Is a Problem

Sometimes when we see a child doing something we don’t want him to do, it makes sense to
explain this to him. Kids may not know all of our rules or our reasons for them. Often, this kind
of explanation can be enough to help a child do better next time.

Set a Consequence

It can be effective to tell kids what will happen if they continue the problem behavior, or if
they do it one more time. For a consequence to be a meaningful deterrent, it must be something
the child doesn’t want, for example, removal of reinforcement, or a punishment of some kind.
The latter parts of this chapter focus on this strategy in more detail.

Keep the Consequence

If the child continues doing the problem behavior after you’ve set a consequence, the next
strategy is to keep the consequence. Then the child can learn from experience that when she be-
haves badly, an unpleasant consequence will occur.

DON’T MESS WITH MR. IN BETWEEN

It’s very important for adults to be firm and consistent in their approach to discipline. Other-
wise kids will not learn what you are hoping they will learn. Then they will continue to feel un-
safe and insecure, and continue their problem behaviors. Of course, adults are not machines, and
no human can be exactly the same all the time. But we can learn from machines, and use this un-
derstanding to help us to help kids. Specifically, let’s learn from slot machines.
Imagine you are playing slot machines that cost a quarter for each play. Now answer this
question: What will you do with a machine that gives four quarters each time you play it?
Chances are, you’ll put another quarter in, and another, and another. Each time, you are being re-
inforced with a small win. Play this machine enough times and you can buy yourself a new car.
You’ve been playing that machine for a while, and it’s always worked for you the same way.
Now what will you do when you put in a quarter, but the machine does not give the four quarters
back? Chances are, you’ll say to yourself, “I know that this machine works; it always works,”
 Discipline Is Love PATS

and you’ll put in another quarter, and another, and another. If you’re still not getting the four
quarters back, after a while you might try hitting or kicking the machine, perhaps out of frustra-
tion, or to try to get it to fix itself.
You’ve put in the quarters, you’ve kicked the machine, and still you’re not getting any quar-
ters back. Now what will you do next? Chances are, you’ve had enough. You’re telling yourself
that this machine doesn’t work anymore, and you’re not going to keep wasting your money onit.
So you’ ve left that machine, and now you’re playing a different one. With this machine, you
put in a quarter and nothing comes back. You put in another quarter and nothing comes back.
You put in another quarter and nothing comes back. You put in another quarter and nothing
comes back. You put in another quarter and—jackpot! Many quarters come back. You put in an-
other quarter and nothing comes back. You put in another quarter and nothing comes back. Now
what will you do? Chances are, you’ll put in another quarter, and another. Because each time,
you're telling yourself, “The next one could be a jackpot.”
Of course, you recognize that last machine as the way the slot machines work in gambling ca-
sinos. This exemplifies the principle of “random intermittent reinforcement,” and it’s the hardest
kind of behavior to get rid of. Because the next try could win the jackpot!
So how does this apply to your discipline approach? Imagine a child who is always reinforced
for a certain problem behavior. That’s like getting four quarters from the machine every time
you put in a quarter. It works, so you keep on doing it. This is why kids keep repeating their
problem behaviors—because in some way, it’s working for them.
Then one day the adults change the rules, and the problem behavior is not reinforced any-
more. That’s like when the quarters stop coming back from the machine. Remember, the behav-
ior won’t stop right away! First, the child may try many more times, perhaps even more than
usual, so be prepared for a bit of a storm. But if you hang tough and keep from giving in, if you
keep from reinforcing the problem behavior, after a while the child will finally realize that it just
doesn’t work anymore. Then, why waste more quarters? Better to try a different machine, find
some new way of getting reinforcement.
The trick, when you are trying a new discipline approach, is to avoid the in between. What
happens if the child is putting in those extra quarters, being frustrated over and over again, and
then suddenly hits a jackpot? Then you have created a random intermittent reinforcement sys-
tem, and the problem behavior will be much more difficult to get rid of, because no matter how
many times you stick to your new rules, the child will keep hoping for a jackpot.
You have surely seen the following scene in the checkout line of a supermarket.

CHILD: Mommy, can I please have one of those?

MOTHER: No.
CHILD: Mommy, please?
MOTHER: No.
CHILD: Mommy, please?
MOTHER: No.
CHILD: Mommy, please?
MOTHER: No.
CHILD: Mommy, please?
MOTHER: No.
CHILD: Mommy, please?
MOTHER: No.
CHILD: Mommy, please?
MOTHER: Okay, here. Just be quiet!
276 CHILD TRAUMA HANDBOOK

I hope you are thinking, “Jackpot!” This mother is training her child to be obnoxious. She is
reinforcing the child for asking over and over again, by teaching the child that if you ask enough
times, there’s a good chance of hitting the jackpot.
If you don’t want your kids to be obnoxious, or to repeat their own preferred problem behav-
iors incessantly, then don’t reinforce it. Stick to your rules every time; don’t hand out jackpots.

PRINCIPLES FOR IMPLEMENTING DISCIPLINE

USING A POSITIVE DISCIPLINE APPROACH

When you are responsible for kids, sometimes you must take actions that they complain
about, such as enforce the rules, take away reinforcements, and give other consequences for
their behaviors. The following principles and practices will help you to do this in a caring and
effective way.

Problem Behavior Is a Way Children Ask for Reassurance

Reassurance calms kids down. When you can keep in mind that discipline is reassurance for
kids, it will be easier for you to do this from a caring mind-set. Your goal is not to punish but to
help kids to feel more safe and secure. When kids are out of control, they need the adult to take
charge and get them back into control. You can do this with discipline. Then they feel protected
and safe.

You Are the Adult

You are the child’s rock of security. Kids need to be able to count on you to protect them, to
keep things safe and under control, and to keep your own promises.

If You Are in Charge, You Are Strong and Can Protect

If you cannot take charge of a kid, then you aren’t very strong and can’t be counted on for
much. You can show you are in charge by enforcing the rules without losing control yourself.
Then kids can feel that someone strong and caring is protecting them and keeping them safe.

Keep Your Promises

Remember, routines, rules, and consequences are all promises. If you “give the kid a break”
and don’t enforce the rules, you are giving the kid a broken promise.

Only Make Promises You Can Keep

Don’t offer treats or special activities that you won’t be able to deliver; it will just teach the
child that you can’t be trusted. Also, don’t threaten consequences that are unfair or overly se-
vere. Later, when you are calmer, you will realize that you were wrong, and you will correct it.
That also teaches the child that you can’t be trusted, that you don’t mean what you say. It’s better
to have small, reasonable consequences prepared ahead of time, so that when it’s time to disci-
pline, you already know what the consequence will be. If you find yourself disciplining while
angry, you can tell the child that you will decide the consequence later.
 Discipline Is Love Zim

Stop a Problem Quickly

Stop a problem before it gets too bad, and before you become too angry. This is the key to the
whole thing. If you stop a problem behavior early, then

* You have offered reassurance at the first cry for help. You’ve come through for the child.
* The child has-not had to escalate the problem behavior to get your attention. He did not
have to act too “bad” to get reassurance from you. He is learning that he can get reassur-
ance with small offenses and may not need big ones. This is not the final goal, but it’s a
good step.
* Because the problem behavior is still small, it only requires a small consequence. This will
be easier for the child to tolerate, and easier for you to tolerate.
* Because you have not had a chance to become angry or frustrated yet, you can discipline
calmly, from a caring mind-set. Then the child can learn more easily that discipline is love,
and so can you.

TIME-OUT

The exact format of your discipline approach isn’t the most important issue. What’s really im-
portant is that you follow the principles and practices, and that you have a clear system that you
stick to. If you don’t like the following time-out system, change it to one that you like better;
that’s fine. But stick to your system, and use these principles.
Many parents have been taught a quickie version of the time-out approach, and have tried it
but found that it didn’t really work for them. That doesn’t mean that time-out will not work in
their household. What it does mean is that they were not taught carefully enough, or that they
were left on their own to do it, and when problems came up, they didn’t know what to do. Time-
out does work, but it should be used within the context presented here (including a safe environ-
ment, focus on the positive, etc.). Also, don’t expect it to work all at once. Kids find the loop-
holes, and it’s our job to plug them up. This is an effective system, but it takes work to get results.
The main point of a time-out is that the child is being removed from the action, from the fam-
ily or group. A time-out intervention should reflect the following principles:

¢ Time-out is nonreinforcing. That means that the other activity (from which the child is be-
ing removed) should be reinforcing. This is part of the context that makes time-out work.
¢ Time-out is nonpunitive. The goal is to keep kids safe and to remove reinforcement for bad
behavior. There is nothing angry or punitive about giving a time-out.
¢ Time-out allows for learning. Kids have a chance to learn that certain behaviors lead to re-
moval of reinforcement. They also have a chance to calm down and to think about what
they did and how they want to act when they are able to rejoin the group or family.

The advantages of the time-out are closely related to the structure of the time-out, and include
the following:

¢ The time-out keeps the child from hurting someone. This keeps the setting safe.
¢ The time-out keeps the child from disrupting, from preventing others from doing their own
activities. When other kids can do what they expected to do, this means that adults are
keeping their promises.
¢ The time-out removes reinforcement for bad behavior. No more quarters!
278 CHILD TRAUMA HANDBOOK

¢ The time-out allows the child time to regain self-control.

¢ The time-out gives the adult a chance to demonstrate control when the child was out of
control. This is reassuring to the child, who has been contained and kept safe.

The time-out method includes the following components:

* Use this with previously established rules. The child should already know the deal before
the time-out is given.
¢ Use with preestablished duration (e.g., one minute for each year of the child’s age). Some
people use thirty-second or one-minute time-outs, to allow the child to return to the family
or group as quickly as possible. In general, shorter time-outs are better, because the goal is
really to set a limit and remove reinforcement, not to drag things out. However, for some
children, a very short time-out may not have the desired effect, so you’llhave to figure out
what works best for your kids, in your setting.
¢ Some actions (e.g., hitting) get automatic time-outs. If damage is already done, it’s too late
to start talking about it; the child is clearly a danger and must be removed immediately. Ad-
ditional consequences could occur as well, depending on your rules and on the nature of
the offense.
¢ Some actions (e.g., disobeying) get a warning. When the child still has a chance to correct
her behavior, then give her the chance. If she can catch herself and get it together without
needing a time-out, that’s great.
¢ Warning: restate request, then count: one, two, three. Tell her what she’s doing and what
you want her to do instead. Count to three in a steady manner so that each count takes about
one second. Do not fudge this or slow the count down, because that would be breaking your
promise.
¢ If the child fails to initiate the action before the end of the count, then say, “Take a time-
out.” Sometimes the child will do what is asked just after the count has finished. He may
say, “I’m doing it; I’m doing it!” but you should tell him, “You missed the chance; you can
do it after the time-out is done.” If you let him get away with it (if you let him do it without
taking the time-out first), you have broken your promise and he will know that he can’t
count on you to do what you say.
¢ Time-out occurs in a designated space. This can be a certain chair, wall, or corner of the
room, or it can be another place farther away. Your choice of a time-out spot will depend on
your facilities, on your staffing, and on the nature of your kids. Make sure that the time-out
spot will allow you to accomplish your goals to keep kids safe, to allow others to continue
in the activity, and to remove reinforcement during the time-out. If you are traveling or not
in your usual setting, you can invent new time-out spots wherever you are.
* Follow rules while in time-out. The child in time-out should not communicate with anyone
during the time-out. He should not make faces or noises; he should not ask you if he’s al-
most done. He should not play with toys or jump around. You will have to make your rules
realistic for the children you work with; some kids can handle being still and silent, while
others should be given something to do such as writing or drawing.
¢ During time-out, the child should receive no conversation or other attention. If the child in
time-out makes faces and other kids laugh, then you haven’t removed the reinforcement,
and others are distracted and not doing their normal activity. You might control this by lo-
cating the time-out spot farther away, by starting the time-out over again whenever the
child in time-out misbehaves, and/or by sending other kids to time-out as a consequence
for interacting with kids in time-out. There’s no one right way to manage this; you’ll have
to figure out what works for you. If possible, it’s good to have the time-out spot in plain
view of the rest of the group. Then the child in time-out can see what he’s missing, and you
 Discipline Is Love 279

can keep an eye on him. However, with kids who are too disruptive, you will need to devise
another plan.
* When the time-out is finished, the child is asked to explain what happened, then is wel-
comed to return to the group/activity. You can help the child learn from the experience by
asking her to state what happened and how she would like to handle it next time. However,
the “cognitive processing” component is not always appropriate. For example, if you are
using thirty-second time-outs during a high-interest activity, it’s probably enough just to
name the behavior that caused the child to get the time-out.

Time-Out Problem Solving

Many problems will arise as you try to use these methods, because kids are all different. Here
are some of the more common types of problems, along with some suggested strategies for han-
dling them:
What if other kids try to interact with the kid in time-out?

¢ Have a rule against that. Enforce consequences for kids who try to communicate with
someone in a time-out.

What if the child acts up in time-out?

¢ Then he is breaking the time-out rules. Start the time-out again when he starts following the
rules again. After a while he will learn that he is just making his time-out longer.
e Ifthe child in time-out is being too distracting, and this is keeping others from doing their
activity, then consider having the time-out spot farther away from the others.

What if the adult can’t resist interacting with the kid in time-out?

¢ If the adult is concerned for the child’s health or safety, then it is appropriate to interact,
even during a time-out. For example, if the child needs to go to the bathroom and really
can’t wait, let him go, and then pick up the time-out where it left off. Of course, if he tries
this every time, then you’Il know to ignore it.
¢ The adult must not get caught up in arguing or explaining to the child during the time-out.
The intervention is negated by giving the child reinforcement instead of removing it. Do
not reward the child for breaking the time-out rules.
¢ If the adult is unable to control his or her own reactions to the child during time-out, con-
sider the situation:
—If this is a staff member who is unable to achieve self-control, the first strategy is educa-
tion and training. If it’s still a problem, then he or she is probably in the wrong job. It
takes a great deal of maturity and self-control to work with distressed kids.
—If this is a parent, other options must be explored. The quick solution is to find a time-out
spot that is far enough from the adult to prevent opportunity for interaction during the
time-out. The parent does not interact until the child has completed the time-out prop-
erly, to say that the time-out is over. This saves the reinforcement for the positive behav-
ior only (for more detail on this approach, see Chapter 10). In the long run, the parent
might benefit from working with a therapist on self-control skills so that she or he can be
more effective in handling the child face to face.
280 CHILD TRAUMA HANDBOOK

What if the child won’t go to time-out, or won’t stay there? Then some way must be found to
enforce the rules, otherwise promises are not being kept and kids are not safe. Here are some
ideas for enforcing rules in this situation:

¢ Ifthe child does not go to time-out immediately, the adult can count to three to indicate the
time the child has to start toward the time-out spot. If the child does not start before the
count is done, then the time-out period is doubled (or add whatever amount of time was
set).
* Ifthe child does not go to time-out and this is an urgent threat to safety, then, depending on
the degree of urgency, the adult must take him away, or let him know that he will be taken
away if he doesn’t go by himself. A typical statement is, “I’1] count to three; if you are not
on your way by then, then that means that you’re asking me to help you get there. One, two,
three.” If he is not already on his way, then the adult should take his hand and walk him
there.
¢ The same strategies can be used for the child who will not stay in time-out. Set up conse-
quences for this, perhaps additional time-out minutes, or some other consequence such as
loss of TV time.
¢ When safety is at stake, and when these other strategies don’t work soon enough to keep
safety, physical restraint must become an option. Otherwise, the situation does not keep
kids safe.

What if the child likes to be in time-out? It’s important to figure out why the child likes to be
there. This can take some careful observation and questioning. Different reasons lead to differ-
ent strategies:

¢ Some kids like time-out because of the attention that this brings them, from kids or adults.
If this is happening, then time-out isn’t being used properly. Figure out the weak link and
fix it. This might mean moving the time-out spot farther away, enforcing consequences for
other kids who encourage this child, or getting the adult under control.
¢ Some kids get themselves placed in time-out to avoid doing tasks they don’t like, or to
avoid situations they find uncomfortable. Kids should not be allowed to escape their obli-
gations, so perhaps (for example) missed schoolwork can be made up during recess. How-
ever, adults can also learn from what the child is avoiding, and make extra efforts to help
her to learn how to handle those challenges.
¢ Some kids find time-out calming. This is not such a bad thing. Work out a system in which
they can take a voluntary time-out to calm themselves down. This can also involve prompt-
ing on the part of the adults. This is a good step toward helping kids to become better at
self-management.

The real key to the time-out system is to catch the problem quickly. If you are new to using
time-outs, try to make sure that you use time-outs at least three times per day in the first week of
practice. Even if you must be very, very strict to do this, it’s worth it to get the practice and get
good at it. If you have allowed a problem to continue long enough to cause you frustration or an-
ger, you probably should have used the time-out strategy previously. That’s okay—just use the
time-out right away, before the situation becomes worse.
Many parents and child care workers object to this suggestion for such active use of time-
outs, stating that this seems overly strict. However, remember that “strict” and “harsh” are very
different in the positive discipline approach. The sooner a problem is stopped, the smaller the
problem will be, and the less chance you will have to get upset about it. If you use this strategy,
and if you stick with it 100 percent for a few weeks, you will find that your kids are calmer and
 Discipline Is Love 281

better behaved. At first they might complain that you’re too strict, but they will notice in the long
run that you don’t yell at them so much anymore.

Discipline Is Love: A Story

This is a story of an unusual intervention made by a therapeutic aide (a paraprofessional) in an

elementary school. The purpose here is not to suggest that the intervention be imitated, but to il-
lustrate one way that a direct careworker tried to help a child.

_ “Tom” was a nine-year-old boy who had experienced significant violence and major losses in his family,
including one family member murdering another. His behavior at school was extremely volatile. The aide’s
job was, In essence, to create a one-person day treatment program for the boy, within the context of a
mainstream classroom in the public school setting. Because Tom’s behavior could become so disruptive,
his time-out spot was not in his own classroom, but in another smaller room down the hall.
By about three weeks after the aide had initiated the milieu treatment program, Tom had learned the
system but still didn’t quite get the point. One day he had to go to his time-out room for ten minutes. He sat
at his desk in the time-out room, jabbing his drawing paper furiously with a marker and muttering to him-
self. After a few minutes, the aide came by and gave him a couple of cookies, then left again to avoid en-
gaging in conversation during the time-out.
Afterward, the aide asked, “Are you wondering why | gave you cookies?” and they talked about it. The
aide was able to explain that he had given the time-out and the cookies for the same reason: that he cared
about Tom and wanted him to be safe and to feel good. Although the aide had been using the safety words
all along, it wasn’t until after this time-out that Tom began to realize that the aide actually cared about him.
Someone who is angry at you and punishing you doesn’t give you cookies!

Natural Consequences

The time-out system will cover many of the discipline issues that arise, but sometimes kids’
behavior requires more of a consequence than a time-out can offer. Even so, angry, punitive re-
venge must be avoided. Set limits to help kids to feel safe and secure, and to help them learn that
their actions do matter, and actions bring consequences. Good actions might bring rewards, bad
actions might bring other consequences. We can help kids learn these important lessons by us-
ing the natural consequences approach. To make this work, it’s important to use the following
principles:

* Keep your promises—be willing to follow through on the consequences you select.
¢ Avoid retaliation or revenge—by definition, this represents adult loss of control.
¢ Avoid depriving the child of meals, sleep, school, and (if possible) other worthwhile activi-
ties. This is bad for the child and becomes a vengeful punishment.
¢ Use consequences that are fair, make sense, and offer opportunities for a positive outcome.

The natural consequences concept can help kids face the real consequences of their actions
and learn from these experiences. Natural consequences are different from punishments in a
very important way. A punishment makes you hurt. An example of a punishment would be that
if you lie, you get a spanking. A natural consequence just naturally results from an action. An
example of a natural consequence is that if you lose the dollar that you were going to use to buy
ice cream, you won’t be able to buy ice cream. No one is punishing you; it’s just what happens.
There are several advantages to using natural consequences rather than punishments:

¢ The child learns that actions have consequences.

¢ This relies on fairness, not revenge. The focus is not on the child’s anger toward the punish-
er, because there is no punishment. This gives the child the chance to focus on himself and
therefore he has a better chance to learn from the experience.
282 CHILD TRAUMA HANDBOOK

¢ The child has a chance to “make up” for the misdeed and rehabilitate herself. This is very
important for kids who get down on themselves and dig themselves deeper and deeper into
their problems and misdeeds and punishments. When a child can fix what she broke, she
has a chance to dig herself out of the hole and start again from a better place. She can repair
relationships, self-esteem, and perhaps her standing in her program or community. This re-
stores resources and supports, and makes more room for hope.

For some problem behaviors, the natural consequences are very obvious, whereas to find the
natural consequences for other problem behaviors can take some creativity. Here are some ex-
amples of common problem behaviors and the natural consequence that might be offered:

You lost that dollar, now you don’t have it for the ice cream you were going to buy.
You were slow getting ready, so you’ll miss the first part of the movie.
You made a mess, so you can clean it up.
You broke it; now fix it or pay for it.
You didn’t give it back on time. Now I know not to lend it to you again until you earn my
trust back.
You haven’t been keeping your grades up, so now you have to finish your homework before
you go out to play. (Of course, in another situation this could also just be a rule and not a
consequence at all.)
You made me wait for you and worry for half an hour after curfew. Now you owe me time.
You can do half an hour of chores to pay me back.
You hurt the group (or family or class or community). Now you can do something to help
the group. Note that this strategy is extremely flexible and is the rationale behind commu-
nity service penalties for minor legal offenses. Here are some examples:
—You disrupted the art class and slowed down everyone’s work. It will be hard for them to
get their work done and still clean up afterward. Why don’t you come in at lunchtime
and clean the room up then?
—When you stole the candy bar, it made everyone here feel unsafe, because now they have
to worry about people stealing. What can you do to help people here to feel safe again?
Maybe if you share your own candy for the next few days, they’!I think that you’re seri-
ous about not wanting to steal again.
—When you broke that chair, you made this a worse place to be; it’s not as nice here any-
more. To make up for that, you can do something to make the place nicer. You can
choose. Do you want to do some work in the garden, or some cleaning inside?

Response Cost

In most cases, as long as the primary focus is on positive behavior, the time-out system plus
natural consequences will be enough to handle the discipline for the problem behaviors. How-
ever, occasionally it can be helpful to include another type of consequence in the mix. This is a
special type of reinforcement remover called response cost. The basic method is to “charge” or
“dock” the child every time a particular behavior occurs. It should be used carefully and accord-
ing to the following principles:

* The problem behavior should be very specific and easy to identify. Examples: cursing,
name-calling, failing to go to the time-out spot when told to, poking other children with a
pencil.
* Use items or activities that are highly valued by the child. You can figure this out by ob-
serving the child. What does he covet? What does he spend his time doing?
 Discipline Is Love 283

* Do notuse this method to harm the child. That means that you should not be thinking about
taking away any object or activity that is important to the child’s health, education, or wel-
fare. For example:
—Don’t take away food (except perhaps dessert).
—If a child is working on social development, don’t take away time with peers. If he is
spending hours every afternoon phoning or instant-messaging friends, then this is fair
game. But if he has only an hour or less for that already, it’s important to his social devel-
opment. Leave it alone.
—If a child needs exercise, don’t take away time for playing sports.
* Find objects or activities that the child values, but you don’t. Fortunately, many kids really
like to play video games or watch TV, but as adults we don’t really mind if the child gets to
watch only ten minutes of TV tonight instead of the hour she was planning on.
¢ Money can also be used as a response cost, but it should be a relatively small amount, with
opportunity to earn it back. Otherwise this becomes a real punishment rather than the mod-
est irritant it is intended to be.
* Don’t get into a hole! If you find that the child is losing and losing, and getting more and
more discouraged, then you are on the wrong track. You should probably make the re-
sponse costs smaller (for example, pennies instead of nickels) or abandon the response cost
strategy altogether.

Response cost can work. However, it is a high-risk strategy because it opens kids to the risk of
repeated failure. When kids feel bad and helpless, this hits their trauma-related sore spot and
they are likely to overreact. Then it’s difficult to pick up the pieces and do well. Also, when they
are experiencing failure with you, they become worried about what will happen next, and
they don’t feel safe. In general, a positive focus is more effective. When the focus stays positive,
you don’t risk the failure trap. Most kids will work hard for incentives, and in most cases, re-
maining problem behaviors can be managed with time-out and natural consequences.

EXERCISE: WHEN WE DON’T COME THROUGH

Part 1: Challenge yourself!

1. Think of a time recently that you did not discipline according to the rules.
2. Be honest with yourself: why did you do what you did? Common reasons include the fol-
lowing:
° Didn't know what else to do that might have helped
Too tired/didn’t have the energy
Too angry or frustrated
Didn’t want to be hard on the kid, because he or she has been through so much already
Wanted to give the kid a break/one more chance
The kid deserved it (he or she is bad, doesn’t care)
Other (what?)
3. Keep notes, just enough to remind you of the situation, what you did, and why.

Part 2: Challenge One Another! (Ideally, in a Small Group)

1. Present the situation, your action, and your reason(s) to your small group.
2. Group members, be respectful! This is a person who cares and is making an effort.
284. CHILD TRAUMA HANDBOOK

3. Group members help the presenter to understand the child’s needs in the situation, using
the fairy tale model as a guide. Use the following worksheet for ideas.
4. Presenter suggests a more productive strategy for next time. Group members respond.

Worksheet: The Child’s Needs in the Problem Situation

Here are some common reasons for not coming through for kids, for not keeping our prom-
ises, not enforcing the rules. Following each reason is at least one idea that can help us to find
our way back to coming through for the kids:

1. Didn’t know what else to do that might have helped

* Try the methods presented in this book: safety theme, positive focus, time-out, natural
consequences.
2. Too tired/didn’t have the energy
¢ Remember the slot machine? Do you want to train the kid to go for the jackpot? Then it
will never stop. It’s worth taking the energy now, even when you’re tired. This will save
energy in the long run.
3. Too angry or frustrated
* She’s acting that way because she’s hurt/scared and asking for help. It’s not just to hurt
your feelings or make you mad; it’s because she doesn’t know any other way to ask yet.
¢ Why not help her sooner, before you get so mad?
¢ Is it okay to talk about what keeps you from coming through for this child the way you
want to? Do you think this is hitting a sore spot of yours?
4. Didn’t want to be hard on the kid, because he or she has been through so much already
¢ Enforcing the rules makes him feel more secure. Then he knows what to expect, knows
he can count on you.
¢ You can enforce the rules without being harsh.
5. Wanted to give the kid a break/one more chance
¢ How many “one more chances” has this kid already had? Did that work the other times?
Did that stop the problem behavior?
¢ When you don’t enforce the rules, you are teaching the kid that you can’t be trusted or
counted on.
¢ When you don’t enforce the rules, the child learns that crime pays. He got some quick
relief or satisfaction from doing the bad behavior, and no penalty. That’s reinforcement
for bad behavior. Is that what you want him to learn?
6. The kid deserved it (he or she is bad, doesn’t care)
* Have you completed a Meaning of Behavior form focused on this child? When you un-
derstand the meaning of the problem behavior, will you still view the kid in the same
way?
* It sounds as if this kid really got to you. Hit a sore spot? What can you do about that?

Discussion

Presenters, share your experiences. Group members, share your experiences.

HANDLING OUR OWN EMOTIONS

One of the consequences of working with kids is that we get involved. We can’t do good work
unless we care, and when we care, our emotions come into play. This exercise can highlight
times that people often come across places where our own emotions can mess us up, keep us
 Discipline Is Love 285

from doing our best. This happens partly because we really care about the kids and want them to
do well. It also happens because when we work with kids, our own sore spots get hit, from our
own histories of trauma and loss. This isn’t automatically good or bad, but it is part of the
territory.
There are five primary strategies for keeping our own emotions in check so that we can do our
est work.

Use the Fairy Tale Model

When we understand kids’ problem behaviors from a trauma perspective, we tend to see kids
as sad, scared, or mad, rather than bad. When we see kids as hurt, we want to help them. When
we can understand children’s problem behaviors by using the Meaning of Behavior form, we see
these behaviors as their way of showing their pain. Then we don’t tend to take their problem be-
haviors personally; it’s not about us. This way of understanding kids helps us to focus on kids
and their needs.

Do Good Work

When we care about kids that we can’t make any progress with, we are likely to feel helpless
and frustrated. It’s important to understand kids as thoroughly as possible and to help them as ef-
fectively as possible. That’s why you’re here. When we are able to help the kids, we feel better
about ourselves, and we feel better toward them. Then our work is less stressful and it’s easier to
stay focused on kids and their needs.

Have Adequate Structures and Supports

You may have looked at your situation and figured out that it’s really impossible. You may be
right. This is a serious problem. If you are unable to keep kids safe, if you are unable to do the
job, it may be that you need more help. For example, you may need access to another room so
that the time-outs can be done without disrupting other kids. You may need an additional adult
working with you, so that when one child is being physically restrained, the others are still being
supervised. You may need respite so that you are not with kids too long during the day. It’s wise
to recognize limitations and try to do something about them.

Stop a Problem Quickly

The quicker you can stop a problem, the better everything goes. Kids get their reassurance be-
fore they have to escalate. The consequence can be small, which kids and adults can tolerate rel-
atively easily. You don’t have a chance to get frustrated or angry because you’ve taken control of
the situation as soon as you noticed it. Kids feel safer when they feel that they are being carefully
supervised and well protected. Everything stays calmer, and it’s easier for you to focus on kids
and their needs.

Monitor Yourself

There are going to be times when your own sore spots come into play. Then you'll have to fig-
ure out how to take care of this. Sometimes awareness is enough. Sometimes you'll want to do
extra work with your own self-control skills, focusing on the challenging situation. Sometimes
you’ll want to work with a therapist on your own trauma/loss history, so you can take care of the
sore spot at its source.
286 CHILD TRAUMA HANDBOOK

There is no shame in having emotional reactions while working with kids; it’s part of the terri-
tory. However, as adults responsible for taking care of kids, for keeping them safe, and for help-
ing them to heal and to achieve their potential, we have special responsibilities. We are responsi-
ble for handling our own emotions so that we can do our job, so that we can come through for the
kids. The kids need this and they deserve it.
As many people have surely told you, this work is not for everyone. Part of our commitment
in working with distressed kids is to take care of ourselves. This might mean stopping a problem
more quickly, reducing our own stress level by exercising more, getting better at self-control
skills, or even going to therapy for a while. Whatever it takes, this is our commitment to kids.
 Chapter 22

Using Incentives for Success

In the fairy tale, the hope of marrying the princess motivated the guy to get himself ready to
slay the dragon. In a child’s life, long-term goals are important, but are not always enough to
carry the child through daily challenges. Kids need all the encouragement and motivation they
can find, to help them to overcome their challenges and learn new skills and habits. We can help
them by identifying, and sometimes creating, sources of motivation, and then attaching these to
the tasks and challenges they face.
Some people object, on philosophical grounds, to the idea of using motivators to get kids to
do what we want them to do. “We shouldn’t need to bribe kids,” they say, “to do what they
should be doing anyway. Kids should do it because they want to, because it’s the right thing.”
Part of me feels the same way. I wish kids were already motivated and able to just do the right
thing. However, this argument has a few flaws:

¢ There’s a big difference between a motivator and a bribe. Motivators encourage us to do the
right thing, whereas bribes encourage us to do the wrong thing. If you’re paid to give some-
one an unfair advantage, that was a bribe. If you’re paid to do your job, that was a pay-
check, a motivator.
¢ We all need motivators to keep us going; there’s nothing wrong with this. We are motivated
by our interest in our work and other activities, by the money we can earn, by the chance to
feel good, by the chance to be with and to help those we care about, and by the chance
to make progress toward our long-term goals. Kids deserve to have these kinds of moti-
vators, too.
¢ Ittakes great effort and determination to change a habit. We are asking kids to change long-
standing habits. To help kids get “over the hump,” some extra motivators may be needed.
That doesn’t mean that we’ll always be throwing all kinds of big rewards at these kids. But
while they are making a special effort to develop new habits, the extra motivators can make
a big difference.

SOURCES OF MOTIVATION

We want to use as many sources of motivation as possible to provide a better chance that, at
any given moment, at least one of these motivational forces are in play. Hopefully many will be
in play at the same time; the more, the better. Here are the sources of motivation that we will
be trying to tap.

High-Interest Activities

High-interest activities are an important, but sometimes overlooked, component of a treat-

ment program. Think about the example of school curriculum. Even many “regular” kids have
trouble staying focused on the classroom activity and on their assignments. Many (though not

287
288 CHILD TRAUMA HANDBOOK

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all) distressed kids have particular trouble with this, as well. To give kids the best chance of be-
ing successful in school, the curriculum should be carefully designed to interest the student as
much as possible. There are many ways to do this—depending on the subject and on the needs of
the students—potentially including making the curriculum personally relevant to the students,
adjusting the level so that it is both accessible and challenging (not too easy, not too hard), and
including other learning modalities such as experiments, music, or performance. Outside the
classroom, high interest activities are also important, so that kids are motivated to participate
and to be successful.

Inclusion in the Family/Group and in the Activity

Many kids really want to be included in activities. Kids generally like to be near others, to
feel that they belong. They also don’t want to miss out on what the others are doing. When kids feel
this way, they want to do whatever it takes to be allowed to keep participating. We can enhance
this motivator by developing a positive family or group culture, and by providing high-interest
activities.

Please the Parent or Caregiver

Many kids will make an effort to please the parent or caregiver, to win approval and attention
and to deepen their sense of attachment or belonging with that adult. We can enhance this moti-
vator by reinforcing positive behaviors, by not reinforcing negative behaviors, and by develop-
ing a positive relationship with the child.
 Using Incentives for Success 289

Opportunities for Success

Kids like to feel good, and it feels good to be successful: to win, to do something well, to do
something right, to make progress toward a goal. When kids have a reason to believe that there’s
a chance to be successful, they’re more likely to make an effort. We can enhance this motivator
by providing numerous opportunities for small, quick successes, to get kids used to having the
success experience. |

The Child’s Personal “Princess”

It’s important to find out what each child’s personal goals are, what she cares about the most,
how she wants her days to go, what she wants for her future. It doesn’t work to tell kids what we
think they should want; others have tried that already. When we know what she wants herself,
then we can help her to work toward what she wants. Then we are on the same team—her
team—and she’s more likely to make the effort.

Formal Incentive Programs

Formal incentive programs can—and should—incorporate these principles in a systematic

way. Formal incentive programs also use the science of learning and reinforcement to help kids
overcome their challenges and develop better habits. Getting a regular paycheck for doing your
job is an example of a formal incentive program—-so is getting an allowance for doing your chores.
This chapter will focus on two types of incentive programs: the point system and the individual
behavior contract.

POINT SYSTEMS

Point systems are commonly used in group educational and treatment settings. The point sys-
tem is a way of keeping track of specified behaviors and awarding points for each child, depend-
ing on which behaviors the child did or did not do within the specified period (e.g., the class, the
day). Points are valuable because a certain number of points earns the child certain privileges or
special activities. One variation of the point system is the “token economy” in which points
count as a kind of in-house “money” that can be exchanged for the child’s choice of prizes, per-
haps from the in-house “store.” Items of higher value cost more points.
Another variation is the level system in which the participant can achieve a higher level by
earning a minimum number of points for a specific period. For example, if a maximum of 100
points can be earned in a day, the participant can move from the first level to the second level by
earning at least seventy-five points in a day for five days in a row. Perhaps the participant can
move from the second level to the third level by keeping this minimum daily point count for ten
days in a row, or by earning at least ninety points in a day for five days in a row. The system can
be designed to suit the needs and goals of the setting. The goal of advancing to a higher level is to
allow the participant to enjoy a higher status and more privileges.
These types of point systems are used in many settings because they offer many benefits:

¢ This approach can be used systemwide, with all children. Staff can be trained to use the
system, and staff can learn how to intervene in a consistent way. This makes it an efficient
and organized way to manage behavior within a program. It can help a program to “make
sense’’—to be coherent and consistent.
290 CHILD TRAUMA HANDBOOK

° This is a flexible approach that can be tailored to suit the setting. The points (and levels, if
any) can be awarded for whatever is most important in the program.
* Kids perceive it as fair if they are all in the same system. Even when kids are being treated
differently because they have earned different levels of privileges, they can recognize that
everyone has the same opportunities. When they are not able to be angry about playing fa-
vorites, they have a better chance of focusing on their own behavior.
¢ Peers can set the example for newcomers. A peer culture can develop around the value of
working to advance oneself. Kids who are more advanced can become leaders and set the
tone for others. When kids in a program value what good behavior can earn, the newer kids
will probably learn to value it too.

Perhaps the bottom line is that these systems can work. When a point system is designed and
run well, it can keep a facility under control and help kids improve their skills and habits.
A point system can’t be bought at the store. It must be designed to fit the needs and circum-
stances of each setting. A system can be designed to express the values and accomplish the goals
that are a priority in a program. Because not everyone is good at designing point systems, it can
be very helpful to study point systems used in other programs or similar settings, which have al-
ready worked out some of the kinks and can provide a head start on a new program.
Even if you have borrowed a nice-looking point system from a similar setting, or if you are
working in a setting that already has an operating point system, don’t be so sure that it’s achiev-
ing all of your goals. When you are using the fairy tale model of treatment, you need to make the
most of kids’ own sources of motivation, and you need to stay focused on the positives, on build-
ing kids’ strength and competence. Not all point systems support this goal. Here are the two
most common shortfalls of point systems, along with suggestions for correcting the problem:

Problem: Some point systems work by docking kids points for each offense they commit,
or for each task they fail to complete. In this type of system, kids may start out with (for
example) 100 points in the morning, and lose points throughout the day whenever they
do something wrong or fail to do something right. Staff in this type of system may say, “I
feel like I’m a prison guard. All I do is bust kids all the time for what they’re doing
wrong. I don’t want to be always focused on the negative like that, but I have to. It’s my
job to keep the score.” Kids may have similar complaints, for example, “All the staff
here does is tell me what I’m doing wrong. No one ever gives me credit for all the things
I do right. But do one little thing wrong, and you can bet I’m gonna hear about it!”” When
this is the atmosphere, the energy and attention is focused on the negative. Then kids
know that negative behavior gets attention, and they also feel unsafe because they are
put down all the time. This is not a good way to build relationships or to help kids to be-
come stronger and more confident.
Solution: The solution is simple: flip the math; count up instead of down. Instead of (using
the same example) starting at 100 and losing points for every flaw, start at zero and add
points for every good action and completed task. That way, it’s the staff’s job to catch
kids doing things right, and the whole focus becomes more positive. This change can
take some creativity, but it’s not too complicated. For example, instead of penalizing a
kid ten points if he swears once or more during the day, you can award him ten points for
keeping control of his mouth (an active, positive way to describe “not swearing’’) all
day. Negative behavior can be restated as an opposite or incompatible positive behavior
that can earn rewards.
Problem: Many point systems rely on the assumption that kids will want what the point
system offers: status, privileges, toys, or whatever. Although the system was probably
designed with popular incentives in mind, not every child cares about what’s popular.
 Using Incentives for Success 291

Some kids will really care about the chance to go to the movies, but others won’t care.
Some kids will want to work for the chance to “buy” a toy, and others won’t. When you
use a one-size-fits-all approach, you'll find that one size may fit many, but not all. You’
fail to engage some of the kids, you won’t be motivating them as you hope to, and they
risk falling through the cracks of your program.
Solution: Even when a point system is used throughout the setting, components of it can be
individualized. Some ways to do this are simple, others are more complicated. The more
complicated way is the individual behavior contract, discussed in detail later in this
chapter. Here are some examples of simple ways to individualize:
* If you are using a token economy in which kids earn points to buy toys, ask each child
in your program which toys she would like to be able to buy, and then you can stock
those in your store.
* You can have a group discussion to find out what kinds of activities the kids are hop-
ing for. Then you can offer these activities as motivators for good behavior. If differ-
ent kids want different activities, and these can be done without involving the whole
group, then kids can each work toward earning the activity of their choice.
¢ Suppose that a maximum of 100 points can be earned in a day. Most of the points, say
ninety, are earned the same way for everyone, but the other ten points can be reserved
for individualized behaviors and accomplishments. This way, one child might earn
that final ten points by controlling his mouth (not swearing), another by showing
friendliness toward peers (being helpful, inviting them to join in activities), and an-
other by practicing penmanship for ten minutes during free time.

INDIVIDUAL BEHAVIOR CONTRACTS

Individual behavior contracts are formal, written agreements between an adult anda child, fo-
cused on specific child behaviors and consequences. The consequences, or incentives, are de-
signed to encourage the child to develop new skills and habits. These contracts can be very ef-
fective in helping kids to make progress, but they have a much better chance of working when
the rest of the important things are also in place. Kids first need to feel relatively safe and secure,
to be involved in high-interest activities, to have positive relationships with adults, and to have
opportunities to succeed. Then the individual behavior contract can help them with challenges
they have not been able to master on their own.
Individual behavior contracts can be used in settings that also use point systems, or in settings
that do not. If you are doing this in a setting that has an established point system, you’ll want to
figure out if, and how, to integrate the two kinds of incentive programs being offered. For exam-
ple, in some settings kids are only allowed to work on their individual behavior contracts while
they are on a higher level in their point system. In other settings, the individual contracts are in
addition to the point system, and one does not depend on the other. You’lI have to figure out what
makes the most sense for your setting and for your kids.

What to Tell Other Kids

If you are using individual behavior contracts, and other kids are in your setting, then you
should expect some questions or complaints from the other kids. “That’s not fair! How come she
gets all this cool stuff and I don’t?” That’s a fair question. Here are several possible ways to
respond.
292 CHILD TRAUMA HANDBOOK

Special Needs Get Special Help

This strategy is most often used when a special-needs child is getting a contract while the
more “normal” kids in the same setting are not. The point here is that children should not be
treated all the same; they should each be treated as special, and each offered what they most
need. You can explain to others that this child has a special problem or special need, and thus re-
quires special help. You might point out that they are getting benefits that this child does not get,
such as good grades, friends, and privileges, because they do not have these special needs. Of
course, you do not want to disclose confidential information, but if kids are in the same setting,
they already know plenty about one another, and it’s okay to name these things. You might also
be able to point out ways that they are getting special treatment, for example by being allowed to
do independent projects, go someplace on their own, or whatever might apply.

Do You Want One, Too?

This strategy is most often used when the other kids in the setting might also benefit from a
chance to focus on improving their own behaviors. Then you can explain that the first child has
made a real commitment to improving himself in certain ways, and that the adults are trying to
help him do this with the contract. “Is there something that you think you’d like to get better at?
Maybe at getting your chores done? Or at being better at following directions the first time? If
there’s something you want to work on, maybe we can do one of these for you, too.” There’s no
harm in offering a simple behavior contract to kids who might not really need one, if it will help
them to feel fairly treated. Everyone’s got something that can be improved!
Individual behavior contracts can range from simple to complex. One size does not fit all, but
there are principles that can guide you, and strategies that work. Here are some of the basics.

Don’t Get Too Ambitious

Target just one behavior, or at most two or three. The smaller your goal, the better chance of
success. Remember, when you are starting a new child on a behavior contract, you are not trying
to solve all her problems at once. You’re trying to help her to build a track record of success, so
that she will be more capable and confident when it comes to tackling other problems.

Be Specific

The behaviors you are targeting should describe a specific action. If you aren’t able to visual-
ize the child doing it, as clearly as if you are seeing it on TY, it’s not specific enough. For exam-
ple, “bad attitude” or “showing respect” are not specific enough. You need to come up with ex-
amples. Try specific behaviors such as “following directions without argument” or “saying
please when asking for something.” When the child does one of these, everyone will be able to
agree that it happened.

Failure-Proof the Contract

The contract should be failure proof, especially at first. This means that there is no opportu-
nity to fail, only to succeed either quickly or slowly. The reason for this is that many kids are eas-
ily discouraged, and if they keep on failing, they might be tempted to give up altogether. Failure-
proof contracts provide fewer opportunities for frustration and discouragement. For example,
suppose a child has a contract that requires him to wake up in a dry bed for five mornings in a
row in order to win the prize. If he goes three mornings and then blows it, he’s lost all his mo-
 Using Incentives for Success 293

mentum and must start over. You can make this a failure-proof contract by saying that as soon as
he has five dry mornings, he’II win the prize. Then if he has three dry mornings and then a wet
one, he hasn’t gained any ground today but at least he hasn’t lost any. He still has only two more
to go, and he’s more likely to keep trying.

Visuals Can Help

When kids can see their contract, it’s easier for them to keep it in mind. So it’s worthwhile to
make the contract visually striking, and to have it posted where the child will notice it. You
might want a drawing of the prize(s) the child is working toward. If she can easily see her prog-
ress at a glance, so much the better.

Arrange for the Likelihood of a Quick Reward

Kids can’t wait forever for their prize; if it takes too long to succeed, they’1l lose hope. Keep in
mind that your first goal is not to make them perfect this week. Your first goal is to help them to
succeed at something, so they’II be willing to take the next step. Set up the contract in a way that,
according to your best guess, they’Il find success pretty quickly.

Consider Multiple Levels of Reward

This is especially useful in more complex contracts. If the “grand prize’ is going to take too
long to win, you might want to have other smaller rewards along the way. This will keep kids
motivated, feeling successful with the more frequent achievements on their way to the larger
goal. For example, a child might earn a cookie for each successful day, on the way to earning an
ice cream sundae for five successful days. For some children, just the fact of getting check marks
or stars on their “chart” can feel like a reward.

Build a Step at a Time

I’ve been encouraging you to start very small, with only one target behavior, and with oppor-
tunities for quick successes. Now think like a personal trainer. Once the child can handle the first
challenge, add a few pounds, but not too many! The goal here is to build achievement and
strength one step at a time, so that kids will continue to face the next challenge, and continue to
succeed.
Individual behavior contracts are not for everyone. If the child is making good progress with-
out a behavior contract, then why fix something that’s not broken? For kids who do need extra
incentives to make progress, a simple behavioral contract may be sufficient. For example, you
might have a chore chart for kids to complete in order to receive their allowance. Or you might
have a contract focused on a specific habit or behavior such as bed-wetting, cursing, or complet-
ing homework.
For many kids whose emotional distress and problem behaviors are severe enough to require
day or residential treatment, a more complex behavior contract will probably be useful. This be-
havior contract becomes a centerpiece of the child’s treatment, and targets the two or three most
significant problem behaviors. If your kids do not fit this category, please read the rest of this
chapter anyway! Many of the principles and techniques that are used to implementa complex in-
dividual behavior contract can also be used with the simpler ones.
294, CHILD TRAUMA HANDBOOK

DESIGNING A MORE COMPLEX CONTRACT

Here is an example of an approach to developing a complex individual behavior contract.

This builds upon and extends what has already been presented on individual behavioral con-
tracts. You might not use every component of this approach, or do it exactly the way it’s pre-
sented here. This is just presented as a model. You will want to use as many of the principles and
techniques as possible, since these will generally maximize the effectiveness of the contract.
Typically, this contract is set up with the therapist’s active participation.

Get the Child to Ask for the Contract

You can get the child to ask for the contract by explaining what it’s about: a way to help the
child develop better habits to achieve his goals, by earning items or activities that he wants. Most
kids do want to achieve their goals, and will jump at the chance to earn incentives. However, if
the child does not actively say that he is interested, do not go ahead with the contract. If it’s
yours, not his, it won’t work. Just back off gracefully, acknowledge that he might not be ready
for this yet, and when he decides that he’s ready to work toward his goals, to let you know. Or
perhaps you’ll check back at another time to see if he’s ready. If other kids are receiving rewards
for their contracts, this one is more likely to want one too.

Use Specific Behaviors, Matched Positive to Negative,

That Are Mutually Incompatible

Don’t use “not [doing the problem behavior]” as a behavior, because you can’t watch some-
one not doing something. Figure out what the child will be doing instead of the bad thing. To
make this work, you might need to identify the situation in which the problem behavior would
most likely occur. For example, if “hitting” usually happens when someone calls him a name,
then “ignoring” would be a positive, and incompatible, alternative behavior. Typically you will
have a list of two or three problem behaviors, with a matching list including an alternative,
positive and incompatible, behavior for each.

Positive and Negative Symbols or Ego Ideals to Go with Each Behavior Cluster

Help your client to think of symbols that represent, on the one hand, the person she is trying to
become, and on the other hand, the problem that she does not want to be anymore. The therapist
should have a good idea of the child’s goals and fears, and can provide help here. However, ide-
ally the child will be the one to come up with the symbols, so that they have the most personal
meaning. Examples of the positive symbol: Teacher, cop, or some celebrity or cartoon figure
such as Batman, Michael Jordan, Ariel. Examples of the negative symbol: Volcano, rat, baby,
broken record, loser. Do you want to be a teacher or a loser? These symbols can convey power
and can help kids focus their energy.

Client-Generated Array of Incentives

It’s also important for kids to suggest their own incentives, the things they want to try to earn.
The more they care about the incentives, the more power the incentives will have. The adult can
encourage the child to “brainstorm” everything she might wish for, whether big, small, or in be-
tween. Items on the list might include a trip to Disneyland, a trip to the local video arcade, a new
CD, a chocolate chip cookie, getting to be the one to choose the movie that is rented for the
group or family, getting to stay up later, getting to be the one who gets the mail from the mailbox,
 Using Incentives for Success 295

one-on-one time playing a game with a favored adult, ice cream, a peach, extra time playing
video games, and on and on. The bigger the list, including a wide range of possible rewards, the
better your chance of creating a contract that will work. This is a good chance to be creative, as
many kids will work for privileges that are good for them, such as special time with an adult, or
being allowed to help with younger kids.

Organize the Incentives by Size

When you are talking with the child about possible incentives, you should have a piece of pa-
per with three columns labeled Small, Medium, and Large. As the child suggests each new item,
you decide which column to place it in. A small incentive can be earned within a short period of
time, perhaps several hours or a day. A medium incentive can be earned in a modest period
of time, perhaps several days or a week. Typically, when four to seven small incentives have
been earned, a medium incentive is earned as well. A large incentive is the grand prize that rep-
resents success in accomplishing the goals of the contract. Typically, when four to seven me-
dium incentives have been earned, the large incentive is earned. The entire contract should take
from one to three months, depending on the age of the child and the circumstances of the setting.

Organize the Incentives by Priority

Once you have completed the list, hopefully with at least a few items in each column (more
than a few is great!), then you need to find out which of the items, in a given column, are most
desired by the child. You can do this by showing the column to the child and asking what her first
choice is in that column, what her second choice is, etc., all the way down the line. Then repeat
this until you have a priority rating for each item in each column. If certain items are rated the
same, that’s okay. For example, supposing that in the Small list, apple and pear are both rated as
the first choice. Later, when you set up the contract, the child can choose an apple or a pear
whenever she earns that level of reward.

Select the Incentives

Now that you have the fantasy list of all possible incentives, you must select the incentives
you’Il actually be using in the contract. Check with all parties regarding the possibility of using
the highest rated incentives on each of the lists. You will also need to use your own judgment in
this regard. In general, you will select the highest-rated item that is likely to work, on each of the
lists. To make sure the item will work, you should check for several things.
When parents are actively involved in the child’s treatment, and in the child’s life, they should
be included as much as possible. When it comes to selecting incentives, parent-related concerns
might include:

¢ Child’s health. Some parents will object to their child being given sweets such as cookies
or soda. If such an item was high on the list and the parent does not agree to it, you’llneed
to cross it off and try the next high-rated item. Sometimes parents will negotiate (for exam-
ple, “It’s okay as long as he brushes his teeth afterward”), but don’t push too hard or they
might end up agreeing when they don’t really approve.
¢ Values clash. Some parents will object to an incentive because it is not consistent with their
values or with what they want their child exposed to. For example, some parents do not al-
low their children to play certain video games or to own certain toys.
¢ Interferes with family life. Some incentives are already present, or anticipated, within the
normal family life, and the parents may not want their hands tied by the terms of the con-
296 CHILD TRAUMA HANDBOOK

tract. For example, if they like to take their family out to a favored restaurant every Friday
night, going out to this same restaurant should probably not be an incentive in the contract.
Otherwise, the family will not be able to follow their normal routine unless the child has
earned the reward. Or even worse, the family will follow their normal routine, and the in-
centive will lose its power because the child is getting it no matter what he does.
Resources, fairness, etc. Make sure that parents can handle what is being asked of them, es-
pecially if they are being asked to contribute money and/or time for the incentives. Make
sure that this contract does not become a way for this child to claim a disproportionate
share of the family’s resources at the expense of the other children in the family. Some fam-
ilies cannot afford even a few extra dollars in a week. On the other hand, even if a family
can afford a trip to Disneyland, that is probably too big a prize for the child to earn.

Several issues should be considered within your setting, especially if other kids are also working
with similar contracts:

¢ Available money and other resources. You can’t offer items that you won’t be able to de-
liver. Is enough money available to purchase the incentives you want to include in the con-
tract? Is a refrigerator located near the place the child will be when it is time to receive his
cold soda? Is the specified adult able to provide one-on-one playing time without compro-
mising the supervision of other kids?
Fairness. Individual behavior contracts are individualized, so we don’t need to knock our-
selves out trying to make sure that everyone gets the same thing. Insead, we try to make
sure that everyone gets whatever’s best for them. Even so, a rough consistency should exist
across contracts, so that at every level, not too much discrepancy occurs in the monetary
value of the prizes. If one child’s grand prize costs $24 and another’s costs $30, that’s prob-
ably okay. But if one is $24 and another is $100, such a discrepancy will lead to problems
in your setting, and the $24-prize may not seem as valuable to the child anymore.

Write the Contract

Once you have the list of matched positive/negative behaviors, the corresponding symbols
that personify each cluster of behaviors, and the best workable incentives at each level, you’re
ready to put it all together. Try to make the contract as short, simple, and clear as you can, while
still covering all the bases. A sample contract follows. The contract should easily fit on a single
page, with plenty of room at the bottom for people to add signatures. The following elements
should be included, in this order:

1. First paragraph: Introducing the contract. First person introduction. Then state the child’s
positive goal/metaphor, explaining this with the desired behaviors and the wanted conse-
quences. Then state the child’s negative metaphor, explaining this with the negative behav-
iors and the unwanted consequences. Finally, introduce the contract as the way to help the
child achieve the goal.
. Second paragraph: How points are earned. Explain in very clear detail how points are
earned on the contract. This should be tied to specific behaviors as well as specific time pe-
riods and places.
. Third paragraph: How rewards are earned. Explain in very clear detail how rewards are
earned on the contract. This is usually a matter of converting accumulated points to Small
rewards, converting accumulated Smalls to Mediums, and then converting the Mediums to
the Large.
 Using Incentives for Success 297,

4. List of metaphors and behaviors. This is done in a column so that the positive metaphor is
the column title for the positive behaviors, and so forth.
5. Signatures. List the name of each person who will be participating in the contract, with
space next to his or her name for a signature. The child’s name should be first.

Create the “Chart”

Contracts need to be kept track of and documented. Typically a daily chart lists the times,
places, and behaviors to keep track of each point and when/how it was earned. This daily chart
may be signed, turned in, or however you have arranged this. Also, an overview chart marks the
child’s progress in the contract as a whole. Make the charts as clear and visually appealing as
possible. Highlight the behaviors and the incentives as much as possible. Think about where the
charts will be kept, to help to remind the child and others of the contract.

Child Actively Obtains Agreement from All Participants

Once the contract is written, then the child signs it and asks others to sign. Of course, you
have made sure that the others have already seen the contract, and already understand their roles.
Even so, it’s important for the child to explain it to each person and tell each person what is ex-
pected from each party. This increases the child’s ownership of the contract and emphasizes that
it is being done for her own goals.

EXERCISE: DEVELOP AN INDIVIDUAL BEHAVIOR CONTRACT

In groups of three, choose a child, a counselor, and a coach.

Part I

Ifyouare the child, role-play the child in the vignette. Don’t do the counselor’s job, but please
be cooperative. [f you are the counselor, use the script, verbatim. If you are asking a question,
give the child a chance to answer before you continue. The words [in brackets] are not to say out
loud, but to guide you on what to do, and in which order. [f you are the coach, observe, and if
necessary, help the counselor to get back on track.

Vignette: Frankie

Frankie is an eleven-year old boy or girl (same gender as the role-player) in a self-contained classroom
at school; all twelve kids in this classroom have been identified as having significant behavior problems.
Frankie was sent to this class because of poor work habits in addition to a habit of harassing other kids.
Frankie’s therapist has told you that Frankie wants to improve upon getting work done in school, so that he
or she can go back to the regular class with the kids whom he or she has always gone to school with.
Frankie also wants to get along better with other kids and have more friends. You have been observing in
the classroom, and you have noticed that Frankie does seem to try to do the work, but upon getting con-
fused or stuck, just gives up and finds something else to do instead. You have also noticed that the times
that Frankie starts to bug other kids (calls them names and makes faces) are when they are talking to one
another but Frankie is not included.
298 CHILD TRAUMA HANDBOOK

Sample Individual Behavior Contract

|, Johanna de Vries, want to be more like a teacher. When I’m like a teacher, | do my work
and | respect others. Then | get good grades and have more friends. Sometimes, though, |
act like a rat. Then | mess around instead of working, and | call other people names, and
end up getting in trouble. To help me get better at being like a teacher, | agree to the follow-
ing contract:

In each of the six class periods each day, | can earn one point for doing my work dur-
ing that period, and one point for respecting others during that period. If |earn eleven
points in a day, | get a two-point bonus; if | earn twelve points in a day, | get a five-point
bonus.

For every ten points, | get a Small reward, either a cookie or a piece of fruit, at the end
of the day. For every six Small rewards, | also get a Medium reward, a banana split
sundae at Ice Cream Palace. When | have gotten six Medium rewards, | get the Large
reward: a sundress from K-Mart.

Teacher Rat
Doing my work Messing around during work time
Respecting others Calling people names

Signatures:

Johanna de Vries

(Father)

(Mother) ee ee eo eee

(Teacher) Ee ian ahteeWik alphe ASeay) ne Bagoal ebats, goal APERE ee

(Aides)

(Therapist)
 Using Incentives for Success 299

Script for Talking with the Child About Setting up the Contract

COUNSELOR: [Warm-up] Frankie, you’ve been in this classroom for over a month now. You’ve
learned how things go here, you know what to do, and it’s obvious that you’re trying. You’ve
said that you want to get better at getting your schoolwork done, so that you can go back to
your regular class. You’ve also said that you wantto get better at getting along with other kids,
so that you can have more friends.
[Get the kid to ask for it.] You’ve probably noticed that other kids have behavior charts, so
when they do the things they’re trying to get better at, they get rewards. Kids are only allowed
to have a chart if they really want to work on something, get better at something. Do you think
you might want to do something like this, have a chance to earn rewards while you’re trying to
get better at doing your schoolwork and stuff?
[Identifying the first problem behavior and a positive alternative.] Okay, so what we’llbe
doing now is talking about the behaviors you want to get better at; then we’ll talk about the
things you’d like to be able to earn. Let’s start with the schoolwork. I’ve noticed that some-
times when you’re doing your assignment, if you get confused or stuck—you’re not sure how
to do it—you just start doing something else instead. Then you get in trouble and your work
isn’t done. When you’re not sure how to do the schoolwork, when you’re feeling stuck, what
do you think you could do if you wanted to be able to get your schoolwork done? [If you get a
good answer, accept it and move on. However, if the child does not respond with a useful idea,
you can ask, “Do you have any other ideas?” If the child still does not come up with a useful
suggestion, you can say, “Let me tell you what some other kids do in this situation, and you
can tell me what you think would work for you.” Then give two or three strategies and let the
child choose. ]
[Identifying the second problem behavior and a positive alternative.] You also said that you
wanted to get along better with other kids. I’ve noticed that you kind of give kids trouble
sometimes; you call them names and make faces. When you do that stuff, do you think that
makes kids want to be with you more, or want to be with you less?
That’s what I think, too. I’ve noticed that you do that when you see other kids talking or do-
ing something and they’re not doing it with you. I wondered if you are just wanting to be in-
cluded, to be a part of things. When you see kids talking or doing something, if you decided
not to call them names or make faces, what could you do so that kids would want to be with
you more? [If you get a good answer, accept it and move on. However, if the child does not re-
spond with a useful idea, you can ask, “Do you have any other ideas?” If the child still does
not come up with a useful suggestion, you can say, “Let me tell you what some other kids do
in this situation, and you can tell me what you think would work for you.” Then give two or
three strategies and let the child choose.]
[Generate the metaphors.] You’ve told me that you want to be able to [name the positive
behaviors] so that you can go back to the regular class, and so that kids will like you more.
What kind of person can you think of who can handle things the way you wish you could? [If
you get a good metaphor here, great. But it can be tricky. You might need to ask it a few differ-
ent ways, perhaps giving examples of different kinds of role models: occupations (e.g.,
teacher, cop, sports star), celebrities, etc.]
You also said that when you do it the bad old way, you’re doing other things during school-
work time, and you’re calling kids names and making faces at them. The problem is, that
means that you’re not getting your work done, and kids don’t like to be around you. What
kind of person or thing do you think of, that’s like that? [If you get a good metaphor here,
great. But it can be tricky. You might have to ask it a few different ways, perhaps giving exam-
ples of different kinds of negative metaphors: baby, loser, chump, etc.]
300 CHILD TRAUMA HANDBOOK

[Make a list of possible incentives.] Okay, now it’s time to make a list of all the things that
you might want to be able to earn as a reward. You won’t get everything on the list; ’ll have to
figure out which things will work. Right now, we’re just having fun, and thinking of every-
thing you might wish for, no matter how big or how small it is. So what kinds of things would
you like to be able to earn? [This is brainstorming. Write down everything without judgment
or critical comment. Put the item under Small if it could be earned in a day or two, Medium if
it could be earned in a week or two, and Large if it could be earned in a month or two. If
needed, encourage the child to think of a variety of possible incentives, including food items,
privileges, activities, toys, etc. Keep going until you have at least five items on each list; more
is okay too.]

Small Medium Large

[Rank order the items.] Okay, we have a lot of things on the list! Actually, ? ve made three
lists, for rewards of different sizes. Now I’m going to ask you to tell me your first choice, and
then your next choice, on each of the lists. So look over all the things on the Small list. Of all
of these, which is your first choice? Which would you want the most? After that, what’s your
next choice? And after that? [Write down | next to the first choice item on the Small list,
2 next to the second choice item, and so on. Continue until each item on the Small list is rank
ordered. Then do the same with each of the other lists. When you have finished, every item
should have a number next to it.]
[Wrap it up.] Okay, that’s enough for today. Now my job is to try and put this together into
a contract, so you can get started on trying to earn the rewards. You won’t be going for all the
rewards on the list—only certain ones. So [Il talk to you tomorrow and show you what I’ve
worked out. Now, before we end, tell me what you liked about this meeting, and what you
didn’t like.

Discussion

Give one another feedback about your experience in this exercise. After the child gives feed-
back, the coach can give feedback as well. The counselor may also have questions or observa-
tions.

Part 2

Once you have completed the list of incentives, give up your previous roles and become a
working team. Using what you got from the first part of this exercise, figure out how to make a
contract that will work. Do this by completing the Contract Form, starting at the top and com-
pleting each item before going to the next.

Discussion Question

1. What was it like to be in each of the roles?

 Using Incentives for Success 301

Contract Form

le : , want to be more likea

(child’s name) (positive metaphor)

When |’m like a a

(positive metaphor) (positive behavior)

and
(positive behaviors)

Then |
(the good things that happen in life when | do these kinds of behaviors)

Sometimes, though, | act like a

(negative metaphor)

Then |
(negative behaviors)

To help me get better at being like a , |agree to the following

contract: (positive metaphor)

| can earn points on my contract as follows:

(Include time, place, and required behaviors, also the maximum number of points possi-
ble.)

| can earn rewards on my contract as follows:

(Name the rewards, and explain how many points/Small reward; how many Smalls/
Medium, and how many Mediums/Large.)

(Positive metaphor) titsts—~—S (Negative metaphor)

(Positive behavior #1) =~ negative behavior)

(Matching/incompatible

(Positive behavior #2) (Matching/incompatible negative behavior)

(Positive behavior #3,ifany) negative behavior)

+—~—~—~—-(Matching/incompatible
Signatures (include names of all parties, child first)
302 CHILD TRAUMA HANDBOOK

IMPLEMENTING THE CONTRACT

Once the contract is signed, you must do it! If the adults in the system don’t follow through,
the whole thing will fall apart. Here are some guidelines that will help you to carry the contract
through to successful completion.

One Adult Should Be the Contract “Champion”’

The contract champion is in charge of making sure that the contract is carefully monitored
and followed, and that everyone is doing their part. Without one person who is clearly responsi-
ble, it’s too easy for things to go wrong, to fall through the cracks.

All Parties Should Be Doing Their Part

The contract champion makes sure that each required action is accomplished. Is the teacher
checking off which behaviors were done during the class period? Are the teacher and the aide
using the right words (more on this later) to prompt the child? Are the right rewards being deliv-
ered at the right time? Is the parent being kept in the loop?

Keep Consistent Discipline and Structure

If the child’s environment is falling apart, he will go back into survival mode, and the contract
won’t be a priority. The contract can’t carry a child through an unsafe or nonsupportive environ-
ment. Only if the structure and support stay in place will the child be able to focus on earning in-
centives and achieving goals.

Keep a Positive Focus

The contract provides a structure for noticing the child’s positive behaviors. Take advantage
of this. Give attention for positive behavior so that this behavior is reinforced. The child who
feels successful will be more likely to persevere.

Label the Child’s Behavior Using the Contract Language

When you see the child engaging in the problem behavior, you can make a comment relating
the behavior to the negative metaphor. When you see the child doing the positive behavior, you
can make a comment relating the positive behavior to the positive metaphor and to the incen-
tives. When you see the child on the edge, you can make a comment highlighting the choices be-
tween the negative behavior/metaphor on one hand, and the positive behavior/metaphor and in-
centives on the other. The contract, including the metaphors and the incentives, is designed to be
emotionally significant for the child, to have power. Using the words and concepts in the con-
tract invokes its power. This can help the child tap into that power and make the right choice.

PROBLEM SOLVING THE INDIVIDUAL BEHAVIOR CONTRACT

No matter how elegant a contract you put together, things can and do go wrong. That doesn’t
mean that you didn’t do a beautiful job. It just means that kids are human, life is complicated,
and things don’t always go as planned. Part of the routine when you implement a behavior con-
tract is to monitor it carefully. When you find that the contract is not working as planned, you
 Using Incentives for Success 303

need to figure out why it isn’t working. Once you discover the problem, you can adjust the sys-
tem accordingly. Most behavior contracts will require some tinkering. Here are some of the
more common problem areas to look for:

* Is a problem behavior being inadvertently reinforced?

* Is the monitoring system failing? Why? Too demanding for the teacher? Parent does not
understand?
* Is the reward system being undermined by failure to reward, or by premature reward?
* Is the child becoming too discouraged? Are there too many opportunities for failure? Are
the rewards too difficult to obtain, too slow in coming?

Problem solving a contract can be very simple, or can require some ingenuity, depending on the
situation. An exhaustive list of possible solutions cannot be provided, but here are a couple of
examples, just to give you an idea of the range of possibilities.

Nina was an eight-year-old girl whose contract focused on getting better at asking an adult for help
when she felt nervous, instead of running away. Although she sincerely wanted to improve her behavior,
and the incentives seemed appropriate, she continued to run away as much as ever. When the adults
studied the situation, they noticed that whenever Nina ran away, this led to a physical restraint (because
otherwise she would just keep going farther and farther away). Of course, many children like to be held by
an adult they trust. Based on a guess that the restraints might have been reinforcing the running-away be-
havior, the consequence was changed. Now, although an adult would still run after her to catch her and
bring her back, Nina would then be put alone in a room with an adult who would not hold her or even talk
with her until she calmed herself down. Once she learned that running away didn’t pay off so well any-
more, it was easier for her to try something new that would be rewarded.

Ryan was a thirteen-year-old boy whose parents were actively involved with his day treatment school
program. Ryan was in this placement mainly because of his habit of being aggressive toward other kids.
He would call them names, punch them, or hit them with objects. He was doing very well with his behav-
ioral contract, which was focused on staying on task in school as well as controlling his aggression. Two
months into the contract, when he appeared close to earning the reward within a few weeks, the whole
thing seemed to collapse. He wasn’t bothering much with his schoolwork anymore, was lashing out at kids
and staff the way he used to do, and was not responding to the prompts that had motivated him with the
contract only days earlier. It turned out that his parents had been so proud of him for doing so well in his
program that they had purchased and given him the “grand prize” (Large) reward, a CD player, over the
weekend. When the boy received the CD player, he thought that meant that his parents didn’t want him to
continue with the contract anymore (or to improve his behavior!), and he stopped working on it. This was
actually a very difficult salvage job, involving several meetings with the family, and finally the creation of a
new contract with a new grand prize. It’s better if you can make sure, up front, that the parents are on
board and understand how to show support.

Ned was a seven-year-old boy who was working with a simple contract: If he could stay in his chair dur-
ing most of each class period, he would earn a treat at the end of the day. After earning a number of daily
treats, he would earn a bigger treat. However, the contract wasn’t working. Ned was immature and did not
grasp the idea that the treat would come at the end of the day. He needed more immediate reinforcement.
The adults started posting a gold star on his chart for every time period in which he earned his point. He
was thrilled with the stars. These became another level of reinforcement (maybe “Very Small”) and this
helped him to stay motivated.

Clarissa was a twelve-year-old girl who was working with a contract focused on staying on task during
classes. However, the chart was not being completed correctly by the teacher. The chart was set up to be
marked after each class period, but the teacher only marked it once or twice on most days. It turned out
that the teacher was willing to do her part, but she was so busy with her large classroom that she just
didn’t usually remember to mark the chart. The system was changed so that whenever the bell rang at the
end of a period, it was Clarissa’s job to take her chart to the teacher to have it marked. This worked, and
the contract got back on track.
304 CHILD TRAUMA HANDBOOK

This chapter has focused on how to help kids achieve their goals by harnessing the things that
motivate them. A number of principles and strategies were presented, with a focus on formal in-
centive systems. In general, these work by integrating trauma treatment principles and practices
with the science of learning and reinforcement. The final example here shows another kind of
incentive program and demonstrates the flexibility of the incentive approach.

POPCORN POINTS: ANOTHER STRATEGY USING INCENTIVES

Tom is the nine-year-old boy who was featured in the “cookies during time-out” story in
Chapter 21. Although he was trying hard with his individual behavior contract, it just didn’t
seem to be making much of a dent in his volatile, aggressive behavior toward his peers. Too
many times in a day he would throw a pencil at another child, grab someone’s book and throw it,
or take a random swing while walking down the hall. The treatment team did not want to disrupt
his behavior contract because otherwise it was going well, so they decided to add something
new to try to reduce the aggression.
Tom really wanted to have more friends, so this was used as a motivator. It was easy to get
Tom to see that when his behavior frightened kids, they would try to stay away from him. If he
did “friendly” things instead, kids would feel safer around him and he would have more chances
to make friends. “Friendly things” was defined by the aide, loosely at first, as anything that Tom
might do that would make other kids feel good around him.
Tom was offered a chance to develop his friendly behaviors, with incentives, as follows. The
aide showed Tom an index card with the words “Popcorn Points” written in large bold letters on
the top edge. The rest of the card was filled with a grid of lines making twenty-five empty boxes.
Tom was told that when the boxes filled up, he would be able to invite a peer of his choice to
make a big batch of popcorn together. Then they would give the popcorn to the whole class. (The
rationale was that friendly behavior would earn rewards that would further improve his social
status.)
He could get the boxes filled by doing friendly things. It was up to the aide to decide which
behaviors “counted” as friendly, and on which occasions those behaviors would earn a check
mark, filling a box on the card. This gave the aide the flexibility to modify the program along the
way. Here’s how it worked.
Early in the program, the aide made a point of noticing many behaviors as “friendly” and as
earning a check mark. For example, the aide would say, “I see that you’re walking past people
without hitting anyone. That makes kids feel safe around you,” and then conspicuously check
off a box. Perhaps half a minute later, this would be repeated. Tom learned that it didn’t take
much to be successful at this game, and he could already smell the popcorn. Gradually, the aide
would notice fewer of the more neutral behaviors (not doing something bad) and award more
check marks for active prosocial behaviors, such as picking up an object that a peer had dropped,
or encouraging a peer who had made a mistake during a game.
One of the initial strategies is called “shaping” because at first the reinforcement is for fre-
quently occurring behaviors, but as the child gets used to making the effort to earn the reinforce-
ment, the reinforcement is progressively given for behaviors closer and closer to the desired
ones. When the desired behaviors are not very frequent initially, shaping can be a good way of
getting things rolling while gradually moving the child closer to where you want him to be.
Another of the initial strategies is called “priming the pump” because the reinforcements are
given so freely early on. This helps boost the child’s confidence in the possibility of success and
gets him used to looking for reinforcement for targeted behaviors. If you don’t prime the pump,
the desired behavior may never start to flow.
 Using Incentives for Success 305

Tom started to look at the aide after doing a behavior that had previously been reinforced, to
see if the aide noticed it this time and had marked the card. Sometimes the aide would comment
that the behavior was friendly, and would make the mark. Sometimes the aide would make the
mark with no comment. Sometimes the aide would make the comment, but no mark! At first,
this confused Tom, but the aide explained again that it was up to the aide to decide which behav-
iors counted and when to make the marks. Tom learned to accept this, but he kept on checking
with the aide to see if and when he was earning the check marks.
The “fading” strategy was used here, because at first, the aide reinforced every possible ex-
ample of the friendly behavior, but later only reinforced some of the examples. Also, the
strength of the reinforcement faded; whereas at first, the reinforcement included eye contact, a
praising comment, and a check mark, later only one or two of those might be used at any one
time. When fading is not introduced too quickly, it can help the child keep up the good habit
even as the structured reinforcements are gradually withdrawn.
This is also an example of the “random intermittent reinforcement” strategy that is used by
the gambling casinos. Kids—like the rest of us—will keep on doing something in the hope of an
occasional jackpot. Tom learned to keep on trying to use friendly behaviors because he knew
that sometimes, some form of reinforcement would come. When combined with fading, the ran-
dom intermittent reinforcement can be very effective in helping the child to keep up the good
habit.
The aide made sure that the first Popcorn Points card was filled in only three days. Tom in-
vited a friend to make popcorn for the class. This made everyone happy with Tom, and Tom felt
pleased with his success. Then the aide said, “You’re getting so good at this, I think we should
make it a little harder. How about thirty points this time?” Tom was proud of his success and glad
to accept the greater challenge.
The whole routine was repeated several times. Each time five more points was added. It never
took more than about a week to fill the card. When the aide felt that Tom was getting discour-
aged or at risk of becoming aggressive, a flurry of check marks would ensue; this usually helped
Tom to get himself back on track. Otherwise, the fading and random intermittent reinforcement
strategies were used more and more. After the third batch of popcorn, Tom asked if he could
work toward making cookies for his class the next time. Yes.
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 Chapter 23

The Magic Words: Cognitive Interventions

Words have power. We can use words to help kids learn and heal.
Words get inside your head and take on a life of their own. See what happens inside your head
when you read the following words.

ea Easy COMIC a...

¢ If at first you don’t succeed...
¢ Quitters never win, and...
¢ You never get a second chance to make...
¢ Winston tastes good...
¢ A day without orange juice is like...

When we choose our words with care and intention, these “cognitive” interventions can help
kids to learn, to think in a different way. The strategy is to “label” kids’ behaviors, by giving the
behaviors a name that will make a difference. We have three overall goals in doing this:

¢ Getting our voice and our words inside the kids’ heads—the way parents, and advertisers,
have done with us. This is done by saying the same words over and over again in the same
situations. Over time, the words take hold. They become the kids’ own thoughts, even
when we are not saying anything, even when we’re not there.
¢ Reinforcing positive intentions and behaviors. We can use cognitive interventions to find
and reinforce positive intentions even when we see negative behaviors. This is a “shaping”
strategy to encourage more of the positive. We can also make comments that support and
reinforce the positive behaviors that we observe.
¢ Help kids to gradually transform their acting out to talking out. This is done by labeling the
intention behind kids’ acting out behaviors. Over time, as kids learn that their intentions are
accepted, they start to express their intentions more directly and effectively.

Here’s one last Tom story to illustrate how words can help to transform behavior over time. In
the first month or two of treatment, Tom required frequent physical restraint. Each time, the aide
used the safety words during the restraint, and described Tom’s prerestraint behaviors as Tom’s
way of asking for help, for external controls to help him feel safe and secure. This was done over
and over again in simple, direct ways. For example, “If I see anything flying from that hand, Pll
know that the hand is asking for help staying in control, and [ll hold it.”
About two and a half months into treatment, one day Tom said, “Can we play that game where
I run and you try to catch me?” He had figured out how to get what he needed without breaking
rules or acting out. He had learned to ask for that physical reassurance with words.
Down the line, we hope kids will get even better at this, more sophisticated. Then they would
say something like, “I’m feeling nervous. Can you hold my hand?” The way we label their be-
havior helps them to make progress, one step at a time, from acting it out to talking it out.
307
308 CHILD TRAUMA HANDBOOK

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STANCE OF THE ADULT

The labeling methods are not very complicated. However, it takes a great deal practice to do
this well and consistently. To paraphrase the old swing standard, “It ain’t what you say, it’s the
way how you say it, that’s what gets results.” Saying the right words does matter. But even the
right words won’t get the job done, unless they come with the right attitude, intention, feeling,
body language, and tone of voice.
For example, if the adult’s words say, “The choice you make is up to you,” while the body and
the tone of voice is saying, “Do it my way or I’ll go nuts,” what do you think the child will
‘hear’? In other words, the delivery of the message should be consistent with the content of the
message. This isn’t always easy, because we really do want kids to do it our way. It makes life
easier for us, and we believe that kids will be better off for it. Still, giving a mixed message
doesn’t get the job done.
 The Magic Words: Cognitive Interventions 309

It would be impossible to control our body language and tone of voice if we were always in
conflict while talking with kids. The way to give kids clear and effective messages is to say the
right words that come from the right place. You can use your caring for the child, your under-
standing of the child, and your understanding of what will be helpful, to keep yourself on track.
Here are some additional guidelines to help you to direct your own attitude in a way that will
help the words to come out right.

Keep an Attitude of Supportive Neutrality

Supportive neutrality means that you do care for the child and hope that she will do well, but
you don’t get emotional about it. Root for the home team, but don’t let the outcome of the game
affect your mood or your day. Root for the child, but don’t worry about a particular behavior;
that’s just part of the overall process. Give the message: “I’ll do my best to help you, but it’s your
choice. I have my life, you have yours. Your choices will affect only you.” When you are able to
convey the attitude of supportive neutrality the following occurs:

¢ Kids feel cared for, but they don’t feel pressured or coerced.
¢ You are in charge of yourself, the child is not in charge of you. If you get too hung up on
what the child does, then she is in charge of you, and she can use her behavior as a tool (a
weapon) to get to you and control how you feel.
¢ When kids do take initiative and make choices, they feel that the choices are theirs. No one
else is to blame when something goes wrong. No one else takes credit when something
goes right. Kids can learn from their own choices and feel proud of their accomplishments.

Use the Power of the Incentive System

When you are working an incentive system, all of the child’s actions can be labeled as the
child making a choice for a particular consequence. When you are working the incentive system,
the following happens:

¢ The child is not fighting with you, only with himself. What happens to him is up to him; it
only depends on the choices he makes. When he can’t focus on anger toward you, there’s a
better chance that he will focus on himself and learn something.
¢ When kids do try to insult or accuse you, you know that it’s only a misplaced expression of
their own frustration with themselves. You know it’s not really about you. So you don’t
have to take it personally, you don’t have to get sucked into an argument—you know
what’s really going on.
¢ Because you’re working an effective system, you can feel confident that you are helping
the child learn from her experiences. This is true whether she happens to be doing well or
poorly at the moment.
¢ When you know the child is learning from every choice she makes, you don’t need her to
make any particular choice at the moment. When you know that her frustration and anger,
even if directed toward you, is really about herself, you don’t need to take it personally or
be offended. When you do not become angry or frustrated, it’s easier to stay focused on the
child, and it’s easier to stay calm and supportive.
310 CHILD TRAUMA HANDBOOK

THE LABELING METHODS

Here are the labels that tend to be more effective with kids:

¢ Name the intention

¢ Name the action
¢ Name the action as a choice for the consequence
Pair the labeling with a specific suggestion

Name the Intention

Kids often don’t even know why they’re behaving in a certain way. Or maybe they do know,
but for some reason they feel that it would not work to express it directly. Perhaps they are afraid
to show their need for fear of being rejected. Maybe they just haven’t learned how to recognize
what they are thinking and feeling, and/or how to express it more directly.
When we name the intention behind the child’s action, we try to do it in a simple and clear
way that kids can easily understand. We also try to do it in a way that shows that we see them ina
positive light and find them acceptable. When we name the intention behind the child’s action,
we are potentially helping kids to

¢ Understand what they were feeling or thinking;

¢ Learn that their intentions are acceptable and don’t need to be hidden or disguised;
¢ Learn that they might have a better chance of having their needs met if they can express
their intentions more clearly; and
¢ Learn how to express it in words.

Paul was a fourteen-year-old boy who belonged to a small group of at-risk teens who received a variety
of special services and recreational opportunities at a local youth center. Several months into his partici-
pation, Paul was invested in the group and had formed positive relationships with the staff. One very pop-
ular activity was a six-week movie series in which, every Tuesday evening, the staff would prepare a din-
ner with one or two of the group members, then the rest of the kids would arrive to eat and then watch the
movie. Sometimes kids got rides from staff; sometimes they found other ways to get to the center.
On the third Tuesday evening of this movie series, it was time for dinner but Paul had not arrived. This
was unfortunate but not a huge surprise, because he had been promised a ride by an unreliable family
member. After dinner and before the movie, when many people were standing around outside, Paul
pulled up in a taxicab. This meant that he had spent perhaps the only few dollars that he had been able to
earn all month, from a small job helping a neighbor to move some junk the week before, to make it to the
movie event.
Paul strode up to the youth center, said a couple of quick hellos to his peers, lit a cigarette, and pro-
ceeded to blow smoke into the face of his favorite staff member—who he knew hated cigarette smoke.
The staff person looked at Paul and asked, “You spent all that money on a taxicab to blow smoke in my
face?” Paul’s face broke into a big smile and he said, “Yeah!” There was no more smoke in the face after
that, and Paul went on to tell the story of how his ride had fallen through and how much money he had
spent to make sure he didn’t miss the movie event.

Why is this story in the “name the intention” section of this chapter? Because that’s what the
adult did, in a friendly, joking way. Let’s speculate a bit, and try to analyze this interaction.
Why did Paul go to all that trouble to show up and then, once he got there, act so stupidly?
Here’s a guess: He cared about being part of the group, but was afraid to show how much he
cared. Many kids have learned that to expose your feelings means to risk being hurt. Since pay-
ing for a taxi showed how much he cared, he was trying to undo this, to make the caring seem
less strong, and less frightening. So he acted casual with kids, and blew the smoke in the face of
his favorite staff member.
 The Magic Words: Cognitive Interventions 31]

When the adult said, “You spent all that money on a taxicab to blow smoke in my face?” the
real message was, “Are you trying to tell me how important it was for you to make sure you
made it here?” or more simply, “You really care about being here, don’t you?” When Paul’s in-
tention—caring about being here—was accepted in a friendly and casual manner, he was not so
afraid anymore, and was able to express himself more directly after that.
Fortunately, “name the intention” interventions work well even when they are not delivered
so subtly. In fact, it’s usually best to spell it out as explicitly as possible. Note that it’s not okay to
tell kids how they feel; that would be intrusive and offensive. So we try to make our point with-
out being too pushy. Here are some examples of how the adult might name the intention behind a
child’s action:

* A sixteen-year-old girl is taking an extra helping of dessert, which is against the rules. The
intervention: “Are you wondering if I’m paying attention?”
¢ A seventeen-year-old boy is alternately looking at a comic book and pretending to snooze
during a group meeting. The intervention: “Are you trying to let us know that this is getting
boring?”
¢ Aseven-year-old girl is storming around during homework time, slamming her book down
and crying, “I hate myself!” The intervention: “Are you trying to let me know that this
might be too hard for you?”
¢ A ten-year-old boy sees two other boys playing with toy cars. He takes one of the cars and,
making a loud engine sound, crashes it through their playing space, destroying their care-
fully laid roadways. The intervention: “It seems like you really want to be playing too.”

Name the intention is perhaps the most powerful of the labeling interventions because it
shows acceptance for the child’s needs, even while implicitly acknowledging that the behavior
is a problem. When the child feels recognized, understood, and accepted, this opens the door to
finding other ways to get his needs met. This intervention also helps kids learn to understand
themselves, and to express themselves.

Name the Action

Naming the action can help to make kids aware of their behavior. Many kids’ bad habits have
become automatic, and they may not even realize that they are doing “it” again. When the action
is named, this serves as a prompt, and they can catch themselves and decide to do better.
When you name the action, you might also want to point out how that action relates to the
child’s goals. You can refer directly to the child’s goals (e.g., if the child wants more friends, you
can explain how her action might affect how peers relate to her) or to the child’s incentive pro-
gram (perhaps referring to the positive or negative metaphors from the individual behavior con-
tract). Here are some examples of name the action interventions:

* You’re looking away while I’m talking to you. That makes me wonder if you’re listening or
not.
¢ When you mutter under your breath like that, people think you’re making a threat or saying
something bad about them. That’s how fights get started.
¢ You’re making your voice loud, like how the “Volcano” acts.
¢ You’re talking calm like how a teacher would do it.
ole, CHILD TRAUMA HANDBOOK

Name the Action As a Choice for a Consequence

Naming the action as a choice for a consequence is a powerful way to help kids to catch them-
selves, make conscious choices, and take responsibility for their behavior. This intervention also
clearly establishes the adult as the interested-but-hands-off helper and prompter, while the child
is free to make decisions that will affect only herself. This intervention is frequently used within
a formal incentive system, but it can apply more widely. Here are some examples of name the ac-
tion as a choice for consequence interventions:

¢ You’re moving too far away. Your body is asking for me to hold your hand.
* Looks like you’re deciding to get a good grade, working hard like that.
¢ When you cheat at pool, you’re choosing to play by yourself, because you know no one
wants to play with a cheater.
¢ You can do your homework now or later. It’s your choice: now during homework time or
later instead of watching TV.

Pair the Label with a Positive Suggestion

Pairing the label with a positive suggestion is a slightly more involved intervention. It may not
always be easy to just slip this in as a quick comment. If you are working with a formal incentive
system, especially with an individual behavior contract, then the positive alternatives have al-
ready been spelled out. Then it’s easier to make the suggestion briefly. Any kind of label—inten-
tion, action, consequences—can be combined with a suggestion. Here are some examples of
pair the label with a positive suggestion interventions:

¢ When you act mean like that, it scares other kids away. If you want to make friends, why
don’t you ask if someone wants to do something with you?
¢ When you say, “I’m stupid,” you’re putting yourself down. That’s against the rules. What
could you say to show that you’re frustrated, that would not lose you points?
¢ If you’re looking for ways to earn back the points you lost, I think that Mr. P. could use
some help moving those boxes.
¢ If you’re having a hard time waiting for dinner, you’re welcome to take a piece of fruit.
¢ It’s not okay to talk about people behind their backs. That makes everyone here feel unsafe.
If you want to know what she did, why don’t you just ask her?

EXERCISE: FIND THE MAGIC WORDS

If you are on your own, you can do this just by filling in the responses in the exercise. How-
ever, this is best done in groups of four. For each vignette, have one person take the child’s part,
and the others take each of the adult parts, in order. Then for the next vignette, each person ro-
tates one position.
The exercise does not involve two-way conversation, not until the discussion. However, each
of the adult statements should be addressed directly to the child.
If you are the child, do not respond to the comments. Just notice what it’s like to be you, for
each of the comments in turn. If you are an adult, do your best to keep the “supportive neutral”
adult stance. Don’t worry too much about being clever; just do your best to be helpful while us-
ing the specified cognitive intervention. It is okay to infer details that are not included in the vi-
gnettes. For example, in your intervention you can refer to (what you imagine might be) the
child’s concerns, goals, or incentives.
 The Magic Words: Cognitive Interventions 313

For Each Vignette

Child: Say what would be a typical “quick relief” (but maybe not helpful) adult response.
In other words, what do you expect to hear, even though maybe you don’t hope for this?
Adult 1: Name the (child’s) action and the positive intention. Address it to the child.
Adult 2: Name the action as a choice for a particular consequence. Address it to the child.
Adult 3: Name the intention and the action, and give a suggestion. Address it to the child.

Discussion After Each Round (Before Going to the Next Vignette)

1. What was it like to be the child for each of the comments (including the feared comment)?
2. What was it like to be the adult for each of the comments?
3. Also give one another feedback and suggestions regarding each of the adults’ presentations
of the cognitive interventions. Did it convey supportive neutrality? Was it effective? Tell
each adult about one of his or her behaviors or statements that worked well, and one that
could be improved.

Vignettes

1. April is a fourteen-year-old girl who has been home for only about a minute. Already,
clothes and books are strewn all over the living room and kitchen.
2. Nathan is a nine-year-old boy who hates to lose. You have seen him dump game boards be-
cause he didn’t like falling behind. Another child is about to surge ahead of Nathan on this
next turn.
3. Crystal is a six-year-old girl who is arguing with another child about a toy that the other
child was, in fact, playing with first. The other child is not backing down, but is clearly
afraid, perhaps because of Crystal’s reputation for hitting and biting her peers.
4, Jeremy is a sixteen-year-old boy who has just come in five minutes late to his job. This is
the third day in a row that he has been late. Having the job is a high privilege, and one of the
only opportunities to earn money in the setting.

SECTION VI BIBLIOGRAPHY

Long, N., Wood, M. M., & Fecser, F. A. (2001). Life space crisis intervention (2nd ed.). Austin, TX: Pro-Ed. The
current authority on life space intervention.
Phelan, T. W. (2003). /-2-3 magic: Effective discipline for children 2-12 (3rd ed.). Glen Ellyn, IL: Child Manage-
ment. A popular parent training guide that works pretty well.
Redl, F. & Wineman, D. (1951). Children who hate. Glencoe, IL: Free Press. The classic on “life-space interven-
tion” with acting-out children.
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 Appendix A

Trauma-Informed Psychological Assessment

Many psychologists may understand the value of trauma-informed evaluation and feedback, but do
not quite know how to deliver this within the constraints of the psychological evaluations they are used to
conducting and the reports they are used to writing. This appendix is not intended as an exhaustive treat-
ment of this subject, but hopefully it will give you a few good ideas for ways that you can make your own
assessments more trauma friendly. The focus here will be on evaluation methodology and especially on
presentation style and content.

TRAUMA-SPECIFIC ASSESSMENT TOOLS

A number of trauma-specific assessment tools can easily be integrated into a psychological battery or
even into clinical practice. Ideally, you will select the instruments that measure what you are most inter-
ested in and that are valid (they measure what they are supposed to measure), sensitive, and efficient. A
selective review of child trauma-related measures is published on the Child Trauma Institute Web site
(www.childtrauma.com) and periodically updated.
The following are several good reasons to use such instruments:

* You can find out about trauma-related symptoms that you might not have been able to detect so ef-
ficiently otherwise.
¢ By using standardized instruments, you can compare your client’s responses to others, and see
where your client’s scores fall within the normative range.
¢ By using validated instruments, you enhance the credibility of your findings. This can make a big dif-
ference when you are giving explanations to the child, the family, the teacher, the judge, or others.

You may also wish to use other standardized instruments, as may be required in your setting, and/or to
find out what you need to know. For example, if a child is having problems with schoolwork, you will
also want to assess possible learning disability and any other angles that might help to explain the prob-
lems.
It’s also important to remember that there is no substitute for a good clinical interview. This is the only
way you can really learn about the current situation, the history of functioning, and how the history of ex-
posure to adverse events may have impacted those. The type of interview described in Chapters 5 and 6
works well for a psychological evaluation. When you have conducted a good interview with the child, a
caregiver, and maybe others (and perhaps some observation as well), then you can integrate the findings
from standardized instruments and have a very strong basis for your conclusions.

WRITING A TRAUMA-INFORMED ASSESSMENT REPORT

This section focuses on general considerations in writing a report, and then on trauma-specific consid-
erations. I want to start by asking a fundamental question: What is the purpose of an assessment report?
The answer will vary according to circumstances, but it generally comes down to this: Someone wants
to have a better understanding of the child so that the right decisions can be made on the child’s behalf.
What this means is that the psychologist is serving as a consultant to the person or people who want to
have the understanding so they can make the decision.

Blo
316 CHILD TRAUMA HANDBOOK

In most cases, the people to whom the report is addressed are parents, teachers, judges, case manag-
ers, and others. So why are assessment reports often written so that they can be understood only by other
psychologists? In my opinion, delivering a nonunderstandable report represents a failure on the consul-
tant’s part. I believe that reports should be written for the clients of the consultation, using language and
concepts they are likely to understand, and limiting the length of the report to what they are likely to actu-
ally read. If you can’t imagine sitting down with those who want the report and giving them all this infor-
mation face to face, you should not be writing it for them.
What would such a report look like? There’s rarely any justification for listing all the specific findings
or scale scores from each test used. The evaluator’s job is to interpret the findings and provide the expla-
nation, the bottom line. So spare your clients all the details and just tell them what they need to know. Ifa
psychologist wants to see your data, you have it on file. No one else wants to see it. By cutting out all that
garbage, you ought to be able to write a good explanation of a child in a couple of pages, more or less. It’s
easier to make it longer, but longer reports don’t get read, so they’re not as useful to your clients. It’s worth
learning how to edit; it helps you to be more clearly understood.
What about the format of the report? Some settings or situations require certain formats, or at least
certain contents are required. For example, many evaluations must provide a formal diagnosis. If a diag-
nosis is required, you must find a way to include it, even if you don’t like the requirement. Even with
meeting various requirements, it is often possible, and worthwhile, to modify the format as needed to do
the job well. It may feel risky to do something different than what has been expected, but if the new prod-
uct is more user friendly, the response is likely to be positive. A less rash alternative is to write the stan-
dard huge report that may be expected, but then to tack on a briefer “summary”—the part that will
actually be read—with a more useful approach.
My next suggestion will not be a surprise to you. I think that trauma-informed assessment reports are
most helpful when they use the fairy tale model. This means that when it is time to give the case formula-
tion, we start out with strengths and resources, then describe the dragon and other challenges, and how
that has led to the symptoms and presenting problems. You can sneak the diagnosis in here somewhere,
but you don’t need to emphasize it; the case formulation is the real focus. The report can end with recom-
mendations for the usual treatment plan, including specific details appropriate to the case.

SAMPLE REPORTS

Here are some examples of real (disguised) assessment reports that exemplify this approach to evalua-
tion and report writing. The required information was included, in a way that allowed the psychologist to
present a trauma-informed case formulation, with language and detail appropriate to the intended read-
ers. The first evaluation was requested as part of a victim compensation case; the others were requested
in a school setting, for kids who were having various school-related problems. These evaluations were
selected to show how a wide range of presenting problems and diagnoses can be presented with a trauma
perspective.

June 2, 2000

LIMITED PSYCHOLOGICAL EVALUATION

of Robert Johnson

Sources of Information

Interviews with:

Arnold Johnson (father) —5/21/00

Natalie Robins (Robert’s girlfriend) —5/27/00
Robert Johnson—5/27/00

Impact of Events Scale; Child Report of Posttraumatic Symptoms—5/27/00

 Appendix A: Trauma-Informed Psychological Assessment OLS,

Reason for Referral

Robert Johnson is an eighteen-year-old man who was referred for evaluation and treatment by his fa-
ther, who expressed strong concern regarding a number of symptoms he had observed, including apathy,
irritability, aggression, and negative outlook. These symptoms reportedly developed following a brutal as-
sault of Robert and another young man on July 5, 1999. This evaluation was requested for guidance re-
garding appropriate treatment or other recommendations, as well as for documentation in a pending civil
suit.

History

Robert was born healthy, without complication, and was described as an “easy baby” No history of
medical problems was reported. Developmental milestones were reportedly on the fast end of the normal
range. Robert was described as a happy child who had many friends and enjoyed many activities, espe-
cially sports. He also showed talent; for example, in his early teens, Robert and his brother each played in
the all-star game in the local baseball Little League. Robert was respected by peers and adults alike as a
“good kid” who always tried to do the right thing.
Although Robert's parents are clearly devoted to their children, their divorce and related family dynam-
ics apparently weighed heavily on Robert. When he reached puberty at age thirteen, he became argu-
mentative with both parents, and depressed; at age fourteen he was hospitalized for a month. Robert ap-
parently responded very well to this treatment, and did not become depressed again. On the contrary, he
was very happy in his late teens, saying he “couldn’t wait for the sun to come up; | looked forward to every
day.”
Robert reported no prior history of major trauma. He has been in two car accidents, but was not seri-
ously injured and reported no posttraumatic reaction on either occasion. No criminal history was re-
ported, with the exception of a single shoplifting incident at age twelve. No substance abuse problem was
reported, although Robert acknowledged a history of occasional recreational use of marijuana.
Robert was an average student through grade school. In middle school, he ranged from near failing to
honor student status, fluctuating while he wrestled with his family situation. In high school he continued to
make passing grades, and graduated, but was more interested in socializing, sports, and work.
Robert has always been full of energy, not only for sports, but for work. Since he was old enough he
generally held down a job, sometimes two. Whether he was in high school, college, or out of school, his
work habits have been a strong point. Robert has worked many types of jobs, reportedly learning quickly
and doing well wherever he applies himself. He has long had an ambition to run his own business. At the
time of the assault, Robert had completed a year of community college, was playing basketball daily, and
working in a local store.

After the Assault

On the evening of July 5, 1999, Robert went with a friend to the park, expecting to meet some other
friends. Instead, Robert and his companion were attacked by a group of young men. They were robbed,
threatened, tortured, and severely beaten. For example, Robert was threatened with a gun, and hit re-
peatedly on the shoulder with the gun. Finally, they were tied up with duct tape and left. Fortunately, Rob-
ert and his companion managed to get free and get to a telephone for help. Later, Robert spent the night
in the hospital, and then several days in bed. The traumatic exposure apparently continued for some time
as he went through the ordeals associated with medical treatment as well as the legal system.
In the weeks following the assault, Robert was unable to sleep, afraid to go out in public, and unable to
get the thoughts and images of the assault out of his mind. He said, “I just couldn't be here,” and on the
spur of the moment he moved to Florida where a friend had offered both work and housing. Later, his girl-
friend moved there to join him. He described this period as a big relief, since there were few reminders of
the assault—“We didn’t even have cable TV.” However, they got homesick, and Robert needed to partici-
pate in the trials, so they returned home by the end of 1999.
Except for the partial, temporary relief Robert obtained by moving away, he has been so intensely
haunted by his memories that his level of functioning has substantially declined in many ways. He sought
help, but after several counseling sessions, he felt only slight relief and had no expectation of further prog-
ress, so he stopped going. According to Robert and to those close to him, the suffering continues, as de-
scribed in the following.
318 CHILD TRAUMA HANDBOOK

Intrusive Symptoms

Intrusive images, memories, and thoughts of the assault persist, causing considerable distress. For ex-
ample, he started a factory job involving twelve-hour shifts, and “I thought about it [the assault] for twelve
straight hours—| couldn’t stand it.” He wanted to quit immediately, but forced himself to stay for a month
before finally giving up. The intrusions also occur when any of a number of cues remind him of the assault.
For example, if he sees a gun on TV, he says, “you can hear it hit your bone.” Robert says that his memo-
ries “overpower any other thoughts—it’s hard to think about anything else.”

Sleep Problems

Robert has been consistently unable to get to sleep before about 3 a.m., and then only after using mar-
jjuana. Since Robert has never had trouble sleeping before, and has never been a regular drug user, he
finds his current situation quite disturbing.

Avoidant Symptoms

Robert has taken to avoiding many formerly pleasurable activities, for example, he has not played bas-
ketball for over a year since the assault, although he used to play daily. His girlfriend reports that he con-
sistently refuses to go out, although they used to enjoy restaurants as well as a variety of social and recre-
ational activities. His explanation for this change varies from “I’m afraid of seeing anyone [I don’t know],
not knowing what can happen,’ to “I just don’t feel like it.” He makes a constant effort to avoid reminders of
the assault, even though that restricts his range of activities to a seemingly absurd extent. For example,
he can’t watch the news or many other TV shows, because of the guns and the stories about interper-
sonal violence. And despite his ambitions and his strong work history, he has taken little initiative in either
getting a new job or going back to school.

Overreacting

Those close to Robert certainly agree with his comment that “it doesn’t take much to set me off [lately].”
Since the assault, Robert has frequently found himself in a rage on small provocation—and sometimes
when others don’t see any provocation at all. “Il could have died at any second’ keeps going through my
mind.” Robert’s girlfriend reports that, although she “used to be able to talk to him about anything,” now
she is turned away with a shouted, “I almost died—I don’t want to deal with your problems!” She also re-
ports that their arguments used to lead to resolution, but now are cut short by Robert's yelling or telling her
to leave. Robert’s father has also observed that Robert now tends to “explode” when faced with minor
conflict; and that Robert’s usual roughhousing with his brother has recently turned vicious on occasion.
Robert acknowledges that he is often angry, has a short fuse, and feels unable to deal with formerly com-
fortable levels of conflict, stress, or frustration.

Negative Outlook

Robert's girlfriend said that he “used to be so positive and optimistic—now he just looks at the down
side.” Robert's father is also concerned that Robert has lost his motivation, pointing out that he has only
worked for one month in the past six. Robert insists that he still “love[s] life’ and has ambitions. However,
he acknowledges that he has been unable to overcome his posttrauma symptoms.
Two objectively scored self-report measures of posttraumatic symptomatology were administered for
another perspective on Robert's symptoms over the previous week. The Impact of Events Scale is a
widely used indicator of posttraumatic symptoms in adults, focusing on the hallmark avoidance and intru-
sion symptoms. Robert scored a 56, way above the cutoff of 30, indicating a “clinical disorder’ level of
symptomatology. The Child Report of Posttraumatic Symptoms is a recently validated measure for chil-
dren and adolescents, which covers a wider range of posttraumatic symptoms. Robert scored a 34, also
well above the “clinical concern” cutoff of 19.

Diagnosis and Recommendations

The data is overwhelmingly consistent with a diagnosis of post-traumatic stress disorder due to the
July 5, 1999, assault. Robert was doing rather well prior to the assault and living what we would consider a
normal and successful life. He has clearly been severely affected by his response to this traumatic event,
 Appendix A: Trauma-Informed Psychological Assessment 319
in every facet of his life. The months following the assault have been characterized by haunting memories,
fear, avoidance, temper, and inaction, and his functioning has been limited accordingly. Robert is
appar-
ently unable to work, play, go to school, sleep, or get along with those closest to him.
Intensive psychotherapy is strongly recommended as a means for Robert to face and work through the
traumatic memory So that it plays a less damaging role in his daily life. Although treatment can be ex-
pected to help considerably, it is impossible to predict the degree to which it may be successful, and con-
versely, the degree to which Robert may be burdened with current symptoms indefinitely.

Ricky Greenwald, PsyD

Licensed Psychologist

CONFIDENTIAL
Psychological Evaluation

Date: June 14, 1999

Name of student: Martin Tuismen
DOB: 4/18/86
Age: 13 years 2 months

Sources of Information: Review of Records; State-Trait Anger Expression Inventory; Trauma Symptom
Checklist for Children; Report of Posttraumatic Symptoms—Parent and Child forms; Revised Children’s
Manifest Anxiety Scale; Children’s Depression Inventory; Child & Adolescent Functional Assessment
Scale (CAFAS); Clinical interview with father and with Martin.

Reason for Evaluation

Martin Tuismen is a thirteen-year-old boy in the seventh grade at King Intermediate School. He has
earned failing grades this year and seems to have a lot of trouble focusing on his work. This supplemental
evaluation was requested as part of a comprehensive Chapter 36 evaluation for information and guidance
regarding possible mental health-related needs.

History and Current Situation

According to father, pregnancy with Martin was normal with no exposure to toxins, and birth was nor-
mal as well, except that he had jaundice and was hospitalized for a week. No other serious injuries, head
trauma, or illnesses were reported, nor current health concerns. Martin was described as an active,
healthy baby with no special problems, who achieved developmental milestones on track. He did wet his
bed on occasion until the age of eight. Martin was described as “rascal” and liked to do things like wrestle
with his uncles, but in a playful (not malicious) way. He has always been good at making and keeping
friends, and has several good friends at present.
Martin is the oldest of three siblings born to the same married parents who were separated when Mar-
tin was ten and divorced a couple of years later. Starting after the earthquake (Martin age seven) the chil-
dren were exposed to a lot of parental conflict (no violence). Although the parents have made consider-
able efforts to be cooperative regarding the children, there is remaining conflict and bitterness, and they
are currently in a legal dispute regarding custody-related issues. Martin and his siblings currently live
about half time with father and half with mother.
Martin always did well in school through the fifth grade, getting mostly Bs and Cs and not getting into
any trouble. However, in sixth grade he had a lot of trouble with his teacher and was frequently placed out-
side the classroom as punishment; he got Ds and Fs then. Then he was changed to a different classroom,
and the new teacher gave him considerable attention, and he got excellent grades for the rest of the year.
This year in a new school he did poorly again. His father has taken away PlayStation until the grades go
up, and is allowing Martin to play on a sports team as long as he keeps his grades up. Martin has pulled
his Fs up to Ds but seems stuck there. He shows a “don’t care” attitude and often doesn’t do his work, or
starts but doesn’t finish, and then doesn’t turn it in.
His father believes that he is hurting inside and has too much on his mind. Father and Martin agree that
he was “normal” until the parental conflict began. Martin is also still bothered by memories of times that
mother’s safety was in jeopardy, once with a medical problem and twice with car accidents.
320 CHILD TRAUMA HANDBOOK

Strengths

Martin is a likable boy who is close to family members. He has good friends who are involved in positive
activities and don’t get into trouble. He is a good athlete and participates in community football and bas-
ketball leagues. His involvement in sports helps him to release some energy and to stay out of trouble. He
has positive and realistic long-term goals. He would like to stop getting into trouble and to do better in
school. Martin believes that he is smart enough to do well, but he would have to work hard at it.

Challenges

The history of exposure to parental conflict and divorce, as well as the scares related to mother’s
safety, left Martin with a pileup of bad feelings such as sadness, hurt, anger, and even self-blame. The on-
going exposure to parental conflict continues to add stress. Finally, when he had trouble with his teacher
last year, it all became “too much” hurt, and Martin just gave up in some way. Now the “don’t care” feeling
takes over much of the time because it feels safer than caring and then getting hurt again. Also, he is so
preoccupied with the bad memories and current stresses and worries that it is difficult to keep his mind on
school work. Then fooling around with peers becomes much more compelling than concentrating on
school. Martin currently qualifies for the diagnosis of adjustment disorder 309.4 with features of dysthy-
mia and ongoing stressors, CAFAS score of 40.

Recommendations

1. Parents can help Martin by getting better at keeping the conflict to the adults and not exposing the
kids to it. This means that they can talk honestly and calmly to the kids but should not bad-mouth the
other parent. Rather, they should encourage and support their children in having positive relation-
ships with the other parent. That way Martin will not need to feel torn apart or like he has to choose
one parent over the other.
2. The more parents can keep consistent rules and routines at home, the more Martin will start to feel
that the bad times are over and things are okay now. It is also helpful for parents to keep their tem-
pers under control when around the kids. Then Martin can feel more secure and less worried about
what might happen.
3. Parents should keep very close track of Martin’s school performance and use privileges or other in-
centives to help Martin to try harder and do better. Parents must keep to agreements they make, fol-
lowing through on both rewards and punishments. Any punishments should be limited to something
small enough that parents will be willing to follow through.
4. Once the stress level is down and Martin is not put in the middle of the adults’ conflict, he could use
some special help in getting through the bad feelings that he has piled up inside. Talking with a ther-
apist can help him to get through those feelings and start to feel better and more hopeful again. A
therapist can also help Martin with self-control skills and self-discipline.

Ricky Greenwald, PsyD

Clinical Psychologist

CONFIDENTIAL
Psychological Evaluation

Date: March 10, 1999

Name of student: Charles Wong
DOB: 3/11/89
Age: 10 years

Sources of Information: Review of Records; Child Behavior Checklist—Parent and Teacher forms; State-
Trait Anger Expression Inventory; Trauma Symptom Checklist for Children; Report of Posttraumatic
Symptoms—Parent and Child forms; Revised Children’s Manifest Anxiety Scale; Children’s Depression
eee Child & Adolescent Functional Assessment Scale (CAFAS); Clinical interview with mother and
wit arles.
 Appendix A: Trauma-Informed Psychological Assessment 321

Reason for Evaluation

Charles Wong is a ten-year-old boy attending regular education classes in the fourth grade at King Ele-
mentary School. This year his school attendance and performance have declined dramatically, and he is
at risk of having to repeat the grade. This supplemental evaluation was requested as part of a comprehen-
See 36 evaluation to provide information and guidance regarding possible mental health-related
needs.

History and Current Situation

Mother reported a normal pregnancy with no exposure to toxins. She said that Charles was a happy,
healthy baby who achieved developmental milestones quickly. Although Charles has positive attach-
ments in his family, mother said that he was “always a loner” and Charles said that he does have a couple
of friends but wishes he had more. Charles has no history of head injury or other injuries; medical history
includes surgery for a neck tumor (?) at age seven, and ear problems, which are ongoing. No other medi-
cal concerns were reported and he is using no medication.
In previous screening, Charles's intelligence and achievement scores have been in the average to
high-average range. He has always done well in school, getting good grades and behaving well, all the
way through the end of the last school year. The first quarter of fourth grade he got mostly As and Bs but
then began missing school more and more often, as well as being very late many days, and he has also
been doing much less of his homework, so now he is at real risk of failing the year. In school there have
been no reports of problematic behavior.
Charles currently lives with his maternal grandmother, mother, stepfather, five siblings, and two cous-
ins. Charles is the second-oldest of the siblings. Charles’s mother and father have been married and di-
vorced twice. When they were together, father regularly physically abused mother and children, and
memories of this abuse continue to bother Charles. Mother reported that father has also let the children
down by failing to follow through on various promises. Father is currently incarcerated in a distant location,
and Charles claims to not care much about his lack of contact with father. Mother remarried three years
ago and the two youngest children are fathered by her current husband. Charles gets along very well with
some of his siblings, including the youngest, but fights a lot with his next-youngest brother, including phys-
ical aggression. Many of the children are beyond the parents’ control and don’t listen despite parents’ vari-
ous discipline attempts. The family has been evicted from various housing situations because of com-
plaints about the children being unruly. There is a lot of arguing in the family and also a lot of love.
Around the time that Charles began to do worse in school and stay home more, his mother had threat-
ened to kill herself by cutting her throat. The children were very worried at the time and hid all the kitchen
knives from her. Charles described this as the most upsetting memory he has, and he admitted that he
likes to stay home sometimes to keep his mother company and make her feel better. Mother described
Charles as “Mommy’s boy” and said that he does care for her and helps out sometimes.

Strengths

Charles is a bright boy who can do well in school if he tries. He can be helpful around the house “when
he wants to be” and is good with his youngest siblings. He likes math and is good at getting around on the
Internet. He associates with positive peers. He feels sad to do badly in school and wants to do better. He
also wishes that he wouldn’t get angry at home and fight with his siblings, and recognizes that this would
come from “feeling different inside.” He has positive and realistic goals for the future, including college and
working with young children.

Challenges

Charles is faced with two major challenges. First, the long exposure to physical abuse has left him with
angry feelings that he doesn’t know how to handle, so he ends up fighting with his siblings and disobeying
his mother and stepfather. The adults are not sure how to really be in charge, so the children (not just
Charles) never can feel entirely secure, and that makes them nervous and they act up even more. The
second challenge is that Charles is worried about his mother, so much that he is willing to miss school to
take care of her. He is trying to keep her feeling happy so that she doesn't get so angry and overwhelmed
that she might want to hurt herself again. Charles currently qualifies for the diagnosis of disruptive behav-
ior disorder NOS (not otherwise specified) 312.9, CAFAS score of 60.
322 CHILD TRAUMA HANDBOOK

Recommendations

1. The first recommendation is to get Charles back to school on time and every day. He should have an
enforced bedtime so that he is less tempted to oversleep, and then awakened on time every morn-
ing and sent (or taken) to school, with no exceptions. Mother can help Charles to feel willing to go to
school by insisting that he go, and by demonstrating that she can take care of herself and be okay. If
the parents are unable to get Charles to school on their own, they should get help, perhaps froma
mental health professional and/or a law enforcement officer.
2. Charles’s mother and stepfather could use some support and advice in getting their kids under con-
trol. When kids have been exposed to trauma such as physical abuse, they feel scared and inse-
cure. When parents can take charge, the kids feel more secure and calm down. This would probably
help Charles to calm down and not to fight so much with his siblings.
3. Therapy might help Charles learn to control his anger better and to get through some of the memo-
ries and bad feelings that make him so mad.

Ricky Greenwald, PsyD

Clinical Psychologist

CONFIDENTIAL
Psychological Evaluation

Date: January 18, 1999

Name of student: Tiffany Delano
DOB: 4/24/82
Age: 16 years 9 months

Sources of Information: Review of Records; State-Trait Anger Expression Inventory; Trauma Symptom
Checklist for Children; Report of Posttraumatic Symptoms—Parent and Child forms; Revised Children’s
Manifest Anxiety Scale; Children’s Depression Inventory; Child & Adolescent Functional Assessment
Scale (CAFAS); Clinical interview with mother and with Tiffany.

Reason for Evaluation

Tiffany Delano is a sixteen-year-old girl who is attending ninth grade at King High School for the sec-
ond time, having also repeated eighth grade. She is a regular education student who has a history of cut-
ting classes and failing to complete assignments; she is also involved in peer conflict. This supplemental
evaluation was requested as part of a comprehensive Chapter 36 evaluation to provide guidance regard-
ing possible mental health-related needs.

History and Current Situation

Tiffany is the second of five girls born to the same still-married parents. According to mother, preg-
nancy was normal with no exposure to toxins, and birth was also normal although birth weight was under
six pounds. Tiffany was described as a healthy baby who liked to be carried and to stay near her mother.
Although she was smaller than average, her developmental milestones occurred on schedule. Normal so-
cial development was also reported. Medical history includes a couple of fever/seizure incidents at about
age four that were never diagnosed or well understood. No other health problems or concerns were re-
ported.
Tiffany has had a long history of school-related difficulty. In early elementary school she did fairly well,
earning mostly Bs and Cs, but in grades four through seven she was getting some Ds as well. In grade
school she often had to miss field trips due to incomplete assignments. It is unclear to what extent the
work may have been too difficult for her, as her mother feels that it may have been over her head, whereas
teacher comments indicate that they felt she was capable. In eighth grade she got involved in a negative
peer group, and with them engaged in such activities as harassing others, substance abuse, and cutting
classes. She failed to pass the year and had to repeat. In ninth grade she also failed and is currently re-
peating.
 Appendix A: Trauma-Informed Psychological Assessment 323

Partway through last year, Tiffany left the negative group of peers and now spends her time with a cou-
ple of good friends who appear to be more positive influences (although details of current activities are
unknown). However, one of the girls from the prior group has apparently engaged in a harassment cam-
paign against Tiffany, which she has found extremely upsetting. This problem continues despite various
attempts at resolution, including mediation as well as calling the police.
Tiffany’s history is significant for trauma, loss, and stress. Although her family is generally supportive,
at times there can be a lot of yelling as well as occasional physical discipline (slap for disrespecting).
When Tiffany was about ten she was exposed to two traumatic experiences, the earthquake and an auto
accident. A year or two later her grandmother died. Over the past few years she has been very upset by in-
volvement in a fight in school, by the harassment of the peer noted previously, and by her cousins’ recent
move out of state. The deterioration of Tiffany’s behavior and school performance closely follows the in-
creasing burden of upsetting experiences she has faced.

Strengths

Tiffany is able to form good relationships with family members as well as friends. Mother and teachers
see her as being generally smart and capable. She helps her younger sisters with their homework and
other tasks, and also helps out at home by cooking. She loves animals. She is image-conscious and takes
care of her appearance. She has realistic and positive goals (to be a beautician) for the future.

Challenges

Tiffany has become overburdened over the years with a series of upsetting experiences. These have
given her a “sore spot” that leads her to have a quick temper, to be angry at authority and peers, to feel
picked on and isolated, to feel that something is wrong with her, to be preoccupied with upsetting memo-
ries, and to feel generally sad and anxious. It is no wonder that she becomes overwhelmed with a legiti-
mately challenging situation such as being harassed, to the point where she can’t concentrate on her
schoolwork. She currently qualifies for the diagnosis of disruptive behavior disorder NOS (not otherwise
specified) 312.9 with posttraumatic features, CAFAS score of 90.

Recommendations

1. Every effort should be made to curtail the peer harassment, through school, legal, or other means.
Tiffany is already under constant pressure from her own feelings; it is unreasonable to expect her to
function well while she is actually being threatened and attacked on a regular basis.
2. Therapy could help Tiffany to work through some of her upsetting memories so that she can move
on instead of being so burdened by them. Additional therapy focus should include motivation as well
as self-control skills.
3. Consistent rules and natural consequences will help Tiffany to learn that what she does matters.
This way she has the best chance of making better choices.

Ricky Greenwald, PsyD

Clinical Psychologist
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 Appendix B

Child Trauma Resources Online

_ Online information changes so fast that I think that the best way to give you good information is to
give you access to information as it develops. Here are a couple of good, reliable sites that can help you to
find what you need, including up-to-date links to other sites.

CHILD TRAUMA INSTITUTE

<www.childtrauma.com>

This site is developed and maintained by Ricky Greenwald, PsyD, the founder and director of the
Child Trauma Institute and the author of this book. This site won’t overwhelm you with links, but the im-
portant ones are there. The site also offers the following:

¢ Information on training programs related to child and adolescent trauma treatment

¢ Information on child trauma assessment, including reviews of measures, samples of some instru-
ments, updated data, and abstracts/reprints of published papers
¢ Information on child/adolescent trauma treatment
¢ Information on trauma and problem behaviors, including abstracts/reprints of published papers
¢ Information for parents, including understandable articles, an “advice column,” and handouts you
can use
e A list of publications that can be accessed on site or else where online
¢ Links to selected sites that offer important information related to child and adolescent trauma

TRAUMA INFO PAGES

<www.trauma-pages.com>

This site is developed and maintained by David Baldwin, PhD. It is highly regarded as the trauma in-
formation site online. Although this site is not specifically focused on children, it is comprehensive in
providing many types of information about trauma, trauma research, and trauma treatment. Here is a par-
tial list of this site’s offerings:

About trauma
Trauma articles
Trauma resources
General support
Trauma bookstore
Disaster handouts and links
Trauma links: psychology, research, medical
Search of this site and several other trauma sites

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 Index

Page numbers followed by the letter “b” indicate boxed material and those followed by the letter “f’ indicate figures.

Abuse, case management, 121 Assessment reports

“Acculturate,” 65 for Charles Wong, 320-322
Acculturation, 65, 66 for Martin Tuismen, 319-320
Action, labeling method, 310, 311 purpose of, 315-316
Active listening (AL), 186 for Robert Johnson, 316-319
Activities for Tiffany Delano, 322-323
motivation, 287-288 Assistant principal, 123
self-care strategies, 52 Attachment
training program, 20-21 evaluation phase, 62
Adolescents and hope, 99
EMDR treatment, 186-187 initial interview, 68-69
exposure procedure instructions, 207-208 trauma wall, 14-15
MI, 100 traumatized child, 41
problem behavior referrals, 23 Attention, reinforcement, 273
time-oriented goals, 103 Attention deficit/hyperactivity disorder, 122
treatment plan, 107 Auto accident, meaning of behavior, 26
treatment plan dialogue, 109-111 Avoidance
Adults in vivo exposure, 227
cognitive interventions, 308-309 Johnson assessment, 318
division among, 261 post—trauma resolution, 225
emotion control strategies, 284-286 PTSD symptoms, 16
and physical restraints, 266 Awareness
role failure, 258, 259-260 child trauma therapist, 40-41
role of, 255-256 family strengthening, 229
safe environment exercise, 263
time-out system, 279, 280-281
Advice, MI approach, 102
Advocacy, case management, 128 Bad things
Affect, definition, 17 Jody’s case formulation, 96
Affect dysregulation, 17-18 John’s case formulation, 93
Affective mastery, 117 Marcus’s case formulation, 94b
After-event impact, trauma characteristic, 10 Michael’s case formulation, 95b
Age, trauma history list, 80 multiple traumas, 97
Alternate time-out system, parent training, 148 Baldwin, David, 325
Angela, case management exercise, 125, 126 Basic needs, safety, 259
Anger, 9 Behavior
Anger management, 159 contract implementation, 302
Anxiety determining meaning steps, 23-24
in vivo exposure, 227 meaning of, 23-25
self-management, 156-159 parent training, 138, 151-152
trauma-induced, 9 post-trauma resolution, 225, 227
Approval, motivation, 288 self-control skills, 159-161
Arguing, role failure, 260 Behavior contracts, 291-293
Art therapy, 181 Beliefs
Assessment blocking, 21 8-22 1
initial contact, 61-62 case formulation, 91
trauma-specific, 315 impact of work, 48
331
ah? CHILD TRAUMA HANDBOOK

Beliefs (continued) Case managers, 37

Jody’s case formulation, 96 Case workers, 4-5
John’s case formulation, 93 Casey
Johnson assessment, 318 case formulation, 91
Marcus’s case formulation, 94b meaning of behavior, 24-25, 26, 28
meaning of behavior, 23, 24, 25 Meaning of Behavior form, 91
Michael’s case formulation, 95b narrative explanation, 91-92
multiple traumas, 97 Challenges
“Blocking beliefs,” 137 Delano evaluation, 323
Body Tuismen evaluation, 320
impact of work, 48 Wong evaluation, 321
self-management skills, 157 Champion, 302
Body language Change, 129
cognitive interventions, 309 Chart, contracts, 297
distress signals, 217 Check-in
Boredom, distress signals, 217 post-exposure session, 212-213
Breaking, role failure, 260 self-control skills, 159
Breaking Down the Memory form term, 29
sample, 199b Child protection, 130-131
trauma story, 202 Child Trauma Institute, Web site, 315, 325
Bryson, memory breakdown, 194 Child trauma therapist. See also Therapist
Buddy system, helplessness reduction, 56-58 characteristics, 40-41
Bullying key principles, 37-40
case management, 121 trauma resolution, 181
most upsetting case, 50 Child welfare agency, 132
unsafe environment, 261
Child welfare worker, 130-131
Childcare workers, 4-5
Children
Caregivers
case formulation, 89-91
rehabilitation of, 118
case management, 121-122
special obligations, 135
coping strategies, 154
Caring, most upsetting case, 49
disclosure restraint, 86-87
Carla, case formulation exercise, 96-97
EMDR treatment, 186-187
Case consultant, exercise, 251, 252b
interview script, 75b, 76
Case formulation
in parental role, 140
contents, 91
description of, 89 problem behavior referrals, 23
evaluation phase, 62, 89 PTSD symptoms, 16-20
exercises, 92-93, 94b, 95b, 96 safe environment, 257-258
fairy tale model, 32-33, 35b, 244b self-control skills, 153, 159
motivation enhancement, 99-100 therapeutic relationship, 47
parent training, 137-138 therapeutic treatment, 65
purposes of, 89-90 time-oriented goals, 102
and trauma treatment, 245b time-out system, 280
Case Formulation for Case Management form trauma burden, 19
Angela, 126 trauma exposure, 11
blank sample, 124b trauma impact, 10-11
Damian, 125-126 and trauma resolution, 179
Case management treatment models, 30
and cooperation, 127-129 treatment plan, 107
fairy tale model, 33, 35b, 244b Choices
parent training, 135 initial meeting, 71
pitfalls/remedies, 129-133 treatment recommendations, 99
post—-trauma resolution, 232 Choices have consequences
role of, 1217,.121-123 description, 161-162
safety issues, 117 exercise, 165, 167
successful interventions, 132 script, 162-163
and trauma resolution, 179 “Circles and arrows,” 161, 162
and trauma treatment, 245b Clarissa, contracts, 303
 Index ISS

Client Coping strategies

break down memories exercise, 197, 200 experiential exercises, 20
choices have consequences exercise, 165 high-risk situations, 154
exposure procedure, 210-211, 221, 222 in vivo exposure, 227
initial interview exercise, 73 relapse prevention, 225, 233
initial interview follow-up questions, 74 and trauma treatment, 245b
problem mapping, 165, 166b Counselors
Safe Place exercise,-176 healing role, 37
trauma history exercise, 83 pitfalls/remedies, 131-132
trauma history follow-up questions, 86 training program, 4-5
“Close down,” 3 Court personnel, 4-5
Coaches, 37 Covenant Children’s Home and Family Services, 1
Cognitive interventions Criminal behavior, 9
exercise, 312-313 “Crisis response,” 29
goals, 307 Culture, training program, 2
Cognitive processing therapy (CPT), 181, 188
“Cognitive-affective-cognitive sandwich,” 37-39, 81-82
Cognitive-behavioral therapy (CBT) Daily life, 255-256
and EMDR, 185-186, 187 Daily routine, safe environment exercise, 263-264
therapeutic practice, 3 Damian
Community mental health centers, interventions, case management exercise, 123, 125-126
132-133 meaning of behavior, 26, 28
Compensation, 55 Damn-Shit-Fuck Progression, 147
Concentration, 9 Dave, exposure selection, 192-193
Confidentiality, 67 Deep breathing
Conflict, 101-102 containment, 175
Connection experiential exercises, 20, 21
helplessness reduction, 58 self-management skills, 157-158
initial contact, 61 trauma history step, 81
RICH model, 41, 42-43 Depression, 9
Consequences Desensitization
advantages of, 281-282 exposure method, 182
discipline, 271 therapeutic practice, 3
examples of, 282 trauma treatment, 245b
labeling method, 310, 312 Developmental history, intake interview, 76
parent training, 148 Diagnosis
safe environment, 260 Johnson assessment, 318-319
self-control skills, 161-162 medical model, 30
setting, 274 Direct care workers, 37
Consistency, 259 Directive therapy, 66
Consolidation Discipline
adult’s role, 256 assumptions about, 271
fairy tale model, 33 case management, 121, 123
intervention stage, 254b consistency, 274-276
trauma treatment, 245b contract implementation, 302
Container, 198 emotion control strategies, 284-286
Containment exercise challenge, 282-283
strength-building approach, 175-176 ignore the negative, 273-274
trauma treatment, 245b inadequate, 283
Contracts natural consequences, 271
basic behavior, 291-293 parent training, 135, 136
complex program, 294-297 parental style, 70
form, 300 positive approach, 271, 272-273
sample, 298 positive approach principles, 276-277
written content, 296-297 post-trauma resolution, 225
Control quick action, 138, 144-145, 277, 280, 285
impact of work, 48 response cost, 282-283
parent training, 138, 150 safe environment exercise, 264
334 CHILD TRAUMA HANDBOOK

Discipline (continued) Exercises (continued)

time-out system, 271 safer environments, 268, 269b
views of, 271 self-care check-in, 50-51
Disclosures, 70 self-care plans, 52
Disruptive behavior, 9 taking a trauma history, 83, 84b, 85b
Distraction, 274 training program, 5, 20-21
District attorney, 131 who helped you and how?, 44-45
Domestic violence, 24, 26 Explanations, 274
‘Don’t care” attitude, 9 Exposure
“Don’t know—don’t care,” 3 completion indications, 211-212
Dysregulation, 17 memory breakdown, 193-197
target selection, 191-193
trauma resolution, 181, 182-184, 188
Edgewood Children’s Center, 1 trauma treatment, 245b
Educational history, 76-77 Exposure session
Ego ideals, 294 blocking beliefs, 218-221
Emergency room, 131 exposure procedure, 207-210
Emotions, 284-286 follow-up, 212-213
Empathy manageable chunks, 201-202
caring relationship, 43 narrative problems, 215-216
MI approach, 101 overexposure signals, 217
Empowerment rationale, 203-205
parent training, 135-136, 138 stopping practice, 207
RICH model, 41 strength resources, 205-207
and trauma treatment, 30 Eye movement desensitization and reprocessing
Erikson, Erik, 15 (EMDR)
Ethnicity, 2 training requirements, 187-188
Evaluation trauma resolution method, 181, 185-188
adult’s role, 255 trauma treatment, 245b
fairy tale model, 32, 35b, 244b
intervention stage, 253b
overview, 61-62 “Fading” strategy, 305
post—-trauma resolution, 232 Fairy tale, trauma treatment, 30-32, 241-243
primary goals, 62 Fairy tale model
and trauma treatment, 245b application exercise, 246-249
Event, 10 case management, 121f
Exercises emotion control strategy, 285
case consultant, 251, 252b intervention stages, 253b-254b
case formulations, 92-93, 94b, 95b, 96 parent training, 135, 136, 138
case management, 123-129 relapse prevention, 234f
deep breathing, 21 self-control skills, 154f
discipline challenges, 283-284 steps, 65f
exposure session, 210-211, 221-222 therapeutic application, 243
fairy tale model application, 246-249 therapy impasses, 249-251
float-back, 21 trauma resolution, 181f
impact of work, 48 trauma treatment, 32-34, 35b, 244b, 245b
individual behavior contract, 297 treatment success, 68
initial interview, 73-74 Family
magic words, 312-313 case formulation testing, 89
meaning of behavior, 25-26 case management interventions, 128-129
memories, 21-22 experiential exercises, 21
memory breakdown, 197-198 parental division, 151
most upsetting case, 49-50 post—trauma resolution, 225, 229-231
peer support, 58 treatment obstacles, 113-114
problem mapping, 163-165, 166b Family activities, motivation, 288
recognizing impact of work, 50 Feedback
safe environment evaluation, 262-267 evaluation process, 61, 62
Safe Place, 176-177 initial meeting, 72
 Index 300

Feelings Helplessness
case formulation, 91 most upsetting case, 49
helplessness reduction, 56 reduction of, 54-55
Jody’s case formulation, 96 High-risk situations, 153
John’s case formulation, 93 Hitting, role failure, 260
Marcus’s case formulation, 94b Hope
meaning of behavior, 23, 24, 25 evaluation phase, 62
Michael’s case formulation, 95b initial contact, 61
multiple traumas, 97 motivation enhancement, 99
problem behavior, 23 RICH model, 41, 44
“Fenced-in” area, 39 therapeutic relationship, 99-100
“Field tested,” 70 traumatized child, 41
Fighting, 9 Hospital, 132
Flashbacks, PTSD, 16 Hostile attribution bias, 16
Float-back exercise, 21 Humanist therapist, 3
sandwich approach, 38-39 Humor, as distress signals, 217
Focus Hyperarousal, 16, 225
child trauma therapist, 41 Hypervigilance, 16
safe environment exercise, 264
Foster parents
role of, 255-256 Imaginal exposure
training, 135 left-over symptoms, 229
Frankie, contract, 297 trauma resolution method, 184
Free will, 100-101 Impulsiveness, 23
Frustration, 9 In vivo exposure
Future movies description, 182-184
motivation enhancement, 103-104 left-over symptoms, 227-229
script, 104-106 trauma treatment, 245b
Incentives
cognitive interventions, 310
complex contract, 294-295
Genogram, 68, 69
exposure session, 202-203
“Getting stronger,” 117
motivation, 289
Getting stronger approach, advantages of, 169
parental concerns, 295-296
Goals
popcorn points, 304-305
evaluation phase, 62
trauma treatment, 245b
fairy tale model, 32, 35b
Individual behavior contract
MI approach, 101, 102-103
complex program, 294
motivation, 289
exercise,297
motivation enhancement, 99
form, 301
movie script, 105-106
implementing, 302
relapse prevention, 233
and motivation, 291-293
trauma treatment phases, 245b
problem solving, 302-304
and traumatized child, 41
sample, 298
Good ending, 194-195
script, 299-300
“Good-enough mother,” 14
Information
Grief, stages of, 12 child trauma therapist, 40-41
and hope, 99
initial contact, 61
Habituation, 182 initial meeting, 72
Hampshire College, training program, 1 RICH model, 41, 42
Harm reduction and treatment, 68
definition of, 236 “Information processing,” 182
fairy tale model, 34, 35b Initial contact, 61
intervention stage, 254b Initial interview
story tale model, 244b with child, 70-73
strategies, 237 exercise, 73-74
Helpers, 206 with family, 68-69
336 CHILD TRAUMA HANDBOOK

Initial interview (continued) Language

follow-up questions, 74 cognitive interventions, 307
importance, 65 safe environment exercise, 263, 266
with parents, 69-70 training program, 2
the rules, 67 “Late bloomers” study, 272-273
Intake interview Law enforcement, 130
extended, 76-77 Learning disability, 121
initial contact, 61-62 Learning theory, 2
Intention, labeling, 310-311 Line staff, 4-5
Interest loss, 9 Lisa, safer environments, 268
International Society for Traumatic Stress Studies’ Lists, trauma history, 79-80, 81
Treatment Guidelines, EMDR, 185 “Tost her childhood,” 15
Interventions
case management, 127
container, 198 Marcus, case formulation exercise, 94b
fairy tale model, 253b-254b Martha, relapse prevention, 235-236
family risks, 114, 115 Meaning of behavior
family strengthening, 229-231 exercises, 25-26
future movies, 103 follow-up, 26, 28-30
meanings of behavior, 28 Meaning of Behavior worksheet
motivation enhancement, 103 blank sample, 27b
overexposure, 217 case example, 24-25
positive parenting, 139b, 140-152 case formulation, 91
self-control skills, 159-161 completion tips, 25
story telling problems, 216 Damian sample, 28b
strength-building approach, 175-176 initial parent interview, 70
time-out, 277 narrative explanation, 24
trauma theory, 2 problem determination, 29-30
treatment recommendations, 99 safer environment exercise, 269b
Introduction Medical history, 76
Jody’s case formulation, 96 Medical model, 30
John’s case formulation, 93 Medical noncompliance, 9
Marcus’s case formulation, 94b Memories
Michael’s case formulation, 95b breakdown exercise, 197-198, 199b
multiple traumas, 96 breakdown session, 196-197
breaking down, 193-195, 199b
experiential exercises, 21-22
exposure selection, 191-193, 211
Jamie, exposure method, 183-184 post—exposure session, 213
Jesse, safer environments, 268 unprocessed traumatic, 12-13
Jessie, meaning of behavior, 26 Mental health professionals
Jody experiential exercises, 21
case formulation exercise, 96 self-care, 47
meaning of behavior, 26 training program, 4
John, case formulation exercise, 93 Mental health system
Johnson, Robert, assessment report, 316-319 pitfalls/remedies, 131-132
Julio, premature termination, 238-239 as practitioner-centered, 181
problem behavior referrals, 23
Menu
initial meeting, 71-72
Kevin, harm reduction, 236-237 self-control skills, 155
Kiibler-Ross, Elisabeth, 12 trauma history step, 80
Michael
case formulation exercise, 95b
meaning of behavior, 26
Labeling Minorities, 65
cognitive interventions, 307-309 Mischa, safer environments, 268
methods of, 310-313 Molestation, meaning of behavior, 26
 Index 337

Monitoring Paraprofessional, 4-5

child trauma therapist, 40-41 Parent training
exposure procedure, 209-210 case formulation, 137-138
high-risk behavior, 153 fairy tale model, 33, 244b
therapy sessions, 39 family strengthening, 231
Motivation parenting skills, 135
as incentive, 287 safety issues, 117
intervention strategy, 103 trauma treatment, 245b
sources of, 287-289 Parents
Motivational interview, 32, 35b authority of, 140-143
Motivational interviewing (MI) case management, 122-123
fairy tale model, 244b case management exercise, 123
movie script, 104-106 initial interview, 68-69
principles/procedures, 100-102 rehabilitation of, 118-119
success of, 100 risk of harm, 121
Mount Sinai School of Medicine, 1 role of, 255-256
Movie safety first, 37
choices have consequences exercise, 165, 167 special obligations, 135
future movies, 103-106 training program, 4-5
imaginative choices, 162-163 and trauma resolution, 179
in vivo exposure, 227-228 trauma therapy, 2-3
treatment goals, 102
treatment plan dialogue, 111-112
treatment recommendations, 99
Narrative explanation, 24, 91-92 Paul, labeling, 310
Natural consequences Pediatricians, 131
advantages of, 281-282 Peer support, 56-58
discipline, 271 “Pep talk,” 29
examples of, 282 Permissiveness, 208
term, 148-149 Personal safety, impact of work, 48
Ned, contracts, 303 Physical discipline, 148
New York City Department of Education, training Physical environment, 264
program, 1 Physical restraint
Nina, contracts, 303 parent training, 147
Nonconfrontation, 101 safe environment exercise, 265-267
Numbness, PTSD, 16 unsafe environment, 261-262
Nutrition, self-care, 52 Physical safety, 258-259. See also Safety
Physical strength, 170-171
Physician, 131
Placebo effect, 30
Occupational hazard, 50 Play therapy
“Once upon a time” imaginal exposure, 184
case formulation, 91 therapeutic practice, 3
initial interview, 68 and trauma resolution, 181
Jody’s case formulation, 96 Point system, incentives, 289-291
John’s case formulation, 93 Police, 130
Marcus’s case formulation, 94b Pony express model, 47
Michael’s case formulation, 95b Popcorn points, 304-305
multiple traumas, 97 Positive attention, discipline, 271, 272-273
“Open up,” 38 Positive parenting handout, 139b, 152
“Opening up,” 3 Post-traumatic stress disorder (PTSD)
Order, exposure treatment, 191, 201-202 Johnson assessment, 318-319
Overexposure and medical model, 30
exposure procedure, 210 self-control skills, 159
problem-solving strategies, 175 symptoms, 16-20
signals of distress, 217 Praise, 73
strength-building approach, 174-175 Predictability, 65
Overreacting, Johnson assessment, 318 Presenting problem, 26, 70
Overtalking, as distress signals, 217 Primary trauma, 191-193
338 CHILD TRAUMA HANDBOOK

“Priming the pump,” 304 Rationalize, 55-56

Privacy, treatment rules, 67 Reassurance
Problem behavior parent training, 138, 139
Jody’s case formulation, 96 problem behavior, 276
John’s case formulation, 93 Recommendations
Marcus’s case formulation, 94b Delano evaluation, 323
Michael’s case formulation, 95b Tuismen evaluation, 320
multiple traumas, 97 Wong evaluation, 322
role of trauma, 23 Reexperiencing, PTSD, 16
Problem Behavior Cycle and Treatment Refusals, trauma history step, 80-81
Recommendations, 108b Rehearsals
Problem map, self-control skills, 163-165, 166b relapse prevention, 233
Problem solving self-control skills, 156, 158
behavior contracts, 302-304 Reinforcement, 70
blocking beliefs, 218-221 Relapse prevention
case management, 121, 122 adult’s role, 256
container intervention, 198, 200 definition of, 233
and hope, 100 fairy tale model, 34, 35b, 244b
Safe Place, 176-177 intervention stage, 254b
self-control skills, 155
strategies, 233
story telling narrative, 215-216
trauma goals, 233
strength-building approach, 175
trauma treatment, 245b
Progressive relaxation, 158
Relationships, 42-43
Prolonged exposure (PE), trauma resolution, 181,
Repetition, exposure, 208-209
182-184, 188
Residential treatment worker
Promises
role of, 255-256
and natural consequences, 281
training, 135
parent training, 138, 143-144, 146, 148
Resiliency, trauma factors, 13-15
positive discipline, 276-277
safe environment, 260-261 Respect
therapy sessions, 40 initial contact, 61
Props, role-play, 143 parent training, 135-136, 138
Prosecutor, 131 RICH model, 41-42
Proximity, trauma characteristic, 10-11 Respect, Information, Connection, Hope (RICH) model
Psychiatrist, 3 description, 41-42
Psychodynamic therapist, 3 initial contact, 61
Psychoeducation Response cost, discipline, 282-283
evaluation phase, 62 Rewards, contracts, 293
fairy tale model, 32-33, 35b, 244b Risk avoidance, self-control skills, 153
family strengthening, 229 Risks
trauma history step, 80 caring relationship, 43
Psychological evaluation overexposure, 174-175
Charles Wong, 320-322 relapse prevention, 233
Martin Tuismen, 319-320 safe environment, 259
Tiffany Delano, 322-323 Role-play
Psychosocial history initial interview, 73
initial parent interview, 69 parent authority, 140-143
intake interview, 76-77 time out, 145-146
Psychotherapy, 65 Routines
Put-downs, 261 safe environment, 259, 260-261
therapy sessions, 40
Rules
Queen’s Medical Center, training program, 1 parent training, 138, 144
Quiz, treatment rules, 67-68 parental division, 151
safe environment exercise, 263
term, 37
“Random intermittent reinforcement,” 275, 305 treatment, 67
Rationale, exposure, 229 Ryan, contracts, 303
 Index 339

Safe environment Shaping, 304

home/work evaluation, 262-267 Shapiro, Francine, 185
safer environments, 268, 269b Shelter workers, training program, 4-5
Safe Place Skepticism, 41
containment, 175 Skill development
exercise, 176-177 helplessness reduction, 54
Safety intervention stage, 253b
adult’s role, 255-256 post—trauma resolution, 225
and attachment, 15 Sleep, self-care strategies, 52
developing conditions, 117-118 Sleep problems, Johnson assessment, 318
disallowed attacks/threats, 261-262 Slot machine metaphor, 146-147
emotional environment, 259 Social support
evaluation phase, 62 self-care strategies, 52-53
fairy tale model, 33 trauma wall, 14
initial interview, 65 Solitude, 48
intervention stage, 253b Sore spots
key principle, 37-39 case formulation, 91
parent training, 135, 138, 140-141 term, 13
physical environment, 258-259 trauma wall, 14
post—trauma resolution, 232 Spiritual beliefs, 48
present environment, 257-258 Stability, 48
relapse prevention, 234 “Stance,” 3
threats to, 259-260 Stepfamily, 151
trauma treatment, 245b “Sticking point,” 218
Sandwich approach Strength building
cognitive-affective, 37 adult’s role, 255-256
float-back exercise, 38-39 intervention stage, 253b
trauma history step, 81-82 with older children, 170
School absences, 9 principles of, 169
School phobia, 114-115, 225 risks of, 174-175
“Secondary traumatic stress syndrome,” 49 safety issues, 117, 119
Security, 40 trauma treatment, 245b
Self-advocacy, 73 with younger children, 170-173
Self-calming techniques, 158-159 Strengths
Self-care Delano evaluation, 323
child trauma therapist, 41 Tuismen evaluation, 320
impact of work, 51-52 Wong evaluation, 321
mental health professions, 47 Strengths/resources, fairy tale model, 244b
personal requirements, 53-58 Stress management, self-care strategies, 52
Self-care check-in, impact of work, 50-51 Structure, exposure, 208
Self-care plans, impact of work, 52 Structured trauma therapy, 181
Self-control, 153, 159-161 Study habits, 225
Self-control skills Subjective units of distress scale (SUDS)
risk avoidance, 153-156 exposure completion, 212
safety issues, 117 exposure selection, 191, 199b
self-control, 153 self-calming skills, 158-159
self-management, 153 trauma history step, 80, 81
trauma treatment, 245b Substance abuse
Self-management skills MI, 100
and fairy tale model, 33, 244b PTSD symptoms, 17
post-trauma resolution, 225 trauma-induced, 9
self-control skills, 153, 156-159 Substance avoidance, 52
and trauma resolution, 179 Success
and trauma treatment, 245b key principle, 40
Self-monitoring MI approach, 102
emotion control strategy, 285 motivation, 289
personal requirements, 53-54 treatment, 68
Self-talk, 158 Suggestion, labeling, 310, 312
340 CHILD TRAUMA HANDBOOK

Suicidal behaviors, 9 Time-out system

Superficiality, as distress signals, 217 advantages of, 277-278
Supervision components, 278-279
case management, 121 as discipline, 271, 277
helplessness reduction, 57 parent training, 144-145
personal requirements, 54 problem solving, 279-280
Supervisor, exercises, 21 Token economy, 291
Supportive neutrality, 310 Toleration, 99
Supports, emotion control, 285 Tom
Survival orientation, 15 cognitive interventions, 307
Symptom-management, 3 discipline story, 281
popcorn points, 304-305
Trauma
Talk characteristics of, 10-11
experiential learning, 47 definition of, 9
and traumatized child, 41 digestion of, 12
Teachers and problem behaviors, 23
safety first, 37 and relapse prevention, 233
training, 135 repetitive, 14
Temperament, trauma wall, 14 therapeutic practice, 3
Termination, conditions, 240 Trauma, attachment disruption, 15
Therapeutic relationship Trauma, behavioral problems, 9
and hope, 99 “Trauma burden,” 19-20
traumatized child, 41-45
Trauma history
Therapist Delano evaluation, 322-323
blocking beliefs questions, 219
initial parent interview, 69
break down memories exercise, 197, 198
intake interview, 76-77
case management interventions, 127
Robert Johnson, 317-318
choices have consequences exercise, 165
trauma treatment, 245b
exposure procedure, 210-211, 222
Tuismen evaluation, 319-320
impact of work, 48-49
Wong evaluation, 321
initial interview exercise, 73-74
Trauma info pages, Web site, 325
initial interview follow-up, 74
Trauma resolution
narrative questions, 215-216
adult’s role, 256
Overexposure questions, 217
personal therapy, 53, 54 fairy tale model, 33, 35b, 244b
physical restraint training, 265 goals/tasks, 179
pitfalls/remedies, 131-132 intervention stage, 254b
problem mapping, 163-164, 166b methods, 181-182
recognition of impact, 50 safety issues, 117
responsibility, 45 start of, 179
Safe Place exercise, 176 and trauma treatment, 245b
safety issues, 37 Trauma story, exposure session, 202-203
security issues, 40 Trauma theory, therapeutic practice, 2, 3, 5
session management strategies, 38 Trauma therapist, 3
style of, 65, 66 Trauma therapy, characteristics of, 2-4
trauma history exercise, 83, 84b, 85b Trauma treatment
trauma history follow-up, 86-87 empowerment model, 30
Therapy and medical model, 30
initial contact, 61 term, 179
personal requirements, 53, 54 Trauma wall
self as tool, 47, 48 description, 12-13
Threats factors impacting, 14-15
role failure, 259-260 “Trauma work,” 179
safety issues, 117 Trauma-informed case formulation
Throwing, role failure, 260 contents, 91
Time description of, 89
children’s sense of, 102 evaluation phase, 62, 89
PTSD symptoms, 18-19 exercises, 92-93, 94b, 95b, 96
 Index 34]

Trauma-informed case formulation (continued) Trigger

fairy tale model, 32-33, 35b, 244b Jody’s case formulation, 96
motivation enhancement, 99-110 John’s case formulation, 93
purposes of, 89-90 Marcus’s case formulation, 94b
Trauma-Informed Case Formulation worksheet, 94b, Michael’s case formulation, 95b
95b multiple traumas, 97
Trauma-informed therapy Triggers
assessment report, 315-316 case formulation, 91
assessment tools, 315 expose to unwarranted, 121
sample assessment reports, 316-323 initial parent interview, 70
Trauma-informed treatment meaning of behavior, 23, 24, 25
anger management, 159 most upsetting case, 50
early challenges, 79 problem behavior, 23
follow-up questions, 86-87 relapse prevention, 233
initial contact, 61 safety issues, 117
initial family interview, 68-69 unwarranted exposure, 262
initial meeting with child, 70-73, 75b, 76 Trust, impact of work, 48
initial parent interview, 69-70 Trust versus mistrust, developmental theory, 15
introduction of, 66 Tuismen, Martin, evaluation, 319-320
parental involvement, 68 Two second rule, initial meeting, 71
premature termination, 238-240
recommendations, 99
the rules, 67 “Vicarious traumatization,” 48
termination, 240 Visualization
trauma history exercise, 83, 84b containment, 175
trauma history script, 85b self-calming skills, 158
trauma history steps, 79-82 Visuals, behavior contracts, 293
Trauma-informed treatment plan Vulnerability
adult’s role, 255 post-trauma resolution, 225-226
parental dialogue, 111-112 of therapist, 48
purpose, 107 trauma factors, 13-15
sample teen dialogue, 109-111
treatment contracting, 112
trauma treatment phases, 245b War veterans, PTSD treatment, 159
Trauma/loss history “War zone,” 179
blank form, 84b Warnings
fairy tale model, 35b, 244b initial meeting, 71
initial parent interview, 69, 70 trauma history step, 79
meaning of behavior, 23, 24, 25 Who helped you and how? exercise, 44-45
practice steps, 79-82 Words
Traumatic Incident Reduction (TIR), 188, 189 cognitive interventions, 307
Treatment contracting safe environment exercise, 263, 266
evaluation, 61, 62 Work environment, 54-55
fairy tale model, 33, 35b, 244b Worksheets, training program, 5
obstacles, 113-116 Workshop leader, 20
and trauma treatment, 245b World Trade Center
treatment plan, 112 impact of, 11
Treatment obstacles Jody’s case formulation, 96
description, 113 traumatic exposure, 10-11
family risks, 113-114 “Worst Things,” 82, 83b
inconsistency, 115
premature termination, 116
risks scripts, 114, 115 Yelling, role failure, 260
Treatment recommendations, contents, 99 “Yes, but” problem, 135, 137
 SCHEELE MEMORIAL LIBRARY

3 6655 00124292 3

RJ 506 .P66 G74 2005

Greenwald, Ricky.
Child trauma handbook

DATE DUE

Concordia College Library

Bronxville, NY 10708
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Abuse, Violence, Maltreatment, and Neglect; Psychotherapy, Mental Health, Psychology, and Psychiatry; Social Work and Human Services; Children and Youth

FINALLY—AN ACCESSIBLE GUIDE THAT TEACHES THE STEP-BY-STEP PROCESSES OF TREATMENT

The is a comprehensive plain-language guide to treatment of trauma-exposed children and

adolescents and those with trauma or loss-related issues. This no-nonsense manual helps the reader understand how and why
kids' behaviors can be related to their history of trauma while teaching practical hands-on clinical skills and interventions.

—Atle Dyregrov, PhD,

Founder, Center for Crisis Psychology, Bergen, Norway

— Charles Figley, PhD,

Director, Florida State University Traumatology Institute

— James Garbarino, PhD,

E. L. Vincent Professor of Human Development, Cornell University

—William Yule, PhD, FBPsS,

Professor of Applied Child Psychology, Institute of Psychiatry, King’s College, London:
Consultant Clinical Psychologist, South London and Maudsley NHS Trust

ISBN-13: 978-0-7890-2793-1
ISBN 0-?890-27593-3
90000
Routledge
Taylor
& Francis Group
www.routledge.com

9"780789"027931
an informa business