Healing Perspectives in Therapy with Traumatized Children - - PowerPoint PPT Presentation

Healing Perspectives in Therapy with Traumatized Children

Presented by: Mary Baldwin, MA & Ivette Salinas, MA Psychology Doctoral Students Our Lady of the Lake University Center For Miracles at the Children’s Hospital of San Antonio

Overview

• Introductions
• Overview of Center for Miracles
• Trauma- Informed Services
• Abuse and the Brain in Elementary Aged Children
• Utilizing a Strength-Based Perspective in Working with Abused Children
• Solution Focused Brief Therapy
• Cultural Considerations
• Trauma-Focused Cognitive Behavioral Therapy
• Dialectical Behavioral Therapy
• Case Conceptualizations
• Questions & Closing Remarks

Center for Miracles at the Children’s Hospital of San Antonio

CHRISTUS Health provides complete medical and psychosocial assessments for children who are referred by Child Protective Services, law enforcement or medical professionals and who are suspected victims of abuse or neglect. Considered pediatric subspecialists, Center for Miracles pediatricians are part of a small, elite group of child abuse specialists in Texas. The team also consists of social workers, a nurse practitioner and psychology/social work interns. Center for Miracles at The Children's Hospital of San Antonio 315 N. San Saba Suite 201 San Antonio, Texas 78207 Clinic Manager: Tim Recinek PH: 210-704-3800

Trauma Informed Services with Children

Quick group activity..

Take 5 minutes to discuss in groups of 2-3

• What was your reaction to this video?
• Did you learn anything that surprised you?
• What does trauma informed work mean to you?
• What types of trauma have you worked with before?

What is trauma and what to expect?

What Is a Traumatic Event?

A traumatic event is a frightening, dangerous, or violent event that poses a threat to a child’s life or bodily integrity. Witnessing a traumatic event that threatens life or physical security of a loved one can also be traumatic. This is particularly important for young children as their sense of safety depends on the perceived safety of their attachment figures.

• Physical, sexual, or psychological abuse and neglect (including trafficking)
• Natural and technological disasters or terrorism
• Family or community violence
• Sudden or violent loss of a loved one
• Substance use disorder (personal or familial)
• Refugee and war experiences (including torture)
• Serious accidents or life-threatening illness
• Military family-related stressors (e.g., deployment, parental loss or injury)

(The National Child Traumatic Stress Network)

Common reactions in young children:

Reactions will depend upon the severity of the trauma, their personality, previous coping skills and support: Children could regress both emotionally, behaviorally and academically May become more clinging, defiant, unhappy and needy of parental attention and comfort The children may first experience some sort of denial that the situation really happened. Increased fears, worries or nightmares Sleep disturbances or eating difficulties may happen Feelings of irritability, anger, sadness or guilt may often emerge. Somatic complaints such as headaches, stomachaches or sweating are not unusual Children and adolescents may repeatedly relive the trauma by acting it out in play or dream Other students may seek to avoid all reminders of the trauma by withdrawing from others, refusing to discuss their feelings, or avoiding activities that remind them of the people or places associated with the trauma. Some loss of interest in school, misbehavior, and poor concentration are other common reactions. These symptoms may range from mild to severe. More severe symptoms may indicate that your child is experiencing Post Traumatic Stress Disorder or Depression.

(The National Child Traumatic Stress Network)

The Brain

❖ The human brain is an amazing and complex organ. It allows us to think, act, feel, laugh, speak, create and love. The brain mediates all of the qualities of humanity, good and bad. Yet the core "mission" of the brain is to sense, perceive, process, store, and act on information from the external and internal environment to promote survival. In order to do this, the human brain has evolved an efficient and logical organization structure. ❖ The brain has a bottom-up organization. The bottom regions (i.e., brainstem and midbrain) control the most simple functions such as respiration, heart rate and blood pressure regulation while the top areas (i.e., limbic and cortex) control more complex functions such as thinking and regulating emotions. https://www.youtube.com/watch?v=lPftosmseYE

Brain Development

❖ It is during childhood that the brain matures and the whole set of brain-related capabilities develop in a sequential fashion. We crawl before we walk, we babble before we talk. ❖ The process of sequential development of the brain and, of course, the sequential development of function, is guided by experience. The brain develops and modifies itself in response to experience. ❖ The simple and unavoidable result of this sequential neurodevelopment is that the organizing, "sensitive" brain of an infant or young child is more malleable to experience than a mature brain. While experience may alter and change the functioning of an adult, experience literally provides the organizing framework for an infant and child. ❖ The brain is most plastic (receptive to environmental input) in early childhood. The consequence of sequential development is that as different regions are organizing, they require specific kinds of experience targeting the region's specific function (e.g., visual input while the visual system is organizing) in order to develop normally. These times during development are called critical or sensitive periods.

Traumatic Experiences & Development

❖ With optimal experiences, the brain develops healthy, flexible and diverse capabilities. When there is disruption of the timing, intensity, quality or quantity of normal developmental experiences, however, there may be devastating impact on neurodevelopment — and, thereby, function. For millions of abused and neglected children, the nature of their experiences adversely influences the development of their brains. During the traumatic experience, these children's brains are in a state of fear-related activation. This activation of key neural systems in the brain leads to adaptive changes in emotional, behavioral and cognitive functioning to promote survival. Yet, persisting or chronic activation of this adaptive fear response can result in the maladaptive persistence of a fear

• state. This activation causes hypervigilance, increased muscle tone, a focus on threat-related cues (typically non-verbal), anxiety,

behavioral impulsivity — all of which are adaptive during a threatening event yet become maladaptive when the immediate threat has passed. ❖ This is the dilemma that traumatic abuse brings to the child's developing brain. The very process of using the proper adaptive neural response during a threat will also be the process that underlies the neural pathology, which causes so much distress and pain through the child's life. The chronically traumatized child will develop a host of physical signs (e.g., altered cardiovascular regulation) and symptoms (e.g., attentional, sleep and mood problems) which make their lives difficult. ❖ There is hope, however. The brain is very "plastic" — meaning it is capable of changing in response to experiences, especially repetitive and patterned experiences. Furthermore, the brain is most plastic during early childhood. Aggressive early identification and intervention with abused and neglected children has the capacity to modify and influence development in many positive ways. ❖ The elements of successful intervention must be guided by the core principles of brain development. The brain changes in a use- dependent fashion. Therapeutic interventions that restore a sense of safety and control are very important for the acutely traumatized

• child. In cases of chronic abuse and neglect, however, the very act of intervening can contribute to the child's catalogue of fearful
• situation. Investigation, court, removal, placement, re-location, and re-unification all contribute to the unknown, uncontrollable and,
• ften, frightening experiences of the abused child. Our systems, placements and therapeutic activities can diminish the fearful nature
• f these children's lives by providing consistency, repetition (familiarity), nurturance, predictability and control (returned to the child).

Yet the poorly coordinated, over-burdened and reactive systems mandated to help these children rarely can provide those key elements.

“The programs and approaches that are flexible have the greatest potential. We tend to deliver our mental health services in a one-size- fits- all approach” (Bruce Perry, 2013)

Regaining Safety and Hope after Trauma...

A Strength-Based Perspective in working with abused children

“You are Brave, You are Safe, You are a Hero”

• (Baldwin & Caballero, 2017)

Strength-Based Therapy

• Focuses on what is working for the child and the family rather than on

what is not working.

• Seeks to explore what children and families have rather than what they

don’t have.

• Emphasizes strengths in their struggle.
• The strengths-based clinician may very well make a clinical diagnosis of a

mental disorder (ADHD, PTSD, comorbid disorder, etc.), but he or she takes steps to ensure that the diagnosis does not become the cornerstone of all subsequent interactions with the client. (Shazer et. al., 2012)

Validating the child as an active participant in therapy…...

• Getting to know the child and the family before the problem
• What would I come to admire about little Johnny if I got to know him?
• If grandma was here, what would she say she admires about Johnny?
• Can you tell me a story about a time when little Johnny did X?
• What would his teachers say they admire/like about him?
• Asking the child about interests in games, sports and characters?
• utilizing this information later in therapy through metaphors
• What did mom tell you about coming to see me today?
• What would I come to admire about mom/dad? Tell me a story

Solution Focused Brief Therapy (SFBT)

The solution-focused model holds that focusing only on problems may not be an effective way of solving them. Instead, SFBT targets the client’s default solution patterns, evaluates them for efficacy, and modifies or replaces them with problem-solving approaches that work The SFBT model is based on the following assumptions:

• Language is a powerful force in creating reality
• Change is constant AND certain
• Emphasis should be on what is changeable and possible
• Clients must want to change
• Clients are the experts in therapy and capable of developing their goals
• Clients are believed to have the resources and strengths to solve their problems
• Therapy can short-term
• The focus on taking steps towards a prefered future

(Shazer et. al., 2012)

SFBT Interventions

Pre-session Change - What has gotten better? Exceptions to the problem - Tell me more about a time when the “problem” wasn’t there? when is it better? Previous Solutions- What have you tried before? Scaling questions- On a scale from 0-10, how hopeful are you that you will be able to overcome x? Where are you at on your goal? Goals- What were you hoping to talk about today? What would be different

• nce you don’t have to come to see me any more?

Experiments/Tasks- Try to notice the number of times when you were able to play with your friends at school, try to notice the times little Johnny comes out

• f his room and plays with his siblings?

(Shazer et. al., 2012)

Cultural Considerations and Cultural Humility

• A lifelong commitment to self-evaluation

and self-critique

• Questioning Assumptions
• A desire to fix power imbalances where

none ought to exist

• The child and the family are also

experts

• Develop partnerships with people and

groups who advocate for others (Tervalon & Murray-Garcia, 1998)

• A process rather than an end

product

• Competency involves more than

gaining factual knowledge

• Includes our ongoing attitudes

toward both our clients and

• urselves

(Waters and Asbill, 2013)

Questions to Ask in Exploring the Cultural Perspective of the Family?

• How do you call what happened?
• What would other family members call it? What would grandma, uncle or

aunt say?

• How do they understand what happened?
• What would other members in your community call it?
• Church, school, doctors, other groups
• What have they recommended?
• What have you tried?
• How has it been helpful?
• How can you be more helpful to them?

Empowering the system the child is in…

“ We need to find people who will be in this child’s life in an enduring way and build their capacity, and help them to understand the child. Because that’s really where the long-term healing comes, in the relationships that are more permanent.” ( Bruce Perry, 2013)

Trauma Focused- Cognitive Behavioral Therapy

• Psycho-education
• Stress- Management
• Affect expression and modulation
• Cognitive coping
• Creative the Trauma Narrative
• Cognitive Processing
• Behavior Management Training
• Parent-Child Sessions

Dialectical Behavioral Therapy (DBT)

❖ DBT has proven to be effective with people who have difficulty regulating their mood and experience very intense emotions. ❖ DBT includes a skills training component to help individuals cope with their extreme range of emotions while maintaining healthy social interactions. ❖ DBT is helpful in teaching skills to manage the painful emotions that may be associated with

• trauma. In DBT, clients gain a better understanding of their emotions and learn to tolerate the

unwanted feelings in a more effective way.

The 4 Modules of DBT

Mindfulness-Focusing on the present (“Living in the MOMENT”). Mindfulness can be described as simply living your life in the present instead of being stuck in the past

• r the future. Practicing mindfulness helps us become more aware of our thought patterns, our

emotions, and how our thoughts and feelings affect our reactions to events. Observe, Describe, and Participate are the core mindfulness “what” skills. They answer the question, “What do I do to practice core mindfulness skills? Non-judgmentally, One-mindfully, and Effectively are the “how” skills and answer the question, “How do I practice core mindfulness skills?” https://www.youtube.com/watch?v=PCJ0R6vAUnw Interpersonal Effectiveness-How to be assertive in a relationship (expressing needs, wants, and saying “no”) but still keeping the relationship healthy and positive. “Let us never negotiate out of fear. But, let us never fear to negotiate.”-John F. Kennedy

DBT

Distress Tolerance-Learning to accept oneself and the current situation. The skills taught focus on dealing with the pain and suffering that is inevitable to the human condition. More specifically, people learn how to tolerate or survive crisis using these four techniques: distraction, self-soothing, improving the moment, and thinking of pros and cons. A lot of distress is not in the present- it is in the past or is anticipated for the future.-Kate Comtois, Ph.D Emotion Regulation-recognizing and coping with negative emotions and reducing one’s emotional vulnerability by increasing positive emotional experiences. Understanding and labeling emotions Reduce emotional vulnerability Decrease emotional suffering

Case Conceptualization

Julie is a 7 year old girl who lives with her parents and two little brothers (4) and (6). Julie is described by her mother as a caring ,smart girl who likes art and

• sports. Her mother and Julie have came in for services after Julie disclosed to a

school counselor that she was sexually abused by her paternal grandfather. Julie was seeing her school counselor after her teacher reported concerns with concentration, anxiety and withdrawal from others. Her mother brought her to see you after Julie refuses to talk to anyone in the family about what

• happened. During the interview you also find out her parents have been

fighting over what has happened and are blaming each other. Julie’s disclosure has caused a rift with her father’s side of the family. Julie misses her grandparents, aunts, uncles and cousins but is not allowed to see them. How would you work with this family?

References

Ackerman, C. (2018, May 10). Dialectical Behavior Therapy: Your #1 DBT Resource (12 Skills PDF). Retrieved May 17, 2018, from https://positivepsychologyprogram.com/dbt-dialectical-behavior-therapy/ Bray, S. (2014, February 20). Emotion Regulation in Dialectical Behavior Therapy. Retrieved May 17, 2018, from https://www.goodtherapy.org/blog/emotion-regulation-dialectical-behavior-therapy-dbt-0318135 Bray, S. (2013, November 12). Interpersonal Effectiveness in Dialectical Behavior Therapy. Retrieved May 17, 2018, from https://www.goodtherapy.org/blog/interpersonal-effectiveness-dialectical-behavior-therapy-dbt-0416134 Chang, L. (2012, July 06). How to Apply Interpersonal Effectiveness Skills. Retrieved May 17, 2018, from https://www.mindfulnessmuse.com/dialectical-behavior-therapy/how-to-apply-interpersonal-effectiveness-skills Comtois, K. (2010, May 13). DBT Distress Tolerance Skills: Helping the Clients Through the Tough Times (and Yourself). Retrieved May 17, 2018, from http://uwaims.org/webinars/slides/AIMS_MHIP_Distress_Tolerance_Skills.Slides_051310.pdf. Evans, A., & Coccoma, P. (2014). Trauma-Informed Care : How Neuroscience Influences Practice. Hove, East Sussex: Routledge. Grohol, J. M. (2018, April 04). An Overview of Dialectical Behavior Therapy | Psych Central - Part 2. Retrieved May 17, 2018, from https://psychcentral.com/lib/an-overview-of-dialectical-behavior-therapy/2/ Perry, B. D., & Marcellus, J. (n.d.). The Impact of Abuse and Neglect on the Developing Brain. Retrieved May 17, 2018, from http://teacher.scholastic.com/professional/bruceperry/abuse_neglect.htm

References

• Shaer. S., & Dolan, Yvonne. (2012). More than Miracles The State of the ARt of Solution - Focused Brief Therapy. Taylor &

Francis: New York, NY. Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9, 117- 125.