Treating Multiply Traumatized Girls In Community Settings

Life Skills/Life Story: Joining Skills Training in Affective Regulation with Narrative Storytelling

Marylene Cloitre, Ph.D. Lana Farina, Psy.D. Lori Davis, Psy.D. Debra Carr, Psy.D. Janelle Brown, Ph.D.

2005
Please do not quote without permission from authors.

7/05
Table of Contents Introduction Guidelines to Therapist Phase I Life Skills Session 1: Introduction to Treatment Provide Psychoeducation about PTSD and Common Reactions to Trauma and/or Stress Provide Rationale and Overview of the Treatment Help the Adolescent to Compile a List of Personal Goals for Treatment Discuss Plans to Meet with the Caregiver Next Session Worksheet: My Goals Session 2: Identification and Labeling of Feelings Discuss the Adolescents Reaction to the First Session Create a Safety Plan and Safety Card with the Adolescent Provide Psychoeducation about the Impact of Trauma and Stress on Coping with Feelings Introduce and Practice Labeling Feeling States Introduce and Practice the Self-Monitoring of Feelings worksheet Introduce and Practice Deep Breathing Assign Between-Session Work Review Safety Plan Meet with the Caregiver: Review Safety Plan and Discuss Caregiver Involvement Worksheet: Feelings List A Feelings List B Name the Feeling Self-Monitoring of Feelings *Optional Session to Prepare for Coping Skills Addressed in Session 3: Self Care and Relaxation Note to Therapist: Rationale for Optional Session Review Between-Session Work Introduce Self-Care and Relaxation Assign Between-Session Work Review Safety Plan Worksheet: Soothing Your Senses Session 3: Coping with Upsetting Feelings 12 7 10

7/05

Review Between-Session Work Provide Psychoeducation about Coping with Upsetting Feelings Identify and Evaluate Current Coping Skills Provide Psychoeducation about Self-Talk Practice Paying Attention to Self-Talk Coping with Upsetting Self-Talk Introduce and Practice the Use of Cognitive Coping Skills Assign Between-Session Work Review Coping Skills and Safety Plan Worksheet: Self-Talk Positive Self-Statements Session 4: Dealing with Upsetting Situations Review Between-Session Work Review any Problems with Implementation of Coping Skills Provide Psychoeducation about Dealing with Upsetting Situations Introduce Concept of Dealing with Upsetting Situations to Achieve Goals Coping Strategies for Dealing with Upsetting Situations Assign Between-Session Work Review Coping Skills and Safety Plan Worksheet: Dealing with Upsetting Situations Session 5: Coping Strategies for Dealing with Upsetting Situations Review Between-Session Work Review Implementation of Coping Skills Coping Strategies for Dealing with Upsetting Situations Assign Between-Session Work Review Coping Skills and Safety Plan Worksheet: Feel Good Activities Session 6: Using Positive Imagery to Deal with Upsetting Feelings Review Between-Session Work Provide Rationale for the Use of Positive Imagery Make Positive Image Collages Assign Between-Session Work Review Coping Skills and Safety Plan

Session 7: Relationships with People: Behavior and Communication Review Between-Session Work Provide Psychoeducation about how Behavior and Communication affect Relationships

7/05
Introduce Skills for Clear Communication Assign Between-Session Work Review Coping Skills and Safety Plan Worksheet: Clear Communication *Optional Session to Expand on Relationship Work Addressed in Session 7: Relationship between Feelings and People: Schemas Note to Therapist: Rationale for Optional Session Review Between-Session Work Provide Psychoeducation about Schemas Provide Psychoeducation about Feelings and Relationship Schemas Introduce the Challenging Schemas Worksheet Assign Between-Session Work Review Coping Skills and Safety Plan Worksheet: Challenging Schemas Session 8: Introduction to Role-playing: Feelings vs. Behavior Review Between-Session Work Describe Role-playing Practice a Simple Role-play Identify Difficult Situations and Conduct Role-plays Assign Between-Session Work Review Coping Skills and Safety Plan Worksheet: Dealing with Others Challenging Schemas Session 9: Role-playing with Focus on Assertiveness Review Between-Session Work Define Assertiveness Identify Current Difficulties in Assertiveness Provide Psychoeducation about Effective Assertiveness Conduct Role-play of Situations Requiring Assertiveness Assign Between-Session Work Review Coping Skills and Safety Plan Worksheet: Basic Personal Rights Dealing with Others Challenging Schemas Session 10: Review of Skills Learned and Transition to Narrative Story Telling (NST) Review Between-Session Work

7/05
Acknowledge Last Skills Session and Review Progress Provide a Brief Rationale of Narrative Storytelling (NST) Elicit Questions and Concerns about Transition to NST Assign Between-Session Work Review Coping Skills and Safety Plan Assess and Review PTSD Symptoms Worksheet: Dealing with Others Challenging Schemas Phase II Life Story - Narrative Storytelling (NST) Session 11: Introduction to NST Note to Therapist: Using the SUDS Rating Scale Review Between-Session Work Review Safety Plan with Adolescent Rationale for NST Elucidation of memories Review Difficulties Concerning Coping Skills and Relationships Assign Between-Session Work: Mastery and Competency Worksheet: SUDS Rating Scale Memory Elucidation Form Mastery and Competency Activity *Note to Therapist: Orientation of Therapist to NST Session 12: NST of First Memory Review Between-Session Work Review Rationale for NST Practice Storytelling of Neutral Memory Conduct First Storytelling Terminate Storytelling Debriefing Assign Between-Session Work: Mastery and Competency Review Coping Skills and Safety Plan Worksheet: SUDS Rating Scale Therapist NST Recording Form Therapist Form for Post NST Emotional State

Sessions 13 15: Continued Work on NST Note to Therapist: Planning Referrals Review Between-Session Work

7/05
Continuing NST NST with Multiple Traumas Moving to Another Memory Selecting the Next Memory Assign Between-Session Work: Mastery and Competency Review Coping Skills and Safety Plan Worksheet: SUDS Rating Scale Therapist NST Recording Form Therapist Form for Post NST Emotional State

Sessions 16: Reviewing Progress and Saying Good-Bye Review Between-Session Work Review Skills Learned in Treatment and Progress of Competency Activity Identify Remaining Goals Say Good-Bye and Provide Referrals Present Certificate of Completion Worksheet: Certificate of Completion Appendix A: Safety Guidelines for Emergent Patients

7/05
Introduction About This Treatment (Life Skills/Life Story) This unique treatment was specifically developed and tested on youth, ages 1221, with histories of multiple traumas. These youth reported experiencing childhood physical and sexual abuse, and other traumas such as community and domestic violence. Multiple traumatization is the rule rather than the exception among urban youth. Many inner-city adolescents with histories of childhood sexual abuse report that they experienced additional traumas. Some also had a serious accident or accident-related injury. Others saw or knew someone who was attacked or died unexpectedly, or witnessed community violence. Although boys and girls report experiencing a similar number of traumatic events, girls are more likely to develop PTSD than boys. Seventy percent of multiply traumatized girls identify childhood physical and/or sexual abuse as their most distressing traumatic experience. Many studies show how common these childhood abuse experiences are. A study mandated by congress in 1998 reported investigating over 2.8 million cases of child maltreatment (physical abuse, sexual abuse, neglect). Of these, they substantiated or found some evidence of maltreatment in approximately 903,000 cases. Roughly 1 out of every 3 to 5 women report having experienced childhood abuse. Experiencing multiple traumas leads not only to more severe PTSD symptoms, but also disrupts development in childhood and adolescence. Multiple traumas disrupt skills in managing emotions and having interpersonal relationships. These problems weaken an adolescents functioning and ultimately, her sense of competence and selfesteem. In addition, these weakened skills lead to limited resources, which an adolescent needs to participate in effective exposure based treatments. Most traumatized adolescents come to treatment because they are not functioning well, not for symptoms of trauma. This treatment aims to enhance an adolescents functioning by increasing emotion management and relationship skills. The treatment approach addresses the consequences of urban trauma, as well as everyday life stressors that keep the adolescent from developing these skills. This treatment provides an opportunity for the adolescent to focus on developing these important skills, which helps them to feel stable and safe in the therapy setting, and develop of a positive relationship with their therapist. This manual addresses cognitive, behavioral, interpersonal, emotional and developmental factors. It allows the therapist to tailor the interventions to adolescents functioning at different levels of development. The interventions range from teaching concrete skills that target problems with emotion management and relationship skills to more complex cognitive interventions. The manual provides optional sessions and

7/05
different selections of activities and handouts so that the therapist can deliver effective interventions to every adolescent. Maintaining sensitivity towards an adolescents level of cognitive functioning is essential for successful treatment. Childhood trauma has been associated with delays in language and cognitive development, low IQ, and poor school performance. These factors may promote social isolation and alienation. Youths with a combined history of trauma and learning disabilities are at greater risk for developing PTSD, depression, low self-esteem, anger and aggressiveness, dissociative symptoms, self-harm, and alcohol abuse than youths without this combined history. Youths with developmental disabilities have a greater risk for developing emotional and psychotic disorders compared to youths without disabilities. Low cognitive ability and developmental delays have been associated with coping difficulties, vulnerability to abuse, and vulnerability to emotional distress. A lack of consistent, effective coping strategies can foster dependency on others and weaken communication, problem-solving, and relationship skills. Youths are likely to have strong negative feelings about having a disability and experience low self-esteem. This specialized treatment targets weak skills that multiply traumatized adolescents often have and provides interventions for different levels of cognitive development. Overview of the Treatment This cognitive behavioral treatment focuses on skills training such as learning to identify and label feeling states, and to identify and change self-beliefs. The treatment also teaches adolescents to develop mastery and self-efficacy and to make healthy goals for the future. It teaches adolescents to identify and tolerate upsetting feelings and to change patterns in relationships that cause problems. The goal is to reduce anxiety and depression and to improve emotion management and interpersonal relationships. Life Skills Adolescents learn about the consequences of trauma and life stress on emotions and relationships. By learning to monitor their emotions, thoughts, and behaviors, adolescents can begin to understand their inner experiences. They learn and practice coping skills to manage emotions (e.g., deep breathing, weighing the pros and cons of tolerating a difficult situation, positive activities). After learning these skills, adolescents role-play challenging situations with others in session. They practice different ways to communicate with parents, peers, and co-workers in order to get their needs met. As adolescents see that they can affect change in their lives, they feel better about themselves. Adolescents who learn to manage their emotions and communicate more effectively will reduce their own risk for revictimization and cope with stressful situations better.

7/05

Life Story (Narrative Storytelling or NST) During this second phase of treatment, adolescents talk about their traumas in detail. This helps them to process these events and integrate them with other life experiences. By processing traumatic experiences, the adolescent gains access to thoughts and feelings associated with her traumas that she may have previously avoided. The therapist provides a safe and supportive environment to facilitate the adolescents storytelling and helps her practice coping skills to manage upsetting feelings. The adolescent uses control in the treatment by choosing memories to discuss and setting a comfortable pace. With repeated storytelling, the adolescent learns that she can discuss her traumatic experiences without feeling overwhelmed by emotional and physical symptoms. One of the goals is for the adolescent to become more aware of triggers related to her traumatic experiences. In addition, this treatment promotes the adolescents use of coping skills to face painful emotions rather than avoid them.

7/05
Guidelines to Therapist Use of this Manual This manual is structured, yet allows flexibility for individual differences in symptoms and skills. For example, some adolescents may have difficulty identifying basic emotions. Others may easily identify and change upsetting self-talk. Thus, the therapist must be flexible in applying the interventions and selecting activities to meet each adolescent at her current level. For example, an adolescent with a large and complex vocabulary of feelings may feel condescended if asked to complete the Name the Feeling handout. Another adolescent may struggle with this concept and need to practice this skill a lot before she moves on to the next skill. It is important that the therapist consider each adolescents knowledge of and prior experience with the material, and cognitive ability in pacing the skills. As in all cognitive-behavioral treatments, weekly homework, or between-session work, is essential to treatment success. The therapist should monitor this work closely. Finally, the therapist should establish and monitor a safety plan with the adolescent before starting this treatment. General Attitudes and Behavior As in any treatment, the value of establishing rapport cannot be overstated. The key to doing good clinical work is developing a therapeutic alliance with the adolescent. The clinician must respect a multiply traumatized adolescents hesitancy to delve into details of traumatic events at the start of treatment. The therapist should not assume that an adolescent would automatically trust her/him and easily disclose personal and upsetting details of her life. Rather, the therapist must understand that rapport with an adolescent is something that develops in an open and accepting environment. The therapist can help facilitate an adolescents level of comfort by having an open dialogue about treatment and the therapists role in treatment. State to the adolescent explicitly that she will be in control of exploring and expressing her emotions and that you will follow her lead, based on the adolescents comfort. This approach empowers the adolescent by giving her a sense of control that she may not have had in other situations. It is also important for the therapist to convey that she/he will respect what the adolescent has to say and how she needs to deal with her experiences. One adolescent indicated that she had many unanswered questions about her abuse that she felt she could never ask. Her therapist invited her to compose a list of questions that they would review in sessions. The adolescents questions included, Why did he

10

7/05
do this to me?, Why does God hate me so much?, How did I end up this way?, Do I have a future now?, and Out of all people, why me? This intervention was important because the therapist incorporated material that was important to the adolescent in working through her experiences. The therapist conveyed to the adolescent that her questions were important and that her input was valuable. This manual includes rationales and clinical illustrations to assist clinicians with potential pitfalls and resistance to treatment. Many adolescents may appear resistant to treatment; however, many factors can contribute to this. An important role of the therapist is to use her/his clinical skills to assess the individual differences that shape an adolescents attitude towards treatment. These factors may include culture, experiences with the family system and peer network, prior experiences with mental health providers, and involvement in the child welfare system. If the adolescent experienced a lack of support when she talked about her traumas in the past, she may expect the therapist to react in a similar way. In this situation, the therapist must strive to create a consistent environment in which the adolescent feels safe and supported. The therapist must be aware of delays in skill abilities that may resemble resistance. For example, an adolescent who consistently does not complete homework assignments may indeed not be able to due to reading and writing deficits. Therapists who are unaware of these issues may feel frustrated and misinterpret such deficits as opposition. Incorrectly labeling this behavior or confronting an adolescent about being oppositional may lead her to feel inadequate. Other adolescents frequently state, I dont know when asked questions about feelings or experiences in sessions. This may represent an avoidance of upsetting feelings, which is characteristic of traumatized individuals. It is important for the therapist to note this pattern and consider the personal relevance these responses may have. If an adolescent is clearly uncomfortable with something happening within a session, the therapist should give the adolescent permission not to answer distressing questions or to move on to other material. Lastly, the therapist should be aware that she/he also serves as a role model for the adolescent. If an adolescent has difficulty with a particular intervention, the therapist should model the skill in session. In addition, the therapist may model the role of a more optimal caregiver who is more responsive and empathic than she may have experienced in the past. This can be a very important emotional experience for the adolescent.

11

7/05
Session 1: Introduction to Treatment Agenda 1. Provide Psychoeducation about PTSD and Common Reactions to Trauma and/or Stress 2. Provide Rationale and Overview of the Treatment 3. Help the Adolescent to Compile a List of Personal Goals for Treatment 4. Create a Safety Plan and Safety Card with the Adolescent 5. Discuss Plans to Meet with the Caregiver Next Session 1. Provide Psychoeducation about PTSD and Common Reactions to Trauma and/or Stress Provide the adolescent with an overview of the symptoms of PTSD, and explain how her symptoms fit into the diagnosis. If the adolescent does not have PTSD, review the symptoms that relate to trauma and/or stress. Adolescents often have short attention spans; thus, it is useful to keep this discussion simple, avoiding jargon and lengthy explanations. For adolescents with a diagnosis or symptoms of PTSD, explain that PTSD is a disorder that can develop after a person goes through a trauma. Examples of traumas include childhood abuse, seeing someone hurt or shot, or being in a bad accident. People develop a set of common reactions to a trauma, and the adolescents symptoms are a normal response to her personal traumas. Explain that PTSD often develops soon after a trauma; however, it can begin at any time after the event. In addition, it can be worse when people experience multiple traumas. Keep in mind that many inner-city adolescents have experienced multiple traumas. The therapist should provide psychoeducation while viewing the adolescents symptoms in a larger context. For example, one adolescent girl may have witnessed gang fighting in her neighborhood streets, domestic violence in her home, and a close family member put in jail. Another girl may have witnessed the sudden or violent death of a loved one. These girls may have a sense of foreshortened future and a pessimistic or cynical view of the world when they are continually exposed to violence and negative events throughout their short lives. The therapist should avoid delving too deeply into the details related to the adolescents childhood abuse at this phase of treatment. Rather, the therapist should emphasize building rapport with the adolescent so that she can begin to

12

7/05
feel safe. At this time, as well as throughout the treatment, it is helpful to involve caregivers or legal guardians (or caseworkers) in the process. This allows them to receive psychoeducation about PTSD and the long-term consequences of trauma and abuse. In addition, it allows them to know what the girls will be learning in the treatment so they can provide additional support. The therapist should schedule a session time with the parent or legal guardian to explain the treatment. Explain that there are 3 groups of symptoms of PTSD (i.e., re-experiencing, avoidance and numbing, and hyperarousal). A person must have symptoms from each group in order to receive the diagnosis. Again, remember to keep the language simple. If the adolescent does not have PTSD, it is useful to explain that there are 3 groups of symptoms that people may have after going through traumatic and/or stressful events. Discuss the symptoms that are relevant to the adolescent. The goal is not only to provide the adolescent with an education about PTSD and reactions to trauma and/or stress, but also to normalize her experience by pointing out that the following symptoms are common reactions to traumas. 1. Re-experiencing: People re-experience traumatic events by remembering or thinking about them when they do not want to. Some people have nightmares and see images (or flashbacks) of the events. These reminders, or triggers, may lead to upsetting feelings or physical reactions (i.e. shaking, sweating, faster heart rate). Specify which of these symptoms the adolescent experiences. The therapist might say, You mentioned that youve had some scary dreams lately, and that you felt sick when you thought about the abuse. These are examples of re-experiencing. 2. Avoidance and numbing: People often try to avoid or ignore things that remind them of a traumatic or stressful event. Common avoidance symptoms include ignoring thoughts or feelings about traumatic or stressful events, avoiding activities, places, or people related with the event, and having difficulty remembering parts of the event. Many people report avoiding family events or returning to old neighborhoods where they might remember a trauma. People also often experience emotional numbing, or difficulty having strong feelings, whether positive or negative. Some people describe feeling like a robot. Numbing symptoms might also include loss of interest in activities, and feeling distant or detached from people. The adolescent may also insist, I dont care!, as an attempt to ignore or numb her upset feelings. The therapist might say, Many times when something upsetting happens, people dont want to talk or think about it because they might feel upset again. Have you had this experience?

13

7/05
3. Hyperarousal: People often experience increased arousal through sleep problems, increased irritability and anger, and difficulty concentrating. They may also experience hypervigilance (being more concerned about what is happening around you than you need to be), and/or an exaggerated startle response (i.e., jumping when you hear a sound). Again, specify which of these symptoms the adolescent is experiencing and how they fit into this category. The therapist might say, You said that sometimes at school, you have thoughts about the abuse that get in the way of focusing on what the teacher is saying, or, Many people with a history of trauma feel on guard a lot of the time. Does this sound like something that happens to you? 2. Provide Rationale and Overview of the Treatment Rationale: Start out by defining the treatment as being for adolescent girls with PTSD related to interpersonal violence, such as childhood sexual or physical abuse. Acknowledge that the adolescent may not have a history of trauma, but may have been in situations that were stressful. Point out that the adolescents current symptoms, such as nightmares, flashbacks and anxiety indicate that there is "unfinished business" related to past trauma and/or stressful events. Note that some people try to cope with this by avoiding or trying to ignore upsetting memories, which is understandable, but ultimately does not work. Others cannot avoid at all and feel overwhelmed by their memories. Some people have both of these experiences at different times. The treatment helps the adolescent develop skills to cope with difficult experiences related to traumatic or stressful events. It also helps the adolescent to face the memories of these events so that she can have more control over them, rather than feeling controlled by them. One of the goals of the treatment is to help the adolescent to integrate her experiences. Some adolescents find the following analogy helpful: we can view the mind as a file cabinet in which we organize and store experiences, helping us to make sense of them and put them in their right place. For example, children might have a file for "birthday parties," where they store memories of particular parties. They build up knowledge about what one brings to a party, what to expect at a party, etc. However, where does a child file and organize the experience of abuse? Typically, they do not label and discuss their abuse experience. Thus, the feelings and memories continue to interfere with life in the present, frequently in the form of PTSD. Part of the goal of talking about the adolescents abuse is to be able to organize her distressing feelings and memories and find a place for them, rather than avoid them. Overview. Explain that this is a two-phase treatment and consists of 16 hour-long, weekly sessions. The first phase will focus on learning skills to cope with upsetting or difficult feelings. In the second phase, the adolescent will talk about her

14

7/05
traumatic experiences through narrative storytelling, as well as continued work with coping skills. PHASE I: SKILLS TRAINING Explain that the goals of this phase are to help the adolescent be more aware of her emotions. She will learn to identify and name her feelings, and to practice skills to reduce upsetting feelings and tolerate distress. Many adolescents with trauma histories have difficulty knowing what they are feeling and/or managing their feelings. Some adolescents feel overwhelmed by their feelings, while others may have learned to cope by not feeling anything at all. Engage the adolescent in a discussion about her experience with this. It may help to give examples such as, "Some girls are never able to feel anger, while others don't feel able to manage their anger at all so that they 'blow up'." Explain that these symptoms often come and go, and that people can have both of these experiences at different times. Explain that one goal of treatment will be to learn how the adolescent can have feelings without becoming overwhelmed. This will first involve the adolescent being more aware of her feelings and triggers for them. Explain that it may be hard for traumatized adolescents to experience and label their feelings because others may have mislabeled or ignored them during childhood. Give examples and ask for relevant examples from the adolescent. Get an initial sense of how others responded to the adolescent's feelings as a child. If she does not readily engage in this discussion, the therapist may invite her to do so with comments or questions such as "Does this strike a chord for you?" Another goal of this treatment is to help the adolescent learn how to get along better with others. The treatment will help her use relationship goals rather than feelings to guide her interactions with others. Explain to the adolescent that she will learn to use the coping skills she learns in treatment in her relationships. Specifically, she will learn how to manage certain feelings that can get in the way of meeting her relationship goals. Ask the adolescent about difficulties she experiences in relationships, prompting with questions and examples as necessary. Try to understand the adolescents style of interacting with others and potential problem areas. Example: Some girls who were abused as children have difficulty being assertive or let others take advantage of them. Is this familiar to you? Example: Some girls who were abused as children have difficulty getting along with their classmates and tend to get into fights at school. Does this happen to you? Example: Are there certain feelings you have difficulty expressing to family and friends? What makes it difficult?

15

7/05
Finally, explain to the adolescent that she will be learning a number of skills so that she can select those that work best for her. PHASE II: NARRATIVE STORYTELLING (NST) Explain that during this phase, the adolescent will talk about her traumatic experiences in session so that she can access the feelings that go with those events. The goal is for her to process the traumas so that she can think about or remember them without experiencing intense symptoms. It may be helpful to remind the adolescent how this will address either her avoidance of thinking about the traumas, and/or feeling overwhelmed or flooded by them. The therapist can explain NST to the adolescent in the following way: "This part of the treatment will help you connect your feelings and your experiences in a safe and supportive place. Staying with your memories rather than avoiding them can be very upsetting at first, but over time, your anxiety and fear will begin to decrease. For adolescents, the idea of reliving painful memories is particularly difficult since they typically live in the moment. They may have trouble seeing that their present avoidance may have long-term consequences. Some adolescents may feel anxious at the idea of talking about their traumatic experiences. It is helpful to explain that NST will begin with manageable memories that work up to ones that are more difficult. Also, emphasize that the work will be collaborative, that the adolescent will set the pace of the work and stop if she needs to. She will also have some new coping skills from the first phase of the treatment to help her with NST. Assure the adolescent that you and she will talk about this part of the treatment again as it gets closer. Some adolescents will want questions answered about NST. Again, it is best to leave this discussion until you approach Phase 2 of treatment. 3. Help the Adolescent to Compile a List of Personal Goals for Treatment Using the sheet entitled My Goals, help the adolescent to compile a list of personal goals for treatment. Encourage the adolescent to identify areas in her life where she has trouble with feelings or in relationships that she would like to improve. An adolescents goals may include concrete wishes such as I want to keep my room clean and I want to stop being late all the time or may be more complex such as Id like to be less angry or I wish I could learn to trust people. Since one of the goals of this treatment is to help bolster an adolescents sense of self, other goals may include areas of interest in an adolescents life. For example, she might like to improve upon academics, athletics or personal strengths such as writing poetry, singing, or dance.

16

7/05
Challenges Many adolescents with a history of childhood abuse have been through the foster care system, placed in group homes, and/or been through legal battles over custody issues. Thus, it is likely that they have received previous psychological treatment and been through a fair number of psychological evaluations. Some adolescents doubt that this treatment will help them to accomplish their goals. They may say, Ive already talked about this stuff and nothing helps. This wont be any different. It is important that the therapist be sensitive to the adolescents frustration but also convey the unique aspects of this treatment. Explain that the focus will be on helping her learn new skills to manage her feelings and relationships better. 2. Create a Safety Plan and Safety Card with the Adolescent Create a safety plan upon which you both can agree. This is important to address concerns about safety, and reminds the adolescent that the therapist is concerned and attentive. The therapist may introduce this task by reviewing information about specific difficulties the adolescent has experienced with managing feelings. If unclear, ask the adolescent what feelings are difficult for her to manage. Explain that it is important to think about ways she will deal with upsetting feelings before moving forward with the treatment. The therapist may remind her that she will be talking about some difficult topics in sessions that may bring up strong feelings. The purpose of the safety card is to plan what the adolescent can do to make herself feel better and identify supportive people she can contact. Social support can help abused adolescents by buffering against stress and reducing upsetting feelings. It can alleviate feelings of shame and self-blame, which sexually abused adolescents often experience, and bolster self-esteem. Sources of support range from family members and friends to school and community organizations. Support from parents can reduce depression among abused adolescents and show that they can receive positive reactions from others. An adolescents perceived social support from a non-offending parent is especially critical. Adolescents are more likely to receive and feel satisfied with support from friends. The shift in focus from parental support to peer support is stronger in girls than boys. In addition, girls are more likely to feel satisfied with support from same-sex peers after disclosing abuse. Adolescents who lack or avoid social supports are more likely to have difficulty because they have restricted sources of affection, nurturance, and guidance. A three-point plan is often helpful. Help the adolescent to write the plan on a card that she can carry in her wallet, backpack, or pocket. The safety card should include the therapists phone number, as well as the phone number of key staff members at the clinic. It should also include the phone number of the nearest emergency room, and any hotlines that may be relevant (see Appendix at end of this manual). The therapist should review this plan at the end of every session, as well as the beginning of Phase II (NST) of treatment.

17

7/05

Examples of Safety Cards: Safety Card for Potentially Suicidal Adolescents - Therapists name, telephone number for therapist and the main clinic, address - Emergency contact (e.g., relative or friend) - Name, phone number, and address of the nearest ER - Plan:

1. If you are feeling suicidal: notify parent/legal guardian or someone at home, or if at school, talk to your teacher or guidance counselor 2. Call your therapist and be sure to leave a phone number where she/he can reach you 3. Call a relative or friend to connect 4. If you feel that you may hurt yourself, go to the nearest ER or call 911 Safety Card for Dissociative Adolescents - Therapists name, telephone number for therapist and the main clinic, address - Emergency contact (e.g., relative, friend) - Name, phone number, and address of the nearest ER - Plan: 1. If you are feeling suicidal: notify parent/legal guardian or someone at home, or if at school, talk to your teacher or guidance counselor 2. If you are feeling spacey: drink a hot or cold beverage to help ground you 3. If that does not help, call a relative or friend to connect 4. If you are feeling scared, call your therapist and be sure to leave a phone number where he/she can reach you Challenges Some adolescents may say that the safety card is unnecessary because they already know who they can call and the appropriate phone numbers. It is helpful to remind the adolescent that even though this task may seem simple now, it is often difficult for people to remember their plans when they feel very upset. The safety card can help her organize herself and remember what to do in an upsetting situation. 5. Discuss Plans to Meet with the Caregiver Next Session

18

7/05
Let the adolescent know that you will be meeting with her parent or guardian at the end of the next session. In this meeting, you will talk about her goals for treatment, provide psychoeducation about PTSD and the effects of trauma, and discuss other important issues such as safety, confidentiality, and caregiver involvement. Give the adolescent an opportunity to raise any questions or concerns related to these issues. Stress that this is the adolescents treatment and that you will respect her privacy. At the same time, a parent or caregiver can provide extra support and understanding throughout treatment, particularly between sessions. Explain to the adolescent that part of your meeting with her parent or guardian at the end of this session will be to review the safety plan and to give him or her a copy of it.

19

7/05
Session 2: Identification and Labeling of Feelings Agenda 1. Discuss the Adolescent 's Reactions to the First Session 2. Provide Psychoeducation about the Impact of Trauma and Stress on Coping with Feelings 3. Introduce and Practice Naming Feeling States 4. Introduce and Practice the Self-Monitoring of Feelings Worksheet 5. Introduce and Practice Deep Breathing 6. Assign Between-session Work: Self-Monitoring of Feelings Worksheets 2x/week 7. Review Coping Skills and Safety Plan 8. Meet with the Caregiver: Review Safety Plan and Discuss Caregiver Involvement

1. Discuss the Adolescents Reactions to the First Session Ask about the adolescents reaction to treatment. Normalize the adolescents response and clarify any questions or concerns.

2. Provide Psychoeducation about the Impact of Trauma and Stress on Coping with Feelings Discuss with the adolescent how her traumas affect how she experiences and expresses her feelings. Discuss the value of paying attention to feelings, understanding triggers (what sets them off), and beginning to work on skills to cope with feelings. Remind the adolescent that many traumatized people have difficulties with feelings. They may feel overwhelmed by them or, in contrast, feel numb. Engage the adolescent in talking about her particular difficulties.

Challenges Make sure to address and clarify the specific nature of the adolescents difficulties in dealing with upsetting feelings. Not all adolescents have the same difficulties. For example, an adolescent may have no difficulty labeling her feelings, but may feel at a loss as to what to do with them. Some adolescents may need help primarily in being able to reduce the intensity of their feelings, while others may need a lot of work to help them access any feelings at all.

20

7/05

Explain that, ideally, when children grow up in a stable home with a nurturing caregiver, they learn to pay attention to their feelings and cope with them. Traumatic experiences such as sexual and physical abuse can cause people to have overwhelming feelings. This often happens in families where caregivers offer little soothing or guidance in dealing with upsetting feelings. Keeping this in mind, try to elicit from the adolescent ways in which her caregivers responded to her feelings. For example, did they consider her feelings important? Did they ignore or mislabel them? Was she told as a child, You are fine, stop crying", when she was clearly upset? Additionally, how did her caregivers handle their own feelings? For example, did they sweep things under the rug, drink, or express scary, out-of-control anger? Was there anyone around even to consider her feelings? When possible, try to provide links between the adolescents emotional experiences with caregivers and her own current difficulties identifying and dealing with feelings.

Challenges Many abused adolescents have conflictual bonds with their abusers and may feel the need to defend them. The therapist needs to convey this information in a way that respects this, using language that does not imply judgment. For example, Your parents, for whatever reason, were not able to/did not help you to deal with difficult feelings." Provide psychoeducation about how feelings guide behavior and tell us which situations to approach or avoid. For example, a feeling of fear should guide us to leave an unsafe situation, or to take steps to be safe. Many girls report finding themselves in dangerous situations such as being alone with a guy in his apartment after a party. They may not realize they are in a potentially unsafe situation until the male becomes overtly aggressive, either sexually or physically. Feelings are also important because they communicate what we feel and need from others. After a traumatic experience, some adolescents are very anxious. They cannot use their feelings to decide how they should act. While people can adjust to feeling anxious, when it is severe, it can be hard for a person to know what they are feeling. It can cause people to overreact, and sometimes to underreact to situations because they are trying so hard not to overreact. Explain that by working on naming her feelings and triggers (things that cause them), the adolescent will be able to use information from her feelings to plan how she should behave.

3. Introduce and Practice Naming Feeling States

21

7/05
Work with the adolescent to identify and name different feeling states using the Feelings List handout. Some adolescents have never learned to differentiate or name their feelings. They can benefit from this activity by learning to clarify different feeling states. Depending on the age and developmental maturity of the adolescent, use either List A or List B. Use List A for adolescents functioning at an earlier stage of development who may have a limited vocabulary of feelings. This list includes basic feelings such as happy, mad, and sad. Use List B for higher functioning adolescents who have a more complex vocabulary of feelings. This list includes several different types of happy, angry, and sad feelings. Review the appropriate list with the adolescent and help define any feelings with which she is unfamiliar. When working with younger or lower functioning adolescents who demonstrate difficulty naming feeling states, have them complete the Name the Feeling worksheet for additional practice. Provide assistance as needed.

4. Introduce and Practice the Self-Monitoring of Feelings Worksheet Introduce the adolescent to the Self-Monitoring of Feelings worksheet. Explain that she will use this sheet to begin tracking her feelings. She will do this by noting what the feeling is, how strong it is, what the situation or trigger is, and how she deals with the feeling. Establish anchors for rating intensity: for example, just a little, somewhat, a lot. Ask the adolescent to identify a situation in the past week that triggered a strong reaction. Complete a self-monitoring sheet together, focusing on any aspects that are unclear to her. This will help the adolescent name her feelings and receive validation from the therapist. Some adolescents can only describe their feelings as physical sensations, so this can be a starting place. Others have the ability to identify and name feelings, but may not know what the triggers are. Once the adolescent understands the self-monitoring activity, point out that these sheets will be important for treatment. They can help the therapist understand the adolescents experiences between sessions. Emphasize that the sheet is most helpful when the adolescent fills it out as soon as she has a strong feeling.

Challenges Some adolescents view self-monitoring as simplistic or trivializing. They may say, "I've told you about these horrible things that happened to me, and you think giving me a worksheet is going to fix it?!" The therapist needs to be sensitive to the adolescent's point, but also make it clear that this is not the expectation at all. In this part of treatment, the focus is on learning about how her traumas affect her feelings in the present. It can help to acknowledge that the task may seem simplistic but that people tell us they are surprised by what they learn about what they're feeling and why.

22

7/05

Some adolescents dislike filling out the self-monitoring sheets because of their similarity to schoolwork. They may say, I have enough to do for school. I dont need to do this here too, or Im coming here to get help, not just to do more homework. The therapist can be empathic to the adolescents point while also emphasizing the many benefits of completing the forms. This feels a lot like schoolwork to you and that can be annoying but there are actually some very important things you can gain from these sheets that might be of real use to you. Why dont we try filling one out together? 5. Introduce and Practice Deep Breathing Rationale: Explain the rationale for deep breathing to the adolescent: "One way to deal with upset feelings is to calm your body down by using deep breathing. When people are upset, they tend to breathe from their chest. They breathe more quickly and deeply, taking in too much oxygen. This can actually make you feel anxious because you can become dizzy, have a hard time catching your breath, and even feel confused. The aim of this exercise is to slow down your breathing and reduce the amount of oxygen you take in, so you will feel less anxious. You can also use it when you are feeling irritable or angry, and as a tool to help you feel more calm and grounded." Assess Baseline. Observe the adolescent as she breathes in her usual way. Have her pay attention to the rate of her breathing. Have her check whether she breathes from her chest or diaphragm. Teach Technique. Model breathing from the diaphragm, placing one hand on your chest and the other on your stomach and have the adolescent imitate. Explain that when breathing from the diaphragm, only the stomach hand should move up and down (or mostly). It can help to invite the adolescent to think of how babies sleep, how their tummy moves up and down. She might also imagine her stomach as a balloon, filling with air and expanding as she inhales, then letting out the air and shrinking as she exhales. Slow Down Rate of Breathing. Instruct the adolescent to take in enough air to fill her stomach, and then let it out slowly. Sometimes breathing through the nose is easier because it is a smaller opening. This can help to control the rate of exhalation. Instruct the adolescent to pause briefly after exhaling before inhaling again. Some adolescents will hold their breath too long at first. Explain that the pause should come after exhaling. Use imagery to help the adolescent understand the desired movement and flow. For example, a wave is a helpful image for some. The image of climbing up a slide (inhaling) and then sliding down (exhaling), and briefly pausing at the bottom before climbing up again has been helpful for some adolescents.

23

7/05
Meditational Component. In order to help slow thoughts and pay attention to breathing, have the adolescent count her breaths as she inhales. Ask her to think of a word such as "relax," or "calm," as she exhales. The adolescent should continue to "10" and then go back to "1." Explain: "It is perfectly natural for other thoughts to come into your mind. Try not to get angry or frustrated, just allow the thoughts to pass through your mind and focus on your counting again." Some people find it helpful to concentrate mostly on the physical sensation of their breathing. Others concentrate on the counting or "relax" statement. Still others will have different ways of focusing that come most naturally to them. Encourage the adolescent to do what works best for her. Importance of Practice. Instruct the adolescent to put aside some time each day where she will be comfortable and not be disturbed. Ask her to practice the breathing for at least 5 minutes twice a day. Emphasize that she will get better at breathing with practice. Only then will she be able to use it as a coping skill when she is anxious.

Challenges Some adolescents feel that the deep breathing exercise is dumb or pointless. They may say Ive tried this before and it doesnt work or How is changing my breathing going to fix my relationship with my boyfriend?! It is important that the therapist be flexible and not engage in a power struggle with the adolescent about practicing the exercise. It is often useful to tell the adolescent, Many people have the same reaction that you are having when they first try this out. Once they practice breathing in this new way, they feel surprised by how much of a difference it makes for them. I am just asking that you give it a try and see how goes for you. 6. Assign Between-Session Work Ask the adolescent to fill out the Self-Monitoring of Feelings worksheet twice a week. The therapist should provide the adolescent with a copy of the appropriate Feelings List to help her clarify feelings. This list is also helpful for adolescents who might have difficulty writing or spelling because they can copy feeling words directly from the list. The therapist should be aware of any developmental delays that might prevent the adolescent from completing homework. This will help the therapist not to misinterpret this as non-compliance and make other accommodations as indicated.

7, Review Coping Skills and Safety Plan Each session should end with a review of the adolescents coping skills, and a review of the safety plan contained on the adolescents index card.

24

7/05

8. Meet with the Caregiver: Review Safety Plan and Discuss Caregiver Involvement Plan to spend at least twenty minutes with the caregiver to review the safety plan that you created with the adolescent. Provide a copy of the plan to the caregiver. Explain the rationale and course of treatment, Discuss how the caregiver can become an integral part of the adolescents treatment by providing emotional support at home and between sessions. Provide the caregiver with educational handouts about PTSD and the effects of early abuse. If you are working with a caregiver who has limited understanding or fluency of the English languages, provide him or her with handouts in their native language. It is often helpful to explain to the caregiver that the treatment will respect the childs cultural background, values and beliefs. Caregiver involvement will vary depending upon several factors including availability and emotional resources. Some caregivers will readily become involved in their childs treatment and comply with your suggestions and requests. Others may be motivated, but also overwhelmed with the demands of daily life. Some may be resistant or avoidant due to the nature of the childhood abuse and their perceived involvement in witnessing the abuse, and/or ongoing court matters related to the abuse. Still others may exhibit poor boundaries and call you repeatedly to criticize their child, and divulge too many details about their own life. In all cases, it is important not to alienate the caregiver, but to let them know that his or her cooperation and involvement is crucial for treatment success. Keep in mind that, in the end, some caregiver involvement is better than none at all. The clinical vignettes below illustrate ways to facilitate productive dialogue between the therapist and caregiver, and point out potential pitfalls and strategies for dealing with them.

Clinical Illustration: Validating a caregivers feelings about abuse N. is a 15-year-old, sexually abused by her father at age 12. Her mother expressed feeling guilty that she could not offer enough emotional support to her daughter. In reality, the mother was supportive of her daughter. She quickly reported the abuse to authorities, worked to have the father removed from the home, and persevered through lengthy criminal proceedings. Unfortunately, the mother was emotionally exhausted by the time her daughters treatment commenced. The therapist praised Ns mother for her efforts to date, and provided psychoeducation to help her understand her own feelings about the abuse:

25

7/05
It sounds like youve been through a lot to help your daughter. It is understandable that you might feel emotionally exhausted. Parents often have difficulty dealing with their own feelings about the abuse. That can make it hard to be as supportive as you would like to be. It may be helpful to think about talking to a therapist who can help you to cope with your own emotions about the abuse and to get some additional support for yourself. When you are feeling stronger and more able to cope with your own feelings about what happened, you will be in a better position to provide support to your daughter. The mother was receptive to this suggestion and the therapist provided her with referrals for treatment. She expressed appreciation for the referral and for the support.

Clinical Illustration: Working with defensive caregivers B. is a 15-year-old African American female, sexually abused by her mothers boyfriend. The abuse was reported to the authorities, and B. was removed from the home. She was living with relatives at the time of the evaluation. Her father was in the process of suing to obtain custody of his daughter. After the evaluation, B.s mother called in an excited state with concerns that her daughter was telling lies about what had happened. The mother insisted that the sex had been consensual, and that B. was a deceitful girl. The mother was also concerned that her daughters report of an earlier episode of sexual abuse by the son of one of her mothers friends was flawed. The role of the therapist in this case was to validate the mothers concerns, but to refocus the mother by explaining the purpose of the treatment. The therapist told the mother: I understand that you have strong feelings about what happened, but my job is to help your daughter with any problems she may be experiencing as a result of the abuse, not to figure out who is to blame and why. It is the courts job to focus on those issues. We could really use your help in trying to help your daughter. After receiving this simple, but essential, explanation, B.s mother appeared to calm down and offered observations of other problem behaviors she had seen in her daughter. The therapist validated her desire to understand the nature and focus of her daughters treatment, and she was encouraged to call if she had questions about the treatment. Clinical Illustration: Working with an adolescent with a history of suicidal ideation

26

7/05
J.B. is a 16-year-old with a history of self-destructive behavior. She endorsed suicidal ideation, but denied a plan. This is a sample dialogue of how the therapist can convey her concerns to the caregiver: I wanted to talk with you a bit about the work I will be doing with J.B. and the types of issues that you and I should communicate about. It is important that we work together because you know your daughter so well and your relationship is so important. We both have a lot of valuable information to share. You can really help me work with J.B. more effectively by helping me understand your experiences with her. We can talk about situations that make J.B. feel upset, what she tends to do when she feels upset, and what helps her feel better. I want you to know about the work J.B. is doing so you can help her to continue to work on her goals and use her skills after therapy ends. This is especially important because your daughter has had times when she felt like hurting herself. Even though she may not be having those thoughts now, it is important to check in with her from time to time and ask how she is doing. We will be talking about some difficult topics in therapy and it is likely that she will be upset at times. While this is natural, we want to make sure that she feels comfortable talking to us about those feelings.

27

*Optional Session to Prepare for Coping Skills Addressed in Session 3: Self Care and Relaxation Note to Therapist: Rationale for Optional Session This optional session is for adolescents functioning at a concrete level of cognitive development or who demonstrated difficulty with the concepts covered in session 2. In session 3, the therapist will introduce several cognitive strategies for coping with upsetting feelings. Adolescents who struggle to pay attention to their thoughts and feelings may have difficulty moving right into this more complex material. They may benefit from learning basic skills for relaxation and self-care to help familiarize them with the concept of coping strategies and prepare them for the work in session 3. More developmentally advanced adolescents who completed the work in session 2 with ease should skip this optional segment and proceed to session 3.

Agenda 1. Review Between-Session Work 2. Introduce Self-Care and Relaxation 3. Assign Between-Session Work 4. Review Safety Plan

1. Review Between-Session Work (Self-Monitoring worksheets) Go over the adolescent's Self-Monitoring worksheets in detail. Address any practical difficulties or misunderstandings regarding their use, such as what goes in which column. Give positive feedback to the adolescent for being able to identify her feeling states. Work with her to identify and name more completely and accurately any feeling(s) with which she had difficulty. The therapist should approach this as a significant part of the session because its material that can be incorporated into the session's theme. If the therapist conveys the value of this material and uses it, she/he will reinforce the adolescents effort. Review the material from Session 2 on the purpose and practice of deep breathing. Model the technique again, and observe the adolescent doing the

28

7/05
breathing. Emphasize the importance of practice to get the best results from deep breathing.

2. Introduce Self-Care and Relaxation Introduce to the adolescent the concept of self-care. In addition to practicing skills to cope with upsetting feelings, there are basic things adolescents can do to help themselves feel good. Ask the adolescent about different ways she takes care of herself. (What are some things you do to take care of your body? What are some things you do to relax?) Reinforce the adolescent for appropriate strategies and add to her list with the following examples: Self-Care 1. Take care of your body. When you are ill, see a doctor. Take any medications prescribed. Taking drugs and drinking alcohol can change how you feel and behave which can be upsetting and cause problems. 2. Eat right. Do not eat too much or too little. Try to eat three balanced meals a day. This gives your body energy to get through the day. Good nutrition helps you stay healthy and grow. 3. Get a lot of rest. Make sure that you get enough sleep to feel rested. If you have trouble sleeping, try to come up with a bedtime routine. 4. Get exercise. Try to get some form of exercise every day for at least 20 minutes. This will help you stay in shape and have energy. Discuss different forms of exercise. 6. Build Mastery. Try to do something every day to make yourself feel good

29

7/05
and in control.

Introduce the concept of self-soothing to help one relax. Explain that it can be useful for people to practice strategies to help themselves relax when they feel upset. Discuss strategies the adolescent has already used to help herself feel calm and situations during which she uses them. Reinforce the adolescent for using appropriate self-soothing skills. Discuss with the adolescent ways of soothing each of the five senses. Explain the benefits of targeting more than one sense at a time to help her relax more quickly and effectively. Review the following list of skills to soothe each of the five senses:

Vision: It can be soothing to look at something pleasant, like flowers, artwork, or images from a magazine, television, or computer. You may go to (or think about) a place that relaxes you, such as a park, a room in your house, or looking at the stars at night. You may want to create something to look at on your own by drawing or painting a picture. You might fix your hair or fingernails to your liking. Hearing: Think about what sounds help to soothe you. What kind of music calms you? You might like to listen to music and maybe sing along to hear your own voice. You may like to listen to a program on television, or listen to peaceful sounds, like birds chirping, waves rolling, or rainstorms. You can call someone who helps you relax on the phone to hear a calm and soothing voice. Smell: Think about your favorite scents. What smells make you feel calm and relaxed? You may put on scented lotion or light fragrant candles. You can smell fresh flowers at home, outside, or in a shop. You may use flowers and herbs to make potpourri. Some people enjoy cooking or baking things that smell nice, like cookies or bread. You can take a walk outside and breathe in the fresh smells of nature, like trees and plants. Taste: It can be soothing to eat a good meal. Think about your comfort foods. Let yourself enjoy a special treat, like a fruit or candy. Pay attention to the flavor, temperature, and texture of what you eat. You may try a special dessert or a soothing drink, like herbal tea or hot chocolate. Take your time and really let yourself enjoy the taste of what you are eating or drinking. Touch: Think about ways you can pamper your body. It can be soothing to

30

7/05
take a hot bubble bath, soak your feet, or get a massage. You may like to put cold water on your face and neck. Try rubbing lotion or oil on yourself. Think about clothing or furniture that feels nice and relaxing. Do you have a favorite chair or blanket? You may like to put on something soft like a sweater or a robe and slippers. Let yourself experiment with different textures. Try petting a furry animal or sinking your hands into water or sand.

3. Assign Between-session Work Assign continued use of Self-Monitoring of Feelings sheets 2 times a week. Remind the adolescent to practice self-care. Assign the Soothing Your Senses handout.

4. Review Coping Skills and Safety Plan Each session should end with a review of the adolescents coping skills and a review of the safety plan contained on the adolescents index card.

31

Session 3: Coping with Upsetting Feelings Agenda 1. Review Between-Session Work 2. Provide Psychoeducation about Coping with Upsetting Feelings 3. Identify and Evaluate Current Coping Skills 4. Provide Psychoeducation about Self-Talk 5. Practice Paying Attention to Self-Talk 6. Coping with Upsetting Self-Talk 7. Introduce and Practice the Use of Cognitive Coping Skills 8. Assign Between-Session Work 9. Review Coping Skills and Safety Plan 1. Review Between-Session Work (Self-Monitoring sheets; Soothing Your Senses sheet) If the adolescent completed the optional session to prepare for coping skills, review the Soothing Your Senses sheet. Reinforce the adolescent for her work and discuss which strategies were most helpful to her (e.g. looking at soothing images versus listening to music). Go over the adolescent's self-monitoring sheets in detail. Address any practical difficulties or misunderstandings regarding their use, such as what goes in which column. Discuss the material the adolescent collected. Typical examples adolescents provide are feelings of sadness, anxiety or anger. Sometimes adolescents have difficulty identifying a specific feeling and write that they felt "overwhelmed" or "upset." Work with the adolescent to define more specifically what upset or overwhelmed means to her. For one adolescent, upset might mean angry, while for another it might mean sad. The therapist might ask questions such as, "Were you crying?" or "Did your muscles feel tense?" "What other physical sensations were you aware of?" Explain that sometimes there is more than one feeling involved. For example, an adolescent can experience anxiety and shame at the same time. The therapist should use the self-monitoring sheets as a significant part of the session. These sheets often provide material to incorporate into the session's theme. If the therapist conveys the value of this material and uses it, it reinforces the adolescents effort.

32

7/05

Challenges If the adolescent did not complete any self-monitoring sheets, assess the reason for this. For example, an adolescent may say, "Well, nothing happened this week." Explain that there does not have to be an event, but sometimes just an experience or a feeling. A feeling can arise just as easily from a worry, thought, or memory. Explain that it may not always be possible to know what triggered a feeling. The first goal is to have the adolescent get into the practice of slowing things down and paying attention to her feeling states. Ask her to choose a situation from the past week and complete it together in the session. If the adolescent continues to come to future sessions without having completed the forms, or feels anxious completing them alone during the week, it may help to have her come early before sessions and do it in the waiting area. It is optimal if adolescents can do this during the week at the time when situations emerge; however, if they cannot, the goal is to find a way to help them generate this material. Again, the therapist should be aware of any developmental delays that may interfere with the adolescents ability to complete this work and make appropriate accommodations in a supportive way. If the adolescent did not complete the optional session, review the material from Session 2 on the purpose and practice of deep breathing. Model the technique again, and observe the adolescent doing the breathing. Emphasize the importance of practicing deep breathing to help the adolescent feel calm and slow down her heart rate and thoughts.

2. Provide Psychoeducation about Coping with Upsetting Feelings Use material from the Self-Monitoring of Feelings sheets and previous sessions to focus on dealing with upsetting feelings. With traumatized adolescents, review how traumas can create more extreme feelings. Also, discuss the lack of guidance the adolescent had in learning to manage them, if appropriate to her history. The adolescent has likely developed ways of coping, some of which are helpful, others which are not. For example, many adolescents report that they zone out when they encounter stressful situations, and that it is hard to identify their thoughts and feelings at the time. Some adolescents may report taking a time out or talking with others. It is important to reinforce the adolescents effective coping skills. The therapist may also point out that her less effective ways of coping are understandable, though not necessarily helpful.

3. Identify and Evaluate Current Coping Skills

33

7/05

Before introducing skills for coping with upsetting feelings, find out from the adolescent the coping skills that she already has. Do not assume she is without them! Assess the frequency with which the adolescent uses these coping skills and how effective they are in helping her feel better. Begin with the base skills the adolescent already has. She may already use some of the skills covered in the next section, or may have effective ones of her own. Perhaps she has idiosyncratic skills that she could use as coping skills.

4. Provide Psychoeducation about Self-Talk Explain to the adolescent that people have different feelings about themselves based on things that happen in different situations. For example, if a peer invites the adolescent to a party, she may feel happy because she thinks others like her. If the adolescent misses the ball in gym class, she may feel upset because she thinks that she is stupid. These thoughts are automatic because they happen quickly and without our even realizing it. This is what we call selftalk. Explain to the adolescent that when people are in difficult situations, they may think or quietly say upsetting things to themselves that make them feel worse. When people feel upset, they are more likely to have trouble thinking clearly and may blame themselves or make very strong, upsetting statements that are incorrect. It is the upsetting thoughts that people have about themselves that can lead to upsetting feelings rather than what is actually happening in a situation. This means that if people change their thoughts, they can also change how they are feeling.

5. Practice Paying Attention to Self-Talk Encourage the adolescent to think about a recent situation that made her feel upset. Help the adolescent to identify her self-talk by asking questions such as, What went through your mind? What did you think about yourself? Record the adolescents responses on the Self-Talk sheet.

6. Coping with Upsetting Self-Talk

34

7/05
Look at the evidence. Use the adolescents example on the Self-Talk sheet to help her practice looking at the evidence. Ask questions such as, Is that thought really true? How do you know it is true? Pay attention to patterns in which the adolescent makes over-generalizations, meaning that she draws conclusions about herself or others based on one or two situations. When people make over-generalizations, they tend to focus on upsetting things that happen while ignoring or forgetting about good things that have happened in similar situations. For example, if an adolescent receives a D on one test, she may think that she is stupid, even though she got Bs and Cs on all of her other tests. If a peer does not invite her to a party, she may think that no one likes her, even though she has many friends. Help the adolescent to think of other reasons to explain why something upsetting may have happened. For the above examples, ask the adolescent, Why else might that have happened? Provide assistance as needed. Maybe she got a D on that test because it was harder than other tests. Maybe her friend did not invite her to the party because it was a very small party and she did not invite many other girls.

35

7/05
7. Introduce and Practice the Use of Cognitive Coping Skills Thought stopping and attention shifting: Explain to the adolescent that in thought stopping, she will shout Stop! to herself silently in her head when upset by worries she cannot stop. After stopping the thought, she should focus on another activity to keep her mind on something else. Examples of attention shifting activities include listening to music, taking a walk, calling a friend, thinking about happy events, or counting backwards. Practice an example of using thought-stopping (i.e., the adolescent imagines that she had an argument with her friend on the phone last night and she keeps thinking about what she said over and over, which makes her feel upset. Have the adolescent say her thoughts aloud and practice saying, stop! Then, have the adolescent practice quietly, thinking about the steps in her mind). Positive self-statements: The use of positive self-statements can be very helpful when the adolescent starts to have an upsetting thought or criticizes herself. Using the sheet labeled Positive Self-Statements, ask the adolescent to make a list of her positive qualities such as, Im a good friend or My teachers tell me Im smart. Some adolescents have a very difficult time identifying their strengths. Encourage them to find something about themselves that they like, even if they may think it is trivial. If the adolescent insists that she cannot come up with anything, the therapist may ask what her best friend would say about her. Explain to the adolescent that it can be very useful to think or say something positive as soon as she catches herself having upsetting self-talk. The therapist may use material from the adolescent's Self-Monitoring sheets to find areas of upsetting self-talk to counter with positive statements. For example, in response to the thought Im a loser, an adolescent may tell herself, Im doing the best I can.

Challenges It is VERY IMPORTANT that the adolescent understand that these coping skills are NOT for covering or avoiding feelings. Rather, they give the adolescent control over managing her feelings and choosing when to tolerate upsetting feelings. Some adolescents resist self-soothing techniques because they need to hold onto pain and anger as a testament to what they experienced. They feel that getting relief by using coping skills would trivialize their suffering. The therapist will need to assess and gently address this, emphasizing that allowing oneself some relief does not invalidate the adolescent's suffering. (e.g., Putting a band aid on a wound to help it heal doesnt mean that the injury didnt happen.)

36

7/05
Not all adolescents will be able to use all coping skills. Encourage the adolescent to try them, but convey that she can focus on those that are most helpful. Some adolescents are "doers" and find it helpful to engage in activities such as writing in a journal or working out. Others are "thinkers," and cope by telling themselves that their distress will only last for a small while, or try to think of happier things. Still others seek social support by hanging out with friends, or doing something nice for someone. In some cases, the therapist may omit certain skills and encourage others, based on their understanding of the adolescent. For example, a very avoidant adolescent may not be encouraged to use thought stopping or attention shifting. Clinical Illustration M has a history of physical and sexual abuse by her mother. At the age of 15, she went into a group home after a few unsuccessful foster care placements. She was withdrawn and had significant difficulty identifying her feelings. M also experienced intense bouts of anger in which she became so enraged that she beat up several of her classmates and her school suspended her. These violent rages and overwhelming feelings of anger interfered with her schoolwork and friendships. In session, M recalled that her mother often ignored and minimized her feelings. She described one occasion when her mother had given her a black eye. Afterward, her mother said to M, "What are you so upset about? Play with your doll and you'll feel better." The therapist was very careful to explain to M that the goal of learning to deal with upsetting feelings was not to cover up or minimize her feelings, but rather to help her deal with them more effectively so she could control her temper and have more success at school and with friends. M was also very hesitant to pay attention to her feelings. She feared that if she actually felt her feelings, she might become overwhelmed or feel depressed or suicidal, as she had in the past. She believed it was "safer" to "put up a brick wall" and avoid looking too deeply at any of her feelings. M found the following analogy to be helpful: If she got a cut on her arm, she could respond by refusing to look at the wound by keeping her eyes shut at all times. On the other hand, instead of avoiding her wound, she could care for her cut by putting on a band-aid or cleaning it to prevent further infection. By attending to her "wound", instead of avoiding it, M was able to see that she could ease her pain in a more permanent manner. 8. Assign Between-Session Work Have the adolescent complete the Self-Talk sheet 2 times a week. Also, ask her to practice using the positive self-statements generated in the session each day.

9. Review Coping Skills and Safety Plan

37

7/05
Each session should end with a review of the adolescents coping skills and a review of the safety plan contained on the adolescents index card.

38

7/05
Session 4: Dealing with Upsetting Situations Agenda 1. Review Between-Session Work 2. Review any Problems with Implementation of Coping Skills 3. Provide Psychoeducation about Dealing with Upsetting Situations 4. Introduce Concept of Dealing with Upsetting Situations to Achieve Goals 5. Coping Strategies for Dealing with Upsetting Situations 6. Assign Between-Session Work 7. Review Coping Skills and Safety Plan 1. Review Between-Session Work (Self-Monitoring Worksheets; Positive SelfStatements) Go over the adolescent's Self-Talk and Positive Self-Statements sheets in detail. Address any practical difficulties or misunderstandings regarding their use. Give positive feedback to the adolescent for completing the work.

2. Review any Problems with Implementation of Coping Skills Discuss the adolescents use of coping skills between sessions and address any difficulties. Reinforce her attempts to use coping skills.

3. Provide Psychoeducation about Dealing with Upsetting Situations Review with the adolescent that PTSD symptoms result from avoiding or ignoring upsetting memories of traumatic experiences. However, upsetting feelings are inevitable and ignoring or denying them does not make them go away. Explain to the adolescent that it is natural to want to ignore or avoid upsetting feelings related to traumatic or stressful experiences. However, over the long-term, avoiding them will only make the pain and suffering worse. The upsetting feelings will keep coming back in one way or another. Since adolescents tend to live in the moment, they may really want to avoid painful thoughts and feelings related to trauma and stress. Learning to confront and deal with upsetting feelings can help the adolescent face challenging situations and feel better.

39

7/05

Upsetting feelings can also tell a person about areas in her life that may need attention or change. Dealing with situations that may involve upsetting feelings can help the adolescent feel better. Adolescents often put a lot of energy into trying not to feel upset and find that they still feel upset anyway. Lastly, introduce the idea that learning to deal with upsetting feelings will make the adolescent open to experiencing pleasant feelings as well. When one avoids feelings, they cut off both pleasant and upsetting feelings, not just upsetting ones. As a result, many adolescent trauma victims have a hard time experiencing many different feelings. They often report feeling "numb" and unable to enjoy things in their lives such as relationships and social activities. Discuss an example from the adolescents personal life when she tried to avoid feeling upset and how effective the avoidance was. (e.g., When you got angry at your friend, you didnt want to feel bad so you left her house and said that you wouldnt speak to her again. Did it really work? Did you stop feeling upset? How long did it last? Did you miss the good things about your friend? Would you like to learn how to cope with those situations differently so that you dont have to run away from upsetting feelings?)

4. Introduce the Concept of Dealing with Upsetting Situations to Achieve Goals One of the main goals of this treatment is to teach skills to help the adolescent deal with upsetting feelings and situations so she can feel better and enjoy her relationships with others. One of the tasks is to identify the adolescent's goals and then think about what could happen while working toward these goals. This concept is particularly important when an adolescent chooses a long-term goal where she might not feel good or get what she wants right away. Thus, instead of learning to deal with upsetting situations per se, the adolescent decides if what she wants is worth dealing with the upsetting feelings she may have as she works towards her goal. Clarify this concept by choosing a situation that is important to the adolescent that she is avoiding because she does not want to feel upset. Discuss what could happen, good and bad, if the adolescent chose to confront the situation, and how she would feel. (e.g. I wrote a poem for extra credit and have to read it in front of the class. My goal is to read the poem so I get the extra credit. Maybe the other girls in the class will think it is not good and tease me. This would make me feel sad. On the other hand, my teacher and the other girls might like it a lot and tell me that I did a good job. That would make me feel proud. Ask the adolescent if getting the extra credit is more important than worrying about whether others will like the poem.)

40

7/05
Challenges Adolescents with abuse histories often avoid dealing with upsetting traumarelated feelings that need to be processed. At the same time, they may also choose to tolerate upsetting feelings in situations that do not pay off, such as going out with boys who treat them poorly. If this is the case, the therapist will need to help the adolescent identify these situations and work with her to build new skills so that she can remove herself from upsetting relationships or situations. Thus, it is particularly important for the adolescent to learn to weigh whether upsetting feelings are worth tolerating to reach a goal. Rather than reinforcing the adolescent's idea that she should tolerate upsetting feelings across the board, the therapist's objective is to help her make choices about when it feels appropriate to do so. 5. Coping Strategies for Dealing with Upsetting Situations Thinking about Pros vs. Cons: Looking at the pros and cons of dealing with upsetting situations can help the adolescent stay focused on her goals. This skill works by choosing a situation that is important to the adolescent that may be upsetting or produce anxiety. Help the adolescent think about what she expects will happen as she works towards her goal. Also, discuss how she will cope with upsetting feelings that may make her feel like dropping out or giving up. Have the adolescent create a list in which she writes down the pros and cons of dealing with upsetting feelings in her selected situation. Help the adolescent come up with questions such as, "Why am I putting myself through this?" "What is my ultimate goal here?" "Will I get enough good out of this situation that it makes dealing with the upsetting feelings worth it?" It is important to use session time to identify and think about 1 or 2 situations that could involve upsetting feelings in depth. Provide a model for how the adolescent can do this on her own outside of sessions. One helpful way to begin is by assessing the pros and cons of being in the current treatment. Is the ultimate goal (i.e., feeling better) and its pros (i.e., focusing on school, getting along with people better) worth dealing with the cons (i.e., talking about upsetting things)? In addition to providing a specific example of how to use the skills, this exercise is a good way to prepare and help the adolescent in facing challenges in the treatment.

Challenges Some adolescents may run through their list of pros and cons in a hurry and without fully considering how they may affect their ability to meet their goals.

41

7/05
Adolescents who quickly decide that goals such as attending treatment or finishing school are worth tolerating the cons may be attempting to please the therapist or give the right answer. The therapist can gently encourage the adolescent to focus on the potential barriers to her goals, as well as strategies to overcome them. For example, the therapist may ask, Which of these cons do you think would be most difficult to manage? How do you think you might handle that? The therapist can also use this opportunity to provide the adolescent with hope and encouragement that she can overcome barriers to her goals by practicing healthy coping strategies. Clinical Illustration L is a 17-year-old adolescent girl with a history of sexual abuse. From ages 7-12, her father molested her in her room. Before the abuse began, L said she trusted her father very much. In high school, L withdrew socially and no longer felt like hanging out with her old friends, particularly guys. She stopped going to parties and to any place where she feared she might meet new people who were not safe. Although L said she feels lonely at times, she also feels protected by a tough attitude used to keep others from getting too close. In treatment, L stated that a boy at school had asked her out a few times. L thought that K seemed cute and nice, but that she always turned him down and even avoided talking to him. L expressed a lot of mixed feelings and nervousness about getting to know someone new, especially a boy. She was sure that he would just be another guy to mess me up. L also recognized that she had recently been feeling lonely and wished she had someone to talk to. She thought she could feel comfortable and have fun with K and feared that if she kept on avoiding him she might miss a good opportunity. As part of treatment, the therapist suggested that L use the skill of assessing pros and cons in order to help her decide if dealing with the upsetting feelings that could arise in this situation would be manageable and worthwhile for her. The therapist initially worked with L to identify her goal. They then worked to shift the focus away from an overwhelming and uncontrollable goal (To develop a long-term relationship with K) to a more realistic and manageable goal (To learn to feel more comfortable and open talking to K at school, and to agree to go on a date with him in a safe place). This intervention helped to reduce L's nervousness. She was then able to come up with a useful list of pros and cons of working towards this goal.

Pros and Cons List GOAL: To express my feelings openly with Ken.

42

7/05

Cons: (What could go wrong?) I could feel uncomfortable I might get my feelings hurt I might feel stupid or nervous I feel lousy Maybe it will get too sexual I might think about times when I got hurt me by someone else

Pros: (What could go right?) I wont feel as lonely if I talk to him He is fun to be with I will have somebody to talk to when

I could do nice things for him I could feel like somebody cares about

7. Assign Between-Session Work For between-session work, have the adolescent practice this skill by writing out the pros and cons for other situations she may encounter or think about during the week using the Dealing with Upsetting Situations worksheet.

8. Review Coping Skills and Safety Plan Each session should end with a review of the adolescents coping skills and a review of the safety plan contained on the adolescents index card.

43

7/05
Session 5: Coping Strategies for Dealing with Upsetting Situations Agenda 1. Review Between-Session Work 2. Review Implementation of Coping Skills 3. Coping Strategies for Dealing with Upsetting Situations 4. Assign Between-Session Work 5. Review Coping Skills and Safety Plan 1. Review Between-Session Work (Dealing with Upsetting Situations sheet) Go over the adolescent's Dealing with Upsetting Situations sheet in detail. Have the adolescent identify the most difficult barrier to her goal from the list of cons. Discuss how she might overcome that barrier. Address any practical difficulties or misunderstandings regarding the sheet. Give positive feedback to the adolescent for completing the work.

2. Review Implementation of Coping Skills Discuss the adolescents use of coping skills between sessions, and address any difficulties. Reinforce her attempts to use coping skills.

3. Coping Strategies for Dealing with Upsetting Situations Explain that since the adolescent is doing hard work by facing and dealing with difficult situations, she should reward herself. The therapist will work with her to make a list of activities she enjoys. This task helps the adolescent become open to experiencing a greater range of feelings. By helping her deal with upsetting feelings, she will also be able to have more pleasant feelings that avoiding situations would have cut off. Talk to the adolescent about what she does to cope with upsetting feelings such as anger or sadness. Responses may range from When Im upset, I call a friend, or I put on my headphones and zone out, to I work out to burn off some energy. Discuss whether these coping strategies are helpful to the adolescent. The adolescent should provide a recent example of when she used one of these coping strategies and talk about how it helped her to feel less upset. Provide the adolescent with positive reinforcement. Encourage her to continue to use these coping strategies when she begins to feel upset.

44

7/05

Some adolescents are unable to come up with a healthy strategy and, for example, yell at a sibling when angry with a friend. Help the adolescent create one or two coping strategies she can try out between sessions. For example, one adolescent reported with guilt that she hit her pet once when she was overwhelmed with anger. The therapist helped her to change this by hitting a pillow instead. Identify Feel Good Activities. Have the adolescent circle as many activities on the worksheet as she currently uses at least once a week. She may also underline any activities that she does not currently use, but would like to try. Typically, adolescents will create a list of at least 3 feel good activities that they can use in their lives to help reduce stress and upsetting feelings. Some examples include listening to music, playing a sport, or playing with pets. On the bottom portion of the worksheet, the adolescent can add any items that are not on the list. When the list is complete, discuss whether the items have been helpful to the adolescent. For example, an adolescent may say, When I write down my feelings in a journal, they begin to make sense to me and I calm down. The adolescent can expand on the activities list through the course of treatment. In future sessions, follow up to see which activities she actively uses each week and what the benefits are.

Challenges This may not be as simple as it sounds for some adolescents. Some adolescents may respond, "I don't know" or "I don't really enjoy anything." They may really need to take time in or out of session to think about this more. The therapist may provide suggestions as a way to get the adolescent thinking about specific activities. They may ask questions such as, Is there something new you have always wanted to try? Other adolescents may respond, "I don't have time for any of these activities". For adolescents who view pleasurable activities as a luxury, the therapist will need to reframe this skill. The therapist may describe it as an important part of recovery from childhood abuse and discuss how the adolescent can make some time in her schedule. It is also important to keep in mind that some adolescent trauma survivors may not feel they deserve to enjoy or nurture themselves. Explore this issue with the adolescent and discuss how feeling like a "bad person" or having low self-worth is a common reaction to childhood abuse and/or neglect. Address how not engaging in pleasurable or soothing activities only makes a poor self-image worse and supports the damaging idea that she does not deserve positive experiences . 4. Assign Between-Session Work

45

7/05

Ask the adolescent to try three of the positive activities she picked from her list.

5. Review Coping Skills and Safety Plan Each session should end with a review of the adolescents coping skills and a review of the safety plan contained on the adolescents index card.

46

7/05
Session 6: Using Positive Imagery to Deal with Upsetting Feelings Agenda 1. 2. 3. 4. 5. Review Between-Session Work Provide Rationale for the Use of Positive Imagery Make Positive Image Collages Assign Between-Session Work Review Coping Skills and Safety Plan

1. Review Between-Session Work (Feel-Good Activities) Review the adolescents use of Feel-Good activities from the past week. Address any difficulties or misunderstandings regarding the use of this coping skill. Give positive feedback to the adolescent for attempts to use this skill to increase positive feelings.

2. Provide Rationale for Use of Positive Imagery Provide the following rationale to the adolescent: One valuable way of coping with stress is using positive imagery. Explain that positive images are pleasant pictures of people, places, things, or words that make them feel good. When people feel upset or nervous, they may have upsetting thoughts and worries that make them feel worse. Explain to the adolescent that by thinking about positive and soothing images, she may feel more calm and relaxed. Explain to the adolescent that since it is often difficult for people to make up positive images on their own, she can practice making positive images by creating a positive image collage.

3. Make a Positive Image Collage

Materials Needed: 1. A piece of white poster board (approximately 13 x 13) 2. Several colorful magazines

47

7/05
3. Scissors 4. Glue-stick 5. A handful of magic markers. Explain to the adolescent that she may cut out pictures and designs from the magazines that make her feel good (e.g., happy or calm), or that stand for things that she likes (e.g., hobbies, things she likes to do, pets or scenes of pretty pictures). Have her arrange them on the cardboard. Some adolescents clip out strings of words or titles to express their thoughts and feelings. Adolescents with trauma histories tend to focus on negative images and may select upsetting or scary pictures for their collage. In these situations, the therapist can remind the adolescent that although it is important to talk about these scary images, the goal of this activity is to focus only on images that make her feel good. Collages may take anywhere from 20 minutes to 1 hour to complete. Be sure to allow enough time for discussion afterward, or divide the activity over two therapy sessions. Have the adolescent sign and date the collage in marker. After the collage is completed, the therapist should ask the adolescent to discuss the meaning of the images she chose.

Challenges Some adolescents may be hesitant about making collages because they question or worry about their artistic abilities. They may say,Im not good at art. Reassure the adolescent that the goal of the collage is not to make the best artwork, but to practice a soothing activity to reduce upsetting feelings. The therapist may say, It might help you to focus on picking pictures that you like without worrying about how your collage will look in the end. The therapist can even leaf through magazines with the adolescent until she feels more comfortable and cuts out at least one or two pictures for her collage. Some adolescents refuse to make a collage because they feel that it is silly or childish. They may say, This is for first graders. I dont need to do this. To address the adolescents resistance and increase her motivation, it is helpful for the therapist to participate by making a collage as well. The therapist may say, I know this may seem childish, but it can actually be fun. Many people your age and older have tried it and ended up enjoying it. How about we do it together? Other adolescents with histories of abuse tend to focus on upsetting images and have a very difficult time identifying positive images. They may look through picture after picture without being able to select any images that they like. By

48

7/05
engaging the adolescent in a more structured discussion about her preferences (i.e., What are your favorite colors, places, and objects?, Who are your favorite celebrities or role models?), it maybe easier for the adolescent to identify and select positive images for her collage. As illustrated below, positive-image collages will be unique to each adolescent, depending upon her sensibilities, general interests, and even coping skills. Additionally, some girls may choose only four images to fill the page, while others may include as many as ten to fifteen smaller images.

Clinical Illustration M is an 18 year-old adolescent who enjoys being around nature. Her collage contained pictures of mountains and forests, and a patch of lilacs. She described it as being very relaxing and peaceful to look at. She also included a picture of a camera to illustrate her love of photography, and a picture of an aromatherapy candle that she likes to light when she feels stressed out. M also selected a picture of a couple holding hands and smiling at each other to represent her excitement about her new relationship with her boyfriend. S is a 14 year-old adolescent with a flair for fashion and a love of music. S chose to decorate her collage with an array of clothing and accessory items that she thought were stylish. She included several musical notes and pictures of rock groups that she really liked. She also included pictures of makeup she likes to use when she gets dressed up to go out, a pint of her favorite flavor of ice cream and a picture of the Manhattan skyline to represent her love for the city. 4. Assign Between-Session Work Ask the adolescent to practice using skills to manage an upsetting situation (record on self-monitoring form). Have her engage in at least three feel good activities that she chose in the previous session.

5. Review Coping Skills and Safety Plan Each session should end with a review of the adolescents coping skills and a review of the safety plan contained on the adolescents index card.

49

7/05
Session 7: Relationships with People: Behavior and Communication Agenda 1. Review Between-Session Work 2. Provide Psychoeducation about how Behavior and Communication affect Relationships 3. Introduce Skills for Clear Communication 4. Assign Between-Session Work 5. Review Coping Skills and Safety Plan

1. Review Between-Session Work (Feel-Good activities; using coping skills) Review the adolescents use of Feel-Good activities from the past week. Address any difficulties or misunderstandings regarding the use of this coping skill. Give positive feedback to the adolescent for attempts to use this skill. Ask what other coping skills the adolescent practiced this past week and discuss their effectiveness.

2. Provide Psychoeducation about how Behavior and Communication affect Relationships Explain to the adolescent that how we behave and communicate with others affects what happens in our relationships and how we feel about them. There are many different ways we can communicate our thoughts and feelings to others that lead to different outcomes. For example, an adolescent may feel disappointed and angry because her sister will not drive her to the store and curse at her. As a result, her sister may become angry and say or do something mean in return. This can lead to an ongoing conflict in which neither girl feels very good about the other. Another adolescent might tell her sister that she feels disappointed and explain why it is important for her to get to the store. In turn, her sister may try to make time to take her to the store or arrange to take her another time. The outcome in this situation would be that the sister understood and cared about what the adolescent needed, and the adolescent got what she needed and appreciated her sister. Note that while it is impossible for us to get our needs met all of the time, we can improve our chances of getting what we want from relationships by planning the way we behave and communicate. 3. Introduce Skills for Clear Communication

50

7/05

The I message. One clear communication tool is an I message, which helps us tell people how their behavior affects us. We can use I messages to communicate both pleasant and upsetting feelings. The purpose of an I message is to focus on what happens as a result of another persons behavior instead of blaming that person. By focusing on the results of a behavior, the adolescent is less likely to make the other person feel attacked. Encourage the adolescent to say the persons name and make eye contact when using I messages. An I message has 3 parts: a behavior, feeling, and result.

1. Behavior: doing? 2. Feeling:

What is happening around you? What is the other person

How does the persons behavior make you feel? What happens as a result?

3. Consequence:

Use this form sentence: When you ____________, I feel _______________ because_______________ (behavior) (feeling) (result)

Examples: (Help the adolescent identify the behaviors, feelings, and results.) When you didnt pick me up, I felt frustrated because I missed my appointment. When you lied about breaking the vase, I felt angry because I got in trouble for it. When you invited me to the movies, I felt happy because I got to spend time with you.

51

7/05
Model for the adolescent how she could have used an I message in a recent situation, and have her practice using the skill. Saying No. For many adolescents who have experienced traumas, it can be difficult to say no. In cases when the adolescent is dealing with someone with whom she does not want to be involved, it is often okay to say No, thank you in a respectful, firm tone. If the other person persists, the adolescent should repeat herself while maintaining eye contact and slightly raising the tone of her voice. A useful technique for dealing with someone who will not take no for an answer, is the broken record. In this technique, the adolescent can simply repeat her response without backing down or allowing other issues to sidetrack her. For example, if a salesperson keeps badgering you to buy a pair of jeans you do not want, you can keep repeating. I understand what you are saying, but Im not interested. Model for the adolescent how she could have said no in a recent situation. Have her practice using the skill. Making Requests. Many adolescents who have had traumatic experiences may have difficulty getting what they need from others. It is useful to focus on 4 pieces of information to help the adolescent plan the best way to ask for what she needs in a situation: the goal, the person, the time, and the request. The therapist should use this opportunity to review the adolescents discussion of social supports in session 2. 1. The goal: What do you want or need? Try to be as specific as possible so that you can make your request to the other person clear. 2. The person: Whom should you ask? It is important to ask someone who can actually do something to help in the situation. You want to approach a person who is able to make something change (someone in a position of authority) or help you feel better (someone who can help you calm down). 3. The time: When should you ask? Is it an emergency or can it wait? Chances are, if there is something you want, like for someone to get you something from the next room or make you something to eat, you could wait a while if you needed to. On the other hand, if there is something important that you need, like to leave class when you are ill, it is appropriate to ask right away. 4. The request: What should you say? When making a request, think about how to state your goal simply. Remember to use I language ( I would

52

7/05
like versus You need to), say the persons name, and make eye contact. Remind the adolescent that when she asks for something clearly, that does not guarantee that she will get it. On the other hand, it is highly unlikely that the adolescent will get what she wants if she does not ask. Example: Pretend that you are sitting in class and you just realized that you left your hat on the bus this morning. What is your goal? Whom should you ask? When? What would you say? Clinical Illustration R is an 18-year-old girl with a history of sexual abuse by her father. When she told family members about the abuse, no one believed her. Eventually, R stopped talking about the abuse because she figured that no one would help her anyway. Currently, R often complains that important people in her life never seem to care when she is upset. As she began to pay attention to how she communicated her feelings and needs to others, she realized that she often told others that she was feeling okay when she was actually quite upset. As a result, others did not comfort or soothe her, as she really wanted them to. Other times, R would state, Im upset! and then wait for the other person to respond. She was often disappointed that others did not react the way she wanted them to. R realized that she was expecting others to read her mind and know what to do to make her feel better. She felt that if someone did not know what she wanted, it meant they did not really understand or care about her. Over time, R learned to communicate her needs more clearly. She began to state exactly what she needed from others. As a result, she made it easier for others to know what to do in order to help her feel better. In turn, she was able to get more support and felt better about her relationships. 4. Assign Between-Session Work Clear Communication sheet: Review the sheet and instructions with the adolescent. You may practice the first item together.

5. Review Coping Skills and Safety Plan Each session should end with a review of the adolescents coping skills and a review of the safety plan contained on the adolescents index card.

53

7/05
*Optional Session to Expand on Relationship Work Addressed in Session 7: Relationship between Feelings and People: Schemas Note to Therapist: Rationale for Optional Session This optional session is for adolescents functioning at a mature stage of development, as it requires abstract thinking. Material in this session builds on your discussion about how personal experiences shape current relationships. It focuses on how the adolescents early experiences contribute to schemas, which affect current relationships.

Agenda 1. Review Between-Session Work (Clear Communication handout, using coping skills) 2. Provide Psychoeducation about Schemas 3. Provide Psychoeducation about Feelings and Relationship Schemas 4. Introduce the Challenging Schemas Worksheet 5. Assign Between-Session Work 6. Review Coping Skills and Safety Plan

1. Review Between-Session Work (Clear Communication handout; using coping skills) Review the adolescents Clear Communication sheet. Address any difficulties completing this sheet and provide positive reinforcement. Give positive feedback to the adolescent for attempts to use good communication skills. Ask what other coping skills the adolescent practiced this past week and discuss their effectiveness.

2. Provide Psychoeducation about Schemas Provide psychoeducation to the adolescent about the concept of schemas. Since adolescents often have difficulty paying attention to lengthy and complex material, it is essential for the clinician to use simple and understandable language. Explain that schemas are rules or expectations we have about how things happen in the world around us. They come from experiences we have had in the past that we expect to repeat again.

54

7/05
Schemas tell us what to expect from others and how to act in different situations. For example, a child may have a schema about how to act in class. The child learned that when she raised her hand, the teacher called on her to speak in class. As a result, now she automatically raises her hand if she wants to speak or keeps her hand down if she does not want to participate. 3. Provide Psychoeducation about Feelings and Relationship Schemas Explain that everyone has schemas about their relationships with others. These schemas reflect ideas about how relationships work (i.e. how people behave and respond to each other). Relationship schemas often come from a childs early experiences with her caretakers. An infant learns that when she cries, a caregiver comes and soothes her. Schemas become more complex with age. As children grow up, they learn that their behavior affects what happens in their relationships. For example, if they do well in school, they will receive praise and feel loved. On the other hand, they may learn that if they misbehave, others may punish or yell at them. Children raised in abusive environments may form ideas and expectations about relationships that are unclear or incorrect. Relationship schemas that form in this type of environment may link care and love with abuse. Because a child is dependent on an abusive caregiver, she will look to him or her to meet her needs and provide her with love. In a physically abusive home, if a caregiver assaults a child when she tries to get a need met, the childs mind forms a link between care and physical assault. She may expect that others in caring relationships will abuse her, such as friends, teachers, or therapists. Schemas stay in childrens minds as they grow up. Current situations that remind the adolescent of the past automatically trigger schemas. An adolescent may think, feel or act in ways that were appropriate when she was younger, even though the current situation may be quite different. These schemas lead her to behave in ways to prepare for what she expects to happen. Explain that relationship schemas can be self-fulfilling even though the result is one that the adolescent does not want. For example, an adolescent may expect others to reject her in relationships. Thus, she is less willing to interact with others and builds a brick wall around her to avoid being close to others. Since other people do not know why she does this, they may think that she is not interested in having a relationship and leave her alone. As a result, she may feel rejected. Adolescents with abuse histories experience great difficulty in situations that trigger schemas about power and control. For example, an overworked

55

7/05
adolescent may feel taken advantage of by her boss who does not pay her what she deserves. This may remind her of an abusive childhood experience and trigger intense anger. The adolescent may be likely to act on feelings that belong to the past instead of responding to the current situation. Clearly, the feeling of anger toward her boss is understandable; however, the intensity of the feeling and the way she expresses it will determine the outcome. If her feelings and schemas from the past drive her behavior, it is unlikely that she will meet her current relationship goals. For example, the adolescent may withdraw and become passive, or she may express anger inappropriately to her boss in an effort to defend herself. Neither of these responses is likely to result in meeting her goal of getting a raise and improving her situation at work. Communicate to the adolescent that one of the primary goals of this treatment is to help her identify relationship schemas that are causing her problems. Initially, the emphasis will be on helping her learn how to recognize when strong feelings from the past affect her. Next, she will learn to catch and manage these feelings before they interfere with present relationships. The therapist may say, Very often people with histories of abuse have strong feelings about upsetting things from the past that get in the way of their current relationship goals. These intense feelings may cause them to act in ways that worked for them when they were in abusive situations, but may no longer work in new relationships. Can you think of times when your feelings have gotten in the way of meeting a relationship goal?

Challenges It is important to note that identifying schemas may initially lead the adolescent to feel overly critical of herself and pessimistic about the future. Thus, it may be helpful to remind her that the goals of the next several sessions will be to create and test different schemas (i.e., different ways of thinking, feeling and behaving in relationships). When addressing distinctions between strong feelings from the past and current relationship goals, be sure to discuss how choosing not to act on these strong feelings does NOT invalidate them or imply that they are inappropriate. Many adolescents with abuse histories are quick to feel ashamed or invalidated. The goal is not to increase the adolescents distrust in her own perceptions. The goal is to help her be aware of situations that trigger feelings from the past that are no longer helpful. Although the adolescent will still be vulnerable to these feelings, the hope is that she will feel more aware of and in control of them. Additionally, she will learn to make new choices in terms of how much these reactions will influence her current behavior. Clinical Illustration

56

7/05

C is a 16- year-old adolescent with a history of physical and sexual abuse by her father, which lasted from ages 8 to 13. Subsequently, childrens services removed her from her parents home and placed her into foster care. C described her household as isolated, chaotic and unpredictable. Her father drank heavily and often became violent. He would become enraged if the slightest thing did not go his way and frequently took his anger out on C. C learned early on that one way to avoid abuse by her father was to be passive and not call any attention to her own needs. When he showed the smallest hint of irritation, C attempted to calm him by being overly helpful and by trying to meet his every demand. Although C no longer has contact with her father, her ideas about relationships that came from this environment continue to guide her behavior in powerful ways. Now, C responds to upsetting situations by becoming passive and is afraid to voice her own needs. She constantly expects others to take out their anger on her and goes to great lengths to avoid provoking anger, sometimes at a great cost to her self. For example, Cs boyfriend had been pressuring her to have sex with him. Although C did not feel ready, she felt she had to give in in order to make sure he wouldnt get mad and dump me. C also complains that she doesnt know how to stand up for herself when talking to friends. She says that she goes along with all of their plans, even when she does not want to because she is afraid to disappoint or anger them. During treatment, one of the primary tasks was to help C become more aware of the above relationship schema. The therapist helped her to understand that while the schema worked for her in childhood because of the specific needs of her father, it was creating problems in her current relationships. In addition, it was useful to clarify the differences between the past (experiences from which the schema was developed) and the current situation. This helped keep C from sliding into the trap of thinking the present is identical to the past, or that she is doomed to repeat the past. The therapist made the following observation: As a child you acted passive because you had very little power and few choices. Now that you are somewhat older and no longer live with your father, you have more supports, such as the people in your group home, friends to speak with and a therapist you can trust. These supports can help make the difference in how you can deal with this situation. 4. Introduce the Challenging Schemas Worksheet The Challenging Schemas worksheet helps adolescents identify and understand what their relationship schemas are and how they come up in the present. This exercise can help make the concepts described above more concrete and personal to each adolescent. Given that many trauma survivors have difficulty holding onto insights from one week to the next, these tools create a record that the adolescent can refer to in later sessions.

57

7/05
It is important to describe the schema worksheet and its rationale. At this time, the adolescent should be comfortable completing the Self-Monitoring of Feelings worksheet. Present the schema worksheet in a similar way, highlighting its importance for discovering information about how the adolescent interacts with others. The therapist should allot time in the session to fill out a schema worksheet with the adolescent and answer any questions about how to use the form on their own. Begin by asking the adolescent about a recent situation in a relationship that was difficult. Prompt the adolescent to respond to the questions in each column of the form and record their answers: What happened in this situation? What did you feel and think about yourself in this situation? What did you feel and think about the other person in this situation? What action did you take, what did you do? Next, continue with the bottom half of the worksheet. Explain to the adolescent that there are other ways she could have reacted to this situation. Help her to come up with ideas about different thoughts and actions. Prompt the adolescent to respond to the questions raised in each column of the form and record their answers: What are your relationship goals in this situation? What else can you feel and think about yourself in this situation? What else can you feel and think about the other person in this situation? What else can you do?

Challenges The adolescent is completing complex work in this session. It is common for adolescents to have difficulty remembering key concepts, particularly around challenging schemas. It may be useful to record important points on an index card (i.e., alternative beliefs the therapist and adolescent identified during the session such as, Everybody makes mistakes. Even when I make mistakes, people will accept me.) This provides the adolescent with something tangible to take with her and review between sessions. Clinical Illustration L is an 18- year-old adolescent girl with a history of childhood sexual abuse by her older cousin. When L told her family about the abuse, they told her to stop making up such ridiculous stories. They were angry with her for shaming the family name. Ls family rarely discussed their feelings or problems openly. They wanted people to think that everything was just fine. Ls parents frequently told her, Stop making trouble for us. Why do you always have to exaggerate everything? or Quit focusing on the negative. In treatment, L shared that she was beginning a new relationship and wanted it to be different. She had never had a long-term boyfriend and many guys felt she was cold and distant. Despite Ls wish to become more open and emotionally

58

7/05
close, she found herself behaving in this new relationship as she had in her past relationship with her family. She talked about being distant from her boyfriend even when he asked her what was bothering her. The therapist used this situation to demonstrate the use of the schema worksheet. With some prompting and guidance from the therapist, L was able to break the situation down. L described how over the week she was feeling very upset about a recent argument she had with her mother. She considered sharing what was going on with her boyfriend as a way of beginning to open up to him. L was able to identify feelings/thoughts about herself that she felt like a trouble maker who might embarrass her family by telling an outsider about her fight. She was also able to express feelings/thoughts about her boyfriend like; he would not believe her and would think that she was exaggerating her feelings about the fight. She was also afraid that he would be uncomfortable and angry with her for talking about negative things and would not want to spend time with her. As a result, L did not share what was happening, shut out her boyfriend and remained upset and very stressed out. Using the worksheet, L identified her relationship goal and came up with different thoughts that she could have about herself and her boyfriend. She acknowledged that her goal was to be more open with her boyfriend. Instead of feeling as if she was causing trouble by speaking about something negative, L realized that what she wanted was simply to share her feelings and get support from someone she cared about. She also realized that instead of rejecting her, her boyfriend might be glad that she was beginning to trust him and confide in him. L wrote down a different action:When my boyfriend asks me what is wrong, I can tell him what is on my mind. If I dont feel ready to tell him about it, I can tell him that its really hard for me to talk about it right now, but that I want to share it with him when I feel ready. 5. Assign Between-Session Work Assign between-session work of completing the Challenging Schemas sheet 2x a week.

6. Review Coping Skills and Safety Plan Each session should end with a review of the adolescents coping skills and a review of the safety plan contained on the adolescents index card.

59

7/05
Session 8: Introduction to Role-playing: Feelings vs. Behavior Agenda 1. Review Between-Session Work (Clear Communication or Challenging Schemas sheets) 2. Describe Role-Playing 3. Practice a Simple Role-Play 4. Identify Difficult Situations and Conduct Role-Plays 5. Assign Between-Session Work: Dealing with Others sheet 6. Review Coping Skills and Safety Plan

1. Review Between-Session Work (Clear Communication or Challenging Schemas sheets) If the adolescent last completed session 7, review the Clear Communication sheet. Address any difficulties completing this sheet and provide positive reinforcement. If the adolescent completed the optional session following session 7, review the Challenging Schemas sheet. Determine whether she had any difficulty completing the form between sessions. If she did not complete the form, discuss her reasons for not doing so and fill out the form together, making sure that she not only understands the purpose of the whole worksheet, but each column. If the adolescent filled out a schema worksheet, review the sheet together, column by column, and follow-up with questions such as, How did you feel after you filled it out?, Was it helpful?, Were you able to see how your thoughts, feelings, and behavior impacted others and vice versa? Can you see that perhaps the next time, you might handle the situation differently? 2. Describe Role-Playing In role-playing exercises, the adolescent plays the roles of her self and another person in a recent upsetting situation. The goal is to think about and practice different ways of behaving. The therapy is a safe place for the adolescent to practice reacting to difficult situations and get feedback from the therapist. The purpose of the role-play is for the therapist and adolescent

60

7/05
to understand what a specific upsetting situation is actually like, and to discuss how the adolescents behavior helped or kept her from getting what she wanted in that situation. Note: It is important for the therapist to pay attention to and praise the adolescents behaviors that are particularly effective.

3. Practice a Simple Role-Play Select an everyday situation that is not particularly upsetting to the adolescent to demonstrate how to do a role-play. Examples include getting directions from a bus driver, asking a teacher for more time to complete an assignment, or getting help from a store clerk to make a purchase.

4. Identify Difficult Situations and Conduct Role-Plays Ask the adolescent to identify one difficult or challenging situation with another person. Ideally, this situation should be somewhat upsetting so that it is important to the adolescent but not overwhelming. Conduct a role-play of the identified situation with the adolescent acting as herself and the therapist acting as the other person in the situation. Before beginning, the therapist should ask the adolescent for specific background information to help he/him respond in a realistic and helpful way. This role-play will give the therapist an opportunity to see how the adolescent has dealt with (or plans to deal with) the situation, rather than relying on the adolescents second-hand description. After completing the role-play, the therapist can share observations, provide feedback, and make suggestions for improving communication and outcomes. When providing feedback, it is important that the adolescent not feel criticized or misunderstood. It is essential to point out strengths, as well as weaknesses, regarding the adolescents style of communication (e.g., When you were describing your feelings about x, you were very clear ). When addressing problems or sticking points, the therapist should talk about how the other person in the situation might have felt or acted. Using the therapists own perceptions might be overwhelming or confusing to the adolescent (e.g., A person in this situation might feel hurt by your comment that you dont really care what she thinks). Most adolescents can benefit from general tips about communication. These may include ways to express feelings without upsetting the other person or getting caught up in side issues. For example, it is important to emphasize how ones feelings cannot be wrong and how adolescents sometimes play

61

7/05
down the importance of their feelings or requests. For example, many adolescent girls will be overly apologetic or start with phrases such as, I know this may seem like Im making a big deal of this, but or I dont mean to be picky, but. Repeat the role-play with the therapist now playing the adolescent and the adolescent acting as the other person in the situation. This is an ideal opportunity for the therapist to model behavior for the adolescent. When the role-play is complete, ask the adolescent how the interaction sounded and whether she could really picture herself using that language and/or behavior. It is also helpful for the therapist to acknowledge how challenging it can be to act in situations when one feels upset. The therapist will be in a good position to comment on this after having had the experience of playing the role of the adolescent (e.g., I can really see how having your classmate say those things would make you feel pretty sad). Finally, the therapist and adolescent should reverse roles once more, giving the adolescent the opportunity to play herself again. In this role-play, the adolescent is encouraged to try behaving in a different way. Afterward, the therapist should ask the adolescent to describe how the role-play felt this time as compared to the first time. Hopefully, she will notice some differences after listening to the feedback. The adolescent may practice the situation until she feels confident about dealing with it. After role-playing, work with the adolescent to complete either the Dealing with Others handout or the Challenging Schemas handout using one of the specific situations role-played in the session. Adolescents who completed session 7A should complete the Dealing with Others handout. Adolescents who completed session 7B should continue working on the Challenging Schemas handout.

Challenges Many adolescents are embarrassed to participate in role-plays. It is important for the therapist to present the activity in such a way that the adolescent does not feel that she is on the spot to perform. The therapist may say, I know doing these role-plays may feel a little awkward at first, but once you get the hang of it, they can be really be useful. Lets try it for a minute and see how it goes. Because of their abuse histories, many adolescents are very sensitive about doing things the wrong way. Adolescents may become angry and defensive, or feel ashamed and withdraw. Neither of these helps the adolescent to establish and practice new relationship skills. Thus, it is critical for the therapist to emphasize the importance of trying new behaviors, as opposed to rejecting the adolescents current ways. Communicate explicitly that there is no right or wrong way to express

62

7/05
oneself, but rather a range of options she can choose from depending on the message she would like to convey in a given situation. Clinical Illustration C is a 14-year-old girl with a history of child sexual abuse by her father. She has been living with a foster mother since age 10. C enjoyed receiving the attention and love from her new mother and became very excited when her foster mother decided to adopt her. C began to excel in school and greatly improved her relationship with her classmates. Recently, Cs foster mother took another child, M, into her care and thought about adopting her as well. C reacted to this news very poorly and began to act out in school. C reports that she now gets easily upset and angry and has a difficult time getting along with others. C shared the above situation with her therapist. The therapist helped C to connect her behavior at school with her feelings about having her foster mother adopt a new child. C was able to identify that she was feeling nervous that her foster mother would not give her any more attention or love her as much as she had in the past. She also identified that she felt angry and jealous of M because she felt like she was taking over her spot in the family. The therapist discussed with C possible options to deal with the situation. The therapist suggested that C could share with her foster mother some of her feelings about having another child enter the family. Initially C responded, Im too embarrassed to talk about it. What would I say anyway? C felt overwhelmed at the idea of explaining her feelings to her foster mother. She feared her foster mother would think she was completely ungrateful and reject her. The therapist suggested a role-play as an experiment to give C an opportunity to think about safe and comfortable ways in which she could share with her foster mother without pushing her away. Initially C played the role of herself and the therapist her foster mother. She began, I dont mean to sound ungrateful and it really isnt a big deal, but I dont feel as good around the house now. At the end of the role-play, the therapist gave C feedback on how this might come across to her foster mother. Specifically, the therapist observed how, in her effort not to offend her foster mother, C downplayed her fears and concerns and was not able to express fully how she was feeling. In real life, her foster mother might not clearly understand Cs concerns and be unsure as to how to respond, which in turn could lead C to feel rejected. The therapist noted that C might feel better if she directly expressed what was going on inside of her. C agreed with the feedback and wanted to try the role-play again. This time she stated to her foster mother, Im hate having M around. You are going to love her more than you love me and you will forget all about me. The therapist praised C for expressing her feelings more directly, but observed how in this role-play, she may have gone too far in other direction which could result in her foster mother feeling attacked and defensive.

63

7/05

Next, the therapist played the role of C and C played the role of her foster mother. The therapist modeled an example of how C might express her feelings more clearly and directly without becoming overly attacking. I have been feeling very nervous and angry since you decided to adopt M. I love you very much and I am scared that now that you have another daughter you are not going to care about me as much. I am nervous that M will take my spot in the family. I liked things the way they were and now I am afraid that I will lose that. Then, she paused to allow the foster mother to respond. The therapist asked C how this sounded to her. C replied, It sounds good when you say it, but Im not sure Ill be able to say like that. The therapist then switched roles again with C to allow her to use the feedback in way that felt natural and comfortable for her. 5. Assign Between-Session Work Assign the between-session task of having the adolescent practice different approaches to difficult situations. Have the adolescent use either the Dealing with Others or the Challenging Schemas handouts to record at least one situation on paper.

6. Review Coping Skills and Safety Plan Each session should end with a review of the adolescents coping skills and a review of the safety plan contained on the adolescents index card.

64

7/05
Session 9: Role-playing with Focus on Assertiveness Agenda 1. Review Between-Session Work (Dealing with Others handout or Challenging Schemas handout) 2. Define Assertiveness 3. Identify Current Difficulties in Assertiveness 4. Provide Psychoeducation about Effective Assertiveness 5. Conduct Role-play of Situations Requiring Assertiveness 6. Assign Between-Session work: Dealing with Others handout or Challenging Schemas handout 7. Review Coping Skills and Safety Plan

1. Review Between-Session Work (Dealing with Others handout or Challenging

Schemas handout)
Review the adolescents Dealing with Others or Challenging Schemas handout. Assist the adolescent in understanding situations that did not go as planned. Together, discuss other behaviors that might have worked better, and how sometimes, no matter how hard we try, things just dont go our way. Reinforce the adolescents attempts at this exercise.

2. Define Assertiveness Begin by defining assertiveness. Explain that being assertive means that a person stands up for her rights by clearly stating her needs or wants in a respectful way. Give the adolescent the list of Basic Personal Rights. Review the rights briefly and ask the adolescent to read it carefully at home. Distinguish assertive behavior from non-assertive and aggressive behavior. In non-assertive behavior, the adolescent ignores or does not express her own rights, needs, and wants. She allows others to go against her rights, or take advantage of her. Non-assertive behavior may lead the adolescent to feel hurt, nervous, disappointed in herself, or even angry.

65

7/05
In aggressive behavior, the adolescent takes out her needs or wants in a disrespectful way, such as by acting out with hostility. Aggressive behavior may lead an adolescent to feel angry, frightened, and guilty. In assertive behavior, the adolescent stands up for her rights in a way that respects the rights of others. Assertive behavior may lead the adolescent to feel confident. 3. Identify Current Difficulties in Assertiveness Help the adolescent identify her personal difficulties with assertiveness. At this point, the clinician is likely to have a good sense of the problems the adolescent has in either being too assertive (i.e., aggressive), underassertive, or both. The clinician should work from specific, real-life examples and look for patterns in the adolescents assertive behavior. The therapist may say, Sometimes people have a hard time expressing their feelings and needs. They may come across as too strong or do not stand up for what they want. Last week, we talked about how you felt when your friend canceled your weekend plans. You became upset and left an angry message on her answering machine. Do you find that when people disappoint you, you become really upset and angry with them? Discuss the adolescents past experiences practicing assertive behavior. Encourage the adolescent to give examples of how others at home modeled assertive, non-assertive and aggressive behavior. Discuss how the adolescent communicated her needs and wants and how others responded to her. The goal of this discussion is for the therapist and adolescent to have clear examples of her typical thoughts, feelings and behaviors around assertiveness and control. These examples also provide details for use in the role-plays. Linking difficulties with assertiveness to early experiences will help to reduce any sense of blame the adolescent may feel about difficulties she may have with her thoughts and behavior.

4. Provide Psychoeducation about Effective Assertiveness It is important to point out that behaving assertively does not guarantee that people will do what we want them to. Sometimes people respond negatively no matter how assertive or respectful we are. Explain to the adolescent that she may still receive negative or unhelpful responses to her assertive behaviors, but that overall she will be more successful in dealing with others. Practice using I messages. This will be a review for adolescents who completed session 7A. The therapist may ask the adolescent to describe

66

7/05
what she remembers about I messages and practice using the skill for a recent situation. For adolescents who completed session 7B, explain that the I message helps us tell another person about how their behavior affects us. The purpose of an I message is to focus on what happens as a result of another persons behavior instead of blaming that person. By focusing on the results of a behavior, the adolescent is less likely to make the other person feel attacked. Encourage the adolescent to say the persons name and make eye contact when using I messages. An I message has 3 parts: a behavior, feeling, and result.

1. Behavior: doing? 2. Feeling:

What is happening around you? What is the other person

How does the persons behavior make you feel? What happens as a result?

3. Consequence:

Use this form sentence: When you ____________, I feel _______________ because_______________ (behavior) (feeling) (result)

Examples: (Help the adolescent identify the behaviors, feelings, and results.) When you didnt pick me up, I felt frustrated because I missed my appointment. When you lied about breaking the vase, I felt angry because I got in trouble for it. When you invited me to the movies, I felt happy because I got to spend time with you.

67

7/05

Model for the adolescent how she could have used an I message in a recent situation, and have the adolescent practice using the skill. 5. Conduct Role-plays of Situations Requiring Assertiveness Complete a role-play of a difficult situation with another person identified earlier with the method described in Session 8.

Challenges Having the therapist take on the role of a person with whom she fears interacting (e.g., a critical teacher) can be distressing to the adolescent, especially if the therapist is effective in role-playing a critical attitude. The adolescent can become convinced that the therapist has negative feelings towards her, which may shake her sense of trust in the therapeutic relationship. The therapist should reinforce the strength of the therapeutic relationship. The therapist may say, It may be uncomfortable for you having me act in this way, but this is just an exercise designed to help you. Remember, this therapy is a place where you can feel safe and comfortable. Often, we try different approaches and even play other people to show problem areas in your life and how you can begin to make positive changes. Adolescent abuse survivors often find that communicating anger in an assertive manner is an especially difficult, even threatening task. They have witnessed firsthand the dangerous consequences of anger through the aggressive acts of their abusers. They are often unaware that they can communicate anger in a way that is safe and useful. For abuse survivors, others may have minimized their anger, leading to feelings of powerlessness, frustration and rage. On the other hand, survivors can also express anger aggressively, leading to feelings of intense guilt, anxiety and fear. Role-playing can help the adolescent develop new ways to communicate her anger appropriately and assertively.

Clinical Illustration K is a 15-year-old adolescent girl who has been having a difficult time in school. She has been receiving poor grades on her exams and her teacher recently sent her out of class for refusing to participate. K s foster mother has been

68

7/05
receiving phone calls from her teacher regularly to complain that K no longer puts any effort into her work. The teacher recently scheduled a meeting with K and her foster mother to address the current situation. Although K feels badly that she is not doing well in school, she says that she no longer tries because she is very angry with her teacher. She thinks that her teacher never listens to anything she says and unfairly picks on her and singles her out in class. K shared the above situation with her therapist. They discussed possible options for how K might manage her anger at her teacher. The therapist suggested that at the upcoming meeting, K could share with her teacher some of what she was feeling and discuss some of the reasons why she was no longer doing as well in school. Initially K responded, I couldnt do that. What would I say? She wouldnt listen to me anyway. K felt that she was powerless to change the situation and feared that she would continue to do poorly for the rest of the school year. The therapist suggested a role-play as an experiment to give K a chance to think through a way that she could express her feelings to her teacher in a way that the teacher might respond positively. Initially K played the role of herself and the therapist her teacher. She began, I dont want to be getting such bad grades and I dont mean to always talk out of turn Im just a little unhappy in the class and thats why Im not doing so well. The therapist praised K for her effort to communicate her feelings and provided her with feedback about how this might come across to her teacher. Because of K s indirect style, the teacher may have difficulty understanding that she feels mistreated in class. Alternatively, K s teacher may pick up on the undertone of anger in her words and become defensive because K did not address the situation openly. The therapist pointed out that K s indirect style kept her feeling safer, but might prevent her teacher from responding directly to her concerns. This would reinforce K s idea that her teacher does not listen to her. The therapist also probed for K s emotional experience of the role-play and verified that she was feeling angry, frustrated and resentful. K agreed with the feedback and asked to play herself again in the role-play. This time she started, You dont listen to me in class and youve been picking on me. You let other people get away with things that you dont let me get away with. I dont bother to try because Im just going to get punished no matter what. At the end of the role-play, the therapist gave K feedback on how this might come across to her teacher. The therapist praised K for her effort to express her feelings more directly, but provided her with feedback that her teacher may feel attacked by this approach and respond in a defensive manner. The therapist then modeled ways in which K could present her feelings to her teacher in an assertive manner using I messages. The therapist said, I have been upset in class lately because I feel that Im singled out more than any of the other kids. It makes me not want to put any effort into my work. The therapist asked K how this sounded to her. K replied, It sounds good. I didnt know you

69

7/05
could say things like that. The therapist then switched roles again with K to allow her to practice expressing herself in way that felt natural and comfortable for her. 6. Assign Between-Session Work The most important task for the week is to practice effective assertive behaviors. Have the adolescent identify a possible activity or situation that will require assertive behavior in the next week. Have her complete either the Dealing with Others handout or the Challenging Schemas handout.

7. Review Coping Skills and Safety Plan Each session should end with a review of the adolescents coping skills and a review of the safety plan contained on the adolescents index card.

70

7/05
Session 10: Review of Skills Learned and Transition to Narrative Storytelling (NST) Agenda 1. Review Between-Session Work 2. Acknowledge Last Skills Session and Review Progress 3. Provide a Brief Rationale of Narrative Storytelling (NST) 4. Elicit Questions and Concerns about Transition to NST 5. Assign Between-Session Work 6. Review Coping Skills and Safety Plan 7. Assess and Review PTSD Symptoms

1. Review Between-Session Work (Dealing with Others handout or Challenging Schemas handout, practicing assertive behavior) Review the adolescents Dealing with Others or Challenging Schemas handout, with an emphasis on issues involving assertiveness. Assist the adolescent in understanding situations that did not go as planned, and together discuss other behaviors that might have worked better. Also discuss how sometimes, no matter how hard we try, things just do not go our way. Reinforce the adolescents attempts at this exercise. Discuss any additional situations in which the adolescent either struggled with assertiveness or practiced assertiveness skills.

2. Acknowledge Last Skills Session and Review Progress Acknowledge that this session marks the end of the Skills-building phase of treatment. Review with the adolescent the work she has done in building and practicing skills to cope with her feelings, deal with difficult situations, and get along with others. Reinforce strengths and positive feelings about the adolescents hard work and accomplishments. Congratulate the adolescent on her hard work and progress during Skillsbuilding. Try to highlight the details of the adolescents progress. The therapist may praise the adolescent with comments such as, You have been really motivated to work on some tough issues, You seem to be able to control your anger more effectively, You have really made an effort to do

71

7/05
your homework regularly. Even praising an adolescents improvement in attendance and timeliness can be immensely helpful at this time. Ask the adolescent for her own thoughts about her progress. Discuss the areas in which she has continued to grow and improve, and let her know that you will continue to build and practice skills during the next phase of treatment. Clinical Illustration R is a 17- year-old adolescent girl who has difficulty controlling her anger and tends to lash out at people close to her when she feels threatened and vulnerable. During therapy, R recognized how her angry feelings interfered with her relationship goals and led her to act in ways that she later regretted. While reviewing her progress, Rs therapist pointed out to her, In the past, you tended to get really angry at people when you felt hurt and disappointed. Often, you wanted to cut off your relationship with them completely. Do you remember when your boyfriend said something you did not like and you immediately wanted to break up? Now, you seem to manage your angry feelings much better. You do not feel as if you have to walk away from relationships when something happens to upset you. You seem more able to identify your goals in relationships, weigh the pros and cons of the situation and tell the person how youre feeling in an assertive way. 3. Provide a Brief Rationale of Narrative Storytelling (NST) Remind the adolescent that in the next phase of treatment, your work will shift toward helping her to make sense of her traumatic memories. She will accomplish this by talking about her traumatic memories repeatedly and understanding their meaning for her now. Explain to the adolescent that in the past, she may have avoided thinking about these memories because they felt overwhelming and upsetting. Avoiding these thoughts and feelings, however, prevented her from understanding and making sense of these painful experiences. The symptoms she currently experiences, such as flashbacks, difficulty sleeping and upsetting feelings and thoughts, are signs that she still has some unfinished business related to the trauma. The storytelling work (NST) will allow her to explore some of these feelings and process them in a safe and comfortable environment with the therapist, while using the relaxation and coping skills she learned in the first phase of treatment. Some adolescents may be very anxious at the idea of talking about their abuse, especially in detail. The therapist may explain that the work will begin slowly. The adolescent will first talk about the memories that are least upsetting, and then gradually work up to more difficult ones. Also, emphasize that the work will be collaborative, that the adolescent will determine the pace of the work and stop if she needs to. Reassure the adolescent that she also developed new coping skills during the first phase of

72

7/05
the treatment to help her with NST. Reiterate once again what those skills are, and how they can be helpful in relieving upsetting feelings. 4. Elicit Questions and Concerns about Transition to NST Many adolescents have worked hard at putting the past behind them so that the idea of talking about traumatic memories can feel very threatening. This is particularly true of adolescents whose memories of the abuse may still be painfully raw. Other adolescents may have had upsetting experiences related to sharing their abuse and are therefore skeptical about how NST can be helpful. Ask the adolescent whether she has any questions or concerns about transitioning to NST. Does she understand the rationale and procedure for NST? What are her concerns and fears about starting to do NST? Encourage the adolescent to be up-front about her concerns. Let her know that she will have time in the next session to discuss any additional questions or concerns she may have about NST.

Challenges Many adolescents are very hesitant about beginning the storytelling work. It is common for an adolescent to skip the next session as a way to avoid dealing with painful feelings about the abuse. If the therapist thinks there is a possibility that the adolescent may no-show the following week, it is often helpful to bring this up during session. The therapist may say, It is very understandable for you to be nervous when talking about these painful issues. I am wondering if one way you are thinking about coping with your feelings is to not come for our session next week. Some adolescents feel frightened about the storytelling work because they may have been upset in the past when they tried to talk about the abuse. One adolescent reported, When I tried talking to my parents about what happened, they just got upset with me and told me not to talk about these things. I never said another word. After awhile, I think I was able to convince myself that it didnt happen. In order to reassure an adolescent, the therapist may say, I know that other people may have told you to ignore your feelings and not to talk about them, but therapy is a place where you can feel safe and comfortable exploring these painful feelings and memories. Some adolescents do not want to do the storytelling work because they are afraid that the painful feelings will overwhelm them if they talk about their abuse. An adolescent may say, The last time I talked about what happened to me, I got so depressed I couldnt get out of bed or go to school for a week. Another adolescent may have attempted suicide in the past and is afraid that she will become so upset that she may try to hurt herself again. The therapist may try to

73

7/05
reassure the adolescent by saying, Bringing up these memories can be very frightening at first and you may feel more upset than usual while doing storytelling work. However, understanding and making sense of what happened to you is an important step in helping you to feel better over time. In order to make sure that you feel safe and comfortable during the storytelling, you can control the pace and decide which memories will be the easiest for you to start with. If you feel that you might become overwhelmed, we can take a break and stop for a bit. 5. Assign Between-Session Work The adolescent should continue to practice using either the Dealing with Others or Challenging Schemas sheet. Encourage her to think about the next phase of treatment between sessions and bring in any questions or concerns to the next session.

6. Review Coping Skills and Safety Plan Each session should end with a review of the adolescents coping skills and a review of the safety plan contained on the adolescents index card.

7. Assess and Review PTSD Symptoms Now that the adolescent has completed Phase I of the treatment and is ready to begin Phase II, the therapist or clinical evaluator should administer the CAPS-CA to assess current symptoms of PTSD. The therapist or evaluator should review the adolescents symptoms with an eye toward noting progress or improvements and to clarify areas that may still be problematic. The therapist may administer the CAPS-CA at the end of session 10. It is a good idea to make plans in advance to let the adolescent and parent/guardian know that she will be in your office for an additional twenty to thirty minutes on that day.

74

7/05
Session 11: Introduction to NST *Note to Therapist: Using the SUDS Rating Scale Subjective Units of Discomfort (SUDS) refers to the intensity of an emotional experience. For example, an adolescent may indicate that she feels just a little upset when her mother scolds her at home; however, she may feel very upset when a peer at school teases her. The SUDS Rating Scale includes ranges of numbers from 0-100 (see attached SUDS Rating Scale). These ratings help the adolescent to establish anchors that she can use to rank her severity of distress during NST. Each adolescent will have her own unique rating system based on her personal life experiences. Hence, one adolescent may report experiencing a SUDS of 50 when describing a memory of sexual abuse, whereas another adolescent may report experiencing a SUDS of 90 when describing a very similar experience. The SUDS rating scale is valuable to treatment because it allows the adolescent and therapist to speak the same language, and have a mutual understanding of the adolescents subjective emotional experience. This is particularly important during NST because it allows the adolescent and therapist to track changes in her level of distress to detect hot spots and monitor habituation. Agenda 1. Review Between-Session Work 2. Review Safety Plan with the Adolescent 3. Rationale for NST 4. Elucidation of Memories 5. Review Difficulties Concerning Coping Skills and Relationships 6. Assign Between-Session Work: Mastery and Competency Activity

1. Review Between-Session Work (Dealing with Others handout or Challenging Schemas handout, address questions or concerns about NST) Review the adolescents Dealing with Others or Challenging Schemas handout. Assist the adolescent in understanding situations that did not go as planned, and together discuss other behaviors that might have worked better. Also, discuss how sometimes, no matter how hard we try, things just do not go our way. Reinforce the adolescents attempts at this exercise. Invite the adolescent to discuss any questions or concerns she has about her transition to NST.

75

7/05

2. Review Safety Plan with the Adolescent Ask the adolescent if she still has her safety card handy in her backpack, wallet, or pocket. If she does not, create a new one. Review the three-point plan so that you are both clear on the plan as you enter this next phase of treatment. In addition, the therapist and adolescent should review this plan the end of each session going forward.

3. Rationale for NST The first goal of this session is to re-introduce the rationale for NST. Again, it is natural for the adolescent to be anxious about beginning this new phase of treatment. Many adolescents say they feel it is time for them to face their fears and deal with their traumatic memories. However, when phase II approaches; they may feel that they are not ready. It is important to normalize the adolescents fears at this time. The therapist may say, I know you may be frightened, or think that you may not be able to handle this. Remember that working with your traumatic memories is one of the reasons you came into treatment. During our last session, we talked about how this part of the treatment may be painful, but in the long run, it will help you feel better about yourself and your relationships. It can help you deal with stressful things that come up in your day to day life.

76

7/05
The therapist should explain the purpose of NST in a clear and understandable manner. Explain to the adolescent that the purpose of NST is to have her relive some of her childhood abuse memories. The therapist may say, It is not easy to understand and make sense of traumatic experiences. When you think about the abuse, or something reminds you of it, you may feel upset. The abuse was very upsetting, so you may want to push away or avoid the painful memories. You may tell yourself, I just have to forget about it. However, as you have already discovered, no matter how hard you try to push away thoughts about the abuse, they come back to haunt you through nightmares, flashbacks, and upsetting thoughts and feelings. These symptoms tell you that the abuse is still unfinished business. In fact, trying to avoid memories of the abuse can make you feel more anxious and upset about the memories. This is because avoidance keeps you from making sense of the thoughts and feelings that go along with the memories. After something happens, your mind starts to organize all of the pieces into a story. When your mind puts all of the pieces together, your feelings are easier to deal with. However, if your mind misses some of the pieces because you avoid the upsetting parts, it never gets to finish the story. When this happens, your feelings can be strong and overwhelming. The goal of this treatment is to help you put all the pieces of your memories together by remembering the abuse. Staying with these memories rather than running away from them may be very upsetting at first. This is a normal reaction. However, over time, it will help you feel less anxious and afraid than you felt when it happened. It is normal to want to avoid memories, feelings and situations that remind you of the abuse. However, the more you avoid dealing with the memories, the more they bother you. As a child, you may have tried to tell others what was happening to you. You may have found that people you tried to tell about the abuse did not believe you or did not want to listen. Someone may have told you to pretend it was not happening, or to try to forget about it. Today, you might not want to talk about it because it might make people feel uncomfortable. In this therapy, you are in a very different situation where it is safe to talk about what happened. I want to hear all about your experiences and will be a good listener. As noted in Session 10, many adolescents feel afraid to talk about the abuse and have a hard time starting the storytelling work. At this point, it is very important to talk about any concerns the adolescent has about this phase of the treatment.

77

7/05
4. Elucidation of Memories During the adolescents initial assessment, she may have provided a brief and general description her abuse without going into details about her most disturbing memories. To prepare for NST, the therapist will need more specific and detailed information about the abuse memories. The therapists role is to assist the adolescent in describing the memories that she will use in the storytelling. Adolescents memories of their abuse experiences vary greatly. Some adolescents may only have one memory, whereas others have many. For this treatment program, ask the adolescent to identify her most disturbing memories that affect her most in her daily life. Before you begin, explain to the adolescent: We will begin doing the storytelling in the next session. In the meantime, we will prepare for it several ways. You have begun to learn how to cope with some upsetting feelings by using the skill of deep breathing. I want to encourage you to continue to practice this skill. Another thing we need to do to prepare for the storytelling is to pick which memories you will talk about. To do this, I need to know more about your memories of abuse. I would like you to describe any specific memories you have of the abuse you experienced as a child. Please tell me about the memories that stand out for you the most, the memories that haunt you regularly during the day or night, the images that you find difficult to get out of your mind. What specific memory first comes to your mind? Tell me what you recall. The therapist should record the adolescents memories on the Memory Elucidation form. The adolescent should report a maximum of 3 memories to make sure that she will have enough time to tell her memory in detail many times over the next few sessions. However, the therapist may only get to 1-2 memories during NST, depending upon how long it takes the adolescents symptoms to decrease, and to deal with any potential resistance to this intervention. The adolescents reporting of her traumatic memories should be brief. It is important that the therapist not probe for excessive details about the adolescents traumatic experiences during this task. Rather, the adolescent should merely identify a few clear memories she has of her traumatic experiences. The adolescent will have time to describe her memories in detail during the actual storytelling. For example, the adolescent may report a memory of a time her mother hit her so hard that she had to go the hospital. The therapist should not probe for details about where she was hit, with what she was hit, how she got to the hospital, etc. during this session.

78

7/05
The purpose of completing the Memory Elucidation form is to compose a record of memories that the adolescent will use in the subsequent NST sessions. If the adolescent begins to provide excessive details, the therapist may gently stop her by saying, You are able to remember a lot of things about this experience. I do want to hear more about it and I will make sure that you have a lot of time to tell me about this memory over our next several sessions. For now, I just want to make a list of your memories so that we can pick which ones you need to talk about most. After the adolescent has finished describing a memory, ask her to assign a SUDS (Subjective Units of Discomfort) rating based on her level of anxiety while describing that event. Your task is to evaluate which memories cause the greatest anxiety for the adolescent. The amount of anxiety the adolescent experienced during the abuse is of less relevance. Similarly, details that the adolescent has a hard time remembering are of less importance, since those details are less likely to affect her daily symptoms (e.g., intrusive images) or functioning. After reviewing the specific traumatic incidents, spend a few minutes discussing with the adolescent which memories cause the most anxiety, and which one is the most difficult to manage. Usually, the most difficult memory has the highest SUDS rating. Some adolescents give more than one incident the highest rating. The adolescent should decide which memory is most upsetting; however, you may share your observations of her behavior while she described the events to assist her. When determining which memories are most upsetting, both memories related to childhood abuse as well as the other traumatic memories should be included.

Challenges While describing one experience of abuse, the adolescent may remember another incident, and shift topics. Gently redirect the adolescent back to describing the first event. Tell her that you will make a note of the second incident, and will return to it after she completes the first one. After you obtain a SUDS rating for the first event, you can then ask the adolescent to describe the second event. When reviewing the adolescents memories of abuse, she may identify other traumatic events (e.g., witnessing the death of a relative or close friend). You should make note of these events and plan to assess them after completing your assessment of the childhood abuse experiences, following the same procedures. If significant traumatic events have occurred, it is critical that these events be included in the assessment.

79

7/05
5. Review Difficulties Concerning Coping Skills and Relationships Review any problems or issues that arose during the past week with regard to using coping skills. Emphasize to the adolescent that although she has entered into the next phase of treatment, it is very important for her to continue practicing and using the skills she learned throughout therapy.

6. Assign Between-Session Work: Mastery and Competency Mastery and Competency: Discuss with the adolescent her talents and/or activities she enjoys. Help her to identify a personal strength (e.g., writing, sports, academics, artistic ability, or musical interest). Make a weekly plan with the adolescent to practice this activity to help her gain a sense of mastery and control, and improve self-esteem. For example, if an adolescent likes to write poetry, have her begin a notebook of poems and bring the book to session each week to show you. If she feels comfortable, she can read poems aloud in session, or consider submitting one to a local newspaper for publication. If an adolescent is interested in sports, she can set a specific goal such as trying out for the school basketball team or working up to 30 minutes of running every other day by the end of treatment. Record the adolescents choice of activity and goal on the Mastery and Competency Activity form. Tell her that you will review her progress towards this goal over the next 6 weeks of treatment.

80

7/05

* Note to Therapist: Orientation of Therapist to NST Adolescents are often reluctant to fully relive the abuse and confront feared images. The adolescent can overcome her reluctance by controlling the pace and intensity of the process. In the first few sessions of storytelling, the adolescent may need more guidance to follow through with the exercise. After several sessions, the adolescent should become more familiar with the procedure and feel less anxious. As this happens, the therapist may use fewer directive statements to bring out descriptions of the childhood abuse memories. The therapist will begin with a practice storytelling, using an imagery scene unrelated to the abuse (e.g., a walking tour of the adolescents home or some other safe place). This familiarizes the adolescent with the procedure and gives her control of the exercise before she talks about the abuse. In the first attempt to relive the abuse, help the adolescent to approach the memory gradually and determine the appropriate level of detail. This also enhances the adolescents sense of control. In subsequent episodes of storytelling, encourage the adolescent to experience the event in greater depth by probing for the emotional and physical reactions that went with the abuse. It is essential that the adolescent not end a storytelling session with a high level of anxiety. It is particularly desirable for the adolescents SUDS level at the end of the storytelling to be lower than it was at the height of the session, even if only slightly. This permits the therapist to draw attention to the fact that the anxiety is habituating. The therapist should plan sessions so that there is enough time at the end to evaluate the adolescents level of distress and, when necessary, practice deep breathing to reduce anxiety. It is very important to encourage the adolescent to talk about her reactions to reliving the abuse and to discuss new details and associations that emerge. The therapist may incorporate these into future storytelling sessions. Forms to use During NST SUDS Rating Scale: The therapist should provide the adolescent with a copy of this scale to use as a guide when she provides SUDS ratings during NST. If the adolescent is unfamiliar with the form, the therapist should spend a few moments reviewing the score ranges and asking for examples (not related to abuse) from the adolescent. For example, an adolescent may give a SUDS rating of 30 to having a disagreement with a friend and a rating of 60 to watching a scary movie. Therapist NST Recording Form: The therapist uses this form to track the adolescents SUDS ratings at various times throughout the storytelling. The therapist should record a brief description of the memory at the top of this sheet, as identified during the Memory Elucidation task. The therapist should ask the

81

7/05
adolescent for a SUDS rating before she begins storytelling of the memory and record this on the Pre-NST line. Once the adolescent begins storytelling, the therapist should request additional SUDS ratings approximately every 5 minutes to monitor the intensity if her emotions. This allows the adolescent and therapist to identify hot spots and monitor habituation. Lastly, the therapist should request a SUDS rating after the adolescent completes her storytelling and record this on the Post-NST line. It is helpful for the therapist to record notes about the content of the storytelling along with the SUDS ratings, as well as any behavioral observations. The therapist may share this information with the adolescent during the debriefing phase of the session. Therapist Form for Post NST Emotional State: The therapist uses this form to record the intensity of the adolescents emotions during NST. Since it may be difficult for the adolescent to identify and articulate feeling states during NST, this form can help her consider different emotions that traumatized adolescents often experience, particularly when re-experiencing events. The therapist completes this form after the adolescent finishes her storytelling of a memory. The therapist may ask, As you were describing this memory, how angry did you feel? If the adolescent reports different levels of intensity throughout the NST, record the highest rating for that memory. Lastly, the therapist asks the adolescent to identify the strongest feeling she experienced during the storytelling. Again, this provides useful information for the therapist and adolescent to discuss during the debriefing phase of the session. Potential Problems During NST Avoidance: In order to maintain control during the storytelling phase of treatment, the adolescent may engage in avoidance behavior. For example, she may become quiet or turn to the side while avoiding extremely upsetting memories such as the perpetrators face, having someone threaten her verbally or physically, or force her to perform sexual acts. If the adolescent has difficulty verbalizing during NST, gently encourage her to refocus on the memory and continue speaking. Avoidance can range from changing or blocking the image, to minimizing its emotional impact, to dissociation. When you notice signs that the adolescent may be using avoidance strategies during NST, you should ask, What is happening? and gently encourage her to confront the difficult image. For adolescents who are prone to dissociation during storytelling, you may want to develop a non-verbal cue that she can use to sign if avoidance is moving toward dissociation. If the adolescent is unable to confront a particular scene without dissociating, you may need to work with less threatening material in the beginning. You may reduce the intensity of the storytelling exercise by not asking for a great depth of detail until the adolescent is able to tolerate lower levels of anxiety.

82

7/05
Another effective technique that can be helpful here is the slow-motion technique. This involves focusing on the image and asking the adolescent to express her thoughts, feelings and physical reactions. If she has difficulty expressing her feelings, the therapist can say in an encouraging tone, Allow all your feelings to be present sadness, anger, guilt, fear. Behavior Changes: Some adolescents display behaviors such as rhythmic shaking, huddling, or a childish tone of voice during NST. Such behaviors typically indicate that the adolescent is fully immersing herself in reliving the abuse. It is important to carefully observe these behaviors and maintain verbal contact with the adolescent. Remind her that it is still safe with you here and that she is doing well in facing the memories. Touching the adolescents arm or hand also can be helpful to ground the adolescent in the present; however, it is important to ask permission ahead of time before using touch. The behaviors will likely diminish within and across sessions. It is not necessary to discuss these behaviors with the adolescent. Doing so may make the adolescent feel self-conscious and hold her back from reliving the experience. Sudden reductions in this type of behavior may signal that the adolescent is starting to use avoidance strategies or even dissociating. Therapist Discomfort: NST will likely include the adolescent describing events that you may find unpleasant. Moreover, the adolescents distress can itself be upsetting for you. You may want to minimize the level of detail and the degree of anxiety the adolescent experiences. You may even want to terminate the session prematurely to spare yourself and the adolescent the discomfort, distress and embarrassment of reliving the experience. You should anticipate feelings of distress and revulsion and keep in mind the importance of letting the adolescents habituation occur. Terminating an NST session prematurely can sometimes slow the habituation process. You must be prepared to guide the adolescent through the story gently. It may be helpful to develop coping self-statements of your own to help you tolerate the painful material. If you are having difficulty with this, it is essential that you seek peer support or supervision.

83

7/05
Session 12: Storytelling of First Memory Agenda 1. Review Between-Session Work 2. Review Rationale for NST 3. Practice Storytelling of Neutral Memory 4. Conduct First Storytelling 5. Terminate Storytelling 6. Debriefing 7. Assign Between-Session Work: Mastery and Competency 8. Review Coping Skills and Safety Plan

1. Review Between-Session Work (Mastery and Competency) The therapist should check in with the adolescent about her selected mastery and competency activity. Ask how often she practices the activity, how she feels while performing the activity, and any resulting beliefs about herself. The therapist should use this opportunity to praise and reinforce the adolescent. Encourage the adolescent to track her progress on the Mastery and Competency sheet.

2. Review Rationale for NST Before beginning the first storytelling, review the rationale for NST and the nature of the debriefing which will follow the storytelling work: Today you are going to spend the first half of the session reliving some of your memories of childhood abuse. The goals of this treatment are to help you make sense of your memories of the abuse and put them together into an organized story. We do this by having you remember and talk about your memories for an extended time. Staying with the memories rather than running away from them may be very upsetting at first. This is a normal reaction to those hurtful events. However, over time, it will help reduce the anxiety and fear that you have with the memories. As we have already discussed, the more you avoid dealing with the memories, the more they disturb your life.

84

7/05

As you face the memories and the strong feelings that go with them, the feelings will become less upsetting. It is important that you repeat your story a few times in session because as you repeat it, you will find that you feel less upset over time. I understand that the idea of doing this may be scary to you. I want to assure you that your braveness and sticking to it will pay off. Telling your story and allowing yourself to experience all of your feelings related to it will help reduce your fear and upsetting feelings. Keeping this in mind will help you to fight the urge to avoid the upsetting images and feelings that are part of the storytelling. Before we begin, do you have any questions about anything that I have said? Immediately after a traumatic event, people often report feeling numb, then extremely sad and pained, and sometimes angry. All of these feelings are part of a natural process that people may experience after a traumatic event. In fact, it is important to experience all feelings that are connected to a trauma to make sense of them and get to a point at which the memories are not so upsetting. The therapist may find it helpful to summarize the rationale for this treatment with the following points. Again, the therapist should strive to communicate these points to the adolescent using as simple language as possible:

Habituation: Repeated reliving of the experience for long periods will lower anxiety. The more often and longer you do it, the better it will work. Emotional Processing: Reliving a trauma memory will incorporate safety information into your memory. You will learn that remembering the trauma is not dangerous and that being anxious or upset also is not dangerous. Repetition: Repetition and long storytelling episodes are necessary because the trauma was so severe, and the fear so intense. It takes longer to process this kind of memory and to habituate to the fear. Thought Suppression: Pushing the thoughts away will not work, given the reexperiencing symptoms the adolescent has. A useful example to use is: Let me show you what I mean. For the next 10 seconds, I want you to think about that which comes into your mind EXCEPT one thing. Whatever you do, DO NOT think about a pink elephant floating above my head for the next 10 seconds. Did it work? Make the point that it is difficult, if not impossible, to push powerful images and memories out of ones mind, and that focusing on the images and memories can be helpful. 3. Practice Storytelling of Neutral Memory

85

7/05

To give the adolescent a sense of how to do the storytelling exercises, conduct a practice storytelling of a neutral memory. You may introduce the exercise in the following way: It may be helpful for you to close your eyes so you wont be distracted. However, if that makes you feel uncomfortable, you may keep your eyes open during the storytelling. (If you choose to keep your eyes open, you may find it helpful to focus on a spot on the wall.) Lets first practice with a scene from your life now that is not related to your childhood abuse. Most people are able to imagine their home or some other familiar and safe place quite easily. I would like you to get comfortable and guide me through a safe and familiar place. Tell me what is happening as you walk through this place.

Use probes to help the adolescent describe what she sees, hears, smells, feels and thinks while walking through the safe place. Encourage her to speak in first person. Also, probe for feeling states and physiological reactions. For example: What do you smell in the kitchen? What do you notice in your body? What sounds do you hear? What are you thinking?

End the practice storytelling after a few minutes and discuss the experience with the adolescent. Ask the adolescent if she has any questions about storytelling. Offer her praise for completing the exercise. For example:

You did a great job staying in the present tense. I felt like I was right there with you as you were describing your house. You did a nice job paying attention to your thoughts, feelings, and what was happening in your body. Thats exactly what I want you to do as we shift to talking about the abuse. 4. Conduct First Storytelling Have the adolescent begin storytelling with a moderately upsetting trauma memory identified during Session 11. It is typical for adolescents to be somewhat hesitant as they begin storytelling work. It will be important for you to provide reassurance, encouragement, and demonstrate confidence in the effectiveness of this technique. Now you are going on a journey back in time. I am going to ask you to remember the memories of the abuse you experienced as a child. I will ask you to recall these painful memories in as much detail as possible, as if the events are actually happening to you. Try to relive the experience; see,

86

7/05
hear, smell, taste and feel everything as if you are there. Although this can be scary, in the back of your mind you will know that you are safe here in my office. You will be in charge of reliving the abuse by describing the experience aloud. I do not want you to tell a story about the abuse in the past tense. I would like you to describe a story in the first person and present tense, as if it were happening now, right here. If you are having trouble bringing the events back to life, I will help guide you by focusing your attention on details of the experience. In our last session we spent some time reviewing some of your memories of your childhood abuse. Among those different memories, you said that you found the time in which [briefly describe the incident] to be moderately upsetting. I would like to start working on that memory today. I want you to tell me what happened during that experience in as much detail as you remember. If you start to feel too uncomfortable and want to run away or avoid it by leaving the image, I will help you to stay with it. You can signal me by [e.g., raising your right forefinger] if your upsetting feelings become so overwhelming that you are unable to stay with the image. From time to time, while you are reliving the experience, I will ask you for your anxiety level on the 0 to 100 SUDS scale. Please respond with your ratings quickly and dont leave the image. If the adolescent needs additional reassurance, you may say something like: I imagine the thought of doing this is very scary. In fact, we even have a word for this -- anticipatory anxiety. Often the anticipatory anxiety is worse than the experience itself. Eventually, imagining the abuse and talking about it will become easier for you. The way we get to that point is through repeated practice. In the beginning, reliving the abuse may make you anxious. The upsetting feelings you have are a signal that you are beginning to process the memories of your abuse. That feels bad at first, but it is a sign that you are finally working through these unfinished memories and putting them to rest. I will be here to help you get through this. This type of treatment has helped many survivors of childhood abuse and it will become easier with time. Proceed with the trauma memory. Be prepared to modify the adolescents first disclosure as necessary to control the intensity of the first storytelling session. For example, if the adolescent has difficulty tolerating a moderately upsetting memory, try a less upsetting one. Use the Storytelling Therapist Record to Record the Adolescents SUDS Ratings regularly during the storytelling exercise.

87

7/05
During the adolescents first description of her traumatic memory, it is best to keep probe questions, requests for clarification, etc. to a minimum. Allow her to describe her experience with little interruption. Most trauma survivors with PTSD experience very high levels of anticipatory anxiety before their first storytelling session, not only about their own reactions, but also uncertainty about the therapists behavior. By minimizing the number of interruptions with probes and clarifying questions in the first telling of the event (or first several reviews), the adolescent will adjust to the storytelling procedure more quickly. This will facilitate the habituation of her anxiety to the memory of the traumatic event. During the adolescents first telling of her memory, you should demonstrate good active listening skills by occasionally saying, Uh-huh, I see, etc. to reassure the adolescent that you are listening. It is best not lead the adolescent by suggesting feeling states or reactions to the trauma which she has not yet identified (e.g., That must have been frightening, Were you angry?). Rather, questions should be open-ended (e.g., How are you feeling? What happens next?) If the adolescent reports a feeling, you can paraphrase her response to show empathic listening skills. If the adolescent has a strong emotional response, such as crying, you should respond empathically (e.g., I understand that must have been very difficult to experience) and praise her for her strength and bravery in being able to deal with the experience (e.g., It takes a lot of courage to confront your memories this way. You are doing a very good job ). Without many probes, the first storytelling often takes only few minutes, usually ranging between 3 and 15 minutes. After the adolescent completes her description, request that she describe the event again, just as before. It is best if the therapist communicates this in a matter-of-fact manner, such as by saying, You did a good job. Can you describe your experience again, just as you did the first time? As before, describe any sensations, thoughts or feelings you can recall related to your experience at the time . Some adolescents have a hard time staying focused on describing the traumatic event, as evidenced by prolonged silence, talking about irrelevant details, or switching the topic to another abusive incident. When this occurs, gently refocus her on the selected memory with statements or questions such as, What happens next?, or, Ill make a note of the incident you just mentioned and we can get back to it at a later time. For now, Id like you to return to the situation you were describing earlier, and pick up at the point when... The therapist may use other encouraging comments, such as: You are doing fine, stay with the image. Stay with your feelings. I know this is difficult. You are doing a good job. Stay with the image, you are safe here.

88

7/05
Feel safe and let the feelings happen. You are getting through it. 5. Terminate Storytelling Terminate the exercise by having the adolescent open her eyes and practice her deep breathing skills. If the adolescents anxiety does decrease within the session of storytelling, comment as follows: You see, your anxiety decreases if you just continue to stay in the situation. I want you to notice that you are much less anxious now than you were at the beginning of the storytelling. I can see that you are more relaxed now than the last time when you faced this upsetting memory. As you can see, the more you face this memory, the less it makes you feel anxious. You see, you confronted the fearful memories and nothing terrible happened. Although it is still a very upsetting memory, with each storytelling it will become less scary. If the adolescents anxiety does not decrease within the session of storytelling, comment as follows: You were feeling very anxious today during the storytelling. You did a great job facing the memory. You were not sure that you would be able to do this. You can give yourself a big pat on the back.

89

7/05
6. Debriefing Debriefing is a key part of the storytelling work. The therapist should always allow adequate time for this following the storytelling itself, before moving on to work on coping and relationship skills. First, the therapist should ask the adolescent what it was like to complete the storytelling. In order to increase the adolescents sense of mastery and control, the therapist should validate the adolescent's efforts during the storytelling. Emphasize that the adolescent is taking control of the memories rather than the memories controlling her. Practice Coping Skills: The therapist should encourage the use of coping skills to restore a sense of calmness (e.g., deep breathing) and help the adolescent to regain her composure after storytelling. As this phase of the treatment continues, the therapist should continue to encourage the adolescent to use these skills and help her to realize that she now has the tools to manage upsetting feelings related to her memories. Explore Meaning of the Storytelling Narrative: Second, it is important to work with the adolescent to use the information gained during storytelling to understand her current beliefs and feelings. Work with the adolescent to understand how her abuse experiences have shaped her beliefs about herself and others, or her behavior in relationships with others. Discuss how she can use information gained during the storytelling to alter those schemas or behaviors.

Clinical Illustration An adolescent sexually abused by her stepfather for several years developed a schema that she was worthless and dirty. During storytelling, she recalled that after raping her, her stepfather would spit at her and say, You dirty whore, you wanted it. During debriefing, the therapist and adolescent focused on this aspect of her memory. The therapist helped the adolescent to incorporate it into a less selfcritical and harsh attitude towards herself. The adolescent accomplished this by recognizing that although her stepfather blamed her for his actions, she was not responsible for the rape and that, at such a young age, there was nothing she could do to prevent it from happening. Having come to this understanding, the adolescent was able to shift her sense of herself as worthless and dirty and focus on her inner strength that it required to survive this experience.

7. Assign Between-Session Work: Mastery and Competency

90

7/05

Mastery and Competency: The adolescent should practice her identified competency activity.

8. Review Coping Skills and Safety Plan Each session should end with a review of the adolescents coping skills and a review of the safety plan contained on the adolescents index card.

91

7/05
Sessions 13-15 Continued Work on Storytelling *Note to Therapist: Planning Referrals As the therapy approaches its last few weeks, the therapist should begin to think about whether the adolescent will require additional treatment. The therapist may wish to consult with a supervisor or treatment team to develop a plan for the adolescent, and begin to identify appropriate services based on the adolescents needs. The therapist should begin to discuss this plan at least 3 weeks in advance of termination to address individualized needs (i.e. the adolescent requires therapy in a particular area, the adolescent requires free treatment, the adolescent needs to check on insurance coverage). The therapist should work these details out prior to termination to allow a smooth transition. Agenda 1. Review Between-Session Work 2. Continuing NST 3. NST with Multiple Traumas 4. Moving to Another Memory 5. Selecting the Next Memory 6. Assign Between-Session Work: Mastery and Competency 7. Review Coping Skills and Safety Plan

1. Review Between-Session Work (Competency Activity) The therapist should check in with the adolescent about her selected mastery and competency activity. Ask how often she practices the activity, how she feels while performing the activity, and any resulting beliefs about herself. The therapist should use this opportunity to praise and reinforce the adolescent. Encourage the adolescent to track her progress on the Mastery and Competency sheet.

2. Continuing NST In sessions 13-15, the therapist and adolescent continue to work on storytelling. For many adolescents, the first NST session is the most difficult one. Often, adolescents have significant anticipatory anxiety prior to the first

92

7/05
NST session that is no longer present at the second. In addition, many adolescents experience at least some reduction in anxiety during the first session, and this can encourage them to continue the storytelling work. Even when adolescents do not experience a significant reduction in anxiety, the therapist may bolster their commitment to work hard by pointing out their success in enduring the storytelling session without any harmful effects. Therefore, it is often best to plunge back into NST in the following session without a review of the rationale or a detailed discussion of the procedure. The session should begin with the same event that was the focus of the previous session. Although many adolescents do not require additional preparation before resuming NST, some do. For example, adolescents who became very distressed, or had a difficult time due to anxiety that did not habituate or dissociation during NST may benefit from a review of the rationale for NST. They may also require additional reassurance that the procedure is in the adolescents best interest. These are some examples of statements the therapist can make to these adolescents: I know that the last storytelling session was not easy for you and you felt really upset in the beginning. Being upset is normal and expected when a person begins to talk about traumatic memories such as the abuse . Since you never had a chance to talk about and make sense of these traumas, they tend to come up at unexpected times without you understanding what triggers them. These upsetting memories can be very scary and disturbing because they seem to come out of nowhere. You may feel you have no control over them. You have fought hard to escape these memories, but the more you have tried to ignore these memories, the more upsetting they have become to you. By focusing on your memories of the abuse on purpose instead of avoiding them, they will begin to come together and form a story that makes sense to you. As you tell the complete story of your abuse, you will also experience many of the painful feelings that you have avoided for a long time. Letting yourself feel these feelings will allow you to get used to them, and finally file the complete story away with the rest of your memories. Then, these memories will no longer be random and uncontrollable. They will no longer cause you to feel such strong and overwhelming feelings. I know that these feelings are painful. As a child, you formed ways to escape these feelings. When you were younger, you did not have the skills to cope with such overwhelming feelings. You also may not have had anyone to support you through this. Although this avoidance helped you to survive as a child, avoiding your upsetting feelings has made them worse and has made it difficult to do many things in life.

93

7/05
Now that you are older, you have chosen to confront not only the memories, but also the painful feelings that go with them. Now you can deal with upsetting feelings better. In this program, you are learning coping skills that you never had before because of your abuse. I know that you might feel more upset for a short time in order to feel better later. This may help you to cope with these feelings and to continue the storytelling we started in our last session. Today we will do another storytelling exercise. Again, I will ask you to give me your SUDS rating every few minutes. When I ask for your SUDS, please call out your rating as quickly as possible, and without leaving the image. As I said earlier, I will encourage you to experience the events in more detail than in the last session. However, you are always in control of the storytelling and you should let me know if you feel you must end the session early. After the first storytelling of a memory, the therapist often takes a more active role in guiding subsequent episodes of the storytelling of that memory. The therapist can use probe questions and hot spots to deepen the processing of the memory. Probe Questions. As the adolescent repeats storytelling of a traumatic event, usually at least two to three sessions, her anxiety decreases substantially (e.g., SUDS ratings below 60). It is helpful to probe for sensory, cognitive and other cues that may trigger anxiety related to the memory. These probes often result in a temporary increase in anxiety when they trigger an important cue for the adolescent. Following this increase in anxiety, however, the adolescent is often able to reach an even lower level of anxiety than before. Examples of these probe questions include: Where are you now? Feel the bed under you. What do you notice around you? Notice what he smells like. Can you feel his weight on you? What are you thinking? How does it feel? Hot Spots. When the adolescents anxiety over a trauma memory declines, it is often useful to probe for hot spots of the memory that are most disturbing. Usually, the hot spot is obvious because it has the highest SUDS rating within the story (e.g., SUDS rating 15-20 points higher than other parts of the story). Examples of hot spots are the moment of penetration, experiencing physical pain, or the start of an upsetting sex act. After identifying a hot spot, the

94

7/05
therapist should make sure there is enough time to talk about this part of the memory. The therapist may request that the adolescent repeat the hot spot again several times (as many as six or seven), immediately after identifying it (e.g., not waiting until the adolescent has completed the whole story). The therapist should provide the adolescent with a copy of the SUDS Rating Scale and continue to track the content of her memories, as well as her SUDS ratings, on the Therapist NST Recording Form. The therapist should complete the Therapist Form for Post NST Emotional State as part of the processing phase at the end of the session.

3. NST with Multiple Traumas Most adolescents abused as children will have more than one memory of their abusive experiences. In addition, some may have experienced traumatic events recently, which are contributing to their PTSD symptoms. For example, many of these adolescents have grown up in neighborhoods in which they witness community violence on a regular basis. In many cases, successful treatment of PTSD in these adolescents will require you to focus on more than one traumatic memory. There are two critical issues to address when determining the pace of treatment of multiple traumatic memories: 1) at which point the therapist should move on from one memory to another; and, 2) which memory to select next for NST.

4. Moving to Another Memory The decision to begin treating the memory of another traumatic event assumes that: 1) the therapist and adolescent identified at least one more traumatic event in Session 11; and 2) the adolescent has a high SUDS rating with that event (e.g., SUDS over 70). You must use your own judgment to determine the potential benefit from treating other traumatic memories with lower SUDS ratings. This treatment protocol includes 4 storytelling sessions. When working with adolescents who have multiple memories of trauma, you should plan to focus on two or three memories. The decision to move on from one memory to another should be based on these criteria: 1. The adolescent has experienced a significant improvement in SUDS ratings. You anticipate little additional gain by staying with this memory (e.g., final SUDS ratings are below 40).

95

7/05
2. The adolescent has experienced some reduction in SUDS ratings, but SUDS remain higher than optimal (e.g., 40-80). The rate of improvement, however, has been slow or has hit a plateau. You expect little additional improvement in the short-term. The adolescent has experienced little or no improvement in SUDS ratings, despite several sessions devoted to one traumatic event.

3.

Among the four storytelling sessions, no more than two should be devoted to one event for adolescents with multiple memories unless you determine that that memory is much worse than the others are.

5. Selecting the Next Memory The first memory to address in NST must be one based in the experience of childhood abuse. However, additional memories that are the focus of NST do not need to relate to childhood abuse. For example, you may target traumatic memories of non-sexual events that occurred in childhood or more recently. After completing work on one memory, select the next memory based on which is currently associated with the highest distress level. The therapist may review the SUDS ratings the adolescent assigned to her memories in Session 11. However, do not assume that the second most distressing traumatic memory will still be just as distressing after the adolescent completes storytelling of the first memory. It is common for habituation to one traumatic memory to generalize to another memory, especially if the two memories share similar features. In order to select the next memory for NST, the therapist should conduct another assessment, using the same procedures as in Session 11. Evaluate only those memories associated with the most distress again. Then, as before, the memory with the highest SUDS should be the focus of NST. Use the same procedures used in NST for the first memory for subsequent memories. Proceed with storytelling for 10-30 minutes, recording SUDS on the Therapist NST Recording Form. In general, it is preferable to select memories for NST that are as different as possible, provided they are all associated with high levels of distress. In addition, when beginning work on a new memory, it is helpful to begin the session with a review of previous memories treated with NST. This ensures that distress related to memories does not rebound when work shifts to another memory.

96

7/05
6. Assign Between-Session Work: Mastery and Competency Mastery and Competency: The adolescent should practice her identified competency activity.

7. Review Coping Skills and Safety Plan Each session should end with a review of the adolescents coping skills and a review of the safety plan contained on the adolescents index card.

97

7/05
Session 16: Reviewing Progress and Saying Goodbye Agenda 1. Review Between-Session Work 2. Review Skills Learned in Treatment and Progress of Competency Activity 3. Identify Remaining Goals 4. Say Good-bye and Provide Referrals 5. Present Certificate of Completion 1. Review Between-Session Work (Competency Activity) The therapist should check in with the adolescent about her selected mastery and competency activity. Ask how often she practices the activity, how she feels while performing the activity, and any resulting beliefs about herself. The therapist should use this opportunity to praise and reinforce the adolescent. Encourage the adolescent to track her progress on the Mastery and Competency sheet.

2. Review Skills Learned in Treatment and Progress of Competency Activity During the final session, the therapist should review the adolescents progress in therapy. Review with the adolescent the work she has done in building and practicing skills to cope with her feelings, deal with difficult situations, get along with others, and make sense of her abuse history. Reinforce strengths and positive feelings about the adolescents hard work and accomplishments. Congratulate the adolescent on the hard work and progress she made in treatment. Highlight the details of the adolescents progress. The therapist may praise the adolescent with comments such as, Talking about what happened to you took a lot of strength and courage, You have learned to manage your anger more effectively, and You seem like you are able to express your needs better and tell people what is on your mind.

Clinical Illustration Melissa is a 15- year-old adolescent girl physically abused by her mother from ages 5 to 10. In therapy, she realized that it was difficult for her to identify her basic emotions such as anger and sadness. Instead, she tried to avoid her

98

7/05
feelings by locking herself in her room and avoiding talking to her family and friends. During therapy, Melissa realized how avoiding her upsetting feeling was not helping her to deal with her past or get her needs met in her current relationships. Over time, she was able to identify her feelings and use the coping skills she learned in therapy to manage her upsetting feelings in a healthier way. Melissas therapist pointed out, In the past, you used to tune out when you felt hurt and avoid talking to people you were close to. Now, not only are you able to pay attention to and recognize your feelings, but you also know how to deal with them and make yourself feel better. Ask the adolescent for her own thoughts about the progress she has made and about her overall experience in this phase of treatment. Discuss the areas in which she may continue to grow and improve. Discuss the adolescents progress in her selected competency activity, reminding her of where she began and where she is now. Review any difficulties or barriers to progress. Reinforce positive behaviors. Together make a plan for continued progress (e.g., continue to practice singing every week and attend an upcoming audition).

3. Identify Remaining Goals Discuss with the adolescent personal goals that she would like to continue to work on after this phase of treatment. The therapist may make suggestions for continued practice and use of coping skills. For example, the therapist may say, You have worked really hard on learning to express your needs in an assertive manner with your boyfriend. You can continue to work on this goal by practicing these new skills in situations with others such as your classmates at school.

99

7/05
4. Say Good-bye and Provide Referrals Discuss with the adolescent her feelings about ending treatment. Some adolescents may feel unsure of their readiness to continue their recovery without the therapy. The therapist should convey that this is a natural and understandable concern, but that people continue to improve after therapy as they come across new opportunities to practice their skills and mastery. The therapist may say, It is very natural to feel worried and nervous when therapy ends. However, many people continue to feel better by continuing to practice the skills they have learned in treatment. For other adolescents, especially those with multiple traumas, the work accomplished during the therapy may seem like a "drop in the bucket," or there may still be significant PTSD symptoms. In such cases, the therapist should assess the adolescents clinical status and make referrals for continuing treatment. Make sure to convey the need to seek further treatment in positive terms. The therapist should emphasize what progress the adolescent made and stress that additional therapy may provide her with the opportunity to relieve her symptoms further and strengthen gains.

Clinical Illustration C is a 17-year-old adolescent living in a group home. She has a history of sexual abuse by her brother. Prior to therapy, C rarely spoke about her abuse because she feared that no one would listen to her or believe what she said. Although she was initially skeptical of treatment, over time, C was able to learn new coping skills that improved her ability to deal with upsetting feelings and get along with others. During NST, C was gradually able to deal with the upsetting feelings related to talking about her memories of the abuse. She was just beginning to make sense of her intense feelings of helplessness and anger. In the last session, C expressed her anxiety about ending treatment by saying, How can we stop now? Its not fair - I just started to feel comfortable talking about this stuff and now its over. The therapist acknowledged that it was very difficult for C to end treatment and reassured her of the progress that she made. She said, It is very understandable to be upset about ending therapy. You have put in a lot of hard work and are beginning to express your intense feelings about what happened to you. Even though our work together is ending, you can continue to talk about these painful feelings and memories with your close friends and your therapist at the group home. You have made a lot of progress and can continue to use the skills you have learned here.

100

7/05

5. Present Certificate of Completion The therapist should present the adolescent with a certificate of completion to reinforce the hard work she has done, and the tremendous advances she made in therapy.

101

Appendix A: Safety Guidelines and Procedures for Emergent Patients

I.

If an adolescent is in immediate danger, call 911.

II. If an adolescent reveals active suicidal or homicidal ideation, it is important for the clinician to assess:

a. Intent and means (i.e., conditions under which the adolescent would act
on ideations).

b. Lethality of intent (Has the adolescent acted on ideations before? Is

there a history of taking steps to harm herself? Does the adolescent have access to stated means?). would not act on ideations? What might she do if home alone and experienced suicidal thoughts or urges to harm herself?). and/or friends; someone who can serve as contact person). adolescents psychiatrist).

c. Adolescents openness to discussing topic (Can she verbalize why she

d. Safety at home and availability of support (Presence of family members e. Medication supervision, if applicable (Consult with and/or notify the

III. After assessing the situation in the above manner, if suicidal/homicidal intent is present:

a. Develop safety plan for reference outside of therapy session. b. Ensure that the adolescent knows where the ER is? (Or the ER closest to
home).

c. Contract for safety. d. Contact the adolescents parents/caregiver (there is no confidentiality

when an adolescent is suicidal or homicidal). transport. arrival.

e. If the adolescent needs to be admitted immediately, call 911 for f. Call ER. Give brief background on the adolescent and estimated time of

SUICIDE HOTLINE:

102

103

National Suicide Hotline: 1-800-SUICIDE (1-800-784-2433) Suicide Prevention Hot Line: 1-800-827-7571 IV. Special Circumstances:

a. Child Abuse:
In cases of suspected or confirmed child abuse (including adolescent witnessing domestic violence), the clinician, being a mandated reporter, is required by law to report the case. OUTLINE of PROCEDURES for MANDATED REPORTING of CHILD ABUSE AND NEGLECT in NYS (New York State Office of Children and Family Services) If there is reasonable cause to suspect that the adolescent is being abused or neglected it must be reported immediately. Reports of child abuse and neglect can be made 24 hours a day, 7 days a week by calling the New York State Central Register (SCR) Child Abuse and Maltreatment Hotline. NYS Central Register of Child Abuse and Maltreatment, Mandated Reporter #1-800-635-1522 Include in report:
Subjects of report (i.e., child, parent, other family/household members)

Name & address, age, gender, race Nature and extent of injuries, abuse, maltreatment Person responsible for injury, abuse, maltreatment Source of report and person making report Any additional information that may be helpful

5 Essential Elements of a Report:

Child under 18 years of age

103

104

Jurisdiction in New York State Demographics Allegations Person legally responsible for child

A signed, written report (LDSS 2221A - attached) must be filed by mandated reporters within forty-eight hours of an oral report. The written report should be submitted to the appropriate local child protective service. The address of the investigative district may be requested from the child protective specialist at the time of making the oral report to the State Central Register of Child Abuse and Maltreatment. Mail a Written Report, form DSS 2221-A, to county Child Protective Services. Legal Protections:

Immunity from civil or criminal liability Confidentiality

A Willful Failure to Report can lead to:

Class A Misdemeanor Civil Liability for Damages

For information or help, call: Prevent Child Abuse New York Prevention Information & Parent Helpline: 1-800-342-7472. All calls are confidential. The SCR relays calls to ACS to begin an investigation when appropriate. Inquiring About the Report: A mandated reporter can receive, upon request, the findings of an investigation made pursuant to his or her report. This request can be made to the State Central Register at the time of making the report or to the appropriate local CPS at any time thereafter. However, no information can be released unless the reporter's identity is confirmed. If the request for information is made prior to the completion of an investigation of a report, the released information shall be limited to

104

105
whether the report is "indicated" (i.e., substantiated), "unfounded," or "under investigation," whichever the case may be. If the request for information is made after the completion of an investigation of a report, the released information shall be limited to whether a report is "indicated" or, if the report has been expunged, that there is "no record of such report," whichever the case may be.

b. Domestic Violence
These Hotlines help the adolescents: 24-Hour Hot Line: 1 (800) 621-4673 Spanish-speaking 24-Hour Hot Line: 1 (800) 942-6908 Hearing Impaired 24-Hour Hotline: TDD: 1 (800) 810-7444 Gay and Lesbian Anti-Violence Project: (212) 807-0197

c. Self-Harming Behaviors
24- Hour Hot Line: 1-800-dontcut (366-8288)

d. Crisis
1. HELPLINE'S Language Bank (212) 532-2400 This 24-hour hotline helps people who want to sort out a problem, to put their lives in perspective or who want to talk to a sympathetic person. It also assists people who are contemplating suicide. 2. National Youth Crisis Hotline (800) 448-4663 This 24-hour hotline is available to children from the ages of 12 to 18. This deals with problems such as drugs, teen pregnancy,

105

106
physical, emotional and sexual abuse, homelessness, prostitution, suicide and more.

106