Prolonged Exposure Therapy for Adolescents with PTSD Emotional Processing of Traumatic Experiences, Therapist Guide (Programs That Work)

Prolonged Exposure Therapy for Adolescents With PTSD

EDITOR-IN-CHIEF

David H. Barlow, PhD

SCIENTIFIC ADVISORY BOARD

Anne Marie Albano, PhD Gillian Butler, PhD David M. Clark, PhD Edna B. Foa, PhD Paul J. Frick, PhD Jack M. Gorman, MD Kirk Heilbrun, PhD Robert J. McMahon, PhD Peter E. Nathan, PhD Christine Maguth Nezu, PhD Matthew K. Nock, PhD Paul Salkovskis, PhD Bonnie Spring, PhD Gail Steketee, PhD John R. Weisz, PhD G. Terence Wilson, PhD

Prolonged Exposure Therapy for Adolescents With PTSD EMOTIONAL PROCESSING OF TRAUMATIC EXPERIENCES

Therapist Guide Edna B. Foa • Kelly R. Chrestman Eva Gilboa-Schechtman

1 2009

1 Oxford University Press, Inc., publishes works that further Oxford University’s objective of excellence in research, scholarship, and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam

c 2009 by Oxford University Press, Inc. Copyright
Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. Foa, Edna B. Prolonged exposure therapy for adolescents with PTSD : emotional processing of traumatic experiences : therapist guide / Edna B. Foa, Kelly R. Chrestman, Eva Gilboa-Schechtman. p. ; cm. — (Programs ThatWork) Accompanied by teen workbook: Prolonged exposure. Includes bibliographical references. ISBN 978-0-19-533174-5 (pbk. : alk. paper) 1. Post-traumatic stress disorder in adolescence. 2. Cognitive therapy for teenagers. I. Chrestman, Kelly R. II. Gilboa-Schechtman, Eva. III. Prolonged exposure. IV. Title. V. Series: Programs that work. [DNLM: 1. Stress Disorders, Post-Traumatic—therapy. 2. Adolescent. 3. Cognitive Therapy—methods. WM 170 F649p 2008] RJ506.P55F63 2008 618.92 8521—dc22 2008021710 9 8

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Printed in the United States of America on acid-free paper

About ProgramsThatWork TM

Stunning developments in health care have taken place over the last several years, but many of our widely accepted interventions and strategies in mental health and behavioral medicine have been brought into question by research evidence as not only lacking benefit but perhaps inducing harm. Other strategies have been proven effective using the best current standards of evidence, resulting in broad-based recommendations to make these practices more available to the public. Several recent developments are behind this revolution. First, we have arrived at a much deeper understanding of pathology, both psychological and physical, which has led to the development of new, more precisely targeted interventions. Second, our increased understanding of developmental issues allows a finer matching of interventions to developmental levels. Third, our research methodologies have improved substantially, such that we have reduced threats to internal and external validity, making the outcomes more directly applicable to clinical situations. Fourth, governments around the world and healthcare systems and policymakers have decided that the quality of care should improve, that it should be evidence-based, and that it is in the public’s interest to ensure that this happens (Barlow, 2004; Institute of Medicine, 2001). Of course, the major stumbling block for clinicians everywhere is the accessibility of newly developed evidence-based psychological interventions. Workshops and books can go only so far in acquainting responsible and conscientious practitioners with the latest behavioral healthcare practices and their applicability to individual patients. This new series, ProgramsThatWorkTM , is devoted to communicating these exciting new interventions to clinicians on the frontlines of practice.

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The manuals and workbooks in this series contain step-by-step detailed procedures for assessing and treating specific problems and diagnoses. But this series also goes beyond the books and manuals by providing ancillary materials that will approximate the supervisory process in assisting practitioners in the implementation of these procedures in their practice. In our emerging healthcare system, the growing consensus is that evidence-based practice offers the most responsible course of action for the mental health professional. All behavioral healthcare clinicians deeply desire to provide the best possible care for their patients. In this series, our aim is to close the dissemination and information gap and make that possible. The program outlined in this therapist guide is specifically intended for adolescents (ages 13–17) with posttraumatic stress disorder. It is based on the principles of Prolonged Exposure (PE), an effective treatment method for adults suffering from various types of trauma. Patients are exposed to safe but anxiety-provoking situations as a way of overcoming their trauma-related fears. Recounting the memory also helps patients emotionally process their traumatic experiences in order to diminish PTSD symptoms. The adolescent program is structured into four phases: (1) pre-treatment preparation, (2) psychoeducation and treatment planning; the beginning of treatment (3) exposures, and (4) relapse prevention and treatment termination. This therapist guide details how clinicians may best use PE techniques to treat adolescents. Each phase of treatment is broken down into modules for the adolescent to work through at his or her own pace. A final chapter addresses how to adapt treatment to the individual client, taking into account the adolescent’s age, developmental level, family situation, and trauma type. Appendices include parent handouts and developmentally appropriate exercises. The corresponding workbook is designed for adolescent use and includes teen-friendly forms to reinforce the skills learned in therapy. This comprehensive program is an important advance in the treatment of adolescents with PTSD. David H. Barlow, Editor-in-Chief, ProgramsThatWorkTM Boston, Massachusetts

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References Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59, 869–878. Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

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Acknowledgments

We are grateful to many colleagues in the United States and in Israel who enriched our thinking with original ideas, contributed to our studies with endless energy, and made this a much better book. In the United States, Norah Feeny and Sheila Rauch were immensely helpful in writing earlier versions of this manual. Sandy Capaldi was a tireless advocate for the treatment, and single-handedly organized and oversaw the recruitment and treatment of the adolescents who participated in the pilot project in the United States and thus helped us learn how to adapt prolonged exposure to this challenging age group. She and the outstanding therapists at Women Organized Against Rape, Laura Benner, Anna Grenier, Marcia Hackett, and Mirta Perez-Betancourt, helped us learn about the community perspective of the treatment and enabled us to keep it real and practical. We also extend our thanks to Carol Johnson, the director of Women Organized Against Rape, who provided us with the resources and encouragement to conduct the pilot study of prolonged exposure for adolescents. In Israel, Naama Shafran contributed quiet wisdom, endless energy, and all-encompassing empathy to all the stages of the treatment project: writing of the treatment manual in Hebrew, recruitment of the participants, meeting adolescents and their families, and analysis of the results. Lilach Rachamim provided outstanding care to many patients, as well as creative and insightful treatment techniques and ideas helping us deal with the most challenging cases. Michal Newborn, alongside Edna Appelboim, Ayala Daie, Olga Goraly, Shelly Dinah Hadija, HarishAvidan, Smadar Orgler, Gitit Peer, Vivian Reutlinger, Avigail Segal, and Yael Tadmor, met and treated many children and adolescents with great sensitivity and care. Professor Alan Apter provided us with resources and access to psychiatric care at the Schneider Children’s Hospital.

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Contents

Chapter 1

Introductory Information for Therapists

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Chapter 2

Assessment and Special Considerations in Treating Adolescent Trauma Survivors 29

Phase I: Pre-Treatment Preparation Chapter 3

Motivational Interview Module (optional)

Chapter 4

Case Management Module

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Phase II: Psychoeducation and Treatment Planning; the Beginning of Treatment Chapter 5

Treatment Rationale Module

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Chapter 6

Gathering Information Module

Chapter 7

Common Reactions to Trauma Module

75 81

Phase III: Exposures Chapter 8

Real-Life Experiments Module

Chapter 9

Recounting the Memory Module

Chapter 10

Worst Moments Module

97 123

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Phase IV: Relapse Prevention and Treatment Termination Chapter 11

Relapse Prevention Module

Chapter 12

Final Session Module

Chapter 13

Tailoring Treatment to the Individual

Crisis Coping Plan

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Trauma Interview Form

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Parent Handouts 179 Additional Materials: Stories and Cards References

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About the Authors

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Chapter 1

Introductory Information for Therapists

This therapist manual is accompanied by the workbook, Prolonged Exposure Therapy for PTSD: Teen Workbook. The treatment and manuals are designed for use by a therapist who is familiar with cognitivebehavioral therapy (CBT) or who has participated in intensive workshops for Prolonged Exposure (PE) by experts of this therapy. This CBT program is designed for working with adolescents aged 13–17 who suffer from posttraumatic stress disorder (PTSD) following a trauma.

Background Information and Purpose of This Program This program is based on PE Therapy, a treatment method for adults developed by Professor Edna Foa and colleagues at the University of Pennsylvania. The overall aim of PE is to help trauma survivors emotionally process their traumatic experiences in order to diminish PTSD and other trauma-related symptoms. The name “prolonged exposure” reflects the fact that the treatment program emerged from the long tradition of exposure therapy for anxiety disorders, in which clients are helped to confront safe but anxiety-evoking situations in order to overcome their excessive fear and anxiety. At the same time, PE has emerged from the emotional processing theory of PTSD, which emphasizes the central role of successful processing of the traumatic memory in the amelioration of PTSD symptoms. Throughout the book we will emphasize that emotional processing is the mechanism underlying successful reduction of PTSD symptoms. The adult PE program has been modified to highlight the developmentally appropriate concerns, strengths, and limitation of adolescents.

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For example, we have increased family involvement in the program, incorporated attention to the social and developmental challenges faced by adolescents, and included developmentally appropriate exercises that can be selected by the therapist in response to the needs of the individual patient. PE for adolescents includes the following procedures: ■

A motivational interview to improve attendance and treatment adherence

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A case management module to address barriers to therapy

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Education about common reactions to trauma

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Breathing retraining, that is, teaching the client how to breath in a calming way

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Repeated in vivo exposure to situations or objects that the client is avoiding because of trauma-related distress and anxiety

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Repeated, prolonged imaginal exposure to the trauma memories (i.e., revisiting and recounting the trauma memory in imagery)

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Review of the treatment and anticipation of future challenges to enhance relapse prevention

Disorder or Problem Focus Traumatic experiences (e.g., sexual or physical abuse, severe traffic accidents, natural disasters, experiencing or witnessing violence) are unfortunately quite common among children and adolescents. Several studies have examined the prevalence of trauma exposure in school samples, reporting trauma rates between 40% and close to 70% (Giaconia et al., 1995; Jenkins & Bell, 1994). In a nationwide sample of 2000 children aged 10–16, 24% reported being victimized (e.g., by physical assault, sexual assault, or kidnapping; Finkelhor & Dzuiba-Leatherman, 1994). Similarly, 25% of youth in a general sample had experienced a high magnitude traumatic event by the age of 16 (Costello, Erkanli, Fairbank, & Angold, 2002). In a representative North Carolina sample, more that two-thirds of children reported that at least one traumatic

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event occurred to them before the age of 16 (Copeland, Keeler, Angold, Costello, 2007). Among hospitalized adolescents, almost all (93%) reported experiencing at least one traumatic event (Lipschitz, Winegar, Hartnick, Foote, & Southwick, 1999). Though most adults and children are resilient and do not develop long-lasting emotional disturbances after they experience a traumatic event, a minority develop chronic problems. The most common negative psychological outcome of trauma is PTSD. PTSD is a severe anxiety disorder characterized by symptoms of reexperiencing (e.g., nightmares or intrusive thoughts), avoidance of trauma-related stimuli (e.g., situations, places, and people), and hyperarousal (e.g., sleep problems and hypervigilance) (American Psychiatric Association [APA], 1994). The percentage of youth developing PTSD following traumatic events is a subject of significant controversy, with rates varying from 0.5% to about 13% (Copeland et al., 2007; Kilpatrick et al., 2003; Thienkrua, et al., 2006). As is the case with adults, once established, PTSD in youth is usually chronic and debilitating (e.g., Pynoos & Nader, 1990; Thienkrua, et al., 2006). Trauma survivors with PTSD are more likely to report health problems than those without PTSD (Davidson & Foa, 1991; Schnurr & Green 2004). Thus, PTSD not only causes psychological distress to the sufferers but also has grave public health and economic implications lasting beyond adolescence and into adulthood.

Diagnostic Criteria for PTSD PTSD is included in the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association [APA], 2000) as an anxiety disorder that may develop in the wake of an event that is experienced or witnessed and involves actual or perceived threat to life or physical integrity. Furthermore, the person’s emotional reaction to this event is characterized by horror, terror, or helplessness. Three clusters of symptoms characterize PTSD: reexperiencing, avoidance, and hyperarousal.

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DSM-IV-TR Criteria for PTSD A.

The person has been exposed to a traumatic event in which both of the following were present: (1)

(2) B.

the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others the person’s response involved intense fear, helplessness, or horror

The traumatic event is persistently reexperienced in one (or more) of the following ways: (1)

recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions (2) recurrent distressing dreams of the event (3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated) (4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event (5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event C.

Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: (1)

efforts to avoid thoughts, feelings, or conversations associated with the trauma (2) efforts to avoid activities, places, or people that arouse recollections of the trauma (3) inability to recall an important aspect of the trauma (4) markedly diminished interest or participation in significant activities

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(5) (6)

feeling of detachment or estrangement from others restricted range of affect (e.g., unable to have loving feelings) (7) sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D.

Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: (1) difficulty falling or staying asleep (2) irritability or outbursts of anger (3) difficulty concentrating (4) hypervigilance (5) exaggerated startle response

E.

Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

F.

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if: Acute: duration of symptoms is less than 3 months Chronic: duration of symptoms is 3 months or more Specify if: With Delayed Onset: onset of symptoms is at least 6 months after the stressor The symptoms of PTSD are quite common immediately after traumatic events, but for most trauma survivors, through natural recovery, the intensity and frequency of these symptoms decrease over time. However, for a minority, the PTSD symptoms persist, become chronic, and interfere with daily functioning. According to the DSM-IV-TR, the diagnosis of acute PTSD is made when symptoms persist for more than 1 month following the trauma and cause clinically significant distress or impairment. PTSD becomes chronic when the symptoms persist for 3 months or more, and is considered as delayed onset when symptoms do not manifest until at least 6 months posttrauma.

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Development of This Treatment Program and Evidence Base As we began to develop a treatment for teenagers who suffer from PTSD, we identified several critical issues that needed to be addressed. First, and most important, we realized the transitional nature of adolescence. Spanning age 13 to 18 and encompassing major developmental changes, adolescence is not a homogeneous developmental phase but rather involves a collection of developmental changes that are unique to each teenager. Thus, treatment of adolescent PTSD, while addressing the key symptoms of the disorder, must also take into consideration the developmental changes that the teenager experiences. Second, adolescents are beginning to individuate from their parents and are developing stronger social ties with their peers. In treatment, we need to include family and social components that would be responsive to the needs of the adolescent and the family. Some adolescents will want and need substantial parental involvement, and others will desire and respond best to a treatment that allows greater privacy. Our treatment includes a family component, but the nature of this component depends on the personality of the adolescent, on his particular point in the separationindividuation process, and the constellation of the adolescent’s family. The content of treatment must also address the social impact of the disorder for those adolescents who are finding their peer relationships altered or disrupted by their PTSD symptoms. Third, we sought to develop an expeditious treatment. Since adolescence is a time of change and development, there are numerous transient and not so transient issues that may arise and that may lend themselves to psychological treatment. We sought to develop an intervention that would target the reduction of PTSD and related symptoms. This means that some problems and concerns that can arise in the life of an adolescent will necessarily be outside of the focus of the treatment. CBT seemed the natural choice for such a focused and structured intervention.

Empirical Support for CBT for the Treatment of PTSD in Adults Empirical support is now quite robust for CBT for the treatment of PTSD in adults (cf., Foa & Meadows, 1997), with exposure therapy having garnered the most empirical support (Rothbaum, Meadows, Resick,

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& Foy, 2000). Exposure therapy was first employed with PTSD in combat veterans (e.g., Fairbank & Keane, 1982), while stress inoculation training (SIT) was used with victims of sexual assault (Kilpatrick, Veronen, & Resick, 1982). Later studies indicated that CBT programs that included an exposure component were effective in reducing PTSD across a wide range of trauma populations, including female victims of rape (e.g., Foa, Rothbaum, Riggs, & Murdock, 1991; Foa et al., 1999, 2005; Resick, Nishith, Weaver, Astin, & Feurer, 2002; Rothbaum, Astin, & Marsteller, 2005) and physical assault (Foa et al., 1999; Foa, Hembree, Feeny, & Zoellner, 2002); domestic violence (Kubany et al., 2004); childhood sexual abuse (CSA; Cloitre, Koenen, Cohen, & Han, 2002; Echeburua, Corral, Zubizarreta, & Sarasua, 1997; Foa, Zoellner, Feeny, Hembree, & Alvarez-Conrad, 2002); male combat veterans (Cooper & Clum, 1989; Glynn et al., 1999; Keane, Fairbank, Caddell, & Zimering, 1989); male and female survivors of motor vehicle accidents (MVAs; Blanchard et al., 2003; Fecteau & Nicki, 1999); refugees (Otto et al., 2003; Paunovic & Ost, 2001); and mixed trauma samples (e.g., Bryant, Moulds, Guthrie, Dang, & Nixon, 2003; Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998). Variations of exposure therapy have been compared with SIT (Foa et al., 1991, 1999), cognitive therapy (CT; Marks et al., 1998; Resick et al., 2002; Tarrier et al., 1999), and eye movement desensitization and reprocessing (EMDR; e.g., Devilly & Spence, 1999; Rothbaum, Astin, & Marsteller, 2005; Taylor et al., 2003). Studies comparing forms of CBT have generally found differences in effectiveness to be small, but several studies favor exposure therapy (e.g., Devilly & Spence, 1999; Foa et al., 1999; Marks et al., 1998; Taylor et al., 2003), indicating that exposure therapy is effective for PTSD resulting from a range of traumas and is as or more effective than other forms of CBT. Among the different exposure therapy programs, PE has been consistently found to be effective (Foa, Rothbaum, & Furr, 2003).

Dissemination The efficacy of treatment for a particular condition is only one important consideration regarding its potential utility in a wide range of clinical settings. Another crucial factor is the ease with which the treatment can be disseminated to therapists in community clinics that

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serve clients with that condition. Because the vast majority of families who seek help for their child’s PTSD are treated in such nonacademic settings, the issue of dissemination of effective treatments into these settings is of paramount importance in making highly effective treatment options accessible. Several recent and ongoing projects with adults speak directly to the question of dissemination. In Resick et al.’s study (2002), PE training consisted of a 2-day workshop for therapists with prior general CBT training, followed by 1-day training a year later. Therapists had high ratings of fidelity to the protocol and obtained outcomes comparable to that in studies by PE experts. Foa’s prolonged exposure plus cognitive restructuring (PE/CR) protocol was successfully disseminated to non-CBT community clinicians in a study comparing PE/CR with supportive counseling for CSA survivors with PTSD. After treatment, 77% of PE/CR completers no longer met PTSD criteria at 6 months follow-up compared to 42% of those who completed supportive counseling (McDonagh-Coyle et al., 2005). The Department of Veteran Affairs (VA) has completed a study comparing PE and counseling for women with PTSD, where PE was disseminated to 24 therapists with varying backgrounds (M.A., Ph.D., M.D., and R.N.) at 12 different veterans affairs medical center (VAMC) sites. Results demonstrate PE to be effective under these conditions as well (Schnurr et al., JAMA 2007). Dr. Foa has conducted several 5-day workshops in Israel, after which PE was successfully disseminated to PTSD clinics for soldiers and veterans, as well as civilian survivors of terrorist attacks. Results indicate that the Israeli clinicians achieved outcomes comparable to that of Woman Organized Against Rape (WOAR) therapists and Penn experts (average of 64% reduction in PTSD severity; Nacasch et al., 2003).

Empirical Support for CBT for the Treatment of PTSD in Children and Adolescents The literature supporting the use of CBT for children and adolescents with PTSD is less extensive, but the studies conducted thus far have indicated that CBT is an effective and practical treatment for various types of trauma in children (e.g. Berliner & Saunders, 1996; Celano, Hazzard, Webb, & McCall, 1996; Cohen & Mannarino, 1996, 1998; Cohen, Deblinger, Mannarino, & Steer, 2004; Deblinger, Lippman, & Steer, 1996; King et al., 2000; Goenjian et al., 1997; March,

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Amaya-Jackson, Murry, & Schulte, 1998; Yule, 1992). Many of these studies, however, have been case studies or case series (e.g., Saigh, 1986, 1989), open clinical trials (e.g., Farrell, Hains, & Davies, 1998), withinsubjects designs that included a short baseline period (e.g., Deblinger, McLeer, & Henry, 1990) or randomized, lagged group experimental designs (Chemtob, Nakashima, & Hamada, 2002; March et al., 1998). The evidence for younger children is stronger than that for adolescents. Cohen, Mannarino, and Deblinger (2006) use the acronym PRACTICE to summarize the common components included in the empirically supported, trauma-specific CBT models currently in use, though not every model includes every component, and some models include additional components or adjunct services. The PRACTICE acronym represents the following components: parental treatment, including parenting skills; psychoeducation; relaxation and stress management skills; affective modulation skills; cognitive coping skills; trauma narrative and cognitive processing of the child’s traumatic experiences; in vivo desensitization to trauma reminders; conjoint child–parent sessions; and enhancing safety and future development. Trauma-focused CBT (TF-CBT; Cohen et al., 2006, Deblinger & Heflin, 1996) includes all of the PRACTICE components and has received the most support to date, with six randomized controlled trials (RCTs) completed. All studies showed TF-CBT to be superior to other active treatments or wait-list control conditions in reducing PTSD symptoms, as well as a variety of other symptoms in children as young as 3 years (Cohen & Mannarino, 1996) and as old as 14 years (Cohen & Mannarino, 1998; Cohen et al., 2006; Cohen, Deblinger, Mannarino, & Steer, 2004; Deblinger et al, 1996). Two additional treatment protocols have been subjected to RCTs and include adolescent subjects. Cognitive-based trauma-focused CBT has been subjected to a pilot RCT by Smith et al., (2007). This treatment, which contains many of the PRACTICE elements, as well as some additional components such as image transformation techniques, demonstrated large effect sizes for PTSD, anxiety, and depression when compared to wait-list controls. Seeking Safety (Najavits, 2002) demonstrated more symptom improvement in adolescent girls with comorbid substance use disorders when compared to treatment as usual. This

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program incorporates many of the PRACTICE components but does not include an active exposure component. Seeking Safety includes as many as 25 treatment topics, but the therapist can pick and choose which topics to cover with a particular client. Thus, Seeking Safety incorporates a good deal of flexibility and additionally can be provided in a group format. Prolonged Exposure for Adolescents (PE-A) is a treatment protocol that is designed to incorporate relevant material from both child and adult trauma-focused CBT, with maximum flexibility and the broadest application in terms of age and type of trauma. It is based on PE for adults because this treatment is brief, flexible, and highly successful in reducing symptoms. It incorporates PRACTICE elements, such as a parental component, conjoint parent–child sessions, enhancing safety, and future development, when those components are relevant for a particular patient, but allows the therapist the freedom to structure these additional treatment elements around the core components of psychoeducation, in vivo and imaginal exposure, and trauma processing, when and if they are pertinent. PE-A has demonstrated preliminary success in reducing PTSD symptoms in adolescents in both the United States and Israel. In this ongoing open trial, 45 adolescents (34 girls) have been treated. All were diagnosed with PTSD. 43 of them completed at least 9 sessions and 2 completed 6 sessions of PE-A following the manual described in the present book. Approximately half the sample were treated in the United States, and the other half were treated in Israel. The average age of the adolescents in the sample was 14.8 (SD = 1.57). The sample exhibited multiple traumas: 20% had PTSD related to rape, 29% related to CSA, 24.4% to terror, 17.8% to MVA, and 8.8% to other traumas. Patients completed the Childhood PTSD Symptom Survey (CPSS; Foa et al., 2001) pre- and post-treatment. The range of the number of treatment sessions was 6–20, with a mean of 12.8 (SD = 3.1). Only 11 patients received more than 15 sessions. PTSD symptom severity as measured by the CPSS was significantly reduced from pre- (M = 27.8, SD = 9.5) to post-treatment (M = 7.6, SD = 6.7), t(44) = 13.21, p < .0001). This represents a mean reduction of 71% on the CPSS, ranging from 3% to 100%, and corresponds to a within-group effect size of 2.13. Seventy one percent of the patients achieved remission by the end of treatment

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(i.e., a post-treatment score of 10 or below on the CPSS, which is the cut-off score corresponding to a PTSD diagnosis). The within-subject effect size of 2.13 found for these 45 patients who received PE is similar to published results of adult assault survivors following treatment with PE. Foa et al. (1999) provided adult female survivors of sexual and nonsexual assault with 9 sessions of PE and obtained a within-group effect size of 2.04 for treatment completers. Foa et al. (2005) provided female survivors of rape, nonsexual assault, and childhood sexual abuse with 9–12 sessions of PE. The total number of sessions was dependent upon the patient’s response to treatment, with additional sessions provided to patients showing less than a 70% reduction in self-reported PTSD severity by session 8. The within-group effect size for completers following an average of 10.4 (SD = 1.5) therapy sessions was 3.33. Thus, the effect size found in the open trial of an average 15 sessions of the adolescent version of PE fell within the range of effect size found in well-controlled studies on adults who received an average of 9–12 sessions of PE for adults. The longer treatment for adolescents is due to a number of factors, such as motivational sessions for adolescents, the inclusion of families in the treatment, and the longer relapse prevention module.

PE Model of PTSD: Emotional Processing Theory As described earlier, PE-A is an adaptation of the highly successful PE treatment for adults and as such is rooted firmly in emotional processing theory, which was developed by Foa and Kozak (1985, 1986) as a framework for understanding the anxiety disorders and the mechanisms underlying exposure therapy. The starting point of emotional processing theory is the notion that fear is represented in memory as a cognitive structure that is a “program” for escaping danger. The fear structure includes representations of the feared stimuli (e.g., bear), the fear responses (e.g., heart-rate acceleration), and the meaning associated with the stimuli (e.g., bears are dangerous) and responses (e.g., fast heart beat means I am afraid). When a fear structure represents a realistic threat, we refer to it as a normal fear structure that acts as a template for effective action to threat. Thus feeling fear or terror in the presence

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of a bear and acting to escape are appropriate responses and can be seen as a normal and adaptive fear reaction. According to Foa and Kozak (1986), a fear structure becomes pathological when (1) associations among stimulus elements do not accurately represent the world, (2) physiological and escape/avoidance responses are evoked by harmless stimuli, (3) excessive and easily triggered response elements interfere with adaptive behavior, and (4) harmless stimuli and response elements are erroneously associated with the threat’s meaning. Foa and Kozak (1985) suggested that the anxiety disorders reflect specific pathological structures and that treatment reduces anxiety disorder symptoms via modifying the pathological elements in the fear structure. These modifications are the essence of emotional processing, which is the mechanism underlying successful treatment, including exposure therapy. According to Foa and Kozak, two conditions are necessary for successful modification of a pathological fear structure, and thereby amelioration of the anxiety symptoms. First, the fear structure must be activated or otherwise it will not be available for modifications; and second, new information that is incompatible with the erroneous information embedded in the fear structure must be available and incorporated into the fear structure. When this occurs, information that used to evoke anxiety symptoms no longer does so. Deliberate, systematic confrontation with stimuli (e.g., situations and objects) that are feared despite being safe or having low probability of producing harm meets these two conditions. How so? Exposure to feared stimuli results in the activation of the relevant fear structure and at the same time provides realistic information about the likelihood and the cost of feared consequences. In addition to the fear of external threat (e.g., being attacked again), the person may have erroneous cognitions about anxiety itself that are disconfirmed during exposure, such as the belief that anxiety will never end until the situation is escaped or that the anxiety will cause the person to “lose control” or “go crazy.” This new information is encoded during the exposure therapy session, altering the fear structure and mediating between-session habituation upon subsequent exposure to the same or similar stimuli, and thereby resulting in symptom reduction.

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Foa and colleagues subsequently refined and elaborated on the original theory of emotional processing, offering a comprehensive theory of PTSD which accounts for natural recovery from traumatic events, the development of PTSD, and the efficacy of CBT in the treatment and prevention of chronic PTSD (Foa & Cahill, 2001; Foa & Jaycox, 1999; Foa & Riggs, 1993; Foa, Huppert, & Cahill, 2006; Foa, Steketee, & Rothbaum, 1989). According to emotional processing theory, the fear structure underlying PTSD is characterized by a particularly large number of stimulus elements that are erroneously associated with the meaning of danger, as well as representations of physiological arousal and of behavioral reactions that are reflected in the symptoms of PTSD. Because of the large number of stimuli that can activate the fear structure, individuals with PTSD perceive the world as entirely dangerous. In addition, representations of how the person behaved during the trauma and their subsequent symptoms, and their negative interpretation of the PTSD symptoms are associated with the meaning of self-incompetence. These two broad sets of negative cognitions (“The world is entirely dangerous,” “I am completely incompetent to cope with it”) further promote the severity of PTSD symptoms, which in turn reinforce the erroneous cognitions (for more details, see Foa & Rothbaum, 1998). Trauma survivors’ narratives of their trauma have been characterized as being fragmented and disorganized (e.g., Kilpatrick et al., 1992). Foa and Riggs (1993) proposed that the disorganization of trauma memories is the result of several mechanisms known to interfere with processing of information that is encoded under conditions of intense distress. Consistent with hypotheses that PTSD would be associated with a disorganized memory of the trauma, Amir, Stafford, Freshman, & Foa (1998) found that lower level of articulation of the trauma memory shortly after an assault was associated with higher PTSD symptom severity 12 weeks later. In a complimentary finding, Foa, Molnar, & Cashman (1995) reported that treatment of PTSD with PE was associated with increased organization of the trauma narrative, and that reduced fragmentation was associated with reduced anxiety whereas increased organization was associated with reduced depression.

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Natural Recovery or Development of Chronic PTSD As noted earlier, high levels of PTSD symptoms are common immediately following a traumatic event, and then most individuals will show a decline in their symptoms over time. However, there is a significant minority of trauma survivors who fail to recover and continue to suffer from PTSD symptoms for years. Foa and Cahill (2001) proposed that natural recovery results from emotional processing that occurs in the course of daily life by repeated activation of the trauma memory through engagement with trauma-related thoughts and feelings, sharing them with others, and being confronted with situations that remind them of the trauma. In the absence of additional traumas, these natural exposures contain information that disconfirms the common post-trauma perception that the world is a dangerous place and that the person is incompetent. In addition, talking about the event with supportive others and thinking about it helps the survivor organize the memory in a meaningful way. Why then do some trauma victims go on to develop chronic PTSD? Within the framework of emotional processing theory, the development of chronic PTSD is conceptualized as a failure to adequately process the traumatic memory because of extensive avoidance of trauma reminders. Accordingly, therapy for PTSD should promote emotional processing. Paralleling natural recovery, PE for the treatment of PTSD is assumed to work through activation of the fear structure by patients deliberately confronting trauma-related thoughts, images, and situations via imaginal and in vivo exposure, and learning that their perceptions about themselves and the world are inaccurate. How does PE lead to improvement in PTSD symptoms? Avoidance of trauma memories and related reminders is maintained through the process of negative reinforcement; that is, through the reduction of anxiety in the short run. In the long run, however, avoidance maintains trauma-related fear by impeding emotional processing. By confronting trauma memories and reminders, PE blocks negative reinforcement of cognitive and behavioral avoidance, thereby reducing one of the primary factors that maintain PTSD. Another mechanism involved in emotional processing is habituation of anxiety, which disconfirms erroneous beliefs

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that anxiety will last forever or will only diminish upon escape. Clients also learn that they can tolerate their symptoms and that having them does not result in “going crazy” or “losing control,” fears commonly held by individuals with PTSD. Imaginal and in vivo exposure also help clients to differentiate the traumatic event from other similar but nondangerous events. This allows them to see the trauma as a specific event occurring in space and time, which helps to refute their perception that the world is entirely dangerous and that they are completely incompetent. Importantly, PTSD clients often report that thinking about the traumatic event feels to them as if it is “happening right now.” Repeated imaginal exposure to the trauma memory promotes discrimination between the past and present by helping clients realize that although remembering the trauma can be emotionally upsetting, they are not in the trauma again and therefore thinking about the event is not dangerous. Repeatedly revisiting and recounting the trauma memory also provides the client with the opportunity to accurately evaluate aspects of the event that are actually contrary to their beliefs about danger and self-incompetence and that may otherwise be overshadowed by the more salient threat-related elements of the memory. For example, an individual who feels guilty about not having done more to resist an assailant may come to the realization that the assault likely would have been more severe had he resisted. All of these changes reduce PTSD symptoms and bring about a sense of mastery and competence. The corrective information that is provided via imaginal and in vivo exposure is further elaborated during the processing part of the session that follows the imaginal exposure.

Benefits and Risks of This Treatment Program Benefits Twenty years of research on PE, some of it described in this chapter, has yielded findings that clearly support the excellent efficacy of PE as a treatment for PTSD. Nearly all studies have found that PE reduces not only PTSD but also other trauma-related problems, including depression, general anxiety, anger, and guilt. Informally, a large number of

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adolescents at end-of-treatment interview reported that this focused intervention has also assisted them face non-trauma-related problems in their lives, such as relationships with family and peers, and identity issues. It helps people to reclaim their lives.

Risks The primary risks associated with PE Therapy are discomfort and emotional distress when confronting anxiety-provoking images, memories, and situations in the course of treatment. The procedures of PE are intended to promote engagement with the range of emotions that are associated with the traumatic memory (e.g., anxiety, fear, sadness, anger, shame, or guilt) in order to help the client process the traumatic memories. As will be described in detail in Chapter 9, during PE the therapist should not only be supportive and empathic in guiding the client through the processing of the trauma memory but also monitor the client’s distress and intervene when necessary to modulate the level of emotional engagement and associated discomfort. When recommending PE to a trauma survivor, the therapist should explain that disclosure of trauma-related information and working to emotionally process these painful experiences in therapy often causes temporary increased emotional distress and can also lead to a temporary exacerbation of psychiatric symptoms, including PTSD, anxiety, and depression. This is described to clients as “feeling worse before you feel better.” However, in a sample of 75 women receiving PE for assault-related PTSD, this temporary exacerbation of symptoms was not associated with worse outcome or with premature termination of treatment (Foa et al., 2002). Moreover, while some clients fail to benefit from this therapy, there are only a handful of case reports of symptom worsening after exposure therapy.

Alternative Treatments Although an extensive review of studies investigating cognitivebehavioral treatments for PTSD is beyond the scope of this therapist manual, our own research findings are consistent with other studies on

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youngsters finding that CBT including exposure therapies is effective in ameliorating trauma-related problems (e.g., Berliner & Saunders, 1996; Celano et al., 1996; Cohen & Mannarino, 1996, 1998; Cohen et al., 2004; Deblinger et al., 1996). Moreover, many studies over the past 20 years have found exposure therapy effective in reducing PTSD and other trauma-related pathology in adults, rendering it the most empirically validated approach among the psychosocial treatments for PTSD and one designated by expert consensus as a first-line intervention (Foa, Davidson, Frances, Culpepper, Ross, & Ross, 1999). In addition to PE and other variants of exposure therapy described earlier in this chapter, CBT programs that have been empirically examined and found effective include SIT, cognitive processing therapy (CPT), CT, and EMDR. For detailed reviews, see Foa and Meadows (1997), Rothbaum et al. (2000), Harvey, Bryant, and Tarrier (2003), and Cahill and Foa (2004).

The Role of Medications Experts consider selective serotonin reuptake inhibitors (SSRIs) to be the first-line pharmacological treatment for PTSD in adult patients (Foa et al., 1999). However, the literature supporting specific pharmacological treatments for children and adolescents with PTSD is quite small and inconclusive. Additionally, a recent Food and Drug Administration (FDA) black box warning has been implemented due to increased suicidal ideation and behavior in depressed children treated with SSRI medication. Literature and black box warning notwithstanding, experts in the field rely on the adult literature and evidence from other child anxiety disorder treatments to support the use of SSRI medication for children and adolescents with PTSD. The broad spectrum of symptoms treated by these medications and their effectiveness in reducing depression and obsessive-compulsive disorder (OCD) symptoms, specifically in children, make these a reasonable choice. Additionally, side effects are relatively minor compared to other medications. More research needs to be conducted to expand our knowledge of pharmacological treatments for PTSD, especially in children and adolescents. Research is also needed to compare the relative efficacy of

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medications, psychosocial therapies, and their combination. Although many PTSD sufferers receive such combined treatment, little is known about its efficacy or about specific treatment combinations. Despite the lack of data to support their use in pediatric patients, we occasionally encounter child or adolescent clients who are already being treated with an SSRI or other appropriate medication for their PTSD and/or depression. On the basis of our experiences, we have no reason to think that concurrent medication treatment hinders the process or outcome of therapy with PE. For adolescents presenting with severe, comorbid depression, ongoing pharmacotherapy may be quite helpful and allow them to participate fully in the PE treatment. However, given the FDA warnings, child and adolescent clients should be appropriately monitored for exacerbation of symptoms during pharmacological treatment.

The Structure of the Program The program is divided into four phases that are completed in consecutive order during the course of treatment. Each phase is comprised of several modules. A module is a therapeutic unit with specific goals. Within each module, there are specific psychoeducational topics to cover and specific skills to learn. Each module is accompanied by homework assignments to review or practice the topics and skills presented in the session. There are certain modules that remain active throughout treatment as ongoing homework assignments. A module does not necessarily coincide with a session. In some cases, the therapist may complete several modules in one session, and in other cases, the therapist may devote several sessions to one module. The progress rate through the modules is flexible and dependent on the patient’s individual progress. However, the order of the phases and modules is not flexible and should be completed in the order they are presented in the manual. A typical course of PE-A lasts approximately 14 sessions, falling in the range of between 11 and 18 sessions.

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Table 1.1 Structure of the Program Phase

Module

Number of sessions

Phase 1: Pre-Treatment Preparation

Motivational Interview (optional) Case Management

1–3 sessions

Phase 2: Psychoeducation and Treatment Planning; the Beginning of Treatment

Treatment Rationale Gathering Information Common Reactions to Trauma

3–4 sessions

Phase 3: Exposures

Real-Life Experiments Recounting the Memory Worst Moments

5–8 sessions

Phase 4: Relapse Prevention and Treatment Termination

Relapse Prevention Final Session

2–3 sessions

Phase 1: Pre-Treatment Preparation The pre-treatment preparation phase is not technically part of PE, but is used, as the name suggests, to prepare the client to better receive and benefit from the treatment that follows. Specifically, the pre-treatment preparation phase is used to enhance treatment adherence and prevent premature dropout from treatment by anticipating and directly addressing behaviors or circumstances that may interfere with therapy. These issues include low motivation, lack of access to resources, impulsive and dangerous behaviors, conflicts with parents, problems at school, and comorbid disorders. Some obstacles may require contact with the school or other social service agencies. Depending on the severity of the obstacle, the therapist may decide to refer the patient for a different kind of therapy before starting the treatment for PTSD, or to postpone the treatment of other problems until after the treatment of PTSD. Alternatively, the therapist may decide to employ concurrent interventions at school or at home to help the adolescent participate more effectively. When there are few issues to address, the motivational interviewing and

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case management modules can be combined and condensed into one session in order to proceed more quickly to the first treatment phase.

Motivational Interview Module

This module is designed to assess and, if necessary, enhance the patient’s motivation to change. Since the adolescent is only rarely the treatment initiator, but is rather referred for therapy by an authority figure (parent, school counselor, etc.), it is particularly important to help him to fully articulate the impact of symptoms on his life, and to describe how life has changed for the worse, and possibly for the better in some ways, since the trauma.

Case Management Module

This module is designed to help the adolescent and the parents identify any obstacles (other than motivation) to treatment and to develop strategies for overcoming the obstacles so the adolescent is able to fully participate in treatment. Obstacles to treatment are highly individual and quite varied in complexity. They include other disorders that may or may not pre-date the trauma, family difficulties, addictions, school and peer problems, privacy concerns, and lack of access to resources. Accordingly, the therapist will review the patient’s functioning in various life domains, conduct a risk assessment, negotiate an agreement regarding privacy of therapy sessions, and explain the rationale for involving parents in certain sessions. The degree of privacy the adolescent is allowed and the degree of parental involvement in treatment are determined at the end of this module.

Phase 2: Psychoeducation and Treatment Planning; the Beginning of Treatment Treatment Rationale Module This module provides an overview of the treatment to the patient and his parents and presents the rationale for the specific techniques to be used. At the end of the first therapeutic session the therapist presents

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the first skill, breathing retraining, which is designed to help the patient cope with anxiety.

Trauma Interview Module

In this module, the therapist gathers information about the trauma, the patient’s specific posttraumatic symptoms, and any dysfunctional cognitions that contribute to the maintenance of the disorder. It includes an optional, motivation-building exercise, Secret Weapons, that is particularly useful for patients who may believe the therapy will be too difficult or that their symptoms will never get better.

Common Reactions to Trauma Module

In this module, the therapist presents information regarding common posttraumatic reactions, identifies the patient’s specific symptoms, and normalizes the patient’s symptoms.

Phase 3: Exposures Real-Life Experiments Module

This module presents the rationale for in vivo exposure and introduces the stress thermometer for rating anxiety levels. The therapist and patient together create a hierarchy for confronting avoided situations and conduct the first Real-Life Experiment. Real-Life Experiments will include confrontation with a variety of readily available experiences that are objectively safe but are avoided because they trigger anxiety and avoidance. Once initiated, Real-Life Experiments are assigned for homework in every session, in order of increasing difficulty.

Recounting the Memory Module

This module presents the rationale and procedure for imaginal exposure. During each session in this module, the patient repeatedly recounts the

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trauma, and is encouraged to add details to the story from one exposure to the next. The therapist assists the patient in emotionally processing the memory, including challenging inaccurate, unhelpful thoughts. The procedures of recounting and processing the memory are repeated for several sessions, and the patient listens to an audiotape of the recounting as homework.

Worst Moments Module

Once the memory becomes easier for the patient to recount, the focus is turned to the most difficult or painful parts of the trauma (the worst moments) in order to enhance emotional processing. The patient recounts the worst moments with prolonged and repeated exposure and processes them in a similar manner as done with the entire memory in the Recounting the Memory Module. This module is typically repeated for two to five sessions.

Phase 4: Relapse Prevention and Treatment Termination Relapse Prevention Module In this module the patient is encouraged to think about difficulties that may arise in the future and how he plans to deal with them, given his experience in therapy. The therapist helps the patient to identify potential triggers of anxiety and tools that can help the patient cope. A final project summarizing the trauma and the treatment process may be assigned.

Final Session Module

This module is the last session of treatment. It also includes a review of the different components of therapy. As some adolescents develop a significant attachment to the therapist, it is an appropriate point to discuss issues that may arise regarding the upcoming separation. Since this session also serves to commemorate the patient’s accomplishments and to celebrate the end of treatment, the patient may invite parents or

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other significant individuals to join in the last part of the session. The patient may also elect to bring snacks or present a final project to his guests.

Trauma-Specific Adjustments There is some similarity in the types of situations avoided by people with PTSD. Often, large crowds, people who resemble a perpetrator, and going places alone top the list regardless of the type of trauma. However, there are many trauma-specific differences as well. For example, those who have experienced a terror attack may be fearful of using public transportation or going to crowded public places, whereas a young woman experiencing a sexual assault in her home may fear being home alone or may avoid sleeping in the dark. When identifying the patient’s avoidances, it is important that the therapist be familiar with the situations typically avoided by people who have experienced particular types of trauma. Chapter 8 has lists of several types of traumas and the types of situations most likely to be avoided by people experiencing that trauma. These lists can be used as a starting point to generate ideas for exposures with the patient as well as for anticipating triggers for relapse.

Some Guidelines for Working With Adolescents The therapist should stay tuned to the developmental level of the patient. Certain adolescents have a mature physical appearance but are less developed emotionally or cognitively. A flexible approach drawing on several engaging tasks such as role-plays, stories, and games may be undertaken. The appendices include several exercises that may augment or replace procedures as needed for less articulate and/or less cognitively and emotionally mature patients. See the section on developmental adjustments in Chapter 13 for more information on adjusting the program to the adolescent’s maturity level. In general, adolescents’ attention span is shorter than that of adults; they may be more impulsive and less aware of their emotions. As a result, the therapist needs to take a more active part in cognitive processing

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and in psychoeducation than would typically be the case with adults. “Taking an active part” does not imply that the therapist should do the work for the patient. As with adults, the patient is the one who will be summarizing the information discussed and interpreting his experiences in therapy. The therapist’s role is to stay attuned to the patient’s level of understanding and find ways to optimize it, if needed. It is important that the patient summarize his understanding after each subsection. The therapist may encourage this by stopping and asking questions, such as, “How does the stress thermometer help us?” or thought-provoking questions such as, “Why do we actually have to practice the real-life experiments several times?” or “Why do we not actually stop the exposure if we see that your anxiety is increasing?” Simple phrasing, in the patient’s own words, is geared to ensure a deeper understanding. The therapist should also stay tuned to ruptures in the therapeutic relationship. In working with adolescents, it is important to maintain a careful balance between being a part of the adult world on the one hand and being a part of the patient’s world on the other. Leaving time to chat about the main events of the patient’s life is crucial in maintaining a good relationship. As, in the course of this treatment, information is presented and understanding is assessed, it is important that the patient does not view the sessions as another “lesson in school.” For example, in asking for summaries during the sessions, the therapist needs to be careful not to present these summaries as “quizzes,” but rather as “checks” on how teamwork is going. For example, the therapist might say, “I am not sure I did a good job explaining this, but it is very important that we are on the same page about it. Could you please tell me what got across?” The work with some adolescents is challenging with respect to the need to maintain therapeutic focus and work in a systematic manner. The therapist needs to model structure and focus during sessions. The therapist can reserve the last few minutes of the session to work on extraneous issues or “problems of the week” that may seem important and intense in the moment but may detract from the intensity of the trauma work. This way, the adolescent can leave feeling his immediate concerns

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were addressed, without sacrificing therapy time needed to address the longer-term goal of reducing PTSD symptoms.

Overview of Parental Involvement It is extremely important that parents or guardians understand the rationale for the treatment and are supportive of the adolescent’s efforts to confront his fears and other emotions related to his trauma. They also need to feel that they know what is going on in their teenager’s treatment. Conversely, adolescents are struggling with issues around their independence and may wish to preserve some privacy within the therapy. One of the most important challenges in delivering mental health treatment to adolescents is the successful integration of the family into treatment without compromising the adolescent’s need for privacy and independence. Ordinarily, adolescence is a developmental stage characterized by increasing attempts to gain independence from the family; this may be an even more important goal for those adolescents who experienced sexual assault or physical abuse and feel let down by families that have failed to protect them from the abuse. Even if the traumatic event did not involve family or close acquaintances, trust in people, including family members, may have been seriously compromised. All parents/guardians will receive handouts with psychoeducational material and tips (see the appendix). Therapists can photocopy these parent handouts from the appendix as needed. This information is designed to help the parent be supportive of the adolescent’s efforts to confront fears and to reassure the teenager if exposures exacerbate PTSD symptoms, depression, and anxiety. Finally, it is important for the therapist to help parents and guardians to separate their own reactions to the trauma and to their teenager’s distress from the teenager’s reactions. This is done by instructing the parents to refrain from strong displays of emotions and from extensively discussing their symptoms in the teenager’s presence; providing private time, sometimes via telephone, for the parents to discuss their concerns with the therapist; and by modeling a conversation style that includes

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the teenager whenever the teenager is present. In addition, parents may be referred for supplementary treatment if indicated.

Use of Workbook The client workbook is used as an adjunct to treatment. It contains brief information corresponding to each module and instructions for completing the various homework exercises. Blank versions of each form used in the treatment are provided, including the in vivo hierarchy and exposure homework tracking forms. There are summaries of psychoeducational materials, including common reactions to trauma and rationales for exposure treatment. Additional materials in an appendix of this guide can substitute or augment specific treatment modules when developmentally appropriate. The way the therapist chooses to introduce these materials is flexible and may be adjusted to the needs of the client. For example, relatively mature adolescents may purchase or be given the workbook to work through alongside the therapist as part of treatment. Less mature adolescents may work more productively if the therapist keeps the workbook and tears out sections to give as handouts during each session. Several of the worksheets in the workbook will need to be reproduced for use in more than one session as well, so it would be helpful to instruct the client to obtain a folder to keep extra materials together between sessions. As the client completes worksheets and assignments, he will bring them in to session to discuss his experience. Most therapists will choose to collect the worksheets to monitor progress. If the adolescent is preparing a final project, these materials can be returned to the adolescent for inclusion in the project near the end of treatment. It is often a pleasant surprise to review these old worksheets later in therapy as the client’s treatment gains are clearly documented on the weekly worksheets. Like the work within the therapeutic sessions, the homework assignments must be methodical and orderly to ensure progress. Emphasize the need for the patient to do his homework systematically. Sometimes, a patient may want to skip certain homework assignments, for example

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“because it is easy and stupid,” or he may choose assignments that were not agreed upon during the session, “because I also felt like doing X.” Such leaps are usually not in the service of the treatment as the patient may feel that his successes or achievements are arbitrary. He will not be able to update his views about his abilities or to internalize the fact that distress and anxiety dissipate with successive exposures.

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Chapter 2

Assessment and Special Considerations in Treating Adolescent Trauma Survivors

Not every traumatized adolescent is a candidate for PE-A. This chapter presents some guidelines for assessing adolescent trauma survivors, identifying and monitoring target symptoms, and determining the client’s readiness for treatment. We also discuss some of the challenges of working with traumatized adolescents using PE-A.

Whom is PE-A Appropriate for? Not every trauma survivor needs a trauma-focused treatment like PE-A. First of all, numerous studies have shown that most people recover naturally from a traumatic event, even if they experience symptoms in the immediate aftermath of the event (Copeland et al., 2007). People often experience PTSD symptoms and other emotional reactions following a traumatic event, but symptoms usually subside in the year following the event, especially the first three months. Second, PTSD is not the only reaction to trauma. Some patients may experience other types of psychological reactions to trauma, with or without accompanying PTSD symptoms, such as depression, chronic anxiety, panic, specific phobia, high levels of anger or shame, and exacerbation of Axis II disorders. PE-A may not be the best choice of treatment for these patients. We recommend considering using PE-A for patients with the following: ■

PTSD lasting at least 1 month after the traumatic event. If full diagnostic criteria are not met, the symptoms of PTSD should be distressing and should interfere with functioning.

■

Related symptomatology (e.g., depression, chronic anxiety, high levels of anger or shame, or Axis II symptoms) may be present but is not the primary diagnosis.

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■

Sufficient memory of the traumatic event(s). The patient must be able to visualize and describe the traumatic event, and there must be at least enough information so that the narrative has a beginning, a middle, and an end.

Comorbid Conditions and Exclusionary Criteria Based mostly on our experience with adult patients, over the past 20 years (Foa, Hembree, & Rothbaum, 2007), we have learned that PE can help PTSD patients who suffer from a range of severe comorbid problems such as major depression or other mood disorders, anxiety disorders, Axis II symptoms, or alcohol or substance abuse. We have also been able to successfully treat clients with mild mental retardation and low literacy, provided we modify the materials to be more accessible to these individuals. However, as with PE for adult patients (Foa, et al. 2007), we continue to recommend several important and commonsense-based exclusionary criteria. The following comorbid conditions, if present, should be treated and stabilized prior to beginning PE-A.

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■

Imminent risk of suicide or homicide. Suicidal ideation is common among PTSD patients, and many have made gestures or attempts in the past, but current high risk of suicidal or homicidal behavior requires immediate clinical attention and stabilization prior to beginning focused PTSD treatment.

■

Serious self-injurious behavior. If the patient is currently engaging in deliberate self-injurious behavior such as cutting or burning, PE-A should be deferred until the patient has learned skills or tools she can use to manage these impulses without acting on them. Patients with a history of either suicidal behavior or self-injurious behavior should be able to make a commitment to use their skills or tools to manage any suicidal or self-injurious impulses without acting on them.

■

Current psychosis. Historically, patients with a history of psychotic disorders have been excluded from psychotherapy studies. As a

result, it is difficult to find validated interventions for use with this population. In our clinic, we have begun offering PE and PE-A to patients if they are stabilized on appropriate medications and currently not exhibiting psychotic symptoms. However, since neither PE nor PE-A has been systematically studied with this population, we would recommend that only clinicians highly experienced with PE or PE-A and/or receiving supervision from a PE or PE-A expert provide this treatment to psychotic adolescents. ■

Current, high risk of assault. We have successfully treated adolescents living in high-risk environments (e.g., high-crime neighborhood, past but not current physical abuse, alcoholic family member in the home, or risk of terror attacks), where there is a high risk of negative life events. However, if the patient is currently living in a situation where there is ongoing abuse or violence, this should be the focus of treatment. You will not only need to make appropriate reports according to your state guidelines regarding child abuse, but also need to delay PE-A until the adolescent is in a safer situation and her symptoms have had time to stabilize.

■

Insufficient or unclear memory of traumatic event(s). PE is not a tool for recovering memories of trauma. While clients do sometimes recall more details of a trauma during treatment with PE-A, we strongly discourage its use with clients who present with only a vague idea that a trauma occurred, or a nonspecific belief that they experienced a trauma.

In addition to these exclusionary criteria, there are several other commonly encountered issues you may need to consider in determining whether to offer a trauma survivor treatment with PE-A. Presence of drug and/or alcohol abuse and dependence: In our clinic, we have begun using PE to treat adults who are concurrently abusing substances. Where appropriate, the substance use is construed as a form of avoidance and targeted for reduction. We also strongly encourage the client to use available supports such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) to reduce or eliminate their substance abuse. We monitor the substance abuse throughout treatment, and are

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especially vigilant for its use as a way to decrease or avoid anxiety and other painful feelings. However, substance abuse and dependence in adolescents is a more pressing concern for parents, educators, and mental health professionals. Levels of substance abuse that may be tolerated in adults are targeted for primary intervention with adolescents by virtue of their immaturity, their legal status, and the increased danger they experience while obtaining and using illegal alcohol or drugs. When you are assessing your adolescent client, it is important to assess both the level of use, the level of high-risk behavior, and the function of the substance vis-`a-vis PTSD. Safety is again the primary concern. PE-A can be implemented in the presence of mild substance abuse where the level of high-risk behavior is minimal. As the level of use and the level of risk rise, the likelihood that substance use will interfere with treatment becomes greater, and the level of safety decreases. Both these outcomes require direct intervention with the substance use so that the patient can productively and safely engage in PE-A. Living or going to school in a high-risk environment: It is reasonable to question whether PE will be effective for someone who lives or attends school in a dangerous area. Unfortunately, many patients find themselves unavoidably living in these circumstances. Consider the person living with the threat of terrorist attacks in Israel or other countries, the young girl living in an impoverished and violent neighborhood next door to a crack house, and the young man under pressure to join a gang to protect himself from the dangers in his neighborhood. Can PE be helpful if the threat of additional trauma is present both during the treatment and afterward? Our experiences in both the United States and abroad have taught us that the answer to this question is often yes. If the patient meets the criteria for PTSD, then it is likely that she experiences unreasonable fear and avoidance related to events in the past as well as reasonable fear related to her present circumstances. It is also likely that the PTSD intensifies her expectation that she will be harmed in her present circumstances. For these patients, it is important to validate the real dangers they face and to help them to distinguish between true danger and trauma-related

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fear. Frequently, we relied on the experience of non-PTSD individuals living in the same environment to assist us in creating this danger vis-`a-vis fear differentiation. Explain to the patient that by working to reduce fears related to past events, she will be in a better position to respond to her current challenges. Most patients will readily agree that they would be more effective in choosing strategies to keep themselves safe if they were able to get rid of unrealistic fears that interfere with judgment. You will need to work with the patient to create in vivo exposures that help to reduce avoidance, but are relatively safe. Severe dissociative symptoms: Dissociative symptoms are part of PTSD, but when the symptoms of dissociation are severe, especially if they merit a separate diagnosis, your clinical judgment must be used to determine if the dissociative symptoms outweigh the PTSD symptoms in terms of functional interference. As with other disorders (major depression, eating disorder, substance dependence, etc.), you must first address the primary diagnosis before moving on to secondary symptoms. In summary, a good candidate for PE-A will have experienced a traumatic event of any type, meet criteria for PTSD or have clinically significant PTSD symptoms related to the trauma, and have a clear memory of the trauma. They may have comorbid disorders and multiple life difficulties, but PTSD will be the primary diagnosis. If other disorders are life threatening or of primary clinical importance, they must be treated and stabilized before initiating PE-A.

Assessment Strategies A thorough assessment will determine whether or not your client is appropriate for PE-A. Be sure to include the following in your assessment battery: ■

Identify the index or target trauma (i.e., the trauma that seems to be causing the symptoms and should be the primary focus of attention in treatment) and find out about other types of traumas and intense negative life events experienced by the patient.

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■

Confirm the diagnosis of PTSD (or presence of significant symptoms) and determine severity.

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Assess for presence of comorbid disorders.

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Prioritize current disorders based on their severity and the associated need for immediate intervention.

In our clinic, the initial evaluation is conducted using both interview and self-report instruments. We always survey the types of trauma the client has experienced in addition to the index trauma—the one that brought her into treatment. We also ask for additional details about the index trauma and have created a Trauma Interview form to help identify important details related to the index trauma. This form is included in an appendix and can be photocopied as needed. To diagnose and assess the severity of PTSD symptoms, we use the Child PTSD Symptom Scale (CPSS; Foa et al., 2001), a 17-item measure that can be administered as a self-report or in interview form. Other Axis I disorders are assessed using a diagnostic interview such as the Schedule of Affective Disorders and Schizophrenia for School-Age Children—Revised for DSM-IV (K-SADS; Orvaschel, Lewinsohn, & Seeley, 1995) or the MINI Neuropsychiatric Interview for Children (MINI Kid; Sheehan et al., 1998). Self-report measures used in our clinic include the CPSS, the Beck Depression Inventory (BDI; Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961; Beck, Epstein, Brown, & Steer, 1988), and the Child Post-Trauma Attitudes Scale (C-PTAS; Johnson, Foa, Jaycox, & Rescorla, 1996), but these are not the only instruments available to assess children and adolescents. Readers are referred to the National Center for Posttraumatic Stress Disorder Web site, where they can find descriptions of a number of other reliable and valid measures that can be used for this purpose. Not only do we routinely evaluate clients’ symptoms pre- and posttreatment in order to determine overall change in target symptoms, but we also evaluate periodically throughout treatment to assess changes during the therapy. This second type of assessment is critical for monitoring progress and guiding treatment decisions. We share the results of both types of assessments with the patient as part of the treatment.

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Special Considerations in Treating Adolescent PTSD Patients Trauma survivors often experience changes in their beliefs about themselves, others, and the world around them. Whether or not the trauma was interpersonal, as in the case of sexual abuse, whether manmade or natural, as in the case of hurricanes or floods, or whether the victim was alone or with others, as in the case of a terror attack or a car accident, survivors are often left with feelings of fear, pessimism, and distrust. Establishing a strong therapeutic alliance is necessary to gain the patient’s trust and to help her emotionally process the traumatic experience. Additionally, the adolescent may be coping with complicated life changes caused by the trauma—legal issues, foster care, physical injury, loss of property, etc. Family and friends who might otherwise be supportive may not be available or willing to lend a hand. Material and interpersonal resources may be strained. Adherence to treatment under these circumstances is particularly difficult for the adolescent given these factors. It is therefore important to establish a firm foundation for the treatment that will help the patient when life begins to interfere with treatment adherence. Foa et al. (2007) suggest several important “cornerstones,” which are detailed next, that you should establish at the beginning of treatment. Though their advice was intended for adult patients, it applies particularly well to adolescents who may be more sensitive to relationship issues than some adults.

Laying the Groundwork for Treatment The idea of facing fear is not new, and indeed “getting back on the horse” after a fall is a familiar concept in American folk wisdom. It is intuitively appealing and deceptively simple. But the reality of facing fear after a traumatic event is anything but simple, and though many patients have tried on their own to face their fears and return to their normal lives, they have discovered the process to be greatly hampered by the competing, and equally appealing urge to avoid. To help the patient complete the treatment successfully, it is important that you, as the therapist, understand conceptually why the treatment works. You will also

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need to develop a strong therapeutic alliance that will allow you to be challenging as well as supportive in the service of facing fear. Finally, you will need to present a clear and convincing rationale for the treatment.

Conceptual Model Emotional processing theory, the conceptual model underlying PE-A, has been described in the previous chapter. Understanding the theory will be helpful to you in a number of ways. First, it will help you anticipate the course of treatment. Though each patient is unique, progress through the modules should follow an expected course that can be shared with the client. Second, the theory will guide you in making treatment decisions and responding to unusual or unexpected problems. Finally, the theory will help you monitor progress and decide when treatment should end.

Therapeutic Alliance A critical component of any therapy is a strong therapeutic alliance. In PE-A, the therapeutic alliance can be enhanced in several ways that are specific to this type of treatment. First, acknowledge the patient’s courage in entering a therapy designed to help her face and overcome strong fears. Many patients view receiving therapy as an admission of weakness and adolescents, particularly, are at a developmental point of establishing independence. By recognizing her courage and aligning yourself with her goals, you help her view treatment as a smart move rather than a failure to act independently. Second, respond to each description of trauma with calmness, acceptance, and support. Even seasoned trauma clinicians will occasionally feel shocked or uncomfortable when faced with the description of a patient’s trauma. It is important to separate your personal reaction from your therapeutic reaction. Many patients report great relief when they are able to tell their story without eliciting judgment, shock, or disapproval. Third, listen closely to the adolescent and use specific examples from her trauma, fears, and symptoms when giving examples and presenting the psychoeducational material and treatment rationale. This helps the patient to know that she

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is understood, and that you are tailoring this treatment to her unique situation. Fourth, demonstrate knowledge and expertise about PTSD and its treatment. Express confidence in the effectiveness of PE-A, in your ability to implement the treatment, and in the patient’s ability to learn the techniques. Be active and positive in encouraging the client to attend the sessions, practice her new skills for homework, and apply them to real-life situations. Fifth, be truly collaborative. In constructing an in vivo hierarchy, selecting trauma memories for imaginal exposure, and making decisions about the focus and pace of treatment, you will act as a consultant or coach, sharing your knowledge of PE-A, guiding the patient, and making recommendations, but her needs, goals, and preferences should always be incorporated into the treatment plan. Adolescents are quick to tune out when they believe they are not being taken seriously by adults. Finally, throughout treatment, provide plenty of support, encouragement, and positive feedback. Foa et al. suggest that good PE therapists are cheerleaders.

Clear and Convincing Rationale for Treatment Throughout much of the treatment, patients are being asked to do things that they have been avoiding because they seem dangerous or because the client feels fear and anxiety when doing them. Much of this activity takes place outside the session, away from your supervision, encouragement, and guidance. It will be up to your patient to follow through on her own, so it is critical that she knows why she is being asked to go against her instincts and confront the things that make her so uncomfortable. A clear and convincing rationale will help her stick to the plan both in and out of session. Your understanding of the conceptual model and your knowledge of the client will help you tailor a convincing rationale that will support her adherence.

Challenges of Treating Trauma Survivors This treatment program is time limited and trauma focused, but it can be difficult to maintain the focus of this treatment when working with PTSD patients, especially adolescents. The lives of PTSD

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patients are often disorganized and complicated. There are other problems besides the PTSD symptoms, and it can be difficult to disentangle the trauma-related problems from the frequent crises that threaten to derail treatment. Adolescents tend to view any problem as a crisis, and will often present with a new and urgent concern, only to abandon it the following week when other issues arise. When an adolescent comes to session focused on the crisis of the moment, it can also be difficult to distinguish her current concerns from PTSD-related avoidance. Chapters 3 and 4 of this manual address the case management and motivational issues that are often at the heart of these crises. These modules were created to anticipate and address some of the unique challenges of adolescent trauma survivors before treatment begins, and to avoid having treatment disrupted or delayed unnecessarily. Nonetheless, even with the best pre-treatment preparation, you may find yourself returning frequently to case management and motivational issues with some patients.

Tips for the Trauma Therapist: How Do You Care for Yourself? There are two important questions that new therapists ask about PE-A. The first question is, “How do I cope with the terrible stories that I will hear?” Once again, understanding the conceptual model underlying PEA can help you manage the difficult emotions that may arise in you or your patient as a part of processing a traumatic experience. The rationale for treatment teaches or explains to the patient that the intense fear and anxiety associated with painful memories will not hurt her as the traumatic event once did and will not last indefinitely if she allows those feelings to be experienced and processed. She will habituate to the trauma memory and the emotions will become less and less intense as she processes them rather than avoids them. As a therapist, this will be true for you too, and you must be able to trust the conceptual model in the same way that you ask the patient to do so. As the patient habituates to the memory and processes the trauma, so will you. The second question often asked is, “How do I cope with my patient’s distress (and manage my own distress)?” Conducting PE-A will at

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times be challenging, and you may find yourself distressed and worried, because your patient is upset during imaginal exposure or because she experiences an increase in anxiety or depressive symptoms. You may also worry about your patient’s safety when she is completing assignments outside your office. Parents or guardians may express concerns or doubts about the treatment as well, especially if they feel the treatment is causing more distress for their child. In all these situations, your familiarity with and confidence in the conceptual model will help you make treatment decisions that are well grounded in research. Your knowledge of the model will also help you educate parents about the benefits of emotional processing. Though the work is sometimes painful, it is often beneficial. As you remind your patient and her parents of this, you will also need to remind yourself. Also remember that though you have powerful tools to offer the patient in the form of PE-A, it is the patient who must ultimately decide to take and use the tools you offer. You will be in a position to make strong, well-supported recommendations to your patient, but it is unwise to try to compel or pressure her to undergo treatment or to complete a particular assignment if she is unwilling. If you present a convincing rationale and the client is not ready to confront her fear and avoidance, it is often more helpful to help her terminate or postpone treatment until she feels ready to fully participate. Finally, it is ideal to have supervision of an experienced therapist as well as consultation with peers to get the needed technical and emotional support to conduct the treatment properly. Regular consultation can help you decide how to proceed when the case is complex and challenging. We highly recommend you have a team or supervision group that meets regularly to discuss trauma cases. This will allow you the opportunity to learn by hearing about other cases besides your own.

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Phase I

Pre-Treatment Preparation

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Chapter 3

Motivational Interview Module (optional)

(Corresponds to chapter 2 of the workbook)

Materials Needed ■

Life Domains form

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Pros and Cons of Therapy form

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Equipment and media to record session

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Introduce motivational interview and determine patient’s motivation for therapy

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Identify the patient’s life domains that have been disrupted as a result of the trauma

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Identify potential benefits of the patient’s participation in therapy

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Identify potential obstacles to the patient’s participation in therapy

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Identify potential costs of the patient’s participation in therapy

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Review discussion and summarize the pros and cons of therapy

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Assign homework

Outline

Overview Since pediatric patients are not usually self-referred, but rather referred for therapy by an authority figure (parent, school counselor, mental health agencies, etc.) it is particularly important to ensure that the

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patient is motivated by a clear understanding of how treatment can benefit him and is prepared for difficulties that may arise in the course of treatment, including the loss of secondary gains that have arisen as a result of the trauma (e.g., greater attention from parents, concessions from the school, or gaining more autonomy by resisting parents’ authority). This module is designed to help the patient weigh the pros and cons of engaging in the treatment process. The module may be brief or extensive, depending on the patient’s level of motivation, as assessed during the intake and/or by the therapist at the beginning of the session. For highly motivated patients, one session will be sufficient to review and discuss the patient’s reasons for engaging in treatment. For less motivated patients, one to three sessions will be needed to help the patient recognize the need for treatment. Forms are provided in the workbook for this purpose. The semi-structured interview is conducted only with the patient, without the parents or guardians. During the motivational interview, you will gather information about the patient’s life before and after the trauma, and help the patient evaluate the changes in functioning that have occurred. The interview is designed to highlight the benefits of reducing symptoms and returning to life as usual, as well as to underscore the possible secondary gain the patient may experience from his condition, and what he may lose as a result of an improvement in his situation (special treatment at home, special benefits at school, etc.).

Motivational Interview If this is your first encounter with the patient, you may want to spend about 10–15 min getting to know the patient and establishing a therapeutic alliance. If the patient has already experienced an intake interview and/or completed intake assessments, be sure to acknowledge the patient’s efforts and inform the patient that this part of your work together will be distinct from the intake in that it will be more specifically related to the treatment goals. You can use the following dialogue to begin the motivational interview: I know that you have spent several hours filling in questionnaires and interviewing. I will not ask you to repeat all that you have already

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done, but I would like to take the time to review and summarize what happened and how it has affected you, so that we have a clearer picture of what we will be working to change. After the patient has told his story, you should summarize a few main points for the patient and ask for confirmation of accuracy of your summary. This is done both for accuracy and to show that you are paying attention to the patient’s efforts to complete the initial assessments and interviews.

Patient’s Motivation for Therapy Next, ask about the patient’s views about therapy in order to determine his level of motivation. ■

“Why did you decide to seek therapy now?”

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“How do you feel about the idea of beginning therapy?”

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“On a scale of 0–10, where 0 represents ‘not at all interested’ and 10 represents ‘very interested,’ how would you rank your level of interest in this current therapy?”

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“What does X (the number the patient chose) mean to you?”

If this number is not clear to you, continue with the following questions: ■

“Why did you choose X and not Y (a lower number)?”

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“What has to be different in order for you to move from X to Z (a higher number)?”

Disruption of Life Domains After discussing the patient’s level of motivation, ask about specific life domains before the trauma and after the trauma. Depending on the patient’s level of motivation, this section of the interview can be abbreviated or extended. For highly motivated patients, it is sufficient to ask about changes generally, and to have an informal discussion of life

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domains that are important to the patient. For less motivated, or less verbal patients, use the Life Domains form in the workbook to query each area and help the patient articulate how the trauma has affected each life domain. The form covers significant areas in the teenager’s life that may have been disrupted as a result of the PTSD, including the following: ■

Emotional health (anxiety, depression, anger, shame, self-confidence, self-esteem, ability to relax)

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Physical health (fitness, diet, exercise, sleep habits, tiredness, injury, and illness)

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Leisure (friends, extracurricular activities, trips)

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School (grades, teachers’ assessments, homework, level of concentration)

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Relationship with family members (fights, level of sharing, sense of closeness)

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Relationship with close friends (fights, level of sharing, sense of closeness)

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Social status in class/social circles (popularity, feel appreciated, people turn to for help)

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Independence (for example, going places alone)

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Use of drugs and/or alcohol

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Body image (“how do you feel about the way you look?”)

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Sources of pleasure (music, sports, hobbies)

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Other things that people the patient’s age are able to do that he does not do at the present time

It is not necessary to discuss every point in detail, especially if it appears that a particular area was not disrupted as a result of the trauma. The following dialogue can be used to begin the discussion: Trauma affects many different areas of life. Some areas may be affected more than others. Are there particular areas of your life that have been changed as a result of the trauma?

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Potential Benefits of Therapy Together with the patient, formulate realistic changes in operational terms, focusing on areas that have deteriorated significantly. Changes may be stated in terms of PTSD symptoms, for example, improved sleep, less avoidance, less irritability. However, it is important to link symptom changes to specific life domains that are important to the patient. Improved sleep can be linked to increased energy for important life activities, less avoidance can be linked to a return to a previous level of activity and independence, and less irritability can be linked to improved relationships and an improved view of self. The following questions may help the patient identify changes he would like to make. ■

“What would you like to change in your life now?”

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“What do you wish you could do at the end of therapy or in 3 months’ time?”

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“What would you like to do when you are older?”

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“What do you think you need to do to meet this goal?”

Potential Obstacles to Therapy In addition to helping the patient understand the benefits of treatment, the patient must be prepared to make a commitment of time and effort and to endure some amount of discomfort in order to realize the benefits. Help the patient identify other responsibilities or interests that may compete with treatment for his time and effort. Discuss the discomfort that is sometimes associated with change: As we mentioned earlier, therapy requires time and effort. At times, you may feel that your level of distress increases before it decreases. Given what you know about yourself and your lifestyle, what do you think may hinder our work? Common answers are busy schedule, multiple activities, difficulty in getting to the clinic, feeling ashamed about being in therapy, parents’ objection, etc. Discuss any issues the patient identifies, and help the patient problem solve around these obstacles.

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Often, past attempts at therapy will color the patient’s view of the current therapeutic effort. Particularly if the treatment was unsuccessful, the patient may recall obstacles that prevented him from engaging in the treatment process or from reaching a successful conclusion to treatment. Inquire about the patient’s past attempts at therapy, if any, in order to identify any potential obstacles to your work together. The following questions can help to clarify how past treatment efforts may be similar or different from the current treatment. ■

“Did you have therapy in the past?”

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“What was it like?”

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“Did it help you? If not—why not?”

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“What made it difficult for you?”

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“If you did not complete a full course of treatment, what made you decide to quit?”

Potential Costs of Therapy While there are obvious benefits to therapy, there may also be hidden costs or secondary gains that can decrease a patient’s motivation. Explain that the patient’s condition may have brought about positive changes in his life (e.g., special treatment at home, greater flexibility and enhanced sensitivity to academic problems from teachers at school, more autonomy from parents). Ask the patient how the trauma may have affected his life in positive ways. Discuss whether the patient will be able to forgo these benefits in order to reduce the PTSD symptoms.

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■

“Are there aspects of your life that have actually changed for the better since the trauma?”

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“What do you feel you have gained from experiencing the trauma?”

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“How important is it to you that you continue to have these benefits?”

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“How important is it to you that you reduce your PTSD symptoms?”

Review and Summary of Pros and Cons Review with the patient the most salient points of the discussion and ask the patient to summarize the pros and cons of engaging in the treatment process to address the effects of trauma on various life domains. It is helpful to make a simple two-column summary of pros and cons (see Figure 3.1). A blank Pros and Cons of Therapy form is provided in the workbook. Use the following dialogue and questions to help the patient identify pros and cons. Any kind of therapy may be difficult and demanding. Let’s think about whether the effort of therapy is in fact worthwhile for you. ■

“What do you stand to gain from not coming to therapy (e.g. free time, special treatment, concessions at school)?”

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“How might therapy change things for the better for you?”

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“Do these gains exceed the losses?”

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“Do you choose to start therapy despite the difficulties?”

The pros and cons list should demonstrate that the benefits of treatment outweigh the costs. Ask the patient to make a commitment to treatment, and to persevere despite some difficulties that may arise during the process.

Pros

Cons

Improved sleep—more energy for school and friends

Will have to attend school regularly when symptoms improve Will need to spend one hour per day doing treatment activities Will require more effort getting to places

Less irritability—get along better with family Less avoidance of being alone—free to ride the bus and walk instead of waiting for car rides Figure 3.1

Example of Completed Pros and Cons of Therapy Form

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Homework

✎ ✎ ✎ ✎ ✎

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Have patient read Chapters 1 and 2 of the workbook. Have patient listen to the recording of the session. Have patient review Life Domains form for accuracy and add any other items that come up during the week. Have patient review Pros and Cons of Therapy form for accuracy and add any other items that come up during the week. Have patient discuss the pros and cons of therapy with parents or friends (optional).

Chapter 4

Case Management Module

(Corresponds to chapter 3 of the workbook)

Materials Needed ■

Crisis Coping Plan form

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Equipment and media to record session

Outline Meeting with the patient only: ■

Explain the rationale for involving the parents in therapy

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Clarify confidentiality and patient’s privacy in therapy

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Discuss patient–parent relationship and preferences for parental involvement

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Assess suicide risk

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Generate crisis coping plan if necessary

Meeting with the parents only: ■

Evaluate parents’ difficulties if necessary

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Discuss patient’s suicide risk if necessary

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Clarify confidentiality and patient’s privacy in therapy

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Discuss patient–parent relationship and preferences for parental involvement

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Meeting with the patient and parents together: ■

Review confidentiality issue

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Have patient and parents agree on crisis coping plan

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Identify other problems the patient has besides PTSD and make a treatment plan

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Determine parental involvement

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Review therapy schedule

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Assign homework

Overview In most cases, this module is conducted with the patient alone, followed by a meeting with the parents alone. When all areas requiring case management have been addressed, a summary meeting is conducted with both the patient and the parents. This module is aimed to provide a comprehensive assessment of the patient’s life, in addition to PTSD. Two areas are emphasized: premorbid difficulties and the family system. With regard to the first, inquire whether the patient’s problems (besides PTSD) existed before the trauma or whether they developed following the trauma. Gather information regarding the severity of the problems and their implications in order to decide whether PTSD is the main problem to be addressed. It is inadvisable to treat several problems at the same time either with the same therapist or with multiple therapists. This does not include the option of psychiatric medication that is closely monitored by psychiatric consults. It is important to assess the strengths and difficulties in the family system. Form a relationship with the parents and assess whether the parents themselves are anxious or suffer from PTSD, thus aggravating the symptoms of their child, especially avoidance. It is important to ascertain whether the parents or guardians recognize the difficulties that their child has and whether they are willing to assist her. In addition, evaluate

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the pattern of communication between the parents and the patient (e.g., how are individuation/separation issues dealt with?). Your assessment regarding these issues as well as the patient’s expressed preferences will determine the parents’ level of involvement in the treatment. This assessment will guide the focus of future parents—therapist meetings and assist in anticipating possible difficulties in therapy. In cases of extreme parental distress or pathology, you may consider referring the parents to psychotherapy.

Meeting With the Patient Only First, meet with the patient alone. To introduce this module, the following dialogue may be used: In this meeting, and perhaps the next one as well, we will focus on other problems and difficulties that may bother you besides those you and I have already discussed. After our discussion, I will meet with your parents to get their take on things. I will then speak to you and your parents together about your privacy in therapy and how involved your parents will be in our work. Rationale for Parental Involvement Explain to the patient that for most of therapy the two of you will work together in private meetings. However, for several reasons, it is important to sometimes involve her parents in the process to a certain degree. First, parents have to understand what PTSD is, and they have to learn about the triggers that aggravate or perpetuate the patient’s difficulties. Second, it is possible that she may need their help in order to deal with some difficulties. Third, we believe that all families, especially those where one member was exposed to a trauma, can gain from the skills she is about to learn in therapy.

Confidentiality and Privacy Tell the patient that like all other patients who receive therapy at your clinic, she has the right to confidentiality. This means that, with few

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exceptions, the content of your meetings are private. However, parents also have a right to know about their child’s therapy and how therapy is progressing. We found that we are able to negotiate between parents and adolescents to provide parents with certain information without revealing all the personal details adolescents have shared with us. Explain that certain things, regardless of how personal they are, must be shared with parents. These are things that if not dealt with may cause severe personal damage or even loss of life.

Discussion of Parental Involvement Ask the patient how she feels about having her parents involved in her therapy: ■

“In general, do you share your feelings with your parents?”

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“Do you feel that your parents understand you?”

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“Does anybody in your family criticize you for having these PTSD-related fears?”

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“Whom do you best get along with at home? Why?”

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“Whom do you least get along with at home? Why?”

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“If you needed help, which member of your family would you turn to? What kind of help would you be able to receive?”

Determine the patients’ preferences about sharing information with her parents. Be prepared to negotiate a compromise if the parents’ preferences, determined later in the session, differ markedly from those of the patient.

Risk Assessment Because adolescence is a period of increased impulsivity and acting out, and because the rates of suicidal ideation and attempts are higher for

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adolescents than for some other age groups, most therapists screen for suicidality, self-injury, and risk-taking behavior as part of their initial evaluation of adolescent patients. Indeed, many teenagers with PTSD will have experienced suicidal thoughts at some point since the trauma. Some will have experimented with drugs and alcohol or taken other risks with their safety. Some may even have engaged in self-injurious behavior at some point. If this information has already been discussed in the assessment, it is appropriate to follow up on the risk factors that were revealed previously and complete a Crisis Coping Plan form as indicated by the patient’s level of risk. If these topics have not been discussed before, it is important to do so before proceeding with other case management issues. Be sure to screen for the following behaviors for both the past and the present: ■

Suicidal thoughts

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History of suicide attempts—their timing, seriousness of intent, family reactions, etc.

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Self-injury (cutting, burning, intentional infliction of pain)

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Substance use (and associated risks, e.g., driving under the influence)

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Other dangerous behavior

If your initial screening reveals a relatively risk-free picture, you can skip to the next section (Meeting With Parents Only). If the patient has experienced any of the above behaviors, proceed with a more thorough risk assessment. Based on the patient’s level of risk, develop a crisis coping plan that addresses the risk factors and specifies healthy, positive coping responses. If the risk is deemed to be severe or extremely severe, it will need to be addressed before targeting PTSD symptoms. Many therapists would want to consult a colleague and the relevant literature. Table 4.1 presents a guideline for responding to the patient’s level of risk. Appropriate therapist responses are given for each level of risk.

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Table 4.1 Therapist Response Based on Risk Factors Present Risk

Factors

Therapist Response

Mild risk

Few risk factors present: suicidal thoughts but no specific plan, no previous suicide attempts

Moderate risk

Some risk factors present: suicidal thoughts and a general plan but good self-control, several reasons to live, no intention to commit suicide or previous suicide attempts Many risk factors present: suicidal thoughts are frequent and intense, plan is specific and lethal and patient has access to it, limited helping resources, self-control and intent are questionable, or previous suicide attempt and low self-control Many risk factors present: suicidal thoughts are frequent and intense, plan is specific and lethal and patient has access to it, limited helping resources, lack of self-control, states intention to attempt

Validate patient’s distress Obtain an agreement to review the issue Develop crisis coping plan if risk factors increase Validate patient’s distress Develop crisis coping plan Review plan periodically

Severe risk

Extreme risk

Validate patient’s distress Develop crisis coping plan Consult with a supervisor or colleague Review plan periodically Hospitalize if risk increases Hospitalization is necessary

Crisis Coping Planning Using the Crisis Coping Plan form in the appendix, discuss how the patient can cope with suicidal thoughts or intentions. Include coping with risky or self-injurious behaviors in the plan if they are present. The plan is structured so that the patient will use less intrusive personal coping strategies first, followed by more intrusive strategies involving other people, and finally the most intrusive and restrictive strategies as a last resort if less restrictive measures fail to improve the situation. Personal coping strategies include engaging in positive activities such as listening to favorite music, taking a walk, playing sports, or watching a movie; supportive self statements such as, “I am a strong person and I

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have been through tough times before”; and talking to a supportive person. The “whom to call” section of the crisis plan designates supportive people whom will be called in case of emergencies. They may include peers, but at least two of the people should be responsible adults (e.g., a parent, a friend of the family, an older sibling, a teacher, or a counselor at school). Coping strategies should also include refraining from activities such as alcohol use, which may reduce inhibitions and increase impulsivity if these behaviors have been present in the past. If the patient continues to feel at risk after engaging in each of the personal coping strategies, she should agree to call the therapist (give contact details to the patient), or a crisis center, and finally, to go to the emergency room if she is unable to improve her mood and reduce risk through less intrusive means. The emphasis is on obtaining an agreement from the patient that she will engage in other coping strategies and/or call for help before carrying out a self-harming or suicidal act. After the patient agrees to the crisis coping plan, she is to share it with the parents in the latter part of the session. You may want to use the following dialogue: If it is okay with you, I would like to sit with your parents alone for a few minutes to hear how they have been coping with your difficulties since your trauma. Afterward, I will ask you to come back so that we can all talk together about any other difficulties you may have, and come to an agreement about your parents’ level of involvement in our therapy. If the patient strongly objects to leaving the room, conduct the rest of the session with the parents in her presence.

Meeting With the Parents Only If this is the first time you are meeting the parents, introduce yourself, including your position in the clinic and any experience you have working with adolescents and their parents. Explain that the purpose of the meeting, and perhaps the next one as well, is the identification and discussion of other problems which may bother the adolescent, apart from the fears discussed in the intake interview. Emphasize that together

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with the patient and the parents you will try to find a way to manage these problems during treatment. At the end of the meeting, clarify the level of parental involvement in therapy and talk about the adolescent’s privacy in this treatment.

Evaluating Parents’ Difficulties If available, consult any assessment materials that parents filled in during the intake before meeting with the parents. Tell parents that in addition to questions about their child, you would like to ask them a few personal questions in order to understand their reactions to their child’s trauma and to help them support her during her treatment. You may use the following questions to better assess the parents’ understanding of the trauma, their child’s reaction to the trauma, and the demands of treatment. ■

“Have you ever experienced a traumatic event yourself?”

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“Do you suffer from posttraumatic distress?”

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“How is it manifested today?”

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“Have you had therapy for these problems or for other problems?”

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“How do you understand your child’s behavior since the trauma?”

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“Does your child’s PTSD create difficulty in your daily life and in family functioning?”

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“How do you react to your child’s difficulties?”

Discussion of Suicide Risk (complete section only if necessary) If the patient displayed moderate to extreme suicide risk, ask parents the following questions:

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■

“Has your child ever tried to commit suicide?”

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“Are you aware of behavior that may be interpreted as self-injuring?”

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“Has your child shared any suicidal thoughts with you?”

If the crisis coping plan has been made with the patient regarding risk of harm, explain the plan to the parents and get their input. Make sure all the parts of the plan are feasible and the parents are able to assist the patient in the event of crisis (e.g., using coping strategies, calling a crisis center, or taking the child to the emergency room).

Confidentiality and Privacy Explain to the parents that they and their child, like all other patients who receive therapy at your clinic, have the right to confidentiality with regard to the issues they discuss with you. It is also important that the patient feels confident that the private details of her discussions in therapy will not be shared with her parents. However, as parents or guardians, they have the right to know about the general outline of their child’s therapy and whether the therapy is advancing in the right direction. Assure the parents that information about behavior that is dangerous or life threatening will be reported to them immediately and fully so that you and they can work together to protect their child. With regard to other issues discussed in therapy, the level of parental involvement will be adjusted according to their and their child’s wishes. In most cases, this explanation will satisfy the parents’ need for information and the patient’s need for privacy. If either the patient or parents have additional concerns, you will need to negotiate a compromise agreement based on the wishes of both parties and taking into account your assessment of the patient and the family.

Discussion of Parental Involvement Consult the parents’ and child’s intake material before proceeding with the following questions. You may want to introduce the questions with this dialogue: I would like to learn a little more about your relationship with your child and figure out together with you and (patient’s name), how you can best support her recovery as we go forward with the treatment.

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■

“Do you feel that your child shares her feelings with you?”

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“Do you feel that you know your child? Do you know about her difficulties? How disagreements and problems are handled (frequency of fights, topics, resolution)?”

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“On the whole, does your child follow instructions? Does she listen to your opinions?”

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“Would you be interested in assisting your child during the course of this therapy? How?”

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“From a practical point of view, is it possible for you to be present at meetings and to assist at home?”

Meeting With the Patient and Parents Together This section is a review of the case management issues. For some patients, it will be brief as there will be few issues to manage. For others it may be extensive. This section should include a discussion of the privacy agreement and the crisis coping plan if such a plan was made. If other problems were identified in the previous meetings with the parent and the patient, this section should include a discussion of how those problems will be managed. You may introduce the agenda with the following dialogue: In this part of the meeting I would like to summarize the information we have discussed so far and establish an agreement about how we will handle the privacy issue. Afterward, I would like to discuss any other problems (patient’s name) suffers from in addition to the PTSD. Once we have a full picture of these problems, we will be able to decide how to address them during the course of this therapy.

Confidentiality Review Remind parents and patient of the confidentiality issues discussed in the previous meetings. Reiterate that patients have a right to privacy, but parents also have a right to know about how their child’s treatment is progressing. Emphasize that though you will withhold many personal

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details the patient shares with you, you must inform the parents about things that may cause significant harm to their child.

Agreeing on a Crisis Coping Plan If a crisis coping plan was made, review the details of the coping strategies. Allow the parents to have input into the plan and obtain a consensus before proceeding to the next section. The emphasis for the patient should be placed on the coping strategies that should be used by the patient to prevent thoughts and feelings from escalating to dangerous behavior, and on involving others if the patient is unable to cope by herself. For the parents, the emphasis is on allowing the patient access to specified coping strategies and on contacting help if coping strategies do not reduce the risk. Both the patient and the parents should agree to the plan before proceeding further.

Identifying Other Problems Ask the patient and her parents to think about any issues that could complicate treatment. In addition to the issues raised by the patient and the parents, you can review the following list to identify potential problems that may require management during the treatment. There is no need to focus on all the topics mentioned, but only on those most relevant to the patient. ■

Difficulties in concentrating at school

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Other difficulties at school

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Conduct disorder (e.g., fights with other children)

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Regressive behavior (e.g., bedwetting problems)

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Depression

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Eating disorders or concerns

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Other anxiety disorders

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Addictions

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■

Family changes (e.g., moving houses, divorce)

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Access to resources (e.g., transportation, child care)

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Other commitments (e.g., an after-school job, extracurricular activities)

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Other problems

Discuss the most significant problems with the patient and her parents and generate some possible solutions. The following questions may be useful in examining each issue. ■

How long has this problem persisted? Did it begin after the trauma or beforehand?

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Does this problem bother the patient on a daily basis? Does it get in the way of everyday activities?

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Do the patient and parents both agree about this problem?

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Does the patient define this problem as a central one in her life (more than the posttraumatic symptoms)?

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Do the parents define this problem as a central one in their child’s life (more than the posttraumatic symptoms)?

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Is an additional assessment required (neurological, other)?

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Is a systemic intervention required (vis-`a-vis school, for example)? If so, are the parents and child willing to sign a form to allow sharing of information?

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Are the patient and the family willing to consider psychiatric medication if recommended?

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Are there any circumstances that will interfere with coming to therapy for another reason, such as transportation and scheduling problems, child care issues, or other responsibilities?

After discussing each problem, the decision whether to continue treatment depends on the complexity of the case. When there are no significant additional problems, and when the decision regarding the level of parental involvement is clear (i.e., parents are cooperative

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and express the desire to assist in the therapy process, and parents respect the patient’s independence), you can summarize the case management issues for the parents and move on to the psychoeducational phase. In more complex cases, when there are entangled family relations or when the patient suffers from significant additional problems, you may decide to defer the summary and schedule another meeting for additional problem solving. In any case, at the end of the process, you will summarize the case management issues and identify how each problem will be addressed during the treatment. In rare cases, you and the family may decide to defer the PTSD treatment until a more pressing issue is addressed, for example, an acutely suicidal adolescent or one with substance dependence.

Determining Parental Involvement In the presence of both the patient and the parents, review preferences regarding the sharing of information and the participation of the parents in the therapy. Consider also one or more of the parent’s availability and willingness to participate in sessions and homework activities. Identify which parent will be responsible for transportation to and from sessions. Aim to help the parties come to an agreement about the level of parental involvement that allows some age-appropriate degree of privacy for the adolescent but leaves room for the adolescent to seek support and assistance from parents as she progresses through the therapy.

Therapy Schedule Give details regarding the number and duration of private meetings with the patient, for example, 14 weekly sessions lasting 60–90 min. In addition, discuss whether you will be meeting with parents separately or asking them to join the last section of some of the patient’s individual meetings, as needed.

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Homework Homework will depend on the amount of work necessary to prepare the patient and the family for treatment.

✎ ✎

✎ ✎

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If there are few case management issues, simply ask the patient to review the materials generated in the session to make sure they are complete and accurate. If there are several case management issues and you plan to use more than one session to address the issues, ask the patient to complete some of the work for homework so you can review it in the next session. (For example, if there are issues involving scheduling and transportation, you may ask the patient or parents to work on adjusting schedules or rounding up reliable means of transportation during the week between sessions, so that they can report back to you in the following session.) Have patient read Chapter 3 of the workbook. Have patient listen to the recording of the session.

Phase II

Psychoeducation and Treatment Planning; the Beginning of Treatment

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Chapter 5

Treatment Rationale Module

(Corresponds to chapter 4 of the workbook)

Materials Needed ■

Parent Handout 1: “What Is PTSD and How Do You Treat It?”

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Equipment and media (2 sets) to record session and breathing exercise

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Review homework

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Describe the structure of treatment

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Introduce the rationale for the treatment to patient and parents

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Introduce breathing retraining

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Assign homework

Outline

Overview The purpose of this module is to present the framework of the treatment. The patient and the parents are provided with the general outline of the therapy and are briefed on the rationale for the treatment. The patient will review the corresponding workbook chapter for homework. The parents will also be given a handout explaining the major points of the session. Though much of the session is psychoeducational in nature, it is important to try and make the discussion as interactive as possible. Use the provided dialogues as a starting point for discussing the treatment with the patient rather than giving a lecture.

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This module typically takes one to two sessions. Always present breathing retraining at the end of the first treatment session. This gives the adolescent a pleasant, helpful experience to take home and will help him to develop a positive association with therapy. Homework Review Begin the session by asking if there are any questions about previous sessions or materials. If you have assigned materials for the patient to review or complete from the case management module be sure to specifically address each assignment. The Structure of Treatment To begin the first session of therapy, explain the general focus and goals of the program. Review the meeting schedule for therapy, for example, typically 12–14 weekly sessions of 90 min each. The following dialogue may be helpful: In this program, we are going to focus on the fears and other distressing emotions you have been experiencing, and on your difficulty coping with them, both of which are directly related to your PTSD. After a trauma such as you have experienced, it is only natural to feel afraid, sad, or ashamed and to have trouble talking about what happened. For some teenagers, the scared and sad feelings will begin to get better after a while. For others, thoughts and feelings about the trauma continue to bother them. Often thoughts and feelings about what happened pop into their minds, and no matter how hard they try, they cannot stop thinking about scary and upsetting things. Some teenagers find that they have a hard time doing things that used to be easy for them, such as going to school, sleeping in their own bed at night, taking buses, walking around in shopping malls, or doing outside activities. Sometimes it can seem like life will never be the same again. (Give examples to match the patient’s history.) Ask the adolescent if he has had these kinds of thoughts and feelings since the trauma. Next you will clarify why we think PTSD symptoms continue to trouble the patient and how this program can help him feel better again.

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Rationale for the Treatment Inform the patient that a major reason PTSD symptoms persist is avoidance of situations, memories, thoughts, and feelings related to the trauma. It is understandably quite common for people to want to escape or avoid things that are painful and upsetting. However, while avoiding painful experiences works in the short run, it actually makes it more difficult to get past the posttrauma reactions and prevents one from returning to everyday activities. Ask the patient if he can think of things that he has avoided since the trauma. Tell him that in this program, he will learn how to face situations he has been avoiding. Use the following dialogue to explain the rationale for exposures: When you confront or face painful memories and situations, rather than avoid them, you will have the chance to process the traumatic experience and get past your reactions to it. For example, if you avoid trauma-related situations that are actually safe in real life, you do not give yourself the chance to realize that these situations are safe and get over your fear of being in these situations. Unless you face the situations, you may continue to believe that they are dangerous and that your anxiety in them will never go away. However, if you face these situations, you will find out that they are not actually dangerous and your anxiety will become less and less as you get used to facing and staying in those situations. As a result, your symptoms will get better. The same is true for facing painful memories. Facing these memories is not dangerous; on the contrary, if you face them repeatedly you will feel better rather than worse. It is for this reason that I will ask you to repeatedly revisit the traumatic memory and to face the safe situations that you are now avoiding.

Techniques: Recounting the Memory and Real-Life Experiments Explain that in order to achieve the goal of facing fears, two techniques will be used during sessions. The first technique is recounting the memory, that is, repeatedly recalling the trauma inside the safe environment of the therapy room and each time expanding the memory by adding details, thoughts, and feelings related to the traumatic event itself. We

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have found that recounting or otherwise engaging with the traumamemory several times for about 20–40 min at a time is quite helpful in reducing trauma-related symptoms. Inquire if this idea of recounting the memory makes sense to the patient and discuss any concerns he may have. Tell the patient that you will also be encouraging him to face situations that he has been avoiding since the trauma because these situations (e.g., walking alone on a street, hearing a song that was playing at the time of the trauma, or wearing the clothes worn on the day of the trauma) remind him, directly or indirectly, of the trauma and it is painful to remember what happened, or because these situations are so similar to what happened during the trauma that he is afraid it will happen again. This is the second part of the treatment program and is called Real-Life Experiments; it can be introduced with the following dialogue: Together we will come up with experiments for you to do as a way of testing your fears and helping you to start doing all the things that you used to do, but have stopped doing since your trauma because you have been feeling afraid. [Give an example related to the adolescent’s avoidance]. As you practice the real-life experiments, you will begin to learn that the situations you are facing are actually relatively safe and that your fear decreases with each repetition. The experiments will help you get past your fears and get back to your life. Inquire if the idea of real-life experiments makes sense to the patient and discuss any concerns he may have.

Unhelpful Thoughts and Beliefs Explain to the adolescent that another reason why he may feel anxious and upset is because of unhelpful, disturbing thoughts and beliefs. After a trauma, lots of teenagers start thinking that the world is a dangerous and disappointing place, and that many people—including themselves—are disappointing. Because of this, even safe situations may seem dangerous or unpredictable. Some teenagers even think that they are weak or out of control and unable to deal even with normal daily stresses. Some may also blame themselves for their behavior during the trauma or for the fact that they developed difficulties after the trauma.

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They may start feeling ashamed about themselves, and they may not want to talk with anyone about what happened to them. Ask the patient if he has any of these kinds of thoughts or feelings about himself. State that some of these changes in thinking are unrealistic or unhelpful. They are unrealistic because they do not accurately represent what usually happens in real life, and unhelpful because they are really negative and make trauma reactions more distressing and hard to resist. Use the following dialogue to illustrate why symptoms become worse following such thoughts: For example, if you believe that the trauma is partially your fault, you may blame yourself and become depressed and ashamed. This will interfere with your ability to get back to your usual life. Or, if you believe that experiencing unwanted thoughts and images is a sign that you are losing your mind, you may try very hard to push the memories out of your mind. However, the more you try to push these memories away, the more they will pop up and the less control you will actually have over the memories. Tell the patient that during treatment, he will learn to identify these negative thoughts when they happen and examine if they are realistic or helpful. This is important because many times these thoughts cause so much anxiety, avoidance, shame, and depression that they make PTSD symptoms worse and dealing with everyday life more difficult. Explain that doing real-life experiments and recounting the memory will help him correct unrealistic thoughts by giving him tools to realistically evaluate whether a situation is in fact dangerous and whether he is able to cope with it. As a result, his everyday coping will improve.

Support and Teamwork In summarizing the rationale for the treatment, let the patient know that even though the therapy may be challenging at times, he will not be alone and will be supported by you as he tackles each new assignment. The following dialogue may be helpful: We are going to work very hard together during the next few months to help you get on with your life. Our work will be intensive and you may

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find that you are experiencing discomfort as we discuss the trauma and your reactions to the trauma. You may even experience a temporary worsening of symptoms. I want you to know that I, as well as other members of our clinic, will be available to assist you when needed. We would be happy to talk with you between sessions if you feel that you cannot cope with your feelings alone. We will all work together as a team in order to help you and your family to overcome the trauma. Answer any questions that the patient has about the treatment program or about the information provided so far. Breathing Retraining Introduce the patient to breathing retraining before he leaves the first meeting. Explain the rationale as follows: Now I will teach you the first tool to help you begin to feel better. It is a new way of breathing that will help you to feel calm and relaxed. Did you know that the way you breathe could affect the way you feel? When we are upset, people may tell us to take a deep breath and calm down. However, taking a deep breath often does not help. Instead, in order to calm down it is important to breathe in and breathe out normally and slowly. It is the breathing out part that helps us to relax, not the breathing in part. When you do this kind of breathing, you will breathe in normally and when you breathe out, say the word CALM or RELAX to yourself very slowly, like this: c-a-a-a-a-a-a-l-m. Model for the adolescent how to inhale and exhale through the nose, and then ask the adolescent to perform the exercise according to the following instructions: Slowly breathe out while you are saying CALM to yourself. Very often, when teenagers become scared or upset, they feel like they need more air and may start to breathe in and out very quickly. This causes them to get too much air, which can feel very uncomfortable. They may even feel anxious or scared. Breathing in and out really fast tricks your body into thinking you need to run away or fight. What you really need to do is to slow down your breathing and take in less air. Why don’t we try this now so you can see the difference? [Have adolescent breathe in rapidly, then do a CALM breath.]

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Instruct the patient to take a normal breath and exhale very slowly as he says the word calm or relax to himself. Train him to pause and count to 4 before taking a second breath. Repeat the entire breathing sequence 10 to 15 times and make a recording of your voice leading the adolescent through the breathing exercise. This recording will be used to help the patient practice breathing for homework. Stress the importance of practice with the following statement: Practice is very important in our work together. You will need to practice this new way of breathing every day, for a few minutes each day. I would like you to practice once in the morning, once after school, and once at night before bedtime by listening to the tape we made. You can even teach this kind of breathing to your mom, dad, sibling, or friend and ask them to practice with you. The workbook instruction and the tape we made will help you remember how to do it.

Parent Meeting During the first treatment session, the parents are invited for the last 10 min of the session and the treatment rationale is explained to them briefly. If family members were present during the trauma, spend a few minutes talking about how each family member responded to it. Reinforce parents for participating in treatment.

Homework For Patient:

✎ ✎ ✎

Have patient read Chapter 4 of the workbook. Have patient listen to the recordings of the session and breathing exercise. Have patient practice breathing exercise 3 times per day. For Parents:

✎

Have parents read the first handout “What Is PTSD and How Do You Treat It?” (you may photocopy the handout from the appendix).

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Chapter 6

Gathering Information Module

(Corresponds to chapter 4 of the workbook)

Materials Needed ■

Trauma Interview form

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Secret Weapons form

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Parent Handout 2: “How Can I Help?”

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Equipment and media to record session

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Review homework

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Conduct trauma interview

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Complete Secret Weapons exercise (optional)

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Meet with parents

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Assign homework

Outline

Overview This module gathers information about the trauma, identifies unhelpful thoughts that may interfere with the patient’s recovery, and, if necessary, motivates the patient by assessing her strengths and resources. We recommend you interview the patient without the parents present so that the patient can feel more comfortable and open about the details of the trauma. The information gathered here will help you understand the patient’s view of the trauma and how her cognitions may be playing a

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role in maintaining PTSD symptoms. You may also find some helpful clues about the kinds of experiences to include on the real-life experiments hierarchy and the kinds of details the patient will need to include as she recounts the memory. This module is usually completed in one session, but may be carried over to an additional session if needed.

Homework Review Ask the patient if she was able to practice the breathing technique that she learned last session. Find out if the patient found the technique helpful, or if there were problems implementing the technique. If the patient did not complete the homework, problem solve with the patient how this and future homework can be completed.

Trauma Interview To introduce the trauma interview, use the following dialogue: The purpose of this part of our meeting is to talk about the trauma you have experienced and to learn more specific details about the events occurring immediately before, during, and after the trauma. I understand that it may be difficult for you to talk about some things. If there is anything I can do to make it easier for you, please tell me. To start, can you tell me a little bit about what happened to you? If the patient has difficulty talking about the trauma, ask the following questions in an open-ended manner to gather more information as appropriate. Make sure to utilize information that you have already gathered. For example, if you know the answer to a particular question from an intake interview or from what you have learned in previous sessions, do not ask the question. Rather, say something in the affirmative, and invite the patient to correct you if needed. For example, “I understand that the trauma occurred exactly 6 months ago. Is that right?” If a question is not applicable or relevant to the type of trauma, then skip over it. Substitute a specific term (e.g., attack, accident) instead of the word trauma where possible.

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Record the patient’s answers on the Trauma Interview form (see appendix). Remember that you will need to refer to this information as you begin to structure exposure exercises and as you help the patient examine unhelpful thoughts and beliefs.

Details About the Trauma ■

“When did the trauma occur (date, day of the week, during the day/night)?”

■

“Where did the trauma occur (at home/at school/somebody else’s house/street/car/bus/shopping mall/other)?”

Feelings During the Trauma ■

“Did you believe during the event that you may die or be severely injured?”

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“Did you feel helpless?”

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“Were you terribly scared?”

Additional Information ■

“Do you blame another person for what happened? If yes, who?”

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“Was anybody else with you during the event? If yes, who?”

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“Did you escape danger by yourself or did you receive assistance?”

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“Did you suffer from injuries?”

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“Did you receive medical assistance?”

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“Do you feel guilty about the trauma or about the way you behaved during the event?”

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“Were you ashamed about the event or about your behavior during the event?”

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Changes in Beliefs and Attitudes ■

“Have you experienced changes in your relationships with people who are close to you?”

■

“Have you experienced changes in your relationship with less intimate friends?”

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“Have you experienced changes in the way you see yourself as a person?”

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“Did anybody blame you/was angry with you for what happened?”

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“Were you scared that someone would be angry with you/blame you?”

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“How difficult do you find it discussing the trauma with other people?”

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“Would you like to mention anything else about the trauma, the events preceding or following it?”

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“How was it for you to discuss those issues?”

Other Questions

When the trauma interview is complete, make a positive statement about the patient’s engagement in the interview if appropriate, such as “you have worked very hard today, and have done a marvelous job in helping me understand what happened to you during the trauma.” Ask the client if it was hard to talk about what happened and normalize any feelings of fear or wish to avoid.

Secret Weapons Exercise (optional) This exercise is designed for clients who continue to feel fearful of the treatment or doubtful of their ability to do what is required in the treatment. It is best done during the session rather than as homework so that the therapist can help the clients complete the form if they are unable to think of the personal resources and strengths that will help

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them complete treatment. However, to save time, it can be assigned for homework and completed in a following session. Use this dialogue to introduce the Secret Weapons form in Chapter 4 of the workbook: Therapy can seem hard at first. No one wants to talk about things that make them upset. It gets easier with practice though. Are there other things you have learned to do that were hard at first, but became easier with practice? What are your talents and skills? Are there some skills that you would like to learn but have not already learned? Are there people who help you learn things? Are there people who are “on your team?” Discuss how the adolescent has the resources to learn to cope with and conquer PTSD symptoms. Cover the following three areas. 1.

Skills and talents include anything the adolescent can do (e.g., sing, dance, write stories, draw, or ride a bike) that demonstrates persistence, the ability to learn, courage, or other good qualities.

2.

Experiences and accomplishments include chores, good grades, awards, recovery from an illness or a broken bone, passing a grade, or any experience that shows the reward of hard work, even if the experience was not pleasant at the time.

3. Allies and assets include people such as teachers, parents, or friends and resources such as school, religious organizations, or clubs, as well as religious figures, prayers, God, or anything that will help the adolescent feel supported and cared for. These three categories are not particularly distinct and may overlap a great deal. The point is to generate a list of evidence that the adolescent is capable of doing something hard or scary, learning from it, and doing it well, and that there are many people who will help her along the way.

Parent Meeting Discuss the “What Is PTSD and How Do You Treat It?” handout (see appendix) with the parents and answer any questions they may

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have regarding the material or their adolescent’s treatment. Continue to praise parents for participating in treatment. If parents have not read the materials, cover the content briefly and reiterate how important they are in their adolescent’s recovery.

Homework For Patient:

✎

Have patient review Chapter 4 of the workbook.

✎

Have patient listen to the recording of the session.

✎ ✎

Have patient complete Secret Weapons form in the workbook if appropriate. Have patient continue practicing breathing exercise 3 times per day. For Parents:

✎

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Have parents read the second handout “How Can I Help?” (you may photocopy the handout from the appendix).

Chapter 7

Common Reactions to Trauma Module

(Corresponds to chapter 5 of the workbook)

Materials Needed ■

Common Reactions to Trauma form

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Parent Handout 3: “Common Reactions to Trauma”

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Equipment and media to record session

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Review homework

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Discuss fear and anxiety as a common reaction to trauma

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Discuss feeling on edge as a common reaction to trauma

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Discuss re-experiencing as a common reaction to trauma

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Discuss avoidance as a common reaction to trauma

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Discuss emotional numbness as a common reaction to trauma

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Discuss anger as a common reaction to trauma

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Discuss guilt and shame as a common reaction to trauma

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Discuss feelings of losing control as a common reaction to trauma

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Discuss changes of perception as a common reaction to trauma

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Discuss feelings of hopelessness as a common reaction to trauma

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Help the patient summarize his reactions to trauma

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Assign homework

Outline

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Overview This module provides information regarding common reactions to trauma and normalizes the patient’s symptoms. This discussion is designed to clearly map out the patient’s specific symptoms and to constitute—together with the information gathered through the trauma interview in the Gathering Information Module—the basis for the imaginal and real-life exposure hierarchies. Equally important, however, the common reactions discussion is intended to educate the patient about the symptoms of PTSD and to help the patient view his own symptoms as common reactions to trauma rather than as a personal failure, or a sign of irreparable damage. The Common Reactions form in the workbook or a dry erase whiteboard may be used to keep track of reactions that the patient has experienced. This module is usually completed in 1–2 sessions, depending on the number of reactions the patient has experienced. You will need to adjust the language and the sophistication of the explanations to the adolescent’s level of cognitive development. With most adolescents this material can be presented in a rather straightforward manner, while bypassing psychological jargon as much as possible. In the case of young or less mature adolescents, consult the Common Reaction Cards and Common Reaction Stories appearing in the appendix Additional Materials. In general, activities using props or stories may be more suitable for younger or less cognitively developed adolescents than the explanation detailed in this chapter.

Homework Review Review homework, including the Secret Weapons form. Discuss any problems the patient is having with breathing practice.

Introduction to Common Reactions to Trauma Introduce the discussion of common reactions to trauma to the patient. The following dialogue can be used to begin:

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As we already know, you are here because you experienced a traumatic event. A traumatic event is an extreme life experience that can create intense emotional and physical reactions. I want to describe to you some of the most common reactions to trauma, and find out if any of these reactions are familiar to you from your own experience. It is important to understand that people react differently. Therefore, you may experience certain reactions stronger than others, and other reactions you may not experience at all.

Fear and Anxiety Explain to the patient that fear and anxiety are natural and necessary reactions to danger. When a person is in a dangerous situation, an internal alarm system is triggered, warning the person and enabling him to react and function in the best way to protect himself. This “alarm system” triggers certain physiological reactions (fast heartbeat, sweating, etc.) and helps the person to focus on external threats that he must defend himself against. Discuss how this alarm system may have been at work in the patient during and following the traumatic event. Direct patient toward physiological signs and thoughts. Questions to ask include ■

“Do you remember how you felt during the traumatic event?”

■

“Do you sometimes feel these same sensations in your body today?”

Tell the patient that during the traumatic event these reactions were natural and necessary, but having them persist is now getting in the way of his daily functioning. Sometimes, fear and anxiety arise when he has memories of the traumatic event; however, sometimes it may appear as though the anxiety has come out of nowhere. Things that may cause anxiety (i.e., triggers) are sights, smells, noises, or any other situations that remind him of the trauma. The more he pays attention to the episodes of anxiety, the more he can identify the triggers that evoke the anxiety. He will begin to realize that sometimes the anxiety that appears to come out of nowhere is actually triggered by things

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around him that remind him of the trauma. Use the following example to illustrate: For example, a person who has experienced a traffic accident may feel sudden anxiety and not understand the cause of it. If he pays attention, he will notice a distant screech of car brakes or a siren, and recognize these triggers as the cause of the anxiety. Ask the patient what triggers fear and anxiety for him. List the triggers on the Common Reactions to Trauma form in the workbook.

Feeling on Edge Feeling on edge is another common reaction. Tell the patient that after a traumatic event, many people feel jittery and on edge almost all the time. A person’s body feels hyper; for example, he may have an accelerated pulse and heartbeat and breathe faster. He is cautious and jumpy all the time, is startled easily, and reacts strongly to minor events. Ask the patient if he experienced an increase in any of these physical symptoms since the trauma. Explain that this physical reaction happens because the body’s normal alarm system is working overtime. As previously discussed, this system activates during an emergency so that we can react to danger. This alarm system also exists in animals, such as cats and dogs, and is nature’s way of protecting us from threats. During a dangerous situation, this system makes us flee the situation, fight against it, or freeze (e.g., an animal may freeze in the middle of the road when a car is coming toward it). These are natural reactions in the face of danger. As a result of trauma, this alarm system may also be activated when there is no real threat. The kinds of events and signs mentioned earlier may trigger the system because they remind the patient of the trauma. Emphasize that because these triggers in themselves do not pose a threat, this is actually a false alarm. Ask the patient if this makes sense to him and simplify or repeat parts of this explanation as needed. Inform the patient that as a result of continuous jumpiness, some people develop concentration difficulties, trouble falling asleep, and restless sleep. Constantly feeling on edge may also cause irritability and

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anger, especially in cases when the person doesn’t get enough sleep. Ask the patient if he has experienced similar problems. Questions to ask include ■

“Do you have more difficulty concentrating since the trauma?”

■

“Do you have problems falling asleep?

■

“Is the quality of your sleep poor?”

■

“Do you also find yourself impatient and irritable?”

■

“Has anybody remarked on your being on edge since the trauma?”

If the patient has any symptoms of feeling on edge, note these on the Common Reactions to Trauma form in the workbook.

Re-experiencing Explain to the patient that sometimes thoughts or feelings about the trauma may pop into his mind and make him feel upset. A reminder can trigger these thoughts, or they may seem to come out of nowhere. This is called re-experiencing. Ask the patient if he sometimes re-experiences the trauma and how he feels when this happens. Record his responses on the Common Reactions to Trauma form in the workbook.

Flashbacks Some people experience an extreme form of re-experiencing called a “flashback.” Flashbacks are very vivid images, which give the feeling that the event is taking place in the here and now. For example, a person may feel as though the assault is actually taking place in the present moment, or he may feel that he actually sees some of what happened. Sometimes, the flashback can be so powerful that the person may feel that the trauma is taking place over and over again. Ask that patient if he has experienced flashbacks. If so, have him describe what he heard, smelled, felt in his body, or saw during the flashbacks.

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Nightmares Some people also re-experience the trauma through dreams. Explain to the patient that nightmares take place because the traumatic event is so horrific and different from daily life that it is difficult for the mind to organize the event and put it away. In order to understand what has happened, the brain keeps on retrieving the event from memory in an attempt to digest it. Ask the patient the following questions: ■

“Have you had nightmares about the traumatic event? What did they include?”

■

“Have you felt changes in your body after waking up from such a bad dream?”

Avoidance Given that the re-experiencing of the trauma causes such distress, fear, and anxiety, many people try to avoid anything that triggers those feelings. They find themselves avoiding all kinds of situations, places, or people that remind them of the trauma. Use the following dialogue to illustrate this point: For example, many teens avoid approaching the place where the trauma happened. Even situations that are only indirectly related to the trauma can cause anxiety and avoidance. For example, some people may avoid going out at night if the trauma occurred at night. Can you think of places or situations you have been avoiding since the trauma? Another type of avoidance is related to thoughts and feelings regarding the trauma. Many people actively try not to recall the trauma, not to talk about it, and not to feel emotions connected with it. Sometimes, as a result of the strong desire to avoid memories and feelings related to the trauma, a person may even experience difficulty remembering certain parts of the event. Ask the patient the following questions:

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■

“Do you make an effort to avoid thinking and feeling about the trauma?”

■

“What do you do in order not to think about what happened to you?”

■

“How do you escape the emotions associated with the trauma?”

■

“Are there parts of the event that you find difficult to recall?”

■

“Are there time gaps in your memory of the event?”

Note the patient’s avoidance on the Common Reactions to Trauma form in the workbook.

Emotional Numbness Another experience that may occur as a result of the attempt to avoid painful thoughts and feelings related to the trauma is a sense of emotional numbness. Use the following dialogue to illustrate: Have you ever felt your leg go numb when you tried to move it? Sometimes, the same thing happens with feelings. It is as though they are buried deep inside and you are only dimly aware of their whereabouts. This sensation may worsen to such an extent that you feel as though you “do not feel anything.” Following the trauma, this lack of feelings may help you feel less fear and anxiety, but it also prevents the experience of positive feelings. So you end up feeling less happy, satisfied, or loving. Discuss if this is a familiar experience for the patient. Questions to ask include ■

“Do you feel emotionally numb, empty, or detached from your surroundings?”

■

“Have you lost interest in things that used to be enjoyable in the past?”

■

“Do you feel distant or detached from other people ever since the trauma?”

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Record any symptoms of emotional numbness on the Common Reactions to Trauma form in the workbook.

Anger Some teens also feel a very strong sense of anger not only toward the traumatic event and the actual people involved in it, but also toward other people in general. The anger is usually an expression of the sense of injustice and the feeling that one was a victim. In cases of assault or terrorist attacks, most of the anger may be directed toward the perpetrator, or toward the group behind the attack. Discuss the patient’s feelings of anger and try to identify any generalizations (e.g., sexual assault victims may harbor hatred toward men). Questions to ask the patient include ■

“Do you feel anger toward anyone in relation to the traumatic event?”

■

“Have you had any thoughts about revenge?”

Next, explain to the patient that sometimes feelings of anger may arise in the presence of people who remind him of the trauma, or who have recovered from it. Some people may also be angry with God for letting them become victims, with the police for not treating them with enough sensitivity, or with teachers, friends, and family members who do not know or understand enough what they are going through. Ask the patient the following questions: ■

“Do you feel angry or aggressive toward people who are close to you?”

■

“Is this different from the way you felt before the trauma?”

■

“How do these feelings affect you and the people close to you?”

The following dialogue can be used to normalize the patient’s feelings of anger toward people close to him: A feeling of anger toward family members and close friends may be especially confusing because it is difficult to understand why you feel so much anger toward the people you hold most dear. However, we tend

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to develop high expectations of people who are close to us, and, therefore, if we are disappointed by them, there is a good chance that we will feel a great deal of anger. Record any anger reactions the patient may have on the Common Reactions to Trauma form in the workbook.

Guilt and Shame In addition to the anger directed toward others, many teens also direct anger toward themselves for things that they did, or did not do, during the trauma. They try to guess how they should have acted or what they should have avoided, and may blame themselves. For example, teens might say to themselves, “I should have been less afraid,” or “I should have known that such a thing would happen.” In addition, teens may sometimes feel guilty about the difficulties they have been experiencing since the trauma, and for the fact that their behavior and avoidances have created difficulties for their family and friends. Discuss if the patient has any feelings of guilt, using the following questions: ■

“Do you blame yourself for what happened?”

■

“Do you believe that if you had behaved otherwise, or avoided doing certain things, the trauma would not have occurred?”

■

“Do you feel guilty about the way you reacted after the trauma, or about the effect your difficulties have on your family and friends?”

■

“Are there people or situations you have been avoiding because they make you feel guilty?”

A person who feels guilty about the traumatic event is actually taking responsibility for the event. This may help him to feel a sense of relative control (“if I had done so and so, I could have prevented it”), but it can also lead to feelings of shame. The patient may also feel ashamed if he reacted differently from what he might have expected during the trauma (e.g., crying, freezing on the spot). It is also possible that he feels ashamed about the difficulties

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he is experiencing now, as if PTSD symptoms were a sign of personal failure or weakness. Other people may contribute to feelings of shame because they believe that the patient did not do enough to prevent the trauma or that he could or should have behaved differently during the event. They may even openly criticize the fact that he has developed difficulties following the trauma. Ask the patient the following questions: ■

“Do you feel ashamed about the way you acted during the trauma or afterward?”

■

“Do you believe that others think that you could have—and perhaps even should have—acted differently during the event?”

■

“Do you believe that people criticize you for the difficulties you have developed since the trauma?”

■

“Do you feel that the way you reacted makes you look weaker than other teens your age?”

If the patient has any feelings of guilt or shame, record these on the Common Reactions to Trauma form in the workbook.

Feelings of Losing Control It is possible that during the trauma the patient felt as though he had no control over his feelings, his body, and his life. Sometimes, the feeling of lack of control may be so powerful that the person may believe that he is “going crazy” or “losing his sanity.” Ask the patient the following questions: ■

“Did you experience thoughts like this during the trauma?”

■

“Have you experienced similar thoughts since the trauma?”

Tell the patient that these kind of thoughts are common, but it is important to remember that the intense emotions and experiences brought on by the trauma are a normal response to extreme stress and not a sign of psychosis. Record any thoughts or feelings of losing control on the Common Reactions to Trauma form in the workbook.

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Changes of Perception Sometimes, a person’s self-image and perception of the world changes following a trauma. The patient may say to himself that he must be a “bad person” because bad things happen to him, or “if I were not so weak and stupid this would not have happened to me,” or “I should have been braver.” Such thoughts may make him feel as though something is deeply wrong with him. Ask the patient the following questions: ■

“Do you have negative thoughts about yourself since the trauma?”

■

“What kind of things do you find yourself saying to yourself?”

■

“What do you think of the way you are feeling and coping?”

Also, explain to the patient that it is not out of the ordinary for a person to experience the world in a more negative way and to suffer from difficulties in close relationships after a trauma. If he thought of the world as a safe place before the trauma, it is possible that now he feels that the world is a dangerous place and that he cannot trust other people. He may also discover that the people he loves most and expects to be the most supportive are not always so. Discuss if any of this is familiar to the patient, using the following questions: ■

“Do you feel that the world is a dangerous place?”

■

“Do you feel that the world is a disappointing place?”

■

“Have you noticed any difficulties in your relations with other people?”

Record any changes of perception (of the self, the world, or others) on the Common Reactions to Trauma form in the workbook.

Feelings of Hopelessness Some people begin to feel helpless and hopeless about their chances to feel better. It may seem as though nothing is fun anymore, and they may believe there is nothing worth living for, and that their plans for the future are no longer important. These thoughts can lead some people to believe they would be better off dead. They may even think of

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harming themselves or committing suicide. Refer to the suicide risk assessment and the crisis coping plan if these have been previously discussed. Questions to ask the patient include ■

“Do you feel sad or depressed?”

■

“Do you cry easily?”

■

“Do you feel ‘stuck in one place’ and hopeless?”

Record any symptoms of depression on the Common Reactions to Trauma form in the workbook. Tell the patient that depression is a common reaction to trauma and often co-occurs with PTSD symptoms. This is often due to the loss of enjoyment and fulfillment that can accompany avoidance and the exhaustion and withdrawal that accompany hypervigilance. Reducing PTSD symptoms often improves depression as well.

Summary As you discuss these reactions with the patient, it is likely that he will endorse several of them. Each time emphasize how common and expected his reactions are. You may feel as if you are saying, “That is a really common reaction/experience/symptom,” like a broken record, but it is important to make the point that his reactions are not unusual, surprising, or wrong. PTSD patients often hide their reactions because they feel that their symptoms are a sign of weakness, extreme pathology, or moral failure. They very often feel that they are the only ones to have difficulty with PTSD. They imagine that most other people would have coped much better than they have coped. This conversation may be the first time the patient is told that his symptoms are actually common, expected, and in fact, a normal reaction to an extreme circumstance. Emphasizing the “common” nature of his reaction will also help him feel less alone and less ashamed. You cannot overemphasize this point. When you have covered the list of common reactions, help the patient summarize his own reactions by discussing which of his reactions are most difficult for him. Ask him if he is surprised to learn that his reactions are quite common in PTSD. Encourage him to continue to look

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for common reactions over the coming week. If he becomes aware of others, he can note them on the Common Reactions to Trauma form and bring it in for discussion in the next session.

Homework For Patient:

✎ ✎ ✎

Have patient read Chapter 5 of the workbook. Have patient listen to the recording of the session. Have patient complete the Common Reactions to Trauma form in the workbook. For Parents:

✎

Have parents read the third handout “Common Reactions to Trauma” (you may photocopy the handout from the appendix).

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Phase III

Exposures

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Chapter 8

Real-Life Experiments Module

(Corresponds to chapter 6 of the workbook)

Materials Needed ■

Real-Life Experiments Step-by-Step form

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Stress Thermometer form

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Real-Life Experiments Data form

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Equipment and media to record session

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Review homework

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Discuss rationale for real-life experiments

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Introduce the method for in vivo exposures, including hierarchy and stress thermometer

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Build hierarchy of real-life experiments

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Conduct joint patient–therapist exposure

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Prepare patient and parents for homework exposures

■

Assign homework

Outline

Overview This module reviews the rationale for exposure, introduces Real-Life Experiments (in vivo exposures), and teaches the patient how to rate the anxiety produced by exposures using the Stress Thermometer. Together,

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you and the patient will generate a list of real-life experiments and rate them using the Stress Thermometer form to produce a detailed and systematic hierarchy. Ideally, the patient will then initiate the first real-life experiment during the session and complete others for homework. This module will remain active until the end of treatment as the patient tackles each of the items on the hierarchy in a step-wise fashion for homework. New items are added throughout the treatment as necessary. At this point, you should have a good sense of the degree of assistance the patient may need, and the extent to which she may be able to receive such assistance from others when embarking on the reallife experiments. You probably also have a clear sense of the extent to which the parents encourage or discourage their child’s avoidances. Older adolescents or more independent ones may ask for their parents’ assistance only when needed. Instruct parents on how to show support when their child asks for their assistance. However, if the patient is a young or dependent adolescent, it is advisable to include the parents from the start in the development of real-life experiments. Also, if the parents encourage the patient’s avoidances, it is important to include them early on in order to model appropriate support. You may choose to conduct the entire first session together with the parents. In most cases, the patient will attend the session on her own and the parents will join in the last 10 min of the session in order to hear the explanation for the real-life experiments, and to receive instructions on whether, and how, they should be involved in the homework. If it appears that the patient is minimizing or is unaware of some avoidances (as indicated by discrepancies in the information obtained earlier from the parents and the patient), you may choose to confront this issue first with the patient, and then, if needed, with the parents.

Homework Review Review common reactions to trauma, in particular those that are relevant for the patient.

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Rationale for Real-Life Experiments The rationale for exposures was first presented in Treatment Rationale Module. Use the following more detailed dialogue to further elaborate the rationale for real-life experiments: In our previous sessions we discussed how it is normal for people to want to avoid situations, feelings, and thoughts that remind them of their trauma. This is because being reminded of the trauma brings back those scared and upset feelings. We also talked about how pushing away the thoughts and staying away from the reminders can help you to feel a little bit better in the short run, but the fear remains inside in the long run. In addition, avoiding real-life situations may temporarily decrease the level of anxiety, but it causes you to do less and less things, and sometimes it makes you lose out on important things (insert examples from patient’s life, e.g., going out with friends, driving to places, or sleeping alone in bed). This kind of restriction (on your independence, on your social life) may cause an even worse feeling of sadness and loneliness. Explain to the patient that since avoidance makes things worse, the therapy is designed to try to help her stop avoiding thoughts and situations so she can confront her fears and learn that the scary thoughts or situations are not really dangerous. Real-life experiments are like “field experiments,” where the patient practices the different situations she has been avoiding in real life in order to see what happens. Give examples from the patient’s history. By doing some of the things she has been avoiding, the patient gets a chance to experience them for real, gather evidence like a detective or a scientist, and see for herself how safe the situations really are. Engage the patient with the following examples: Have you done any experiments in your science classes? What do you usually do in an experiment? (For example, state your hypothesis or what you think will happen, gather evidence for and against the hypothesis, and perform a procedure that tests the hypothesis.) Why is it necessary to collect data? (Data provides evidence that the hypothesis may be true or false.)

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OR Do you ever watch detective movies? Have you ever noticed how often the answer that seems obvious isn’t the right one? Why is it important for the detective to check all the facts for himself? (For example, sometimes appearances can be deceiving, things are not always as they seem at first glance, etc.; it is important to make sure that you get the right answer even if you have to collect more information.) Habituation Explain to the patient that she will gradually get used to doing the things she avoids if she does them again and again. With repetition she will be less and less afraid because she will learn that the anxiety does not last forever, but decreases with each exposure. Another reason why anxiety decreases is that the patient realizes that the situation she was afraid of and avoided is actually safe and there is no real reason to avoid it. Use the following dialogue for further explanation: What is this “getting used to” process? When you come across a situation you usually avoid, you probably feel anxious and fearful at first. For example, your heart beats fast, your palms are sweaty, you feel a tremble, and you want to leave the situation immediately. However, if you stay in the situation, you will find that, much to your surprise, your anxiety begins to decrease after a while. It is also useful to use graphs depicting anxiety level to illustrate the habituation process. In Figure 8.1, the horizontal axis represents time Anxiety The point where you avoid the situation

Time

Figure 8.1

Avoidance Reduces Anxiety in the Short Run

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passing by and the vertical axis represents the patient’s level of anxiety. Ask the patient what she thinks will happen when she encounters a scary situation. Have her draw and label a line representing her anxiety on a blank sheet of paper or white board. If appropriate, say that what usually happens is that her anxiety increases with time, and then she avoids the situation by leaving in order not to feel anxious anymore. If the patient has a tendency to leave a situation, reinforce the importance of staying in the situation with the following dialogue: I can understand why you would want to leave a situation that causes anxiety, but by doing so you are actually making your situation worse. If you escape the situation once your anxiety starts to increase, you do not learn that with enough time in the situation the anxiety will decrease and discover that the situation is actually not dangerous. When you avoid the situation rather than face it, you conclude wrongly that “you have saved yourself ” from something terrible. As a result, the next time you enter such a situation, your anxiety level will be high again, you will leave again, and the cycle of avoidance will continue. It is important to mention to the patient that the learning process is a gradual one. In the first exposure, the anxiety may only decrease a little bit or not at all, but the more times an individual practices, the less anxiety she feels. Use another graph (see Figure 8.2) to illustrate this

Anxiety

Time

Figure 8.2

Anxiety Habituates With Successive Exposures

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concept. Make sure you mention the fact that while the peak anxiety in the first exposure is still high, each subsequent peak gets smaller and smaller. Eventually, the anxiety does not even peak, and the individual reacts to the situation that used to be scary with a calm and confident feeling.

Other Ways Exposure Helps Reduce Anxiety Explain to the patient that confronting safe situations that make her anxious because of the trauma will help her to see that the situations are not dangerous after all. If she continues instead to avoid those situations she will continue to believe that the situations are dangerous. Exposure provides the “evidence” needed to remind her that the situation is safe. Explain also that some people avoid trauma-related situations simply because the anxiety is so uncomfortable and they believe that the anxiety will never go away. By confronting the situation and experiencing her anxiety reducing as she remains in the situation, she will learn that her anxiety is temporary and will go away with repeated confrontation of the feared situation. Perhaps most important, overcoming trauma-related fears by confronting the anxiety-provoking situations will help the patient feel better about herself and more competent to overcome the PTSD symptoms that have been bothering her. She will begin to be able to do the things she enjoyed doing in the past but had stopped doing because of the trauma. In short, she will begin the process of getting her life back.

Introduction to In Vivo Exposure Method You may want to use the following story to introduce the method to be used with real-life experiments. Once there was a little boy digging in the sand near the ocean’s edge when a big wave came in and washed over him. He got very upset and scared. He cried and wanted to go home. The next day, he didn’t want to go to the beach at all.

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Ask the patient what she would do in order to help the boy get rid of his fear, then continue with the story. To help him get rid of his fear his mother took him for walks on the beach for the next few days. At first they would walk on the dry sand away from the water. She would hold his hand and gradually they walked closer and closer to the water. By the end of the week, the little boy was able to walk in the water alone. With practice and encouragement, he overcame his fear of the water and was able to enjoy the beach again.

In Vivo Hierarchy Discuss what the boy learned with the patient. Explain that a similar method will be used to help the patient overcome her fears. Together, you and the patient will prepare a list of situations she has been avoiding because of her trauma-related fears. Then you will look at these situations and see which ones are the hardest and which ones are the easiest. Use the following dialogue to present the real-life experiments hierarchy: As we work together in therapy, we are going to make a list of the things you are avoiding. Some will be very difficult and others will be easier for you. Practicing the real-life experiments will be like climbing a ladder. The first steps are the least difficult situations. They are like the lowest steps on a ladder. The next steps will be higher and more difficult, but you will climb them one at a time from lowest to highest. With time, practice, and encouragement, you will be able to conquer your fear and start to enjoy many situations again.

Stress Thermometer Next, direct the patient’s attention to the Stress Thermometer form in Chapter 6 of the workbook. Explain that when she makes her list of situations that she has been avoiding, you will need a way to measure

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how upsetting or scary or sad the situations make her feel. Describe how the thermometer works with the following dialogue: On the thermometer there are markings from “0” to “10.” “10” is a feeling that is so upsetting; it’s the worst you have ever felt in your life. A “0” is when you are not feeling upset at all. At “10” you might have a racing heart, trembling, upset stomach, and breathing problems. You would feel very scared. At “0,” you would be breathing normally, feeling just fine and relaxed. You would not be noticing any fear or anxiousness. Use the anchoring procedure in the workbook to help the patient identify real-life examples or “anchors” that correspond to the different levels of anxiety on the stress thermometer. Often, the trauma will top the stress thermometer as the most anxious situation the patient can recall. For the remaining anchors, try to help the patient think of situations that are not related to the traumatic experience so that the anchors will be less likely to change as the patient’s anxiety improves with treatment. Anchoring the points of the stress thermometer to real examples of stressful experiences that are familiar to the patient will help her describe her anxiety more accurately during exposures.

Creation of Real-Life Experiments Hierarchy Following are examples of commonly identified exposure items for several common trauma types. However, keep in mind that just as the trauma was an idiosyncratic experience for the patient, so will be the avoidance it generates. In vivo homework exposures will include confrontation with a variety of experiences readily available in the patient’s life. The experiences should be objectively quite safe but are avoided by the patient because they trigger anxiety. Sexual and Physical Abuse and Assault

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■

Sexually oriented and/or violent material (books, TV, pictures)

■

Physical contact with others (e.g., hugging, kissing)

■

Persons who look similar to assailant

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Smells, sounds, and sights that were present during the trauma (cologne, alcohol, music, television program, clothing, personal items, etc.)

■

Photo of assailant

■

Police, hospital, other “place” reminders

■

Being home alone

■

Crowds

■

Public transportation

■

Darkness

■

Strangers

■

Men (if male assailant)

■

Loud voices, yelling

Terror Attacks ■

Sudden or loud noise (glass shattering, etc.)

■

Police officers

■

Foreign nationals or foreign-language speakers

■

Public transportation

■

Playing outside

■

Crowded shopping mall or store

■

Open space

Motor Vehicle or Other Accidents ■

Riding in a car or similar activity

■

Sudden or loud noise (glass shattering, etc.)

■

Police officers

■

Similar vehicle

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■

Similar route

■

Similar driving conditions

Natural Disasters ■

Unusual weather conditions

■

Sirens

■

Same season of the year

Sudden Death ■

Funerals

■

Hospitals

■

Emergency vehicles

■

Death-related situations (e.g., chest pain, choking sounds)

■

Photos of the deceased

■

Belongings of the deceased

■

Talking about the deceased

Safety Behaviors As you are identifying avoidance in the patient’s everyday life, some situations will not be readily obvious because of the patient’s use of safety behaviors. For example, a patient may be willing to take public transportation, but only if she carries a pocket knife. Look for “lucky” charms or talismans such as wearing a certain article of clothing or jewelry; “safe” people such as best friends, relatives, or siblings who do not objectively increase safety, but who provide a safe feeling due to their presence; ritualistic behaviors such as taking a certain seat in the bus or car; and defensive behaviors such as carrying a weapon or not carrying money or a wallet. Dropping the safety behavior should be an exposure item on the hierarchy and the patient should work toward performing all items without the use of safety behaviors.

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Types of Exposures As you build the real-life experiments hierarchy, consider the following three types of activities for inclusion on the list. 1. Activities that are perceived by the adolescent as more dangerous than they are in reality. These activities evoke fear because the probability of experiencing another trauma is often greatly exaggerated after a traumatic event. Exposures of this type may be trauma specific, such as riding in cars (after a car accident), or talking to men or boys in safe settings (after an assault). They may also be very general in nature, for example, regardless of the trauma, many people with PTSD avoid crowds, being alone, or both. 2.

Situations that are reminders of the traumatic event. These are people, places, objects, and activities that trigger memories of the event and are avoided because the memories are associated with uncomfortable feelings such as fear, shame, or helplessness. These include a wide range of trauma reminders such as wearing the same or similar clothing as was worn on the day of the trauma, smelling odors or hearing music that were present during the trauma, and having contact with people who were present during the trauma, even if they were not involved in the trauma. Reminders can also include simply telling about the details of the trauma.

3. Situations or activities that increase pleasure or demonstrate competence. These can be assigned, not because they are related to the trauma, but because the patient avoids them due to loss of interest. This kind of assignment, called “behavioral activation,” is particularly helpful for adolescents who are depressed or withdrawn after experiencing a trauma. These exposures include re-engaging in sports, clubs, hobbies, friendships, family responsibilities such as chores, and other enjoyable or important activities that may have been neglected in the aftermath of the traumatic experience. This type of “behavioral activation” may be added to the in vivo exposure hierarchy even if the experience does not trigger much anxiety, but rather is avoided due to loss of

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interest or emotional numbing symptoms. These items may be rated lower on the hierarchy and attempted relatively early in the treatment.

Estimating the Degree of Dangerousness of Real-Life Experiments Some patients will ask questions regarding the degree of real danger involved in certain situations that they have been avoiding. Discuss the issue with the patient, and also with her parents if appropriate, while considering the following criteria: 1.

Is the behavior normative in comparison to other adolescents her age? For example, with regard to activities in high-crime neighborhoods, choose exposures that include behaviors that are normative to the patient’s family and peer group, such as taking public transportation and meeting friends in the afternoon, but not behaviors that are nonnormative, such as walking alone at night.

2.

To what degree do the avoidances limit the patient’s life? For example, avoiding public transportation may be acceptable for adolescents who did not use it before the trauma. This depends on where the adolescent lives and on her degree of mobility without public transportation. If after inquiring into these criteria you are confident that the avoidances are limiting and not normative, discuss the issue of dangerousness with the patient.

3. What is the likelihood of danger? Help the patient make a realistic estimate of the possibility of danger. For example, if the patient completely avoids riding in automobiles for fear of having an accident, consider with her the frequency with which she and others have safely ridden in cars in the past. If the activity is objectively dangerous or illegal, for example, speeding in an automobile, using drugs, or becoming intoxicated, these activities should not be included in the real-life experiments, even if they do evoke considerable trauma-related anxiety.

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The process of discussing these issues models for patients how to examine new situations that may come up to determine if their avoidance is reasonable, based on safe, normative behavior, or if their avoidance is unreasonable, based on trauma-related fears and should be confronted. It also provides a model for examining other types of questionable behaviors or situations. These include risky behaviors such as substance abuse, curfew violations, inappropriate internet relationships, and driving over the speed limit. Some adolescents will disclose risky behavior during the therapy, and regardless of whether the behavior is related to the trauma, the same rationale assessment of dangerousness described in this section can help you discuss the behavior with the patient without engaging in a power struggle. Using the same criteria of dangerousness (i.e., normative behavior and the degree of limitation or risk involved) can help you reach an agreement with the patient to stop these types of behavior, at least during the period of therapy.

Building the Real-Life Experiments Hierarchy It is now time to prepare a list of all the situations the patient has been avoiding. To construct the real-life experiments hierarchy, use the white board or the Real-Life Experiments Step-by-Step form in the workbook to make a list of all of the situations that the patient avoids. See Figures 8.3 and 8.4 for examples of completed hierarchies. At this stage of the development of the hierarchy, include any avoidance regardless of whether or not an appropriate way to confront the avoidance seems clear. Later in the planning, as described shortly, you will work with the patient to find a way to confront the avoidance directly and safely. If the patient is not able to come up with avoided situations, use the information gathered in the earlier sessions, particularly the Gathering Information Module and Common Reactions to Trauma Module, to start a conversation about avoidance. Also, explore common areas of avoidance for specific trauma types as described earlier. For instance, in cases of terrorist attacks, the therapist should inquire about riding public

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Real-Life Experiments Step-by-Step List the situations you have been avoiding, then rate each situation using the stress thermometer. You will re-rate the situations in the last session of the program. Real-Life Experiments

Initial Rating

Final Rating

Talking to a friend about the accident

5

1

Sitting in the front of a bus

6

2

Wearing my seatbelt

5

0

Sitting in the front seat of the car

7

1

Walking on the sidewalk along a busy street

4

2

Sound of sirens

6

0

Driving/riding over 25–30 mph

9

2

Being inside a hospital, especially the ER area

6

2

Driving or riding in cars at night

10

0

Wearing turtleneck or neck scarf (feels confining)

7

0

Driving near a large truck or van

10

1

Smell of gasoline

9

1

Figure 8.3

Example of a Completed Hierarchy for a Motor Vehicle Accident Survivor

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Real-Life Experiments Step-by-Step List the situations you have been avoiding, then rate each situation using the stress thermometer. You will re-rate the situations in the last session of the program. Real-Life Experiments

Initial Rating

Final Rating

Being around a group of men

9

2

Taking a walk by myself

8

1

Sitting next to a man on the bus

10

2

Sleeping in the dark

7

0

Going to the bathroom with door unlocked

8

2

Being in the house alone

6

1

Smell of cigars

9

2

Writing poetry

4

0

Talking to strange men

10

2

Hearing someone say (the perpetrator)’s name

7

1

Walking to the store by myself

5

0

Wearing short pants

6

1

Figure 8.4

Example of a Completed Hierarchy for a Sexual Assault Survivor

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transportation, going out to shopping malls, restaurants, and other public places. In cases of sexual assault, the therapist should inquire about sleeping alone in bed at night and talking to boys/men. Some situations that patients avoid do not readily lend themselves to straightforward exposure. For example, a teenager who has been sexually assaulted may avoid talking to adult men she does not know well. Another may avoid the smell of alcohol because it was present on a perpetrator’s breath. A victim of a car accident may actively avoid the smell of gasoline. Sending a teenager to talk to strangers or to smell alcohol or gasoline for an exposure exercise is not a reasonable or safe way to confront anxiety, especially since you will be asking the patient to engage in the activity repeatedly, for a relatively long period of time. For these situations you will have to engage in a bit of creative engineering to provide the client with an anxiety-provoking situation that is both safe and effective. In the first situation, you can ask the client to talk to male strangers by sending her to a shopping center or mall where she can ask male sales associates for directions or sales assistance. She will repeat the exposure in one store after another for the specified amount of time. This provides brief, appropriate encounters with male strangers but does not involve undue risk. Though no situation is 100% safe, talking briefly to sales clerks in a mall carries far less risk than walking up to male strangers on the street and holding extended conversations with them. Exposure to the smell of alcohol can be provided by asking a parent or responsible adult to put some alcohol on a washcloth or rag. The patient can smell the cloth without the need to carry around a bottle of alcohol. Similarly, by simply pumping gas and leaving the residue on her hands for a period of time, a teen can confront the smell of gas without risking her health by directly breathing the noxious fumes from a container of gasoline.

Rating the List Once you and the patient have generated the list of avoided situations, rate the level of anxiety associated with each item on the list. In order

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to reach a sufficient level of anxiety during exposures, different characteristics of avoided situations, such as the time of day and the people present, could be combined. For example, going to the shopping mall with a parent could be rated 6, while going alone (provided that the age of the patient is appropriate) could be rated 8. Prevent overrating by comparing two situations on the list. For example, “you say that going to school and sleeping in your room are both 9. Does one situation frighten you more? Do both situations frighten you the same as the attack itself? What is scarier? Can you rate the other items lower in order to show that they are not as scary as the attack itself?” When the ratings have been confirmed, explain to the patient how they will be used for real-life experiments. We will start the real-life experiments with a situation rated 4–5, and afterward we will advance to a situation rated higher. During the experiments, you need to remain in the situation for at least 30–45 min or until your anxiety has decreased by half (for example, from 8 to 4 on the stress thermometer). It is very important that you remain in the same situation until you feel that the anxiety has decreased, at least a little. Even if at first you feel that it is not decreasing at all, and perhaps even increasing, you will see—as we spoke earlier—that anxiety is like a wave, and if you stay in the situation long enough, it will start to come down by itself. For some people, the anxiety only slightly decreases in the first experiments. It is very important to continue and repeat the experiments because after a few trials the anxiety will decrease. It is important that you re-rate your anxiety each time you attempt the exposure so we can find out if your anxiety is decreasing, increasing, or staying the same. Sometimes a patient will rate everything on the list very high, and be unable to generate activities that are at an appropriate stress level to begin the first few experiments. In this case, you may need to vary the conditions to bring down the patient’s level of anxiety. For example, some situations are less frightening in daytime rather than nighttime, and some situations are more tolerable when there is another person present. In a sense, you will help the patient create a mini-hierarchy within one item on the list, as the following example makes clear. This example also appears in the patient workbook.

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Example: Driving on the Highway The original hierarchy item is “driving on the highway.” The mini-hierarchy is as follows: 1.

Patient is a passenger in a car driven by a “coach” (supportive friend or family member) around a suburban neighborhood.

2.

Patient drives the car around the suburban neighborhood with the coach as a passenger.

3.

Patient drives on a multilane city street with the coach as a passenger.

4.

Patient is a passenger in a car driven by the coach on the highway during low traffic time.

5.

Patient drives with the coach as a passenger on the highway during low traffic time.

6.

Patient drives with the coach as a passenger during moderately heavy traffic time.

7.

Patient drives alone on the highway during moderately heavy traffic time.

8.

Patient drives alone on the highway during heavy traffic time.

In this example, each situation is attempted in turn so that the patient is gradually able to return to driving on the highway. The patient does not progress to the next situation until her peak anxiety in the previous situation stays lower than about half the original rating for the situation.

Joint Patient–Therapist Exposure in Session When possible, arrange to conduct the first in vivo exposure with the patient in session to encourage the patient to remain in the situation until habituation occurs. If you choose not to conduct a joint exposure with your patient, skip to the next section in order to prepare the patient for homework exposures.

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Sometimes, the real-life exposure hierarchy includes items that can be practiced within the session—for example, sitting in the waiting room with unfamiliar people, crossing the street outside the clinic, listening to scary noises together, and walking down the center of a hallway and not close to the walls. If you can identify such a task on the patient’s list, practice it together for the first time in this part of the session. Afterward, the patient may choose additional exposures to practice for homework. Carrying out a joint exposure in session may provide you with important information regarding the patient’s safety behaviors and other avoidances. You may want to dedicate an entire session for the joint exposure, if the adolescent seems particularly anxious or is having difficulty understanding the instructions. If appropriate, invite the parents to join this part of the session in order to model how to support the patient during exposures. You can introduce the joint exposure to the patient with the following dialogue: During this session, we will practice your first real-life experiment together. I would like to accompany you so that I can understand your anxiety and what happens to you when you are frightened. I would also like to make sure that you understand all that you have to do during an experiment. Afterward, when you practice the homework experiments alone, you will be able to recall our first experiment and remind yourself of the procedure. (If you will be including the parents in the experiment) I have asked your parents to join us so they can learn how to help you with the real-life experiments homework.

Conducting In-Session Real-Life Experiment Choose a situation from the patient’s hierarchy rated between 4 and 5 and conduct the experiment for 45 min. Prepare the patient for the reallife experiment using the following dialogue: It is likely that once we practice the experiment you will feel anxious or frightened at first. It is important that you remember that we chose situations that scare you, but that are not really dangerous. We are going to do this together, and I am here to help you. I will ask you to

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rate your anxiety every few minutes, and in 45 min, when we finish the experiment, we can talk about what you learned from this experience. If we see that the situation is not scary for you at all, we will select a different experiment. Ask the patient about her level of anxiety every 5 min during the experiment. Record ratings (before, after, highest) on the Real-Life Experiments Data form. See Figures 8.5 and 8.6 for examples of completed forms. At the end of the experiment, discuss the process with the patient. It is important to congratulate her on carrying out the task.

Post-Exposure Processing If the anxiety decreased significantly during the experiment, point out to the patient that her anxiety decreased as predicted. Remind her that her anxiety will continue to decrease as she practices and that she should persist with the homework exposures. If anxiety stays the same or increases, point out that it is sometimes necessary to repeat the exposure more than once before seeing significant decreases in anxiety. Encourage the patient to persist with the homework in order to realize gains. It is extremely important to reinforce the patient for simply sticking with it and carrying out the experiment. Some patients may feel at the end of the exposure that their anxiety did not decrease at all, however, an examination of the rating conducted during the experiment will show that the anxiety did in fact decrease, but perhaps not as much as the patient had hoped. It is possible that some patients will underestimate the value of the experiment, or claim that the task was not anxiety provoking enough. In such cases, it is important to go back to the hierarchy and point out to the patient that other tasks that seem scary may also turn out to be easier than expected.

Preparation for Homework Exposures For the first homework exposures, choose situations rated 4 to 5 that the patient can practice daily. By the end of therapy, the patient is

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Real-Life Experiments Data Record your stress ratings before and after each real-life experiment. Also record the highest stress rating that you experienced during the real-life experiment. REMINDER: Remain in the situation for at least 30–45 minutes or until the stress ratings have decreased by half. Situation:

riding as a passenger in a car(to school, mom driving) Before

After

Highest

4/17/05

8

8

9

4/19/05

8

6

8

4/21/05

6

5

6

4/22/05

4

3

4

4/23/05

3

3

3

Before

After

Highest

4/17/05

10

4

10

4/18/05

6

3

6

4/19/05

4

3

5

4/20/05

2

2

2

4/21/05

2

2

2

4/22/05

2

1

2

Date & Time

Situation:

sitting with friends at lunch (without hiding scar from accident)

Date & Time

Figure 8.5

Example of a Completed Form for a Motor Vehicle Accident Survivor

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Real-Life Experiments Data Record your stress ratings before and after each real-life experiment. Also record the highest stress rating that you experienced during the real-life experiment. REMINDER: Remain in the situation for at least 30–45 minutes or until the stress ratings have decreased by half. Situation:

Walking around the block Before

After

Highest

Date & Time 7/12/06

5pm

8

4

9

7/13/06

5pm

6

3

6

7/14/06

6pm

5

3

5

7/15/06

4pm

3

2

3

7/17/06

4pm

2

1

2

Before

After

Highest

7/12/06

10

8

10

7/13/06

8

6

9

7/14/06

8

5

8

7/15/06

5

3

5

7/17/06

3

1

3

Situation:

wearing a skirt

Date & Time

Figure 8.6

Example of a Completed Form for a Sexual Assault Survivor

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supposed to practice all the situations listed in the hierarchy. If it appears that problems may arise during the exercises (e.g., lack of time, lack of privacy), discuss with the patient how to overcome these obstacles or choose other tasks. Review the exposure instructions given in the workbook, which includes the section Dos and Don’ts for Real-Life Experiments. Reinforce the importance of staying in the situation with the following dialogue: When you practice the experiment, you may feel anxious or frightened at first. For example, it is possible that your heart will begin racing, your palms will become sweaty, and you will start to tremble. You may want to exit the situation immediately. However, in order for the experiment to succeed and for you to overcome your fears, it is important that you remain in the situation for 30–45min or until the anxiety decreases. After your anxiety decreases by half according to the stress thermometer, you may stop the experiment and move on to different activities. Remind the patient that if she stops the experiment while feeling very anxious, she will not have all the information and experience necessary to learn that the situation is actually not dangerous, and, therefore, the next time she faces the same situation her anxiety level will be very high again. However, if she remains in the situation, her fear and anxiety will decrease until she is able to approach the same situation without feeling fear or anxiety. Emphasize that the more she practices, the less frightened she will feel and the less she will feel the need to avoid the situation. Inform the patient that sometimes the anxiety does not decrease in the first practice, but reiterate that it will with repeat exposure.

Importance of Working Systematically Discuss the importance of working systematically with the patient. It is possible that when conducting the homework experiments during the week, she may decide to conduct a different experiment from what was agreed upon. She may even want to do a task that she thought would cause her great anxiety. Ask her what she thinks would happen if she suddenly decided to conduct an experiment rated a “9.”

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Explain that it is likely that her anxiety will be very high and that it will prevent her from carrying out the experiment (use the metaphor of a going to the gym after not exercising for a long time—the muscles will cramp making it impossible to continue the workout). If this happens, she may feel failure and disappointment. On the other hand, if she manages to do the task, she may think that now “everything is easy” and will not make the effort of practicing the other, easier tasks on the list. This may cause her to continue avoiding the same “easy” situations and keep her from advancing in therapy. Next ask the patient what she thinks would happen if she advances gradually from a “5” to “6” situation. Emphasize that by advancing step by step she will acquire confidence and understand that the anxiety decreases with practice. She will feel a sense of accomplishment and be able to stop avoiding.

Parental Involvement At this point, invite the parents to join the session and briefly explain to them about real-life experiments, and discuss their level of involvement in their child’s homework. If the patient agreed that the hierarchy be shown to her parents, present it to them at this point. If not, just discuss an agreed upon example. Explain that the list is hierarchical, advancing from experiments that cause a low level of anxiety to experiments that cause a higher level of anxiety. Say that the process will be like climbing a ladder one step at a time. Ask parents if they can think of any other situations, places, activities, or people their child has been avoiding. If new information arises, add the relevant tasks to the list. Encourage parents to actively support their adolescent in doing real-life experiments using the following dialogue: When doing her homework, your child may feel anxious or fearful in the beginning. This is where you can be a cheerleader for her. Before you leave today, we will discuss how she wants you to be involved in the experiments. You can help her to stay in the situation by making supportive, encouraging comments like, “you are doing a great job facing your fear,” and “I know this is hard, but it will help you feel

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better in the long run.” She may need you to be present and watch at first, but then gradually decrease your direct involvement until she is doing it entirely by herself. You and she will negotiate this process over the next week as she practices. Remind her to use the stress thermometer to rate her distress during the exercise. If the parents are being asked to assist with the real-life experiments, ask them if they understand the procedures and if they are comfortable with their assigned tasks (e.g., accompanying the patient during the experiment, reminding her of the homework assignments, or encouraging her to practice them). Invite the parents to ask questions about the procedure and their role (if any). Emphasize that the patient sets the pace together with the therapist, and so the parents’ role is to help the patient complete the experiments, not to set the plan for them. Remind parents that the experiments may cause the patient some anxiety at first, but eventually she will be able to enter the situation without feeling scared and upset. The more often she practices each situation on her list, the less fear and avoidance she will have.

Homework For Patient:

✎

Have patient read Chapter 6 of the workbook.

✎

Have patient listen to the recording of the session.

✎ ✎ ✎

Have patient start real-life experiments using the stress thermometer and recording ratings on the Real-Life Experiments Data form in the workbook. Have patient add avoidance situations as necessary to the Real-Life Experiments Step-by-Step form. Have patient continue practicing relaxed breathing exercise if necessary. For Parents:

✎

Have parents assist with real-life experiments as discussed.

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Chapter 9

Recounting the Memory Module

(Corresponds to chapter 7 of the workbook)

Materials Needed ■

Recounting the Memory Session Record

■

Recounting the Memory Data form

■

Equipment and media (2 sets) to record session and recounting the memory

■

Review homework

■

Provide rationale for recounting the memory of the trauma

■

Discuss the beneficial effects of recounting the trauma

■

Coach the patient to recount the trauma

■

Troubleshoot problems of over- and under-engagement

■

Help the patient to process the traumatic memory

■

Help the patient identify unhelpful thoughts and beliefs

■

Conduct parent meeting

■

Assign homework

Outline

Overview In this module, the patient practices the second exposure technique, recounting the memory. Recounting the memory can be done in several

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ways; however, the preferred method is imaginal exposure. If the patient is unable to verbally recount the memory, you may offer other options such as writing down the memory, drawing the memory through different pictures, or recounting it through stories. After each exposure, time is spent emotionally processing the memory, and challenging unhelpful thoughts as necessary. Repeat this module at least for two additional sessions, skipping the rationale section, as long as the patient is advancing well. In general, adolescents may have a shorter span of attention in comparison to adults. Avoid exposures that are too long, thus enabling the patient to stay attentive throughout. During the exposures you should note the patient’s possible worst moments according to the patient’s reaction and level of distress. Once the patient begins to feel less anxious with the entire memory, advance to the Worst Moments Module.

Homework Review Discuss how the patient is progressing with the real-life experiments. Review the Real-Life Experiments Data form and check for any problems with using the stress thermometer.

Rationale for Recounting the Memory Continue the discussion on the rationale for exposures begun in the Treatment Rationale Module. Tell the patient that this next technique will help him face his scary memories, thoughts, and feelings about the trauma so that he can learn to be less afraid and upset. Address the adolescent’s avoidance with the following dialogue: We have spoken about the fact that you avoid thinking about the trauma because recalling it causes anxiety or other negative feelings such as sadness or anger. The trauma was a scary incident and today you are trying to keep memories of it away in an attempt to avoid the pain they cause. You may be saying to yourself things like “don’t think about it,” “time will cure everything,” or “I just need to forget about it.” It is possible that your friends and family are also telling you to

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leave the past behind and move on. But, as we can see, the more you make an effort to distance the memories, the more you are haunted by the experience. The scary thoughts and feelings continue to happen, indicating that the trauma is actually far from being over for you. Explain to the patient that the purpose of therapy in general, and recounting the memory in particular, is to stop being afraid or ashamed of the memories related to the trauma. The goal is to stay with the harsh images and not to flee from them. If the patient does not push the images out of his mind, he will reach a point where his anxiety decreases. This is a similar process to what the patient experienced in real-life experiments. Tell the patient that it is normal to want to run away from the memories, thoughts, images, and feelings that remind him of the trauma; however, the more he avoids them, the more they will disrupt his life. This technique will teach him how to control the memories, instead of having them control him. Use the following metaphor to illustrate: The traumatic experience is kept in your memory like a book. You are trying to keep this book closed and never read it. But, what is actually happening is that the book opens by itself, suddenly and unexpectedly, on different pages, and you find yourself “reading” scary parts against your will. Our goal is to help you read this book from beginning to end several times until we manage to put some order into the pages. As a result, in the future, you will be able to open up the book on whatever page you want, read it, browse through it, or just leave it closed, not out of fear but out of boredom. Remind the patient that his previous attempts to run away from the memory did not really work because he is more distressed now than before the traumatic event happened—he still has symptoms of PTSD. Ask the patient if he is always able to avoid thinking about the trauma. Emphasize that such attempts do not work for most people.

Thought-Stopping Experiment (optional) If the patient does not show understanding or identification with the difficulty of keeping thoughts away, try the following experiment of thought-stopping:

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When you try very hard to push something out of your mind, it only seems to make it pop up more often. Let’s try an experiment. Get comfortable. In this experiment I want you to start thinking about whatever comes into your mind. You can think of anything you wish, except, whatever you do, DO NOT think about a small purple elephant. You can think of anything else, any kind of animal, or any thought at all, but DO NOT think of a small purple elephant. If a thought or a picture of a small purple elephant pops into your mind, I want you to push it out as best you can. Wait 2–3 min and ask the patient if it was hard to push the small purple elephant out of his mind. Explain that trying to push away a scary memory is just like trying to push away that thought of the purple elephant. Spend a few minutes talking about how the experiment shows that trying to avoid a thought makes one think about it more. Encourage the patient to talk about how this relates to his own situation.

Effects of Recounting the Memory Explain to the patient that recounting the traumatic memory helps him recover from trauma-related problems in several ways as are described next.

Digesting the Memories Tell the patient that since avoiding scary memories does not work, he must learn to digest them. Use the following dialogue to illustrate the process: Some people like to think of it this way. Suppose you have eaten a very large meal that you cannot digest. This feels very uncomfortable doesn’t it? Your stomach rumbles and it may even hurt. The way to feel better is to digest the food. Likewise, your scary feelings, bad dreams, and upsetting thoughts are happening because they have not been digested

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well by your mind. By recounting your trauma memories, you can start to digest them so they will stop interfering with your life. Explain that the purpose of recounting the memory is to enable the patient to think about the trauma, talk about it, and see things that are related to it without feeling high anxiety which disrupts his life. This process requires confronting anxiety-provoking memories which he would otherwise avoid. In order for this to work properly, he must repeat the process again and again, expanding the scope of the memory each time. Inquire if the adolescent has any questions before continuing. Inform the patient that similar to the process of real-life experiments, he may feel that his anxiety increases when first recounting the memory. It is only natural that such a harsh memory will bring about distress at first. Stress, however, that the more the adolescent keeps on recalling the trauma—instead of avoiding it as he did in the past—the more he will see that the memory itself cannot harm him and that his anxiety gradually decreases with time.

Other Beneficial Effects Next discuss other ways that recounting the memory helps to process the trauma. Use the following dialogues.

Discrimination

Being exposed to the memory will enable you to discriminate between the trauma itself and the memory of the trauma. That is, it will help you realize that the trauma happened in the past, and that now is not the past, even if you think about the trauma. While there was a real danger during the trauma and there was a reason to be anxious and scared, remembering the trauma is not dangerous and therefore there is no need to be scared or anxious about the memory or while remembering the trauma. By recounting the trauma you will learn that the memory does not have any power over you; it is only a memory.

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Organizing the Memory

Telling the story over and over again helps organize the memory and digest the trauma. By staying with the memories you will begin to make sense of the trauma so that it won’t feel so confusing and dangerous. You will begin to learn things as you do this. One of the things you can learn very quickly is that remembering and telling the story of the trauma does not harm you. Getting Used to the Memories (Habituation)

Continuous recounting of the trauma will reduce your anxiety and will teach you that anxiety does not last forever and that you do not need to run away from the memory in order to stop your fear and anxiety. The more you recall and recount the trauma, the better this process will work. Repetition is necessary to get used to the memories and decrease anxiety. Gaining Control

You may feel that the anxiety of recalling the trauma will make you “fall to pieces” or go crazy. The fear of losing control is understandable and natural, but one of the things you will learn during the recounting of the memory is that despite the temporary increase in the level of anxiety, you will not fall to pieces and you will not go crazy. In fact, the more you practice recounting the memory, the more your sense of control will increase. You will discover that you have the power to overcome anxiety, as well as other obstacles in your life. Question the patient to make sure that he understands why recounting the memory of the trauma is helpful and answer any questions he may have before proceeding to the recounting exercise.

Recounting the Memory of the Trauma The patient’s narrative should be recorded each session so that he can listen to it for homework. This recording should be separate from the

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recording of the rest of the session for ease of use. Before beginning, instruct the patient to recount the memory in first person present tense and to repeat the story several times with eyes closed. If the patient objects to closing his eyes, allow him to recount the story with his eyes open. After a few exposures, you can encourage the patient to try to recount the memory with his eyes closed. Begin by giving the patient the following instructions: Now, I will ask you to close your eyes and tell me the story, as it happened, from the beginning to the end. Try to tell the story in the present time, as if it is happening now, for example, “I am walking/driving/sitting/etc.” Make sure your story is as detailed as you can remember. Talk about what happened, and what you were thinking and feeling at the time. Mention all the things that happened to your body. Include everything you remember. Before you begin the story, I will ask you to tell me your level of distress according to the stress thermometer. During the story, every few minutes, I will ask you “how much?” and you will tell me the number that reflects your level of anxiety at that moment. Does this sound clear to you? Once you finish recounting the story, do not open your eyes. If we reach the end of the story before the end of our time, I will say “from the beginning,” and you will know that I would like you to start recounting the story from the beginning. Let us decide together now which moment we shall call the beginning of the event and which moment we shall call the end of the event. Ask for a stress thermometer rating at the beginning, every five minutes during, and at the end of the story. Record these ratings on the Recounting the Memory Session Record form. This form can be used to collect important information during the session and to keep track of the patient’s progress across sessions.

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Recounting the Memory Session Record Patient name:

Therapist:

Date:

Session number:

Description of the Memory:

Time Begin:

Stress Rating:

Notes:

5 min 10 min 15 min 20 min 25 min 30 min 35 min 40 min 45 min 50 min Processing:

Assessment:

Homework:

Next appointment date:

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Time:

The first time the patient tells the story, allow him to choose what to focus on. If he has a hard time getting started, you may suggest he starts by describing the setting where the trauma occurred or the people involved. Especially in the first attempt, encourage and compliment any efforts the patient may make. Once the patient has gone through the story or the portion of the story that is the focus of the session, ask him to repeat it again with his eyes closed until 30 min have passed. As the patient repeats the story, you may interrupt briefly to ask questions to help clarify thoughts and feelings related to the trauma. ■

“What are you feeling?”

■

“What are you thinking?”

■

“What is your body feeling?”

■

“What happens next?”

It is also helpful to make encouraging comments occasionally throughout the recounting, but do not engage in detailed discussion or distract the patient’s attention from the memory itself. (Keep to short comments of a few words.)

Guidelines for Imaginal Exposures Dos: ■

Create a safe and supportive atmosphere for the exposure

■

Provide clear instructions

■

Help the patient return to present tense when telling the story

■

Encourage the patient with frequent, short remarks

■

Ask for the level of distress every 5 min

■

If questions are required, ask short questions of no more than a few words

■

Write down possible worst moments (according to the patient’s reaction and level of distress)

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Don’ts: ■

Do not engage in discussion during exposure

■

Do not ask long questions

■

Do not express an opinion regarding the patient’s emotions

Troubleshooting Over-Engagement It is normal for patients to become upset while recounting the memory. In fact patients may display a range of intense affective responses as they work through the traumatic memory. Intense emotion is most often a sign that the patient is properly engaged with the memory, and is therefore a productive development when it occurs. However, in some cases, the patient may become overly engaged with the memory, such that he becomes stuck at a particular part of the story and is unable to go on, or is unable to respond to the therapist’s prompts. If the patient is particularly upset or unwilling to continue, remind him that it is a memory from the past, it is not happening now. Use the following statements to encourage the patient: ■

You are doing a great job.

■

I can really imagine what happened.

■

I can see how hard you are working to put in all the details.

■

This is a memory. It can’t hurt you now. It is safe to tell the story.

In extreme cases of continuous over-engaging, suggest that the patient recount the story with his eyes open, or write down the memory and read it out during the session.

Under-Engagement Sometimes the patient may find it difficult to express his feelings. He may be afraid to start crying because he imagines that if he starts, he

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will never be able to stop. In order to avoid distress and to maintain a sense of self-control, the patient may behave evasively during the session. For example, he may become quiet or suggest other activities that are unrelated to the exercise. At this point, encourage the patient to reengage in the exercise and direct him through some of the following statements: ■

You are doing a great job, and it is important that you connect to your memory even more.

■

Help me see and feel everything as you did then.

■

While recalling the event, focus on your body. How do you feel now?

■

Focus on your senses—what do you see? smell? touch?

■

Focus on your feelings—what do you feel?

■

Focus on your thoughts during the event.

■

When did you understand that something “different” was happening?

■

This is just a memory. It cannot hurt you now. You can feel safe telling the story.

Processing the Memory of the Trauma When the exposure is over, praise the patient for his efforts. Discuss the experience with the patient. The following questions may be helpful in starting the discussion. ■

“How was it for you to tell the story this time/for the first time in this way?”

■

“Did you notice anything about the story?”

■

“Did you notice anything about yourself or about your reaction to the recounting?”

Compare the stress thermometer ratings at the beginning and at the end of the exposure. If the patient’s anxiety has decreased in the session, ask the following questions:

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■

“How did your anxiety decrease?”

■

“What do you learn from this?”

■

“What happened as a result of recounting the memory?”

Point out that scared and sad feelings get less upsetting as the patient keeps working on the memory. In subsequent sessions, you may want to use the following dialogue: You seem more relaxed today than the last time you worked on this part and I noticed that you added more details. As you can see, the more you work on the situation, the less it bothers you. Is it as upsetting to think about as it used to be? If the patient’s anxiety has not decreased in the session, reinforce the patient for his effort as follows: I see that you were feeling very upset today while we were working on your memory. You did a great job facing the memory. You were not sure that you would be able to do this, but you confronted your fears. You can give yourself a big pat on the back. Here is a list of questions you may use to help the patient process the memory. 1.

“How did you feel?”

2.

“What did you think?”

3. “How do the new details contribute to your understanding?” 4.

“Have you understood things you did not understand in the previous recounts?”

5.

“You have spoken about X (a feeling: shame, guilt, etc.). What do you think or feel about it now? Do you still feel X?”

6.

“Given our discussion about common reactions to trauma, what do you think of the way you behaved since the trauma?”

7. “With regard to new details added to the memory of the event, you recalled X (e.g., somebody helped you)—how do you understand the behavior/functioning of the people around you during the event?”

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8.

“How does this new detail influence your beliefs about people’s indifference or evil nature or your perception of the world as an unsafe place?”

9. “What have you learned about your ability to handle anxiety?” 10.

“What have you learned about the effects of recounting the trauma again and again?”

Identifying Unhelpful Thoughts and Beliefs During the recounting of the memory and discussion that follows, stay alert to the presence of unhelpful thoughts or beliefs that may be increasing the patient’s level of distress. In processing the imaginal exposure, you may help the patient identify and examine these beliefs, especially with regard to the parts where he reported high anxiety. The goal is to increase the adolescent’s awareness of the impact these beliefs have on his negative emotions and on the persistence of PTSD symptoms, and to modify them when needed. Always use questions that are on the developmental level of the patient. With very young adolescents, this may mean simply focusing on what the patient feels when he has the negative thoughts, and developing alternative thoughts. Typically, cognitive challenging techniques will be used less frequently with younger adolescents.

Post-Trauma Appraisals Sometimes the patient’s current distress comes from the way he thinks about the trauma now, rather than from the particular thoughts that went through his mind at the time of the event itself. To identify these post-trauma appraisals it is useful to ask questions such as ■

“Thinking back to the trauma, what seems the worst thing about it now?”

■

“What does it mean to you that this happened?”

■

“What does it say about you?”

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You can ask similar questions about the patient’s appraisal of his PTSD symptoms: ■

“Why do you think you feel upset and afraid now?”

■

“What do you think feeling this way means about you?”

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“How does this fit with what we have talked about common reactions to trauma?”

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“How does it make you feel to think of yourself in this way?”

Challenging Unrealistic Cognitions If you identify unhelpful thoughts during the recounting of the memory or the processing ask the patient to examine the accuracy of his unhelpful thoughts. Challenge unrealistic cognitions with the following: ■

“What is the ‘hard’ evidence for this thought?”

■

“Do you think that this thought is really true?”

■

“What would you tell a good friend if he said to you that he felt the way you describe?”

■

“Can you think of a different way of looking at the situation?”

Be on the lookout for an emotional response that arises and disrupts the processing of the memory. Taken to the extreme, feelings such as guilt, shame, anger, or sadness call for special attention during the processing section. Inquire into the thoughts at the basis of these feelings and challenge them through questions or tasks.

Guilt

When a patient feels guilty about the way he coped during the traumatic event, or about the fact that he “brought it upon himself ” (e.g., convinced parents to let him go where the attack took place), help him identify the parties bearing true responsibility for the event (e.g., the attacker). Stress the fact that by feeling guilty, one takes upon oneself

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sole responsibility for an incident that was actually out of one’s control. In addition, help the patient imagine a situation where a person who is close to the patient experienced a similar trauma. Ask if the patient would blame that person for what happened to him.

Shame

Patients may feel ashamed about the way they reacted during the trauma, or about the fact that they developed PTSD symptoms following the incident when other people did not. With regard to the reaction during the incident itself, the sense of shame may be accompanied by thoughts that other people would not have felt scared or would have responded more effectively. Help to normalize the patient’s reactions during the incident by reviewing common reactions to trauma. Many times the feeling of shame, which may surface during the imaginal exposures, is accompanied by an avoidance of talking to close friends or family about the trauma or PTSD symptoms. Assign real-life experiments where the patient shares experiences from the incident or from current difficulties with close family or friends. In addition, ask the patient to interview other people who were with him during the event, or who experienced a similar incident, about their feelings and fears.

Anger

When the patient reports high levels of anger, accompanied with an increase on the stress thermometer, you can presume that there is another emotion—a more anxious one—causing the intrusive symptoms and the increase in distress. In dealing with feelings of anger during therapy in general and during imaginal exposure in particular, begin with validating the emotion (e.g., “You have every right to be angry. The assailant was very wrong.”). Next, however, it is important to examine with the patient what he stands to gain or lose from his anger. Direct him to first deal with the anxiety and the avoidances, which eventually—in most cases—will lead to a decrease in the levels of anger.

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Mourning

In the first 6 months after losing someone close it is natural to avoid recalling the trauma in which the person was killed, as well as to refrain from enjoyable activities (in order not to “betray” the deceased). It is also natural to have strong feelings of longing and yearning toward the person who died. During the processing section, it is important to normalize these reactions and to allow the appropriate space for mourning. Encourage the patient to clarify his feelings toward the deceased by writing him a letter, or by allocating specific time during the session in which the patient will tell the deceased all the important things that are on his mind and imagine how he would have responded. Stress the fact that although the person is gone, the relationship with that person may be kept alive through memories.

Parent Meeting Meetings with parents will typically take place after the first in-session imaginal exposure exercise, and in alternating sessions for the remainder of therapy. However, if the parents request additional time it can be scheduled as needed. For the first meeting regarding imaginal exposure, the following dialogue may be helpful: Today your child began focusing on the memory of the trauma during the session. He did a great job, and—if he chooses—he will be sharing some of his work with you over the next week. Recounting the memory will help him begin to process what happened to him. Traumatic memories can seem very disorganized and confusing at first. As he begins to organize or digest his memory, he will learn that the memory is not dangerous. His anxiety will also decrease as he works with the memory. As he starts to realize that he can control his anxiety, he will become less afraid and avoidant. This should result in an improvement of his PTSD symptoms. Emphasize to parents that it is important that they continue to encourage their adolescent’s attendance and completion of homework. Their

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attitude toward therapy is critical in helping him remain enthusiastic. The process of digesting the traumatic memory is difficult and the adolescent may need some encouragement and support from parents in order to attend future sessions. Parents can help him focus on the long-term goal of feeling better and reducing symptoms. If he finds it difficult to go to therapy, it may be helpful for parents to blame any possible avoidance on the traumatic memory and the distress it has caused, rather than on the adolescent himself.

Homework For Patient:

✎ ✎ ✎ ✎

Have patient read Chapter 7 of the workbook. Have patient listen to the recording of the session. Have the patient listen to the recording of recounting the memory daily and write down his level of distress on the Recounting the Memory Data form. Help the patient choose real-life experiments from his hierarchy to practice for homework. For Parents:

✎ ✎

Have parents encourage the patient to complete assignments. Instruct parents to be available to help with real-life experiments if requested by the patient.

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Chapter 10 Worst Moments Module

(Corresponds to chapter 8 of the workbook)

Materials Needed ■

Recounting the Memory Session Record form

■

Recounting Worst Moments form

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Triggers and Tools form

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Equipment and media (2 sets) to record session and recounting worst moments

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Review homework

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Coach patient to recount the most difficult parts of the trauma

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Help patient process the most difficult parts of the trauma

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Conduct parent meeting (optional)

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Prepare for Relapse Prevention Module

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Assign homework

Outline

Overview As recounting the memory of the trauma becomes easier, the emotional processing is intensified by having the patient concentrate primarily or exclusively on the most currently distressing parts of the trauma,

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called the “worst moments.” The Worst Moments Module should be introduced after 3–5 sessions of imaginal exposure have been conducted and habituation has begun to occur. This module will be the primary focus of treatment until you are ready to introduce relapse prevention. Meet with the patient alone for most of each session, reserving 10–15 min as needed at the end to check in with parents.

Homework Review Review the Real-Life Experiments Data form. Continue to encourage the patient to take on more difficult items on the hierarchy as the less challenging items become easier. Review the Recounting the Memory Data form. Make sure the patient is listening to the tape several times per week. Process the patient’s thoughts and feelings that arose during the imaginal exposure homework. Use a similar approach to processing as described for recounting the full memory (see Chapter 9).

Recounting Worst Moments Before the first session of recounting the worst moments, review the parts of the trauma that seem to produce the most anxiety/distress for the patient. To identify these use information about the patient’s thoughts, feelings, and physical reactions when recounting the full narrative of the trauma during earlier imaginal exposure sessions. “Worst moments” are the sections that were reported by the patient to have the highest stress thermometer ratings and in which the patient looked especially distressed, or they may be sections that the patient skips over or runs through very quickly. Prior to beginning the exposure, explain to the patient that up to this point, each time she worked on the memory, she recounted the memory of the entire trauma from beginning to end. In this next module, she will only focus on those parts of the memory that are still anxiety provoking for her. The following dialogue can be used to begin:

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You are making great progress and are starting to feel less scared and sad just like we hoped. So, we are going to work on the memory a little differently today. When someone starts feeling better and stronger as you are, we begin to focus on the hard parts or the “worst moments” of the trauma memory. What are the hardest parts for you to talk about? If the patient is unable to identify any hard parts, then choose a portion of the memory that you think could be a potential worst moment and ask the following: ■

“What about [target section]? This seems to be very hard for you to talk about. Is it harder than [an easy part of the memory]?”

■

“What other parts are hard like [target section]?”

Compare the patient’s reported hardest parts with your impression from previous sessions. If the two coincide, then move on to Worst Moments Exposure. If not, query about the potential worst moments that were not spontaneously mentioned by the patient. Review these with the patient as well and identify those portions of the story that you both agree are the most difficult parts of the exposure. Record the worst moments on the Recounting the Memory Session Record form so that you can refer back to them in future sessions. You may photocopy this form as needed. You may choose 3–5 portions of the trauma to work on for the Worst Moments Module.

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Recounting the Memory Session Record Patient name:

Therapist:

Date:

Session number:

Description of the Memory:

Time Begin:

Stress Rating:

Notes:

5 min 10 min 15 min 20 min 25 min 30 min 35 min 40 min 45 min 50 min Processing:

Assessment:

Homework:

Next appointment date:

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Time:

Once the worst moments have been identified, explain the exposure method to the patient. The following dialogue may be used: Today, instead of going through the whole memory from beginning to end, I will ask you to tell about these worst moments one at a time. We will pick one to begin with, and we will work on the others later. You will focus in on this memory as if you are zooming in for a close-up, recounting with as much detail as possible what happened and what you felt, saw, heard, and thought in that part of the memory. We will work on that part until we feel that we have “worn it out” and your stress thermometer rating has decreased. When that part is done, we will move on to the next one. Any questions? Choose a worst moment with which to begin. This should be the least distressing of the various identified worst moments. Review the worst moments one at a time in a repetitive manner (as many as 6–7 times) during a single session. The same exposure techniques outlined in the Recounting the Memory Module are used for this focused exposure. Query for more information about thoughts, feelings, and sensations during these exposures. Ask for stress thermometer ratings at least every 5 min, though you may wish to ask more frequently if the section of the story is very short. Record these ratings on the Recounting the Memory Record Session form. When the stress ratings decrease to a range of 2 or 3, you may stop the exposure and process the emotions and thoughts associated with that section of the story. Some Worst Moments Exposures will span more than one session because the stress ratings associated with a particular part of the story may decrease slowly.

Processing Worst Moments Repeat the procedure for processing the memory as outlined in the Recounting the Memory Module. Some worst moments will require more lengthy discussion, but often the processing of worst moments can be brief, which allows time to move on to additional Worst Moments Exposures if there is time left in the session. As you work your way through the list with the patient, review the stress ratings associated with each worst moment from time to time. It

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is not unusual for stress ratings to decrease across the board even before each worst moment has been tackled. By the time you reach the latter items on the list, it may even be unnecessary to do imaginal exposure with the item because the patient has adequately processed the thoughts and feelings associated with that item before reaching it. Once all the worst moments have been adequately processed, that is, when the stress ratings associated with each of them are reduced to 3 or less, the module is finished.

Parent Meeting (optional) Parent meetings can be used to elicit additional support for the adolescent during homework, to answer parents’ questions or concerns, or to give the adolescent a chance to demonstrate treatment gains to the parents. In some cases, parents will wish to meet frequently just to get a quick update and remain involved. In other cases, parents are content to meet only if there are specific issues to address. If needed, or if requested by the client or parents, meet with parents following one or more of the Worst Moments Exposure sessions. The following dialogue may be used to reinforce parental involvement: We have begun focusing on the worst parts of the trauma during our sessions. You may notice in your adolescent some increased reluctance to come to sessions or to engage in homework due to the distressing nature of the work. I am very proud of the hard work she has done recounting the memory. I hope you can remain supportive and encourage her to keep up the good work. It is very helpful for kids to hear that their parents are aware of the efforts they are making and are proud of them. In this case, you cannot praise too much.

Preparation for Relapse Prevention Module At the end of the last session of the Worst Moments Module, assign the Tools and Triggers form as homework. When presenting the form, you may want to use the following dialogue:

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In our next session, we will talk about your future direction after therapy ends. To prepare, I would like you to dedicate some time during your homework this week to think about what you feel you have learned from therapy. What have been the tools that helped you deal with your fears? Under which situations does your fear increase?

Homework For Patient:

✎

Have patient read Chapter 8 of the workbook.

✎

Have patient listen to the recording of the session.

✎ ✎ ✎

Have patient listen to the recording of recounting worst moments at least once a day and track stress thermometer ratings on the Recounting Worst Moments form. Help patient choose real-life experiments from her hierarchy to practice for homework. Have her track stress thermometer ratings on the Real-Life Experiments Data form. At the last session of this module, assign the Triggers and Tools form. For Parents:

✎

Have parents assist with homework as appropriate.

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Phase IV

Relapse Prevention and Treatment Termination

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Chapter 11 Relapse Prevention Module

(Corresponds to chapter 9 of the workbook)

Materials Needed ■

Triggers and Tools form

■

Equipment and media to record session

■

Review homework

■

Identify potential symptom triggers

■

Plan coping strategies for symptom relapse

■

Review tools acquired in therapy

■

Plan the last session (optional)

■

Conduct parent meeting (optional)

■

Assign homework

Outline

Overview The Triggers and Tools form, which reviews the tools acquired in therapy, is introduced at the end of the Worst Moments Module. Using the worksheet will help the patient lead today’s discussion. He should be given the opportunity to think about future difficulties that may arise, and about how he plans to cope with them in a creative way. The review of the tools learned in therapy is designed to be an organizing repetition of the patient’s ideas. Encourage the patient as much as possible to

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explain the processes himself, and, if required, assist the patient through Socratic questions. This module typically takes one session and may be combined with the Final Session Module if desired, especially if the therapist and patient have elected not to do a final project.

Homework Review Review the Real-Life Experiments Data form. The patient should have finished or nearly finished with the items on the real-life experiments hierarchy. Review the Recounting the Memory Data form and discuss the last repetition of the Worst Moments Exposure that the patient did for homework. The bulk of this module will be spent reviewing the Triggers and Tools form completed as homework in the previous session.

Identification of Triggers This module starts with a discussion of potential triggers of the patient’s PTSD symptoms. The following dialogue may be used to begin: As you know, we now have only a couple of sessions left. Now that our therapy is coming to an end, and many of your anxieties and difficulties have decreased, I wanted us to think and talk about what may cause distress and aggravate your symptoms in the future. I asked you to think of these issues in your homework assignment, and now I would like us to go through the triggers you listed. Review the Triggers and Tools form the patient has prepared for homework. If the list is skimpy, help the patient expand the list of possible triggers to include all areas of the patient’s life. If the patient gets stuck, encourage him to think of different life areas by asking short, openended questions (e.g., “What about school?”, “What about dating?”). Following are common life areas and examples of potential triggers.

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Trauma-Related Events: reminders and unfinished business related to the trauma, such as anniversary dates, memorial services, or appearing in court. Additional Traumatic Events: coping with an additional traumatic event that happens to the patient or to someone close to him. Health Problems: coping with additional health problems (especially relevant for patients who already suffer from health problems, regardless of the trauma). School: starting at a new school; studying for and taking exams; going on school trips that include sleeping away from home; dealing with the requirements of strict teachers; receiving bad grades; accepting criticism. Social life: changes in the social circle; problems with friends; dating someone new; coping with a breakup. Family Life: death of a relative; divorce; changes in family dynamics (birth of a sibling, sibling leaving home, etc.). Ask the patient to add any new ideas to the list of triggers he completed for homework. If needed, use an additional Trigger and Tools form. You may photocopy this form from the workbook as needed.

Planning Coping Strategies Once you have reviewed the list of possible triggers that may aggravate the patient’s symptoms, discuss with the patient how he will be able to cope with these triggers and overcome them. List the coping strategies next to the corresponding situations on the Triggers and Tools form. Once complete, hand over the form to the patient so that he will be able to consult it in case of future crises after therapy ends. Encourage the patient to imagine how he will be able to cope with potential difficulties. Draw comparisons between the current therapeutic strategies and future situations he may encounter, for example: “What did you do in our therapy when you encountered a similar problem?” You may also want to encourage the patient to brainstorm

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additional sources of help within the family, community, school, etc. (e.g., a trusted relative or teacher). For example, if he encounters a new and frightening situation he may wish to discuss the situation with a parent or friend to determine if the situation is really dangerous or simply triggering unhelpful or unrealistic thoughts. If the situation is not dangerous, he will know from your work together that it is best to confront this kind of fear. He can then design graduated exposures to help himself overcome the fear.

Review of Tools As you develop the list of coping strategies, be sure to include the strategies and skills the patient has acquired in therapy. If the patient does not spontaneously identify specific strategies learned in the treatment, use the following sample dialogues to prompt him to think about how each strategy or skill would generalize to other situations and how he might apply each one in the future.

Real-Life Experiments

Through the experiments you overcame your avoidance. You had a chance to learn the facts about a situation and to get used to doing things that seemed scary or uncomfortable beforehand. By practicing the experiments over and over again, you were able to start doing things that you had stopped doing since the trauma and you felt better about yourself.

Recounting the Memory

When you faced your fearful thoughts they became less powerful. Once you stopped avoiding the memories that made you feel scared, you began to feel stronger and more in control of your thoughts.

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Challenging Thoughts

You learned how to question your beliefs about yourself, others and the world to make sure your thinking is in line with reality. You became very skilled at recognizing when you were letting the trauma or other unpleasant situations distort how you were thinking about the present. Once you were able to recognize unhelpful and unrealistic thoughts you could modify them to be more useful.

Pleasurable Activities

Engaging in pleasurable activities even when your mood was down made you feel better. As a result of doing things you enjoyed, your mood actually improved, so you learned that you should not wait for your mood to pick up in order to take part in pleasurable activities.

Sharing Emotions

Talking about your feelings with trusted family and friends gave you a sense of relief and identification, and it also assisted in digesting your feelings.

Breathing

As you’ve learned, the way we breathe can affect how we feel. Practicing slow calm breathing helped you to slow down and feel more relaxed.

Summary Emphasize that the adolescent owns these tools and can keep using them after therapy ends. Reinforce the patient’s accomplishments and his

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ability to face future challenges. You may want to use the following dialogue to end the session: Remember when you began this program, I told you that our work together would be like learning to ride a bicycle. Once you learn how, you never forget, even if you have not ridden for a long time. Just because you will not come here anymore does not mean that you will forget what you have learned. You will be able to keep all these tricks and tools and use them whenever you need to. I would like to remind you of all your impressive achievements in therapy. You faced difficult tasks that seemed impossible at first. You should remember this the next time you find yourself in a challenging situation. I have full confidence in your ability to cope with difficulties and unpleasant feelings. All you have to do is just start riding this bike again.

Planning the Last Session (optional) The final session is used to celebrate the patient’s accomplishments, review treatment gains with parents or significant others, or highlight his achievement in some other way. Some patients will wish to use one or more sessions and some homework time to prepare a final project, which may be a scrapbook, a journal, a collection of artwork, or some other product representing his journey throughout the therapy (see more suggestions under Making A Final Project). The content of the final project and the final session is purposely left vague in this guide as it is more of a summary of the treatment than treatment itself. Some patients will prefer to make a big event of the end of treatment and others will prefer simply to meet as usual, review treatment, and say good-byes. These preferences should be respected as much as possible. However, in either case you should recognize and summarize the patient’s accomplishment in some way during the final session. Discuss with the patient how he would like to end his treatment and plan accordingly—inviting parents or significant others, planning for snacks, or preparing other ways of marking the event (e.g., certificate of accomplishment) if that is the patient’s wish.

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Making a Final Project You may want to introduce the concept of a final project with this script: As a final project, you can put an end on the book that you “wrote” about your scary memory. Let’s choose something that shows how far you have come and how much you have learned. If the patient is interested in making a final project, the following are some ideas you may want to present. It may be helpful for the patient to do a number of these activities and put them all together as a keepsake book. 1.

Cover Sheet—let the adolescent name the book (e.g. “My Book About Me,” “My Scary Time”) and either draw or print out a picture that has meaning to him.

2.

What Happened to Me—the adolescent writes or types out the entire memory narrative.

3. After the Trauma—the adolescent writes about things that changed for him after the trauma, including his PTSD symptoms, his feelings and beliefs, family changes, etc. Be sure also to have the adolescent include a paragraph or more about how he feels now in comparison, in order to make this activity a positive one. 4.

What I Learned in Therapy—the adolescent writes about the major techniques learned (breathing exercise, real-life experiments, and recounting the memory) as well as why they were used and how he may be able to use them in the future.

5. A Letter to the Perpetrator—the adolescent writes a letter (not meant to be sent) to the perpetrator about how he feels now about what happened. This exercise may spur a discussion of forgiveness and what that means to the adolescent. 6.

Ten Years From Now—the adolescent writes in detail about what he wants to be doing in 10 years.

7. Ten Good Things About Me—the adolescent writes ten things about himself that are positive. Be sure to have the adolescent include his strength in surviving the trauma as well as finishing this program.

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8. Taking Care of Myself—the adolescent identifies things that upset him and problem solves ways to address these issues in the future. Be sure to suggest techniques learned in the program whenever possible. 9. Three Wishes for Myself and the World (And How I Can Make Them Come True)—the adolescent identifies three wishes as well as makes a plan for how he can accomplish them.

Parent Meeting (optional) Review the patient’s relapse prevention strategies with the parents to help them understand that the behavioral changes that took place in treatment should continue even when treatment is finished. If there are additional real-life experiments left to be done, make a plan with the patient and the parents to complete these items soon after treatment ends so that the momentum begun in treatment is not allowed to extinguish before the final items on the hierarchy are conquered. Review plans for the final session, especially if the patient intends a celebration or wishes to present a final project to the parents.

Homework

✎ ✎ ✎ ✎ ✎

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Have patient read Chapter 9 of the workbook. Have patient listen to the recording of the session. Remind patient that the next session is the last. Have patient complete any projects or plans needed for the final session. Have patient continue with any real-life experiments left on his hierarchy and track stress thermometer ratings on the Real-Life Experiments Data form.

Chapter 12 Final Session Module

(Corresponds to chapter 10 of the workbook)

Materials Needed ■

Copy of patient’s first Recounting the Memory Data form

■

Copy of patient’s Real-Life Experiments Step-by-Step form

■

Props for graduation ceremony (optional)

■

Conduct treatment termination interview

■

Discuss the patient’s feelings about ending treatment

■

Terminate therapy, which may include presentation of a final project and/or a graduation ceremony

Outline

Overview This is the final session; it is important that both patient and therapist enjoy the sense of accomplishment and success that accompanies the end of therapy. If agreed upon beforehand, the patient may present a final project and/or a graduation ceremony may be held. (See ideas for final projects in Chapter 13.) However, many adolescents will be eager to end therapy and return to life as usual, in which case, the termination portion of the session can be relatively short and to the point, reviewing treatment progress, getting feedback from the patient about the therapy experience, and saying good-bye. As discussed previously, in some cases, the Relapse Prevention and Final Session Modules may be done

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within the same session. If there are further issues that need therapeutic attention, some time can be allotted to discuss referrals or future plans with the patient and the parents or guardians.

Treatment Termination Interview Begin the session by having the patient compare how he feels today in comparison to when he started therapy. Note any improvement in symptoms, as well as areas where the patient could do more work. Next, have the patient recount the memory of the traumatic event, from beginning to end, as you did during the previous sessions (though limit the story to 20 min). Ask the patient to rate her anxiety every few minutes. Then compare the anxiety ratings during the last recounting of the memory with the first recounting (see patient’s first Recounting the Memory Data form). Ask the patient the following questions: ■

“How do you understand the difference in the ratings?”

■

“What helped you the most to have this change in the stress thermometer ratings (recounting the memory in session, breathing, cognitive processing, listening to recordings at home, etc.)?”

Next go over the patient’s hierarchy of real-life experiments and have the patient rate her current level of anxiety for each item. Afterward, read aloud the list and compare the anxiety ratings with those at the beginning of therapy. If there are some items that have hardly changed since the beginning of therapy, discuss possible reasons for the current anxiety and whether enough exposures were conducted. Often, the items that have changed most are the items the patient practiced most in the homework. Items which received little practice or were not attempted because of time constraints are the items that change the least, though some generalization may have occurred. Encourage the patient to continue to systematically confront any remaining items left on the hierarchy. End the termination interview by asking the patient for feedback about the overall therapy experience. Use the following questions: ■

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“What helped you the most to be able to face the trauma (recounting the memory, breathing, cognitive processing, etc.)?”

■

“In general, what do you feel helped you the most in therapy? What do you feel did not help you so much?”

■

“Do you have any recommendations that may help in treating other adolescents like you? Any suggestions on things we should emphasize, add, or remove from the program?”

Feelings About Ending Treatment As with any therapeutic relationship, there may be some sadness or reluctance to terminate as treatment comes to an end. This may be because of fears of “going it alone” without the benefit of the therapist’s support and guidance, or it may be because of a genuine fondness that the patient has developed for the therapist. It is also possible that the patient feels relief or even excitement that treatment is finally over. These are all natural feelings that can develop as the patient faces the end of the treatment relationship. It is important to give the patient a chance to discuss her feelings about ending the therapy in a way that allows room for both sadness and happiness as some patients will feel ambivalent. You can give the patient an opportunity to discuss these feelings by asking her directly how she is feeling about ending treatment. Be prepared to normalize her emotions about termination, and to remind her of skills she has learned in treatment that will assist her in coping with any difficult emotions.

Termination of Therapy To end the session, ask the patient about her plans for the future (education, work, recreation, etc.). If necessary, discuss any outstanding therapeutic issues and make referrals for additional treatment. If the patient has prepared a final project, have her present at this time. You may want to ask parents and any other guests to join for the presentation, as well as the graduation ceremony if there is one. Lastly, congratulate the patient on completing treatment and say your good-byes.

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Chapter 13 Tailoring Treatment to the Individual

The modules presented here are designed for a typical adolescent presenting for treatment. However, adolescents as a group are anything but predictable and homogeneous. Indeed, the developmental period of adolescence includes individuals who are leaving childhood to begin the long transition to adulthood, as well as those who are about to enter adulthood from adolescence. A 13-year-old adolescent would not be expected to think, act, and feel the same as a 19-year-old adolescent. To further complicate the picture, the development of each individual follows its own unique course with some children showing signs of psychosexual maturation as early as 10- or 11-years-old, and others as late as 15 or 16. Two 13-year-olds may be as different from each other as they are from a typical 16-year-old. Treatment, then, for this heterogeneous group of individuals must be flexible enough to address the needs of adolescents who are almost adults as well as those who are really still behaving and responding like children. The family structure of the adolescent may vary significantly as well. The modules presented here assume at least some participation by a parent or guardian who brings the child to treatment and participates in part of the session on a regular basis. While a supportive and involved parent or guardian is the most desirable situation, some adolescents find themselves without this resource due to circumstances outside their or the therapist’s control. You must be prepared to work with the family structure that presents for treatment, whatever that may be. Finally, the treatment materials as presented thus far are nonspecific with regard to the trauma experienced by the adolescent. In practice, you will need to adapt the materials to address the specific content of the adolescent’s experience. Much of the information necessary to make these

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adaptations will come from the adolescent himself, but it will be helpful to have some basic information about common trauma presentations so you can guide the process more efficiently. Fortunately, Prolonged Exposure for Adolescents (PE-A) is based on a tradition of behavioral principles that have been shown to be effective across a wide range of individuals. Understanding the basic conceptual model of Prolonged Exposure (PE) will allow you the freedom to adapt the content and presentation of the therapy to treat the patient regardless of age, developmental level, family presentation, or trauma type. The core elements of PE will not change, but your presentation style, the metaphors and examples you use to illustrate the treatment to the patient, and the manner in which you construct the imaginal and in vivo exercises may change according to the needs of the patient. This chapter will provide practical advice based on the conceptual model underlying PE, as well as our extensive experience adapting the treatment for a wide variety of patients.

Core Elements of Prolonged Exposure According to Foa and Kozak (1986), the treatment of pathological fear requires (1) accessing the fear structure (i.e., bringing the person into contact with the feared situation such that his fear structure is activated) and (2) providing corrective information that serves to modify the excessive or unrealistic aspects of the fear structure. The PE therapist should keep in mind these objectives when designing treatment interventions. For example, a good in vivo exposure hierarchy is composed of exposure situations that match the individual’s specific fear structure. For a survivor of a motor vehicle accident, who is excessively fearful of being a passenger in a car because “you never know when an accident will happen”, in vivo assignments might include (1) gradual exposure to riding in a car (e.g., first riding with trusted parent in “safer” suburban areas, then riding with other family members or friends, riding in the city, and finally, riding on an interstate highway during rush hour) and

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(2) remaining unharmed during these experiences (i.e., not having an accident), thus modifying the belief that riding in a car is fraught with danger. When modifications to the treatment are indicated, the theory will provide guidance. For example, an adolescent who skips over parts of the narrative of his trauma memory, and works hard to avoid discussing those parts or using explicit language during the imaginal exposure is most likely not accessing his fear structure, and he is strengthening his avoidance because skipping the difficult and painful parts is negatively reinforcing. He is essentially avoiding the worst feelings, thoughts, or images associated with his trauma memory just as he does in everyday life. You may need to help this patient understand why his avoidance, although understandable, interferes with his recovery from PTSD, and work with him to find ways to increase his ability to engage in all of the salient aspects of the trauma memory so that it may be processed. The model will help you provide a convincing rationale that makes sense to the patient and will bolster his courage in choosing to confront trauma-related stimuli rather than avoid them, and will help you know how to respond to the patient’s struggles with avoidance behavior. It will guide your construction of the in vivo hierarchy, and help you figure out when and how to modify the standard procedures for imaginal exposure.

Tailoring Treatment to the Patient’s Age Techniques such as drawing, writing, puppets, games, and activities are commonly used to help younger patients participate in therapy and are used to modify the treatment exercises so that they are more acceptable to them. However, these therapy aids are not used haphazardly, but in a way that is consistent with the conceptual model underlying PE. Drawing and writing are primarily used to help younger patients participate in imaginal exposure. Though the drawing and writing takes the place of the narrative, the therapist still interacts with the patient so that the patient is able to tell what is happening in the story. Puppets are used

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with young children to help them tell the story. The child can use the puppet to “talk” for him or he can talk to a puppet held by the therapist. In either case, the puppet helps the child feel more comfortable while still allowing him to discuss distressing material. Games and activities are used with children and adolescents of all ages. With young children, short games and activities can be offered as rewards for completing therapy tasks. With both younger and older children, games may be created from the module to facilitate learning the material. For example, a guessing game could be constructed from the Treatment Rationale Module or the Common Reactions Module. The patient can win points for answering a quiz about the module correctly. When you are conducting treatment with children and younger adolescents, you will also need to be knowledgeable of child and adolescent development so that your modifications are appropriate to the age of the patient. In general, cognitive abilities become more fluent with age; children and younger adolescents are more limited than older adolescents and adults. With younger adolescents and children, you may need to shorten and simplify the rationale. Using simple, illustrative metaphors that are repeated from session to session can help the younger patient learn the rationale for treatment. These include the metaphor of the therapist as coach, metaphors comparing in vivo exposure to detective work or scientific experiments, and metaphors comparing treatment and gradual exposure to learning to ride a bike by using training wheels at first, or for very young ones, learning to swim by using water wings before advancing to deep water. The attention spans of younger adolescents and children are shorter and they are more easily distracted by environmental stimuli. Session time may need to be shortened or breaks taken. You may need to positively reinforce participation in the session by allowing for some rewards at the end of the session, such as time for the patient to play a computer game or board game, to take a walk with you, or even to color or draw when the therapeutic portion of the session is finished. You will typically need to verify understanding of key components of the rationale and assist with processing the exposure exercises in a much more concrete way with younger patients, and even with some older adolescents who are less mature than their peers.

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Adolescents tend to be more impulsive and more emotionally volatile than adults and they may be less able to identify and name their emotions. This can result in feelings of frustration, confusion, and responses of “I don’t know” when asked about emotions. You may need to educate adolescents about emotions in order to help them clarify and describe their experiences. It may be useful to describe the differences between thoughts, behaviors, and emotions to inform the adolescent that it is possible to experience more than one emotion at a time and to link emotions to physical sensations. For the youngest patients, it may also be helpful to use feeling charts or lists to assist them to find the right words to describe their experiences.

Modifying the Psychoeducational Material Understanding the rationale is important in motivating patients to do the difficult work necessary to confront their fears. However, the rationale may be more difficult to grasp for younger patients. As described above, simple metaphors repeated throughout the treatment can help them grasp the concepts underlying PE. For the youngest clients, we provide stories that illustrate key concepts of PE Therapy. These stories can be read to the patient by the therapist and again by the parent as homework. Children and adolescents who like to read may prefer to read the stories on their own. Though the stories were originally designed for children, we have discovered that even some young adolescent patients enjoy and benefit from these short, easy-to-read stories. Some of the stories are provided in an appendix. In treating younger or more dependent adolescents, it is vitally important that the parents are also “on board” with respect to the understanding of the treatment rationale. Thus, some time needs to be set aside to explain the basic premises of the treatment to the adolescents’ caregivers. Common reactions to trauma are normally presented as a discussion and a form is provided for the patient to list the reactions he has experienced. They may also be presented using a story, or by using flash cards to present each of the common reactions and allowing the patient to sort the cards according to whether or not he has experienced the reaction in the past or present. Hands on activities such as this allow the younger

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patient to engage in the discussion of common reactions more fully. The activity also gives you a chance to observe first hand the patient’s understanding of his own symptoms and his relationship to the trauma.

Modifying Real-Life Experiments Real-life experiments, or in vivo exposures, are designed to help the patient habituate to the discomfort associated with confronting his fears, and to provide the patient with corrective information about the feared situations on the in vivo hierarchy. Age and developmental adjustments are primarily targeted toward doing what is necessary to help the patient carry out the experiment. Younger patients often have difficulty organizing the time between sessions and structuring a time to do the experiment. They will often wait until the last minute and try to do their exposure homework the night before session or forget entirely until it is too late to complete the homework. In addition, real-life experiments will often include activities that younger children cannot carry out on their own, for example, traveling to a mall or shopping area, purchasing an item needed for exposure, or planning an outing where an exposure will take place. Transportation, financial considerations, and other logistical problems will require the assistance of an older person. If a parent or guardian is available to assist, you should include them at the end of the sessions to plan how each homework exercise will get done. The parent can help identify another individual to assist if the parent will not be available. Sometimes another relative, an older sibling, or even a friend or neighbor can help with some or all of the real-life experiments. The parent or designated assistant can provide logistical support (transportation, financial assistance, supervision), remind the patient to complete the exercise during the week, and help the patient keep track of his fear ratings.

Modifying Recounting the Memory Ideally, the patient will recount the traumatic event by closing his eyes and telling the story in the present tense. Even younger adolescents can

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understand the instructions for recounting the memory and most are able to complete this exercise without significant modification. Occasionally, we have encountered adolescent patients who refuse to close their eyes as they recount the memory. We have also encountered adolescents who are extremely shy, or so filled with shame that they have difficulty speaking to the therapist at all. Finally, very young or developmentally immature adolescents and children may find the verbal task confusing or overwhelming. Younger adolescents and children may become much more engaged by drawings than by communicating verbally. There are several ways to modify this portion of the treatment to help the patient complete the narrative. ■

Eyes open—instruct the patient to keep his eyes open during the recounting

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Past tense—instruct the patient to tell the story in a more conversational style

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Third person—instruct the patient to tell the story as if talking about someone else

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Writing, typing, or dictating—instruct the patient to write the story or offer to type it while the patient dictates to you

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Drawing part or all of the story—instruct the patient to draw scenes from the story (this can be especially helpful if the scene was chaotic or confusing)

These are listed in order of preference from smallest to greatest departure from the procedures presented in the module. If you choose to modify the treatment, in most cases, begin with the smallest modification and proceed down the list only if the first modification is unsuccessful in helping the patient complete the narrative of the trauma. With older patients, you can systematically withdraw the modifications, eventually encouraging the patient to tell the story with eyes closed, in first person, and in present tense. This will help provide a corrective experience for the patient as he learns that he can tell the story in this way without harm. With younger patients, however, you may complete the treatment primarily using drawings or writing because developmentally, this is the

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best way for the patient to access the fear structure. In this case, you will discuss the patient’s drawings with him so that he is verbally describing to you what is happening in the pictures. The patient may write the memory in session by hand or using the computer. Ask the patient to write the story without editing the content or correcting grammar, spelling, or punctuation errors. Once he has finished a first draft, ask the patient to read the story adding any additional material and editing as needed during the session. If the patient writes the story by hand instruct him to double space to leave room for corrections and additions. If the patient is typing on the computer or dictating to the therapist, double space and print the narrative in a large, clear font. The patient should then read the story and add details as described. Stress thermometer ratings should be recorded every 5 min and the memory should be re-read with the corrections and additions. Some teenagers like making a “presentation” on the computer that includes both text and pictures. With some children and adolescents, it is helpful to alternate between more verbal and more visual techniques to encourage more complete processing and to elicit more details. The visual techniques may include drawing parts of the scene or oneself during the event. With very young children, drawing may be used to elicit the narrative. In this technique, the child is requested to draw about what happened to him. As the child draws, the therapist asks the child to tell about what he is drawing. For very avoidant adolescents who write the memory and refuse to say it aloud or talk about it with the therapist, it may be helpful to have them write the memory and then use a fill-in-the-blank technique. For example, if the adolescent refuses to read the memory once he has written it, the therapist may read it aloud while typing it into the computer. Once the entire memory has been typed, the therapist may go through it and add “blanks” where more detail about the actual events (clothing the perpetrator was wearing, color of the room, etc.) and the adolescent’s thoughts, feelings, and beliefs can be inserted by the adolescent. Therapists must be very careful to pull for pertinent information that will help the adolescent to process the memory and not to lead the adolescent in any way.

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Example of Fill-in-the-Blank Technique:

Memory: I walk into my bedroom to look for my notebook. I can’t find it. I turn around and he grabs me and pushes me on the bed. He pulls down my pants. I don’t want to scream. I tell him to stop over and over. When he stops, I go downstairs. I don’t tell anybody. Memory with added blanks: I walk into my bedroom to look for my notebook. I can’t find it. I turn around and

grabs me and pushes me on the bed.

He is wearing

.

He looks

.

I am thinking to myself

.

He pulls down my pants. I don’t want to scream. I feel

.

I tell him to stop over and over. I think

.

When he stops, I go downstairs. I feel

.

I don’t tell anybody because

.

With this technique, the memory narrative expands and becomes more detailed, allowing the adolescent to more fully engage in the memory. This technique can be used repeatedly in session, as time allows, and over a number of sessions until the narrative has been adequately processed.

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Modifications for Patients Without Family Involvement As described earlier, a supportive and involved parent or guardian is the ideal for this treatment, but it can be adapted to meet the needs of patients who do not have a supportive family member available to them. With the oldest adolescents, treatment can very much resemble the treatment of a young adult. These patients bring themselves to treatment, complete their assignments on their own, and function independently, even though they may still live with a parent or an older relative. In these cases, it is a simple matter to leave out the parent portion of the sessions, although you may still wish to send home handouts if the adolescents have an older relative whom they wish to have information about their treatment. Since there won’t be a parent to help structure homework, you should take extra time at the end of the session to plan out the homework schedule. You may also want to arrange check-in phone calls to help the patient remember the homework and to reinforce the patient when he carries out the assignments. Patients in group homes or foster care may have only limited access to the foster parent or house parent though they will likely have more supervision than the adolescents described above. These patients may need help explaining the treatment to the foster parent or guardian so they can complete some of the assignments at home. If the guardian is not available for sessions you may schedule time on the telephone to give the rationale for treatment and to describe the homework assignments so the adolescent will not receive resistance from the guardian. Be sure to send the handouts to the guardian and follow up with a periodic phone call to make sure the guardian remains supportive of the treatment and aware of the adolescent’s progress. With the youngest adolescents and children, it is necessary to have at least some participation by a parent or other adult. These patients need more support and supervision than older patients and will need the help of a parent or other adult to structure and complete homework assignments. If one individual is unable to complete the treatment with the patient, you may look for a cooperative effort, using extended relatives, older siblings, school guidance counselors, or a family friend, as long as the other adults involved learn the rationale and are given clear instructions about their role in the treatment.

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In some cases, we have been able to provide “mentors” or helpers to the patient to assist with exposures and to provide support. These young adults were students in a psychology program who volunteered for the program as part of their curriculum. They were assigned to patients who appeared to need additional support or assistance with the treatment. The mentor’s role was to assist with real-life experiments when the parents were unavailable due to stressful job or family conditions, or when the parents were themselves traumatized and therefore appeared to exacerbate rather than alleviate their child’s distress during the exposures. Mentors need to be closely supervised by the therapist to maintain close communication within the treatment team.

Summary It can, at times, be tempting to abandon standardized treatment because the patient’s situation is very complicated or because the patient does not respond in the expected manner. However, your patient need not give up the unquestionable benefit of empirically tested treatment simply because he does not fit the profile of a “perfect” patient. The reality of effectiveness research, to which this treatment has been subjected, is that there is no perfect patient. Life is messy, and no patient is messier than an adolescent. Many of the patients in the pilot studies and in the on-going clinical trials would be considered complicated or unusual in some way and these patients have provided us with the incredible opportunity of learning how to respond to real patients effectively using our treatment. The result is a well-supported, standardized treatment that is flexible enough to treat a wide range of patients. In this chapter, we have tried to outline what we believe are some theoretically consistent modifications that make the treatment more accessible to more adolescents while remaining true to the underlying theoretical model. But flexibility does not equal carte blanche. Let the literature be your guide, and when the literature does not address your specific patient let the underlying theory be your guide. As you adapt various aspects of the treatment, you are likely on solid ground if your adaptation is consistent with the underlying theory, but on shaky ground if your adaptation violates the basic assumptions underlying emotional processing theory.

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Crisis Coping Plan This is a plan to help me cope with suicidal or self-destructive feelings. If I start to think about hurting myself or engaging in dangerous behavior, I will do the following: 1. 2. 3. 4.

I will also call: 1. 2. 3. 4.

If, after trying all of these coping activities, I still want to hurt myself, I will contact my therapist, at

.

If I cannot reach my therapist immediately, I will contact Crisis Center: If I am still unable to improve my mood, I will go to Emergency Room:

Signature

Witness

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Trauma Interview Form Details About the Trauma: When did the trauma occur (date, day of the week, during the day/night)?

Where did the trauma occur (at home/at school/somebody else’s house/street/car/bus/ shopping mall/other)?

Feelings During the Trauma: Did you believe during the event that you may die or be severely injured?

Did you feel helpless?

Were you terribly scared?

Additional Information: Do you blame another person for what happened? If yes, whom?

Was anybody else with you during the event? If yes, who?

Did you escape danger by yourself or did you receive assistance?

Did you suffer from injuries?

Did you receive medical assistance?

Do you feel guilty about the trauma or about the way you behaved during the event?

Were you ashamed about the event or about your behavior during the event?

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Trauma Interview Form continued Changes in Beliefs and Attitudes: Have you experienced changes in your relationships with people who are close to you?

Have you experienced changes in your relationship with less intimate friends?

Have you experienced changes in the way you see yourself as a person?

Did anybody blame you or was angry with you for what happened?

Were you scared that someone would be angry with you or blame you?

Other Questions: How difficult do you find it discussing the trauma with other people?

Would you like to mention anything else about the trauma, the events preceding or following it?

How was it for you to discuss those issues?

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Parent Handouts

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Parent Handout 1: What Is PTSD and How Do You Treat It? You and your child are about to begin a treatment program for adolescents with posttraumatic stress disorder (PTSD). As parents and caretakers of teenagers who are experiencing PTSD, we would like to give you some information about the disorder so you may help your child’s recovery. We also realize that when something bad happens to a child, parents and guardians suffer too. Included in these handouts is information on how you can take care of yourself, so you are ready to help your child. Therapy can be challenging at times; parents and guardians are helpful coaches and cheerleaders for their child. PTSD and Its Symptoms PTSD refers to symptoms that can occur after an upsetting or traumatic event. The main symptoms of PTSD include: ■

Re-experiencing the event. This can take the form of unwanted memories, dreams, or flashbacks. It also involves becoming upset when reminded of the event.

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Avoiding reminders of the trauma. This can include avoiding thoughts, feelings, places, situations, or events that are reminders of the traumatic event. It can also include problems such as loss of interest in activities that used to be enjoyed, not feeling close to others, and having difficulty experiencing emotions.

■

Increased anxiety. This can cause sleep problems, difficulty concentrating, irritability, anger, feeling on edge, feeling as if danger is all around, and becoming easily startled.

In the next few weeks, you will learn more about these symptoms and how to recognize them in your child. Unfortunately, traumatic events are pretty common. Events that can cause traumatic stress vary and include things such as house fires, physical and sexual assault, dog bites, and car accidents. A child does not need to experience an event directly to have symptoms of PTSD. Witnessing an accident, a shooting, or domestic violence can cause feelings of fear, horror, and helplessness and lead to PTSD as well. It is helpful for parents and teenagers to remember that PSTD and the resulting changes in thoughts, feelings, and behavior after a trauma are normal. In fact, most people who experience a major trauma have symptoms of PTSD immediately afterward. Some people will feel much better within a few months after the event, others recover more slowly, and some do not recover well enough without seeking the help of a professional. When problems last longer than a month, or when they interfere significantly with everyday life, treatment for PTSD may be helpful. Treatment for PTSD The best therapy available for helping people recover from PTSD is cognitive-behavioral therapy (CBT). This kind of treatment focuses on reducing the fear related to the trauma and getting back into activities that teenagers have given up due to fear or loss of interest after the trauma. There are two main parts of this type of treatment. continued

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The first part is Real-Life Experiments where your child confronts safe situations that he or she avoids because he or she became afraid of them after the trauma. The second part is Recounting the Memory. In this activity, your child will tell the story of the traumatic event from memory. As we said before, many teenagers who have experienced a trauma try to avoid thoughts and feelings associated with that event. Many teenagers also avoid situations, places, and activities that remind them of the trauma or because they just feel scary. However, while avoiding these things can make your child feel more comfortable in the short run, it actually can make the problem worse in the long run, because it stops him or her from overcoming his or her fears. Recounting the Memory and Real-Life Experiments work by exposing your child to his or her own fears. It may sound strange to help your child by exposing him or her to what he or she is most afraid of. But when your child confronts his or her feared memories or situations in an orderly way under relatively safe circumstances, several things happen. First, going over the memory helps teenagers to make sense of what happened. Second, teenagers learn that thinking about what happened and feeling upset or anxious are not dangerous. Third, by realizing that thinking about something is not harmful, teenagers become less fearful of other situations that remind them of the trauma. Fourth, teenagers learn that they can handle their fear and anxiety and feel better about themselves. Finally, teenagers learn that the more they think, talk about, and experience memories or situations that were avoided, their fear and distress gradually decrease. In other words, they again become comfortable in these situations. This is similar to a child who falls off his bike, gets hurt, and does not want to ride again. The child refuses to ride for a while but, over time, wants to ride again as he sees his friends riding. The child may get on the bike again slowly, first riding only close to home and for short amounts of time. Eventually, he realizes that riding a bike does not have to be scary, and by forcing himself to ride again the child is able to overcome the fear he had since he fell. It is the same way with memories too. Thinking and talking about the memories of a traumatic event will allow your child to remember the trauma with less distress, and he or she will learn that the memories are not dangerous. Remembering the painful memories in a safe space with a therapist also allows teenagers to gain control over the memories and these memories become less likely to pop up when they don’t want them to. After a trauma, a child’s beliefs about himself and about the world may change. He may see situations as dangerous when before the trauma the situation would not have bothered him at all. He may find that his attitude has become more negative than it used to be, or that his self-image has gotten worse. These are all considered trauma-related changes in thinking. How teenagers think about themselves, the world, and other people affects how they feel. That is why it is useful to pay attention to how the experience has changed your child’s thoughts and beliefs. As your child goes through the therapy program, we will discuss these changes. We will sometimes explore these changes in thinking to see how they affect his or her feelings and whether they are helpful or not. Confronting memories through drawing, writing and talking, and doing Real-Life Experiments may seem difficult at first, and many parents worry that it will be too difficult for their child. While you may find that this treatment is challenging for you and your child, it should help him or her to feel better about himself or herself and about what happened.

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Parent Handout 2: How Can I Help? During the coming sessions you will receive ■

Information about PTSD

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Instructions about how to support your child’s recovery process

■

Tips on how to cope with your own distress

■

The opportunity to practice these strategies with the therapist

In addition, your child will begin a series of homework assignments called “Real-Life Experiments” that will help him or her begin to take back territory that has been lost to PTSD-related fears and anxieties. Parents often ask, “How can we help?” To help answer this question, many of your child’s therapy sessions can include time for you to meet with the therapist so that you may gain information, learn some new skills, and have time to discuss any issues or concerns that arise during treatment. In some cases, family involvement will be less and in others, more intensive. Depending on how PTSD affects your family, your therapist will talk with you about how you can be helpfully involved in treatment. In addition, there are several handouts such as this one, prepared especially for parents. What follows is a list of tips, or things to keep in mind as you and your child begin the therapy process: Tip 1. The traumatic event caused the problem, not the child. By viewing PTSD symptoms as a natural response to trauma, you and your child can let go of the idea that he or she is the problem. This is an important first step toward teaming up with one another to recover from PTSD. Focusing on what your child is doing well, not the problems he or she is having can be helpful. If your child has begun to engage in inappropriate or disruptive behaviors since the trauma, talk to your child’s therapist about strategies to address the behavior without making your child feel as if he or she is the problem. Tip 2. You and your child have been doing the best you can. Neither you nor your child is to blame for the difficulties that the trauma has caused for your family. You and your child have done the best you can to recover from the trauma, but now need some help in managing some of the consequences of what has happened. You should not feel that coming to therapy means you have failed as a parent in some way. A good, caring parent knows when to ask for help, and does, even if it is hard to do so. Tip 3. Be mindful of what you say around your child. Often, teenagers feel that what happened to them is their fault, and they may feel guilty. To help protect your child’s feelings, try not to discuss your child’s problems with others in his or her presence. Try to avoid discussing or expressing your own intense emotions in front of your child. Remember that he or she may blame himself or herself for making you upset, or believe you are angry with him or her because you are angry about the trauma. This includes making sure that he or she doesn’t overhear you on the telephone or discussing events in another room or expressing your emotions about the problem. This does not mean that you should hide your feelings, but rather choose the time and place to discuss your feelings directly, in a helpful way, so your child is not left to draw his or her own conclusions about why you are upset or angry. Your child’s therapist can help you with this. continued

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Tip 4. Be a cheerleader for your child. As a cheerleader, you can help motivate your child as he or she begins to confront his or her fears. If you are supportive and confidently neutral, you will help to reduce your child’s anxiety as he or she begins exposing himself or herself to frightening situations. Criticism or punishment makes symptoms worse because they decrease your child’s motivation. Think about PTSD as an illness such as asthma. Just as you wouldn’t criticize your child for having asthma, as it is beyond her control, we recommend you try not to criticize your child for behaviors he or she is (or is not) engaging in because of PTSD. Also keep in mind that while the tasks chosen for Real-Life Experiments may seem small and insignificant, they are challenges for your child so it is important for the practice to go at your child’s pace. Your support and encouragement will contribute to your child’s confidence as he or she tackles the more difficult tasks. You can also help correct any misconceptions your child may have, such as being able to fight all of his or her symptoms at once. Just as cheerleaders cheer for only the play at hand, you can cheer your child on to complete only the homework task at hand. When your child is ready, you may also take on the role of co-therapist or coach, in addition to remaining a consistent cheerleader. Tip 5. Your child must set the pace to confront his or her fears. Your child had something unpredictable and uncontrollable happen to him or her. It is very important for the success of therapy that your child be given back control in choosing when and how to face his or her fears. As you learn about the treatment strategies we will be using over the next few weeks, you may be tempted to use techniques before your child is ready. Please resist the urge, as pushing your child too fast may actually increase the length of therapy. Tip 6. Be open to hearing about your child’s fears and anxieties, but do so when the child wants to talk about things. Do not insist that he or she talk about the trauma. Let your child know that you are interested in hearing everything he or she wants to tell you. If your child does talk about the trauma praise him or her for talking about it. Tell him or her how glad you are that he or she is able to tell what happened. Never express horror or anger as this may frighten the child from future conversations. If what your child says is upsetting to you it is important that you find someone else that you can discuss your own feelings with. Tip 7. Seek additional help if your own emotions are interfering with everyday life. It is important that you are able to set your emotions aside as you help your child, but this doesn’t mean that your emotions are unimportant. In fact, avoiding emotions can cause problems for parents in the same way it does for teenagers. If you are struggling with difficult emotions, talk to your child’s therapist. Your child’s therapist can help you decide if finding a therapist for yourself, in addition to the work your child is doing, would be helpful for you and your family. Tip 8. Encourage your child to speak kindly to himself or herself. Scolding or negative self-talk will increase symptoms and decrease motivation to change. Continue to be a cheerleader and coach by reminding your child of the territory he or she has already reclaimed from PTSD. This will provide additional encouragement and help your child to develop positive coping thoughts. This is important not only for the child but also for parents, family members, and friends who are struggling with the changes brought about by the trauma. Tip 9. Assist your child in the homework task as a co-therapist or coach. Helping with homework is always done with your child’s permission. For example, your child may ask you to walk part of the way with him or her while he or she practices walking to school. While your child is experiencing the anxiety, you can act as coach by stating, “It seems like your fears are making it hard for you today. Remember the anxious feelings will get smaller with time.” In addition, you can ask your child what his or her fear temperature is at 1–2 minute intervals so that your child can “see” his or her fear decreasing.

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Parent Handout 3: Common Reactions to Trauma Your child has arrived at our clinic after experiencing a traumatic event. A traumatic experience produces an emotional shock and may cause many emotional problems. Because everyone responds differently to trauma, your child may experience some of these reactions more than others. Some may not be experienced at all. It is helpful for parents and teenagers to remember that many of the changes experienced after a trauma are normal. In fact, most people who experience a major trauma have severe problems in the immediate aftermath. Some will feel much better within three months after the event; others recover more slowly, and some do not recover well enough without help. Becoming more aware of the changes felt since the trauma is a first step toward recovery. Like adults, teenagers commonly experience fears, anxiety, and other symptoms of PTSD. But, while adults and older teenagers can often describe their feelings with words, younger teenagers are more likely to show their distress through changes in their activities and relationships. Fear and Anxiety The most commonly experienced reaction to trauma is fear and anxiety. Fear and anxiety are natural and necessary responses to a dangerous situation. When a person is in a dangerous situation, an internal alarm system is triggered, warning the person and helping him to react in the best way. This “alarm system” triggers certain physical reactions (racing heartbeat, sweating, etc.) and helps the person to focus on the threat that he must defend himself against. During the traumatic event itself these reactions are natural and necessary, but when these reactions last for many months or years after the traumatic experience has ended, they get in the way of life. The child’s view of the world may change from one of safety and predictability to one that is unpredictable and dangerous. Sometimes fear and anxiety can seem to come out of the blue, but often they are brought on by triggers or cues that remind the child of the trauma. Triggers may include places, time of day, certain smells or noises, or other situations. Re-Experiencing Unwanted thoughts and feelings associated with the trauma are called re-experiencing symptoms. Older teenagers may be able to report that the trauma is always on their minds. Younger teenagers may seem preoccupied and quiet, but be unable to say what is on their minds. Cues or triggers associated with the traumatic event may cause strong emotions and/or physical reactions such as racing heart, sweating, or trembling. For example, a child who has experienced a car accident may become fearful or upset when driven by the scene where the accident happened. Both younger and older teenagers may have nightmares or they may have night terrors (awaken in a state of upset or terror, but be unable to recall a dream or experience that provoked the feelings). Some teenagers may experience flashbacks, which are very vivid images or extreme reactions in which the child feels as if the event is happening again. For example, a child that was traumatized in a shooting incident may jump to hide behind a barrier upon hearing a car backfire or a fireworks explosion. Very young teenagers may be observed engaging in repetitive play that symbolizes the trauma. Re-experiencing symptoms occur because the traumatic experience is so shocking and different from the child’s everyday experiences that it doesn’t fit with what the child already knows and understands about the world. It is as if the mind of the child is trying to go over the event again and again to better digest and understand what happened. continued

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Avoidance Another common problem for teenagers is avoidance. Avoidance reactions can be thought of as attempts to manage the pain related to the trauma. Some teenagers may try to push the thoughts away or distract themselves when thoughts or feelings associated with the trauma come into their minds. When reminded of the trauma, teenagers may change the topic or engage in distracting or disruptive activities to avoid thoughts or feelings. Teenagers may also avoid situations, places, or activities that remind them of the trauma. For example, a child bitten by a dog while playing outside may begin to avoid going outside even when no animal is present. Younger teenagers, particularly, may begin to associate the absence of parents with danger and will therefore refuse to sleep alone, express fear of the dark, and become clingy with caregivers and parents. Some have difficulty returning to school or daycare, especially if the trauma happened while the parents were not present. Some teenagers may become withdrawn and lose interest in play activities or peers. Teenagers may work so hard to avoid painful emotions that they experience periods of numbness, where they find it difficult to feel any emotions at all. Like adults, older teenagers may begin to use or increase their use of drugs or alcohol as a means of coping with the pain they are experiencing. Unfortunately, substance use can slow down recovery and cause problems of its own if unchecked. High Arousal High arousal of the body is another common reaction during fear and anxiety. People who experience high levels of arousal feel jittery and on edge almost all the time. They feel that their bodies are hyper; for example, they have accelerated pulse and heartbeat or increased muscle tension. They are cautious and jumpy all the time, they are startled easily, and they react strongly to simple things. High arousal develops because the trauma overworked the body’s normal alarm system triggering a “fight, flight, or freeze” response. The “fight, flight, or freeze” response is how we gear up to protect ourselves when danger threatens. Our bodies begin to pump out more adrenalin to give us energy to run away, to fight for survival, or to freeze as a way of hiding from danger. These responses are natural reactions in the face of danger. Unfortunately, the triggers and cues that remind us of the traumatic event can make it seem like danger signals are everywhere. This triggers the alarm system to give an alarm when there is no real threat. Because these triggers in themselves do not pose a real threat, this is actually a false alarm. Since traumatized teenagers sees danger signals everywhere, they are in a constant state of anxiety. Because of the heightened state of anxiety, teenagers often have difficulty falling or staying asleep. Concentration may also be difficult, and they can seem irritable and easily frustrated much of the time. Schoolwork may suffer; relationships with peers and family members may become strained. Teenagers may seem sensitive and easily brought to tears, or younger teenagers may have tantrums. Some teenagers may seem jittery, jumpy, or unable to sit still. Loud noises or sudden movements can easily startle them, and they may become increasingly watchful and alert to their surroundings. Grief and Depression The trauma and the reactions that follow can so disrupt everyday life that the child feels tremendous grief and depression. This can include feeling sad, down, hopeless, or despairing. continued 185

Parent Handout 3: Common Reactions to Trauma continued Some teenagers will be able to tell how they are feeling while others will show how they are feeling by their behavior. A depressed child may appear more reserved, withdrawn, or detached from other people. Depressed teenagers may also seem irritable, angry, or frustrated at times. This can be very confusing for parents and other people who care for the child because it is often those closest to the child who receive the brunt of the child’s anger and frustration. For teenagers not used to feeling angry, these feelings can seem out of control and frightening. Some teenagers can develop a preoccupation with death or have difficulty imagining themselves in the future. It can sometimes seem that the trauma has ruined all their plans and hopes. If depression is severe, the child may even feel that life isn’t worth living anymore and express thoughts or wishes to be dead. While this reaction to trauma is not uncommon, it is certainly one of the more frightening reactions for parents and one that can best be managed in coordination with a mental health professional. Guilt and Shame Many teenagers feel tremendous guilt and shame about the trauma. A child who witnesses domestic violence between his parents may believe that his parents fought each other because of him. Teenagers often feel responsible for much of what happens in their lives, good or bad, but this may be especially true if adults or peers have blamed them or lead them to believe that they deserved what happened to them. For example, a child that has been abused by an adult caretaker may have been told that he deserved the abuse because he was a “bad child.” Teenagers may also be confused in this way if they trusted or admired the person who hurt them, or if they enjoyed some parts of the relationship with the person who hurt them. Feeling guilty or responsible for a trauma may also make the child feel as if he has more control over the event, or that he can avoid the event in the future. However, self-blame can intensify feelings of shame and depression. Self-image may suffer greatly after a trauma. Self-blame and guilt may lead to feelings of worthlessness and a belief that the child deserves to be punished. The child may expect future negative events as a result. Many teenagers will tell themselves that they are weak or stupid for not being able to control or stop the traumatic event. The child’s image of the world often suffers as well. It is very common to feel that others can’t be trusted, and to expect that other people are dangerous. This can make it difficult for the child to make friends or trust caretakers. Effects on Sexual Beliefs and Behavior Some sexually abused teenagers may develop distorted beliefs about sexuality and sexual behavior. For some teenagers, this can lead to fear and avoidance of normal, developmentally appropriate behaviors. For example, normal teenaged interest in dating and the opposite sex can be disrupted or delayed. For other teenagers, maladaptive beliefs can lead to sexual acting out such as inappropriate touching and showing, sexual language or gestures, and preoccupation with sexual themes. Older teenagers may engage in sexual relationships before they are emotionally or intellectually ready. These behaviors can compound the trauma and lead to further experiences of shame and exploitation. It is important for parents and caretakers to remember continued

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that it is not the child’s fault that the trauma has affected the child’s sexuality, and to respond to this type of behavior without shaming or punishing the child. A mental health professional can help parents find ways to help the child develop healthy sexuality when sexual abuse has begun to affect development negatively. Connection Between Reactions Many of these reactions are connected to one another. For example, a child who experiences an unwanted reminder of the traumatic event may become fearful and anxious. The child may then blame herself for not being able to cope with her anxiety. She may tell herself that she is stupid or crazy because she cannot control her emotions. This can lead to further emotional upset, tearfulness, and feelings of being out of control. This increases fear and anxiety. As the child begins to process the trauma and her reactions to it, her understanding will increase and so will her feelings of competence and control. Common Reactions of Parents As a parent, you may be experiencing your own reaction to the trauma. Sometimes this occurs because the whole family experienced the trauma (e.g., a house fire). When this happens, parents may be dealing with their own reactions, in addition to those of their child. Other times, even if the trauma was experienced by the child alone, parents’ connection and attachment to their child can lead them to feel as if they experienced a trauma as well. Sometimes parents experience intrusive thoughts, react to reminders of the trauma, and have feelings of guilt and blame because they feel that they were unable to protect their child from harm. Like the child, parents may avoid situations and places that trigger memories surrounding the trauma. Because remembering the trauma is so painful, parents may avoid thinking about it and encourage the child to stop thinking and talking about it. Statements like, “Put it behind you,” “Think about happy thoughts,” and “Forget it ever happened,” can be well meaning, but can get in the way of both the parent’s and the child’s processing of the event. Parents may also develop extreme fear and anxiety about their child’s safety and well-being. Parents can react to these feelings of trauma by overprotecting the child. The parents’ actions may communicate the parents’ fears to the child and can add to the child’s anxiety and upset. Sleep and concentration problems are also common among parents of teenagers who have experienced trauma. The same “fight, flight, or freeze” response is at work in the parents’ lives as they deal with the urge to protect their child from further harm. Parents may find themselves scanning the environment for danger as they become increasingly mistrustful of other people who have access to their child. The constant heightened arousal can lead to irritability and poor concentration and feelings of incompetence and lack of control. Just as the child needs to become aware of the changes that have taken place as a result of trauma, parents must become aware of their own reactions to the trauma as a first step toward processing and understanding the trauma itself. If a parent’s reactions are difficult to manage, or if reactions interfere with the parent’s ability to help the child recover, it is important for the parent to get assistance so that both parent and child can move past the trauma.

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Additional Materials: Stories and Cards

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Rationale for Treatment Story Monica’s Scary Memory This is a story about teenager named Monica who has a scary memory of something bad that happened to her. Her memory may not be the same as yours. She may also be dealing with and reacting to her memory in a way that is a little different from you. The purpose of the story is for you to see that other teens go through scary times, too, and this is an example of what happened with one girl. Monica is a teenager with a scary memory about a very bad time when she was hit by a car while walking to school. She always tries to push the memory out of her head, and think of something else. She tries to avoid anything that may remind her of the memory. But no matter what she does, the memory always seems to pop up and ruin her day, just when she thinks things are starting to get better. Even when Monica is sleeping she has nightmares. Many days, she is scared all of the time. One day, Monica’s parents took her to meet Brenda, a therapist, as she was always afraid, and was having trouble sleeping. “My name is Brenda, and I am here to help you,” the therapist began. “In order to help you become less afraid, over time, I will encourage you to talk about the time when you were hit by a car.” “What was that?!” Monica asked, amazed. “I don’t think I heard you. You want me talk about what?! You really want me to talk and think about it?” Monica thought Brenda was crazy. Why would she want to talk about when that car hit her? It gave her the jitters and made her feel bad. So bad that she would get stomachaches. “Let me ask you a question,” Brenda said. “Has pushing the memory out of your head been working? Has it been making you feel better?” “Umm . . . ” Monica didn’t want to answer. “I would guess that the memory just keeps popping up, no matter how hard you try to forget about it,” Brenda said. Monica wondered how Brenda knew what was happening. “I feel like I am always pushing it out of my head,” Monica admitted. “It won’t stay gone for long.” “Hmm,” Brenda was thinking. “I also wonder if there are things you used to do before the accident that you don’t do anymore.” “Well, I don’t go to friends’ houses or go outside much at all,” Monica said. Brenda explained to Monica that, sometimes, when people go through a scary experience, they do not want to talk or think about it, so they stay away from things that might remind them of it. “Do you miss visiting friends and going outside?” she asked. “Yes,” Monica replied, “I miss both a lot. I think that some of my friends don’t call me as much anymore because I won’t hangout with them.” continued

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“And are you thinking about the accident less, now that you’re not hanging with your friends as much?” “No, I think about it even more because I am stuck in my house by myself, when I really want to be with my friends,” Monica told her. “It sounds like pushing away the scary memory isn’t helping you very much,” Brenda replied. Brenda told Monica that if she talked about the memory, and said what happened out loud, it would start to seem less scary. It sounded crazy, but it’s true. And Brenda should know. Monica figured out that Brenda was able to guess what she was thinking and feeling because she had worked with lots of other teens who had scary memories, too. These were middle- and highschool kids who were in car accidents, watched people get hurt, or were hurt by someone they loved and trusted. Monica began to feel more comfortable with Brenda. She really seemed to get how she was feeling. “What we’re going to do in therapy may be hard at first,” Brenda explained. “Talking about the memory is like going swimming. When you first get into the water, it’s icy cold. It’s so cold and uncomfortable you just want to run out of the pool because it seems like you will never stop shivering. But, after awhile, you get used to the water, and soon you are splashing around and the water feels okay.” Monica understood what she was saying. Monica asked Brenda if she thought she would ever be able to hang out with her friends at their houses. “Yes,” Brenda said. “When you start to do the things you were avoiding because of the traumatic event, you get a chance to see that those things are really safe, and can be fun again. Let me give you an example, when you were little, did you used to be afraid of the boogeyman?” “Kind of,” Monica admitted. “Are you still afraid of the boogeyman?” “No,” Monica said. “I learned I had nothing to be scared of.” “How did you learn that?” Brenda asked. “One night, I got up all the courage I had, turned on my bedroom light, and saw that there was nothing there.” Monica smiled as she remembered that she even checked the closets and under the bed. “That’s what we’re going to do together,” Brenda said. “In therapy, I will help you find ways of shining a bright light on your memory so you can see what’s really there and learn it’s not dangerous. I will even teach you how to watch your memory in slow motion, so you don’t miss any important parts. You and I are going to wear lots of different hats together. Sometimes we’ll be detectives, examining your memory through magnifying glasses to see what’s really there. Other times we’ll be scientists—gathering information and doing experiments to prove that going to the movies or hanging out with friends isn’t dangerous anymore.” continued

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Rationale for Treatment Story continued Monica was beginning to get used to idea of talking to Brenda more and more. She was glad when Brenda told her that, over time, she would be able to see her memory as in the past. And, that Monica would learn that her memory is something that can’t hurt her anymore. Monica was relieved when Brenda said that being scared does not last forever. “If you practice,” she said, “you will get really good at confronting your fears, facing them head on, and helping to make them go away.” Monica said that the best part would be when she starts to feel good about herself, and have fun again. “That will happen,” Brenda reassured her. “And when it does, you can put your memory on a shelf, just like the detective who solves the case and puts the file in a drawer. The memory won’t tell you to be scared all the time anymore. It will stay in the drawer until you decide to think about it again.” Monica liked the sound of that. She was beginning to believe that with time she could conquer her fears. But still she had doubts. “I still feel afraid to think about what happened,” she told Brenda. “What if I get so scared that I start crying?” “It’s normal to feel afraid at first,” she said. “Crying is ok. Learning to talk about what happened to you is just like learning to do most difficult things. At first, you feel you can’t do it and that you might break down. But, with time, it becomes easier and you learn not to be so afraid.” “Remember,” Brenda continued, “you won’t be doing this alone. I will support you until you are ready to manage the memory by yourself. And we will work slowly, and in a way that is comfortable for you.” By the time Monica left Brenda’s office, she felt hopeful for the first time in awhile. From talking to Brenda, Monica learned that a memory is a story that is already finished. She also learned that pushing away the memory was not helping her feel better. While scary, talking about what happened—bringing it out into the light—made sense. Brenda would be there to make sure Monica knew she was safe, and that the memory cannot hurt her like it did before.

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Common Reactions Cards (for younger teenagers) Cut out the cards or transfer the information to index cards. Sort the cards into piles as you discuss common reactions with the patient. Let one pile represent common reactions the patient has experienced and let the other pile represent reactions the patient has not experienced. If the patient is able, have him write examples directly on the card to personalize the information. Have several blank cards available to write in reactions that are not on the cards provided.

FEAR AND ANXIETY

SOME PLACES DON’T FEEL SAFE

TRIGGERS

AVOIDANCE

SCARY DREAMS or NIGHTMARES

TROUBLE PAYING ATTENTION

FLASHBACKS

FEELING ON EDGE

IRRITABILITY

FREEZE, FLEE, OR FIGHT

NOT FEELING MUCH OF ANYTHING (EMOTIONAL NUMBNESS)

SADNESS, FEELING DOWN, OR DEPRESSED

GUILT, SHAME, BLAME

BEING HARD ON MYSELF

TROUBLE GETTING ALONG WITH OTHERS

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Common Reactions Story Tommy’s Scary Time and His Leftover Feelings Tommy had a scary time. Someone hurt him. He was afraid to tell. He didn’t want to talk about it because it made him feel upset all over again. Even though the scary time was over, Tommy had a lot of leftover thoughts and feelings from the time when he was hurt. Tommy tried to forget about it. He wanted everything to go back to the way it was before he got hurt. He tried to pretend that nothing had happened, but sometimes the leftover thoughts and feelings about the time he got hurt would pop into his mind. He tried to push the thoughts and feelings away and think of something else. But they kept bothering him. He worried that he might get hurt again. He sometimes felt afraid. He sometimes felt sad. He had trouble doing things he used to do, like playing with his friends and going to school. Whenever something reminded Tommy of that terrible time, he would feel like it was happening again. He would feel scared, sad, and helpless. For instance, Tommy got upset when he saw a person who looked a little bit like the person who hurt him. Tommy felt so upset that he had a hard time when he wanted to go to sleep at night. He would stay awake for a long time and feel very anxious before he fell asleep. Then when he got to sleep he had lots of nightmares. Tommy also had problems going to school unless his dad or his mom walked the whole way with him. Even then, he was constantly looking around to see if any scary people were trying to hurt him. He had a hard time concentrating on his schoolwork because thoughts and memories of the time he was hurt kept popping into his mind. This happened even more when the time of day came around to when the terrible thing happened. Sometimes Tommy had a hard time sitting still. He would jump when he heard loud noises. His heart would race and his hands get sweaty right in the middle of class or worship. Sometimes he would lose his temper too. Everyone gets mad sometimes, but Tommy would get mad about things that never used to bother him. Sometimes he’d get mad for no reason. Sometimes he felt like hitting other people. Sometimes he would cry and yell. Anyone who knows what it is like to have leftover upset feelings from a terrible time could understand why Tommy got mad. After all, he never asked for these problems. Anyone in Tommy’s situation could have the same kind of trouble. Sometimes Tommy would think, “Why did a scary time have to happen to me?” He thought that maybe he was a bad person, that it was his fault because the scary time happened to him and he still had these leftover, upset feelings. He began to stay away from his friends because he just did not feel like playing. continued

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He even felt embarrassed and ashamed, though it was not his fault that he got hurt. He was afraid if he told what happened to him that his mom and dad would be angry with him. He was afraid they would think he was a bad boy because something bad happened to him. Tommy felt sad about having these problems. But anyone could have these problems if something scary and upsetting happened to him or her. Finally, one day Tommy and his mom went to the doctor’s office. Mom said they were special doctors who would talk to him and draw pictures with him instead of giving him shots and checking his eyes and ears. Tommy was very nervous at first, especially when the doctor asked him about what happened. Tommy felt embarrassed to say what happened to him. But after awhile, it got easier, and Tommy began to feel less afraid. The doctor told Tommy that it was not his fault that something bad happened to him. She told him that other kids who had scary times felt just the same as Tommy felt. She helped Tommy and his mom think of ways for Tommy to begin to feel better. Soon he was able to think of the scary time without crying and getting upset. He even started to play with his friends again. Tommy learned that other boys and girls also feel scared and sad and embarrassed when something terrible and scary happens to them. Tommy also learned that it was not his fault that the scary time happened to him. He learned that his mom and dad were not angry with him at all about the scary time. He learned to draw pictures about what happened and about the feelings and thoughts that bothered him. He even learned that he could talk about it. He learned that he did not have to feel afraid and upset anymore. Tommy felt strong and brave that he was able to tell what happened. He felt good to know that it was not his fault.

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About the Authors

Edna B. Foa, PhD, is Professor of Clinical Psychology in Psychiatry at the University of Pennsylvania and Director of the Center for the Treatment and Study of Anxiety. She received her PhD in Clinical Psychology and Personality from the University of Missouri, Columbia, in 1970. Dr. Foa devoted her academic career to study the psychopathology and treatment of anxiety disorders, primarily obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and social phobia and is currently one of the world’s leading experts in these areas. Dr. Foa was the chair of the DSMIV Subcommittee for OCD and co-chairs the DSM-IV Subcommittee for PTSD. She has also been the chair for the Treatment Guidelines Task Force of the International Society for Traumatic Stress Disorder. She is Chief Editor of Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies, First Edition (2000) and Second Edition (in press). Dr. Foa has published several books and over 250 articles and book chapters and has lectured extensively around the world. Her work has been recognized with numerous awards and honors. Among them are the Fulbright Distinguished Professor Award; the Distinguished Scientist Award from the American Psychological Association, Society for a Science of Clinical Psychology; the First Annual Outstanding Research Contribution Award presented by the Association for the Advancement of Behavior Therapy; the Distinguished Scientific Contributions to Clinical Psychology Award from the American Psychological Association; the Lifetime Achievement Award presented by the International Society for Traumatic Stress Studies; the Annual Signature Service Award from Women Organized Against Rape; Honorary Doctorate Degree of Philosophy by University of Basel; and the Senior Scholar Fulbright Award. Kelly R. Chrestman, PhD, is a clinical psychologist at the Center for the Treatment and Study of Anxiety at the University of Pennsylvania

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School of Medicine. She received her PhD in Clinical Psychology from the Nova Southeastern University in 1994. She has extensive experience in the cognitive-behavioral treatment of posttraumatic stress disorder and other anxiety disorders, cross-cultural psychology, health and wellness, and management of stress. Her publications focus on community and professional responses to trauma, particularly domestic violence, and the development of PTSD in women. Dr. Chrestman’s professional activities include psychological treatment of children and adults with anxiety disorders, clinical training and supervision of therapists treating PTSD, and teaching graduate courses in psychological assessment. Eva Gilboa-Schechtman, PhD, is Senior Lecturer of Clinical Psychology at Bar-Ilan University in Israel and Director of Psychopathology Laboratory at the Gonda Brain Sciences Center. She received her PhD in Cognitive Psychology from Northwestern University in 1993, and completed her clinical retraining in 1997. She studies social anxiety, depression, and posttraumatic stress disorder and is interested in basic psychopathology and in treatment outcome. She has received many research grants and has published extensively on these topics. Dr. Gilboa-Schechtman was a primary investigator of a NIMH study treatment in adolescent victims of single-event traumas. She is the founder and director of the Child and Adolescent Post-Trauma Clinic in Israel. She lectures on anxiety and depression disorders in Israel, Europe, and the United States.

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