Breaking the Cycle: Utilizing TF-CBT to Address Generational Trauma

1. Breaking the Cycle: Utilizing TF-CBT to Address Generational Trauma Mark Peterson, LMSW Liz Sharda, LLMSW

2. Learning Objectives Participants will be able to: 1. define trauma, including acute, chronic, and complex types of trauma. 2. name one finding of the ACE Study. 3. identify the eight core components of Trauma-Focused Cognitive Behavior Therapy.

3. What is trauma? A traumatic or life-threatening event that is outside the normal range of daily human experience. It arises when adult/children experience or witness such an event These events confront people with such horror and threat that it may temporarily or permanently alter their capacity to cope, their perception of biological threat and their self-concepts.

4. What is trauma? Acute Chronic Complex

5. Post Traumatic Stress Disorder Can occur in childhood, adolescence, or adulthood. May become apparent immediately or be delayed until adulthood May involve both psychological and physical symptoms Often occurs along with other conditions like depression, substance abuse, memory and thinking problems

6. 3 Major Characteristics of PTSD Repeated reliving of memories of the traumatic experience Avoidance of reminders of the trauma, and the numbing, detachment and emotional blunting that often coexist with intrusive recollections Patterns of increased arousal (hyper arousal) expressed by hyper vigilance, irritability, memory & concentration problems, sleep disturbances and an exaggerated startle response

7. van der Kolk, B. (2005) Developmental trauma disorder. Psychiatric Annals, 35(5): 401-408. Developmental Trauma Disorder Group within the NCTSN advocating for inclusion in the DSM-V Criteria: Exposure Triggered pattern of repeated dysregulation in response to trauma cues Persistently altered attributions and expectancies Functional impairment

8. Adverse Childhood Experiences Study (ACES)*

9. Wylie, M.S. (2010, September/October). As the twig is bent. Psychotherapy Networker, 34(5), 54-58. ACE Study Kaiser Permanente � Vincent FelittiCenters for Disease Control � Robert Anda 26,000 consecutive patients receiving a non-illness related comprehensive medical exam were asked if they�d be willing to answer a series of questions regarding unpleasant childhood experiences.

10. Wylie, M.S. (2010, September/October). As the twig is bent. Psychotherapy Networker, 34(5), 54-58. ACE Study 71% (17,337) agreed to participate Respondants: Average age: 57 77% Caucasian 74% attended college 50% male, 50% female

11. Wylie, M.S. (2010, September/October). As the twig is bent. Psychotherapy Networker, 34(5), 54-58. ACE Study Researchers surveyed and interviewed participants in detail about ten categories of negative childhood experiences 3 major groupings: Abuse (physical, sexual, emotional) Neglect (physical, emotional) Household dysfunction (domestic violence, absent parent, incarcerated household member, substance use, mental illness) Each category counts as 1, with a total �ACE Score� of up to 10

12. Wylie, M.S. (2010, September/October). As the twig is bent. Psychotherapy Networker, 34(5), 54-58. ACE Study � Findings Adverse experiences in childhood were common: Only 33% had an ACE score of zero Adversity usually came as a package deal: If one category was present, there was an 87% chance that there was at least one other category present 1 in 6 had an ACE score of 4 or more 1 in 9 had an ACE score of 5 or more 66% of a middle-class, predominantly white, educated population with good health insurance had suffered maltreatment or family dysfunction as children

13. Wylie, M.S. (2010, September/October). As the twig is bent. Psychotherapy Networker, 34(5), 54-58. ACE Study - Implications There is a profound relationship between childhood adversity and the various mental, physical, and social disorders that plague our society.

14. Wylie, M.S. (2010, September/October). As the twig is bent. Psychotherapy Networker, 34(5), 54-58. ACE Study ACEs have a vast influence in the development of biomedical conditions, even half a century after childhood. ACEs radically increase the risk for: Heart and lung disease (48% greater risk) Diabetes STDs (including HIV) Hepatitis Chronic pain High ACE scores are also correlated with diseases, including cancer, coronary artery disease, and chronic obstructive pulmonary disease, even when controlling for (or without) conventional risk factors like smoking, air pollution, and high cholesterol.

15. Wylie, M.S. (2010, September/October). As the twig is bent. Psychotherapy Networker, 34(5), 54-58. ACE Study High ACE scores are even correlated with early death: Participants with an ACE score of 6 or more die, on average, TWO DECADES earlier than those with a score of 0.

16. Wylie, M.S. (2010, September/October). As the twig is bent. Psychotherapy Networker, 34(5), 54-58. ACE Study � WHY? Maltreated children are more likely to become hooked on self-soothing habits: smoking, drinking, overeating, promiscuous sex, illegal drugs. Long-term addictions begin as temporary fixes for problems like anxiety, fear, anger, depression, low self-esteem, loneliness, and despair.

18. Trauma-Informed Intervention Elements: Skill-building Gradual exposure Narrative Cognitive restructuring Examples: ARC (Attachment, Self-Regulation, and Competency) CPP (Child-Parent Psychotherapy) Seeking Safety TF-CBT (Trauma-Focused Cognitive Behavior Therapy)

19. What is Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)? Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a components-based model of psychotherapy that addresses the unique needs of children with PTSD symptoms , depression, behavior problems, and other difficulties related to life experiences.

20. Source: Child Sexual Abuse Task Force and Research & Practice Core, National Child Traumatic Stress Network. (2004). How to Implement TF-CBT. Durham, NC and Los Angeles, CA: National Center for Child Traumatic Stress. What is TF-CBT? (cont�d) TF-CBT is a short-term treatment approach that can work in as few as 12 sessions. It also may be provided for longer periods of time depending on the child�s and family�s needs. Individual sessions for the child and for the parents or caregivers, as well as joint parent-child sessions, are part of the treatment. As with any therapy, forming a therapeutic relationship with the child and parent is critical to TF-CBT.

21. Source: Child Sexual Abuse Task Force and Research & Practice Core, National Child Traumatic Stress Network. (2004). How to Implement TF-CBT. Durham, NC and Los Angeles, CA: National Center for Child Traumatic Stress. What Symptoms Does TF-CBT Address? PTSD symptoms: re-experiencing, avoidance/numbing, hyperarousal Depression Anxiety Behavior problems Sexualized behaviors Trauma-related shame Interpersonal trust Social competence

22. Source: Child Sexual Abuse Task Force and Research & Practice Core, National Child Traumatic Stress Network. (2004). How to Implement TF-CBT. Durham, NC and Los Angeles, CA: National Center for Child Traumatic Stress. TF-CBT Research Study 1: Deblinger, E., Lippmann, J., Steer, R. (1996). Sexually abused children suffering posttraumatic stress symptoms: Initial treatment outcome findings. Child Maltreatment, 1(4), 310-321. 100 sexually abused (SA) children, 8-14 years old, and parents randomized to TF-CBT for child only, parent only, child plus parent, or treatment as usual (TAU) Children receiving TF-CBT experienced significantly greater improvement in PTSD symptoms. Children of parents receiving TF-CBT experienced significantly greater improvement in depressive and behavioral symptoms; parents experienced significantly greater improvement in positive parenting practices. Differences sustained at 2-year follow-up.

23. Source: Child Sexual Abuse Task Force and Research & Practice Core, National Child Traumatic Stress Network. (2004). How to Implement TF-CBT. Durham, NC and Los Angeles, CA: National Center for Child Traumatic Stress. TF-CBT Research Study 2: Cohen, J.A., Mannarino, A.P. (1997). A treatment study for sexually abused preschool children: Outcome during a one-year follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 36(9), 1228-1235. 86 SA children, 3-6 years old, and parents randomized to TF-CBT or nondirective supportive therapy (NST), followed for one year post-treatment. Children receiving TF-CBT experienced significantly greater improvement in total behavior problems, internalizing, externalizing, and PTSD symptoms characteristic of young sexually abused children at one year follow up.

24. Source: Child Sexual Abuse Task Force and Research & Practice Core, National Child Traumatic Stress Network. (2004). How to Implement TF-CBT. Durham, NC and Los Angeles, CA: National Center for Child Traumatic Stress. TF-CBT Research Study 3: Cohen, J.A., Deblinger, E., Mannarino, A.P., Steer, R.A. (2004) A multi-site, randomized controlled trial for children with sexual abuse-related PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 43(4), 393-402. 229 SA children, 8-14 years old, and parents randomized to TF-CBT or Child-Centered Therapy (CCT) at two sites, followed for one year post-treatment. More than 90% experienced multiple traumas Children receiving TF-CBT experienced significantly greater improvement in PTSD, depression, behavior problems, shame, and abuse-related attributions. At one-year follow-up, children with multiple traumas and initial high levels of depression did worse in CCT group only, suggesting that TF-CBT is more effective than CCT for these children.

25. What are the components of TF-CBT?, cont�d The specific components of TF-CBT are summarized by the acronym PRACTICE. Psychoeducation is provided to children and their caregivers about the impact of trauma and common childhood reactions. Parenting skills are provided to optimize children�s emotional and behavioral adjustment. Relaxation and stress management skills are individualized for each child and parent.

26. What are the componenets of TF-CBT?, cont�d Affective expression and modulation are taught to help children and parents identify and cope with a range of emotions. Cognitive coping and processing are enhanced by illustrating the relationships among thoughts, feelings and behaviors. This helps children and parents modify inaccurate or unhelpful thoughts about the trauma. Trauma narration, in which children describe their personal traumatic experiences, is an important component of the treatment.

27. What are the components of TF-CBT?, cont�d In vivo mastery of trauma reminders is used to help children overcome their avoidance of situations that are no longer dangerous, but which remind them of the original trauma. Conjoint child-parent sessions help the child and parent talk to each other about the child�s trauma. The final phase of the treatment, Enhancing future safety and development, address safety, helps the child regain developmental momentum, and covers any other skills the child needs to end treatment.

28. Project Return Home Trauma-informed, evidence-based therapy for children in out-of-home placement (foster care, kinship care, etc.) and their biological parents Children ages 6 through 18 �Parallel services� for kids, bio parents, foster parents Trauma-Focused Cognitive Behavior Therapy (TF-CBT) Provided at Bethany�s Family Counseling Center Pilot group began in May 2009

29. Program Objectives: Reduce behavioral problems extending from complex childhood trauma Reduce the number of disrupted foster care placements Increase the rate and timeliness of child-family reunifications Reduce the recidivism rate for repeat out-of-home placement Create a more trauma-informed child welfare system

30. Trauma Awareness Foster parent training Foster care staff training TF-CBT training for therapists Partnership with developers of TF-CBT Other training and public awareness opportunities

31. Resources TFCBT Web Training http://tfcbt.musc.edu National Child Traumatic Stress Network: http://nctsn.org Child Trauma Academy http://www.childtrauma.org National Center for PTSD http://www.ptsd.va.gov