Trauma Narration Level 1 - Oklahoma...

Trauma Narration – Level 1 5/11/2017

Natalie GalloRoy Van TassellMichael Gomez 1

Trauma Narration –

Level 1Natalie Gallo, Roy Van Tassell, and Michael Gomez

Center on Child Abuse & Neglect

Child Study Center

Objectives

• Revisit the rationale for Trauma Narration (TN)

• Learn how to structure TN based on different trauma histories

• Learn and practice how to construct a timeline

• Learn and practice how to construct a “Chapter 3”

• Learn and practice caregiver TN preparation

Why Trauma Narration?

• Desensitize the child to traumatic reminders – “Take the heat out”

• Unpair thoughts, reminders, or discussions of the traumatic event from overwhelming

negative emotions such as terror, horror, extreme helplessness, shame, or rage

• Thereby decreasing avoidance and hyperarousal symptoms

• It is the MEMORY that is fueling the PTSD symptoms, the EMOTION surrounding

that memory



Purpose of Trauma Narration

• Goal = DESENSITIZE

• You CAN talk about this even if it is uncomfortable (ergo 4-7 range)

• 10 is too much

• 1 is too little (either no problem or disconnected)

1 5 104 7


• Red Flag Cognitive Distortions (BUT DO NOT PROCESS YET)

• You do not process a cognition while actively in TN for the same reason you do not try to rebuild a house as it is actively on fire

• Put out the fire, THEN begin restructuring

• What you are allowed to do is this:

• “Billy that’s a really heavy thought you wrote there. I want to make sure you have a chance to talk about it. Can I make a mark here and I promise we’ll come back to it later?”

• Some children have had “desensitization by the system”

• This is NOT the same as Trauma Narration


• Contextualize traumatic experiences

• Trauma is only one part of child’s life experience and self-concept, rather than the defining aspect of both

• Conetextualization aids in addressing negative beliefs about the world, self, and the future

• You have done this before many times in every Lit class you ever took

• It is why The Iliad can be millennia old but still have MANY different interpretations

• Final chapter is where you do this the most directly

• But the child, themselves, will tend to do it spontaneously during a TN (let them, it’s pretty cool)

• Implicit in TF-CBT is that it is not creating a story that is important but finding a more adaptive interpretation of their story



GRADUAL EXPOSURE

IS THE HEART OF TF-

CBT

Wait. Didn’t you used to call it Trauma

Narrative???• Ya, we did, but we changed it for a good reason

• “Narrative” indicates . . .

• An endpoint, that once the story is written you and/or the child are “done”

• “Narration” indicates . . .

• A beginning point, that this may very likely be the first time a child will, in a therapeutic way, START the encapsulation of their story

• With the implication that they will do this many times throughout their lives

• So you are not giving them a concrete thing, you are showing them a process for therapeutically perceiving their story and having control over the story and, therefore, their experiences

When Trauma Narration?

• “C” Student (3 Questions)

• Can they do a relaxer?

• Can they tell the difference between a thought and emotion?

• Younger children get a pass here

• Can they report on a SUDs scale?

• And a GEC (Good Enough Caregiver)

• The burden of proof is on YOU

• You have to give me a REALLY good reason to NOT go into TN

• Otherwise I’m expecting you to go into TN after you have taught the child the Cognitive Triangle



Strong Handshake

• Have MULTIPLE rationales

• Cleaning the wound

• Coke bottle

• Roller coaster

• Scary movie

• Also go back to your psychoeducationbooks (e.g., Jesse’s Story)

• The TF-CBT workbook has good language as well

• Lead in VERY strong (no limp handshake)

• CAREGIVER needs rationale too

• Surgery metaphor

• Prep the caregiver (at the latest) at the last cognitive coping session

• Research indicates that children say TN was the most helpful part

Structure is

your friend

TF-CBT Workbook Page 6

Telling My Story

I will tell my story by

______________________________________.

I may have some heavy feelings when I tell

my story. It is time to take a break if my

heavy feelings are:

I will use these skills to calm heavy feelings:

1.

2.

3.

A Little

A Middle

A Lot

1

3 7

10

STRUCTURE IS YOUR FRIEND• Time (perhaps the MOST important)

• For highly avoidant or highly hyperactive children but good for ALL children

• Consider use of a timer

• Caveat, they HAVE TO be working

• “Cushion” session (e.g., 10 minute free time after TN work)

• “Healthy” distraction

• Some children need something to play with while doing the TN

• Make sure to put structure around this; meaning SET IT UP BEFOREHAND

• Behavior Chart

• Some children will need this not just in TN, but throughout the model

• You can praise effort; beware you are not praising content

• Room

• How are you going to physically arrange the room?

• Will you have the same room throughout sessions?

• Do you need a “ring”? (i.e., a physical boundary where you do the TN)



The Timeline (aka “Gradual Exposure

Hierarchy”)

• Biggest mistake during your first TN = No Timeline

• You (and your child) need a road map

• If you take the time to do this, the TN will be MUCH more smooth

• I promise

• Many ways to do this

• Sticky notes

• On the floor

• Big sections of butcher paper

• Clock

• TIMELINE IS TRAUMA NARRATION!

• So do your SUDs check, relaxers, etc

Happy Memories

1 y.o. 10 y.o. 5 y.o.

Hard Memories

“DHS took us out of our

house” – 9 y.o.

“Moved in with Mrs.

Johnson” 9 y.o. [August

2013]

“First time I

remember dad hitting

mom. She was

bleeding.” 4 y.o.

[Summer]

1 y.o. 10 y.o. 5 y.o.


house” – 9 y.o.



2013]

“I saw dad break

mom’s jaw” – 9 y.o. [2

days after his birthday]

“Mom took us on a

trip to Dallas” – 8 y.o.

“Dad hit me so hard I had to

go to the hospital. He told

them I fell” 8 y.o. (summer)

“First time I


mom. She was

bleeding.” 4 y.o.

[Summer]

“Dad pulled out a gun and said he was

gonna kill all of us” 5 y.o. [right before

Xmas]

“My uncle took me

camping” – 6 y.o.

Happy Memories

Hard Memories



1 y.o. 10 y.o. 5 y.o.


house” – 9 y.o.



2013]

“I saw dad break

mom’s jaw” – 9 y.o. [2

days after his birthday]

“Dad hit me so hard I had to

go to the hospital. He told

them I fell” 8 y.o. (summer)

“First time I


mom. She was

bleeding.” 4 y.o.

[Summer]

“Dad pulled out a gun and said he was

gonna kill all of us” 5 y.o. [right before

Xmas]

“Mom took us on a

trip to Dallas” – 8 y.o.“My uncle took me

camping” – 6 y.o.

Happy Memories

Hard Memories

NOTE: Can also

spatially rank them.

Time to Practice – Prep and Timeline

Case Scenario: Billy and MaryWilliam “Billy” Batson is a 12-year-old male who, along with his 10-year-old biological sister Mary,

were referred by their Oklahoma Department of Human Services (OKDHS) worker, John Fawcett,

due to behavioral and emotional problems related to abuse and neglect. Billy and Mary were

removed from their home due to parental substance use (methamphetamine) and witnessing

domestic violence between their biological mother, Marilyn Batson, and her boyfriend, Adam Sivana.

Specifically, Mr. Sivana and Ms. Batson manufactured, distributed, and used methamphetamine while

in the presence of Billy and Mary. Both children reported witnessing multiple incidents of drug use

or manufacturing by Mr. Sivana and Ms. Batson. Mary reported to Mr. Fawcett that she saw, on

multiple occasions, her mother taking “white stuff ” and then “acting scary.” In addition, Mr. Sivana

would oftentimes become violent towards Ms. Batson in the presence of the children. Billy and

Mary witnessed multiple incidents of domestic violence by Mr. Sivana towards Ms. Batson. At the

time of removal, Billy reported to Mr. Fawcett that he remembered seeing Mr. Sivana choke his

mother on the floor and that he tried to fight Mr. Sivana off. From Mr. Fawcett’s report, Billy

reported that “I know when Adam and mom are going to fight because mom always turns up the TV

in their room really loud but I still hear things breaking.”



Case Scenario: Billy and Mary

Billy and Mary are currently in a kinship foster placement with their maternal uncle, Dudley Batson.

Mr. Batson reported that when the children were placed with him they were “like two zombies” and

had difficulty speaking to anyone. He stated that he is concerned mostly about Billy. He stated he is

worried about two main problems for Billy. First, he is concerned about his aggression and acting

out at school. He stated Billy will get in fights with other boys at school and does not listen to his

teacher. Mr. Batson reported that these problems are not present at home. Second, he reported that

Billy will “zone out” for long periods of time. He stated Billy will not talk about any incidents of the

abuse at this point in time but that he talks for long periods of time about a fantasy world he has

created where he is a superhero called Captain Marvel and his best friend is an imaginary tiger named

“Tawny”. Mr. Batson is worried that Billy may have emerging schizophrenia. When asked about his

concerns regarding Mary he stated that she tends to be quiet and does not seem to have any

problems at this time. He stated she is struggling in school (e.g., her teachers report difficulties with

academics) but that her teachers say that “she is one of the quieter ones” and does not present with

disruptive behaviors at home or school.

Case Scenario: Billy and Mary

When speaking to the children neither of them endorsed any suicidal or homicidal ideation or

current child abuse or neglect. When Billy was asked why he was brought in to the clinic he said

“Cause I get in fights.” When asked by the therapist if there was anything that bothered Billy, he

said “I’m afraid Adam will come back to hurt Mary and Uncle Dudley.” When Mary was asked why

she was brought in to the clinic she stated she did not want to answer the question and became

tearful. When asked if there was anything that bothered her, she said “monsters in my dreams.”

Happy Memories

1 y.o. 12y.o. 6 y.o.

Hard Memories


house” – 11 y.o.

“Moved in with Uncle

Dudley” 11 y.o.

[December 2014]

“First time I

remember Adam hit

mom.” 5 y.o.

[Summer]



How to structure the TN

• Make sure to do the following

• SUDs check-in

• WRITE IT DOWN

• Cool down

• Use a timer if necessary

• The rule is “As long as we are working the timer stays on”

• NEVER finish in the middle of a SUDs max out

The Two Cornerstones of Good TN’s

• SPECIFICITY

• Bad specificity: “I was beat and saw my mom hit and oh ya there was that one time I saw a guy shot.”

• GOOD specificity: “It was last summer when I was 10. It was after school. I walked in and shut the door and could hear yelling. I went in the living room and saw my dad with his hands on my mom’s neck. She was gagging.”

• COHERENCY

• Bad coherency: “When the police showed up they had like vests on. And my foster mom ended up being nice but my mom went to jail and my mom was cooking meth. The cops kicked the door and it was scary but I got to go to a nice home so it’s okay”

• GOOD coherency: “The first thing I heard was the police yelling. They said, ‘come out now’. They didn’t wait cause they broke the door with like a big battering ram. My mom grabbed a gun, started shooting when the door broke.”

Who, What, When, Where Beginning, Middle, End

How to structure the TN

• YOU must be at least 3 steps ahead of the family at all times

• Notice we are almost 20 slides in and we are just NOW talking about chapters

• That’s because the key to a good TN is PREPARATION!!!

• YOU must know what the structure will be like BEFOREHAND

• Usually chapter format but other formats are possible

• Usually will add in a Neutral Narrative

• Neutral Narrative Type 1 = A Happy Memory

• Neutral Narrative Type 2 = Before the Trauma



Pop Quiz

• How would we structure the following TN’s (i.e., how would each chapter

look?)

• One Trauma

• 5 Trauma’s

• Complex Trauma

One Trauma

• Chapter 1 = About Me

• Chapter 2 = Happy Memory (NN Type 1) OR Before the Trauma (NN Type 2)

• You can do a Chapter 2A (Happy Memory) AND a Chapter 2B (Before the Trauma) for

highly avoidant kids

• Chapter 3 = The Trauma

• Chapter 4 = Final Chapter

• Variations = What I’ve learned? What I would tell other kids who have gone through

trauma? What I want my future to be like? Etc.

Multiple Traumas• Chapter 1 = About Me

• Chapter 2 = Happy Memory

• Caveat – with some kids this can QUICKLY turn into a chapter 3

• Chapter 3 = Bronze Medal

• Chapter 4 = Silver Medal

• Chapter 5 = Gold Medal




You got this

from the

timeline



Important points• First, if/when kids have problems with the TN, do NOT give up; just add

structure

• Second, ALWAYS make sure to check in with the caregiver about how the child is doing outside of session

• Homework becomes fun activities for the family to do together

• Third, retype these AS SOON AS POSSIBLE

• Also use this time to plan what your questions will be for next session

• Last, the final chapter is your DOVETAIL into Cognitive Processing

• Depending on how you set it up, you may be able to process the majority of maladaptive cognitions if you do it right

Complex Trauma (cause this is a whole other

presentation in and of itself)

• First, complex trauma and complex history are NOT equivalent

• A single incident of rape could result in complex trauma

• And 20 incidents of physical abuse can result in standard PTSD

• The child has internalized VERY core beliefs and now picks out experiences that support those beliefs (so this becomes much harder to process)

• Second, you have been collaboratively identifying themes THROUGHOUT the PRAC components (you CANNOT start to try and identify them at session 10)

• Third, for TN with Complex Trauma, you become a lawyer

• “So your Bronze Medal Theme is ‘Everyone will leave me.’ Okay Billy, let’s be lawyers. Start telling me your exhibits A, B, C, D, etc of why you have a strong case for that.”

Complex Trauma• Chapter 1 = About Me

• Chapter 2 = Happy Memory

• Caveat – with some kids this can QUICKLY turn into a chapter 3

• Chapter 3 = Bronze Medal THEME

• Chapter 4 = Silver Medal THEME

• Chapter 5 = Gold Medal THEME






Example Q’s Used to Facilitate TN

Development

• What time of day was it?

• Who else was home?

• What did you do after ____ stopped?

• What did your body feel like when ____ ?

• Where on your body did ____ touch/hit you?

• What part of ____’s body did he touch/hit you with?

31


Development

• What did ____ say to you?

• How long did it last?

• What did ____ face look like?

• 5 senses

• Your fall back questions are always

• Tell me more.

• What do you mean?

• Then what happened?32


Development

• I always add in the following questions at the end of TN

• What was the hardest part about this memory?

• What part do you think about the most now?

• What part did you think you would never tell anyone?

• The reason is you’re looking for the hottest spot of that memory

33



What do I say when we start?

• You’ve learned a lot so far about upsetting/confusing events, feelings, coping, relaxation, and thoughts. Congratulations! These are all important things that will help you as you begin to tell about the upsetting/confusing event(s) that happened to you. You get to decide where you want to start and how you would like to tell your story. If you start feeling strongly upset, you can stop, and I will help remind you of ways to manage your feelings. You’re in charge!

• I straight stole this from the TF-CBT workbook

• You said that the third hardest thing that happened was when your mom and dad got in a fight last Christmas. Start at the beginning and tell me so I can see it through your eyes. I’ll start writing when you start talking.

• I’ve also used “I wasn’t there so help me to see it as if I was right there beside you”

Draft 1- Billy

I was at home with Mary and we were watching TV. We always have to watch TV because

mom can’t afford a babysitter. I was eating Teddy Grams and telling Mary to be quiet because

mom and Adam were fighting in the next room because their TV was loud. Then the door

opened and mom ran out. Mom ran fast. Adam ran too. I told Mary to hide under the bed

and I ran too. I saw mom on the floor and Adam was on top of her. I ran at Adam and he hit

me. He hit me hard but I should have still gotten up. Then the police showed up and took

Adam and mom away. Mary and me went to stay with Mr. and Mrs. Vasquez for a little while

then we went to live with Uncle Dudley.

Where do you want to go with Draft 2?



Draft 2-3 - Billy

I was at home with Mary and we were watching TV. [Q-Where were you at home?] We were

in our bedroom and were having lunch. It was a Saturday cause we didn’t have school. [Q-“What

were you watching?”] I was watching Justice League because I like superheroes and I’m a superhero

too. We always have to watch TV because mom can’t afford a babysitter. I was eating Teddy

Grams and telling Mary to be quiet because mom and Adam were fighting in the next room

because their TV was loud. [Q-Tell me more about that] Whenever mom and Adam have the TV

really loud it means they’re fighting or gonna fight. They always do that. Then the door opened and

mom ran out. [Q-Feeling and Thought] I felt scared at a 8. I was thinking “Something really really

bad is gonna happen,” and “Mary might get hurt. I have to protect Mary cause Captain Marvel would

protect his sister.” Mom ran fast. Adam ran too. [Q-Feelings and Thoughts] I was really really

mad at a 10. My head was saying “Adam shouldn’t be hurting my mom and I’m not going to let him.

It’s my job to fight bad guys and he’s a bad guy.”

Draft 2-3 – Billy (cont.)

I told Mary to hide under the bed and I ran too. [Q-Feelings and Thoughts] I was scared at a

10 because if Mary got hurt it would be my fault. I was also mad at a 10 too because I knew I

was going to have to fight Adam. I thought “Adam’s a bad guy and I’m a good guy. I won’t let him

hurt people anymore.” I saw mom on the floor and Adam was on top of her. [Q-Tell me

more about that.] He had his hands around her throat. I got really scared when I saw that and

couldn’t move for a little while. [Q-1-10] I was scared at 10. I know that’s bad cause Captain

Marvel wouldn’t be so scared he couldn’t move. I could hear mom making a sound cause she was

trying to breathe and Adam wouldn’t let her. She was trying to scratch his face but he didn’t move.

He looked really really mad. I ran at Adam and he hit me. [Q-He hit you?] Ya, he hit me with his

fist in the mouth. I started bleeding cause he busted my lip. I didn’t like how my blood tasted so I

spit at him. Then he hit me again with his fist and I couldn’t get up. He went back to choking my

mom after that.

Draft 2-3 – Billy (cont.)

He hit me hard but I should have still gotten up. [Q-Feelings and Thoughts] I felt stupid at a 10

cause I couldn’t stop him and I guess I also felt mad at a 10 too cause I couldn’t stop him. I thought,

“I hate you!!!” and “I’m going to kill you!!!” [Q-What happened next?] I saw Adam’s phone near

the table. I think it fell out when he and my mom were fighting. I picked it up and crawled under the

kitchen sink and called 911. Adam couldn’t see me. [Q-Feelings and Thoughts] I was scared at a 10

and sad at a 8. I was thinking “I think my mom is dead.” But I called the police because I promised

Mary if Adam hurt mom again I’d call them. Then the police showed up and took Adam and

mom away. Mary and me went to stay with Mr. and Mrs. Vasquez for a little while then we

went to live with Uncle Dudley.



The 3 Reasons Susan Will Cut You• If you do not CHECK SUD’s

• If you do not WRITE DOWN (or in some way document)

• If you PROCESS

Then this is the last thing you will see

Time to Practice – TN Draft Practice

Draft 1- Mary (Bronze Medal)

Billy and I were in the car. Mom took us to find Adam. We

were at a gas station for awhile waiting. Adam worked at a

truck place where they deliver stuff. Mom said, I know

that, I don’t want to say cause it’s a bad word, he’s cheating

on me. That’s what she said. Adam was walking to his car

and he saw mom across the street. He was super mad she

was there. That’s when he started hitting her. There was

lots of blood. Then the cops came. She went back to him.

She always does.



Caregiver Trauma Narration Conjoint Prep

• Preparation is your friend

• The Conjoint Session is 80% complete BEFORE the child and parent

ever walk in the room together

• You are NOT watching a movie, you are DIRECTING a movie

• Therefore be very directive in both the child prep, caregiver prep, and in the

actual session

• The Conjoint Session is a GREAT place to address and restructure

maladaptive cognitions


• Step 1: Review TN with child to determine which parts to share with caregiver

• DO NOT ask “Can I share it?”; Ask “Any parts you don’t want shared?”

• If the child says “NO!!!” review with them why

• Sometimes they have valid reasons

• Oftentimes they are afraid they will get in trouble

• Create a PG version (Parent Guided Version) collaboratively with the child

• LAST resort is you can share the neutral narrative and final chapter

• Majority of the time they say, “Ya, it’s okay”


• Step 2: Review selected TN pieces with caregiver prior to conjoint session (you’re doing a LOT of work here)

• What does the caregiver think the child will need to hear from them or experience to feel positively about the TN process?

• What does the caregiver, him/herself, need to navigate this process

• The session with you and the caregiver alone is the time for them to yell and scream, NOT when the child is in the room

• Check in with the caregiver on their SUDs (You are running this EXACTLY like a standard TN session)

• Remember the obvious things

• For example, the caregiver should tell the child “I love you” or “I’m proud of you”

• WRITE THIS DOWN




• Step 3: NOW you have permission to bring them in

• STILL run this EXACTLY like a TN session SUDs check in, cool

down, etc.

• At any point you can pull the rip cord (but ONLY do this if absolutely

necessary)

• You’ve already written down everything, so this is actually the easy part

Time to Practice – Step 2 Caregiver Prep

YOU WILL NEVER HAVE A CONJOINT

PARENT CHILD SESSION THIS HARD

Information about TF-CBT and a map of Oklahoma

treatment providers can be found on our website:

www.oklahomatfcbt.orgChild Study Center Number

Natalie Gallo, Roy Van Tassell, and Michael Gomez

405-271-5700

Ask for Child Trauma Services (CTS)

http://www.oklahomatfcbt.org/

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