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What is Trauma?

• A stressful situation which overwhelms an individual’s coping mechanisms and causes a sense of disconnection from IDD and Trauma: Adaptations of feelings of control, connection, and meaning • Trauma may lead to symptoms of post-traumatic stress or a diagnosis of post-traumatic stress disorder; not everyone who TFCBT and CBT for Depression experiences trauma develops PTSD • A traumatic response is a normal response to an abnormal situation Bob Werstlein PhD • Different Types of Trauma – Accidents, Natural Disasters, Illness verses Interpersonal, Daymark Recovery Services Relational/Attachment Trauma – “Big T” versus “Little t” Trauma – Simple versus Complex Trauma

Prevalence of Trauma Among Children Prevalence of Trauma Among Women

• 60 % exposed annually • Lifetime prevalence 51%(6% men), • 3.5 Million CPS reports, 794,000 substantiated 10%(5%)develop PTSD annually in US • Severe physical/sexual abuse in homeless 91% • In NC, 5000 sexual abuse and assault cases • Sexual assault during military service 33% reported to law enforcement, 1,000 of each • Lifetime prevalence of domestic violence 44% substantiated annually • Robbery victimization 1-4 per 1,000(2-4 men) age 12 and older • Aggravated assault 2-4 per 1,000(3-4 men)

Prevalence of Trauma Among MH SA Public Sector Populations Prevalence of Trauma Among IDD • Exposure to multiple traumas 90% • Underreported due to lack of communication, • History reported by 75% of SA clients credibility, and inability to make a report • 55-99% of women in SA treatment • More likely to experience trauma, especially • 85-95% of women in MH treatment physical and sexual abuse in adults and kids • • 11-38% of men)33-59% of women) in SA 2.5 to 10 X higher rates of child maltreatment treatment have PTSD and SA Dx • PTSD rates from 2.5 to 50% • Interpersonal violence/crime rates 4-10% higher than general population

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IDD and Trauma: Increased Prevalence of Trauma Among IDD Vulnerability • Lifetime prevalence of sexual abuse 90% and • IDD clients are trained to be compliant, 10 or more abusive incidence 49% dependent on care givers for long periods of time, inadequate supervision, a strong desire • 44% had relationship with abuser related to for acceptance and fear of rejection, social IDD isolation, impaired communication or • Child maltreatment evident in 10-25% of all mobility, cognitive delays limit understanding IDD of what is happening, easier to manipulate, less critical thinking, less likely to receive sex education and recognize sexual abuse, discrimination, poverty and more comorbidity

Examples of Trauma More Likely for Examples of Trauma IDD Clients • Sexual Abuse and assault, physical abuse and • Neglect or omission of adequate, accidents, assault, community and domestic violence, bullying, hospitalizations, restraints, historical or intergenerational violence, withholding, stealing or overdosing serious accidents, unexpected loss of loved medications, financial abuse, relocation, hate one, medical procedures or conditions, war crimes, caregiver relationship transitions, and terrorist attacks, institutional abuse, violence at the hands of housemates or second hand exposure caregivers or witnessing such

Increased Health/Social Problems with Adverse Childhood Events(ACE) Higher ACE Scores • Emotional abuse, emotional neglect • SUD, Depression, suicide attempts, early • Physical abuse, physical neglect initiation of sexual activity, adolescent and • Sexual abuse unintended pregnancy, SDT’s, multiple sexual • Drug addicted or alcoholic family member partners, risk for intimate partner violence, • Incarceration of a family member early initiation of smoking, • Loss of parent to death or abandonment • COPD, Fetal death, ischemic heart • MI, depressed, or suicidal family member disease(IHD), liver disease • Witnessing domestic violence against mother

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Negative life Events More Prevalent for Factors Effecting The Response To IDD Clients Trauma • Staffing changes, people moving in and out of • Previous trauma experience(s), coping skills of positions, periods of time covered by non regular the victim prior to the experience, the nature caregivers, separation from family/caregiver, serious injury or illness, death of close friend of of the trauma, how close to the trauma, relative, moved house or room or changes in relationship to the abuse or victim, perception decorations or furniture, increased arguments of the person involved about the experience, with others, change in daily routine, subjected to chronicity and severity of the trauma, level of verbal abuse, witnessed physical violence or stress of life experiences at the time of the verbal abuse, medication changes, physical trauma, response of the support system to the restraint or violence event

Increased IDD Vulnerability to Effects Increased IDD Vulnerability to Effects of Trauma of Trauma • Limited range of coping/adaptation skills • Less social support or ability to gather such • Less experience in managing negative life • Fewer protective factors that would limit the events effects of trauma(i.e. effective parenting or • Early separation from parents or family system caregiver supports, social connections, good communication, problem solving, and self stress may limit stress management ability regulation skills, positive beliefs about self, beliefs • More vulnerable to stress related thoughts, that life has meaning, spirituality/faith, feelings, and behaviors socioeconomic advantages, pro-social peers and • Decreased psychological flexibility friends, stable and safe effective communities

Effects of Trauma: Neurological Effects of Trauma: Biological

• Trauma activates stress hormones and • Somatic complaints, sleep disturbance(DFS, neurochemicals which acutely results in flight, nightmares), headaches, urological problems, fight or freeze and chronically changes brain stomach aches, fatigue, forgetfulness, functioning and structure due to confusion, concentration problems, neuroendocrine system impacts, over activation of HPA axis in the brain and flashbacks, sexual numbing, increased flight, constant production of stress hormone fight or freeze response, and chronic health cortisol, and impact on emotion and fear problems response(amygdala) and memory(hippocampus)

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Effects of Trauma: Emotional Effects of Trauma: Cognitive

• Shock, numbness, restricted range of affect, • Distrust of others or expectations they may be disconnectedness, fear, anger, impatience, harmed by everyone worry, anxiety, sadness, depression, • Overestimation of and preoccupation with powerlessness, ineffective, overwhelmed, danger untrusting, unsafe, inner turmoil and pain, self • Low self esteem and self blame blame, self doubt, shame, and secrecy • Helplessness and hopelessness about the future • Shame, stigma, or survivor guilt

Effects of Trauma: Behavioral Effects of Trauma: Social

• Crying, agitation, irritability, rage, passiveness, • Isolation detachment, over working, diminished interest in activities, self injurious relationship strains/dysfunction, neglect of behaviors, suicidality, reenactments(right the responsibilities, poor or overprotective wrong), disassociations, risky, impulsive parenting, feeling unlikable or strange in social behaviors, compulsive behaviors, problems situations, avoidance of sexual or trauma with eating, rigid behaviors, substance abuse, related activity, passive avoidance, disengaged and panic/phobias from the dating process, and re-victimization

Trauma and PTSD in the IDD Client Effects of Trauma: IDD

• Symptoms overlooked due to attributing • PTSD symptoms more like those in children behaviors to IDD(diagnostic overshadowing) • Behavioral reactions-regressive or aggressive • Assessment is difficult due to receptive and • Inappropriate or unusual statements, expressive language deficits stereotypical behaviors, inappropriate speech, • Age and developmental level influence reduced self care, reduced adaptive behavior expression of PTSD symptoms and ability to • Reenactments-repetitive themes or aspects of cope with trauma the trauma expressed in interactions with • Higher IQ-greater ability to avoid exposure others played out as victim or victimizer to • More vulnerable to PTSD and trauma effects gain mastery or control over the experience

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Effects of Trauma: IDD Effects of Trauma: IDD

• Interpersonal disruption-avoids connecting or • Interpersonal disruption-aggression-bold or relating-worries about who is working, secretive acting out including aggression repeated statements about unrelated events, toward self, others, property or pets, testing inability to assert or protect oneself, distant, and breaking rules, and increased impulsivity preoccupied and daydreaming, phobic mannerisms to avoid cues or situation that • Exacerbation of pre-existing psychiatric trigger unpleasant sensations or memories, conditions(i.e. depression, panic disorder) refusal to participate in activities or work without reasons, decline in skills after prior gains

Key Developmental Capacities Shaped Key Developmental Capacities Shaped by Trauma by Trauma • Ability to modulate, tolerate, or recover from • Capacity for self soothing extreme affect states • Ability to initiate or sustain goal directed • Regulation of bodily functions behavior • Capacity to know emotions or bodily states • Coherent self, identity • Capacity to describe emotions or bodily states • Capacity to regulate empathic arousal • Capacity to perceive threat, safety or danger

Traumatic Stress Symptoms Traumatic Stress Symptoms

• Re-experiencing-thoughts and feelings pop • Increased arousal-always afraid something bad into one’s mind, reliving what happened, feels will happen, more easily startled/jumpy, trouble like it’s happening again, get’s upset at with sleep or concentration reminders • Dissociation-things feel unreal, like a dream, • Avoidance-tries to block it out and not think trouble remembering parts of what happened about it, to stay away from reminders, feels • Flashbacks, hyper-vigilance, terror, anxiety, numb or no emotions difficulty with problem solving, numbness, depression, SA, self injury, eating problems, poor judgement, repeated victimization, aggression

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Symptoms as Adaptations Symptoms as Adaptations

• The event is over but not one’s reactions • Ask what purpose does the symptom serve • The intrusion of the past into the present • Every symptom helped one cope in the past presents as distressing intrusive memories, and is still in the present in some way flashbacks, nightmares, or overwhelming • If we understand how the behavior is emotional states adaptive, we may be able to substitute a less problematic behavior • Re-experiencing is the key to many symptoms • One instinctively uses the same self protective • Symptoms represent an attempt to cope they coping strategies(i.e. hyper-vigilance, best they can with overwhelming feelings dissociation, avoidance, numbing)

Trauma Informed Care General Recommendations

• Trauma informed refers to all of the ways in • Recognize the primacy of trauma, expect it, which a system understands trauma and the incorporate knowledge about trauma into all ways to be responsive to the impact of aspects of care, be hospitable and engaging, traumatic stress and thus decreases the risk of ask respectably and be prepared to listen, see re-traumatization as well as contribute to symptoms as attempts to cope and survive, recovery from traumatic stress see both vulnerabilities and strengths, our primary goal is to empowerment and recovery, avoid re-traumatization, and coordinate care/case manage

Core Principles of Trauma Informed Care IDD Screening and Assessment TIC • Awareness-knowing the role of trauma • Identify trauma history as early as possible. • Safety-ensuring physical and emotional safety Such is complicated by lack of preparation of discomfort by clinician, challenge of rule out • Trustworthiness-making tasks clear and of symptoms that may present as anxiety or maintaining appropriate boundaries depression, client’s shame, secrecy, or denial • Choice-respect /prioritize choice and control of trauma, or co-occurring SUD often seen as primary • Collaboration-share power as we can • Universal screening that is relatively brief/ non • Be Strength-based versus punitive threatening of client and through caregivers

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IDD Screening and Assessment TIC IDD Screening and Assessment TIC

• Develop rapport and trust • Remain non-judgmental, sensitive, and patient • Give explanation of prevalence data as • Identify risk behaviors and help explain client rationale for questions to remove sense of behavior through lens of what has happened isolation and shame • Get input from client for treatment goals • Ask about witnessed violence physical abuse, designed to reduce the negative impacts of sexual assault or unwanted sexual touch, trauma on client’s life threatened violence etc. inform client of • Symptoms can impact behavior, judgement, reasons to set limits on disclosure school/work performance and social connections even if subthreshold for Dx

IDD Screening and Assessment TIC: Questions Assessment for PTSD in IDD Clients • Can you tell me a little bit about what • Difficult due to diagnostic overshadowing and happened to you? Where would you like to lack of standardized instruments other than begin? In what ways do you feel your DM-ID Fletcher et al 2007 experience continues to effect your daily life? • Caregivers are not able to report as they don’t How do you cope with your experience? have the information or do not recognize When you had this experience, did you think events as traumatic you would be seriously hurt? Do you dream or • Differential diagnosis is essential as have nightmares about what happened? Do misdiagnosis is possible such as autism, IED or you ever feel like it is happening all over schizophrenia again? What reminds you about it?

PTSD Assessment Tools in Research Assessment for PTSD in IDD Clients with IDD Clients • May need to rely on others to recognize • The Lancaster and Northgate Trauma Scale significant departures from baseline behavior • Bangor Life Events Schedule for ID(BLESID) that may signal a traumatic response • Pediatric Emotional Distress Scale PEDS • Time delay between trauma and • Behavior Problems Inventory BPI manifestation of symptoms can complicate • Adaptive Behavior Scale-residential and diagnosis, temporal factors are relevant community SABS • Ward Anger Rating Scale WARS • The Brief Symptom Inventory BSI • Impact of Events Scale IES

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Effectiveness of TIC with IDD Avoid Re-traumatization

• Violating boundaries, breaking trust, unclear • Better subjective health and lower prevalence expectations, inconsistent rule enforcement, of chronic illness among women with co- chaotic treatment environment, rigid agency occurring disorders policies that preclude safety, obtaining UDS in • Marked reductions in use of restraints and non private manner, disruption in routines, seclusion in psychiatric care for kids disrespectfully challenging the client’s report • Increased client satisfaction staff patience and of trauma, labeling rage or other feeling about consistency and ability to deescalate, and the trauma as pathological, minimizing, decreased counter aggressive actions between discrediting, or ignoring client feelings, clients and staff (Keesler 2014) unnecessary staff changes

Trauma Specific Interventions When to Start Trauma Treatment

• Interventions designed to address violence, • No major current crisis or instability, client is trauma, and related symptoms using safe coping skills and wants to do this • Goals to increase skills that allow clients to work, reaches out for help when in danger, better manage symptoms and reactions and not using substances such that emotionally to eventually reduce debilitating symptoms upsetting work may increase use, suicidality and prevent further traumatization or violence has been assessed, system of care is stable and consistent, and staff are available with formal training

Key Messages in Trauma Recovery Providing TIC

1. It is not happening now- The trauma is over. It is in • the past. You are here in the present To the best of your ability and within your 2. You are safe-The adults here are responsible for your given time constraints-Loose the labels, let her safety and you are worthy of care and protection tell her story, give her time and space to tell 3. You are not inherently dangerous/toxic- What is her story, let her lead, respect her voice and inside you (thoughts, feelings, dreams, impulses, etc.) cannot hurt you or others choice, recognize her perspective and cultural 4. You are good-Whatever you have experienced and context, offer support and whatever you have had to do to survive, you are a good, strong person who can contribute to your validation(communicate care and concern, community avoid passing judgement), ask questions, 5. You have a future listen to what she has to say, offer information and assistance

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Increase Protective Factors and 10 Foundations for Safe Trauma Therapy Resiliency From Trauma Essentials by Babette Rothschild • Environment-A reliable support 1. First and foremost: establish safety for the client within and outside therapy. system(friend/family), access to safe and 2. Develop good contact between therapist and client as stable housing, timely and appropriate care a prerequisite to addressing traumatic memories or • Behaviors-good self care(sleeping , eating, applying any techniques—even if that takes months or years. exercise, practicing good boundaries, using 3. Client and therapist must be confident in applying the positive coping strategies) “breaks” before they use the “accelerator.” • Traits-a sense of meaningfulness, internal 4. Identify and build on the client’s internal and external locus of control, perspective to see change as resources. 5. Regard defenses as resources. Never get rid of coping a challenge, a vigorous approach to life strategies or defenses; instead, create more choices.

(Rothschild, 2011, pp. 13-16)

10 Foundations for Safe Trauma Therapy Special Considerations with Sexual From Trauma Essentials by Babette Rothschild Trauma Survivors

6. View the trauma system as a pressure cooker. Always work to reduce • Men and women are statistically equally likely to have —never to increase—the pressure. experienced some form of sexual abuse; Males are less 7. Adapt the therapy to the client, rather than expecting the client to likely to disclose adapt to the therapy. This requires that the therapist be familiar with • Female perpetrators are more common than we think several theory and treatment models. and a man CAN be raped by a female 8. Have a broad knowledge of theory—both psychology and physiology • Shame is especially high in this population of trauma and PTSD. This reduces errors and allows the therapist to • The body’s natural response/reflex to sexual touch create techniques tailored to a particular client’s needs. frequently needs to be addressed to reduce shame 9. Regard the client's individual differences, and do not judge for noncompliance or for the failure of an intervention. Never expect on • Disruptions in sexual activity are common (hypersexual intervention to have the same result with two clients. vs. little/no sexual interest) 10. The therapist must be prepared, at times—or even for a whole course • Not every person who has a “non-consensual” sexual of therapy—to put aside any and all technique and just talk with the experience views this experience as traumatic client. (Rothschild, 2011, pp. 15-16)

Trauma Specific Treatment Integrated Treatment for Trauma and Models(none normed for IDD) SUD • Cognitive Processing Therapy CPT • A Women’s Path to Recovery • Trauma Focused CBT • Alcohol Behavioral Couple Therapy ABCT • Exposure Therapy • Boston Consortium Model Trauma Informed • EMDR SA Treatment for Women • Skills training in Affective and Interpersonal • Forever Free Regulation • Helping women Recover and Beyond Trauma • Stress Inoculation Training • Seeking Safety • Narrative Therapy • Trauma Recovery and Empowerment Model

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Adaptations of Evidenced Based Treatment for IDD CBT for IDD • A Manual of Cognitive Behavior Therapy for • A Manual of Cognitive Behavior Therapy for People with Learning Disabilities and People with Learning Disabilities and Common Common Mental Disorders Mental Disorders-Therapist Version, Angela • TFCBT Hassiotis, Marc Serfaty, Kiran Azam, Sue • EMDR Martin, Andre Strydom, Michael King, • • DBT Camden & Islington NHS Foundation Trust and University College London, 2012

CBT for IDD and Depression or Anxiety CBT for IDD and Depression or Anxiety

• Several studies have concluded that people with • The individual’s level of comprehension, level learning disabilities have the necessary of expression, ability to self-report, and self- prerequisite skills to engage in many of the interventions associated with CBT (Dagnan et al, regulation skills are important factors in their 2000; Joyce et al, 2006; Sams et al, 2006). These suitability for CBT skills include the ability to link situations to emotions (Dagnan et al, 2000); the capacity to differentiate between thoughts, feelings, and behavior (Sams et al, 2006); and an aptitude for correctly identifying emotions (Joyce et al, 2006)

CBT General Adaptations CBT General Adaptations

• Be more specific and didactic and present key • The involvement of a caretaker or support concepts in extremely concrete ways worker is essential in assisting the client to • Provide extra support in the form of visual move successfully through the program as aids such as pictures, drawings, and signs for they assist the client with homework certain tasks such as mood monitoring, assignments and help the client bring this presenting temporal concepts, and identifying material into sessions automatic negative thoughts • Take therapy at a slower pace, using repetition, and encouraging “overlearning”

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Communication Tips Communication Tips Being Understood

• If you do not understand, it is important that • Use simple, straightforward, everyday you do not pretend to have understood language and limit the number of key concepts or ideas you communicate to no • Give the person plenty of time to respond more than three per sentence • Listen carefully • Use concrete examples, simple sentences and • Look at the person when he or she is talking language • If you still cannot understand, ask the client if • Use context as communication constantly it is okay to ask the support worker for help • Regularly asking them to summarize or repeat with communication what has been discussed

Communication Tips Being Understood Communication Tips

• Speak slowly using everyday words • Agree to a short two-to three minute talk on the • Think about how to ask questions subject he or she wishes to discuss, then go back • Link your explanation with everyday things to the topic at hand • Write the key information down • Socratic questioning may help the reluctant client • Use pictures or symbols express thoughts, feelings, ideas, and beliefs • Focus on non-verbal communication • Be sensitive to any cultural issues the person may • If facing echoed speech or perseveration, be have with regard to eye contact, personal space, patient, suggest a break, distract the client, or and gestures that may have different meanings shorten the session than what you are accustomed to

Communication Tips CBT Treatment Protocol

• Avoid leading questions and keep • Three Phases suggestibility at a minimum • Early/initial phase (sessions 1–4) • Make sure clients understand what has been • Middle phase (sessions 5–14) said and give clear instructions without • Final phase (sessions 15–20) leading them

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Phase I Goals Goal 1 Assess Language and Suitability

• Complete a language assessment and evaluate • Assess cognitive level and language skills-Test the client’s suitability for CBT for the Reception of Grammar TROG 2 • Explain the role and extent of involvement of the support worker in therapy to the client • Assess memory, reading ability, writing ability • Address the reasons the client has been referred • Assess Attentional control and perceptions • Describe the CBT model of treatment and the about how much he or she controls and importance of homework influences events in life • Confirm that the client will attend all sessions • Assess the client’s motivation and willingness • Provide psychoeducation to engage in therapy

Goal 2 The Role of The Caregiver in Therapy Goal 3 Reasons for Therapy • Why including the caregiver is useful • Explain and elicit the client’s understanding of • The extent to which the caregiver will need to the emotional and behavioral difficulties(i.e. “I participate in sessions and homework am seeing you because I hear you feel • How much information the client is sad/scared/worried/etc.” comfortable sharing with the caregiver • Explore presenting complaints and the client’s • The caregiver will keep information perception of how much the problem affects confidential him or her

Goal 4 CBT and Homework Improve Homework Compliance

• Explain what CBT is, how it works, the • Involve the client in deciding what tasks he or rationale for treatment, what the aim will be, she will be doing outside the session what the rules of therapy are, and how important homework is during the process • Set tasks that provide a no-lose situation • Homework should be tailored to the client’s • Make sure the client understands the task and needs, relevant to the topics covered, build on the reason for doing the task skills practiced, and encourage the client to • Make sure the client understands the benefits engage in the kinds of changes necessary and importance of doing the homework tasks while still being realistic and manageable

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Homework Rating Scale Questions Homework Rating Scale Questions

• How well did the client understand what to do • How much did the task help the client gain and the reason for doing the task? control over his or her problems? • How well did the client do in completing the • Did the task help the client progress in therapy task? • If the homework task was not completed, you • How much of the task was the client able to do? should ask the support worker to fill out the • How difficult/easy did the client find the task? “Resource 2—Checklist of Reasons for Not • How much did the client enjoy the task? Completing the Homework Tasks and bring to • How well did the task match therapy goals discuss at next session

Homework Assignments Goal 5 Attendance

• Create a list of issues or problems that the client • Secure a commitment from the client to would like to address during therapy attend all the sessions • Complete a weekly activity schedule WAS • Sheet 1—What Is Cognitive Behavioral Therapy? • Use MI strategies such as developing • Sheet 2—Linking Thoughts, Feelings, and discrepancy, avoiding arguments, and Behaviors for Depression supporting self efficacy • Sheet 3—Linking Thoughts, Feelings, and Behaviors for Anxiety • Sheet 4—Linking Thoughts, Feelings, and Behaviors for Anger

Phase 1 Summary Psycho-education

• What skills does the client possess that will • Info Sheet 5—What Is Depression? help him or her? • Worksheet 3—When I Feel Depressed • Does the client understand what treatment • Worksheet 4—Good and Bad Things in My Life” entails? • Recommend the picture book Feeling Blue published by the Royal College of Psychiatrists • What materials and tasks can help the client website (Royal College of Psychiatry, 2009 to practice and improve these skills? • http://www.rcpsych.ac.uk/publications/booksbey • Does the client have any concerns or worries ondwords/bbwonlineversions/feelingblue/blueco about the treatment? ver.aspx

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Psycho-education Anxiety Psycho-education Anxiety

• Use an informational body map to illustrate • Info Sheet 6—What Is Anxiety? common physiological symptoms associated • Info Sheet 7—Signs of Anxiety (Body Map) • Worksheet 5—When I Get Anxious I Feel (Body with anxiety as well as a blank version that Map) allows the client to point to and discuss • Anger-keep an anger diary for a week so you and physical symptoms he or she experiences the client can begin to make the link between his when feeling anxious or her triggers and the resultant thoughts and feelings. The more the client can understand the links between what triggers his or her anger and how he or she responds to it, the more the client will feel able to manage it

Triggers to Anger in IDD Anger Management Strategies

• Problems with communicating feelings • Role-play to help the client try out new • Feeling misunderstood behaviors • • Gently challenge dysfunctional assumptions Feeling scared or intimidated and help the client to come up with a more • Believing that they can’t trust themselves due balanced view of a given situation to past experiences (e.g. a past example of • Behavioral-walk away, get calm, rethink reacting to a situation with anger and physical • Help the person recognize what he or she is aggression and worrying it might happen feeling and help him or her feel confident again) enough to communicate it effectively

Phase 2 The Middle Sessions 5-14 Session Format

• Discuss and work through different life situations and • Set an agenda with client how to better manage them • Manage anxiety and depression • Review the previous session • Discuss relaxation techniques and healthy living • Review Homework • Explore the client’s thoughts, feelings, and behaviors • Discuss and Address Problems: Set Goals and and establish the links between them Work Toward Resolution • Train the client to use alternative techniques to cope with negative thoughts and unhelpful behaviors. • Create goals that are specific, realistic, • Explore additional skills that will encourage the client position, can be monitored, and time limited to use CBT techniques independently • Worksheet 7—My Goal

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Session Format Foci of Treatment

• Establish Homework Task(s) for the Next • Relaxation and Healthy Living Session • Reducing Anxiety and Stress Levels: Using • Session Summary and mutual feedback Relaxation Techniques • Remind client of next session • Healthy Living Techniques-reduce caffeine, improve sleep habits, exercise, increase prosocial contacts

The Midpoint Review Linking Thoughts, Feelings, and Behaviors • Approximately halfway through this phase, • Begin by Discussing and Identifying Feelings- spend a session or two reflecting with the Resource 3—Image Bank-target simple client and the support worker about progress emotions being made in treatment and the client’s goals • Make the thought-feeling link-Work to for the remainder of treatment establish a set of examples from the client’s personal experience in which the client felt a particular emotion and a particular thought arose as a result

Linking Thoughts, Feelings, and Behaviors Specific Cognitive Techniques • Finally, Establish the Relationship Between • Identifying and Challenging Key Thinking Style Thoughts, Feelings, and Behaviors Errors • Unnecessarily focusing on negative thinking for • See table too long is detrimental to the therapeutic process • Worksheet 12—Unhelpful Ways of Thinking • Worksheet 8—Thoughts and Feeling Diary • Worksheet 13—“How I Am Thinking” Diary • Worksheet 9—Thoughts, Feelings, Behaviors • Worksheet 14—A Different Way of Thinking • Worksheet 10—Good Times • Worksheet 11—Bad Times

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Specific Cognitive Techniques Schemas Work

• Using the Survey Method to Challenge Beliefs • Worksheet 15—My Good Thoughts About Me • Schemas Work-negative schemas (attitudes and • Worksheet 16—My Thoughts About Me That Are assumptions) are formed due to an individual’s Not Nice negative experiences in childhood such as • Worksheet 17—My Worrying Thoughts About Me parental criticism, criticism from teachers, and • Worksheet 18—My Worrying Thoughts About peer rejection Things That Will Happen • Common Negative schemas-I’m a failure • Worksheet 19—My Good Thoughts About Things (self)Everyone thinks I’m stupid. (world), I’ll never That Will Happen be good at anything. (Negative view of the • Worksheet 20—Core Beliefs future) • Worksheet 21—My Core Beliefs

Addressing Anxiety States Specific Cognitive Techniques

• Worksheet 15—My Good Thoughts about Me • Guided Discovery-provide the client an • Worksheet 17—My Worrying Thoughts about opportunity to learn how to overcome Me problems that he or she has not come across • Worksheet 18—My Worrying Thoughts about before by applying his or her skills to such Things That Will Happen situations • Worksheet 19—My Good Thoughts about Things That Will Happen

Specific Behavioral Techniques Specific Behavioral Techniques

• Positive Reinforcement • Assign Graded Tasks • It is important to provide people with depression lots • Prepare a list of situations of gradually of praise, as they tend to focus on negative aspects of themselves increasing difficulty, assign these tasks over • Helping depressed people identify positive events is an time, and then ask the client to complete each essential step in the healing process, as they are likely task and monitor his or her mood or anxiety to view all events as negative while completing the task without running • Fundamentally, you need to work toward encouraging away or engaging in safety behaviors( people who are depressed to be nice to themselves, as behaviors aimed at preventing the feared they have likely internalized negative voices and this, in consequence from happening) part, drives the depression

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Specific Behavioral Techniques Specific Behavioral Techniques

• The client must stay with the situation until • Pleasure Predicting Experiments the anxiety reduces or the mood improves. • The aim is to challenge fortune-telling and encourage the client to see that predictions he or she makes are The biggest problem with exposure also excessively biased by emotions paradigms is that the client is liable to leave • Ask the client to describe activities he or she enjoyed the provoking situation when it reaches its prior to becoming depressed, list these activities, ask emotional peak. This negative reinforcement the client to predict how much he or she believes the said activity would be enjoyable now on a scale of 0- makes it much more difficult for the client to 100 percent, as the client to engage in the activity, ask engage in the provoking event the next time the client to rate how much he or she actually enjoyed the activity

Specific Behavioral Interventions Additional Skills

• Designing and Implementing Behavioral • Assertiveness Training Experiments • Info Sheet 8 - Assertiveness Scale. Parameters • Help clients test beliefs, recognize negative • Voice intensity (loud vs. quiet) thoughts and replace them with more positive • When to respond (impulsive vs. appropriate) ones, and build strategies to cope with • Duration of response (focused vs. lengthy) difficulties appropriately • Eye contact • Body language (threatening vs. appropriate) • Ability to listen (listening to others vs. talking constantly

Additional Skills Additional Skills

• Worksheet 22—How to Be More Assertive: • Social Skills Training • Role-plays of social situations Aggressive to Assertive • Behavioral experiments that get the client to engage with • Worksheet 23—How to Be More Assertive: people around them • Reframing thoughts so that clients don’t automatically Passive to Assertive assume people perceive them negatively • Picking up on positive stimuli from the people around them • Worksheet 24—How I Can Be More Assertive by keep records in positive data logs • Working to help the client understand that others may be empathic • Worksheet 25—Important People in My Life • Worksheet 26—Things People Like About Me

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The Final Phase Sessions 15-18 Ending Treatment

• Goals • Ask the client to list strategies he or she has • Summarize the key points covered in the learned and utilized to cope with depression treatment and anxiety and discuss ways in which the • Go over the main skills and strategies covered client can continue to use these techniques to manage future situations and events • Bring the treatment to an end • Discuss how the client feels about the • Address and put in place measures for relapse treatment process prevention

Possible Questions Phase 3 Final Sessions

• What have you learned from these sessions • After Treatment: Relapse Prevention • How do you think therapy has helped you? • Did you enjoy (and what did you enjoy about) the • Create a list of problems/situations that the treatment? client thinks may cause his or her symptoms • What have you learned about managing depressive thoughts? to recur, develop a list of cognitive and • What have you learned about managing anxiety? behavioral strategies to deal with them, • What strategies do you now have to deal with depression and anxiety? How can you use these strategies to better explain how to recognize and identify early manage depression and anxiety? signs of relapse to both the client and the • In what ways can you continue to improve your depression and anxiety management skills? Are there specific areas support worker that need improvement?

Adaptation to Trauma Focused CBT Phase 3 Final Sessions TFCBT • Worksheet 27—Things I Learned in CBT • Why TFCBT manual is good to adapt: It is • Worksheet 28—Important Things to strength based, focuses on development of competency skills, uses CBT techniques which Remember from My Work with the Therapist are easy to adapt for IDD clients, already • Resource 4—CBT Certificate structured for use across a wide range of developmental levels, focuses on greater resilience(i.e. strong self esteem, ability to self sooth, feelings of competency to deal with challenging situations, applicable for single episodeor complex trauma

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TF CBT TF CBT Format

• Before adapting TF CBT for IDD, staff should • Family Therapy Model be trained in TFCBT! http://tfcbt.musc.edu/ • Session generally divided between time with • Treating Trauma and Traumatic Grief in client, caregiver, and both together Children and Adolescents Cohen JA, • 90 minute session(shorten for IDD) Mannarino AP & Deblinger E 2006 New York • Sessions end with time to do something fun The Guilford Press together to allow the client to re-center before leaving

Who Can Act as Coach Phases of Treatment

• Parent, Group home staff, teacher, advocate, • Assessment any care giver involved with the client on a • Address safety issues regular basis willing to commit to regularly • Psychoeducation attending sessions with the client • Skills Development • Trauma Narrative • Trauma Processing • Reintegration

Assessment Safety

• NCTSN baseline trauma assessment-assess • Is the client in a safe environment, what is risk types and frequency of traumatic experiences for re-traumatization, does client need extra • Assessment of severity of trauma symptoms help in dealing with ongoing environmental (UCLA-PTSD Index or Trauma Symptom stressors(i.e. bullying, teasing etc.), are there Checklist) cognitive distortions that increase the current • Adaptations-include all significant caregivers, perception of danger assess for secondary trauma due to societal of community response(myth that client has not been impacted or can not benefit)

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Psychoeducation Skill Development

• Provide general education about impact of • Feelings identification trauma on normal functioning • Personalized relaxation skills • Provide specific information about the trauma • the client experienced in language that is Positive self talk understandable • Cognitive coping(cognitive triangle, • Teach about TF-CBT phases and how relationship between thoughts, feelings and treatment will progress behaviors) • Risk reduction-identify red flag situation, • Thought Stopping safety plan, increase assertiveness skills • Teach Caregiver as well

Skill Development Adaptations Trauma Narrative: Chapters to Include

• Restrict the number of feelings you teach • All about me, Chapter on how they entered Rx • Build a basic vocabulary • Use the baseline trauma assessment to guide • Use multisensory teaching tools • Work from least to most threatening trauma • Use lots of repetition in creative ways • Write all trauma components on slips of paper • Use lots of examples related to everyday life and draw one at a time to work on • Continue to present information in different • After all known aspects of trauma have been ways and be patient for understanding worked on, ask what was the worst part, don’t assume you know

Narrative Session Format Narrative Session Format

• Check in on client’s stress level at beginning of • Help caregiver deal with their own emotions, each session, if high, use skills to reduce it discuss any distortions caregiver is • With the client, review the narrative experiencing like unwanted self blame, developed last session, continue to use stress unrealistic expectations of what they can do, management skills as needed fears the client has been forever damaged • Add any new information that client brings up • End each session with fun time, this may be a • Go on to the next part of the trauma narrative group activity with caregiver or client alone • Spend time alone with caregiver and review information client produced in the narrative

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Narrative Adaptations for IDD Trauma Processing

• Be creative in the ways in which the narrative • Review the narrative, identify thoughts that is recorded(i.e. dictate responses, draw are not helpful and areas where thoughts and pictures, role play, sing or dance, sand tray, feelings are mission, identify places where the use play client’s thoughts are accurate and praise • Go slowly-more time is needed to absorb the them, add to the chapter on starting therapy information/integrate the modified cognitions and the progress the child is making • Repetition is essential for learning-client may return repeatedly to inaccurate or unhelpful cognitions

Trauma Processing Adaptations for IDD Re-integration Session Format

• Go slowly • Integration is usually done with client and • Provide lots of support caregiver together • • Begin by assessing the client’s and caregiver’s Review skills as needed readiness for this phase • It is especially important to use the cognitive • Remind about rational for these joint sessions triangle, identify cognitive distortions as • Reintegration rationale-the caregiver has the unhelpful thoughts, and then correct them in opportunity to demonstrate comfort in the narrative hearing and talking about the trauma while also modeling appropriate coping

Reintegration Rationale cont. Reintegration Sessions

• The client can share the narrative(communicating • The client shares the trauma narrative they openly)and experience pride further reducing have developed with the caregiver feelings of shame and distress • The caregiver praises the client’s hard work, • Communication about the trauma is enhanced asks open ended non threatening and misunderstandings and confusion is clarified questions(i.e. how did you decide to tell and the groundwork is laid for discussion of the someone what happened), and answers the trauma to continue after therapy ends(caregiver client’s questions(i.e. why is mom mad at me emphasizes desire to be helpful and supportive) because her boyfriend got in trouble)

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Integration TF-CBT Adaptations For IDD

• Client and caregiver discuss together lessons • Be sure all members of treatment team are learned, application of those lessons, the use using the same language to address trauma of affect regulation skills for other life • Simplify techniques to increase understanding stressors, and plans for the future • Work hard on generalization to other settings • Adaptations-be sure the client has sufficient • Allow more time/repetition for skill learning support in all environments, work on specific • ways in which new skills can be generalized to Use multisensory tools to aid in learning various situations in the client’s life • Don’t assume the material is too complex for the client to learn

Resources Questions

• www.seekingsafety.org • Sarah Dunagan LPA Regional Director 828-773- • www.samhsa.gov/nctic 7301 [email protected] • www.istss.org • Bob Werstlein PhD Licensed Psychologist • www.issd.org Training Director 980-621-8682 • • www.ptsd.va.gov [email protected] • www.sidran.org • www.nctsn.org

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