12 - Trauma/stress

Question 1

Explain how post-traumatic growth relates to positive psychology.

Answer 1

A lot of people would experience smt that would typically be a traumatic event, but they look back at it like “that’s smt that shaped me positively as a person”

Question 2

What is the PCL-5?

Answer 2

Post-traumatic stress disorder checklist
- Questionnaire that looks at different symptoms seen following traumatic events that are consistent with PTSD

Question 3

True or false: Most people who experience a traumatic event develop PTSD

Answer 3

False: Most do not develop PTSD
→ BUT you can develop a PTSD-like syndrome following an event that doesn’t meet criterion A (like a relationship betrayal)

Question 4

What does the word trauma stand for?

Answer 4

Wound
→ p.ex: trauma center in a hospital is a physical wound

Question 5

What does trauma do to the brain?

Answer 5

• Trauma blows out centers in the brain that are fundamental to your psychology, which leads to consequences
  → bad thing that happens to you that you don’t see coming, and you don’t fully have the internal structures to really understand it
  → it’s a big surprise that isn’t inscribed in your typical script

Question 6

We’re more vulnerable to traumas that are ___.

Answer 6

Personal;
→ we have a hard time understanding the experience we’re having
→ we have a hard time mapping on what this means for us now, what it means about the person, about the world, etc.

Question 7

Give an example of an especially vulnerable trauma experience for a child.

Answer 7

• A child witnesses his dad having frequent unpredictable allergic reactions – during one of these, the dad falls down the stairs and breaks his back, the ambulance comes
• Very scary because it involves a parent which is very primal
• Following this, the child becomes hypervigilant, starts taking on a lot of chores at the house, checking on his dad; if the dad coughs or scratches his skin, the child sees it as a danger and feels a lot of the same emotions felt during the actual event
• The child might develop beliefs about the experience
  → p.ex: “if i had just been there, I could’ve prevented him from breaking his back” “i’m responsible for his care and safety”

Question 8

What happens if a trauma is not addressed?

Answer 8

• If not addressed, your nervous system never calms down and continues to tell you you’re in danger, because you don’t understand what happened and why
  → p.ex; if someone breaks into your house but you don’t know how they got in, it scares you because you don’t know what to fix or adjust to make sure it doesn’t happen again

Question 9

How does PTSD look in the DSM (criterion)?

Answer 9

Criterion A: has to fit a narrow definition: smt where life is threatened (either your own or somebody proximate to you), can be real or simply experienced as life-threatening at the time, has to be physically or sexually violent
Criterion B: presence of one (or more) of the following intrusion symptoms associated with the event, beginning after the traumatic event occurred
1 - Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s
2 - Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s
3 - Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring
4 - Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5 - Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s
Criterion C: persistent avoidance of stimuli associated with the traumatic event beginning after the traumatic event has occurred
→ this is really hard to do, especially that even colours can trigger certain memories
→ this further increases the feelings and fear associated with the trauma
Criterion D: negative alterations in cognitions and mood
Criterion E: marked alterations in arousal and reactivity associated with the traumatic event

Question 10

What is cognitive processing theory?

Answer 10

• Talk about different types of emotions and we categorize them to help understand them
• Natural emotion is like a fire
  → the emotion is strong and lasts a while at first, but if you don’t add anything to it, the fire will die down naturally
  → this is how human grief reactions work (you still feel the loss, but you don’t feel the same intensity of the emotion every hour of every day), as well as other emotions
• Manufactured emotion
  → manufactured by cognitions and thoughts; the thoughts are the logs in the fire, and if you keep adding logs to this fire, the fire is not gonna stop burning; the intense emotions initially felt during the trauma will keep happening

Question 11

When something shocking happens to you that you don’t see coming, it’s normal to have…

Answer 11

• It’s normal to have a strong emotional reaction and to have tons of thoughts and beliefs and imagination to see what caused it to happen
  → it’s normal to have a bunch of PTSD symptoms after living smt shocking (dreams related, big emotional reactions triggered by cues, etc.)
  → but PTSD is when the natural recovery doesn’t occur possibly because you didn’t talk about ti with people enough, or the people that you did talk about it didn’t offer information that was helpful or true, which just fueled the fire and maintain guilt, shame, fear, terror, etc.

Question 12

True or false: People get mixed about when the events happened and the order of events

Answer 12

True: This can shift perspective

Question 13

What is a stuck point?

Answer 13

• Stuck points are thoughts that you have that keep you stuck from recovering
• These thoughts may not be 100% accurate
• Stuck points may be:
  –> Thoughts about your understanding of why the traumatic event happened
  –> Thoughts about yourself, others, and the world that have changed dramatically as a result of the traumatic event
• Stuck points are concise statements (but they must be longer than one word)
• Stuck points can often be formatted in an “if-then” structure: “if I let others get close, then I will get hurt”
• Stuck points often use extreme languages, such as “never”, “always”, and “everyone”

Question 14

How are assimilated beliefs different from overaccommodated beliefs?

Answer 14

• Assimilated beliefs: related to the past
• Over-accommodated beliefs: present and future

Question 15

What is the add on in traumatic stress treatment in comparison to anxiety treatment?

Answer 15

• Safety planning is added
• Trauma narrative is added

Question 16

How is traumatic stress similar to anxiety?

Answer 16

• Safety behaviours are very similar to anxiety behaviours here

Question 17

What is safety planning in trauma treatment?

Answer 17

• When someone has experienced smt very frightening, the first question is “how did this happen”, if you can’t really answer this question, the threat still remains
• A trauma is a true alarm (contrary to anxiety), so you want to establish if the trauma has stopped and will it happen again

Question 18

What is trauma narrative in trauma treatment?

Answer 18

• A story (like a book) about the trauma
• Start it off before the trauma actually occurs, then you lay the trauma out as if it was a story, and include the beliefs (this is how we find the stuck points)
• It’s a good way for the child and the parent to then talk about the event

Question 19

What is moral injury?

Answer 19

• When you violate your own values and you behave in some way that is contrary to it (whether on purpose or by mistake)

Question 20

What are the goals of safety planning?

Answer 20

• The child will understand how to maintain his or her personal safety
• The child, parent, and therapist will develop a plan to ensure safety in the present and future
• The child and parent will understand and follow the safety plan
  if time is right, your main objective is to develop a plan for the child’s present and future safety

Question 21

What are the materials used in safety planning?

Answer 21

• Fear thermometer and fear ladder (2 unrated copies, for anxiety/trauma), feeling thermometer (for depression), or behaviour rating scale (for disruptive behaviour)
• Educative materials as needed (pamphlets, dolls, videos)

Question 22

What are the 8 main steps in safety planning? (name them)

Answer 22

1) Obtain weekly ratings
2) Minimize self-blame
3) Review basic facts and vocabulary
4) Teach child to detect danger
5) Discuss body ownership
6) Develop safety plan
7) Address secrets
8) Activity: Rehearse plan

Question 23

Elaborate on the first 4 steps of safety planning.

Answer 23

1) Obtain weekly ratings
- If main focus is traumatic stress or anxiety, use the fear thermometer to obtain fear ladder ratings from both child and parent
- If main focus is depressed mood, use the feelings thermometer to take a rating
- If main focus is disruptive behaviour, take a parent rating with the behaviour rating scale
2) Minimize self-blame
- There is a risk that children will interpret your plan to teach safety skills as evidence of their having failed to respond appropriately to the traumatic event
→ p.ex: “i did not do the proper things to keep myself safe, this was my fault” (this is a stuck point)
- To minimize this risk, start out by normalizing and validating the child’s previous responses to trauma, and praise him or her for doing what he or she knew to do at the time
3) Review basic facts and vocabulary
- Review basic facts related to the type of trauma the child experienced
→ p.ex: statistics related to sexual abuse, natural disasters, etc.
- Ensure the child has the appropriate vocabulary to discuss the trauma
→ p.ex: children who have been sexually abused may need to review anatomical names for body parts
- May require outside research to prepare to cover this material (for therapist)
4) Teach child to detect danger
- Discuss with the child how to detect actual danger cues (“true alarm”) in their environment (how to correctly identify a true alarm)
→ p.ex: what sort of question is not an ok question, what person is safe or not…
- Because not all danger has external cues (smelling smoke), should also discuss what sorts of feelings we have when in danger
→ could include physiological cues (sweating, heart racing) or affective cues (guilt, anger, worry)
→ may include rehearsal or role plays in which the child acts out a scenario they might face
- Example
→ let’s say you believe someone in your family is angry and about to start a fight. Let’s talk about how you would know that is about to happen? What clues are there and how would you feel?

Question 24

Elaborate on the last 4 steps of safety planning.

Answer 24

5) Discuss body ownership
- If trauma involves sexual abuse, discuss body ownership nothing that some parts are private
- Clarify the difference between “good touch” and “bad touch” and note if it makes them uncomfortable, it can be a sign to use the safety plan
6) Develop safety plan
- Write down steps a child can take in the future to ensure safety
- For situations in which steps can be taken to minimize or appropriately confront the danger, the plan should incorporate such steps
→ p.ex: not leaving candles lit, learning how to use extinguisher
- For situations in which the danger cannot always be addressed directly (p.ex abuse or domestic violence), the emphasis should be placed on identifying safe places and people to whom the child can turn
- The written safety plan can include:
–> Identifying safe people to talk with about; dangerous or uncomfortable things; Identifying safe places to go when smt dangerous is happening; Calling 911 OR Planning how to ask for help (can write script tgt)
- The plan should involve sequential steps, such that if the first doesn’t work, there’s a back up
7) Address secrets
- If the nature of the trauma could involve the child being asked to keep it a secret, review the difference between safe and unsafe secrets
- Example:
→ safe secrets are secrets we don’t keep forever, and that are fun
→ unsafe secrets are secrets that kids are asked to keep from parents and never tell anyone about
→ these are secrets that kids don’t want to keep and feel uncomfortable keeping
8) Activity: Rehearse plan
- Practice the plan tgt by imagining an unsafe scenario

Question 25

What is something the psychologist should do after a safety planning session?

Answer 25

- Leave ‘em laughing! → end the session on a fun note, with a game or activity or other exercise that will leave the child feeling really good about the work you have done today

Question 26

How do parents play into trauma treatment?

Answer 26

- At the end of a session, it can be helpful to brief him or her on the materials covered **1) Consider privacy** → before bringing the parent in the room, ask the child if there’s anything that they told you today that they don’t wanna share with the parent **2) Review concepts** → have the child present the safety plan to the parent → encourage the parent to suggest additions to the plan, to practice the skills at home with the child, and to alert others who may be involved

Question 27

What are some helpful tips for safety planning?

Answer 27

- Depending on family situation, a parent may be involved in the entire session, including rehearsing their responses to the child’s safety plan - There are excellent books and videos available for education about personal safety → but, since kids learn best via interactive discussion and role plays, make sure that these materials are integrated into more active presentation of safety skills and planning - Did you praise often? Did you review often by asking questions? Did you simplify steps as needed? Did you pace match that of the child or family?

Question 28

What are the goals of a trauma narrative?

Answer 28

- The child will understand the reason for creating a story about the traumatic event - The child will initiate or add to a written narrative about the trauma - Through relaxation and repeated exposure to the narrative, the child will learn to control anxious responding to traumatic cues - The child can find ways to challenge blaming or catastrophic thoughts related to the event - The parent will understand the progress being made using these strategies *if time is tight, make sure the child understands the rationale and adds some new content to the trauma narrative*

Question 29

What are materials used for a trauma narrative?

Answer 29

→ fear thermometer and fear ladder for anxiety and trauma → feeling thermometer for depression → behaviour rating scale for disruptive behaviour → start-and-stop practice record → writing materials

Question 30

What are the 12 main steps for a trauma narrative (name them)?

Answer 30

1) Obtain weekly ratings 2) Introduce rationale 3) Create feeling of safety 4) Introduce fear thermometer 5) Activity: Fear thermometer 6) Activity: Relaxtion 7) Develop narrative 8) Encourage thoroughness 9) Provide reassurance and elicit coping skills 10) Develop the final chapter 11) Practice reading 12) Take ratings

Question 31

Elaborate on the first 4 steps of a trauma narrative.

Answer 31

**1) Obtain weekly ratings** - If main focus is traumatic stress or anxiety, use the fear thermometer to obtain fear ladder ratings from both child and parent - If main focus is depressed mood, use the feelings thermometer to take a rating - If main focus is disruptive behaviour, take a parent rating with the behaviour rating scale **2) Introduce rationale** - Explain the entire rationale of creating a trauma narrative - Start the rationale with a non-traumatic event (smt before the trauma) - Many people find it difficult to think about or discuss their bad experiences, especially the bad moment, so you want to make sure you ask explicitly when you prompt them - When one tries to avoid thinking or talking about them, the memories may come back unexpectedly in a way that is vivid and upsetting → it’s important to develop control over these memories by discussing them, little by little **3) Create feeling of safety** - Reassure the child that although you plan to write about it or discuss the events that happened, you are there to assure their safety and comfort and provide support **4) Introduce fear thermometer** - If child has not yet been introduced, do so here and point out how it will be used to monitor the degree of fear and to help you know if things are getting uncomfortable

Question 32

Elaborate on steps 5 - 8 of a trauma narrative.

Answer 32

**5) Activity: fear thermometer** - Have the child give a rating for his or her current level of fearfulness - Ask the child how they would rate their fear in other situations to see if they understand **6) Activity: relaxation** - Review and practice skills learned in the relaxation module - Use the fear thermometer and feelings thermometer to rate the child’s emotional state before and after relaxing **7) Develop narrative** - Once in a relaxed state, begin writing or adding to the narrative - Often useful to begin with a non-traumatic chapter - Over multiple sessions, the writing will involve the traumatic event itself - Encourage the child to describe the content surrounding the event - Until the narrative is complete, do not challenge any negative or catastrophic thoughts reported by the child, simply record them and note to revise them later **8) Encourage thoroughness** - While the child is writing, encourage them to write all the memories, as well as the thoughts and physical sensations that accompany them

Question 33

Elaborate on steps 9 - 12 of a trauma narrative.

Answer 33

**9) Provide reassurance and elicit coping skills** - If the child seems overwhelmed, remind them that these are only feelings and are not related to smt that is happening rn, but smt that happened in the past - If the anxiety becomes too elevated, you may prompt them to use a relaxation to establish control **10) Develop the final chapter** - Once the trauma has been described entirely (over a few sessions), have an additional final section where the child describes the ways in which they have changed, how their life is different now, and what advice they'd give to other children **11) Practice reading** - When the writing is done for the day, ask the child to read everything that they've written so far from the very beginning - If they're hesitant, offer to read it aloud for them and, if there's time, they can read it then after - Typically, the child should feel less emotional and physiological activity after each repitition **12) Take ratings** - Use the fear thermometer or feelings thermometer before and after each reading to quantify the degree of anxiety within each session - If the child decreases in ratings, point this out to them for evidence that they're making progress

Question 34

What is the final step of a trauma narrative?

Answer 34

**Address cognitions** - Once the narrative is entirely complete and has been read aloud over several sessions, determine whether the child has any lingering blaming thoughts or overestimations of recurrence --> p.ex: "it was my fault" or "I know it will happen again" - If so, you may introduce the appropriate cognitive module to address these beliefs - Review specific examples of problematic thoughts in the narrative with the child, and determine whether they are accurate and helpful - Ask the child to identify the types of thoughts present and to provide alternatives - Then, the narrative can be edited to reflect the child's more accurate thoughts *Follow this by a relaxation activity and leave em laughing*