CH 6: Trauma Psychoeducation

Psychoeducation in TF-CBT

• Psychoeducation is a major, ongoing component of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for both the child and caretaker.

Goals of Psychoeducation

• Normalize the child's and parent's responses to traumatic events.

• Provide information about typical psychological and physiological responses to trauma.

• Reinforce accurate cognitions about what occurred.

Implementation

• Ideally begins at the initial intake phone call by being supportive and normalizing responses.

• Continues during the assessment process with the same goals.

Benefits of Psychoeducation

• Provides emotional relief to parents by informing them that their child’s responses are not unusual and that clinicians have treated similar cases with positive outcomes.

Providing General Trauma Information

• Share information about the frequency of the specific trauma, typical experiences, and causes.

• For example, provide information sheets on sexual abuse, including statistics, types of abuse, and reasons for not reporting it.

• These resources help dispel myths and misinformation.

Dispelling Myths

• Address specific misconceptions, such as a boy fearing he will become gay due to experiencing pleasure during sexual abuse.

• Direct discussion and information sheets can clarify these concerns.

Addressing Various Traumas

• Provide general information about the effects of witnessing domestic violence, school violence, etc.

• Help families understand they are not alone in facing these challenges.

• Offer sample information sheets (Appendix 1).

Interactive Activities

• Use games and activities to enhance understanding, such as the "What Do You Know" card game about sexual abuse, physical abuse, and domestic violence.

Common Emotional and Behavioral Responses

• Share empirical information about common reactions to specific traumas.

• This validates the child's and parent's experiences, showing their responses are not unusual.

• Clinicians can provide firsthand feedback based on their experience with other children who have experienced similar traumas.

Vicarious Trauma

• Acknowledge and validate parents' vicarious trauma reactions (e.g., anxiety, sleep difficulties).

• Inform them that their reactions are common and not abnormal.

Utilizing Resources

• Use children’s books that describe common reactions to trauma, written by professionals or trauma survivors.

• These books convey that children are not alone and offer ways to cope with painful feelings.

Multimedia Resources

• Use videos, such as those created with the NCTSN, to validate and normalize emotional and behavioral reactions.

• Examples:

  • The Promise of Trauma-Focused Therapy (addresses sexual abuse; www.nctsnet.org/products/promise-trauma-focused-therapy-childhood-sexual-abuse-2007-video)

  • The Hope of Family Focused Interventions for Child Physical Abuse (addresses physical abuse; www.nctsnet.org/products/hope-family-focused-interventions-child-abuse-2010-video)

Providing Diagnostic Information

• Explain the child’s diagnosis in a straightforward manner, avoiding excessive clinical terminology.

• For example, describe PTSD symptoms as:

  • Reexperiencing symptoms: painful reminders of the trauma.

  • Avoidant symptoms: ways to seek relief from emotional pain.

  • Hyperarousal symptoms (distractibility, difficulty sleeping, irritability): ways the brain and body show the traumatic event overwhelmed the child’s ability to cope.

• Highlight commonality with other populations that experience similar issue such as members of the U.S. military after deployment.

Describing Available Treatments

• Reassure children and parents that TF-CBT has strong empirical support.

• Inform them that most children experience significant symptom reduction and develop coping skills through this model.

• Convey hope and confidence that children can overcome the effects of trauma, even with severe symptoms or multiple traumas.

Trauma Reminders

• Use the term "trauma reminders" instead of "trauma triggers" to suggest the possibility of adaptive responses.

• Help children and parents identify their trauma reminders (people, places, things, smells, etc.).

• Example: A boy's agitation and aggression when his foster mother made chili, which reminded him of his biological father beating his mother.

• Help them develop more adaptive responses to these reminders.

Managing Current Symptoms

• Provide strategies to manage current symptoms for several reasons:

  • Symptomatic relief improves the child's well-being and functioning (e.g., addressing sleep disruption).

  • Addressing concerns shows understanding and respect for the child and parent.

  • Successful management builds confidence in the therapist and the TF-CBT model.

Collaboration

• Emphasize collaboration between the therapist and child/parent from the outset of treatment.

Addressing Concerns

• Take the child’s/parent’s concerns seriously and develop strategies to address them immediately.

Ongoing Psychoeducation

• Use psychoeducation throughout the treatment process.

• Example: During the parenting component, address cognitive distortions (self-blame, unrealistic sense of threat) that interfere with effective parenting.

• Normalize resistance to creating a trauma narrative and predict possible increases in avoidance or symptoms.

• Encourage parents to share observations and support the child’s commitment to therapy.

Orienting to the TF-CBT Model

• Explain the philosophy of TF-CBT in the initial session:

  • Acknowledge significant PTSD or other trauma-related symptoms.

  • Explain that these symptoms need early intervention to prevent long-term difficulties.

  • Briefly review the child’s specific symptoms.

  • Emphasize the importance of gradually and supportively talking about the trauma.

  • Assure that trauma discussions will not begin until the child has coping skills.

  • Highlight collaboration with the parent and welcome their suggestions.

  • Respect diverse cultural, religious, and family traditions in dealing with trauma.

  • Reiterate the effectiveness of TF-CBT and the hope for significant improvements.

Psychoeducation for Traumatic Grief

• Provide additional information for children who have experienced the death of a loved one due to trauma.

• Acknowledge intentionality in deaths due to terrorism or homicide.

• Consult with parents or religious leaders on how to explain these events in a manner consistent with the family’s beliefs and the child’s developmental level.

• Refer to Chapter 17, “Grief Psychoeducation,” in Part III for more information.

Gradual Exposure

• Use correct names for the child’s trauma experiences (e.g., “sexual abuse," “domestic violence,” “death”) instead of euphemisms.

• Maintain an open body posture, normal voice volume, and eye contact when discussing trauma, modeling positive coping.

Troubleshooting

Multiple Comorbid Conditions

• Be honest about the child’s difficulties while emphasizing positive aspects.

• Accurately identifying comorbid conditions can be a relief to parents.

• Provide resources for parents on conditions like ADHD (e.g., Barkley’s [2000] Taking Charge of ADHD) or bipolar disorder (e.g., Birmaher’s [2004] New Hope for Children and Teens with Bipolar Disorder).
  *Decrease guilt, burden, and frustration by helping families understand and address these conditions.

• Diagnosing comorbid conditions can be difficult during acute trauma exposure.

• Discuss differential diagnostic possibilities and plans for evaluation.

• Consider a “wait-and-see” approach, suggesting that difficulties may resolve with trauma-focused treatment.

• Acknowledge when you don’t have all the answers.

Comorbid Condition as Primary

• Acknowledge that a comorbid condition may be more primary than trauma symptoms.

• Address the comorbid condition first (e.g., conduct problems leading to arrests) before trauma treatment.

Inappropriate Questions

• Meet individually with the parent and child separately during TF-CBT sessions.

• If meeting together, define some information as “adults only” or “for kids and parents to share.”

• Meet privately with the parent to share “adult only” information and model why certain questions are inappropriate to ask in front of the child.

Information Overload

• Avoid providing all psychoeducation in the first session to prevent overwhelming families.

• Provide written material to be reviewed at home.

• Gauge the parent’s response and ask questions to ensure they are not overloaded.

Therapist's Personal Trauma History

• Decide whether to share personal trauma history; consider both benefits and risks.

• Be clear about your reasons for sharing and minimize troubling or distracting details.

• Share to convey understanding and empathy.

• Be aware that sharing can compromise privacy and that family members may misinterpret intentions.

• Ensure the focus remains on the child and family.

• Avoid situations where children or parents feel they need to “take care” of the therapist.

• Be prepared for the possibility of family members becoming offended or dismissive.

Child's Lack of Interest

• Present information in the context of a question-and-answer game.

• Offer points and praise for what children know.

• Correct any misconceptions.

Complex Trauma Presentations

• Recognize that children with complex trauma may be too dysregulated to tolerate psychoeducational information at the beginning of treatment.

• Start with general relaxation and affective regulation strategies.

• Introduce psychoeducational information when the child has a greater sense of self-regulation and control.