Lecture 4: Treatment of complex trauma Flashcards
(34 cards)
trauma definition=
an emotionally painful experience that overwhelms a persons ability to cope (feeling out of control)
primary or secondary trauma: direct or indirect experience of trauma. it refers to a single experience, complex trauma to a series of experiences.
childhood trauma is exposure to trauma before 18 yrs.
types of trauma go beyond abuse and life threatening experiences:
- physical abuse, emotional abuse, sexual abuse, physical neglect, emotional neglect
- household dysfunction: high conflict parental divorce, witnessing domestic violence, parental mental illness or substance abuse
- living in an unsafe neighbourhood, experiencing discrimination or bulying, living in foster care, natural disasters, accidents
Children who have experienced any type of trauma are more likely to experience other types of trauma.
prevalences of (complex) trauma, measured in adverse childhood experiences
- foster care: 70% has three or more adverse childhood experiences
- adolescents: 62% at least one ACE, 18% three or more
PTSD
- After trauma exposure, individuals may develop (symptoms of) Post-Traumatic
Stress Disorder (PTSD). It is a normal response to an abnormal experience. - PTSD usually develops within the first 6 months after trauma exposure. However, symptoms can also develop after 6 months: late/delayed onset PTSD (due to avoidance, anniversary effects, talking about it…)
Symptoms:
Intrusive symptoms:
- repetitive, unwanted memories of the event
- flashbacks to the event (re-living)
- recurrent nightmares
- severe distress when reminded of the event
- physical reactions such as increased heart rate, sweating, dissociating (the body is still in this stress mode, body keeps the score) -> sometimes affect without recollection
Avoiding thoughts or feelings of the event:
- resisting to talk about it
- avoiding situations that may bring back unwanted memories
Heightened arousal:
- being easily startled or fearful
- struggling with irritability or angry outbursts
- having trouble concentrating, falling or staying asleep
- being overly aware of surroundings and potential threats
Changes in thoughts and feelings:
- struggling to remember important parts
- distorted beliefs about yourself or others
- recurrent feeelings of anger, fear, guilt, shame
- feeling detached from others
risk factors for PTSD development are:
- Trauma characteristics (type, onset, frequency, perpetrator(s)…)
- Demographic and personality characteristics (gender, age, resilience…)
- Secondary stressors (low social support, parental stress…)
- Comorbid (internalizing) psychopatholog
cPTSD diagnosis
- in ICD10, sibling diagnosis alongside classical PTSD
- In addition to PTSD features, CPTSD consists of (more severe) disturbances in self-organization:
- Emotional dysregulation (persistent sadness, suicidal thoughts, explosive anger)
- Negative self-perception (feelings of worthlessness, shame and guilt)
- Interpersonal disturbances (feeling distant from others, relational difficulties)
Individuals with CPTSD are exposed to earlier, more long-lasting and invasive events of primarily interpersonal nature (e.g., severe abuse and/or neglect) and struggle with poorer functional impairment
development of cPTSD
- trauma exposure produces natural and productive behavioral and emotional reactions. however, these reactions may generalize to innocent trauma reminders or triggers (memories, a loud noise) that automatically elicit arousal, fear, through classical conditioning.
- avoidanct behaviours may develop due to operant conditioning, and may be reinforced to minimize the experiencing of trauma-related symptoms and emotions, eventually limiting children and adolescents capacity to engage in interactions with the world.
-> trauma has the potential to disrupt young individuals’ physical, emotional, cognitive,
behavioral, and social development and adjusment
As childhood and adolescent trauma disrupt development, they have been linked to a spectrum of (lasting) adverse health consequences:
- Physical conditions such as obesity and diabetes (~ risky behaviors)
- Symptoms of anxiety and depression, ADHD diagnosis
- Lower perceived social support, lower social skills
- Behavioral/conduct problems
- Poor sleep quality and school-related problems
dose-response relationship (more trauma = more adverse effects)
interventions for (complex) trauma characteristics
Goal: optimizing children’s and adolescents’ functioning in all domains of life
How? By helping them overcome:
* Traumatic avoidance
* Feelings of shame, sadness, fear, anger…
* Cognitive, behavioral, and social difficulties
Yet: treatment studies in children and adolescents are scarce
child-centered play
background:
– anna freud and melanie klein
– person-centered philosophy of carl rogers: non-directive techniques, children develop self-actualization, children can solve their own problems, leads to positivee self-growth
– a developmentally responsive, play based intervention
– young children between 2-10 yrs, who experience social, emotional, behavioral and relational difficulties
– Play-based:
- children use play to learn, process emotions, and make meaning of the world
- children use symbols to communicate their ideas and emotions
- play therapy allows for the symbolic expression of children’s inner conflict
- Using toys, children can attain mastery by using imagination to modify the story
- This way, children can process and heal from their trauma
– the therapeutic relationship is important: the therapist provides a safe and consistent (same toys, same place) environment:
- in which a child can process inner experiences and feelings through play and symbols
- in which a child can experience full acceptance, empathy, and understanding
(even when their behavior requires limits)
– the therapist responds to the chidls defensiveness with openness and empathy
- allowing the child to learn something new (i can trust others even though i am defensive)
- allowing the child to develop trust and impulse control
- allowing the child to build identity, self-worth, decision-making skills, coping skills
-> stimulating adaptive self- and interpersonal functioning
voorbeeld CCPT
- Accepts the child as he is
- Allows him to express himself freely
- Recognizes his feelings and behaviors and reflects those back to him in a way that allows him to gain insight into his own behavior
- “You are protected”
- “You want me to help you and don’t remember it”
- Maintains and communicates a respect for his ability to solve problems
- “You want to hide. I am wondering whether you can tell or show me how to do it. Look at that, you were able to do it. You just knew how to make that work.
maar hoe verandert het dan het gedrag van het kind
CCPT doesn’t reinforce negative behaviors — it meets the emotional need underneath so that the behavior becomes unnecessary.
Limits are still set — behavior isn’t ignored; it’s redirected within a safe, consistent structure.
Real change comes from the child feeling safe enough to try new ways of being — not from external control.
In essence, children are able to experience the
natural self-actualizing tendency at work and
learn to trust themselves in the process, an
experience that was taken from them during
their adverse experiences.
voorbeelden van corrective experiences
- Testing the Therapist and Finding Safety
Child’s belief: “Adults get angry and leave when I push them.”
Behavior: The child throws toys near the therapist or says something provocative (“I hate you”).
Therapist’s response: Calmly sets a limit with acceptance.
“You’re really mad, and I’m still here with you. I won’t let you get hurt or me get hurt.”
Corrective experience: The child learns that anger doesn’t always lead to abandonment or punishment. Trust begins to build.
- Aggressive Play Leading to Containment
Child’s belief: “I’m dangerous. My anger is out of control.”
Behavior: Child acts out violent scenarios — shooting, smashing, dominating play.
Therapist response: Reflects emotional intensity while setting firm boundaries:
“That soldier is really powerful — it seems like he has a lot of big feelings to get out. Let’s keep that smashing to the soft toys so no one gets hurt.”
Corrective experience: The child sees that big emotions can be expressed and contained, without being harmful or rejected.
- Caregiving Themes in Play
Child’s belief: “I have to take care of everyone. No one takes care of me.”
Behavior: The child tends to injured dolls, acts as the “mom” in charge of everything.
Therapist response: Reflects the caregiving while gently introducing curiosity:
“You’re making sure everyone is okay — it looks like a big job. I wonder who takes care of the mom when she’s tired?”
Corrective experience: The child begins to consider their own needs — a shift from parentified roles to feeling deserving of care.
- Avoidance of Play or Connection
Child’s belief: “If I open up, I’ll get hurt or ignored.”
Behavior: Child refuses to engage, stays quiet or plays alone.
Therapist response: Respects their space but stays emotionally present:
“You don’t feel like talking today, and that’s okay. I’ll be right here with you.”
Corrective experience: The child experiences emotional presence without pressure, learning that connection is possible without intrusion.
- Repeating Rescue Scenarios
Child’s belief: “No one will come for me.”
Behavior: Child sets up repeated play where a character is trapped, lost, or abandoned.
Therapist response: Joins the play and eventually helps rescue the figure:
“They were stuck for a long time — it must’ve felt really scary. But now they know someone will come.”
Corrective experience: The child experiences a different outcome — someone does come, someone does care.
effectiveness and efficacy of CCPT
decreases in externalising, internalising, parental stress and parental empathy, child empathy, emotion regulation and social competence (16 sessions over 8 weeks)
trauma-focused CBT
- Treatment for children and adolescents between 3 and 18 years old who have experienced/witnessed traumatic events
- A skill-based model that incorporates trauma-sensitive interventions with CBT and FBT principles and techniques
- Psychoeducation, skill building, exposure, trauma narrative processing, parental involvement
- The therapist provides a safe environment for children, adolescents, and their parents to share their thoughts and feelings, to overcome stigma, shame, and self-blame
- In case of dangerous acting-out behaviors, active suicidal behavior or substance abuse difficulties: children/adolescents benefit more from other evidence-based interventions to stabilize these behaviors (e.g., DBT-A)
TF-CBT treatment programme
first PRAC components (skill-based), then TICE components (trauma-focused)
- PRAC (coping skills phase): Psychoeducation, Pareting skills, Relaxation skills, Affective modulation skills, Cognitive coping skills
- T (trauma narrative and processing phase): trauma narrative and processing
- ICE (treatment consolidation and closure phase): In vivo mastery of trauma reminders, Conjoint youth-caregiver sessions, Enhancing safety
TF-CBT kenmerken van het treatment programme
- 8-20 sessions
- parental skills and gradual exposure are implemented in all program components
- progressive programme: each component builds on previously mastered skills
- number of sessions: more sessions in case of severe emotional dysregulation (often foster care)
- gradual exposure: activities that directly engage children and parents in mastering avoidance of thoughts, feelings, reminders and memories. also activities: talking, writing, creating arts
- parallel child and parent sessions, combined with conjoint sessions
TF-CBT: Psychoeducation
Providing the child and parents with information about:
* The nature of traumatic experiences: their prevalence, causes, common reactions…
* Trauma reminders: any internal/external cues that remind children of their original
trauma and elicit trauma responses
- Identifying the child’s trauma reminders and connecting these to the child’s trauma responses (making sense of the trauma)
- Understanding that the child’s emotional and/or behavioral problems are trauma-related
* Treatment
To reassure children and parents that they are not alone or abnormal. Occurs throughout the treatment (when needed)
gradual exposure is implemented by the therapist through….
- Referring to the child’s traumatic experiences by name (‘car accident’, ‘domestic violence’) rather than using a euphemism (‘the bad things that happened’)
- Directly looking at and facing the child and parents when using words that describe the traumatic experiences
- Not lowering voice tone when talking about the child’s traumatic experiences as it might convey secrecy, shame, or discomfort
-> The therapist models nonavoidance
Parents are considered the primary agent of change in their children
- Parents are informed about their child’ symptoms
- Parents receive interventions that parallel those their child is receiving
- Parents are supported in addressing their own emotional reactions to their child’s trauma so that they can become sources of strength, support, and belief
- Parents are assisted in recognizing and addressing dysregulation in their child
- Enhancement of positive parenting (using praise, positive attention)
- Decreasing parental distress
TF-CBT: relaxation skills
- Traumatized children suffer from physiological dysregulation
- Relaxation interventions refocus children and parents on enjoyable activities and encourage them to learn to self-soothe
- Relaxation interventions: focused breathing, yoga, muscle relaxation, dancing, blowing bubbles, drawing,…
- Gradual exposure is implemented by helping children and parents develop a variety of relaxation strategies for when they experience trauma reminders in different scenarios/settings (at school, at bedtime, at a friend’s house)
TF-CBT: affective modulation
Traumatized children have often learned to suppress their feelings or have learned
that the only safe feeling to express is anger (because when i show anger, people stay away and they cannot hurt me)
Child sessions:
* First step is affective expression: children learn to identify and express their feelings via photographs of faces, drawing, or other creative interventions
* Second step is affective modulation: children learn to manage their difficult feelings via problem solving, role playing, social support seeking…
Parallel parent session(s):
* Parents express their own feelings about the trauma and develop optimal coping ways
* Parents learn to assist their child in expressing feelings and model appropriate affect expression and modulation
voorbeeld van zo’n affective modulation oefening
Compare emotions to weather:
“Just as the weather changes, our emotions can change too”
Sometimes it’s sunny (happy)
Sometimes it might be rainy (sad)
Or stormy (angry)
Role-playing: illustrate scenarios where affect modulation comes into play
- Challenging situation: loosing a game
- Successfully manage your emotions and discuss why it was helpful
nog een voorbeeld van chat lol
Example: 9-Year-Old Child with Trauma History
Presenting issue: Child becomes overwhelmed with anger when reminded of a past domestic violence incident. She’s been having angry outbursts at school and home.
🔹 Session Activity: Feelings Thermometer
Step 1: Identify and label emotions
The therapist introduces a feelings thermometer with zones:
Green = calm
Yellow = a little upset
Orange = very upset
Red = out of control
Therapist:
“Let’s think about what your body feels like in each zone. What does your body do when you’re in the red zone?”
Child:
“My face gets hot. I yell. I want to hit.”
Therapist:
“That’s really helpful to know. Your body is giving you signals, like warning lights. And when you notice those, you can do something to help yourself before it gets to red.”
🔹 Step 2: Teach a regulation strategy (e.g., deep breathing)
Therapist introduces:
“Let’s practice a trick called ‘Smell the flower, blow out the candle.’” (inhale slowly through nose, exhale slowly through mouth)
They role-play using the breathing technique when the child notices herself getting to the orange zone.
🔹 Step 3: Practice with role-plays or triggers
Therapist:
“Imagine you’re in class and someone says something mean. Where are you on the thermometer?”
Child:
“Orange.”
Therapist:
“Let’s try our flower-and-candle trick right now. Ready?”
Child does deep breathing. Therapist reinforces:
“Great job noticing your body and calming it down. That helps your brain stay in charge, not your anger.”
TF-CBT: cognitive coping
Children and parents learn to understand the connections between their thoughts, feelings, and behaviors
They examine their own patterns of negative thinking and change dysfunctional thoughts about everyday events. Only parents use cognitive coping for processing their maladaptive thoughts about their child’s traumatic event (child is not ready yet).
