This guide has described various techniques and approaches for the cognitive, emotional, and relational processing of traumatic memory.
Based on initial and ongoing assessment with the Assessment-Treatment Flowchart, and applying the Problems-to-Components Grid, the clinician is advised to customize the type and extent of intervention for any given adolescent, so that the youth’s specific difficulties can be addressed in a systematized manner using relevant components. At the same time, an overbridging philosophy of these guidelines has been a focus on the therapeutic relationship: both as a necessary support for the hard work of trauma processing, as well as a technical requirement for the resolution of the relational/interpersonal difficulties of many adolescent trauma survivors.
Although the actual processing and desensitization of traumatic material typically varies in degree from session to session, and certain general aspects of treatment transcend technique, per se, it is also true that therapy for trauma survivors often works best when it conforms to a basic structure. Such a framework allows the therapist to assess the client’s current needs, determine treatment priorities, provide relevant processing activities as appropriate, reassess the client’s current state, de-escalate emotional responses, when necessary, and provide end-of session closure.
In general, we suggest that individual therapy for traumatized adolescents involve one 50-60 minute session per week, in addition to group and/or family sessions that may occur on a weekly to monthly basis. As stated elsewhere, group and family sessions occur after the adolescent has engaged in a course of individual therapy. In a minority of cases, more than one individual session per week may be indicated, and, in some cases, family or group therapy may be more frequent or completely absent. The frequency of individual sessions may decrease to biweekly and then monthly meetings as the client improves and nears termination.
Adapting from Briere and Scott (2012), some version of the following is appropriate for the individual therapy session:
- Pre-session : The ATF-A should be reviewed, and principle targets for the session ascertained. These targets may change as the session unfolds, but they should not be abandoned unless necessary (e.g., when the client discloses or experiences a new trauma, or is in crisis).
- Opening (5-15 minutes):
1. Spend a few minutes making contact with the client. This may include discussion of relatively neutral topics, including recent activities or events in the client’s life. Authentic caring and interest should be expressed early in the session, and repeated thereafter as appropriate.
2. Inquire about any changes in the youth’s life since the last session.
- Have there been any new traumas or victimization?
- Has the client engaged in any dysfunctional or self-destructive behaviors?
- If any of the foregoing is of concern, work to assure or increase the client’s ongoing physical safety. Do this before (or instead of) formal trauma processing.
3. Check with the adolescent regarding his or her internal experience since the last session. Ask if intrusive or avoidance symptoms have increased significantly. If yes, determine the nature of the trigger(s) and the thoughts, feelings, and/or memories they produced. Normalize the experience and validate symptoms as internal trauma processing. If the intrusions or avoidance responses are substantial, consider decreasing the intensity of exposure and activation in the current session.
4. Based on information from the opening part of the session, revise – if necessary – the goals of treatment for the session.
- Mid-session (20-30 minutes):
1. Provide emotional and cognitive memory processing, staying within the therapeutic window whenever possible. Facilitate the youth’s discussion of his or her trauma history, support identification and expression of emotions when possible. For younger clients, this may include expressive activities such as drawing, collages, etc. Communicate caring and support.
2. If significant processing turns out to be contraindicated (i.e., because it is potentially overwhelming), revert to psychoeducation, general discussion, affect regulation skill building, or focus on cognitive interventions.
3. Avoid therapist-centered activities, extensive interpretation, or lecturing. Maintain and communicate a nonjudgmental, caring, and accepting attitude.
- Later in session (15-25 minutes):
1. Debrief, normalize, and validate any material (cognitive or emotional) or client responses that emerged during the session.
2. Inquire about the adolescent’s experience during emotional or cognitive processing, as well as any other thoughts or feeling he or she had during the session.
3. Provide cognitive reconsideration, as needed, for additional cognitive distortions that emerged during debriefing.
- Ending (Last 5-15 minutes):
1. Remind the client (if necessary) of the potential delayed effects of trauma processing, including possibly increased flashbacks, nightmares, and – for some clients – a desire to engage in avoidance activities such as substance abuse or tension-reduction behaviors. Do this in a non-catastrophizing/non-pathologizing way, and omit this step if it does not appear necessary.
2. If relevant, acknowledge and validate any relational activation and/or processing that occurred in the session. Reframe and/or normalize any conflict or relational distortions that occurred as potential evidence of good therapeutic interaction. This is not a time to engage in further relational processing, only to acknowledge and reassure.
3. Provide safety planning (if necessary) regarding dangers identified in the session, or any possible self- (or other-) destructive behavior that may emerge between sessions.
4. If the client’s level of emotional activation remains high, spend a few minutes in a breathing or relaxation exercise
5. Provide closure statements (e.g., summing up the session) and encouragement.
6. Explicitly refer to the time and date of the next session.
7. End with some communication of caring, appreciation, and hope.