1. Intervention for Trauma
Cognitive Behavioral
Intervention for Trauma
In Schools (CBITS)

2. Part 1: Why a trauma program in schools?

3. “Interpersonal violence is a public health emergency… and
one of the most significant
public health issues facing America” C. Everett Koop, JAMA, 1992

4. Some children are at greater risk for violence exposure
Males
Older children
Early conduct problems
Living in urban areas
Lower socio-economic status
Schwab-Stone, 1995, 1999

5. Why a program for traumatized students?
One night several years ago, I saw men shooting at each other, people running to hide. I was scared and I thought I was going to die. After this happened, I started to have nightmares. I felt scared all the time. I couldn’t concentrate in class like before. I had thoughts that something bad could happen to me. I started to get in a lot of fights at school and with my siblings.
Martin, 6th grader

6. Consequences of violence exposure
Post traumatic stress disorder (PTSD)
Re-experiencing
Numbing/Avoidance
Hyperarousal
Prevalence in adolescents
4% of boys
6% of girls
75% of those with PTSD have additional mental health problem
Breslau et al., 1991; Kilpatrick 2003, Horowitz, Weine & Jekel, 1995

7. Consequences of violence exposure
Post traumatic stress disorder (PTSD)
Depression
Substance abuse
Behavioral problems
Poor school performance

8. How does violence exposure impact learning?
Decreased IQ and reading ability (Delaney-Black et al., 2003)
Lower grade-point average (Hurt et al., 2001)
More days of school absence (Hurt et al., 2001)
Decreased rates of high school graduation (Grogger, 1997)
Increased expulsions and suspensions (LAUSD Survey)

9. How did this program come about?
Concerned with the impact of violence on students, Los Angeles Unified School District officials wanted an effective program for traumatized students
Based on the best available science
Tailored for the school setting
Designed for children and families of diverse ethnic and social backgrounds
So what we set out to do was quite straightforward but also very ambitious, and that was to develop and evaluate a program specifically designed to meet their needs.
We started by drawing on expert consensus and current practice guidelines about what such a program would look like, but then spent time meeting with school staff and parents to ensure that it was culturally sensitive and to tailor it for the schools.

10. CBITS Program 10 child group therapy sessions for trauma symptoms
1-3 individual child sessions for exposure to trauma memory and treatment planning
Parent outreach, 2 sessions on education about trauma, parenting support
1 teacher session including education about detecting and supporting traumatized students (1 session)

11. Goals of CBITS Symptom Reduction Build Resilience
PTSD symptoms
General anxiety
Depressive symptoms
Low self-esteem
Behavioral problems
Aggressive and impulsive
Build Resilience
Peer and Parent Support

12. Part 2: Does it work?

13. High rates of violence exposure in LAUSD 6th grade students
Knife or gun involved
Type of exposure reported
Victimization
Witnessed violence 0%
20%
40%
60%
80%
100%
All 769 children

14. Screening also identified many children with clinical symptoms
Type of exposure reported
Symptoms

15. Results PTSD and Depressive symptoms decreased
Grades and classroom behavior improved
As trauma symptoms decreased, grades improved
Teachers reported fewer classroom learning problems after program
Parents reported overall improved behavior and functioning
As a clinician and researcher, I’ve very excited about these results showing that such a program can really help kids
But was it a program that could be rolled out- was it a program that people wanted in their schools

16. What did students say?
“The group helped me because I don’t have nightmares about that anymore. I don’t think about what happened anymore. Even though I was nervous when I shared this in the group, I felt much better after that. It helps kids concentrate better in class and improve their grades like I did and get along with their teachers”
Martin
Well, you remember Martin….

17. What did families say?
“My son is not afraid to come to school anymore… he comes home and talks to me. Before he would just cry and not say anything. Now he’ll come home and tell us what’s bothering him. I realize how important it is to spend time with our kids and listen to them.”
Martin’s mother

18. What did teachers say?
“I was surprised that so many students qualified for the program.”
“Initially, I was concerned because students would be pulled out of class… they weren’t going to do as well. But then you could see them settling down… and doing better.”
“I’ve noticed that after the program, students just seem more comfortable in class. And because they are more comfortable, they behave better and do better in class.”
And teachers, while surprised that so many children qualified, and initially concerned about pulling kids out of class, saw the difference the program was making for their students, and ended up being some of the most enthusiastic supporters.

19. Part 3: How do we Screen?

20. How do we screen students for CBITS?
Step 1. Administer screening surveys to class-sized groups
The screener includes:
Shortened Life Events Scale: 9 items asking about violent events
Foa’s Child PTSD Symptom Scale: 17 items
Screening should be conducted as close to first CBITS session as possible (within 1-2 months)

21. How do we screen students for CBITS?
Step 2. Score screener to identify eligible students for CBITS
Life Events cut-off score: 3 or more points OR any weapon-related event
PTSD cut-off score: 14 or more points

22. How do we screen students for CBITS?
Step 3. Interview eligible students individually
Verify survey results and identify main traumatic event
Assess appropriateness for group

23. Part 4: CBITS Step by Step

24. Materials Needed Required Supplies -Group leader Manual
-Student activity worksheets
Optional supplies
-Chalkboard/large writing pad
-Crayons, Markers, Color pencils

25. CBT: Friend or Foe? Assumptions about Cognitive Behavioral Therapy
Concerns about Manualized Interventions
CBT in school setting:
Acceptable
Feasible
Amenable to group structure
Focus on building skill
Empowering
Point of this slide is to help you understand your trainees and what you’ll need to help them with
Among the assumptions and concerns, be sure to include:
Doesn’t allow use of clinical skills and creativity
Too structured/rigid; can’t be individualized (recipe/cookbook)
Doesn’t get to the root of the problem/real problem
Exposure can be retraumatizing
After eliciting these issues, tell trainees that you will come back to them at the end of the training. You can say that these are familiar concerns, and it sometimes takes actually running a group before you can see how it works, how to individualize it, and whether it retraumatizes students or not.
Introduce the second part of the slide by saying:
Why does CBITS make sense in school?

26. A Conceptual Model of the CBITS Program
Traumatic Event(s)
Impairment
PTSD symptoms
Depressive symptoms
Behavioral problems
Social dysfunction
School dysfunction
CBITS
Targets of CBITS
Coping skills
Parent & peer support
Cognitions / Attributions
Long Term
Adjustment Problems
PTSD
Depression
Violent Behavior
Substance Use
Begin with the traumatic event on the far left. Show how it leads to problems/symptoms, and then to long-term adjustment problems.
Explain that not everyone has problems following trauma, that some kids are resilient, and that some common resilience factors in in the box at the top. But for CBITS, we are picking kids who ARE having problems
CBITS tries to bolster these resilience factors – builds coping skills, parent and peer support, and also tries to change the more negative, maladaptive thoughts and interpretations kids are having.
CBITS also tries to reduce symptoms directly by reducing anxiety and improving behavior.

27. Introduction to the Group (Session 1)
Includes:
M&M game for warm-up
Introduction to the group rationale
Discussion of confidentiality
Beginning of any group management techniques such as
Reward chart for good behavior
Group rules
Goals Worksheet
List the elements of session 1.
Explain that the manual does not include specific instructions for managing the group, but they can draw on their own experiences as to what they want to do. Can discuss ideas here or at the end of the training.
Draw Attention to Goals worksheet

28. Conceptual model for participants (Session 1)
What we think
Stress or
Trauma
“ This is how we introduce the theory to group members in Session 1.”
Role play it for the group: What we think, what we do, and how we feel are all related. When a stressful event happens, it affects everythinga bout us--all of the areas on the triangle.
Car accident example: If you were in a car accident while you and your mom were on the way to the store, what might you think the next time your mom wanted to drive you to the store? (It could happen again, the car is dangerous) How would you feel? (anxious, afraid) What would you do? (avoid the car, avoid the store, etc.)
What we do
How we feel

29. Thoughts Behaviors Feelings
Thoughts, behaviors and feelings are related in a bidirectional system. Each one affects the other, and changing or shifting one part of the system causes shifts in each of the other parts.
Ask audience for example of something they’ve done for fun lately. Ask for thoughts, feelings, and how they were behaving (I.e.,Thoughts: “I’m really excited to be spending time with this person.” “I heard this was a great movie and can’t wait to see it” “I’ve always wanted to go on this ride” Feelings: Excited/Happy Behaviors: smiling, engaged, approachable).
Offer an example of another person in the same situation who is thinking very differently (i.e., “ I can’t believe I have to spend time with my parents” “ I heard that this movie was lame and I wish I was seeing something else” “ I hate rides like this” Feelings: resentful, sad, anxious. Behaviors: sullen, looking down, arms crossed, unapproachable, not interacting. Now offer a shift in this same person’s feelings (I.e., they suddenly see someone they like or want to impress), etc.
Feelings

30. Each Channel addressed with specific interventions
Tailoring CBT Treatment
Each Channel addressed with
specific interventions
Feelings/Physio. Arousal Relaxation
Thoughts Cognitive Restructuring
Behaviors: Avoidance Exposure
Impulsive (social problem
solving)
How treatment addresses thoughts feelings and behaviors, can tailor the focus for individuals depending on their sx expression,etc.

31. Psychoeducation about trauma and symptoms (Session 2)
Why?
To reduce stigma about trauma symptoms
To build peer and parent support
To increase parent-child communication about problems
How?
Structured group discussion about symptoms
Handouts sent home about symptoms
Homework assignment to discuss with parents
Psychoeducation- people often feel out of control or embarrassed about their symptoms so it is important to de-stigmatize the symptoms of anxiety, anger, and grief that follow stress or trauma and introduce the concept of PTSD as a disorder that can be treated, rather than an out-of-control set of symptoms that will last forever.
Parents are often unaware of the trauma or the child’s symptoms. Other times they are not aware of the link between the anxiety/other symptoms that the child is experiencing and a traumatic event and the ways that the symptoms are currently interfering in the child’s life.

32. Psychoeducation about trauma and symptoms (Session 2)
Pitfalls
Pathologizing
Embarrassing students with extreme symptoms
Need to keep tone educational and stress commonalities across students
Role play talking to students about trauma symptoms using child-friendly language by asking group members what some common reactions to stress are—then after each response complete the symptom, normailze it, and offer hope by explaining how the program will address it ir help them work on it.
Also introduce the concept of anxiety: Anxiety plays an important role in our bodies. It is like our body’s fire alarm alerting us that something is wrong. Example: caveman approaches a creature (saber-tooth tiger is popular). How does he feel? (afraid, anxious) What does he do? (run) So he feels anxious and knows he better leave so he can be safe. What if he didn’t get anxious? (he’s lunch) Emphasize the importance of anxiety and normalize the reaction. The problem is, when we experience a stressful or scary event, then our bodies start to get anxious, or set off the fire alarm, even when there is no danger. So what we’re going to work on in this group is to be able to control that anxiety and recognize when things are safe, so we don’t have to feel anxious all the time.
Have trainees practice talking about symptoms using language similar to the manual in small groups or dyads.

33. Relaxation training & fear thermometer (Session 2)
Why?
To enable child to reduce anxiety
To enable child to observe his or her own anxiety level
To introduce a common language in describing “fear” or “anxiety”
How?
Exercise combining positive imagery, slow breathing, and muscle relaxation
Fear thermometer used throughout the groups
Homework assignment to practice at home
Relaxation training- reducing anxiety and gaining a sense of control over anxiety symptoms
Introduce fear thermometer as a common language in describing their feelings; students can practice during relaxation exercise

34. The Fear Thermometer Very anxious Not anxious at all 10 9
8 – Walking home from school alone 7 6 5 4
3 – Going out on playground at recess 2 1
Not anxious at all

35. Relaxation training & fear thermometer (Session 2)
Pitfalls
Rarely students feel panicky during exercise
Giggling
Explain that you’ll move around the room, check in with students, perhaps touch them on the shoulder to check in. Warn them that it sometimes seems funny.
Demonstration and Activity
Role play manual script, help group generate other methods they use during relaxation (soothing music, aromatherapy; other RT scripts that they’ve found useful with their population); also generate methods to deal with giggling and decrease self-consciousness (seating arrangements facing away from each other or facing in same direction, acknowledging it will happen, recording RT onto an audiotape and playing it for the group while leaders also do RT and model instead of observe, etc.)

36. Group Activity What are your body clues when you are feeling anxious?
Think of TWO different triggers that make you feel anxious
Fear Rating 3-4
Fear Rating 7-8
3. What things do you do to help you relax/cope…..?
Divide into groups of 3-5. Assign a group leader/facilitator, recorder, and reporter. Get back into one group and proceed with reporters from each group giving overview.
Raise hand, stand, switch chairs

37. Cognitive therapy (Sessions 3 & 4)
Why?
To increase children’s ability to observe their own thoughts and interpretations, and to challenge ones that are getting in their way
Focus is on thoughts like,
“The world is dangerous, I can’t trust anyone”
“I can’t deal with things, what happened is my fault”
How?
Didactic and exercises (the “Hot Seat”)
“Is there another way to look at this? Is there anything I can do about this? How do I know this is true? – catastrophic fears
If this is true, what’s the worst/best/most likely thing to happen? – common fears
Lots of practice in session and on worksheets at home
Cognitive Therapy- focusing on distortions around world dangerousness and personal incompetence where the children were taught to recognize maladaptive thoughts and to combat them by replacing them will more realistic appraisals of danger and competence
The fact is that all humans have inaccurate or unhelpful thoughts
Examples: Chicken Little and Spongebob Squarepants or Harry Potter (link in Feeling Thermometer ratings as going through different points in example and after telling story go back and have audience help character come up with more helpful or accurate thoughts and see ho wit changes FT ratings, affect, behavior). Use other examples from community, like athletes, pop culture celebrities, etc.
COMMON ISSUES:
It is important to clarify that cognitive restructuring should only be used with MALADAPTIVE THOUGHTS (that is, inaccurate and/or unhelpful). So if a child has a thought about a situation (I.e., come home and mom’s drunk, thinks “this is bad news and/or unsafe” this is very likely to be accurate and adaptive. Thus, we don’t want to challenge or change these thoughts. This is an example of a situation where we would want to be sure the child could use social problem solving to look at options for managing their thoughts and actions in the situation. AGAIN, this section is to help get at some of the core unhelpful thoughts that are interfering with children’s functioning.
It is important to note that the idea is not to go from an inaccurate “negative “ thought to an inaccurate “positive” thought. For example, if someone hates public speaking, their automatic thoughts prior to a presentation may be “I am going to forget what to say.” “I will have a heart attack” “they will see me shaking and laugh at me” “I will look stupid” “I can’t do this” . It is no more helpful to have the the person think unrealistic positive thoughts, such as “I will have a great time” “I love public speaking” “I will be amazing and feel perfectly comfortable”. It will be helpful to arrive at a realistic group of thoughts that are more accurate and also helpful such as, “This may be uncomfortable but I can get through it” “It usually gets easier once I get started” “ Even if I forget something, they don’t know what I was going to say in the first place” “ I’ve felt this way before and it never turned out as bad as I feared.”

39. RECOVERY SCHEMAS Traumatic Event Post - Trauma Events Records Self
“It was not my
fault, I handled it
as well as could be
expected.”
“Some but not all people
can be trusted, PTSD
symptoms are normal and
temporary.”
SCHEMAS
Self
Schema
“I am mostly
competent.”
World
“The world is
mostly safe.”
Pre
Trauma Records:
Balanced, flexible premises about
“self” and “world”
RECOVERY
This is a model of how RECOVERY happens after trauma.
Highlight three parts, and how each is pretty balanced and flexible:
“pre-trauma records” up top
“trauma records” to the left side
“post-trauma records” on the right side
All these interact to develop “schemas” in the middle.
Schemas that contain ideas like “I am mostly competent” and “The world is mostly safe” would lead a person to eventual recovery
From: Foa, E. B. & Jaycox, L. H. (1999.) Cognitive-behavioral treatment of post-traumatic stress disorder. In Spiegel, D. (Ed.)
Efficacy and Cost-Effectiveness of Psychotherapy. Washington, DC: American Psychiatric Press.

40. Schematic model underlying pathology
Traumatic
Event
Post -
Trauma
Events
PATHOLOGY
Records
“I failed, It is
my fault, I
deserve what
happened.”
“People are
untrustworthy,
PTSD symptoms are
dangerous.”
SCHEMAS
Self
Schema
“I am entirely
incompetent.”
World
“The world is
entirely
Pre
Records:
Extreme, rigid premises
about “self” and “world”
From: Foa, E. B. & Jaycox, L. H. (1999.) Cognitive-behavioral treatment of post-traumatic stress disorder. In Spiegel, D. (Ed.)
Efficacy and Cost-Effectiveness of Psychotherapy. Washington, DC: American Psychiatric Press.
Schematic model underlying pathology
This is a model of how PATHOLOGY, or LINGERING PROBLEMS happen after trauma.
Highlight three parts, and how each is in this model are rather rigid or negative
“pre-trauma records” up top
“trauma records” to the left side – can point out here that SELF-BLAME is a really big problem in kids
“post-trauma records” on the right side
All these interact to develop “schemas” in the middle.
Schemas that contain ideas like “I am entirely incompetent” and “The world is entirely dangerous” would lead a person to continued problems

41. Cognitive therapy (Sessions 3 & 4)
Pitfalls
Too much focus on surface thoughts, not the ones that drive emotion
Need to look for thoughts that “match” emotion. Can keep an eye out for the most common maladaptive thoughts related to trauma
Could make students feel badly about the way they think
Continually normalize these kinds of thoughts, link them to traumatic event
Demonstration
DEMO: 1) Link between Thoughts and Feelings: Walking into Cafeteria Example from manual (list on board)
2) Guide through Hot Seat Procedure
3) Pass out and review List of questions to challenge anxious/dangerous thoughts and demonstrate with
A) Noise in the other room example (using a trainer or a volunteer in hot seat; questions to coach)
B) Example relevant to trainees (I.e., you just got a voice mail from boss/supervisor saying “I need to see you right away.” with volunteer from audience
C) If time allows, another example from group or from manual

42. Cognitive restructuring
Here’s an example of a child identifying automatic and hot seat thoughts and a visual representation of them.
Note: This is not an example from the manual.

43. ADAPTIVE COGNITIVE COPING THOUGHTS
Can use this cartoon to indicate that adaptive thinking does not always do it all – that we recognize REALITY and that bad things do happen. Explain that we have various ways to work on problems, and the cognitive one is just one way.

44. Exposure: Processing the trauma memory [Individual Session(s)]
Why?
To decrease anxiety when thinking about the trauma
To help child “process” or “digest” what happened to them
To build parent and peer support and reduce stigma
How?
Individual sessions in which child recounts the trauma
Encouragement to talk about the trauma at home while the groups are running
Exposure-the first exposure to trauma memory occurred in the privacy of the individual therapy session.
Subsequent exposures took place in group, through drawings and descriptions of the event.
An emphasis on feelings of grief allowed children to express and cope with grief reaction.

45. Avoidance 1 9 8 7 6 FT 5 4
Avoidance is an important concept to understand in this program, and something we need to teach students because we’re going to be asking them to start approaching things they have been avoiding since the trauma, including thoughts or memories of the event, or people or places associated with the event.
What happens when you approach something that you typically avoid? You feel very anxious. What happens when you then avoid it? Your anxiety immediately goes down. So avoidance is terribly reinforcing, because you quickly learn that you have less anxiety if you avoid that situation.
Then there’s the snowball effect. The longer we avoid something, the huger it becomes and more and more anxiety becomes associated with it. Example, of first day of school. You feel anxious and don’t go, how do you feel the second day? And two weeks later? 3 2 1
Time

46. Exposure-Avoidance vs. Habituation1 9 8 7 S 6 U 5 D S 4
Show white line (as seen in last slide)
What happens if you stay in the situation (or stick with the thought or memory), even though you feel anxious, and do not avoid it? Your anxiety level may stay high for longer, but it will eventually decrease (show gray line). Child-friendly example: how long can you run as fast as you can? What happens to your body after a short time? It becomes tired because it can’t maintain that level of energy/adrenaline. The same is true for anxiety. Our bodies can’t stay revved up forever, we eventually adapt to the situation when we realize that all the bad things we thought would happen don’t, that we can handle it, and our anxiety goes down. 3 2 1
Time

47. Exposure-Habituation contd.1 9 8 7 S 6 U 5 D S 4
After repeated exposures to the situation, our anxiety begins to decrease; it doesn’t go up as as high and it comes down more quickly. 3 2 1
Time

48. How to help students process the memory
Provide an example and rationale of why to do this
Tell the student to tell the story of the trauma in movie-like details and take notes
Break down story into parts and ask student what he/she feels (NOW) at each part
Ask student to re-tell story, and get fear ratings for the 2-3 most bothersome parts.
Repeat until distress is reduced if possible, or schedule another meeting
Plan for disclosure and support in the group meetings (Sessions 6 and 7)
Demo:
1) Provide rationale with Food/digest example. Today we are going to help you start digesting it by talking about it and also make a plan for how to continue digesting it for the rest of the group, Then you will: a) feel less upset about it each time you think of it b) Learn that it is a bad memory that can’t hurt you anymore or make you go crazy and c) Learn that you can take control of your feelings and do things to make yourself feel better.
2) Have student tell event like a movie-in detail and take some notes on each part of the story
3) Ask student to give current FT rating for each part of the story (how hard is it for you to think/talk about that part of your story RIGHT NOW).
4) Ask student retell story several times, askking for 2-3 ratings at the parts of the story that seem most salient based on their initial ratings. Have student retell story until ratings come down significantly (at least half of what they were at their highest for those parts).
5) Discuss with child which parts of story he/she would like to work on in the group sessions (6 & 7)
6) Ask student how she/he may feel supported by the group and also support other group members.
COMMON ISSUES
Trainees need to be frequently reminded (including during supervision of role plays) that FT ratings are to reflect how it feels to think/talk about parts of the story RIGHT NOW IN THE PRESENT, not what it was like then (that will always be bad).
Trainees sometimes struggle with when to begin and end the trauma narrative, We try to keep it to the same day…what was happening just before the event; when did it come to a naturalistic conclusion (usually same day for family and community violence—but could be longer in cases of abduction, natural/technological disaster, etc.). The trauma narrative should not include all of the continued negative consequences of the event (these can be addressed in hierarchy, problem solving etc.)
GRIEF: when a child has lost a loved one or vital resources (things), this session enables the child to process some of their grief related to their traumatic event. Given a chance to talk about and process what happened, a child may be able to start to also remember positive things about the person and not just the traumatic thing or event that is part of their symptomatology. Although they will miss that person and whatever happened was terrible, they can also reflect on positive memories about the person.

49. Therapist Stance During Exposure
Quiet
Supportive / empathic
Probing only as necessary to engage the student
Not asking why’s or how’s or trying to analyze what happened
Demo:
1) Provide rationale with Food/digest example. Today we are going to help you start digesting it by talking about it and also make a plan for how to continue digesting it for the rest of the group, Then you will: a) feel less upset about it each time you think of it b) Learn that it is a bad memory that can’t hurt you anymore or make you go crazy and c) Learn that you can take control of your feelings and do things to make yourself feel better.
2) Have student tell event like a movie-in detail and take some notes on each part of the story
3) Ask student to give current FT rating for each part of the story (how hard is it for you to think/talk about that part of your story RIGHT NOW).
4) Ask student retell story several times, askking for 2-3 ratings at the parts of the story that seem most salient based on their initial ratings. Have student retell story until ratings come down significantly (at least half of what they were at their highest for those parts).
5) Discuss with child which parts of story he/she would like to work on in the group sessions (6 & 7)
6) Ask student how she/he may feel supported by the group and also support other group members.
COMMON ISSUES
Trainees need to be frequently reminded (including during supervision of role plays) that FT ratings are to reflect how it feels to think/talk about parts of the story RIGHT NOW IN THE PRESENT, not what it was like then (that will always be bad).
Trainees sometimes struggle with when to begin and end the trauma narrative, We try to keep it to the same day…what was happening just before the event; when did it come to a naturalistic conclusion (usually same day for family and community violence—but could be longer in cases of abduction, natural/technological disaster, etc.). The trauma narrative should not include all of the continued negative consequences of the event (these can be addressed in hierarchy, problem solving etc.)
GRIEF: when a child has lost a loved one or vital resources (things), this session enables the child to process some of their grief related to their traumatic event. Given a chance to talk about and process what happened, a child may be able to start to also remember positive things about the person and not just the traumatic thing or event that is part of their symptomatology. Although they will miss that person and whatever happened was terrible, they can also reflect on positive memories about the person.

50. Exposure: Processing the trauma memory [Individual Session(s)]
Pitfalls
Student gets very upset, feels overwhelmed
Therapist needs to take care to temper the experience (e.g., fast forward) for the student and normalize upset
Student feels nothing, shuts down
Therapist can ask for more detail, find ways to engage student. But in early intervention group approach, not necessary to “dig up” the trauma if there is little distress.
Demo:
1) Provide rationale with Food/digest example. Today we are going to help you start digesting it by talking about it and also make a plan for how to continue digesting it for the rest of the group, Then you will: a) feel less upset about it each time you think of it b) Learn that it is a bad memory that can’t hurt you anymore or make you go crazy and c) Learn that you can take control of your feelings and do things to make yourself feel better.
2) Have student tell event like a movie-in detail and take some notes on each part of the story
3) Ask student to give current FT rating for each part of the story (how hard is it for you to think/talk about that part of your story RIGHT NOW).
4) Ask student retell story several times, askking for 2-3 ratings at the parts of the story that seem most salient based on their initial ratings. Have student retell story until ratings come down significantly (at least half of what they were at their highest for those parts).
5) Discuss with child which parts of story he/she would like to work on in the group sessions (6 & 7)
6) Ask student how she/he may feel supported by the group and also support other group members.
COMMON ISSUES
Trainees need to be frequently reminded (including during supervision of role plays) that FT ratings are to reflect how it feels to think/talk about parts of the story RIGHT NOW IN THE PRESENT, not what it was like then (that will always be bad).
Trainees sometimes struggle with when to begin and end the trauma narrative, We try to keep it to the same day…what was happening just before the event; when did it come to a naturalistic conclusion (usually same day for family and community violence—but could be longer in cases of abduction, natural/technological disaster, etc.). The trauma narrative should not include all of the continued negative consequences of the event (these can be addressed in hierarchy, problem solving etc.)
GRIEF: when a child has lost a loved one or vital resources (things), this session enables the child to process some of their grief related to their traumatic event. Given a chance to talk about and process what happened, a child may be able to start to also remember positive things about the person and not just the traumatic thing or event that is part of their symptomatology. Although they will miss that person and whatever happened was terrible, they can also reflect on positive memories about the person.

51. Approaching anxiety-provoking situations(Session 5)
Why?
To teach children that anxiety does not last forever
To get children able to do all the things they want and need to do
To build confidence
How?
Identify things children are avoiding related to the trauma, that are safe to do
Make a plan for decreasing that avoidance
Practice approaching those situations and staying long enough for anxiety to decrease or go away

52. Anxiety fear hierarchy
Fear Thermometer
Fear Hierarchy
Situation Rating
Going to the park alone 10
Going to the park with friends 8
Going to the park with parents 6
Playing outside alone 6
Playing outside w/ brother
Seeing best friend 4
Going to different park 4
Driving past park 2
Most Scared/Upset 10 9 8 7 6 5 4 3 2 1
(Demonstrate with worksheets from manual.) The child will identify one or two things they have been avoiding/that’s been hard for them to do since the trauma that is impacting their lives/functioning. As the facilitator, your job is to help the child break those things down into manageable steps by creating a hierarchy. For example, this student identified going to the park, playing outside, and seeing his friend as things he avoided. His fear thermometer ratings for those two things were 10, 6 and a 4. The therapist helped him break each of those things down by altering the situation to make it less anxiety-provoking (using other people or places), getting ratings for each situation, so that he has a hierarchy with a range of ratings. The goal is to identify situations that are less anxiety provoking to start with and build mastery. Remember that imaginal exposures, looking at pictures or internet images, reading about things or situations, can be good first steps ina hierarchy that may have rating under a 4.
Least Scared/Upset

53. Approaching anxiety-provoking situations (Session 5)
Pitfalls
Does not apply to all students
Focus on this with avoidant students. For non-avoidant students, put other useful things on their hierarchy (e.g., talking in front of class)
Parents do not support homework
Work with parents on their own anxiety and avoidance, find a motivator for them to get things back to normal at home
It is too dangerous to approach these activities
Dangerous situations should not be attempted. Instead, find ways to make them safe (vary time of day, alone or with others, location)
They get more anxious, not less
Careful planning is crucial
Demo:
Session 5 fear hierarchy construction—we ask them to rank order a list of things they may be avoiding or may have stopped doing after the stressor (handouts: List, feeling thermometer, instructions, homework sheet) Ask them for examples of a particular case & what had been avoided.
Have trainees break up into pairs (they can think about what avoidance may have been caused by the trauma example used in the individual sessions role play) and take turns playing role of clinician/child to construct a rounded out hierarchy. Have them finish the role play by assisting the “child” in selecting 2 items form the hierarchy that would be appropriate for the homework assignment.

56. Exposure: Processing the trauma memory (Sessions 6 & 7)
Why?
To decrease anxiety when thinking about the trauma
To help child “process” or “digest” what happened to them
To build parent and peer support and reduce stigma
How?
Group sessions in which the child draws pictures or tells others about the trauma
Builds upon Individual Session Work
Encouragement to talk about the trauma at home while the groups are running
Imaginal, Pictorial, & Verbal exposures
Exposure-the first exposure to trauma memory occurred in the privacy of the individual therapy session. Subsequent exposures took place in group, through drawings and descriptions of the event. An emphasis on feelings of grief allowed children to express and cope with grief reaction.
It can be helpful to role play the guided imaginal exposure, so that trainees get the idea of how a general guidance can provide individualized exposures (I ask kids to hold up fingers with ratings as we go to be sure they are habituating—you can demonstrate this with the trainees if time permits).

57. Social problem-solving (Sessions 8 & 9)
Why?
To decrease impulsive reactions and decisions
To improve real-life problems
To build skills in handling future problems
How?
Teach children the link between thoughts and actions
Teach children to “brainstorm” solutions to a problem
Teach children to weigh the “pluses and minuses” or “pros and cons” for possible actions
Practice in group with real problems and worksheets at home
Social Problem-Solving: Standard social-problem solving techniques were taught to combat the anger and impulsivity that can follow a traumatic event

58. Social problem-solving (Sessions 8 & 9)
Pitfalls
Get stuck on a complicated problem.
Work on just a part of the problem. Pick examples carefully.
Seems impossible to solve this one.
Therapist can examine own negative thoughts! Can always put information-gathering, seeking social support on the list of solutions.
Demo: 1) Thoughts influence actions—use an example from session 8 SO CHECK OUT YOUR THINKING BEFORE ACTING
2) 4 parts to every problem (list these on the board and discuss)
3) PS: BRAINSTORM, PROS and CONS, JUST DO IT, Choose new plan if necessary
4) Go through an example (namecalling/rumor, parents fighting) OR watch DVD
5) Use an example generated by your group. It can be powerful to include a more serious example as well, such as domestic violence or parental substance abuse. Emphasize that students will give a range of possible actions during brain- storming, which is ok, because we want them to see that they have options, even in terribly difficult situations. Help students identify pros and cons of each.
6) Split up group to role play Pros and Cons

59. Graduation/Relapse Prevention (Session 10)
Certificates
Celebration of Progress
Special activity/food/party
Troubleshooting and applying CBITS skills to upcoming stressors
This is the final session to celebrate the students’ hard work and the progress they have made. It’s nice to have a celebratory environment and maybe special food/drink. Take some time to directly appreciate something about each child’s role in the group and/or progress. Many times the group members also like to say something positive about each other member. Also emphasize relapse prevention strategies; helping students plan for dealing with on-going issues or other stressful events that may happen or be foreseeable, and address specific areas of concern based on students’ symptom presentation (eg, for a student who avoids, how can they address that so they don’t start avoiding again, etc.)

60. Other Treatment Issues
Inclusion/Exclusion Criteria
Referrals
Reinforcement/Rewards
Homework
Missed Sessions
Few students were excluded in our study, but each site needs to decide their own criteria (eg, some may chose to include sexual abuse trauma if they are in a community clinic, etc.)
-Have referrals available for students who may need additional clinical services; for families, including those who choose not to participate; and for parents who would benefit from their own services.
-Although not discussed explicitly in the manual, the use of reinforcement and rewards is encouraged. The tasks we ask them to do are difficult, so it is important to reward their efforts. Even students who do not turn in homework, for example, should be rewarded for going through the exercise in group.
-Even though we encourage and reward students for completing their homework, expect that not all homework sheets will be turned in. The beginning of each session is scheduled for homework review and is a great time to allow students to practice during the session. Often, students will say they did not complete the sheet but they did practice something, so sharing it with the group is helpful to reward their efforts and to reinforce the concepts.
-Students will miss sessions, it’s not unusual, and how to handle it depends on your resources. If you have time to meet individually with those students before the next session, that is great, but it is sometimes not possible. The homework review at the beginning of the session can help students who missed catch up. If a student misses the first session, it is important to meet with them before session two to review confidentiality and introduce the group concept. Otherwise, use your clinical judgment to determine the best way to handle missed sessions. (An often asked question: students have not been excluded or punished for missing sessions.)

61. Parent and Teacher education sessions
Parent Education Sessions
2 sessions related to CBITS
Cover the 6 main techniques
2 sessions relevant to other parent concerns
Teacher Education Sessions
Overview of CBITS program
Tips for working with traumatized youth
Parent participation is often less than optimal, but the program still works! Try to reduce attendance barriers by providing food, child care, altering the times of day, etc. Examples of other parental concerns including parent management/discipline strategies and immigration issues. Parents often find support during these sessions, which tend to focus on common symptoms.
Teacher sessions are difficult to schedule due to teacher schedules. Options: try to get on the agenda of an existing meeting or during a teacher prep day when they have time. Teachers often want information about how the program will affect them, so important to cover logistics such as group schedule, pulling students from class, concerns about students acting out when they return to class, etc.

62. Part 5: Next Steps for CBITS Implementation

63. Gaining support from the school administration
First meeting with the Principal
Discuss the impact of PTSD in terms relevant to educators
Academic achievement
Grades and standardized tests
Emotionally Disabled (ED) Students and IDEA
Improving classroom behavior and performance
Coordinate with other relevant services on campus

64. Gaining support from school community
Liaison with teachers
Find ideal time for group
Present education about trauma to teachers and respond to any concerns about program
Outreach to parents
Depending on community and school issues, consider working with parent leaders to engage parents in process
Develop parent component depending on needs of parents

65. Forming CBITS groups
Screen about 60 students to form one group of 6-8 participants
If there are multiple groups, consider age and gender in forming groups
Start at the beginning of the quarter to make sure that there is time to screen, score, meet with eligible students individually, and complete the program (17-20 weeks)