I wrote this out for a masters level clinical social work class that I teach and thought some of its principles are applicable to our convo’s here. If not, well, whatever:
(Note: This is a specific step in trauma focused CBT which comes after the child went through the crucial therapeutic step of creating his or her trauma narrative)
As always, notes are appreciated
1. Be ready.
Before the first session of cognitive processing, review the trauma narrative to plan for the session. Remember, cognitive processing involves challenging thoughts and beliefs that the child may firmly believe; it’s not a simple matter of just telling them new information. Therefore, review the child’s thoughts that were written down or verbalized, looking for examples that may be inaccurate or unhelpful (though it’s also great to identify thoughts that are accurate and praise and reinforce them).
2. Re-read the trauma narrative with particular attention to thoughts
In session, go over the trauma narrative. As each thought that was written down (or verbalized) is expressed, inquire about whether that thought was accurate and helpful. For some unhelpful or inaccurate thoughts, the client will be able to identify how his or her perceptions have changed since the event. For others, additional discussion will be necessary. You should pay close attention for thoughts or beliefs that reflect shame, guilt or responsibility for the trauma or its consequences, self-esteem, trust in others, and current and/or future safety. This is not, of course, an exhaustive list.
3. Challenge unhelpful or inaccurate cognitions
It’s important to recognize that cognitive processing interventions are NOT simply “having a talk with” a client, or “arguing away” a person’s unhelpful or inaccurate beliefs. Rather, these interventions challenge and engage the client in a process that examines his or her thoughts and beliefs. There are several effective ways of challenging thoughts, and no one technique is likely to be successful with all issues, or with all children. Therefore, it is best to learn how to address cognitive errors using numerous methods. The most common method is called “progressive logical questioning,” which is sometimes also referred to as “Socratic questioning.” This technique, common in cognitive psychotherapies, employs a series of questions designed to draw out clients’ unhelpful or inaccurate cognitions to their logical conclusions. In most cases, these conclusions are very undesirable or downright silly (“I can never have any friends ever again for the rest of my life” or “I will be traumatized again and again every day for the rest of my life, even though that has not happened to me so far.”), even though they may seem real to clients.
4. Employ role playing or experiential exercises
Other techniques that can engage clients in the process of examining their cognitions about the trauma involve role-playing or perspective-taking activities. These can be employed with children of all ages, though some modifications are likely to be necessary with younger children who lack the capacity to think about their own mental processes.
Best friend role play
Useful for clients who exhibit unrealistic levels of responsibility or shame related to the trauma. Very simply, the client is instructed to take on the role of his or her best friend, and the therapist takes on the role of the client. The task is to have the client/best-friend counsel the therapist/client regarding the client’s cognitions. (Other roles besides “best friend” can accomplish the same basic goal—parent, therapist, etc.)
Now and then role play
In this exercise, the client is asked to ‘go back in time’ to give him or herself advice about what to do about the trauma before and/or after it happens. The therapist can either play the role of the client “then,” or the client can act out both parts.
The child is asked to draw a pie chart and assign “pieces” of various sizes to different individuals who might bear some responsibility for the trauma (e.g., the perpetrator, non-offending family members, the client). The client may assign pieces and sizes to whomever he or she wants, and the size of the piece corresponds to that person’s percent of responsibility for the trauma. The therapist can then discuss the relative sizes of pie pieces with the client and use this as an exercise to help the client verbalize his or her thinking about why the trauma happened. A revised pie can be drawn if the client’s thinking about responsibility changes.
Talk show host role play
The client assumes the role of advice-giving talk-show host or radio psychologist. The therapist (and/or other family members) takes the role of callers seeking advice regarding their own experiences with trauma. The “callers’” questions address areas of particular concern for the client.