The TF-CBT model includes conjoint sessions in which the child and parent meet with the therapist to review educational information, practice skills, share the child's trauma narrative, and engage in more open communication. These sessions are intended to provide opportunities for parents and children to practice skills together, thereby enhancing the parent-child relationship, while also gradually increasing the child's comfort in talking directly with the parent about the child's traumatic experience (s) as well as any other issues the child (or parent) wants to address. In general, conjoint sessions should be carefully structured and parents should be very well prepared in order to increase the likelihood that the parent-child interactions experienced during these sessions feel safe, productive, and positive. Conjoint sessions are not convened until parents have gained sufficient emotional control to participate in such a way that they serve as effective role models of coping for their children. Thus, it is important to assess parents' and children's readiness for conjoint sessions. This assessment may be done primarily through continued observa tion of clients' coping, responsiveness to skills assignments, and emotional reactions to trauma-related material in individual sessions. Some parents, for example, may be well prepared emotionally to begin to engage in brief conjoint sessions with their children focused on psychoeducation and/or coping skill building early on in treatment, and then after some individual session preparation, are very comfortable with the conjoint sessions to share the child's trauma narration and processing later in treatment. Other parents need quite a bit of time to gradually face the trauma the child experienced, while developing their coping and parenting skills, before they are ready for any conjoint sessions.
Conjoint Child-Parent Sessions to Share Trauma Narration and Processing
The conjoint sessions in which children's trauma narratives are shared require considerable preparation in advance with parents in individual sessions. The approach, preparation, and sharing of the trauma narrative in conjoint sessions, however, may vary considerably depending on the dynamics, emotional adjustment, and the coping styles of the parent and child. With foster parents, for example, the preparation may involve having the participating foster parent read the child's narrative in individual sessions with the therapist as the child is developing the narrative. This can help the foster parent gain compassion for all the child has been through and understand the connections between the child's behavior problems and the traumas. Other parents require more time to master the coping and parenting skills in individual sessions before reading the child's narrative. In particular, parents whose children experienced sexual abuse and parents who struggle with sorrow and guilt about the traumas endured may respond better to hearing a fully processed narrative
when it is almost completed in individual parent sessions with the thera-pist. Although the therapist should have started to address the parent's personal maladaptive cognitions related to the child's traumas during the cognitive coping and processing skills component (Chapter 10), the parent may need more time to address additional maladaptive thoughts and/or painful feelings that arise from hearing the child's trauma nar-rative. Thus, it may be helpful to share the child's narration, as the child is developing it, with the parent as well. Either way, the reviewing of the narrative by parents in individual sessions can often take a couple of sessions so that parents can read, process, and prepare how they would like to respond when their children share their narratives in conjoint sessions, so as to best support their children during these sessions. Finally, it should be emphasized that sharing the child's narrative during the conjoint sessions is not a mandatory aspect of TF-CBT. In fact, in some cases, parents are not emotionally able to participate much in conjoint sessions and the sharing of the trauma narrative is contrain-dicated. Though this is relatively rare, in some cases, despite therapists' efforts to assist these parents in coping, the parents due to their own experience of childhood trauma, untreated PTSD, or depression and/ or a history of recent substance abuse) may be unprepared to cope with
hearing the details of the child's traumas. Such parents are often in their own individual therapy or may be given a referral for additional individual support. However, they may still be able to support their children to successfully complete TF-CBT. In some cases, for example, although the therapist may not feel the parent is emotionally prepared to hear the entire narrative, the child can be encouraged to read his her final narrative chapter about what was learned in the course of therapy or what he/she would tell other children about participating in treatment. Other parents may not be able to hear details of the child's traumar expert-ences but can supportively participate in other conjoint activities with the child, such as addressing safety planning or other aspects of positive parent-child communication, as described below. In sum, as noted above, the planning, preparing, and structuring of conjoint sessions should be determined based on therapists' clinical judgment on a case-by-case basis. Conjoint sessions designed for the sharing of the narrative typically occur after the child and parent have completed cognitive processing of the child's trauma experiences in individual sessions with the thera-pist. The therapist and family should decide together whether conjoint sessions would be helpful, the timing of the initiation of such sessions, and/or whether there should be relatively fewer or more conjoint sessions than individual sessions. For many families, it is easier to begin conjoint sessions with the practicing of
skills) and/or more general discussions about the trauma (e.g., playing a question-and-answer game in which parents and children compete to see who knows more general information about the trauma(s) experienced). This gradual exposure approach allows them to experience meeting together to practice skills and to gain comfort in talking about the trauma in the abstract, which in turn prepares them for reading and reviewing the trauma narrative together later in treatment For 1-hour sessions, the conjoint sessions are typically divided so that the therapist first meets with the child for 15 minutes, then with the parent for 15 minutes, and finally, with the child and parent together for 30 minutes. The therapist should be flexible in adjusting this division of time to each individual family's needs. If the goal of the conjoint sessions in the final phase of treatment is to share the child's narrative, then prior to having each set of conjoint ses-sions, the child should have completed the trauma narrative, be comfort I able reading it aloud and discussing it in therapy with the therapist, and be willing to share it with the parent. The parent should have heard the therapist read the complete trauma narrative in previous individual parent sessions, be able to emotionally tolerate reading the trauma narrative (i.e., without sobbing or using extreme avoidant coping mechanisms), and
and Counseling Page 4 *g Options – All comments be able to reflectively listen and or make supportive verbalizations when practicing responses during parent therapy sessions. In some instances, the therapist may need to review the child's narrative with the parent several times in order to help him/her gain sufficient emotional composure for the conjoint sessions to be productive. In addition, the therapist should role-play this interaction with the parent to ensure that his/her responses to the child are supportive and appropriate. The therapist can provide the parent with simple guidance to follow when responding to the child's reading of the narrative. For example, it is very helpful for parents to focus on utilizing reflective listening skills during the sharing of the narrative. The therapist, in fact, can encourage the child to pause after each chapter for the parent to reflect back some of what was shared. It is often helpful for parents to simply repeat back some of the actual words of the narrative. It can be explained to parents that by repeating some of their children's words, they are demonstrating very directly that they have heard what their children have shared, they are comfortable using the words needed (e.g., vagina, penis, intercourse, shoved, killed, burned, died) to discuss the trauma, and their children can come to them in the future to discuss related concerns. With young children's narratives, parents can repeat back the children's exact sentences, whereas with older children and teens, given the longer length of the narratives, it is more appropriate for parents to summarize what they have heard. Still, it is important for parents to reflect on the more challenging aspects of what was shared, using the language their teenagers used, again to demonstrate parental
willingness to discuss what was shared as openly as necessary. When the parent seems emotionally prepared to review the narrative with the child, the therapist should begin to work individually with the child to prepare him/her. The therapist should have the child read the trauma narrative out loud in individual sessions and suggest that the child is ready to share it with the parent. The therapist should have already mentioned, at previous trauma narrative sessions, that sharing the narra tive with the parent might occur.) The therapist should then suggest that the child write down questions or items that he/she would like to discuss with, or ask, the parent. These questions may pertain to trauma-related or other content about the child's traumatic experience(s) which the child would like to be able to talk with the parent about more openly. Some examples include how the parent feels about the petson who perpetrated the trauma; the parent's feelings or thoughts about the trauma; or any other questions about the trauma or family relationships the child may have. Despite being told that the child is not the cause of the trauma by the parent as well as others, it is surprising how often children continue to demonstrate a desire and need to ask their parents if they were, or are, mad at them for any reason. The therapist should have children discuss
these matters in individual sessions and assist them in formulating any questions that continue to trouble them. During the individual session with the parent (15 minutes before the conjoint session), the therapist should once again read the child's trauma narrative to the parent to ascertain that the parent is prepared to hear the child read the book or the section of the book to be shared directly with the parent. The therapist should then go over the child's questions with the parent and assist him/ her in generating optimal ways of responding. The parent may also have questions for the child, and the therapist should help the parent phrase these in appropriate ways. During the conjoint family session, the child may read the trauma narrative he she has written to the parent and therapist. However, sometimes children prefer the therapist read the narrative due to their desire to watch the parent's reactions and/or as a result of ongoing fears relating to upsetting the parent. The therapist may agree to read the narrative or suggest that the child and therapist take turns reading chapters. At the conclusion or during planned pauses after chapters have been read, the parent and therapist should praise the child for his/her courage in writing this trauma narrative and being able to read it to the parent. The child should then be encouraged to raise issues of concern from the list prepared earlier, taking time to discuss each issue to the satisfaction of both parent and child. If the parent has also prepared questions for the child, these should be asked after the child has completed his/her ques-
tions. The therapist's role in this interchange should be to allow the child and parent to communicate directly with each other, with as little intervention as possible from the therapist. If either the child or parent has difficulty, or if either expresses an inaccurate or unhelpful cognition that the other does not challenge, the therapist should intervene if judged clinically appropriate), so that the cognition does not go unquestioned. The therapist should also praise both the parent and child for completing the trauma narrative and conjoint family session components of treatment with such success. At the end of this conjoint session, the therapist, parent, and child should decide on the content of the conjoint session to occur the following week. Often the child and parent have enjoyed this session so much that they are enthusiastic about having another ard want to raise more issues to talk about together. If there was awkwardness or difficulty in communication, they may be less positive about the idea, but in this sit-uation, the therapist should actively encourage another joint session in order to improve the parent's and child's comfort with talking about these subjects. The conjoint sessions may also be used to provide and reinforce psychoeducation about the child's trauma-related symptoms, the specific type of traumatic event (s) the child experienced, etc.
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