Psychoanalysis of Perks of Being a Wallflower

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What Constitutes Childhood Trauma?

Many children1 experience stressful events as they are growing up. They are faced with challenging situations, such as parental divorce or the death of a beloved elderly relative, which may be difficult, painful, and stressful to varying degrees. Yet these experiences would not usually be considered traumatic, which by definition is a qualitatively different expe- rience. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) has revised the definition of events that qualify as “traumatic” (i.e., those that can lead to trauma- specific diagnoses such as posttraumatic stress disorder [PTSD]) to include those that the child directly experiences, witnesses, or learns about that involve actual or threatened death, serious injury, or sexual violence (American Psychiatry Association, 2013, p. 271). Some examples include, but are not limited, to child physical, emotional, or sexual abuse or neglect; witnessing or being the direct victim of domes- tic, community, or school violence; severe motor vehicle and/or other accidents; natural and human-made disasters; violent or accidental death of a parent, sibling, or other important attachment figure; exposure to

1 Throughout this book, the term children is used to refer to children and adolescents and parent to refer to the nonoffending parent(s) or primary caregiver(s) attending treatment with the child, recognizing that this adult is often not the child’s birth par- ent.

C H A P T E R 1

The Impact of Trauma and Grief on Children and Families

Cohen, Judith A., et al. Treating Trauma and Traumatic Grief in Children and Adolescents, Second Edition, Guilford Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/rutgers-ebooks/detail.action?docID=4774206. Created from rutgers-ebooks on 2021-01-15 05:59:57.

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4 TRAUMA‑ FOCUSED COGNITIVE‑ BEHAVIORAL THERAPY

war, terrorism, or refugee conditions; and multiple or complex traumas. There is lively discussion within the child trauma field about whether the DSM concept of trauma is too narrow, both in conceptualizing the types of experiences that can lead to trauma responses and the nature of those trauma responses. Many believe a new diagnostic entity is needed to cap- ture these two concepts (Briere & Spinazzola, 2005)

Even after experiencing such traumatic events, many children are resilient and do not develop enduring trauma symptoms. Several factors, including developmental level, inherent or learned resiliency, and exter- nal sources of support, may influence which children will develop diffi- culties. A child’s response to a traumatic event may be mediated by his/ her age and developmental level. For example, it appears that for short- lived traumas, younger children are more dependent on their parents’ reaction to that trauma than older children (regardless of how great their exposure); if their parents cope well and are supportive of the child, many younger children do not develop serious or long- lasting trauma symptoms (Laor, Wolmer, & Cohen, 2001). However, ongoing interpersonal trau- mas that start early in life have the potential to cause even more serious trauma symptoms in young children than older children. Younger chil- dren do not have the developmental capacities for understanding or self- regulating when the person who should be protective is unable to shield the child or is even perpetrating the violence (Lieberman & Van Horn, 2008, pp. 22–24). Thus, in some traumatic circumstances, younger age may be protective whereas in other circumstances, it may confer greater risk.

Another documented factor that significantly impacts children’s response to trauma is the amount and quality of trauma- related emo- tional support that they receive. In fact, parental support was found to be a significant predictor of children’s mental health outcomes in two Trauma- Focused Cognitive- Behavioral Therapy (TF-CBT) treatment out- come studies (Cohen & Mannarino, 1996b, 1998b, 2000). Moreover, it is important to note that parental support can be learned and modeled by treatment providers. Parents can concretely demonstrate support to their children after trauma in various ways. These include reassuring their child that they will remain present and available to protect him/her; showing and expressing love and support; helping the child understand that things will work out using positive statements; modeling affective and behavioral modulation; and expressing belief in the child verbally and in other ways. The impact of a similar (or even a co- experienced) stressor may vary considerably from child to child depending on each child’s inherent resiliency, learned coping mechanisms, and the availabil- ity of external sources of physical, emotional, and social support. Even stressors that are considered to be traumatic universally (e.g., being the

Cohen, Judith A., et al. Treating Trauma and Traumatic Grief in Children and Adolescents, Second Edition, Guilford Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/rutgers-ebooks/detail.action?docID=4774206. Created from rutgers-ebooks on 2021-01-15 05:59:57.

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The Impact of Trauma and Grief 5

victim of rape, witnessing a murder) are experienced as less traumatic by some children than by others. This variability is illustrated by the con- trasting presentations of two 13-year-old girls who were raped by perpe- trators they met online. In each instance, the girl believed that she was meeting a 15-year-old boy in a private location for their first face-to-face date; in both cases the girl instead was confronted by a much older man who forced her into his car, drove her to a secluded spot, and violently raped her while making berating and victim- blaming statements. Each girl reported the rape within a few months to a parent who believed, sup- ported, and sought help for her respective daughter. Neither girl had a previous psychiatric history. The first girl presented with moderate PTSD symptoms. In contrast, the second girl presented with severe PTSD and depressive symptoms, as well as self- injurious (cutting) behaviors, sub- stance abuse, school truancy, and questions about her gender identity. The first girl believed that the rape happened because of the perpetra- tor’s criminal behavior. The second girl believed that the rape occurred because “I’m stupid and worthless, just like he [the perpetrator] said.” These contrasting cognitions suggest very different coping responses (and perhaps inherent resilience based on genetic or other factors), as well as ways that intervention might be individually tailored to meet these respective girls’ needs.

It is common to observe a marked range of responses to the same traumas experienced even among siblings in the same family exposed to the same horrific events. For example, in one case of ongoing neglect and parental substance abuse, after the mother had been absent for several days, the 10-year-old son and 13-year-old daughter found their mother lying in the hall, dead of an apparent overdose. The son developed severe PTSD symptoms whereas his 13-year-old sister denied any PTSD or sad- ness about her mother’s death, presenting primarily with anger at her mother and externalizing behavior problems. In another situation in which there was a long- standing history of domestic violence, the father shot the mother in front of the children, killed the youngest son, and then turned the gun on himself. All of the surviving children were pres- ent when this occurred. However, all three children had markedly differ- ent responses. The youngest surviving child, a 7-year-old girl, had severe symptoms of PTSD; the 14-year-old son had no apparent PTSD or depres- sive symptoms but had serious aggression problems that required inpa- tient hospitalization; the 12-year-old daughter had only moderate depres- sive symptoms and focused on caring for and comforting her younger sister. Clearly, the reasons for the vastly different responses are complex, but the bottom line is that the experience of trauma depends not only upon exposure to a traumatic event but also on the individual child’s response to that event.

Cohen, Judith A., et al. Treating Trauma and Traumatic Grief in Children and Adolescents, Second Edition, Guilford Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/rutgers-ebooks/detail.action?docID=4774206. Created from rutgers-ebooks on 2021-01-15 05:59:57.

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6 TRAUMA‑ FOCUSED COGNITIVE‑ BEHAVIORAL THERAPY

This variation in response occurs, in part, because children have unique ways of understanding traumatic events, making meaning of these events in relation to themselves, accessing familial and other forms of support, coping with the psychological and physiological stress associ- ated with these events, and integrating these events into their larger sense of self. Particularly when children experience interpersonal traumas (e.g., child abuse, domestic violence, traumatic deaths), they not only develop “typical” PTSD responses such as overgeneralized fear or maladaptive cognitions and hyperarousal, but they also often struggle with the loss of their primary attachment figure and of their identified role in the fam- ily. Frequently, children report that the latter changes are the most dif- ficult and painful. One teen experienced chronic neglect and commercial sexual exploitation by her mother’s drug dealers. This teen took care of her younger siblings, frequently missing school or going without food herself to fulfill this role. After her teachers reported her truancy, Child Protective Services (CPS) investigated and removed the children from the mother’s care. The teen was separated from her younger siblings because they were placed together in a different foster home. Shortly thereafter, her mother was found dead of a heroin overdose. When starting treat- ment, the teen stated that her “worst” trauma was being removed from her mother’s care and separated from her younger siblings. She blamed her mother’s death on CPS for removing them from the home, suggest- ing that this prevented her from being able to “keep an eye on my mom.” She worried constantly about her younger siblings and exhibited extreme anger at “the system” for hurting her family. She had PTSD symptoms related to sexual abuse and neglect, but her most urgent initial present- ing symptoms were related to separation from her siblings and loss of her role as the person who protected them. This response made sense in the context of her perceptions of what had helped her family survive.

The treatment model described in this book, TF-CBT, was developed for traumatized children. Like any treatment model, TF-CBT is not a “one-size-fits-all” approach. This model is not appropriate for every child who has been exposed to a traumatic experience, but only for children who have trauma- related emotional or behavioral problems (“trauma responses”) to serve as the treatment target(s) in TF-CBT.

These trauma responses often, but do not always, correspond to symp- toms of PTSD. Children do not need to meet full PTSD diagnostic criteria to receive or benefit from TF-CBT. Some children may have relatively few symptoms associated with typical PTSD but may have other types of trauma responses. As described in the following section and in more detail in the next chapter, children’s trauma responses may include dys- regulation of affect, behavior, biology, cognitions, interpersonal/attach- ment relationships, and/or perceptions. Children with a wide range of

Cohen, Judith A., et al. Treating Trauma and Traumatic Grief in Children and Adolescents, Second Edition, Guilford Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/rutgers-ebooks/detail.action?docID=4774206. Created from rutgers-ebooks on 2021-01-15 05:59:57.

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The Impact of Trauma and Grief 7

symptoms benefit from TF-CBT. With that said, not every behavioral or emotional symptom is necessarily related to a child’s trauma experience. Careful and skillful assessment and case formulation are critical initial steps in effectively implementing TF-CBT. This process is detailed in the following chapter.

The TF-CBT model can also be tailored to meet individual children’s needs. For example, a child with complex trauma may need modifica- tions that include providing more TF-CBT treatment sessions (up to 25 for children with complex trauma), changing the proportionality of TF- CBT phases to focus more on the initial stabilization skills, and imple- menting the enhancing safety component at the beginning of treatment as described elsewhere (Cohen, Mannarino, Kliethermes, et al., 2012).

As described in detail below, this book also describes the application of TF-CBT for children who have experienced traumatic grief. We define childhood traumatic grief as the development of significant trauma symptoms following the death of a parent, sibling, or other important attachment figure that interfere with typical grief responses, leading to co- occurring trauma and maladaptive grief responses. Debate continues about how to best define, describe, and assess traumatic, complicated, or maladaptive grief responses across development. The most recent example is the inclusion of persistent complex bereavement disorder in DSM-5 as a “condition for further study” (American Psychiatric Associa- tion, 2013, p. 789). Regardless of how such difficulties are defined in the future, effective interventions are needed to ameliorate children’s men- tal health symptoms, particularly when these persist for many months or even years following the death of an important attachment figure. The traumatic grief treatment approach described in this book integrates trauma- and grief- focused components in a sequential manner, such that once trauma symptoms have abated, the therapist helps the child and par- ent to resume a more typical grief process. The trauma- focused treatment components are described in Part II of this book, and the grief- focused treatment components are described in Part III.

What Are Trauma Symptoms?

We use the term trauma symptoms to refer to emotional, behavioral, cog- nitive, physical, and/or interpersonal difficulties directly related to the traumatic experience. These symptoms often, but not always, correspond to symptoms of PTSD, but they also encompass many other symptom constellations, often those associated with depression, anxiety, behavior, and/or substance use problems. Children with trauma symptoms may experience a profound change in the way they see themselves, the world,

Cohen, Judith A., et al. Treating Trauma and Traumatic Grief in Children and Adolescents, Second Edition, Guilford Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/rutgers-ebooks/detail.action?docID=4774206. Created from rutgers-ebooks on 2021-01-15 05:59:57.

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8 TRAUMA‑ FOCUSED COGNITIVE‑ BEHAVIORAL THERAPY

and/or other people as a result of their exposure to one or more trau- matic events. These changes are expressed in their cognitions as well as in their affective responses, both of which are reflected in the new DSM-5 cluster of negative alterations in cognitions and mood associated with the trauma (Cluster D). There is growing evidence that many of these children also experience psychobiological changes, which may contribute to the development and maintenance of these psychological symptoms. We have divided these symptoms into several general categories: affective, behavioral, cognitive, interpersonal, complex trauma, and biological trauma symptoms. These divisions are somewhat arbitrary in that these areas of difficulty overlap and continuously interact. For example, as we described earlier, two critical changes that may occur after trauma are loss of impor- tant attachment relationships and loss of family roles. We have chosen to include these in the affective, cognitive, and interpersonal categories, but they could easily have merited separate categories.

Trauma symptoms often occur in response to trauma reminders (sometimes called triggers). Trauma reminders are internal or external cues that remind children of their original trauma experiences. Trauma reminders may include people, places, things, conversations, activities, objects, situations, thoughts, memories, sounds, smells, or internal sensa- tions that the child associates with the traumatic event(s). When the child is confronted with a trauma reminder, he/she may experience feelings similar to those experienced during the original trauma. This can lead the child to think and act as if the trauma were recurring, even though he/ she is now safe. One perpetrator would use a loud and threatening voice to intimidate a child from disclosing the physical and sexual abuse. When the child was subsequently placed in foster care and her foster mother or teachers at school raised their voices to discipline her, she became extremely dysregulated and angry. On one occasion, the child ran away in fear that the foster mother would abuse her after using a harsh voice to correct her. Neither the child nor her foster mother was aware that she was responding to the trauma reminder of loud or harsh voices. Once they recognized this during TF-CBT treatment, they were able to develop successful alternative strategies.

Children are often brought to treatment because of behavioral or emotional dysregulation rather than because of their trauma history. This is particularly the case for youth with complex trauma who present with significant dysregulation in multiple domains of functioning. Since parents and other adults often do not understand that these problems are related to the child’s previous trauma experiences, it is critical to rec- ognize, identify, and make connections between trauma reminders and the child’s presenting symptoms. Doing so helps the family conceptualize

Cohen, Judith A., et al. Treating Trauma and Traumatic Grief in Children and Adolescents, Second Edition, Guilford Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/rutgers-ebooks/detail.action?docID=4774206. Created from rutgers-ebooks on 2021-01-15 05:59:57.

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The Impact of Trauma and Grief 9

the child’s problems as trauma responses, which then often allows family members to embrace the child’s need for trauma- focused treatment.

Children who experience traumatic grief also are triggered by loss reminders and change reminders. Loss reminders cue the child to remem- ber the person who died. These reminders include seeing pictures of or hearing people talk about the deceased person; birthdays or anniver- saries; or significant holidays, such as Mother’s or Father’s Day. Change reminders are cues that trigger thoughts about how a child’s way of life or identity has changed after the death. For example, when a child who has lost his Army father in combat has to transition from living among service members to a neighborhood of civilian families, he has not only lost his father, he has lost his way of life. The child whose newly widowed mother becomes the sole breadwinner may experience considerable disruption in the continuity of her life, not to mention the loss of her father.

Affective Trauma Symptoms

Common affective trauma symptoms include fear, sadness or depressive symptoms, anger, and/or severe affective dysregulation (i.e., frequent mood changes and/or difficulty tolerating negative affective states). Fear is both an instinctive and learned reaction to frightening situations. Children instinctively experience fear in life- threatening situations; the autonomic nervous system responds to this perceived danger by releasing large amounts of adrenergic neurotransmitters, which further reinforce anxiety. Fearful memories are also encoded in the brain differently than those from nontraumatic memories. Some children will subsequently experience the same physiological and psychological fear reactions when exposed to reminders of the traumatic event (e.g., a child who was in a serious car accident, which may have included a fatality, may become terrified whenever he/she rides past the site of the accident). This fear response can then become generalized so that people, places, things, or situations that are inherently innocuous but that remind the child of the traumatic event will cause the same level of fear as the original trauma (e.g., this child might experience intense fear when riding anywhere in a car). The intrusion of fearful memories is characteristic of PTSD; chil- dren may have intrusive, frightening thoughts during the day or scary dreams at night. In younger children the content of these scary dreams may not be related to the traumatic event in an obvious way, but may instead depict other frightening things; the development of new fears (with no apparent relationship to the trauma other than temporal prox- imity) may be a PTSD symptom in very young children (Scheeringa, Zea- nah, Myers, & Putnam, 2003).

Cohen, Judith A., et al. Treating Trauma and Traumatic Grief in Children and Adolescents, Second Edition, Guilford Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/rutgers-ebooks/detail.action?docID=4774206. Created from rutgers-ebooks on 2021-01-15 05:59:57.

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10 TRAUMA‑ FOCUSED COGNITIVE‑ BEHAVIORAL THERAPY

In addition to specific fears, more diffuse anxiety may develop due to the sudden, unpredictable nature of the trauma. This anxious state may leave children feeling generally unsafe and hypervigilant, on guard to protect themselves from being taken by surprise the next time. A sense of impending danger can impinge on children’s ability to engage in develop- mentally appropriate tasks and contribute to their taking on responsibili- ties well beyond a maturity level typical for their age; or alternatively, to disengage from school, appropriate peers, and family and become proac- tively aggressive in the belief that this is the only way to survive. General anxiety can result in the “parentification” of a child or contribute to a child’s effort to be “perfect” to ward off potential threats in the future. A constant vigilance for possible omens of future threats and other anxiety- driven behaviors can also take hold. All of these behaviors interfere with healthy adjustment and can lead to the development of comorbid general- ized anxiety disorder as well as other comorbidities.

Children may develop overwhelmingly sad or depressive feelings after a trauma. These may arise in response to an abrupt loss of trust in other people and the world (e.g., loss of innocence, faith, or hope in the future). Many traumatized children experience more concrete losses, which lead to extreme sadness. Specifically, after a death or traumatic separa- tion that might occur suddenly, perhaps due to parental incarceration, deportation, the child’s placement in foster care, or other circumstances, children may develop intense sadness, yearning for the attachment fig- ure, and the longing to be reunified. A child with traumatic grief might develop persistent suicidal ideation in an attempt to effect a reunifica- tion with a deceased parent or other deceased attachment figure. Other children also experience concrete losses during their trauma and may develop significant sadness; for example, the child who is shot or hit by a car or one who is severely beat or burned during physical abuse often experiences physical pain as well as loss of function or damaged appear- ance of body parts. Sexual abuse may result in painful genital injuries and/or one or more sexually transmitted diseases. A fire or natural disaster may result in children’s loss of personal belongings, their homes, or even the lives of loved ones. In the face of these real losses, children often develop maladaptive beliefs or cognitions (described below), which significantly contribute to depressive and other negative affective states. For example, children’s developmentally appropriate egocentric view of the world may lead to self-blame for the traumatic event, which in turn may lead to depressive symptoms that include guilt, shame, diminished self- esteem, feelings of worthlessness, and even a longing to die. Nega- tive self-image—an important issue for many traumatized children— can contribute to maladaptive choices in peers and romantic partners and self- destructive behaviors such as substance abuse, cutting, unsafe sexual

Cohen, Judith A., et al. Treating Trauma and Traumatic Grief in Children and Adolescents, Second Edition, Guilford Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/rutgers-ebooks/detail.action?docID=4774206. Created from rutgers-ebooks on 2021-01-15 05:59:57.

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The Impact of Trauma and Grief 11

practices, and suicide attempts, all of which are strongly associated with a history of child abuse or other traumas. The bottom line: Significant sad- ness and other depressive symptoms may occur as part of PTSD Cluster D (negative change in affect).

Anger may result from the awareness that the traumatic event was unfair in the sense that the child didn’t do anything to “deserve” the trauma. Other children, particularly those experiencing physical abuse or bullying, may develop anger as they observe the behavior of caretakers or others who cope inappropriately with difficulties or frustrations. Children experiencing domestic violence may develop “traumatic bonding” (Ban- croft & Silverman, 2002, pp. 39–41), in which they align themselves with the abuser (described in more detail later in the chapter). Anger in trau- matized children may take the form of noncompliant behavior, unpredict- able rages or tantrums, or physical aggression toward property or other people. Children who have experienced sexual abuse may also engage in sexual aggression toward others. It is important to keep in mind that some children have significant anger or externalizing behavioral problems that predated traumatic events; this point again emphasizes the importance of conducting a careful assessment and case formulation in determining whether trauma treatment is appropriate for an individual child.

Severely or chronically traumatized children may become highly sen- sitive and overreactive to trauma reminders (e.g., behaviors or situations that they associate with previous traumas). For example, one study indi- cated that children who have been physically abused perceive angry faces (a trauma reminder for such children) much more readily than nonphysi- cally abused children (Pine et al., 2005). Children with complex trauma commonly develop a dysfunctional degree of hypersensitivity or anger to perceived rejection because parental or other rejection in their past experience was associated with, and served as an early warning signal for, abusive or other traumatic acts. Severely traumatized children often display affective dysregulation, that is, sudden and/or extreme changes in affect accompanied by difficulty regaining affective modulation. Severe affective dysregulation occurs more commonly in children who have experienced multiple or complex trauma experiences as described below (e.g., child abuse or domestic violence), than in children who have expe- rienced a single, nonintentional traumatic event. Far from receiving the nurturing, supportive, and well- modulated coping response from parents after the trauma that would model for children how to manage upset- ting affective states, much complex trauma is perpetrated by parents who then disregard, invalidate, or even punish the child for displaying fear, sadness, or anger. For example, a child who witnessed domestic violence was told by his perpetrating parent to “shut up,” which was followed by his battered mother smacking him and yelling at him. Thus the parents not

Cohen, Judith A., et al. Treating Trauma and Traumatic Grief in Children and Adolescents, Second Edition, Guilford Publications, 2017. …