SAN DIEGO – Before Laura Merchant begins trauma-focused cognitive-behavioral therapy with children and their caregivers, she provides an estimate for them of the number of treatment sessions that will be required for effective intervention.
This approach “has made a huge difference, especially for older teens and parents, when they have a sense that [therapy] won't take forever,” said Ms. Merchant, a licensed clinical social worker who is assistant director of the Seattle-based Harborview Center for Sexual Assault and Traumatic Stress. “It gives them a sense of hope.”
When developing a treatment plan, she uses her clinical judgment to estimate the number of sessions. “I tell them, 'I think this is something that may take 5 sessions, or 12 sessions,' whatever I think it may be,” she said at a conference sponsored by Rady Children's Hospital, San Diego. Then she tells them, “When we get around that time, we're going to see how things are going and see if we need to renegotiate [the number of sessions] one more time.”
Establishing a functional outcome or goal with the children and caregivers is another important part of effective trauma-focused cognitive-behavioral therapy. “My original therapeutic framework was to be very nondirective and very client centered,” Ms. Merchant commented. “I still believe we need to be client centered, but I'm also going to hold in my head what the goals are that we've agreed upon, and I'm going to keep track of that information so that when the clients get off track a bit, my job is to kind of rein them back and get refocused and readjusted so that leads to a functional outcome.”
She said she favors a treatment approach that focuses on the here and now. “I'm also going to be focusing on [current] thoughts and feelings, and how those thoughts and feelings are impacting behaviors,” Ms. Merchant explained. Assessing how the child is functioning at home, at school, and with peers is important. “If they have problems in those areas, it probably means that they need some help,” she said.
Common affective trauma symptoms include fear, sadness, anger, anxiety, and affective dysregulation. The ability to be levelheaded “can be challenging” in this patient population, she said.
Behavioral symptoms may include avoidance; modeling maladaptive behaviors such as sexualized and violent behaviors; anger outbursts; substance abuse; self-injury; defiance/disobedience; and trouble interacting with peers.
Ms. Merchant recommended the following measures: the UCLA Posttraumatic Stress Disorder Index for exposure to trauma, the Child PTSD Symptom Scale for posttraumatic stress symptoms, the brief version of the Screen for Child Anxiety Related Emotional Disorders (SCARED) for anxiety and posttraumatic stress symptoms, the Mood and Feelings Questionnaire for depression, and the Pediatric Symptom Checklist to screen for psychosocial problems.
Ms. Merchant had no relevant conflicts of interest to disclose.
Keep Questions Open Ended
Laura Merchant uses open-ended questions when counseling children who have been victims of trauma or sexual abuse. Common questions may include:
▸ Tell me about the times you think about it. What are you doing?
▸ When you think about it, what do you think about?
▸ How bothered are you when you think about it?
▸ What do you do to make it stop? Does it work?
▸ What thoughts upset you most?
▸ What do you tell yourself when you have these thoughts?