Who are clients with problem behaviors?

Treating problem behavior
Who are clients with problem behaviors?

This short article is about treating problem behavior by trauma inform approach.
Dr. Ricky Greenwald firmly believe that Clients with problem behaviors are often unresponsive to treatment. Sometimes the client has no active interest in changing. Often, even when someone dose want to change, willpower, social support and prayer are not enough. And even when your client is working hard with you the standard treatment approaches (self – control skills training, problem solving, communication skills) may not really do the job.

Why not? One string possibility is that the clients posttraumatic stress symptoms have not been taken into account. Dr. Ricky Greenwald believes exposure to trauma or loss is extremely common among those with problem behaviors can lead to a range of treatment impediment. Trauma exposed individuals may have impaired empathy and not care about the pain they cause others.

Trauma – Informed Treatment for problem Behaviors:
Problem behaviors are a big problem. As a society we are extremely concerned about youth and adult aggression and crime, domestic violence, child abuse, alcohol and drug abuse, and other addictions (gambling and pornography). We are also concerned about the angry acting out, sexual acting out and poor self-discipline that can lead to distressed relationship, unwanted pregnancy, school or work failure, health problems, and impaired quality of life.
Because such problems are so serious and so common, we have tried long and hard to solve or at least mitigate them. The primary standard of care, across problem behavior types, is self – management skills training, most notably focusing on anger management or relapse prevention. The other most common ways we try to control or eliminate problem behaviors include the following:
Parent training, especially for parents of children and preteens with problem behaviors.
Success experiences such as trying to rehabilitate criminals by finding them a job.
Education and peer support, often in groups such as alcoholics anonymous.
Legal and social sanction against the problem behaviors, sometimes leading to loss of privileges, financial penalties, incarceration social isolation.
Telling the perpetrator of the problem behaviors to stop it.
Positive thinking.
We try these because they work – at least a little, sometimes – and that’s better than nothing. But it may not be much better than nothing! Individuals with problem behaviors are notoriously difficult to help, and (with the exception of discipline training for parents of younger children) the standard of care tends to entail many more misses than hits. Indeed, many individuals with problem behaviors have learned, from repeated experiences, to feel hopeless regarding the prospect of treatment leading to meaningful change. And many therapists have learned, from their own experiences, to share that hopelessness.
For example, in the well – known “Willie M” study, comprehensive assessment and intensive case management were employed to individualize treatment from a menu options for aggressive / violent adolescents who had at least one additional disability such as emotional disturbance. In this model program, no expense was spared to provide each individual with the optimal intervention. Even so, compared with participants who were in the program so briefly that virtually no treatment was provided, participants with at least 1 year in the program showed no benefit in either number of post treatment arrests or time until first arrest.
The bottom line is that the treatment often fails to lead to client change. We typically encounter one or more of the following obstacles:
Many clients are not motivated to change.
Many clients do not engage in or commit to the treatment.
Many clients stop attending or participating in the treatment.
Many clients who make an effort in treatment fail anyway. The problem is too hard to overcome.
Many clients who appear to succeed in treatment then relapse, or they go back to their old problem behaviors.
Therapists often acknowledge a reluctance to work with problem behavior clients, because the obstacles to treatment are so difficult to overcome. That is understandable; therapists don’t like feeling ineffective and helpless any more than anyone else does. However, recognizing the problem, and perhaps avoiding it, doesn’t solve it. The key to solving a problem is understanding it.
Trauma role in problem behaviors:
Trauma exposure has been definitively implicated as leading to a higher risk
of problem behaviors in comprehensive literature reviews of violence/aggression, substance abuse, sexual offending antisocial/criminal behavior and even pathological gambling. The underlying process that leads from victimization to development of problem behaviors does not seem to require direct correspondence of victimization history and type of problem behavior. For example, a victim of sexual abuse is at higher risk of becoming a sexual abuser but is also at higher risk of becoming a substance abuser or developing some other problem. Although we have long been aware of the prevalence of trauma exposure
among problem behavior populations, we have until recently done nearly nothing to address trauma-related issues. An early example of an enlightened approach to this issue among juvenile delinquents was the Boys Town model:
Take them out of their bad environments and they will do better. This is also the prevailing model for children removed from abusive situations: Put them in a safer environment and the problem is over. Although that strategy can work with a few people, it fails to take into account the long term psychological processes that trauma exposure can engender and that interfere with improvement. This book’s treatment approach is based on the proposition that trauma is the key to understanding the treatment obstacles experienced by problem behavior clients. Therefore, it is essential to explain trauma and its role in the development and persistence of problem behaviors (including obstacles to treatment). On the basis of this understanding, solutions to the treatment obstacles are presented within the framework of a trauma-informed treatment approach.
Prevalence of Trauma:
Not long ago, trauma was defined as a horrific event “beyond the scope of normal human experience. To qualify as traumatic, an event should be subjectively perceived as threatening to a person’s life or physical integrity and should include a sense of helplessness along with fear, horror, or disgust. Such events might include being in a car accident, house fire, or natural disaster, being raped, or being assaulted. Through research we have learned to identify a wider range of events as being possibly traumatic—for example, witnessing a parent or sibling being beaten, or being diagnosed with a life-threatening illness. The bad news is that traumatic events are not beyond the scope of normal human experience. By the time most individuals become adults, they will have been exposed to one or more traumatic events. This is not just true for those growing up in high-crime urban areas. Even our (presumably) best-protected children experience trauma. For example, a study of second-year college students found that 84% had already experienced at least one major trauma. Among disadvantaged populations, very few escape exposures to major trauma events Trauma during childhood and adolescence is so common as to be normative. And of course, the longer someone lives, the more opportunity there is for exposure to trauma. When we are working with a client, we should assume trauma exposure. The Diagnostic and Statistical Manual of Mental Disorders, definition of a traumatic event is overly restrictive from a clinical perspective, because other adverse life events can have a trauma-like impact. For
example, a person’s response to a significant loss can be virtually identical to a posttraumatic response, except that following loss, hyper arousal may not be present. The research on so-called adjustment disorder shows that many children and adolescents do not adjust to or recover from a range of adverse events but maintain some symptoms indefinitely. Research with adults has shown that distressing life events such as divorce, chronic illness, or unemployment tend to lead to equal or greater posttraumatic stress disorder (PTSD) symptoms than do those events that are technically defined as traumatic When working with a distressed client, we do not ask if the adverse past event technically qualifies as a trauma. We offer essentially the same treatment regardless of whether the source of the distress is an earthquake, a sexual assault, or a death in the family. In this book, the term trauma is intended to apply to major trauma as well as loss and other adverse life events, as long as the event has had a trauma-like impact on the client.
The Trauma Wall:
A popular saying is, “What doesn’t kill you makes you stronger,” or, less colloquially, that we grow from adversity. Although this certainly can be true, it is
not always the case. Sometimes what doesn’t kill you may still hurt you or cause damage. So how does this work—why does it go one way rather than the other? Here a food analogy is helpful. Usually, we chew food, swallow it, and digest it. Ideally, we do something similar with an upsetting experience, such as what described in the stages of processing grief.
For example, let’s say your dog dies. Maybe you don’t think about it or process it every minute of the day, but now and then you do think about it, remembering different aspects: how frisky she was when you first got her, how she liked to have her belly scratched, how badly you feel about having let her out the day she got hit by a car. You remember, you talk to others, you take a walk, you write, you cry, you laugh. Little by little—or bite by bite—the hurt becomes smaller as more gets processed, integrated, “digested.” When an upsetting experience is digested, it becomes your nutrition, something you grow from. Then it becomes part of integrated long-term memory, part of the past. It is not as fresh or upsetting anymore. Along with the emotional processing, we have organized the elements of the experience into a coherent story, including a perspective that allows us to move on. For example, you might say to yourself, “Well, she loved to play outside. I guess there was always the risk of an accident, but she would have been miserable tied up,” and “She was a great dog. I’ll always love her.” However, sometimes upsetting experiences do not get processed in this ideal way. Sometimes it’s just too much to face, to take bites out of. Maybe the event was too upsetting and overwhelming; maybe you try to talk about it and are punished for that (perhaps by parents getting upset or peers rejecting you); maybe just when you are ready to take a bite out of this upsetting memory, another challenge comes along. It can be so difficult to face this upsetting memory, to tolerate it, that many people try to push it aside, push it behind a wall. This brings quick relief, so the strategy is experienced as helpful. Unfortunately, it provides only a temporary solution. Here the food analogy does not quite match what happens with trauma memories. If you eat food that is bad for you, you get rid of it. If you have an experience that’s bad for you, you may try to get rid of it (by pushing it behind the wall), but it’s not gone. The only way out is to go through—through the memory processing system into long-term memory. Until the memory is processed, or digested, it stays behind the wall.
Although the wall may provide temporary relief, this system has problems. First, the memory stays fresh and keeps its power indefinitely, until it is digested. I have worked with people months, years, and even decades after the trauma, and the quality of the unprocessed memory is the same. When asked to concentrate on the memory, they say things such as, “It’s so vivid it’s like it just happened yesterday,” or, even more telling, “I’m there.” Also, although the memory retains its freshness and power, it is still behind the wall, so we can’t get at it with the rest of our psychological resources the way we can with processed memories. This means that the memory, or parts of the memory, can negatively influence us and we may feel helpless to stop it. For example, many rape victims will say, “I know in my head that it wasn’t my fault, that I didn’t do anything wrong, that I didn’t deserve that. But I can’t help feeling ashamed, dirty, to blame.” In other words, the healthy part that knows better can’t manage to influence the powerful beliefs and feelings that are shielded behind the wall. Furthermore, the memories stored behind the wall are always waiting for a chance to come out, go through the system to be digested, and become part of the past. Sometimes the memory-related thoughts and emotions burst out from behind the wall. When this happens, we say that the memory-related material was “triggered” or activated by a reminder, something thematically related. It is as if the memory is seeing its chance and saying, “Me too! Can I finally come in and get processed already?” Another way of explaining this is that the stuff piled up behind the wall is like a sore spot and when some kind of reminder hits that sore spot, the reaction is stronger than others might expect.
This is because the person is not just reacting to what’s happening right now; the
old stuff is kicking in, too.
For example, consider a certain 12-year-old boy who has been routinely physically abused at home. Behind the wall is piled-up fear of being attacked, a sense of helplessness, and rage. When he is accidentally bumped in the hallway, he experiences the modest irritation that the situation might objectively elicit, plus the sore spot reaction from the stuff piled up behind the wall. Now he has such a strong reaction it is as if he is being traumatized on the spot; subjectively, he believes that he is being attacked. He experiences this as “too much” (as with the original trauma) and becomes desperate to get rid of the fear, anger, and helplessness. How to get rid of it as quickly as possible? Fortunately, he knows what to do: He punches the attacker. This so-called “problem behavior” is actually a solution; it pushes the fear and helplessness away. For this boy, the real problem was the sore spot reaction’s overwhelming affect. The technical term for that sore spot reaction is affect dysregulation. In a nutshell, this is a primary reason that problem behavior clients persist with their symptoms: because the symptoms provide quick relief or protection from the overwhelming effect of the sore spot reaction.
Situational Reactivity Leading to a Cycle of Problem Behaviors:
Furthermore, trauma-related affect dysregulation may trigger reactivity to a variety of situations and stimuli perceived as thematically related to the trauma. One study found that situations triggering trauma-related helplessness, and to a lesser extent fear or horror, accounted for initiating 81% of the “offense cycle” patterns of a sample of adolescent sex offenders, according to therapist ratings While the acting-out behavior may provide immediate relief from the trauma-related thoughts and feelings, the consequences of that behavior often serve to confirm the negative lessons initially learned from the trauma, thus reinforcing reactivity and continued susceptibility to reoffending.
Trauma-Related Treatment Challenges:
If trauma is one of the keys to the development and persistence of problem behaviors, then trauma treatment should be part of the solution. Unfortunately, adding a trauma treatment component would tend to make the treatment even
more challenging to accomplish. Like treatment for problem behaviors, trauma treatment has also been plagued by high dropout rates and in particular, both children and multiply traumatized individuals are considered especially challenging to treat. Antisocial adolescents are notoriously resistant to engaging in treatment in general and may be particularly difficult to engage and maintain in conventional trauma treatments. Trauma-related obstacles to treatment of problem behavior clients include challenges related to treatment engagement and to treatment tolerance and persistence.
Selecting a Trauma Treatment Structure:
The mental health field has been strongly influenced by physicians and psychiatrists, who have advocated for the medical model of diagnosis and treatment. In the medical model, the doctor determines what’s wrong and, based on the diagnosis, implements the designated treatment. The medical model is ideal for broken bones, diseases that respond to a particular medicine, and many others
medical conditions. In many instances, the correct diagnosis does lead to the correct treatment, which leads in turn to cure. However, when treating someone for posttraumatic-stress-related problems, the medical model is not appropriate. Traumatized people already feel damaged and helpless; that’s part of the problem. What happens when a helping professional takes an authoritarian role with a traumatized “patient” and says, “I know your diagnosis and I can treat you”? The professional conveys the message that “I know what’s wrong with you and I will fix you.” This only confirms the traumatized person’s perception— “I guess I really am damaged and helpless”—and reinforces the problem. Even the word patient implies that the person’s role is to sit and wait, presumably until the doctor gets around to providing the treatment and effecting the cure. Trauma-informed treatment requires a different attitude on the part of the helping professional. An empowerment model is needed that can allow and encourage the client to take initiative, to actively participate in each stage of the treatment, to recover from the trauma, and to grow from it. Quite a bit of research has been conducted to determine which types of interventions help traumatized clients the most; these include psychoeducation, stabilization, development of coping skills, and trauma resolution. Such interventions are typically sequenced within a phase model of treatment which represents the current standard of care I’ve organized these interventions, plus treatment components specific to problem behavior issues, into a systematic approach that I call the Fairy Tale model of trauma-informed treatment in this model, the fairy tale is used (loosely) as an analogy, with elements of the story corresponding to the various treatment components.
The Fairy Tale:
Once upon a time …
There was a small kingdom, about the size of a small town. Things were pretty regular there: People did their jobs, kids went to school, some people went to church or temple or mosque and some didn’t. Sometimes people would get together to share food, play games, play music, talk. Most people got along, but not everyone. And that’s the way things were.
Until one day …
The dragon came. One day the dragon ate a cow right out of a farmer’s pasture. Another day the dragon ate a dog right out of someone’s front yard. The parents told their kids that they weren’t allowed to go outside anymore. But they found out that kids aren’t very good at not going outside. So the parents stayed home to guard their kids, to keep them safe from the dragon. And even people who didn’t have kids were staying inside; they were nervous about the dragon, too. Things really slowed down in this kingdom. When people did get together, here’s what they talked about: “How come our kingdom has a dragon, anyway? The other kingdoms don’t have one.” They didn’t know, and they wanted to know. So they started coming up with ideas. This group of people blamed that group of people; that group of people blamed some others. Pretty soon, everyone was blaming someone, and they were all mad at each other. It didn’t take long until this kingdom got a bad reputation. People from the other kingdoms, well, they didn’t know about the dragon, but they sure knew what was going on. They would say, “The people in that kingdom don’t go to work, the kids don’t go to school, nobody gets along, they’re all mad at each other. They’re messed up.” And that’s the way things were.
Until one day …
A knight in shining armor came along. Well, he wasn’t really a knight, and he didn’t have any armor. He was just some guy who happened to be passing through. But the people in the kingdom saw something in him. “You!” they said, “You can slay the dragon; you’re just the one to do it!” The guy said, “No, sorry, I’m not a dragon-slayer; you have the wrong guy. I’ve been walking a long way, and I’m looking for this girl I’m in love with. But I don’t know where she lives.” He pulled a picture out and showed it around. “Have you seen her?” The people said “Yes, she’s our princess; she lives here. And what a coincidence: She really wants to get married—to whoever slays the dragon!” When the guy heard this, he said, “Well, in that case, I’m your man. Take me to your dragon!” So they took him to the dark place where the dragon was sleeping. The guy saw the dragon and said, “Whoa, this is a bad idea! I can’t handle this dragon; no way! It’s huge, looks really strong, it’s covered with scales, it breathes fire. Let’s just forget the whole thing!” The people said “No, you can do it; we know you can! Look, you can work out, do exercises, build yourself up. We’ll help—we’ll get you a personal trainer. And remember the princess!” The guy said, “Oh yeah, the princess!” He was in love with this princess, and he really wanted to marry her. “Okay, I don’t know about this personal trainer stuff, but I’ll give it a try and see how it goes.” So they gave him a personal trainer and took him to the schoolyard to start on his exercises. But he couldn’t stay focused! Every time he got started on some exercise, he would suddenly stop and look all around—he was afraid the dragon would get him while he was out there, exposed. So he wasn’t making any progress. This was clearly not working. So they took him to a clearing at the edge of the forest where there were high trees on one side. Then they worked to build a high fence around the rest of the clearing. Everybody pitched in, cutting lumber, putting it up, securing it, cooking for the workers. Even the little kids were helping: bringing water to people, carrying messages, doing whatever they could. And it wasn’t long until they had a high fence around the rest of the clearing. Then the guy could concentrate on his exercises. Then he really got to work. He did push-ups and sit-ups, lifted weights, ran laps, did all kinds of exercises. Every day the trainer added a pound or two to the various weights. Every day the guy became a little stronger, a little faster, a little more agile. After a while, he started looking pretty good. When they thought he was almost ready, they had a couple of athletic teenagers dress up like dragons to give him some practice. He didn’t use the sword, just a stick, but he got to practice his dragon-fighting moves.
Finally, the day came: He was ready. He faced the dragon, fought it, and slew it. He did marry the princess. But things didn’t just go back to exactly the same way that the kingdom used to be. For one thing, they now had a hero in their midst. People from the other kingdoms were saying, “That kingdom has a dragon-slayer; I wish we had one.” And everyone in the kingdom felt proud and walked a little taller; they knew they’d all helped out and been a part of it. But they were still asking each other, “How come our kingdom had a dragon, anyway? I wonder if we’ll get another one?” And they didn’t know. And they wanted to know. So they hired a consultant.
The consultant looked everywhere and interviewed everyone, and she finally called a meeting to tell them her findings. “You have two problems here. First of all, you throw all your garbage in the dump; it’s this huge pile of garbage that stinks for miles around. That smell attracts dragons.” So they decided that everyone would put their garbage in a compost pile in their own yard. Then there’d be no big smell to attract dragons—and compost is good for the gardens anyway. The consultant also told them, “Here’s your other problem. On the edge of the kingdom where the farms are, there are all these low fields; it’s flat, flat, flat for miles! Dragons are lazy, and this place is just too easy for a dragon to cruise right in.” So they decided to plant clusters of apple trees here and there in the fields. It wouldn’t be impossible for a dragon to come, but with all the barricades it wouldn’t be as easy as before.
Then they had a lot of apples. So every year at harvest time, they had a big Apple Festival, and people would come from all the kingdoms for miles around. There were all kinds of contests for the tastiest apples, the biggest apples, the best apple pies, and plenty of food, games, music—everything a festival should have. The highlight of the festival was on Saturday night, the event everyone would go to: the dragon-slaying contest. Of course, they didn’t have a real dragon, so whoever had won the year before got to play the dragon. All year long, young people from all the kingdoms were practicing, training, hoping that they’d be the one to win the big contest at the next year’s festival. Not only was this great fun, but also, if another dragon ever did show up, they would be ready! Then, they did live happily ever after—more or less.
The end.
The Fairy Tale Model of Trauma-Informed Treatment:
The fairy tale was presented as the metaphorical basis of a phase model for an effective, comprehensive approach to trauma-informed treatment. Each step in treatment is related to the corresponding portion of the fairy tale. The treatment steps follow.
This includes the history of trauma/loss, strengths/successes, and circumstances in which the problem symptoms/behaviors occur.
◾ In the fairy tale, the kingdom just seemed “messed up” from the outside. If you knew about the dragon, what people were doing was still unfortunate, but at least it made sense.
◾ It is also important to focus on the client’s strengths and resources, which are the foundation for success in treatment. In the fairy tale, some guy came along who eventually became the dragon slayer. In real life, the client is his or her own knight in shining armor and becomes the dragon slayer himself or herself. We need hard facts so that when we say to the client, “You— you’re the one who can do it,” we have good reasons for believing this.
◾ Remember that famous expression, “It takes a kingdom to slay a dragon”? The guy in the story didn’t do it by himself. So part of the evaluation is to learn about the resources available in the kingdom, or in the family and community.
Motivational Interviewing/Goal Setting:
It takes a great amount of work, persistence, and courage to overcome trauma-related problems. Clients are not likely to commit to this unless we can help them identify their own goals—what they want for themselves—and understand how doing these treatment activities can help them to achieve their goals. This is the motivational component; most people won’t do all this work just because someone else says they should. In the fairy tale, without the princess, nothing would happen. With the princess in the picture, it’s still a daunting task, but the guy says, “I guess I’ll give it a try and see how it goes.”
Trauma‑Informed Case Formulation and Psychoeducation:
Based on the evaluation, we communicate our understanding to our clients, including the connection between the trauma/loss history and the presenting problem, as well as an emphasis on the client’s strengths and resources that can be brought to bear on solving the problem. This shared understanding becomes the basis for the treatment plan, which includes trauma treatment.
Treatment Contracting:
The treatment contracting involves coming to an agreement to pursue specific activities in service of the client’s goals, in light of the strengths and challenges highlighted in the case formulation. The treatment plan typically includes doing activities to become more safe and stable, to gain better self-control skills and emotional strength, and to face and work through the trauma memories. In other words, fence-around, personal training, and slay the dragon.
Principles of Trauma-Informed Treatment:
Each of the steps in treatment is made up of a number of specific interventions. These are taught in detail in the coming chapters. For now, I wish to introduce a few key principles that pervade the trauma-informed treatment approach: safety, structure, sensitivity, and success.
The traumatized client’s primary concern is safety. People feel safe when they know what to expect and what to do—when they feel that things are under control. Therapists can do many things to help clients to feel safe in therapy, such as the following:
◾ At the beginning of the first session, introduce rules and expectations including the schedule for meeting, the purpose/goals of meeting, conditions of confidentiality, and what the client is expected to do in sessions.
◾ Keep your promises. Be ready and start the session on time. (If you can’t do this reliably, don’t make the promise.)
◾ Start each session the same way. Routines are reassuring. The starting routine can be as simple as a check-in; for example, many therapists start by saying, “Tell me something good and something bad that happened since last time we met.” In addition to the predictability value of the fact of the routine, this is also a good way to find out what’s going on in the client’s life. Often this material can be used in support of the treatment plan. For example, if the client reports having handled a confrontation poorly, this event can be used for practicing self-management skills.
◾ End each session the same way. Routines can be developed around putting toys or materials away, talking about what’s next in the client’s day, or asking the client to say something he or she liked and something he or she didn’t like about the meeting. Again, part of the value is the fact of the predictability of the routine, and part of the value is helping the client to gain closure on the session, regain composure, and to be ready for what’s next in his or her day.
When we are working our way through the treatment steps in the Fairy Tale model, we are asking our clients to face progressively greater emotional challenges. For example, as early as the second meeting, we are asking the client to tell us all the worst things that ever happened to him or her. Most people habitually avoid talking about this kind of thing because it makes them upset. So what happens when they answer our questions, get upset, and then the session is over—what then?
In many circles, therapists have a bad reputation because this issue is managed poorly. Many therapists are trained to believe that their job is to help the client to “open up”—to be expressive, get out feelings, work on issues. Then the difficult material is activated, the client is upset, and the client is sent on his or her way. How many school teachers have had to complain, “It’s bad enough that she gets taken out of my class—my class is important, she comes to school to learn! But then when she comes back after a meeting with the counselor, she’s all upset, she can’t concentrate, she’s a mess!” Similarly, many family members have complained that the client is “a mess” in one way or another for some period after therapy. Although some therapists believe that this is just the inevitable fallout that comes from doing therapy, these therapists are wrong. They are not trained in trauma treatment. Remember, like the rest of us, clients learn from experience. What do clients learn from the experience of being “a mess” after their therapy session? They learn that bad things happen if they open up with you. One client said, “Last time, after I left here, I was still heated, and I ended up getting into a stupid argument. It wasn’t good. I don’t want to talk about that [upsetting personal] stuff anymore.” When clients and their families regularly experience bad outcomes from therapy sessions, it gives therapy (and the therapist—you) a bad reputation. Spouses, parents, teachers, and others feel that therapy is an imposition, a disruption to the day. They don’t see it helping the client but instead actually doing harm. So these others are more likely to press for termination of the client’s therapy, or at least not to support it as actively as you would prefer. Also, the clients in this situation are likely to become more resistant and more reserved. Why trust the therapist who keeps setting you up for problems? Why open up if it only gets
you upset and gets you in trouble? The wise trauma therapist minimizes the risk of bad outcomes to sessions by using the following strategies:
◾ Carefully control what is discussed in a session so that the challenge (level of distress) is consistent with what the client can be expected to tolerate or handle. Using the personal trainer metaphor, if your client lifted 15 pounds in the previous meeting, you don’t give him or her 50 pounds this time—you give the client 15 again, or maybe 18 or 20 if you think the client is ready. With this approach, the client experiences repeated successes with progressively greater challenges and is unlikely to become overwhelmed.
◾ Use the cognitive-affective-cognitive sandwich. This jargon term (sorry about that!) means that you surround the emotional/expressive component of your session with more structured components grounded in rational thinking. For example, you might start out by reminding the client of the reason he or she is going to talk about the hard thing, how this relates to his or her goals. In the middle you do work with the emotion, at whatever level the client is ready to handle. The emotional component is finished with calming activities so that the level of upset or arousal is diminished. Then you go back to the cognitive, perhaps by discussing what was learned or by reorienting to what’s next in the client’s day. This helps the client contain the emotion and regain composure. Although no strategy works 100
Percent of the time, therapists who make a practice of using the sandwich tend to have far fewer problems with their clients being “a mess” later on.
No matter how carefully we follow the Fairy Tale model, no matter how well we plan, surprises can always occur. We are working with humans! So it’s important to continually monitor how your clients are doing and what is going on with them. Frequently, when things are not going according to plan, it’s because the client does not feel safe anymore. If we are paying attention, we have a chance of catching this and addressing it.
◾ A 55-year-old woman has been doing well in treatment and is ready for trauma resolution. The therapist prepares her for this, and they plan to start on it at the next meeting. Then for the next two meetings, at the last minute something comes up and the woman cancels. The therapist calls her up and asks her to please show up for the next scheduled meeting and tells her that the plan to talk about the trauma is off for now. When the woman shows up at the next meeting, she eventually explains that she does not feel ready to talk about the trauma yet and was afraid to come to sessions for that reason.
◾ A 22-year-old man has been very cooperative in treatment for the first four sessions with his employee assistance program counselor. Today he seems angry, refuses to answer questions in any detail, and keeps looking at his watch. The counselor asks him if he is in a hurry today. The man says, “Yes, I’m under a deadline, and I really should be working right now!” The counselor thanks the man for saying that; after all, he is here to do better at his job, not to miss his deadlines. They agree to reschedule their meeting so the man can leave and fulfill his work obligation.
◾ A 10-year-old boy has been working well in treatment and has completed several sessions of trauma resolution work already. However, in this session he refuses to talk about the memory that is already partly resolved. The therapist is stumped and is unable to get a decent explanation from the boy. Later, the therapist mentions to the boy’s mother that he seemed different today and did not accomplish as much as usual. The mother reports that she had blown up at her son a couple of days earlier and threatened to send him to live with his father if he didn’t get a better attitude. In each of these cases, some pressing concern prevented the client from moving forward according to the therapist’s plan. If the therapist just barges ahead, the client’s concern is not addressed. Then the client might feel disrespected or pressured and take protective action. On the other hand, when the therapist notices when things are not going smoothly and shows respect and concern, the client learns that the therapist cares and wants what is good for the client. In general, the more the therapist can do to help the client to feel safe and supported, the more work the client will be able to accomplish in therapy. Our goal is to create a “fenced-in” safe area in the room, in the therapy relationship itself. This allows the rest of the work to proceed.

Motivational Interviewing:
Motivational interviewing (MI) is a directive counseling approach—involving both
style and specific procedures—designed to elicit motivation and action for positive behavioral change. It explicitly avoids the authoritarian, confronted approach which has been shown to increase client resistance. Intervention components are the following:
Individual assessment and feedback focusing on the discrepancy between behaviors and goals.
Emphasizing the individual’s free choice and responsibility for his or her own behavior.
Providing advice to make a positive change.
Offering a “menu” of ways to accomplish the change.
Attitude of empathy and acceptance of the client’s perspective.
Interventions to enhance self-efficacy, reinforcing self-confidence and optimism regarding goal achievement.

MI has been applied successfully to engaging clients in treatment for a wide range of client issues including substance abuse, health-related behaviors, high risk behaviors, and compliance with treatment for a wide range of problems. A number of MI studies with adolescents have also yielded consistently positive outcomes.
A similar approach, focusing on positive future goals, is also catching on within sex offender treatment. MI has contributed to positive outcomes even in lieu of subsequent treatment; however, the gains deteriorate over time. It is essential to capitalize on the client’s motivation by offering further treatment activities likely to lead to more robust and lasting change. In this treatment approach, MI contributes to engagement, goal identification, and commitment to treatment.

Cognitive-Behavioral Therapy:
Cognitive-behavioral therapy (CBT) refers to an array of structured intervention strategies designed to provide corrective experiences, to develop more constructive ways of thinking and behaving, and to enhance specific self-management skills. A review of treatments for antisocial youth found CBT approaches—particularly those focused on interpersonal problem-solving skills, reappraising social cues, connecting behaviors to consequences, and punishing maladaptive choices while reinforcing prosocial choices—to be of modest but significant benefit in reducing problem behaviors. “Seeking Safety,” a structured package of trauma-sensitive CBT interventions, has also been found effective in treatment of substance abusers with PTSD. In a controlled anger treatment study in an adult PTSD population, severely volatile veterans’ participation in anger management therapy led to increased self-control as well as reduction of apparently unrelated trauma symptoms (intrusive thoughts and images), whereas standard trauma treatment did neither. Anger treatment completers maintained their post treatment gains at 18-month follow-up. These findings were consistent with another study, in which a multicomponent treatment for combat-related PTSD found incremental effects for both the exposure and the anger management components.

Why should self-management training lead to reduced posttraumatic symptoms? Perhaps because when problem behaviors are reduced, the environment responds by becoming less hostile and more supportive. When the environment is experienced as being safer, survival mode can be relaxed and the trauma is less pressing, more part of the past. In other words, a side effect of effective personal training may be that the fence becomes stronger. In this treatment approach, CBT contributes to establishing and maintaining the sense of safety and self-efficacy. Modifications to the Chemtob et al. manual were made for developmental appropriateness and enhanced treatment acceptance, also adding the consequence-oriented component found effective in the Kazdin review.
Relapse Prevention and Harm Reduction:
Cognitive-behavioral relapse prevention and harm reduction interventions focus on strategies for avoiding anticipated problematic situations and stressors, coping with them, and coping with anticipated relapse to prevent further deterioration. This approach has been used with some success in treating a range of addictions as well as with sex offenders. although when used as a stand-alone intervention its limitations have also been noted. It has not yet been widely applied to other types of problem behavior treatment. In one study, this approach was used in combination with other skills training with adults arrested for driving while disqualified (often as a consequence of a drunk driving conviction). Compared with a matched control group, this treatment reduced incidence of driving while disqualified; other criminal offending was reduced as well. The CBT skills training component of this treatment approach includes a module on avoiding high-risk situations. Following the trauma resolution phase, the treatment returns to a skills focus using relapse prevention and harm reduction methods to anticipate and prepare for future challenges and support maintenance of gains.

Mina Dashtbali
Social worker of Children and adolescents

Ahrens, J., & Rexford, L. (2002). Cognitive Processing Therapy for incarcerated adolescents with PTSD. Journal of Aggression, Maltreatment & Trauma, 6, 20216.
Ricky, Greenwald. (2009). Treating Problem Behaviors, A Trauma – Informed Approach. International Standard Book Number‑13: 978‑0‑415‑99801‑7 (Softcover).


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