Mending the Circle - ICCTCicctc.org/PMM Handouts/HC MC Handout Days 3 and 4.pdf · Mending the...

BigFoot & Schmidt, 2007 1

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Honoring Children

Mending the Circle2

HC-MC Session Structure

Sessions 1 to 6 Sessions 7 to 12 Sessions 13 to 18

Components

Psychoeducation

Parenting Skills

Relaxation

Affective Expression and Modulation

Cognitive Coping

Components

Trauma Narrative & Cognitive Processing (Mending the Circle)

In Vivo Mastery

Components

Conjoint Child-Parent Sessions (Mending the Circle)

Enhancing Future Safety

• Each PRACTICE component incorporates the HC-MC model components: Spirituality, Relational, Mental, Emotional, Physical•Similar 12-18 session goal for HC-MC completion.•Family trauma history may extend service needs and therapy timeframe.

RELATIONAL

MENTALPHYSIC

AL

EMOTIONAL

SPIRITUAL

RELATIONAL

MENTALPHYSIC

AL

EMOTIONAL

SPIRITUAL

RELATIONAL

MENTALPHYSIC

AL

EMOTIONAL

SPIRITUAL

First 1/3rd Middle 1/3rd Last 1/3rd

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TF-CBT Components: PRACTICE

Physical

MentalEmotional

Relational

Spiritual

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PRACTICE: Psychoeducation

Physical

MentalEmotional

Relational

Spiritual


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Psychoeducation: Physical

Goals:Normalize child’s and parents’ physical reactions to severe stressProvide information about common physical responses to trauma and stress

• Empirical information if available• Clinician’s experience with other children• Written literature by victims

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Psychoeducation: Emotional

Goals:Normalize child’s and parent’s emotional reactions to severe stressProvide information about common emotional responses to trauma and stress

• Empirical information if available• Clinician’s experience with other children• Written literature by victims

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Psychoeducation: Mental

Discussion Points - Common Responses to Trauma and Stress:– The impact of cumulative stress and multiple

traumatic events on one’s ability to cope and maintain balance

– How imbalance due to poor coping skills may lead to unhealthy, destructive and harmful behaviors

– How cumulative stress and trauma impacts families (patterns of poor coping, poor role modeling, disconnectedness, rejection)

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Discussion Points - Trauma Exposure:General information about the trauma type that the child experienced

FrequencyWho experiences itWhat causes itHow people and systems may react to this type of child trauma

The topic of historical trauma may come at the beginning of treatment or as treatment evolves. Therapists should be prepared to explore with the family the relevance of historical trauma to

the current traumatic event.



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Discussion Points - The Healing Process:HC-MC Treatment details

Set goals together with child and familyTypical number and length of sessionsSession format

Individual child sessionsIndividual parent/caregiver sessionsJoint child/parent/caregiver/family sessions

General session plan Treatment componentsUse of homework


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Psychoeducation: Spiritual

Assist family in articulating their definition of wellness and balance

Discussion Points:The importance of balance in fostering wellnessCircle Example: One travels on the pathway around the Circle

The components of balanceCircle Example: The interrelated parts of the Circle -

spiritual, physical, mental, emotional, relational

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Discussion Points - Trauma and Imbalance:The impact of trauma exposure on wellness Circle Example: Trauma experienced on one’s pathwayaround the Circle can cause imbalance within thedifferent parts of the Circle, which leads to unwellness.

These concepts may be simplified to meet the client’s developmental capabilities

Circle Example: Use of colors to have child identify howtheir Circle looks now as compared to how they want itto look in the future.


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Discussion Points - The Healing Process:How the process of restoring balance contributes to healing and well-beingHow treatment is an important part of the process toward healingThat treatment works to restore balance and well-beingThere is hope for child and family recovery



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Psychoeducation: Relational

Discussion Points - The Healing Process:– The importance of commitment to treatment in

healing.– The level of systemic commitment that has been and

is being made to help the child and family in their healing process

-Child and Family - Community-Provider - Tribe -Program -Federal Agencies

– Assisting the family in identifying the helpers and healers that will be part of their healing process.

– Establish necessary linkages to systemic supports (legal, medical, educational).

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Psychoeducation: Relational

Integrating “All My Relations” into Treatment

Questions for family: •Which primary caregiver(s) will be available to regularly participate in sessions in order to provide continuity?•Who else will be involved in treatment sessions? In what way? How can we most effectively integrate these individuals into treatment?•Who will be involved in healing activities outside of treatment sessions? In what way?

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PRACTICE: Parenting

Physical

MentalEmotional

Relational

Spiritual

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Parenting: Spiritual

Honoring Children• Children are the center of the Circle and

parents and extended family around the Circle are the primary providers of guidance and support.

• Encourage the family to seek guidance from spiritual helpers and healers for support in the healing process.

• Families can be the child’s strongest source of healing.


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Parenting: Spiritual

• Use of Medicine (sweetgrass, tobacco, cedar, corn pollen)

• Coming of Age ceremony• Lodge Ceremony

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Parenting: Relational

Honoring Children• The caregiver's responsibility is to nurture and

expand the positive nature of the child, to touch the child with honor and respect.

• Native Concepts of Parenting:– Honoring Children– Indirect Discipline– Modeling– Storytelling– Use of Extended Family

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Storytelling

Modeling

Ritual

Shunning/Ignoring

Honor

Consistency

Time Out

Connectedness

PraiseParent

Child

Naming

Ceremony

Giveaway

Circle

Modeling

Everyone is a relative

Logical & Natural

Consequences

Reinforcement

Differential Attention

Using Support Network

Parenting Skills Applied in HC-MC

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Parenting: Relational

Integrating “All My Relations” into Treatment

• Work with the family to identify who is important within the family Circle. This could be individuals within the family, community, within or outside the tribe.

• Discuss with the family how they view the identified relations as helpful in the family’s healing process.

• Parents and extended family may influence children through teaching, role modeling, and providing structure.


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• Nature walks• Vision Quests and retreats

Parenting: Physical and Emotional

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Parenting: Mental

• Use of animal stories• Incorporating winged ones, two-legged

ones, and four-legged ones

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PRACTICE: Relaxation

Physical

MentalEmotional

Relational

Spiritual

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Animals have always been our teachers. They teach us when to stay and fight, to run, to fly, to form a circle, to become a herd, to escape danger.

We have to be aware of what we see, think, feel, and how we respond. By understanding our body’s reaction to a situation, we can understand that it’s nature’s/Spirit’s way of telling us how to care for ourselves in a safe way.


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Traditional Activities:• Singing/Chanting

– Requires deep breathing– Use of repetition

• Meditation/Prayer– Helps with centering– Eliminates external

stimulation

Relaxation:Physical, Emotional, Relational

Controlled Breathing

• Smudging• Playing Instruments

(drumming, flute)-Pacing breath to beat & intensity of music-Wind instruments require deep, controlled breathing

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Traditional Activities:• Beadwork/Quilting• Woodwork• Leatherwork• Herbs and Gardening• Drumming


Enjoyable Activities

• Tending animals/pets

• Family/ExtendedFamily Time

• Singing

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Enjoyable Activities

Traditional Activities:• Drumming, Dancing• Soothing Sports

Canoeing Walking/HikingSwimming Horseback Riding

• Active Sports Team Sports Running/JoggingRodeo Rock Climbing

•Soothing ActivitiesSweatlodgeBraiding HairMassageTending a Firepit

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Relaxation: Mental

Use appealing and familiar images when teaching relaxation techniques.

For example, don’t suggest visualizing a wave with youth who haven’t seen the ocean. Instead, explore what images they find meaningful, enjoyable and relaxing.


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Relaxation: Relational

• Relaxation can also incorporate family activities such as board games, storytelling, watching television, etc.

• When teaching relaxation techniques, incorporate the caregivers into the session so that they also learn and can assist the youth outside of therapy.

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Relaxation: Spiritual

Ensure that images are appropriate and not a violation of tribal or cultural mores.

Image ideas:– Controlled Breathing - the sway of a shawl,

trees swaying in the breeze, birds in flight

– Muscle Relaxation – flexing and releasing a fishing rod, tensing and releasing a bow, in and out motion of paddling a canoe

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PRACTICE:Affective Expression and Modulation

Physical

MentalEmotional

Relational

Spiritual

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Our feelings are important tools that give us needed information about situations we encounter. For example, fear tells us to protect ourselves because danger is near and happiness tells us that we are safe and can relax.

Sometimes when problems occur, one’s feelings become confusing and overwhelming. When a person doesn’t understand or is overwhelmed by their feelings, the feelings may no longer guide that person’s thoughts and actions toward a good direction.


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Affect Regulation: Spiritual

Traditional Activities:• Use of Stories (Animal, Elements)• Use of Colors/Directions• Masks• Carvings (Totem)

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Affect Regulation: Emotional

Traditional Activities:• Use Native Language for Feeling

Words• Use of Relevant Pictures of

Expressions of Feelings • Dolls

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Affect Regulation: Physical, Mental, Relational

Traditional Activities:• Use of Sound• Music, Song, Drum• Weaving, Pottery• Dance, Movement

•Record Keeping

•Drawing•Painting•Writing•Beading•Shield Making

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• What is anger?• What is the difference between anger

today and anger historically?• What are AI/AN children taught today

about the expression of anger?• What purpose does anger serve today?• What is the relationship between anger

and trauma?• How do you address this in treatment?

Anger, Children and Trauma: Group Discussion


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Addressing Anger• Use concepts of respect and honor to address

violent behavior.• Respect for self, others, animals, and things should

always be acknowledged.• Honoring all feelings is important, but destructive

and harmful expression of feelings is disrespectful.• Even a wolf knows that there are always more than

two choices. Thinking can’t be only black and white.

• Respectful behavior toward others means that violent behavior won’t be tolerated.

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EMOTIONAL

Practice:Creating Cultural Representations

of Emotional Expression

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PRACTICE: Cognitive Coping and Processing I

Physical

MentalEmotional

Relational

Spiritual

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Trauma is a part of the circle of life. There is a long history of trauma in Native American families, communities, and Nations.

Trauma is like a roadblock or burden in our path. Healing is the way to make the roadblock or burden more manageable or to make it go away completely.

Healing means that the circle is whole again. One must know how to change one’s thinking, feelings, and beliefs about a traumatic experience in order to regain balance or harmony.


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The Cognitive Triangle

Think

FeelDo

Trigger

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Cognitive Coping & Processing I: Spiritual

Discussion Points:

•What one thinks and feels influences how one treat oneself and others.

•One has the power to create a change through what one thinks, feels, and does.

•This change can move one closer to or farther away from balance and harmony.

Use the Circle to demonstrate interconnectedness between thoughts, feelings and behaviors

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RELATIONAL

MENTALPHYSICAL

EMOTIONAL

SPIRITUAL

Trigger

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Cognitive Coping & Processing I: Spiritual

Use the Circle to demonstrate interconnectedness between thoughts, feelings and behaviors

Discussion Points:

•When an individual addresses one component, it can create a shift in every other component.

•Best friend examples

•It is important to ask oneself:

•Is this <thought, feeling> accurate?

•Is this <thought, feeling, action> helpful in creating balance within the Circle?


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Cognitive Coping & Processing I: Mental

One goal is to help children and parents view events in more accurate and/or helpful waysTF-CBT problem-solving steps fit within AI/AN concepts.Consider image options when teaching problem solving steps

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Technique: Problem-SolvingExample:

Describe the problemIdentify possible solutionsConsider the likely outcomesPick the solutionEvaluate your choice

Adaptation: Use stories to explain problem-solving How and why storiesCoyote storiesTurtle Technique

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Technique: Positive Self-Talk

Adaptations: • Have children consider how their namesake

would think about the situation• Have them consider how an animal helper

would respond to take care of themselves• Teach the child to leave bad thoughts behind

through offerings or rituals

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Adaptations for thought interruption and positive imagery:

• Consider using the instruction given when entering a lodge or ceremony to leave bad thoughts at the door and enter in a good way.

• Use imagery to send away unhelpful thoughts (stories of places and animals; smudging)


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Use songs and/or drumming to displace unhealthy thoughts

Cognitive Coping & Processing I: Physical

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Mending the Circle

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PRACTICE: Trauma Narrative

Physical

MentalEmotional

Relational

Spiritual

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PRACTICE: Cognitive Coping and Processing II

Physical

MentalEmotional

Relational

Spiritual


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PRACTICE: Conjoint Parent-Child Sessions

Physical

MentalEmotional

Relational

Spiritual

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Your life is built on the life of your ancestors and the gift you give to them is in doing for future generations. There is always someone in back of you and someone ahead.

Everyone wants a record of what happened. Because we learn through the experiences of others, your story will benefit future generations.

This is your own story…Your yesterday, today and tomorrow.

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Beliefs That May Hinder Creating the Trauma Story

– Once something has happened, you are supposed to forget and move on.

– This is not a parent’s role; rather, this is the role of spiritual helpers and healers.

– There is supposed to be a lesson learned and talking about it means that one hasn’t yet learned it.

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– If you discuss trauma, it is an invitation for it to reoccur.

– What happens to you is predetermined and beyond your control.

– Trauma is caused by a spiritual person’s misconduct and that talking about it would reflect badly on the individual and/or family.

– When trauma results in death, talking about it may hinder the person’s journey to the next world.

Beliefs That May Hinder Creating the Trauma Story


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Beliefs Supporting Creating the Trauma Story

• Fear helps one to learn, but one must face their fears in order to learn.

• To be balanced, one must resolve those symptoms that create imbalance.

• One’s understanding of traumatic experiences can be distorted. In sharing your story, you can learn through the eyes and ears of others.

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• Telling your story in a good way is to give the gift of respect to yourself and others.

• Learning through the telling of your story helps you to progress on your journey around the Circle.

• Reminders of bad experiences will always exist. Telling your story will reduce the power that they hold when they appear on your pathway.

Beliefs Supporting Creating the Trauma Story

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Warriors have to be courageous as they face uncertainty and danger when confronted by an enemy. Warriors challenged their enemies by uniting together.

Confronting one’s trauma experience can also create feelings of uncertainty and danger. Uniting with All my Relations will provide one with the spiritual strength to move forward in a healing way.

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Mending the Circle

•There is a history of oral tradition within the AI/AN culture.

•Stories carry the history and experience of people. The way that we know of others is by the retelling of their stories.

•Sharing of one’s stories has always been expected.


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•Sharing stories has always been a way of teaching, connecting with others, sharing news, and learning from others’ experiences.

•Stories have been recorded in different ways (painting, pottery, hieroglyphics, carvings, song).

•There are different kinds of stories. Some stories are not to be changed. Others can be adapted.

Mending the Circle

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Mending the Circle

•As the family re-enters the Circle, they will invite past experiences (memories, thoughts, feelings) into their journey.

•Unanticipated trauma memories may also resurface during this process.

• They may utilize this opportunity to confront their own trauma history.

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•The healing Circle may also include memories of many ancestors who did not complete their journey.

•Spiritual and relational connections may extend to those ancestors and re-awaken the impact of historical trauma.

Mending the Circle

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•The therapist may work with the family to determine how to address historical trauma and grief through this healing journey.

•The family may seek opportunities with helpers and healers to symbolically and ceremonially help their ancestors to complete their journey.

Mending the Circle


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Preparations•Help the child and family to recognize the tools and resources they have gathered on the healing journey and how these can be utilized in this process.

•Support the family in their decision to re-enter the Circle and consider with them what will change as a result (relationships, expectations).

Mending the Circle

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Preparations

•Help the family to identify “All my Relations” who will share this part of the journey with them.

•Assist the family in following protocol to invite helpers and healers.

•Collaborate with helpers and healers in coordinating healing practices.

Mending the Circle

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Preparations

•Help the child and family to identify what story to tell and the way to tell it.

•Help the child and family determine who will be involved in the story-making and how.

Mending the Circle

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Considerations:•Will this be the child’s individual journey at first, with the family joining later?

•Will the family start together to create the story?

•Will family members create their own parts to contribute to a longer story?

•How does the child and family wish to present the story? And to whom?

Mending the Circle


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Considerations:•Are there ceremonies, rituals, symbolisms that are particularly meaningful to the child and family?

•At what pace will the child and family want to create and tell their story?

•How will the child and family know when this portion of the journey is complete?

Mending the Circle

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Ways for Creating and Telling the Trauma Story

•Story Stick•Writing•Music/Song/Dance•Carving

•Totem•Soapstone

•Beading

•Mask•Pottery•Figurines•Oral•Acting•Painting/Drawing

Mending the Circle

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When animals get hurt, their natural instinct is to clean their wounds to promote healing. This is their way of taking care of themselves.

The bear may find it painful to remove debris from an injury. But, the bear does this because he knows that this is necessary for his body to become well. Healing must take place for the bear to be able to use his body to gather food and to protect himself. He must tend to the hurt until it is healed.

When the bear is without pain, he knows that he is ready to return to his path on the Circle. 72

Making Meaning of Trauma

Story of the Bear

Mending the Circle


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MENDING THE CIRCLE

Practice(Telling the Story)

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PRACTICE: In Vivo Mastery

Physical

MentalEmotional

Relational

Spiritual

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PRACTICE: Enhancing Safety

Physical

MentalEmotional

Relational

Spiritual

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PRACTICE: Enhancing Social Skills

Physical

MentalEmotional

Relational

Spiritual


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Relationship to the Structural World

Balance within the structural world involves: – Contributing (work, creativity, philanthropy)– Managing time (learning, work, play, rest)– Understanding and upholding rules and laws– Participating in academic pursuits– Practicing safety– Respecting property

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Council Making

At this point in the journey, it is time for the family to re-evaluate their progress through the healing journey using the components of the Circle.

The family may wish to mark this point of their journey with ceremony, renewal, cleansing, or celebration.

The family may determine that this is an appropriate time for the journey with the therapist to change or to end.

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Council-Making

Assessing Trauma-Exposed

Children


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Why Use Assessment?

• Gather information not disclosed during the intake interview

• Identify salient symptoms• Assess changes in symptoms over time• Identify systemic needs

Slide adapted from”Assessment-Based Treatment for Traumatized Children” by Nicole Taylor, PhD, Chadwick Center for Children & Families, San Diego

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How Clients Benefit from Assessment

• Validates feelings and thoughts• Validates appropriateness of treatment• Helps clients identify and clarify treatment

goals• Helps clients understand they are having

normal reactions to an abnormal experience (trauma event/s)

• Reinforces treatment progress

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Assessment-Based Treatment

Initial ScreeningTriage (refer out if needed)Assessment• Family interview• Standardized measuresIntegrate assessment information to identify treatment needs

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Assessment-Based Treatment

Establish treatment goals Determine treatment pathwayConduct treatment• Re-evaluate periodically to determine

progressComplete treatment


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To get the full unique client picture use:

Multiple ReportersClinical Judgment

Behavioral ObservationObjective Standardized

Measures86

Assessment Components

Physical

Mental

Emotional

Relational Spiritual

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Assessment - Spiritual

• Strength of foundation for spiritual beliefs• Extent of support from family and

community for spiritual beliefs• Quality of relationships with spiritual

healers and guides• Opportunity for practice of spiritual beliefs

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Assessment - Mental

Coping Resources– Ability to self-soothe– Ability to problem-solve– Ability to access support network

Cognitive/Language DevelopmentChild Attributions

– About self» “It’s okay for me to hurt others to get what I want.”

– About others» “ “How can I love and hate the person who hurt me?”

– About the trauma» “What happened is my fault.”


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Assessment - Physical

Internalizing• Somatic disorders

(e.g., headaches, stomach aches)

Externalizing• Oppositionality• Aggression• Impulsivity• Hyperactivity

Risk-Taking• Substance use• Suicidal Ideation• Self-mutilation• Sexual acting out• Delinquency

– Truancy– Running away– Illegal acts

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Assessment - Emotional

• Internalizing Symptoms: – Anxiety– Depression – Avoidance

• Understanding by child and family of feelings of self and others

• Understanding by child and family of use of words to describe feelings

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Assessment - Emotional

• Child’s and family’s development of emotional expression skills

• Family’s beliefs about emotional expression (acceptability of feelings, when and how to express feelings)

• Tribal Cultural beliefs that may affect emotional expression

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Assessment - Relational

• Quality, quantity, and proximity of communication and relationships with:– Parent(s)/Caregivers– Family and Extended Family (siblings, cousins,

etc.)– Peers– Mentors– Helpers and Healers


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• Child’s attributions about the parent(s)/family

• Parental attributions about the child• Child’s developmental capabilities• Child’s responsibility for the trauma

• Parental behaviors

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• Parental/Caregiver discipline practices• Issues related to visitation and shared

custody• School functioning• Relationship with the environment

– Connectedness to animals, nature

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Assessment – Additional Areas

• Resiliency Factors– Coping resources– Relational supports– Community connectedness– Opportunities for support– Positive peer group– Safe environment

• Other Risk Taking Behaviors• Substance abuse in family• Peer violence

•Trauma History•Individual•Family•Community•Tribe

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Team DiscussionHow do you assess the following

domains at your site?

SPIRITUAL:

MENTAL:

PHYSICAL:

EMOTIONAL:

RELATIONAL:

TRAUMA HISTORY & EFFECTS:


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Using Trauma Assessment

Measures

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Useful Internet Sites• NCTSN

– www.nctsn.org– Database of information on instruments for use with

children and adolescents

• National Center for PTSD– www.ncptsd.va.gov/– Describes several trauma exposure and PTSD

assessment instruments– Can request a free copy of the Traumatic Events

Screening Inventory

• The Chadwick Center– www.chadwickcenter.org– Download the manual: Assessment-based

Treatment for Traumatized Children: A Trauma Assessment Pathway

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UCLA PTSD Index

Child’s trauma history and PTSD symptoms• Child and Caregiver report versions• Takes 5-10 minutes to complete• Child report:

– Ages 7 and above– 22 items assessing symptoms B, C, and D as

well as associated features– Administration

–Interview substituting specific trauma for “bad things that happened”

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• Caregiver report: – 13 items assessing trauma event

exposure– 14 items assessing response– 21 items assessing B, C, and D

symptoms and associated features

UCLA PTSD Index


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• Scoring and Interpretation– Clinical impression of trauma-related

symptoms– Separation anxiety, generalized anxiety,

and triggered behavior problems not assessed, but important for young children

• Available in multiple languages, including Spanish

UCLA PTSD Index

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Trauma Symptom Checklist for Children (TSCC)

• 54-item trauma-specific self-report measure of children’s responses to traumatic events

• For children ages 8-16• Approximately 10 minutes to complete• English and Spanish versions• Subscales:

Anxiety DepressionAnger Post-traumatic StressDissociation Sexual Concerns

» Overt» Fantasy

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Trauma Symptom Checklist for Young Children (TSCYC)

• 90-item caregiver measure of trauma-related symptoms for children ages 3-12

• Approximately 20 minutes to complete• English version• Subscales:

– Anxiety -Depression– Anger/Aggression -Dissociation– Posttraumatic Stress -Sexual Concerns

Intrusion AvoidanceArousal Total 104

Mock Case Presentation


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Physical

Mental

Emotional

Relational Spiritual

Treatment Plan - Discussion

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Treatment Planning

• HC MC may be incorporated into part of a larger treatment plan for families with more therapeutic needs.

• When creating a treatment plan with the family, ask what they consider to be their priority needs. Often this may include assistance with behavior management or helping children cope with stressors (handling nightmares, separation anxiety, school refusal).

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For children with few or no significant PTSD symptoms, specific components may be selected for use in therapy based on the child’s presenting concerns.

Treatment Planning

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These are our gifts for you to

use on your journey…

Mending the Circle - ICCTCicctc.org/PMM Handouts/HC MC Handout Days 3 and 4.pdf · Mending the...

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