(p. 61) Sessions 2 and 3: Mindfulness, Relaxation, and Cognitive Tools
■ Therapist Forms
■ Youth Forms
■ Raisins or other pieces of fruit the child enjoys to complete the mindfulness exercise
■ Introduce the concept of tools.
■ Teach the youth behavioral relaxation techniques, including progressive muscle relaxation and deep breathing, and introduce The Feelings Thermometer.
(p. 62) ■ Guide the youth through the visual imagery exercise.
■ Teach the concept of mindfulness.
■ Instruct the child on how to apply cognitive techniques such as recruiting positive thoughts and using thought insertion techniques.
■ Encourage the youth to develop her own tools.
■ Continue teaching and practicing skills during session 3.
■ Assign take-home activities.
This session should be conducted with the child.
During sessions 2 and 3, the therapist and child counteract the effects of adverse life events and chronic traumatic stress by focusing on three areas:
1. Management of physiological symptoms related to fear, anxiety, and threat
2. Emotional awareness and control over emotions
3. Cognitive restructuring to help manage intrusive, pervasive, and negative thoughts
In addition to their protective role during the upcoming narrative exposure, these new skills help the child identify her bodily sensations, thoughts, and emotions, and—through this awareness—help her gain mastery and control over her reactions.
Two sessions are devoted to developing this skill set to reinforce the importance of practice and rehearsal. Session 2 consists of training in the application of the tools whereas session 3 is devoted to practicing the new skills. As with any skill, with practice, tool use becomes more natural and is thus more readily available during stressful situations. Using the example of a skill the youth has learned, such as swimming, best illustrates the importance of rehearsal. Having the child practice tool use outside of therapy during stressful everyday-life situations encourages skill mastery and generalization.
(p. 63) Goal
■ Teach the child exercises that will help her acquire mindfulness, relaxation, and cognitive skills. These exercises are useful during examination of the life timeline in the upcoming chronic traumatic stress history sessions (sessions 4 and 5), during completion of take-home activities, and later during the exposure sessions.
Introduction to Tools
At the beginning of session 2 reintroduce the youth to the concept of tools, which was first mentioned during session 1. Use the Session 2 Review Form (Worksheet 5.1) to ensure you cover all topics during this session. Redisplay the Toolbox (Chapter 4, Worksheet 4.3) and invite the child to add tools to the worksheet as she learns them. Eventually, she will include in her Toolbox only those tools she chooses and that she finds most helpful. Inform her that these tools will help her become more aware of her emotions, thoughts, and bodily sensations, and that these tools will also help her in regulating or controlling these emotions, thoughts, and bodily sensations. Tell the child that, initially, the tools included in her own personal Toolbox include those the therapist teaches and, later, those she develops.
Tools will be helpful to manage heightened emotional reactions during and after treatment. An example of a heightened emotion is fear, often characterized by a fight-or-flight response. Here is a sample script to describe the fight-or-flight reaction and introduce the idea of developing tools:
During this therapy you are going to learn some important skills that may make you feel stronger and more capable of managing difficult situations.
(p. 64) Have you ever started to cross the street and then suddenly there was a car coming at you and you jumped back on the curb just in time? Do you remember how it felt? It probably took you a while to calm down afterward. Well, here’s what happened in your body at that time. Your brain sensed the danger and rapidly fired off a chemical message to your bloodstream. Your heart reacted instantly with a mighty contraction and pumped a huge, extra burst of blood to your arms and legs. This is part of our ancient cave-time reactions. If a saber-toothed tiger was coming at you, you would have needed the blood in your legs to run as fast as you could, or the blood in your arms to fight off the tiger.
So, when you jumped back on the curb, not only did all the physical things happen to your body, but also your body diverted blood from your digestive system. After this took place, you might have felt sick to your stomach.
When the brain fires off that first chemical message, it continues to do so as long as it senses danger. It takes anywhere from 15 minutes to more than an hour for the body to return to its normal state. In a true emergency, your body’s ability to react this way can keep you alive. It’s a wonderful thing that our bodies can do this.
However, when a person experiences chronic traumatic experiences, sometimes this reaction happens in greater or lesser degrees even when there isn’t a real danger in the environment. Our bodies may react to cues in the environment and may interpret them as dangerous; sometimes we are startled, even when a situation is not dangerous.
So here’s the most important thing to know. You can stop this flight-or-fight reaction in its tracks by using tools. For example, use long, slow, deep breathing. Your body cannot have a fight-or-flight reaction while you are taking long, slow, deep breaths. You shouldn’t breathe like this [huff and puff quickly], because that only makes the situation worse. But when you breathe like this [demonstrate taking long, slow, deep breaths], you are controlling your body’s reaction. You may still have some reaction, because your brain has already fired off the chemical message, but you can stop it from doing anything further, and you decrease the amount of time you feel the anxiety reaction.
The introduction of deep breathing and progressive muscle relaxation should be accompanied by an explanation of the bodily sensations associated with fear (such as rapid heartbeat, hyperventilation, sweaty palms, clenched muscles, and so on), with a particular focus on the youth’s (p. 65) individual fear response. Simple awareness and labeling of such physiological processes can provide relief to the child. In some cases, the physiological reaction can be the first indicator of fear, and thus is a signal of distress or a cue. Breathing and muscle relaxation exercises enable awareness and promote control over the fear response. Explain to the child that fear and stress are often experienced in the body, and that tools can help control these bodily sensations.
Here is a sample script for teaching slow, deep breathing:
We’re going to breathe together. We’re going to breathe in a large breath, while my finger goes up a mountain, but slowly. Then we’re going to breathe out slowly while my finger comes back down the mountain. We’ll do this three times. Then, after that, you can indicate with your finger how we go up and down the mountain, and I’ll follow you, and we’ll do this three more times. Breathe in slowly through your nose [say this while your index finger completes the first leg of an inverted V suspended in the air between you and the child] now breathe out slowly through your mouth, as if you were breathing out through a straw [say this while your index finger comes down the second leg of the inverted V].
Repeat this breathing process two more times and then let the child conduct the exercise three more times.
After practicing the breathing, have the child monitor her body to determine whether there are any changes. You can share how, for many people, these exercises are calming, but for others it may not disrupt anxiety. Have the child write this exercise on her Toolbox if he finds the exercise helpful. Use The Feelings Thermometer (discussed later in this chapter) to monitor feelings before and after exercises.
Progressive Muscle Relaxation
With progressive muscle relaxation, we teach the child the difference between feeling tense and feeling relaxed. Walk the child through relaxing the major muscle groups (feet, legs, trunk, chest/arms, shoulders, and head), with the child tensing each muscle group and holding it for about 10 seconds, and then letting it go (relaxing).
(p. 66) Repeat each muscle group three times, working up the body beginning at the feet and continuing up to the head. Here is a sample script you might use to teach progressive muscle relaxation:
We’re going to work on teaching you and your body how it feels to be relaxed and how it feels to be tense. Sometimes, we are not aware of how these feel. When you feel anxious or scared, but you don’t want to feel that way, progressive muscle relaxation can help your body calm down and become relaxed. Before we begin, get comfortable in your chair with your hands gently resting on your lap and your feet flat on the floor. You may wish to close your eyes as we do these exercises.
Lifting your legs slightly, point your toes like a dancer and hold them really hard, as if they cannot bend. Do this while I slowly count … 1 … 2 … 3. Okay, now place your feet back on the floor. Now your feet feel relaxed. Let’s repeat this two more times.
Lift your legs and hold them out in front of you; make them rigid and hard as a rock. 1 . . . 2 . . . 3 . . . now relax. Now your legs feel relaxed. Let’s do that two more times.
Next, pull your stomach in as hard as you can and hold it … 1 . . . 2 . . . 3. Now release your muscles. Your stomach feels relaxed. Let’s do this two more times.
Pretend that you are going to pick up an orange in each hand to make juice. Now I want you to squeeze your hands, arms, and chest really hard to get all the juice out of those oranges . . . 1 . . . 2 . . . 3. Now let your hands drop loosely at your sides. Now your hands, arms, and chest are relaxed. Let’s do this two more times.
Lift your shoulders up until they can almost touch your ears. Hold it . . . 1 . . . 2 . . . 3, then drop them. Now your shoulders are relaxed. Let’s do that two more times.
Reach both hands straight out in front of you, overlapping your hands. Keeping them straight, lift them over the top of your head. Now bring them behind you, looking at them with your head, so that your arms, head, and back are draped over the back of your chair. Try to look at the wall behind you while your head is upside down. Hold it for 1 . . . 2 . . . 3. Now, bring your arms to the front of you. Now your back is relaxed. Let’s do this again two more times.
(p. 67) Jaw
Make the biggest smile you can, trying to get the corners of your mouth to touch your ears. Hold it for 1 . . . 2 . . . 3, then go back to your regular smile. Now your jaw is relaxed. Let’s do that again two more times.
We are going to scrunch up our face, like we’ve tasted something really sour, or smelled something awful, and we’ll purse out our lips. Hold it for 1 … 2 … 3, then let these muscles go. Now your face is relaxed. Let’s do that two more times.
Encourage the child to practice progressive muscle relaxation every night before he goes to sleep.
The Feelings Thermometer
Through the use of The Feelings Thermometer (Worksheet 5.2), you can monitor the intensity of a given emotion and adjust the intervention accordingly. This tool also facilitates the youth’s emotional awareness and provides the child with a sense of control over by increasing awareness on the level of emotion experienced. As with the relaxation tools, also encourage using The Feelings Thermometer outside the sessions.
Introduce The Feelings Thermometer to monitor feelings before and after exercises. Explain to the youth that she will be using this tool to assess her emotional state during the life timeline story of positive, neutral, and negative life events, and that she can also use it to track her own emotions in her everyday life. Note that you will also use the thermometer to gauge her emotional level during therapy.
Visual imagery contributes to relaxation and provides relief from negative thoughts and emotions. Learning that positive imagery can be generated may be particularly helpful with symptoms of reexperience, such as intrusive thoughts.
Here is a sample script to teach visual imagery. Feel free to elaborate on the basic imagery exercise if this seems helpful to the child. (p. 68)
Sit comfortably. Put both feet flat on the floor and place your hands loose on your lap. Close your eyes and take a nice deep breath and begin to breathe in a relaxed, easy way. Now imagine you are in a place you like. It feels very good being there. Look around you and try to really see this place. Describe it to yourself. Maybe it’s sunny; maybe the moon is out. Perhaps there’s some water that you can touch. Perhaps there are friendly animals or flowers. You feel good here, relaxed. It is a private place, you don’t need to tell me what or where it is.
I’m going to be quiet for a minute so you can explore and simply enjoy being in this special place. This is your special place. You can think of this place anytime you want to feel better. It is always there for you. Now when you are ready, you can open your eyes.
If the child has trouble finding an imaginary place, vary this exercise by asking her what places she enjoys—for example, the ocean—then describe the scene, with the waves lapping peacefully, seagulls flying overhead, dolphins jumping, the sand feeling warm between her toes, and so on.
The relaxation and visual imagery exercises build a foundation for mindful awareness. These skills teach that the body and mental images are interconnected with emotional states. Through these skills, the child learns to recognize the current moment experience. For example, the child may be able to identify and verbalize an emotion (such as anger) when feeling the physical sensation (such as an increased heart rate). The child may learn, for example, that her anger manifests in tightness and tension in her body. She is trained to use mindfulness skills to move toward or into the anger, rather than resisting it or reacting in a maladaptive manner. The child is then trained to pause and practice a few mindful breaths, or to do a simple yoga pose, while feeling the anger. After taking the mindful pause, the child then checks back into her emotional states and observes how the mindfulness practice may have shifted the experience of anger. It is common for children to report that simple mindfulness practices, such as breathing, help them feel calm, happy, and relaxed. Children may include mindful breathing or the name of their favorite yoga poses in their Toolbox as a resource they can use to help them cope with stressful experiences.
(p. 69) Introduction to Mindfulness
Participate in the activity with the child to normalize the experience, which may seem a bit strange at first. Sitting next to the child, take hold of a raisin (or other food) and follow the prompts below.
Explore the raisin in the following ways:
■ Touch: How does the raisin feel when you touch it?
■ Smell: How does the raisin smell if you hold it close to your nose?
■ Sight: What colors do you see in the raisin and what does the texture look like?
■ Sound: If you hold the raisin between your fingers and bring it close to your ear, what do you hear as you roll it between your fingers?
■ Taste: What does it feel like when you put the raisin between your lips? Roll the raisin around in your mouth. What do you sense? Bite into the raisin slowly. What do you taste? What is the sensory experience of slowly chewing and eating the raisin bite by bite?
Take a few minutes to process the experience and reflect on the potential benefits of this practice for the child. Ask her to reflect and tell a story about the experience. Coach the child to verbalize the thoughts, emotions, and sensations she had during the exercise.
Standing Meditation Practice: Standing like a Mountain
Tell the child to practice the standing meditation practice safely. If the posture does not feel good, she should not perform it. Find a location where the child feels safe and there is enough space available.
The mountain pose can be held for about seven breath cycles or longer. This is also an ideal pose to practice throughout the day—for example, when standing in line, waiting for the bus, right before bed, or first thing in the morning.
1. Place your feet together or a hip-width distance apart.
2. Make your spine long.
(p. 70) 3. Lift your sternum, or breast bone.
4. Make sure your chin is parallel to the ground.
5. Imagine the crown of your head is lifting—for example, ask the child to picture a helium balloon that is gently lifting her head up.
6. Press down through the balls of the feet and lift the toes up in the shoes and notice how that action increases sensation in the legs.
When the child is in the posture, ask her to tell you about a mountain. What do mountains look like? Do they move? Do they make noise? How strong are they? Encourage the child to process and narrate the experience in terms of emotions, thoughts, and sensations.
Positive thoughts and thought insertion techniques begin to address the youth’s automatic negative thoughts. The term automatic thoughts refers to the individual explanations tied to the negative emotions. These thoughts occur spontaneously and are not well processed or thought out. Because of this lack of processing, people often accept these thoughts as truth. Automatic thoughts generally have their basis in a person’s deeper underlying beliefs and assumptions about herself and the world.
Negative automatic thoughts are self- generating. They lead to further negative thinking and, in this way, create a chain that becomes self-sustaining—a cycle of negativity. These negative thought chains are associated with depression and anxiety. Inserting positive thoughts, which are not automatic and require conscious effort, can facilitate disruption of the chain. Both the thought insertion technique and the positive thoughts technique facilitate increased awareness of the unconscious automatic thoughts cycle.
Positive Thoughts and Thought Insertion Techniques
Instruct the child on how to use cognitive techniques such as recruiting positive thoughts and thought insertion techniques. The Thought Insertion Model (Worksheet 5.3), the Thought Insertion Worksheet (Worksheet 5.4), and the Positive Thought Worksheet (Worksheet 5.5) help facilitate the practice.
(p. 71) Have the youth practice both positive thought and thought insertion anchoring on a negative event from the previous week. Note that the event does not need to be traumatic. Practicing replacing negative thoughts with positive ones in therapy can help the child develop the ability to develop her own positive thoughts in the future.
Note on Negative Thoughts
While encouraging new thinking and more control over feelings, caution the child that this does not mean that negative thoughts and images must always be shut down or avoided. Negative cognitions and emotions are normative and serve a real purpose. The feelings of fear, sadness, and anger often serve as indicators of real danger and harm in a person’s environment. It is natural and healthy to feel afraid when in a threatening situation or to grieve a genuine loss. The tools are designed to help youths cope in situations in which the emotions or thoughts are interfering with their functioning. Tools may help manage emotions that have become so pervasive they hamper the ability to experience positive situations.
Development of Personal Tools
Children that are engaged in treatment may develop their own tools. This is a good prognostic sign. In our experience, the use of these tools leads to even better outcomes. These tools may be activities such as sports or art. If the youth is not involved currently in any such activities, you might encourage her to pursue an activity she might enjoy. For children who associate arousal states with negative emotions, the arousal of exercise and sports can create more positive associations, which make this sensation more tolerable. Here is an example of personal tool development:
Ava, a sexual abuse survivor, often experienced panic and an overwhelming fear of being attacked while in the shower. She shared with her therapist that singing sometimes calmed her down and made her feel better. The therapist encouraged Ava to sing aloud or under her breath in situations in which she experienced trauma-related fears. The tool worked to help Ava relax. Listening to music and singing became a powerful tool for Ava to express emotions and cope with traumatic symptoms during the course of therapy.
(p. 72) Help youths generate a list of their own relaxation tools, including activities such as writing, painting, drawing, acting, exercising, doing sports, playing music, or swimming. These tools can be based on preexisting hobbies or interests, or those that are newly developed.
Practice all new skills and encourage the youth to practice them at home between sessions. Emphasize to the child that, just as any other skill, tools get better with practice. For example, ask, “If I gave you a guitar and had you play me a song right now, how would that go? What about if I had you take lessons for a few months and then you played me a song?” You may also ask her for an example from her own life of something she had to practice to do well.
Selecting Skills for the Toolbox
After practicing all the skills, have the child determine which tools she wants to maintain in her Toolbox. Evaluate how well each tool fits the youth’s strengths. If a particular tool seems too difficult to understand or practice, it may not need to be included in the child’s Toolbox.
At the end of session 3, remind the youth that she will begin applying these tools in the next session as she begins to discuss her life events.
• Have the youth practice skills between sessions, including the following:
■ Deep breathing
■ Progressive muscle relaxation
(p. 73) ■ Visual imagery
■ Mindfulness (e.g., breathing, yoga poses)
■ Positive thought and thought insertion techniques
• Encourage the youth to develop her own relaxation tools (e.g., sports, music)