LifeSKillsLifeStory Manual

Treating Multiply Traumatized Girls
In Community Settings
Life Skills/Life Story:

Joining Skills Training in Affective Regulation with
Narrative Storytelling
Marylene Cloitre, Ph.D.

Lana Farina, Psy.D.
Lori Davis, Psy.D.
Debra Carr, Psy.D.
Janelle Brown, Ph.D.
© 2005
Please do not quote without permission from authors.
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Table of Contents
Introduction 7
Guidelines to Therapist 10
Phase I – Life Skills
Session 1: Introduction to Treatment 12
Provide Psychoeducation about PTSD and Common Reactions to Trauma

and/or Stress
Provide Rationale and Overview of the Treatment
Help the Adolescent to Compile a List of Personal Goals for Treatment
Discuss Plans to Meet with the Caregiver Next Session
Worksheet: My Goals
Session 2: Identification and Labeling of Feelings
Discuss the Adolescent’s Reaction to the First Session

Create a Safety Plan and Safety Card with the Adolescent
Provide Psychoeducation about the Impact of Trauma and Stress on
Coping with Feelings
Introduce and Practice Labeling Feeling States
Introduce and Practice the Self-Monitoring of Feelings worksheet
Introduce and Practice Deep Breathing
Assign Between-Session Work
Review Safety Plan
Meet with the Caregiver: Review Safety Plan and Discuss Caregiver
Involvement
Worksheet: Feelings List A
Feelings List B
Name the Feeling
Self-Monitoring of Feelings
*Optional Session to Prepare for Coping Skills Addressed in Session 3:

Self Care and Relaxation
Note to Therapist: Rationale for Optional Session

Review Between-Session Work
Introduce Self-Care and Relaxation
Review Safety Plan
Worksheet: Soothing Your Senses
Session 3: Coping with Upsetting Feelings
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Provide Psychoeducation about Coping with Upsetting Feelings
Identify and Evaluate Current Coping Skills
Provide Psychoeducation about Self-Talk
Practice Paying Attention to Self-Talk
Coping with Upsetting Self-Talk
Introduce and Practice the Use of Cognitive Coping Skills
Review Coping Skills and Safety Plan
Worksheet: Self-Talk
Positive Self-Statements
Session 4: Dealing with Upsetting Situations

Review any Problems with Implementation of Coping Skills
Provide Psychoeducation about Dealing with Upsetting Situations
Introduce Concept of Dealing with Upsetting Situations to Achieve Goals
Coping Strategies for Dealing with Upsetting Situations
Worksheet: Dealing with Upsetting Situations
Session 5: Coping Strategies for Dealing with Upsetting Situations

Review Implementation of Coping Skills
Coping Strategies for Dealing with Upsetting Situations
Worksheet: “Feel Good” Activities
Session 6: Using Positive Imagery to Deal with Upsetting Feelings

Provide Rationale for the Use of Positive Imagery
Make Positive Image Collages
Session 7: Relationships with People: Behavior and Communication

Provide Psychoeducation about how Behavior and Communication affect
Relationships
Introduce Skills for Clear Communication
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Worksheet: Clear Communication
*Optional Session to Expand on Relationship Work Addressed in Session 7:

Relationship between Feelings and People: Schemas

Provide Psychoeducation about Schemas
Provide Psychoeducation about Feelings and Relationship Schemas
Introduce the Challenging Schemas Worksheet
Worksheet: Challenging Schemas
Session 8: Introduction to Role-playing: Feelings vs. Behavior

Describe Role-playing
Practice a Simple Role-play
Identify Difficult Situations and Conduct Role-plays
Worksheet: Dealing with Others
Challenging Schemas
Session 9: Role-playing with Focus on Assertiveness

Define Assertiveness
Identify Current Difficulties in Assertiveness
Provide Psychoeducation about Effective Assertiveness
Conduct Role-play of Situations Requiring Assertiveness
Worksheet: Basic Personal Rights
Dealing with Others
Challenging Schemas
Session 10: Review of Skills Learned and Transition to Narrative Story

Telling (NST)

Acknowledge Last Skills Session and Review Progress
Provide a Brief Rationale of Narrative Storytelling (NST)
Elicit Questions and Concerns about Transition to NST
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Assess and Review PTSD Symptoms
Worksheet: Dealing with Others
Challenging Schemas
Phase II – Life Story - Narrative Storytelling (NST)
Session 11: Introduction to NST
Note to Therapist: Using the SUDS Rating Scale

Review Safety Plan with Adolescent
Rationale for NST
Elucidation of memories
Review Difficulties Concerning Coping Skills and Relationships
Assign Between-Session Work: Mastery and Competency
Worksheet: SUDS Rating Scale
Memory Elucidation Form
Mastery and Competency Activity
*Note to Therapist: Orientation of Therapist to NST
Session 12: NST of First Memory

Review Rationale for NST
Practice Storytelling of Neutral Memory
Conduct First Storytelling
Terminate Storytelling
Debriefing
Therapist NST Recording Form
Therapist Form for Post NST Emotional State
Sessions 13– 15: Continued Work on NST
Note to Therapist: Planning Referrals

Continuing NST
NST with Multiple Traumas
Moving to Another Memory
Selecting the Next Memory
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Therapist NST Recording Form
Therapist Form for Post NST Emotional State
Sessions 16: Reviewing Progress and Saying Good-Bye

Review Skills Learned in Treatment and Progress of Competency Activity
Identify Remaining Goals
Say Good-Bye and Provide Referrals
Present Certificate of Completion
Worksheet: Certificate of Completion
Appendix A: Safety Guidelines for Emergent Patients
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Introduction
About This Treatment (Life Skills/Life Story)
This unique treatment was specifically developed and tested on youth, ages 12-21, with
histories of multiple traumas. These youth reported experiencing childhood physical and sexual
abuse, and other traumas such as community and domestic violence. Multiple traumatization is
the rule rather than the exception among urban youth. Many inner-city adolescents with histories
of childhood sexual abuse report that they experienced additional traumas. Some also had a serious
accident or accident-related injury. Others saw or knew someone who was attacked or died
unexpectedly, or witnessed community violence.
Although boys and girls report experiencing a similar number of traumatic events, girls are
more likely to develop PTSD than boys. Seventy percent of multiply traumatized girls identify
childhood physical and/or sexual abuse as their most distressing traumatic experience. Many studies
show how common these childhood abuse experiences are. A study mandated by congress in 1998
reported investigating over 2.8 million cases of child maltreatment (physical abuse, sexual abuse,
neglect). Of these, they substantiated or found some evidence of maltreatment in approximately
903,000 cases. Roughly 1 out of every 3 to 5 women report having experienced childhood abuse.
Experiencing multiple traumas leads not only to more severe PTSD symptoms, but also
disrupts development in childhood and adolescence. Multiple traumas disrupt skills in managing
emotions and having interpersonal relationships. These problems weaken an adolescent’s functioning
and ultimately, her sense of competence and self-esteem. In addition, these weakened skills lead to
limited resources, which an adolescent needs to participate in effective exposure based treatments.
Most traumatized adolescents come to treatment because they are not functioning well, not
for symptoms of trauma. This treatment aims to enhance an adolescent’s functioning by increasing
emotion management and relationship skills. The treatment approach addresses the consequences
of urban trauma, as well as everyday life stressors that keep the adolescent from developing these
skills. This treatment provides an opportunity for the adolescent to focus on developing these
important skills, which helps them to feel stable and safe in the therapy setting, and develop of a
positive relationship with their therapist.
This manual addresses cognitive, behavioral, interpersonal, emotional and developmental

factors. It allows the therapist to tailor the interventions to adolescents functioning at different levels
of development. The interventions range from teaching concrete skills that target problems with
emotion management and relationship skills to more complex cognitive interventions. The manual
provides optional sessions and different selections of activities and handouts so that the therapist can
deliver effective interventions to every adolescent.
Maintaining sensitivity towards an adolescent’s level of cognitive functioning is essential for

successful treatment. Childhood trauma has been associated with delays in language and cognitive
development, low IQ, and poor school performance. These factors may promote social isolation and
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alienation. Youths with a combined history of trauma and learning disabilities are at greater risk for
developing PTSD, depression, low self-esteem, anger and aggressiveness, dissociative symptoms, self-
harm, and alcohol abuse than youths without this combined history.
Youths with developmental disabilities have a greater risk for developing emotional and
psychotic disorders compared to youths without disabilities. Low cognitive ability and developmental
delays have been associated with coping difficulties, vulnerability to abuse, and vulnerability to
emotional distress. A lack of consistent, effective coping strategies can foster dependency on others
and weaken communication, problem-solving, and relationship skills. Youths are likely to have strong
negative feelings about having a disability and experience low self-esteem. This specialized treatment
targets weak skills that multiply traumatized adolescents often have and provides interventions for
different levels of cognitive development.
Overview of the Treatment
This cognitive behavioral treatment focuses on skills training such as learning to identify and
label feeling states, and to identify and change self-beliefs. The treatment also teaches adolescents
to develop mastery and self-efficacy and to make healthy goals for the future. It teaches adolescents
to identify and tolerate upsetting feelings and to change patterns in relationships that cause
problems. The goal is to reduce anxiety and depression and to improve emotion management and
interpersonal relationships.
Life Skills
Adolescents learn about the consequences of trauma and life stress on emotions and
relationships. By learning to monitor their emotions, thoughts, and behaviors, adolescents can begin
to understand their inner experiences. They learn and practice coping skills to manage emotions (e.g.,
deep breathing, weighing the pros and cons of tolerating a difficult situation, positive activities). After
learning these skills, adolescents role-play challenging situations with others in session. They practice
different ways to communicate with parents, peers, and co-workers in order to get their needs met. As
adolescents see that they can affect change in their lives, they feel better about themselves.
Adolescents who learn to manage their emotions and communicate more effectively will reduce their
own risk for revictimization and cope with stressful situations better.
Life Story (Narrative Storytelling or NST)
During this second phase of treatment, adolescents talk about their traumas in detail. This
helps them to process these events and integrate them with other life experiences. By processing
traumatic experiences, the adolescent gains access to thoughts and feelings associated with her
traumas that she may have previously avoided. The therapist provides a safe and supportive
environment to facilitate the adolescent’s storytelling and helps her practice coping skills to manage
upsetting feelings.
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The adolescent uses control in the treatment by choosing memories to discuss and setting a
comfortable pace. With repeated storytelling, the adolescent learns that she can discuss her
traumatic experiences without feeling overwhelmed by emotional and physical symptoms. One of the
goals is for the adolescent to become more aware of triggers related to her traumatic experiences. In
addition, this treatment promotes the adolescent’s use of coping skills to face painful emotions rather
than avoid them.
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Guidelines to Therapist
Use of this Manual
This manual is structured, yet allows flexibility for individual differences in symptoms and
skills. For example, some adolescents may have difficulty identifying basic emotions. Others may
easily identify and change upsetting self-talk. Thus, the therapist must be flexible in applying the
interventions and selecting activities to meet each adolescent at her current level. For example, an
adolescent with a large and complex vocabulary of feelings may feel condescended if asked to
complete the “Name the Feeling” handout. Another adolescent may struggle with this concept and
need to practice this skill a lot before she moves on to the next skill. It is important that the therapist
consider each adolescent’s knowledge of and prior experience with the material, and cognitive ability
in pacing the skills.
As in all cognitive-behavioral treatments, weekly homework, or between-session work, is

essential to treatment success. The therapist should monitor this work closely. Finally, the therapist
should establish and monitor a safety plan with the adolescent before starting this treatment.
General Attitudes and Behavior
As in any treatment, the value of establishing rapport cannot be overstated. The key to doing
good clinical work is developing a therapeutic alliance with the adolescent. The clinician must respect
a multiply traumatized adolescent’s hesitancy to delve into details of traumatic events at the start of
treatment. The therapist should not assume that an adolescent would automatically trust her/him
and easily disclose personal and upsetting details of her life. Rather, the therapist must understand
that rapport with an adolescent is something that develops in an open and accepting environment.
The therapist can help facilitate an adolescent’s level of comfort by having an open dialogue
about treatment and the therapist’s role in treatment. State to the adolescent explicitly that she will
be in control of exploring and expressing her emotions and that you will follow her lead, based on the
adolescent’s comfort. This approach empowers the adolescent by giving her a sense of control that
she may not have had in other situations.
It is also important for the therapist to convey that she/he will respect what the adolescent has
to say and how she needs to deal with her experiences. One adolescent indicated that she had many
unanswered questions about her abuse that she felt she could never ask. Her therapist invited her to
compose a list of questions that they would review in sessions. The adolescent’s questions included,
“Why did he do this to me?”, “Why does God hate me so much?”, “How did I end up this way?”, “Do I
have a future now?”, and “Out of all people, why me?” This intervention was important because the
therapist incorporated material that was important to the adolescent in working through her
experiences. The therapist conveyed to the adolescent that her questions were important and that her
input was valuable.
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This manual includes rationales and clinical illustrations to assist clinicians with potential
pitfalls and resistance to treatment. Many adolescents may appear resistant to treatment; however,
many factors can contribute to this. An important role of the therapist is to use her/his clinical skills
to assess the individual differences that shape an adolescent’s attitude towards treatment. These
factors may include culture, experiences with the family system and peer network, prior experiences
with mental health providers, and involvement in the child welfare system. If the adolescent
experienced a lack of support when she talked about her traumas in the past, she may expect the
therapist to react in a similar way. In this situation, the therapist must strive to create a consistent
environment in which the adolescent feels safe and supported.
The therapist must be aware of delays in skill abilities that may resemble resistance. For
example, an adolescent who consistently does not complete homework assignments may indeed not
be able to due to reading and writing deficits. Therapists who are unaware of these issues may feel
frustrated and misinterpret such deficits as opposition. Incorrectly labeling this behavior or
confronting an adolescent about being oppositional may lead her to feel inadequate. Other
adolescents frequently state, “I don’t know” when asked questions about feelings or experiences in
sessions. This may represent an avoidance of upsetting feelings, which is characteristic of
traumatized individuals. It is important for the therapist to note this pattern and consider the personal
relevance these responses may have. If an adolescent is clearly uncomfortable with something
happening within a session, the therapist should give the adolescent permission not to answer
distressing questions or to move on to other material.
Lastly, the therapist should be aware that she/he also serves as a role model for the
adolescent. If an adolescent has difficulty with a particular intervention, the therapist should model
the skill in session. In addition, the therapist may model the role of a more optimal caregiver who is
more responsive and empathic than she may have experienced in the past. This can be a very
important emotional experience for the adolescent.
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Session 1: Introduction to Treatment
Agenda
1. Provide Psychoeducation about PTSD and Common Reactions to Trauma and/or Stress
2. Provide Rationale and Overview of the Treatment
3. Help the Adolescent to Compile a List of Personal Goals for Treatment
4. Create a Safety Plan and Safety Card with the Adolescent
5. Discuss Plans to Meet with the Caregiver Next Session
1. Provide Psychoeducation about PTSD and Common Reactions to Trauma and/or Stress
 Provide the adolescent with an overview of the symptoms of PTSD, and explain how her
symptoms fit into the diagnosis. If the adolescent does not have PTSD, review the symptoms that
relate to trauma and/or stress. Adolescents often have short attention spans; thus, it is useful to
keep this discussion simple, avoiding jargon and lengthy explanations.
 For adolescents with a diagnosis or symptoms of PTSD, explain that PTSD is a disorder that can
develop after a person goes through a trauma. Examples of traumas include childhood abuse,
seeing someone hurt or shot, or being in a bad accident. People develop a set of common
reactions to a trauma, and the adolescent’s symptoms are a normal response to her personal
traumas. Explain that PTSD often develops soon after a trauma; however, it can begin at any
time after the event. In addition, it can be worse when people experience multiple traumas.
 Keep in mind that many inner-city adolescents have experienced multiple traumas. The therapist
should provide psychoeducation while viewing the adolescent’s symptoms in a larger context. For
example, one adolescent girl may have witnessed gang fighting in her neighborhood streets,
domestic violence in her home, and a close family member put in jail. Another girl may have
witnessed the sudden or violent death of a loved one. These girls may have a sense of
foreshortened future and a pessimistic or cynical “view of the world” when they are continually
exposed to violence and negative events throughout their short lives.
 The therapist should avoid delving too deeply into the details related to the adolescent’s
childhood abuse at this phase of treatment. Rather, the therapist should emphasize building
rapport with the adolescent so that she can begin to feel safe. At this time, as well as throughout
the treatment, it is helpful to involve caregivers or legal guardians (or caseworkers) in the process.
This allows them to receive psychoeducation about PTSD and the long-term consequences of
trauma and abuse. In addition, it allows them to know what the girls will be learning in the
treatment so they can provide additional support. The therapist should schedule a session time
with the parent or legal guardian to explain the treatment.
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 Explain that there are 3 groups of symptoms of PTSD (i.e., re-experiencing, avoidance and
numbing, and hyperarousal). A person must have symptoms from each group in order to receive
the diagnosis. Again, remember to keep the language simple. If the adolescent does not have
PTSD, it is useful to explain that there are 3 groups of symptoms that people may have after
going through traumatic and/or stressful events. Discuss the symptoms that are relevant to the
adolescent. The goal is not only to provide the adolescent with an education about PTSD and
reactions to trauma and/or stress, but also to normalize her experience by pointing out that the
following symptoms are common reactions to traumas.
1. Re-experiencing: People re-experience traumatic events by remembering or thinking about

them when they do not want to. Some people have nightmares and see images (or
“flashbacks”) of the events. These reminders, or “triggers”, may lead to upsetting feelings or
physical reactions (i.e. shaking, sweating, faster heart rate). Specify which of these
symptoms the adolescent experiences. The therapist might say, “You mentioned that you’ve
had some scary dreams lately, and that you felt “sick” when you thought about the abuse.
These are examples of re-experiencing.”
2. Avoidance and numbing: People often try to avoid or ignore things that remind them of a
traumatic or stressful event. Common avoidance symptoms include ignoring thoughts or
feelings about traumatic or stressful events, avoiding activities, places, or people related with
the event, and having difficulty remembering parts of the event. Many people report avoiding
family events or returning to old neighborhoods where they might remember a trauma.
People also often experience “emotional numbing”, or difficulty having strong feelings,
whether positive or negative. Some people describe “feeling like a robot”. Numbing
symptoms might also include loss of interest in activities, and feeling distant or detached
from people. The adolescent may also insist, “I don’t care!”, as an attempt to ignore or numb
her upset feelings. The therapist might say, “Many times when something upsetting happens,
people don’t want to talk or think about it because they might feel upset again. Have you had
this experience?”
3. Hyperarousal: People often experience increased arousal through sleep problems, increased
irritability and anger, and difficulty concentrating. They may also experience hypervigilance
(being more concerned about what is happening around you than you need to be), and/or an
exaggerated startle response (i.e., jumping when you hear a sound). Again, specify which of
these symptoms the adolescent is experiencing and how they fit into this category. The
therapist might say, “You said that sometimes at school, you have thoughts about the abuse
that get in the way of focusing on what the teacher is saying”, or, “Many people with a history
of trauma feel ‘on guard’ a lot of the time. Does this sound like something that happens to
you?”
2. Provide Rationale and Overview of the Treatment
 Rationale: Start out by defining the treatment as being for adolescent girls with PTSD related to
interpersonal violence, such as childhood sexual or physical abuse. Acknowledge that the
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adolescent may not have a history of trauma, but may have been in situations that were stressful.
Point out that the adolescent’s current symptoms, such as nightmares, flashbacks and anxiety
indicate that there is "unfinished business" related to past trauma and/or stressful events. Note
that some people try to cope with this by avoiding or trying to ignore upsetting memories, which is
understandable, but ultimately does not work. Others cannot avoid at all and feel overwhelmed
by their memories. Some people have both of these experiences at different times.
 The treatment helps the adolescent develop skills to cope with difficult experiences related to
traumatic or stressful events. It also helps the adolescent to face the memories of these events
so that she can have more control over them, rather than feeling controlled by them.
 One of the goals of the treatment is to help the adolescent to integrate her experiences. Some
adolescents find the following analogy helpful: we can view the mind as a file cabinet in which we
organize and store experiences, helping us to make sense of them and put them in their right
place. For example, children might have a file for "birthday parties," where they store memories
of particular parties. They build up knowledge about what one brings to a party, what to expect at
a party, etc. However, where does a child file and organize the experience of abuse? Typically,
they do not label and discuss their abuse experience. Thus, the feelings and memories continue
to interfere with life in the present, frequently in the form of PTSD. Part of the goal of talking
about the adolescent’s abuse is to be able to organize her distressing feelings and memories and
find a place for them, rather than avoid them.
 Overview. Explain that this is a two-phase treatment and consists of 16 hour-long, weekly
sessions. The first phase will focus on learning skills to cope with upsetting or difficult feelings. In
the second phase, the adolescent will talk about her traumatic experiences through narrative
storytelling, as well as continued work with coping skills.
PHASE I: SKILLS TRAINING
Explain that the goals of this phase are to help the adolescent be more aware of her emotions.
She will learn to identify and name her feelings, and to practice skills to reduce upsetting feelings
and tolerate distress. Many adolescents with trauma histories have difficulty knowing what they
are feeling and/or managing their feelings. Some adolescents feel overwhelmed by their
feelings, while others may have learned to cope by not feeling anything at all. Engage the
adolescent in a discussion about her experience with this. It may help to give examples such as,
"Some girls are never able to feel anger, while others don't feel able to manage their anger at all
so that they 'blow up'." Explain that these symptoms often come and go, and that people can
have both of these experiences at different times.
Explain that one goal of treatment will be to learn how the adolescent can have feelings without
becoming overwhelmed. This will first involve the adolescent being more aware of her feelings
and triggers for them. Explain that it may be hard for traumatized adolescents to experience and
label their feelings because others may have mislabeled or ignored them during childhood. Give
examples and ask for relevant examples from the adolescent. Get an initial sense of how others
responded to the adolescent's feelings as a child. If she does not readily engage in this
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discussion, the therapist may invite her to do so with comments or questions such as "Does this
strike a chord for you?"
Another goal of this treatment is to help the adolescent learn how to get along better with others.
The treatment will help her use relationship goals rather than feelings to guide her interactions
with others. Explain to the adolescent that she will learn to use the coping skills she learns in
treatment in her relationships. Specifically, she will learn how to manage certain feelings that
can get in the way of meeting her relationship goals. Ask the adolescent about difficulties she
experiences in relationships, prompting with questions and examples as necessary. Try to
understand the adolescent’s style of interacting with others and potential problem areas.
Example: “Some girls who were abused as children have difficulty being assertive or let others
take advantage of them. Is this familiar to you?” Example: “Some girls who were abused as
children have difficulty getting along with their classmates and tend to get into fights at school.
Does this happen to you?” Example: “Are there certain feelings you have difficulty expressing to
family and friends? What makes it difficult?”
Finally, explain to the adolescent that she will be learning a number of skills so that she can select
those that work best for her.
PHASE II: NARRATIVE STORYTELLING (NST)
Explain that during this phase, the adolescent will talk about her traumatic experiences in session
so that she can access the feelings that go with those events. The goal is for her to process the
traumas so that she can think about or remember them without experiencing intense symptoms.
It may be helpful to remind the adolescent how this will address either her avoidance of thinking
about the traumas, and/or feeling overwhelmed or flooded by them.
The therapist can explain NST to the adolescent in the following way: "This part of the treatment
will help you connect your feelings and your experiences in a safe and supportive place. Staying
with your memories rather than avoiding them can be very upsetting at first, but over time, your
anxiety and fear will begin to decrease.” For adolescents, the idea of reliving painful memories is
particularly difficult since they typically live “in the moment”. They may have trouble seeing that
their present avoidance may have long-term consequences.
Some adolescents may feel anxious at the idea of talking about their traumatic experiences. It is
helpful to explain that NST will begin with manageable memories that work up to ones that are
more difficult. Also, emphasize that the work will be collaborative, that the adolescent will set the
pace of the work and stop if she needs to. She will also have some new coping skills from the
first phase of the treatment to help her with NST. Assure the adolescent that you and she will talk
about this part of the treatment again as it gets closer. Some adolescents will want questions
answered about NST. Again, it is best to leave this discussion until you approach Phase 2 of
treatment.
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3. Help the Adolescent to Compile a List of Personal Goals for Treatment
 Using the sheet entitled “My Goals,” help the adolescent to compile a list of personal goals for
treatment. Encourage the adolescent to identify areas in her life where she has trouble with
feelings or in relationships that she would like to improve. An adolescent’s goals may include
concrete wishes such as “I want to keep my room clean” and “I want to stop being late all the
time” or may be more complex such as “I’d like to be less angry” or “I wish I could learn to trust
people.” Since one of the goals of this treatment is to help bolster an adolescent’s sense of self,
other goals may include areas of interest in an adolescent’s life. For example, she might like to
improve upon academics, athletics or personal strengths such as writing poetry, singing, or dance.
Challenges
Many adolescents with a history of childhood abuse have been through the foster care system,
placed in group homes, and/or been through legal battles over custody issues. Thus, it is likely that they
have received previous psychological treatment and been through a fair number of psychological
evaluations. Some adolescents doubt that this treatment will help them to accomplish their goals. They
may say, “I’ve already talked about this stuff and nothing helps. This won’t be any different.” It is
important that the therapist be sensitive to the adolescent’s frustration but also convey the unique
aspects of this treatment. Explain that the focus will be on helping her learn new skills to manage her
feelings and relationships better.
2. Create a Safety Plan and Safety Card with the Adolescent
 Create a safety plan upon which you both can agree. This is important to address concerns about
safety, and reminds the adolescent that the therapist is concerned and attentive. The therapist
may introduce this task by reviewing information about specific difficulties the adolescent has
experienced with managing feelings. If unclear, ask the adolescent what feelings are difficult for
her to manage. Explain that it is important to think about ways she will deal with upsetting
feelings before moving forward with the treatment. The therapist may remind her that she will be
talking about some difficult topics in sessions that may bring up strong feelings. The purpose of
the safety card is to plan what the adolescent can do to make herself feel better and identify
supportive people she can contact.
 Social support can help abused adolescents by buffering against stress and reducing upsetting
feelings. It can alleviate feelings of shame and self-blame, which sexually abused adolescents
often experience, and bolster self-esteem. Sources of support range from family members and
friends to school and community organizations. Support from parents can reduce depression
among abused adolescents and show that they can receive positive reactions from others. An
adolescent’s perceived social support from a non-offending parent is especially critical.
Adolescents are more likely to receive and feel satisfied with support from friends. The shift in
focus from parental support to peer support is stronger in girls than boys. In addition, girls are
more likely to feel satisfied with support from same-sex peers after disclosing abuse.
Adolescents who lack or avoid social supports are more likely to have difficulty because they have
restricted sources of affection, nurturance, and guidance.
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 A three-point plan is often helpful. Help the adolescent to write the plan on a card that she can
carry in her wallet, backpack, or pocket. The safety card should include the therapist’s phone
number, as well as the phone number of key staff members at the clinic. It should also include
the phone number of the nearest emergency room, and any hotlines that may be relevant (see
Appendix at end of this manual). The therapist should review this plan at the end of every
session, as well as the beginning of Phase II (NST) of treatment.
 Examples of Safety Cards:
Safety Card for Potentially Suicidal Adolescents

- Therapist’s name, telephone number for therapist and the main clinic, address
- Emergency contact (e.g., relative or friend)
- Name, phone number, and address of the nearest ER
- Plan:
1. If you are feeling suicidal: notify parent/legal guardian or someone at home, or if at school,
talk to your teacher or guidance counselor
2. Call your therapist and be sure to leave a phone number where she/he can reach you
3. Call a relative or friend to connect
4. If you feel that you may hurt yourself, go to the nearest ER or call 911
Safety Card for Dissociative Adolescents

- Therapist’s name, telephone number for therapist and the main clinic, address
- Emergency contact (e.g., relative, friend)
- Name, phone number, and address of the nearest ER
- Plan:
1. If you are feeling suicidal: notify parent/legal guardian or someone at home, or if at school,
talk to your teacher or guidance counselor
2. If you are feeling spacey: drink a hot or cold beverage to help ground you
3. If that does not help, call a relative or friend to connect
4. If you are feeling scared, call your therapist and be sure to leave a phone number where
he/she can reach you
Challenges
Some adolescents may say that the safety card is unnecessary because they already know who
they can call and the appropriate phone numbers. It is helpful to remind the adolescent that even
though this task may seem simple now, it is often difficult for people to remember their plans when
they feel very upset. The safety card can help her organize herself and remember what to do in an
upsetting situation.
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5. Discuss Plans to Meet with the Caregiver Next Session
 Let the adolescent know that you will be meeting with her parent or guardian at the end of the
next session. In this meeting, you will talk about her goals for treatment, provide
psychoeducation about PTSD and the effects of trauma, and discuss other important issues
such as safety, confidentiality, and caregiver involvement. Give the adolescent an opportunity
to raise any questions or concerns related to these issues. Stress that this is the adolescent’s
treatment and that you will respect her privacy. At the same time, a parent or caregiver can
provide extra support and understanding throughout treatment, particularly between sessions.
Explain to the adolescent that part of your meeting with her parent or guardian at the end of
this session will be to review the safety plan and to give him or her a copy of it.
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Session 2: Identification and Labeling of Feelings
Agenda
1. Discuss the Adolescent 's Reactions to the First Session

2. Provide Psychoeducation about the Impact of Trauma and Stress on Coping with Feelings
3. Introduce and Practice Naming Feeling States
4. Introduce and Practice the Self-Monitoring of Feelings Worksheet
5. Introduce and Practice Deep Breathing
6. Assign Between-session Work: Self-Monitoring of Feelings Worksheets 2x/week
7. Review Coping Skills and Safety Plan
8. Meet with the Caregiver: Review Safety Plan and Discuss Caregiver Involvement
1. Discuss the Adolescent’s Reactions to the First Session
 Ask about the adolescent’s reaction to treatment. Normalize the adolescent’s response and
clarify any questions or concerns.
2. Provide Psychoeducation about the Impact of Trauma and Stress on Coping with Feelings
 Discuss with the adolescent how her traumas affect how she experiences and expresses her
feelings. Discuss the value of paying attention to feelings, understanding triggers (what “sets
them off”), and beginning to work on skills to cope with feelings. Remind the adolescent that
many traumatized people have difficulties with feelings. They may feel overwhelmed by them or,
in contrast, feel numb. Engage the adolescent in talking about her particular difficulties.
Challenges
Make sure to address and clarify the specific nature of the adolescent’s difficulties in dealing with
upsetting feelings. Not all adolescents have the same difficulties. For example, an adolescent may have
no difficulty labeling her feelings, but may feel at a loss as to what to do with them. Some adolescents
may need help primarily in being able to reduce the intensity of their feelings, while others may need a lot
of work to help them access any feelings at all.
 Explain that, ideally, when children grow up in a stable home with a nurturing caregiver, they learn
to pay attention to their feelings and cope with them. Traumatic experiences such as sexual and
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physical abuse can cause people to have overwhelming feelings. This often happens in families
where caregivers offer little soothing or guidance in dealing with upsetting feelings.
 Keeping this in mind, try to elicit from the adolescent ways in which her caregivers responded to
her feelings. For example, did they consider her feelings important? Did they ignore or mislabel
them? Was she told as a child, “You are fine, stop crying", when she was clearly upset?
Additionally, how did her caregivers handle their own feelings? For example, did they sweep
things under the rug, drink, or express scary, out-of-control anger? Was there anyone around even
to consider her feelings? When possible, try to provide links between the adolescent’s emotional
experiences with caregivers and her own current difficulties identifying and dealing with feelings.
Challenges
Many abused adolescents have conflictual bonds with their abusers and may feel the need to
defend them. The therapist needs to convey this information in a way that respects this, using language
that does not imply judgment. For example, “Your parents, for whatever reason, were not able to/did not
help you to deal with difficult feelings."
 Provide psychoeducation about how feelings guide behavior and tell us which situations to
approach or avoid. For example, a feeling of fear should guide us to leave an unsafe situation, or
to take steps to be safe. Many girls report finding themselves in dangerous situations such as
“being alone with a guy in his apartment after a party”. They may not realize they are in a
potentially unsafe situation until the male becomes overtly aggressive, either sexually or
physically.
 Feelings are also important because they communicate what we feel and need from others. After
a traumatic experience, some adolescents are very anxious. They cannot use their feelings to
decide how they should act. While people can adjust to feeling anxious, when it is severe, it can
be hard for a person to know what they are feeling. It can cause people to overreact, and
sometimes to underreact to situations because they are trying so hard not to overreact. Explain
that by working on naming her feelings and triggers (things that cause them), the adolescent will
be able to use information from her feelings to plan how she should behave.
3. Introduce and Practice Naming Feeling States
 Work with the adolescent to identify and name different feeling states using the Feelings List
handout. Some adolescents have never learned to differentiate or name their feelings. They can
benefit from this activity by learning to clarify different feeling states. Depending on the age and
developmental maturity of the adolescent, use either List A or List B. Use List A for adolescents
functioning at an earlier stage of development who may have a limited vocabulary of feelings.
This list includes basic feelings such as happy, mad, and sad. Use List B for higher functioning
adolescents who have a more complex vocabulary of feelings. This list includes several different
types of happy, angry, and sad feelings. Review the appropriate list with the adolescent and help
define any feelings with which she is unfamiliar.
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 When working with younger or lower functioning adolescents who demonstrate difficulty naming
feeling states, have them complete the “Name the Feeling” worksheet for additional practice.
Provide assistance as needed.
4. Introduce and Practice the Self-Monitoring of Feelings Worksheet
 Introduce the adolescent to the Self-Monitoring of Feelings worksheet. Explain that she will use
this sheet to begin tracking her feelings. She will do this by noting what the feeling is, how strong
it is, what the situation or trigger is, and how she deals with the feeling. Establish anchors for
rating intensity: for example, “just a little, somewhat, a lot”.
 Ask the adolescent to identify a situation in the past week that triggered a strong reaction.
Complete a self-monitoring sheet together, focusing on any aspects that are unclear to her. This
will help the adolescent name her feelings and receive validation from the therapist. Some
adolescents can only describe their feelings as physical sensations, so this can be a starting
place. Others have the ability to identify and name feelings, but may not know what the triggers
are. Once the adolescent understands the self-monitoring activity, point out that these sheets will
be important for treatment. They can help the therapist understand the adolescent’s experiences
between sessions. Emphasize that the sheet is most helpful when the adolescent fills it out as
soon as she has a strong feeling.
Challenges
Some adolescents view self-monitoring as simplistic or trivializing. They may say, "I've told you
about these horrible things that happened to me, and you think giving me a worksheet is going to fix it?!"
The therapist needs to be sensitive to the adolescent's point, but also make it clear that this is not the
expectation at all. In this part of treatment, the focus is on learning about how her traumas affect her
feelings in the present. It can help to acknowledge that the task may seem simplistic but that people tell
us they are surprised by what they learn about what they're feeling and why.
Some adolescents dislike filling out the self-monitoring sheets because of their similarity to
schoolwork. They may say, “I have enough to do for school. I don’t need to do this here too,” or “I’m
coming here to get help, not just to do more homework.” The therapist can be empathic to the
adolescent’s point while also emphasizing the many benefits of completing the forms. “This feels a lot
like schoolwork to you and that can be annoying but there are actually some very important things you
can gain from these sheets that might be of real use to you. Why don’t we try filling one out together?”
5. Introduce and Practice Deep Breathing
 Rationale: Explain the rationale for deep breathing to the adolescent: "One way to deal with upset
feelings is to calm your body down by using deep breathing. When people are upset, they tend to
breathe from their chest. They breathe more quickly and deeply, taking in too much oxygen. This
can actually make you feel anxious because you can become dizzy, have a hard time catching
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your breath, and even feel confused. The aim of this exercise is to slow down your breathing and
reduce the amount of oxygen you take in, so you will feel less anxious. You can also use it when
you are feeling irritable or angry, and as a tool to help you feel more calm and grounded."
 Assess Baseline. Observe the adolescent as she breathes in her usual way. Have her pay
attention to the rate of her breathing. Have her check whether she breathes from her chest or
diaphragm.
 Teach Technique. Model breathing from the diaphragm, placing one hand on your chest and the
other on your stomach and have the adolescent imitate. Explain that when breathing from the
diaphragm, only the stomach hand should move up and down (or mostly). It can help to invite the
adolescent to think of how babies sleep, how their tummy moves up and down. She might also
imagine her stomach as a balloon, filling with air and expanding as she inhales, then letting out
the air and shrinking as she exhales.
 Slow Down Rate of Breathing. Instruct the adolescent to take in enough air to fill her stomach,
and then let it out slowly. Sometimes breathing through the nose is easier because it is a smaller
opening. This can help to control the rate of exhalation. Instruct the adolescent to pause briefly
after exhaling before inhaling again. Some adolescents will hold their breath too long at first.
Explain that the pause should come after exhaling. Use imagery to help the adolescent
understand the desired movement and flow. For example, a wave is a helpful image for some.
The image of climbing up a slide (inhaling) and then sliding down (exhaling), and briefly pausing
at the bottom before climbing up again has been helpful for some adolescents.
 Meditational Component. In order to help slow thoughts and pay attention to breathing, have the
adolescent count her breaths as she inhales. Ask her to think of a word such as "relax," or "calm,"
as she exhales. The adolescent should continue to "10" and then go back to "1." Explain: "It is
perfectly natural for other thoughts to come into your mind. Try not to get angry or frustrated, just
allow the thoughts to pass through your mind and focus on your counting again." Some people
find it helpful to concentrate mostly on the physical sensation of their breathing. Others
concentrate on the counting or "relax" statement. Still others will have different ways of focusing
that come most naturally to them. Encourage the adolescent to do what works best for her.
 Importance of Practice. Instruct the adolescent to put aside some time each day where she will
be comfortable and not be disturbed. Ask her to practice the breathing for at least 5 minutes
twice a day. Emphasize that she will get better at breathing with practice. Only then will she be
able to use it as a coping skill when she is anxious.
Challenges
Some adolescents feel that the deep breathing exercise is “dumb” or “pointless.” They may say
“I’ve tried this before and it doesn’t work” or “How is changing my breathing going to fix my relationship
with my boyfriend?!” It is important that the therapist be flexible and not engage in a power struggle with
the adolescent about practicing the exercise. It is often useful to tell the adolescent, “Many people have
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the same reaction that you are having when they first try this out. Once they practice breathing in this
new way, they feel surprised by how much of a difference it makes for them. I am just asking that you
give it a try and see how goes for you.”
6. Assign Between-Session Work
 Ask the adolescent to fill out the Self-Monitoring of Feelings worksheet twice a week. The
therapist should provide the adolescent with a copy of the appropriate Feelings List to help her
clarify feelings. This list is also helpful for adolescents who might have difficulty writing or spelling
because they can copy feeling words directly from the list. The therapist should be aware of any
developmental delays that might prevent the adolescent from completing homework. This will
help the therapist not to misinterpret this as non-compliance and make other accommodations
as indicated.
7, Review Coping Skills and Safety Plan
 Each session should end with a review of the adolescent’s coping skills, and a review of the
safety plan contained on the adolescent’s index card.
8. Meet with the Caregiver: Review Safety Plan and Discuss Caregiver Involvement
 Plan to spend at least twenty minutes with the caregiver to review the safety plan that you
created with the adolescent. Provide a copy of the plan to the caregiver. Explain the rationale
and course of treatment, Discuss how the caregiver can become an integral part of the
adolescent’s treatment by providing emotional support at home and between sessions.
Provide the caregiver with educational handouts about PTSD and the effects of early abuse. If
you are working with a caregiver who has limited understanding or fluency of the English
languages, provide him or her with handouts in their native language. It is often helpful to
explain to the caregiver that the treatment will respect the child’s cultural background, values
and beliefs.
 Caregiver involvement will vary depending upon several factors including availability and
emotional resources. Some caregivers will readily become involved in their child’s treatment
and comply with your suggestions and requests. Others may be motivated, but also
overwhelmed with the demands of daily life. Some may be resistant or avoidant due to the
nature of the childhood abuse and their perceived involvement in witnessing the abuse, and/or
ongoing court matters related to the abuse. Still others may exhibit poor boundaries and call
you repeatedly to criticize their child, and divulge too many details about their own life. In all
cases, it is important not to alienate the caregiver, but to let them know that his or her
cooperation and involvement is crucial for treatment success. Keep in mind that, in the end,
some caregiver involvement is better than none at all.
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 The clinical vignettes below illustrate ways to facilitate productive dialogue between the
therapist and caregiver, and point out potential pitfalls and strategies for dealing with them.
Clinical Illustration: Validating a caregiver’s feelings about abuse
N. is a 15-year-old, sexually abused by her father at age 12. Her mother expressed feeling
guilty that she could not offer enough emotional support to her daughter. In reality, the mother was
supportive of her daughter. She quickly reported the abuse to authorities, worked to have the father
removed from the home, and persevered through lengthy criminal proceedings. Unfortunately, the
mother was emotionally exhausted by the time her daughter’s treatment commenced.
The therapist praised N’s mother for her efforts to date, and provided psychoeducation to help
her understand her own feelings about the abuse:
“It sounds like you’ve been through a lot to help your daughter. It is understandable that you might
feel emotionally exhausted. Parents often have difficulty dealing with their own feelings about the
abuse. That can make it hard to be as supportive as you would like to be. It may be helpful to think
about talking to a therapist who can help you to cope with your own emotions about the abuse and to
get some additional support for yourself. When you are feeling stronger and more able to cope with
your own feelings about what happened, you will be in a better position to provide support to your
daughter.”
The mother was receptive to this suggestion and the therapist provided her with referrals for
treatment. She expressed appreciation for the referral and for the support.
Clinical Illustration: Working with defensive caregivers
B. is a 15-year-old African American female, sexually abused by her mother’s boyfriend. The
abuse was reported to the authorities, and B. was removed from the home. She was living with
relatives at the time of the evaluation. Her father was in the process of suing to obtain custody of his
daughter.
After the evaluation, B.’s mother called in an excited state with concerns that her daughter was
“telling lies” about what had happened. The mother insisted that the sex had been consensual, and
that B. was a deceitful girl. The mother was also concerned that her daughter’s report of an earlier
episode of sexual abuse by the son of one of her mother’s friends was flawed.
The role of the therapist in this case was to validate the mother’s concerns, but to refocus the
mother by explaining the purpose of the treatment. The therapist told the mother: “ I understand that
you have strong feelings about what happened, but my job is to help your daughter with any problems
she may be experiencing as a result of the abuse, not to figure out who is to blame and why. It is the
court’s job to focus on those issues. We could really use your help in trying to help your daughter.”
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After receiving this simple, but essential, explanation, B.’s mother appeared to calm down and
offered observations of other problem behaviors she had seen in her daughter. The therapist validated
her desire to understand the nature and focus of her daughter’s treatment, and she was encouraged
to call if she had questions about the treatment.
Clinical Illustration: Working with an adolescent with a history of suicidal ideation
J.B. is a 16-year-old with a history of self-destructive behavior. She endorsed suicidal ideation,
but denied a plan. This is a sample dialogue of how the therapist can convey her concerns to the
caregiver:
“I wanted to talk with you a bit about the work I will be doing with J.B. and the types of issues
that you and I should communicate about. It is important that we work together because you know
your daughter so well and your relationship is so important. We both have a lot of valuable
information to share. You can really help me work with J.B. more effectively by helping me understand
your experiences with her. We can talk about situations that make J.B. feel upset, what she tends to
do when she feels upset, and what helps her feel better. I want you to know about the work J.B. is
doing so you can help her to continue to work on her goals and use her skills after therapy ends.
This is especially important because your daughter has had times when she felt like hurting
herself. Even though she may not be having those thoughts now, it is important to check in with her
from time to time and ask how she is doing. We will be talking about some difficult topics in therapy
and it is likely that she will be upset at times. While this is natural, we want to make sure that she
feels comfortable talking to us about those feelings.”
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*Optional Session to Prepare for Coping Skills Addressed in Session 3: Self Care and
Relaxation
 This optional session is for adolescents functioning at a concrete level of cognitive

development or who demonstrated difficulty with the concepts covered in session 2. In
session 3, the therapist will introduce several cognitive strategies for coping with upsetting
feelings. Adolescents who struggle to pay attention to their thoughts and feelings may have
difficulty moving right into this more complex material. They may benefit from learning
basic skills for relaxation and self-care to help familiarize them with the concept of coping
strategies and prepare them for the work in session 3. More developmentally advanced
adolescents who completed the work in session 2 with ease should skip this optional
segment and proceed to session 3.
Agenda
1. Review Between-Session Work

2. Introduce Self-Care and Relaxation
4. Review Safety Plan
1. Review Between-Session Work (Self-Monitoring worksheets)
 Go over the adolescent's Self-Monitoring worksheets in detail. Address any practical difficulties
or misunderstandings regarding their use, such as what goes in which column.
 Give positive feedback to the adolescent for being able to identify her feeling states. Work
with her to identify and name more completely and accurately any feeling(s) with which she
had difficulty. The therapist should approach this as a significant part of the session because
its material that can be incorporated into the session's theme. If the therapist conveys the
value of this material and uses it, she/he will reinforce the adolescent’s effort.
 Review the material from Session 2 on the purpose and practice of deep breathing. Model the
technique again, and observe the adolescent doing the breathing. Emphasize the importance
of practice to get the best results from deep breathing.
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2. Introduce Self-Care and Relaxation
 Introduce to the adolescent the concept of self-care. In addition to practicing skills to cope
with upsetting feelings, there are basic things adolescents can do to help themselves feel
good. Ask the adolescent about different ways she takes care of herself. (“What are some
things you do to take care of your body? What are some things you do to relax?) Reinforce the
adolescent for appropriate strategies and add to her list with the following examples:
Self-Care
1. Take care of your body. When you are ill, see a doctor. Take any medications prescribed.
Taking drugs and drinking alcohol can change how you feel and behave which can be
upsetting and cause problems.
2. Eat right. Do not eat too much or too little. Try to eat three balanced meals a day. This
gives your body energy to get through the day. Good nutrition helps you stay healthy and
grow.
3. Get a lot of rest. Make sure that you get enough sleep to feel rested. If you have trouble
sleeping, try to come up with a bedtime routine.
4. Get exercise. Try to get some form of exercise every day for at least 20 minutes. This will
help you stay in shape and have energy. Discuss different forms of exercise.
6. Build Mastery. Try to do something every day to make yourself feel good and in control.
 Introduce the concept of self-soothing to help one relax. Explain that it can be useful for
people to practice strategies to help themselves relax when they feel upset. Discuss strategies
the adolescent has already used to help herself feel calm and situations during which she uses
them. Reinforce the adolescent for using appropriate self-soothing skills.
 Discuss with the adolescent ways of soothing each of the five senses. Explain the benefits of
targeting more than one sense at a time to help her relax more quickly and effectively. Review
the following list of skills to soothe each of the five senses:
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Vision: It can be soothing to look at something pleasant, like flowers, artwork, or images
from a magazine, television, or computer. You may go to (or think about) a place that relaxes
you, such as a park, a room in your house, or looking at the stars at night. You may want to
create something to look at on your own by drawing or painting a picture. You might fix your
hair or fingernails to your liking.
Hearing: Think about what sounds help to soothe you. What kind of music calms you? You
might like to listen to music and maybe sing along to hear your own voice. You may like to
listen to a program on television, or listen to peaceful sounds, like birds chirping, waves rolling,
or rainstorms. You can call someone who helps you relax on the phone to hear a calm and
soothing voice.
Smell: Think about your favorite scents. What smells make you feel calm and relaxed? You
may put on scented lotion or light fragrant candles. You can smell fresh flowers at home,
outside, or in a shop. You may use flowers and herbs to make potpourri. Some people enjoy
cooking or baking things that smell nice, like cookies or bread. You can take a walk outside
and breathe in the fresh smells of nature, like trees and plants.
Taste: It can be soothing to eat a good meal. Think about your “comfort foods”. Let yourself
enjoy a special treat, like a fruit or candy. Pay attention to the flavor, temperature, and texture
of what you eat. You may try a special dessert or a soothing drink, like herbal tea or hot
chocolate. Take your time and really let yourself enjoy the taste of what you are eating or
drinking.
Touch: Think about ways you can pamper your body. It can be soothing to take a hot bubble
bath, soak your feet, or get a massage. You may like to put cold water on your face and neck.
Try rubbing lotion or oil on yourself. Think about clothing or furniture that feels nice and
relaxing. Do you have a favorite chair or blanket? You may like to put on something soft like a
sweater or a robe and slippers. Let yourself experiment with different textures. Try petting a
furry animal or sinking your hands into water or sand.
3. Assign Between-session Work
 Assign continued use of Self-Monitoring of Feelings sheets 2 times a week. Remind the
adolescent to practice self-care. Assign the “Soothing Your Senses” handout.
 Each session should end with a review of the adolescent’s coping skills and a review of the
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Session 3: Coping with Upsetting Feelings
Agenda

2. Provide Psychoeducation about Coping with Upsetting Feelings
3. Identify and Evaluate Current Coping Skills
4. Provide Psychoeducation about Self-Talk
5. Practice Paying Attention to Self-Talk
6. Coping with Upsetting Self-Talk
7. Introduce and Practice the Use of Cognitive Coping Skills
1. Review Between-Session Work (Self-Monitoring sheets; Soothing Your Senses sheet)
 If the adolescent completed the optional session to prepare for coping skills, review the
Soothing Your Senses sheet. Reinforce the adolescent for her work and discuss which
strategies were most helpful to her (e.g. looking at soothing images versus listening to music).
 Go over the adolescent's self-monitoring sheets in detail. Address any practical difficulties or
misunderstandings regarding their use, such as what goes in which column. Discuss the
material the adolescent collected. Typical examples adolescents provide are feelings of
sadness, anxiety or anger. Sometimes adolescents have difficulty identifying a specific feeling
and write that they felt "overwhelmed" or "upset." Work with the adolescent to define more
specifically what upset or overwhelmed means to her. For one adolescent, upset might mean
angry, while for another it might mean sad. The therapist might ask questions such as, "Were
you crying?" or "Did your muscles feel tense?" "What other physical sensations were you
aware of?" Explain that sometimes there is more than one feeling involved. For example, an
adolescent can experience anxiety and shame at the same time.
 The therapist should use the self-monitoring sheets as a significant part of the session. These
sheets often provide material to incorporate into the session's theme. If the therapist conveys
the value of this material and uses it, it reinforces the adolescent’s effort.
Challenges
If the adolescent did not complete any self-monitoring sheets, assess the reason for this. For
example, an adolescent may say, "Well, nothing happened this week." Explain that there does not
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have to be an event, but sometimes just an experience or a feeling. A feeling can arise just as easily
from a worry, thought, or memory. Explain that it may not always be possible to know what triggered a
feeling. The first goal is to have the adolescent get into the practice of slowing things down and paying
attention to her feeling states. Ask her to choose a situation from the past week and complete it
together in the session.
If the adolescent continues to come to future sessions without having completed the forms, or
feels anxious completing them alone during the week, it may help to have her come early before
sessions and do it in the waiting area. It is optimal if adolescents can do this during the week at the
time when situations emerge; however, if they cannot, the goal is to find a way to help them generate
this material. Again, the therapist should be aware of any developmental delays that may interfere
with the adolescent’s ability to complete this work and make appropriate accommodations in a
supportive way.
 If the adolescent did not complete the optional session, review the material from Session 2 on
the purpose and practice of deep breathing. Model the technique again, and observe the
adolescent doing the breathing. Emphasize the importance of practicing deep breathing to
help the adolescent feel calm and slow down her heart rate and thoughts.
2. Provide Psychoeducation about Coping with Upsetting Feelings
 Use material from the Self-Monitoring of Feelings sheets and previous sessions to focus on
dealing with upsetting feelings. With traumatized adolescents, review how traumas can create
more extreme feelings. Also, discuss the lack of guidance the adolescent had in learning to
manage them, if appropriate to her history. The adolescent has likely developed ways of
coping, some of which are helpful, others which are not. For example, many adolescents
report that they “zone out” when they encounter stressful situations, and that it is hard to
identify their thoughts and feelings at the time. Some adolescents may report taking a “time
out” or talking with others. It is important to reinforce the adolescent’s effective coping skills.
The therapist may also point out that her less effective ways of coping are understandable,
though not necessarily helpful.
3. Identify and Evaluate Current Coping Skills
 Before introducing skills for coping with upsetting feelings, find out from the adolescent the
coping skills that she already has. Do not assume she is without them!
 Assess the frequency with which the adolescent uses these coping skills and how effective
they are in helping her feel better.
 Begin with the base skills the adolescent already has. She may already use some of the skills
covered in the next section, or may have effective ones of her own. Perhaps she has
idiosyncratic skills that she could use as coping skills.
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4. Provide Psychoeducation about Self-Talk
 Explain to the adolescent that people have different feelings about themselves based on
things that happen in different situations. For example, if a peer invites the adolescent to a
party, she may feel happy because she thinks others like her. If the adolescent misses the ball
in gym class, she may feel upset because she thinks that she is stupid. These thoughts are
“automatic” because they happen quickly and without our even realizing it. This is what we
call self-talk.
 Explain to the adolescent that when people are in difficult situations, they may think or quietly
say upsetting things to themselves that make them feel worse. When people feel upset, they
are more likely to have trouble thinking clearly and may blame themselves or make very
strong, upsetting statements that are incorrect. It is the upsetting thoughts that people have
about themselves that can lead to upsetting feelings rather than what is actually happening in
a situation. This means that if people change their thoughts, they can also change how they
are feeling.
5. Practice Paying Attention to Self-Talk
 Encourage the adolescent to think about a recent situation that made her feel upset. Help
the adolescent to identify her self-talk by asking questions such as, “What went through
your mind? What did you think about yourself?” Record the adolescent’s responses on the
Self-Talk sheet.
6. Coping with Upsetting Self-Talk
 Look at the evidence. Use the adolescent’s example on the Self-Talk sheet to help her
practice looking at the evidence. Ask questions such as, “Is that thought really true? How
do you know it is true?” Pay attention to patterns in which the adolescent makes “over-
generalizations”, meaning that she draws conclusions about herself or others based on one
or two situations. When people make over-generalizations, they tend to focus on upsetting
things that happen while ignoring or forgetting about good things that have happened in
similar situations.
 For example, if an adolescent receives a “D” on one test, she may think that she is stupid,
even though she got “B’s” and “C’s” on all of her other tests. If a peer does not invite her to
a party, she may think that no one likes her, even though she has many friends. Help the
adolescent to think of other reasons to explain why something upsetting may have
happened. For the above examples, ask the adolescent, “Why else might that have
happened?” Provide assistance as needed. Maybe she got a “D” on that test because it
was harder than other tests. Maybe her friend did not invite her to the party because it was
a very small party and she did not invite many other girls.
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7. Introduce and Practice the Use of Cognitive Coping Skills
 Thought stopping and attention shifting: Explain to the adolescent that in thought stopping,
she will shout “Stop!” to herself silently in her head when upset by worries she cannot stop.
After stopping the thought, she should focus on another activity to keep her mind on
something else. Examples of attention shifting activities include listening to music, taking a
walk, calling a friend, thinking about happy events, or counting backwards. Practice an
example of using thought-stopping (i.e., the adolescent imagines that she had an argument
with her friend on the phone last night and she keeps thinking about what she said over and
over, which makes her feel upset. Have the adolescent say her thoughts aloud and practice
saying, “stop!” Then, have the adolescent practice quietly, thinking about the steps in her
mind).
 Positive self-statements: The use of positive self-statements can be very helpful when the
adolescent starts to have an upsetting thought or criticizes herself. Using the sheet labeled
“Positive Self-Statements”, ask the adolescent to make a list of her positive qualities such as,
“I’m a good friend” or “My teachers tell me I’m smart.” Some adolescents have a very difficult
time identifying their strengths. Encourage them to find something about themselves that
they like, even if they may think it is trivial. If the adolescent insists that she cannot come up
with anything, the therapist may ask what her best friend would say about her.
 Explain to the adolescent that it can be very useful to think or say something positive as soon
as she catches herself having upsetting self-talk. The therapist may use material from the
adolescent's Self-Monitoring sheets to find areas of upsetting self-talk to counter with positive
statements. For example, in response to the thought “I’m a loser,” an adolescent may tell
herself, “I’m doing the best I can.”
Challenges
It is VERY IMPORTANT that the adolescent understand that these coping skills are NOT for
covering or avoiding feelings. Rather, they give the adolescent control over managing her feelings and
choosing when to tolerate upsetting feelings. Some adolescents resist self-soothing techniques
because they need to hold onto pain and anger as a testament to what they experienced. They feel
that getting relief by using coping skills would trivialize their suffering. The therapist will need to
assess and gently address this, emphasizing that allowing oneself some relief does not invalidate the
adolescent's suffering. (e.g., “Putting a band aid on a wound to help it heal doesn’t mean that the
injury didn’t happen.”)
Not all adolescents will be able to use all coping skills. Encourage the adolescent to try them,
but convey that she can focus on those that are most helpful. Some adolescents are "doers" and find it
helpful to engage in activities such as writing in a journal or working out. Others are "thinkers," and
cope by telling themselves that their distress will only last for a small while, or try to think of happier
things. Still others seek social support by hanging out with friends, or doing something nice for
someone. In some cases, the therapist may omit certain skills and encourage others, based on their
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understanding of the adolescent. For example, a very avoidant adolescent may not be encouraged to
use thought stopping or attention shifting.
Clinical Illustration
M has a history of physical and sexual abuse by her mother. At the age of 15, she went into a
group home after a few unsuccessful foster care placements. She was withdrawn and had significant
difficulty identifying her feelings. M also experienced intense bouts of anger in which she became so
enraged that she “beat up” several of her classmates and her school suspended her. These violent
rages and overwhelming feelings of anger interfered with her schoolwork and friendships. In session,
M recalled that her mother often ignored and minimized her feelings. She described one occasion
when her mother had given her a black eye. Afterward, her mother said to M, "What are you so upset
about? Play with your doll and you'll feel better." The therapist was very careful to explain to M that
the goal of learning to deal with upsetting feelings was not to cover up or minimize her feelings, but
rather to help her deal with them more effectively so she could control her temper and have more
success at school and with friends.
M was also very hesitant to pay attention to her feelings. She feared that if she actually felt her
feelings, she might become overwhelmed or feel depressed or suicidal, as she had in the past. She
believed it was "safer" to "put up a brick wall" and avoid looking too deeply at any of her feelings. M
found the following analogy to be helpful: If she got a cut on her arm, she could respond by refusing to
look at the wound by keeping her eyes shut at all times. On the other hand, instead of avoiding her
wound, she could care for her cut by putting on a band-aid or cleaning it to prevent further infection.
By attending to her "wound", instead of avoiding it, M was able to see that she could ease her pain in a
more permanent manner.
 Have the adolescent complete the Self-Talk sheet 2 times a week. Also, ask her to practice
using the positive self-statements generated in the session each day.
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Session 4: Dealing with Upsetting Situations
Agenda

2. Review any Problems with Implementation of Coping Skills
3. Provide Psychoeducation about Dealing with Upsetting Situations
4. Introduce Concept of Dealing with Upsetting Situations to Achieve Goals
5. Coping Strategies for Dealing with Upsetting Situations
1. Review Between-Session Work (Self-Monitoring Worksheets; Positive Self-Statements)
 Go over the adolescent's Self-Talk and Positive Self-Statements sheets in detail. Address any
practical difficulties or misunderstandings regarding their use. Give positive feedback to the
adolescent for completing the work.
2. Review any Problems with Implementation of Coping Skills
 Discuss the adolescent’s use of coping skills between sessions and address any difficulties.
Reinforce her attempts to use coping skills.
3. Provide Psychoeducation about Dealing with Upsetting Situations
 Review with the adolescent that PTSD symptoms result from avoiding or ignoring upsetting
memories of traumatic experiences. However, upsetting feelings are inevitable and
ignoring or denying them does not make them go away.
 Explain to the adolescent that it is natural to want to ignore or avoid upsetting feelings
related to traumatic or stressful experiences. However, over the long-term, avoiding them
will only make the pain and suffering worse. The upsetting feelings will keep coming back
in one way or another. Since adolescents tend to live in the moment, they may really want
to avoid painful thoughts and feelings related to trauma and stress. Learning to confront
and deal with upsetting feelings can help the adolescent face challenging situations and
feel better.
 Upsetting feelings can also tell a person about areas in her life that may need attention or
change. Dealing with situations that may involve upsetting feelings can help the adolescent
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feel better. Adolescents often put a lot of energy into trying not to feel upset and find that
they still feel upset anyway.
 Lastly, introduce the idea that learning to deal with upsetting feelings will make the
adolescent open to experiencing pleasant feelings as well. When one avoids feelings, they
cut off both pleasant and upsetting feelings, not just upsetting ones. As a result, many
adolescent trauma victims have a hard time experiencing many different feelings. They
often report feeling "numb" and unable to enjoy things in their lives such as relationships
and social activities.
 Discuss an example from the adolescent’s personal life when she tried to avoid feeling
upset and how effective the avoidance was. (e.g., “When you got angry at your friend, you
didn’t want to feel bad so you left her house and said that you wouldn’t speak to her again.
Did it really work? Did you stop feeling upset? How long did it last? Did you miss the good
things about your friend? Would you like to learn how to cope with those situations
differently so that you don’t have to run away from upsetting feelings?”)
4. Introduce the Concept of Dealing with Upsetting Situations to Achieve Goals
 One of the main goals of this treatment is to teach skills to help the adolescent deal with
upsetting feelings and situations so she can feel better and enjoy her relationships with
others. One of the tasks is to identify the adolescent's goals and then think about what
could happen while working toward these goals. This concept is particularly important when
an adolescent chooses a long-term goal where she might not feel good or get what she
wants right away. Thus, instead of learning to deal with upsetting situations per se, the
adolescent decides if what she wants is worth dealing with the upsetting feelings she may
have as she works towards her goal.
 Clarify this concept by choosing a situation that is important to the adolescent that she is
avoiding because she does not want to feel upset. Discuss what could happen, good and
bad, if the adolescent chose to confront the situation, and how she would feel. (e.g. “I wrote
a poem for extra credit and have to read it in front of the class. My goal is to read the poem
so I get the extra credit. Maybe the other girls in the class will think it is not good and tease
me. This would make me feel sad. On the other hand, my teacher and the other girls might
like it a lot and tell me that I did a good job. That would make me feel proud.” Ask the
adolescent if getting the extra credit is more important than worrying about whether others
will like the poem.)
Challenges
Adolescents with abuse histories often avoid dealing with upsetting trauma-related feelings
that need to be processed. At the same time, they may also choose to tolerate upsetting feelings in
situations that do not pay off, such as going out with boys who treat them poorly. If this is the case,
the therapist will need to help the adolescent identify these situations and work with her to build
new skills so that she can remove herself from upsetting relationships or situations. Thus, it is
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particularly important for the adolescent to learn to weigh whether upsetting feelings are worth
tolerating to reach a goal. Rather than reinforcing the adolescent's idea that she should tolerate
upsetting feelings across the board, the therapist's objective is to help her make choices about
when it feels appropriate to do so.
 Thinking about Pros vs. Cons: Looking at the pros and cons of dealing with upsetting
situations can help the adolescent stay focused on her goals. This skill works by choosing a
situation that is important to the adolescent that may be upsetting or produce anxiety.
Help the adolescent think about what she expects will happen as she works towards her
goal. Also, discuss how she will cope with upsetting feelings that may make her feel like
dropping out or giving up.
 Have the adolescent create a list in which she writes down the pros and cons of dealing
with upsetting feelings in her selected situation. Help the adolescent come up with
questions such as, "Why am I putting myself through this?" "What is my ultimate goal
here?" "Will I get enough good out of this situation that it makes dealing with the upsetting
feelings worth it?"
 It is important to use session time to identify and think about 1 or 2 situations that could
involve upsetting feelings in depth. Provide a model for how the adolescent can do this on
her own outside of sessions. One helpful way to begin is by assessing the pros and cons of
being in the current treatment. Is the ultimate goal (i.e., feeling better) and its pros (i.e.,
focusing on school, getting along with people better) worth dealing with the cons (i.e.,
talking about upsetting things)? In addition to providing a specific example of how to use
the skills, this exercise is a good way to prepare and help the adolescent in facing
challenges in the treatment.
Challenges
Some adolescents may run through their list of pros and cons in a hurry and without fully
considering how they may affect their ability to meet their goals. Adolescents who quickly decide
that goals such as attending treatment or finishing school are worth tolerating the cons may be
attempting to please the therapist or “give the right answer”. The therapist can gently encourage
the adolescent to focus on the potential barriers to her goals, as well as strategies to overcome
them. For example, the therapist may ask, “Which of these cons do you think would be most
difficult to manage? How do you think you might handle that?” The therapist can also use this
opportunity to provide the adolescent with hope and encouragement that she can overcome
barriers to her goals by practicing healthy coping strategies.
L is a 17-year-old adolescent girl with a history of sexual abuse. From ages 7-12, her father
molested her in her room. Before the abuse began, L said she trusted her father very much. In
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high school, L withdrew socially and no longer felt like “hanging out” with her old friends,
particularly guys. She stopped going to parties and to any place where she feared she might meet
new people who were not “safe.” Although L said she feels lonely at times, she also feels
protected by a tough attitude used to keep others from getting too close.
In treatment, L stated that a boy at school had asked her out a few times. L thought that K
seemed cute and nice, but that she always turned him down and even avoided talking to him. L
expressed a lot of mixed feelings and nervousness about getting to know someone new, especially
a boy. She was sure that he would just be “another guy to mess me up.” L also recognized that she
had recently been feeling lonely and wished she had someone to talk to. She thought she could
feel comfortable and have fun with K and feared that if she kept on avoiding him she might miss a
good opportunity.
As part of treatment, the therapist suggested that L use the skill of assessing pros and
cons in order to help her decide if dealing with the upsetting feelings that could arise in this
situation would be manageable and worthwhile for her. The therapist initially worked with L to
identify her goal. They then worked to shift the focus away from an overwhelming and
uncontrollable goal (To develop a long-term relationship with K) to a more realistic and manageable
goal (To learn to feel more comfortable and open talking to K at school, and to agree to go on a
date with him in a “safe” place). This intervention helped to reduce L's nervousness. She was then
able to come up with a useful list of pros and cons of working towards this goal.
Pros and Cons List
GOAL: To express my feelings openly with Ken.
Cons: (What could go wrong?) Pros: (What could go right?)
I could feel uncomfortable I won’t feel as lonely if I talk to him
I might get my feelings hurt He is fun to be with
I might feel stupid or nervous I will have somebody to talk to when I feel lousy
Maybe it will get too sexual I could do nice things for him
I might think about times when I got hurt I could feel like somebody cares about me
by someone else
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 For between-session work, have the adolescent practice this skill by writing out the pros
and cons for other situations she may encounter or think about during the week using the
Dealing with Upsetting Situations worksheet.
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Session 5: Coping Strategies for Dealing with Upsetting Situations
Agenda

2. Review Implementation of Coping Skills
1. Review Between-Session Work (Dealing with Upsetting Situations sheet)
 Go over the adolescent's Dealing with Upsetting Situations sheet in detail. Have the
adolescent identify the most difficult barrier to her goal from the list of cons. Discuss how she
might overcome that barrier. Address any practical difficulties or misunderstandings
regarding the sheet. Give positive feedback to the adolescent for completing the work.
2. Review Implementation of Coping Skills
 Discuss the adolescent’s use of coping skills between sessions, and address any difficulties.
Reinforce her attempts to use coping skills.
 Explain that since the adolescent is doing hard work by facing and dealing with difficult
situations, she should reward herself. The therapist will work with her to make a list of
activities she enjoys. This task helps the adolescent become open to experiencing a greater
range of feelings. By helping her deal with upsetting feelings, she will also be able to have
more pleasant feelings that avoiding situations would have cut off.
 Talk to the adolescent about what she does to cope with upsetting feelings such as anger or
sadness. Responses may range from “When I’m upset, I call a friend,” or “I put on my
headphones and zone out,” to “I work out to burn off some energy.” Discuss whether these
coping strategies are helpful to the adolescent. The adolescent should provide a recent
example of when she used one of these coping strategies and talk about how it helped her
to feel less upset. Provide the adolescent with positive reinforcement. Encourage her to
continue to use these coping strategies when she begins to feel upset.
 Some adolescents are unable to come up with a healthy strategy and, for example, yell at a
sibling when angry with a friend. Help the adolescent create one or two coping strategies
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she can try out between sessions. For example, one adolescent reported with guilt that she
hit her pet once when she was overwhelmed with anger. The therapist helped her to
change this by hitting a pillow instead.
 Identify “Feel Good” Activities. Have the adolescent circle as many activities on the
worksheet as she currently uses at least once a week. She may also underline any
activities that she does not currently use, but would like to try. Typically, adolescents will
create a list of at least 3 “feel good” activities that they can use in their lives to help reduce
stress and upsetting feelings. Some examples include listening to music, playing a sport, or
playing with pets. On the bottom portion of the worksheet, the adolescent can add any
items that are not on the list.
 When the list is complete, discuss whether the items have been helpful to the adolescent.
For example, an adolescent may say, “When I write down my feelings in a journal, they
begin to make sense to me and I calm down.” The adolescent can expand on the activities
list through the course of treatment. In future sessions, follow up to see which activities
she actively uses each week and what the benefits are.
Challenges
This may not be as simple as it sounds for some adolescents. Some adolescents may
respond, "I don't know" or "I don't really enjoy anything." They may really need to take time in or
out of session to think about this more. The therapist may provide suggestions as a way to get the
adolescent thinking about specific activities. They may ask questions such as, “Is there something
new you have always wanted to try?” Other adolescents may respond, "I don't have time for any of
these activities". For adolescents who view pleasurable activities as a luxury, the therapist will
need to reframe this skill. The therapist may describe it as an important part of recovery from
childhood abuse and discuss how the adolescent can make some time in her schedule.
It is also important to keep in mind that some adolescent trauma survivors may not feel
they deserve to enjoy or nurture themselves. Explore this issue with the adolescent and discuss
how feeling like a "bad person" or having low self-worth is a common reaction to childhood abuse
and/or neglect. Address how not engaging in pleasurable or soothing activities only makes a poor
self-image worse and supports the damaging idea that she does not deserve positive experiences.
 Ask the adolescent to try three of the positive activities she picked from her list.
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Session 6: Using Positive Imagery to Deal with Upsetting Feelings
Agenda

2. Provide Rationale for the Use of Positive Imagery
3. Make Positive Image Collages
1. Review Between-Session Work (“Feel-Good” Activities)
 Review the adolescent’s use of “Feel-Good” activities from the past week. Address any
difficulties or misunderstandings regarding the use of this coping skill. Give positive feedback
to the adolescent for attempts to use this skill to increase positive feelings.
2. Provide Rationale for Use of Positive Imagery
 Provide the following rationale to the adolescent: One valuable way of coping with stress is
using positive imagery. Explain that positive images are pleasant pictures of people,
places, things, or words that make them feel good. When people feel upset or nervous,
they may have upsetting thoughts and worries that make them feel worse. Explain to the
adolescent that by thinking about positive and soothing images, she may feel more calm
and relaxed.
 Explain to the adolescent that since it is often difficult for people to make up positive
images on their own, she can practice making positive images by creating a “positive
image collage”.
3. Make a “Positive Image Collage”
Materials Needed:
1. A piece of white poster board (approximately 13” x 13”)
2. Several colorful magazines
3. Scissors
4. Glue-stick
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5. A handful of magic markers.

 Explain to the adolescent that she may cut out pictures and designs from the magazines
that make her feel good (e.g., happy or calm), or that stand for things that she likes (e.g.,
hobbies, things she likes to do, pets or scenes of pretty pictures). Have her arrange them
on the cardboard. Some adolescents clip out strings of words or titles to express their
thoughts and feelings.
 Adolescents with trauma histories tend to focus on negative images and may select
upsetting or scary pictures for their collage. In these situations, the therapist can remind
the adolescent that although it is important to talk about these scary images, the goal of
this activity is to focus only on images that make her feel good.
 Collages may take anywhere from 20 minutes to 1 hour to complete. Be sure to allow
enough time for discussion afterward, or divide the activity over two therapy sessions. Have
the adolescent sign and date the collage in marker. After the collage is completed, the
therapist should ask the adolescent to discuss the meaning of the images she chose.
Challenges
Some adolescents may be hesitant about making collages because they question or worry
about their artistic abilities. They may say,”I’m not good at art.” Reassure the adolescent that the
goal of the collage is not to make the best artwork, but to practice a soothing activity to reduce
upsetting feelings. The therapist may say, “It might help you to focus on picking pictures that you
like without worrying about how your collage will look in the end.” The therapist can even leaf
through magazines with the adolescent until she feels more comfortable and cuts out at least one
or two pictures for her collage.
Some adolescents refuse to make a collage because they feel that it is silly or childish. They
may say, “This is for first graders. I don’t need to do this.” To address the adolescent’s resistance
and increase her motivation, it is helpful for the therapist to participate by making a collage as
well. The therapist may say, “I know this may seem childish, but it can actually be fun. Many people
your age and older have tried it and ended up enjoying it. How about we do it together?”
Other adolescents with histories of abuse tend to focus on upsetting images and have a very
difficult time identifying positive images. They may look through picture after picture without being
able to select any images that they like. By engaging the adolescent in a more structured
discussion about her preferences (i.e., “What are your favorite colors, places, and objects?”, “Who
are your favorite celebrities or role models?”), it maybe easier for the adolescent to identify and
select positive images for her collage. As illustrated below, positive-image collages will be unique
to each adolescent, depending upon her sensibilities, general interests, and even coping skills.
Additionally, some girls may choose only four images to fill the page, while others may include as
many as ten to fifteen smaller images.
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M is an 18 year-old adolescent who enjoys being around nature. Her collage contained pictures
of mountains and forests, and a patch of lilacs. She described it as being “very relaxing and
peaceful to look at.” She also included a picture of a camera to illustrate her love of photography,
and a picture of an aromatherapy candle that she likes to light when she feels stressed out. M also
selected a picture of a couple holding hands and smiling at each other to represent her excitement
about her new relationship with her boyfriend.
S is a 14 year-old adolescent with a flair for fashion and a love of music. S chose to decorate
her collage with an array of clothing and accessory items that she thought were stylish. She
included several musical notes and pictures of rock groups that she really liked. She also included
pictures of makeup she likes to use when she gets dressed up to go out, a pint of her favorite flavor
of ice cream and a picture of the Manhattan skyline to represent her love for the city.
 Ask the adolescent to practice using skills to manage an upsetting situation (record on self-
monitoring form). Have her engage in at least three “feel good” activities that she chose in
the previous session.
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Session 7: Relationships with People: Behavior and Communication
Agenda

2. Provide Psychoeducation about how Behavior and Communication affect Relationships
3. Introduce Skills for Clear Communication
1. Review Between-Session Work (“Feel-Good” activities; using coping skills)
 Review the adolescent’s use of “Feel-Good” activities from the past week. Address any
difficulties or misunderstandings regarding the use of this coping skill. Give positive feedback
to the adolescent for attempts to use this skill. Ask what other coping skills the adolescent
practiced this past week and discuss their effectiveness.
2. Provide Psychoeducation about how Behavior and Communication affect Relationships
 Explain to the adolescent that how we behave and communicate with others affects what
happens in our relationships and how we feel about them. There are many different ways
we can communicate our thoughts and feelings to others that lead to different outcomes.
For example, an adolescent may feel disappointed and angry because her sister will not
drive her to the store and curse at her. As a result, her sister may become angry and say or
do something mean in return. This can lead to an ongoing conflict in which neither girl
feels very good about the other.
Another adolescent might tell her sister that she feels disappointed and explain why it is
important for her to get to the store. In turn, her sister may try to make time to take her to
the store or arrange to take her another time. The outcome in this situation would be that
the sister understood and cared about what the adolescent needed, and the adolescent got
what she needed and appreciated her sister. Note that while it is impossible for us to get
our needs met all of the time, we can improve our chances of getting what we want from
relationships by planning the way we behave and communicate.
3. Introduce Skills for Clear Communication
 The “I” message. One clear communication tool is an “I” message, which helps us tell
people how their behavior affects us. We can use “I” messages to communicate both
pleasant and upsetting feelings. The purpose of an “I” message is to focus on what
happens as a result of another person’s behavior instead of blaming that person. By
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focusing on the results of a behavior, the adolescent is less likely to make the other person
feel attacked. Encourage the adolescent to say the person’s name and make eye contact
when using “I” messages.
An “I” message has 3 parts: a behavior, feeling, and result.
1. Behavior: What is happening around you? What is the other person doing?
2. Feeling: How does the person’s behavior make you feel?
3. Consequence: What happens as a result?
Use this form sentence:
When you ____________, I feel _______________ because_______________

(behavior) (feeling) (result)
Examples: (Help the adolescent identify the behaviors, feelings, and results.)
“When you didn’t pick me up, I felt frustrated because I missed my appointment.”
“When you lied about breaking the vase, I felt angry because I got in trouble for it.”
“When you invited me to the movies, I felt happy because I got to spend time with you.”
Model for the adolescent how she could have used an “I” message in a recent situation, and
have her practice using the skill.
 Saying No. For many adolescents who have experienced traumas, it can be difficult to say
“no”. In cases when the adolescent is dealing with someone with whom she does not want
to be involved, it is often okay to say “No, thank you” in a respectful, firm tone. If the other
person persists, the adolescent should repeat herself while maintaining eye contact and
slightly raising the tone of her voice.
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A useful technique for dealing with someone who will not take “no” for an answer, is the
broken record. In this technique, the adolescent can simply repeat her response without
backing down or allowing other issues to sidetrack her. For example, if a salesperson
keeps badgering you to buy a pair of jeans you do not want, you can keep repeating. “I
understand what you are saying, but I’m not interested.”
Model for the adolescent how she could have said “no” in a recent situation. Have her practice
using the skill.
 Making Requests. Many adolescents who have had traumatic experiences may have
difficulty getting what they need from others. It is useful to focus on 4 pieces of
information to help the adolescent plan the best way to ask for what she needs in a
situation: the goal, the person, the time, and the request. The therapist should use this
opportunity to review the adolescent’s discussion of social supports in session 2.
1. The goal: What do you want or need? Try to be as specific as possible so that you can
make your request to the other person clear.
2. The person: Whom should you ask? It is important to ask someone who can actually
do something to help in the situation. You want to approach a person who is able to make
something change (someone in a position of authority) or help you feel better (someone
who can help you calm down).
3. The time: When should you ask? Is it an emergency or can it wait? Chances are, if
there is something you want, like for someone to get you something from the next room or
make you something to eat, you could wait a while if you needed to. On the other hand, if
there is something important that you need, like to leave class when you are ill, it is
appropriate to ask right away.
4. The request: What should you say? When making a request, think about how to state
your goal simply. Remember to use “I” language (“I would like…” versus “You need to…”),
say the person’s name, and make eye contact.
Remind the adolescent that when she asks for something clearly, that does not guarantee
that she will get it. On the other hand, it is highly unlikely that the adolescent will get what
she wants if she does not ask.
Example: Pretend that you are sitting in class and you just realized that you left your hat on
the bus this morning. What is your goal? Whom should you ask? When? What would you
say?
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R is an 18-year-old girl with a history of sexual abuse by her father. When she told family
members about the abuse, no one believed her. Eventually, R stopped talking about the abuse
because she figured that no one would help her anyway. Currently, R often complains that
important people in her life never seem to care when she is upset. As she began to pay attention to
how she communicated her feelings and needs to others, she realized that she often told others
that she was feeling “okay” when she was actually quite upset. As a result, others did not comfort
or soothe her, as she really wanted them to. Other times, R would state, “I’m upset!” and then wait
for the other person to respond. She was often disappointed that others did not react the way she
wanted them to.
R realized that she was expecting others to “read her mind” and know what to do to make
her feel better. She felt that if someone did not know what she wanted, it meant they did not really
understand or care about her. Over time, R learned to communicate her needs more clearly. She
began to state exactly what she needed from others. As a result, she made it easier for others to
know what to do in order to help her feel better. In turn, she was able to get more support and felt
better about her relationships.
 Clear Communication sheet: Review the sheet and instructions with the adolescent. You
may practice the first item together.
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*Optional Session to Expand on Relationship Work Addressed in Session 7: Relationship

between
Feelings and People: Schemas
 This optional session is for adolescents functioning at a mature stage of development, as it

requires abstract thinking. Material in this session builds on your discussion about how
personal experiences shape current relationships. It focuses on how the adolescent’s early
experiences contribute to schemas, which affect current relationships.
Agenda
1. Review Between-Session Work (“Clear Communication” handout, using coping skills)

2. Provide Psychoeducation about Schemas
3. Provide Psychoeducation about Feelings and Relationship Schemas
4. Introduce the Challenging Schemas Worksheet
1. Review Between-Session Work (“Clear Communication” handout; using coping skills)
 Review the adolescent’s Clear Communication sheet. Address any difficulties completing
this sheet and provide positive reinforcement. Give positive feedback to the adolescent for
attempts to use good communication skills. Ask what other coping skills the adolescent
practiced this past week and discuss their effectiveness.
2. Provide Psychoeducation about Schemas
 Provide psychoeducation to the adolescent about the concept of schemas. Since

adolescents often have difficulty paying attention to lengthy and complex material, it is
essential for the clinician to use simple and understandable language. Explain that
schemas are rules or expectations we have about how things happen in the world around
us. They come from experiences we have had in the past that we expect to repeat again.
Schemas tell us what to expect from others and how to act in different situations.
For example, a child may have a schema about how to act in class. The child learned that
when she raised her hand, the teacher called on her to speak in class. As a result, now she
automatically raises her hand if she wants to speak or keeps her hand down if she does not
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want to participate.
3. Provide Psychoeducation about Feelings and Relationship Schemas
 Explain that everyone has schemas about their relationships with others. These schemas
reflect ideas about how relationships work (i.e. how people behave and respond to each
other). Relationship schemas often come from a child’s early experiences with her
caretakers. An infant learns that when she cries, a caregiver comes and soothes her.
Schemas become more complex with age. As children grow up, they learn that their
behavior affects what happens in their relationships. For example, if they do well in school,
they will receive praise and feel loved. On the other hand, they may learn that if they
misbehave, others may punish or yell at them.
 Children raised in abusive environments may form ideas and expectations about
relationships that are unclear or incorrect. Relationship schemas that form in this type of
environment may link care and love with abuse. Because a child is dependent on an
abusive caregiver, she will look to him or her to meet her needs and provide her with love.
In a physically abusive home, if a caregiver assaults a child when she tries to get a need
met, the child’s mind forms a link between care and physical assault. She may expect that
others in caring relationships will abuse her, such as friends, teachers, or therapists.
 Schemas stay in children’s minds as they grow up. Current situations that remind the
adolescent of the past automatically trigger schemas. An adolescent may think, feel or act
in ways that were appropriate when she was younger, even though the current situation
may be quite different. These schemas lead her to behave in ways to prepare for what she
expects to happen.
 Explain that relationship schemas can be self-fulfilling even though the result is one that
the adolescent does not want. For example, an adolescent may expect others to reject her
in relationships. Thus, she is less willing to interact with others and “builds a brick wall”
around her to avoid being close to others. Since other people do not know why she does
this, they may think that she is not interested in having a relationship and leave her alone.
As a result, she may feel rejected.
 Adolescents with abuse histories experience great difficulty in situations that trigger
schemas about power and control. For example, an overworked adolescent may feel taken
advantage of by her boss who does not pay her what she deserves. This may remind her of
an abusive childhood experience and trigger intense anger. The adolescent may be likely to
act on feelings that belong to the past instead of responding to the current situation.
Clearly, the feeling of anger toward her boss is understandable; however, the intensity of
the feeling and the way she expresses it will determine the outcome. If her feelings and
schemas from the past drive her behavior, it is unlikely that she will meet her current
relationship goals. For example, the adolescent may withdraw and become passive, or she
may express anger inappropriately to her boss in an effort to defend herself. Neither of
these responses is likely to result in meeting her goal of getting a raise and improving her
situation at work.
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 Communicate to the adolescent that one of the primary goals of this treatment is to help
her identify relationship schemas that are causing her problems. Initially, the emphasis will
be on helping her learn how to recognize when strong feelings from the past affect her.
Next, she will learn to catch and manage these feelings before they interfere with present
relationships. The therapist may say, “Very often people with histories of abuse have strong
feelings about upsetting things from the past that get in the way of their current
relationship goals. These intense feelings may cause them to act in ways that worked for
them when they were in abusive situations, but may no longer work in new relationships.
Can you think of times when your feelings have gotten in the way of meeting a relationship
goal?”
Challenges
It is important to note that identifying schemas may initially lead the adolescent to feel
overly critical of herself and pessimistic about the future. Thus, it may be helpful to remind her that
the goals of the next several sessions will be to create and test different schemas (i.e., different
ways of thinking, feeling and behaving in relationships).
When addressing distinctions between strong feelings from the past and current
relationship goals, be sure to discuss how choosing not to act on these strong feelings does NOT
invalidate them or imply that they are inappropriate. Many adolescents with abuse histories are
quick to feel ashamed or invalidated. The goal is not to increase the adolescent’s distrust in her
own perceptions. The goal is to help her be aware of situations that trigger feelings from the past
that are no longer helpful. Although the adolescent will still be vulnerable to these feelings, the
hope is that she will feel more aware of and in control of them. Additionally, she will learn to make
new choices in terms of how much these reactions will influence her current behavior.
C is a 16- year-old adolescent with a history of physical and sexual abuse by her father,
which lasted from ages 8 to 13. Subsequently, children’s services removed her from her parents’
home and placed her into foster care. C described her household as isolated, chaotic and
unpredictable. Her father drank heavily and often became violent. He would become enraged if
the slightest thing did not go his way and frequently took his anger out on C. C learned early on
that one way to avoid abuse by her father was to be passive and not call any attention to her own
needs. When he showed the smallest hint of irritation, C attempted to calm him by being overly
helpful and by trying to meet his every demand.
Although C no longer has contact with her father, her ideas about relationships that came
from this environment continue to guide her behavior in powerful ways. Now, C responds to
upsetting situations by becoming passive and is afraid to voice her own needs. She constantly
expects others to take out their anger on her and goes to great lengths to avoid provoking anger,
sometimes at a great cost to her self. For example, C’s boyfriend had been pressuring her to have
sex with him. Although C did not feel ready, she felt she had to “give in” in order to make sure “he
wouldn’t get mad and dump me”. C also complains that she “doesn’t know how to stand up” for
herself when talking to friends. She says that she “goes along” with all of their plans, even when
she does not want to because she is afraid to disappoint or anger them.
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During treatment, one of the primary tasks was to help C become more aware of the above
relationship schema. The therapist helped her to understand that while the schema worked for her
in childhood because of the specific needs of her father, it was creating problems in her current
relationships. In addition, it was useful to clarify the differences between the past (experiences
from which the schema was developed) and the current situation. This helped keep C from sliding
into the trap of thinking the present is identical to the past, or that she is doomed to repeat the
past. The therapist made the following observation: “As a child you acted passive because you had
very little power and few choices. Now that you are somewhat older and no longer live with your
father, you have more supports, such as the people in your group home, friends to speak with and a
therapist you can trust. These supports can help make the difference in how you can deal with this
situation.”
4. Introduce the Challenging Schemas Worksheet
 The Challenging Schemas worksheet helps adolescents identify and understand what their
relationship schemas are and how they come up in the present. This exercise can help
make the concepts described above more concrete and personal to each adolescent. Given
that many trauma survivors have difficulty holding onto insights from one week to the next,
these tools create a record that the adolescent can refer to in later sessions.
 It is important to describe the schema worksheet and its rationale. At this time, the
adolescent should be comfortable completing the Self-Monitoring of Feelings worksheet.
Present the schema worksheet in a similar way, highlighting its importance for discovering
information about how the adolescent interacts with others. The therapist should allot time
in the session to fill out a schema worksheet with the adolescent and answer any questions
about how to use the form on their own.
 Begin by asking the adolescent about a recent situation in a relationship that was difficult.
Prompt the adolescent to respond to the questions in each column of the form and record
their answers: What happened in this situation? What did you feel and think about yourself
in this situation? What did you feel and think about the other person in this situation?
What action did you take, what did you do? Next, continue with the bottom half of the
worksheet. Explain to the adolescent that there are other ways she could have reacted to
this situation. Help her to come up with ideas about different thoughts and actions.
Prompt the adolescent to respond to the questions raised in each column of the form and
record their answers: What are your relationship goals in this situation? What else can you
feel and think about yourself in this situation? What else can you feel and think about the
other person in this situation? What else can you do?
Challenges
The adolescent is completing complex work in this session. It is common for adolescents to
have difficulty remembering key concepts, particularly around challenging schemas. It may be
useful to record important points on an index card (i.e., alternative beliefs the therapist and
adolescent identified during the session such as, “Everybody makes mistakes. Even when I make
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mistakes, people will accept me.”) This provides the adolescent with something tangible to take
with her and review between sessions.
L is an 18- year-old adolescent girl with a history of childhood sexual abuse by her older
cousin. When L told her family about the abuse, they told her “to stop making up such ridiculous
stories.” They were angry with her for “shaming the family name.” L’s family rarely discussed their
feelings or problems openly. They wanted people to think that everything was “just fine.” L’s
parents frequently told her, “Stop making trouble for us. Why do you always have to exaggerate
everything?” or “Quit focusing on the negative.”
In treatment, L shared that she was beginning a new relationship and wanted it to be
different. She had never had a long-term boyfriend and many guys felt she was “cold” and
“distant.” Despite L’s wish to become more open and emotionally close, she found herself behaving
in this new relationship as she had in her past relationship with her family. She talked about being
distant from her boyfriend even when he asked her what was bothering her.
The therapist used this situation to demonstrate the use of the schema worksheet. With
some prompting and guidance from the therapist, L was able to break the situation down. L
described how over the week she was feeling very upset about a recent argument she had with her
mother. She considered sharing what was going on with her boyfriend as a way of beginning to
open up to him. L was able to identify feelings/thoughts about herself that she felt like a “trouble
maker” who might “embarrass” her family by telling an “outsider” about her fight. She was also
able to express feelings/thoughts about her boyfriend like; he would not believe her and would
think that she was exaggerating her feelings about the fight. She was also afraid that he would be
uncomfortable and angry with her for talking about “negative” things and would not want to spend
time with her. As a result, L did not share what was happening, shut out her boyfriend and
remained upset and “very stressed out.”
Using the worksheet, L identified her relationship goal and came up with different thoughts
that she could have about herself and her boyfriend. She acknowledged that her goal was to be
more open with her boyfriend. Instead of feeling as if she was causing trouble by speaking about
something negative, L realized that what she wanted was simply to share her feelings and get
support from someone she cared about. She also realized that instead of rejecting her, her
boyfriend might be glad that she was beginning to trust him and confide in him. L wrote down a
different action:”When my boyfriend asks me what is wrong, I can tell him what is on my mind. If I
don’t feel ready to tell him about it, I can tell him that it’s really hard for me to talk about it right
now, but that I want to share it with him when I feel ready.”
 Assign between-session work of completing the Challenging Schemas sheet 2x a week.
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Session 8: Introduction to Role-playing: Feelings vs. Behavior
Agenda
1. Review Between-Session Work (Clear Communication or Challenging Schemas sheets)

2. Describe Role-Playing
3. Practice a Simple Role-Play
4. Identify Difficult Situations and Conduct Role-Plays
5. Assign Between-Session Work: Dealing with Others sheet
1. Review Between-Session Work (Clear Communication or Challenging Schemas sheets)
 If the adolescent last completed session 7, review the Clear Communication sheet.
Address any difficulties completing this sheet and provide positive reinforcement.
 If the adolescent completed the optional session following session 7, review the
Challenging Schemas sheet. Determine whether she had any difficulty completing the form
between sessions. If she did not complete the form, discuss her reasons for not doing so
and fill out the form together, making sure that she not only understands the purpose of the
whole worksheet, but each column.
If the adolescent filled out a schema worksheet, review the sheet together, column by
column, and follow-up with questions such as, “How did you feel after you filled it out?”, “
Was it helpful?”, “Were you able to see how your thoughts, feelings, and behavior impacted
others and vice versa?” “Can you see that perhaps the next time, you might handle the
situation differently?”
2. Describe Role-Playing
 In role-playing exercises, the adolescent plays the roles of her self and another person in a
recent upsetting situation. The goal is to think about and practice different ways of
behaving. The therapy is a safe place for the adolescent to practice reacting to difficult
situations and get feedback from the therapist. The purpose of the role-play is for the
therapist and adolescent to understand what a specific upsetting situation is actually like,
and to discuss how the adolescent’s behavior helped or kept her from getting what she
wanted in that situation. Note: It is important for the therapist to pay attention to and
praise the adolescent’s behaviors that are particularly effective.
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3. Practice a Simple Role-Play
 Select an everyday situation that is not particularly upsetting to the adolescent to

demonstrate how to do a role-play. Examples include getting directions from a bus driver,
asking a teacher for more time to complete an assignment, or getting help from a store
clerk to make a purchase.
4. Identify Difficult Situations and Conduct Role-Plays
 Ask the adolescent to identify one difficult or challenging situation with another person.
Ideally, this situation should be somewhat upsetting so that it is important to the
adolescent but not overwhelming. Conduct a role-play of the identified situation with the
adolescent acting as herself and the therapist acting as the other person in the situation.
Before beginning, the therapist should ask the adolescent for specific background
information to help he/him respond in a realistic and helpful way. This role-play will give
the therapist an opportunity to see how the adolescent has dealt with (or plans to deal with)
the situation, rather than relying on the adolescent’s second-hand description. After
completing the role-play, the therapist can share observations, provide feedback, and make
suggestions for improving communication and outcomes.
 When providing feedback, it is important that the adolescent not feel criticized or
misunderstood. It is essential to point out strengths, as well as weaknesses, regarding the
adolescent’s style of communication (e.g., “When you were describing your feelings about x,
you were very clear”).
 When addressing problems or sticking points, the therapist should talk about how the other
person in the situation might have felt or acted. Using the therapist’s own perceptions
might be overwhelming or confusing to the adolescent (e.g., “A person in this situation
might feel hurt by your comment that you don’t really care what she thinks”).
 Most adolescents can benefit from general tips about communication. These may include
ways to express feelings without upsetting the other person or getting caught up in side
issues. For example, it is important to emphasize how one’s feelings cannot be “wrong”
and how adolescents sometimes “play down” the importance of their feelings or requests.
For example, many adolescent girls will be overly apologetic or start with phrases such as,
“I know this may seem like I’m making a big deal of this, but…” or “I don’t mean to be
picky, but….”
 Repeat the role-play with the therapist now playing the adolescent and the adolescent
acting as the other person in the situation. This is an ideal opportunity for the therapist to
model behavior for the adolescent. When the role-play is complete, ask the adolescent how
the interaction sounded and whether she could really picture herself using that language
and/or behavior. It is also helpful for the therapist to acknowledge how challenging it can
be to act in situations when one feels upset. The therapist will be in a good position to
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comment on this after having had the experience of playing the role of the adolescent (e.g.,
“I can really see how having your classmate say those things would make you feel pretty
sad”).
 Finally, the therapist and adolescent should reverse roles once more, giving the adolescent
the opportunity to play herself again. In this role-play, the adolescent is encouraged to try
behaving in a different way. Afterward, the therapist should ask the adolescent to describe
how the role-play felt this time as compared to the first time. Hopefully, she will notice
some differences after listening to the feedback. The adolescent may practice the situation
until she feels confident about dealing with it.
 After role-playing, work with the adolescent to complete either the “Dealing with Others”
handout or the “Challenging Schemas” handout using one of the specific situations role-
played in the session. Adolescents who completed session 7A should complete the
“Dealing with Others” handout. Adolescents who completed session 7B should continue
working on the “Challenging Schemas” handout.
Challenges
Many adolescents are embarrassed to participate in role-plays. It is important for the therapist
to present the activity in such a way that the adolescent does not feel that she is “on the spot” to
perform. The therapist may say, “I know doing these role-plays may feel a little awkward at first, but
once you get the hang of it, they can be really be useful. Let’s try it for a minute and see how it goes.”
Because of their abuse histories, many adolescents are very sensitive about “doing things the
wrong way.” Adolescents may become angry and defensive, or feel ashamed and withdraw. Neither
of these helps the adolescent to establish and practice new relationship skills. Thus, it is critical for
the therapist to emphasize the importance of trying new behaviors, as opposed to rejecting the
adolescent’s current ways. Communicate explicitly that there is no “right or wrong way” to express
oneself, but rather a range of options she can choose from depending on the message she would like
to convey in a given situation.
C is a 14-year-old girl with a history of child sexual abuse by her father. She has been living
with a foster mother since age 10. C enjoyed receiving the attention and love from her “new
mother” and became very excited when her foster mother decided to adopt her. C began to excel in
school and greatly improved her relationship with her classmates. Recently, C’s foster mother took
another child, M, into her care and thought about adopting her as well. C reacted to this news very
poorly and began to act out in school. C reports that she now gets easily upset and angry and has a
difficult time getting along with others.
C shared the above situation with her therapist. The therapist helped C to connect her
behavior at school with her feelings about having her foster mother adopt a new child. C was able
to identify that she was feeling nervous that her foster mother would not give her any more
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attention or love her as much as she had in the past. She also identified that she felt angry and
jealous of M because she felt like she was “taking over” her spot in the family. The therapist
discussed with C possible options to deal with the situation. The therapist suggested that C could
share with her foster mother some of her feelings about having another child enter the family.
Initially C responded, “I’m too embarrassed to talk about it. What would I say anyway?” C felt
overwhelmed at the idea of explaining her feelings to her foster mother. She feared her foster
mother would think she was “completely ungrateful” and reject her. The therapist suggested a role-
play as an experiment to give C an opportunity to think about safe and comfortable ways in which
she could share with her foster mother without “pushing her away”.
Initially C played the role of herself and the therapist her foster mother. She began, “I don’t
mean to sound ungrateful and it really isn’t a big deal, but I don’t feel as good around the house
now.” At the end of the role-play, the therapist gave C feedback on how this might come across to
her foster mother. Specifically, the therapist observed how, in her effort not to offend her foster
mother, C downplayed her fears and concerns and was not able to express fully how she was
feeling. In real life, her foster mother might not clearly understand C’s concerns and be unsure as
to how to respond, which in turn could lead C to feel rejected. The therapist noted that C might feel
better if she directly expressed what was going on inside of her.
C agreed with the feedback and wanted to try the role-play again. This time she stated to
her foster mother, “I’m hate having M around. You are going to love her more than you love me and
you will forget all about me. ” The therapist praised C for expressing her feelings more directly, but
observed how in this role-play, she may have gone too far in other direction which could result in
her foster mother feeling attacked and defensive.
Next, the therapist played the role of C and C played the role of her foster mother. The
therapist modeled an example of how C might express her feelings more clearly and directly
without becoming overly attacking. “I have been feeling very nervous and angry since you decided
to adopt M. I love you very much and I am scared that now that you have another daughter you are
not going to care about me as much. I am nervous that M will take my spot in the family. I liked
things the way they were and now I am afraid that I will lose that.” Then, she paused to allow the
foster mother to respond. The therapist asked C how this sounded to her. C replied, “It sounds
good when you say it, but I’m not sure I’ll be able to say like that.” The therapist then switched
roles again with C to allow her to use the feedback in way that felt natural and comfortable for her.
 Assign the between-session task of having the adolescent practice different approaches to
difficult situations. Have the adolescent use either the Dealing with Others or the
Challenging Schemas handouts to record at least one situation on paper.
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Session 9: Role-playing with Focus on Assertiveness
Agenda
1. Review Between-Session Work (Dealing with Others handout or Challenging Schemas handout)
2. Define Assertiveness
3. Identify Current Difficulties in Assertiveness
4. Provide Psychoeducation about Effective Assertiveness
5. Conduct Role-play of Situations Requiring Assertiveness
6. Assign Between-Session work: Dealing with Others handout or Challenging Schemas handout
1. Review Between-Session Work (Dealing with Others handout or Challenging Schemas handout)
 Review the adolescent’s Dealing with Others or Challenging Schemas handout. Assist the
adolescent in understanding situations that did not go as planned. Together, discuss other
behaviors that might have worked better, and how sometimes, no matter how hard we try,
things just don’t go our way. Reinforce the adolescent’s attempts at this exercise.
2. Define Assertiveness
 Begin by defining assertiveness. Explain that being assertive means that a person stands
up for her rights by clearly stating her needs or wants in a respectful way. Give the
adolescent the list of Basic Personal Rights. Review the rights briefly and ask the
adolescent to read it carefully at home.
 Distinguish assertive behavior from non-assertive and aggressive behavior.
In non-assertive behavior, the adolescent ignores or does not express her own rights, needs,
and wants. She allows others to go against her rights, or take advantage of her. Non-
assertive behavior may lead the adolescent to feel hurt, nervous, disappointed in herself, or
even angry.
In aggressive behavior, the adolescent takes out her needs or wants in a disrespectful way,
such as by acting out with hostility. Aggressive behavior may lead an adolescent to feel
angry, frightened, and guilty.
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In assertive behavior, the adolescent stands up for her rights in a way that respects the
rights of others. Assertive behavior may lead the adolescent to feel confident.
3. Identify Current Difficulties in Assertiveness
 Help the adolescent identify her personal difficulties with assertiveness. At this point, the
clinician is likely to have a good sense of the problems the adolescent has in either being
too assertive (i.e., aggressive), under-assertive, or both. The clinician should work from
specific, real-life examples and look for patterns in the adolescent’s assertive behavior. The
therapist may say, “Sometimes people have a hard time expressing their feelings and
needs. They may come across as too strong or do not stand up for what they want. Last
week, we talked about how you felt when your friend canceled your weekend plans. You
became upset and left an angry message on her answering machine. Do you find that
when people disappoint you, you become really upset and angry with them?”
 Discuss the adolescent’s past experiences practicing assertive behavior. Encourage the
adolescent to give examples of how others at home modeled assertive, non-assertive and
aggressive behavior. Discuss how the adolescent communicated her needs and wants and
how others responded to her. The goal of this discussion is for the therapist and adolescent
to have clear examples of her typical thoughts, feelings and behaviors around assertiveness
and control. These examples also provide details for use in the role-plays. Linking
difficulties with assertiveness to early experiences will help to reduce any sense of blame
the adolescent may feel about difficulties she may have with her thoughts and behavior.
4. Provide Psychoeducation about Effective Assertiveness
 It is important to point out that behaving assertively does not guarantee that people will do
what we want them to. Sometimes people respond negatively no matter how assertive or
respectful we are. Explain to the adolescent that she may still receive negative or unhelpful
responses to her assertive behaviors, but that overall she will be more successful in dealing
with others.
 Practice using “I” messages. This will be a review for adolescents who completed session
7A. The therapist may ask the adolescent to describe what she remembers about “I
messages” and practice using the skill for a recent situation.
For adolescents who completed session 7B, explain that the “I” message helps us tell
another person about how their behavior affects us. The purpose of an “I” message is to
focus on what happens as a result of another person’s behavior instead of blaming that
person. By focusing on the results of a behavior, the adolescent is less likely to make the
other person feel attacked. Encourage the adolescent to say the person’s name and make
eye contact when using “I” messages.
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An “I” message has 3 parts: a behavior, feeling, and result.
1. Behavior: What is happening around you? What is the other person doing?
2. Feeling: How does the person’s behavior make you feel?
3. Consequence: What happens as a result?
Use this form sentence:
When you ____________, I feel _______________ because_______________

(behavior) (feeling) (result)
Examples: (Help the adolescent identify the behaviors, feelings, and results.)
“When you didn’t pick me up, I felt frustrated because I missed my appointment.”
“When you lied about breaking the vase, I felt angry because I got in trouble for it.”
“When you invited me to the movies, I felt happy because I got to spend time with you.”
Model for the adolescent how she could have used an “I” message in a recent situation, and
have the adolescent practice using the skill.
5. Conduct Role-plays of Situations Requiring Assertiveness
 Complete a role-play of a difficult situation with another person identified earlier with the
method described in Session 8.
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Challenges
Having the therapist take on the role of a person with whom she fears interacting (e.g., a
critical teacher) can be distressing to the adolescent, especially if the therapist is effective in role-
playing a critical attitude. The adolescent can become convinced that the therapist has negative
feelings towards her, which may shake her sense of trust in the therapeutic relationship. The
therapist should reinforce the strength of the therapeutic relationship. The therapist may say, “It
may be uncomfortable for you having me act in this way, but this is just an exercise designed to
help you. Remember, this therapy is a place where you can feel safe and comfortable. Often, we
try different approaches and even play other people to show problem areas in your life and how you
can begin to make positive changes.”
Adolescent abuse survivors often find that communicating anger in an assertive manner is
an especially difficult, even threatening task. They have witnessed firsthand the dangerous
consequences of anger through the aggressive acts of their abusers. They are often unaware that
they can communicate anger in a way that is safe and useful. For abuse survivors, others may have
minimized their anger, leading to feelings of powerlessness, frustration and rage. On the other
hand, survivors can also express anger aggressively, leading to feelings of intense guilt, anxiety and
fear. Role-playing can help the adolescent develop new ways to communicate her anger
appropriately and assertively.
K is a 15-year-old adolescent girl who has been having a difficult time in school. She has
been receiving poor grades on her exams and her teacher recently sent her out of class for refusing
to participate. K’ s foster mother has been receiving phone calls from her teacher regularly to
complain that K no longer puts any effort into her work. The teacher recently scheduled a meeting
with K and her foster mother to address the current situation. Although K feels badly that she is
not doing well in school, she says that she no longer tries because she is very angry with her
teacher. She thinks that her teacher never listens to anything she says and unfairly “picks” on her
and singles her out in class.
K shared the above situation with her therapist. They discussed possible options for how K
might manage her anger at her teacher. The therapist suggested that at the upcoming meeting, K
could share with her teacher some of what she was feeling and discuss some of the reasons why
she was no longer doing as well in school. Initially K responded, “I couldn’t do that. What would I
say? She wouldn’t listen to me anyway.” K felt that she was powerless to change the situation and
feared that she would continue to do poorly for the rest of the school year. The therapist suggested
a role-play as an experiment to give K a chance to think through a way that she could express her
feelings to her teacher in a way that the teacher might respond positively.
Initially K played the role of herself and the therapist her teacher. She began, “I don’t want
to be getting such bad grades and I don’t mean to always talk out of turn – I’m just a little unhappy
in the class and that’s why I’m not doing so well.” The therapist praised K for her effort to
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communicate her feelings and provided her with feedback about how this might come across to
her teacher. Because of K’ s indirect style, the teacher may have difficulty understanding that she
feels mistreated in class. Alternatively, K’ s teacher may pick up on the undertone of anger in her
words and become defensive because K did not address the situation openly. The therapist pointed
out that K’ s indirect style kept her feeling safer, but might prevent her teacher from responding
directly to her concerns. This would reinforce K’ s idea that her teacher does not listen to her. The
therapist also probed for K ’s emotional experience of the role-play and verified that she was
feeling angry, frustrated and resentful.
K agreed with the feedback and asked to play herself again in the role-play. This time she
started, “You don’t listen to me in class and you’ve been picking on me. You let other people get
away with things that you don’t let me get away with. I don’t bother to try because I’m just going to
get punished no matter what.” At the end of the role-play, the therapist gave K feedback on how
this might come across to her teacher. The therapist praised K for her effort to express her
feelings more directly, but provided her with feedback that her teacher may feel attacked by this
approach and respond in a defensive manner.
The therapist then modeled ways in which K could present her feelings to her teacher in an
assertive manner using ”I” messages. The therapist said, “I have been upset in class lately because
I feel that I’m singled out more than any of the other kids. It makes me not want to put any effort
into my work.” The therapist asked K how this sounded to her. K replied, “It sounds good. I didn’t
know you could say things like that.” The therapist then switched roles again with K to allow her to
practice expressing herself in way that felt natural and comfortable for her.
 The most important task for the week is to practice effective assertive behaviors. Have the
adolescent identify a possible activity or situation that will require assertive behavior in the
next week. Have her complete either the Dealing with Others handout or the Challenging
Schemas handout.
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Session 10: Review of Skills Learned and Transition to Narrative Storytelling (NST)
Agenda

2. Acknowledge Last Skills Session and Review Progress
3. Provide a Brief Rationale of Narrative Storytelling (NST)
4. Elicit Questions and Concerns about Transition to NST
7. Assess and Review PTSD Symptoms
1. Review Between-Session Work (Dealing with Others handout or Challenging Schemas handout,
practicing assertive behavior)
 Review the adolescent’s Dealing with Others or Challenging Schemas handout, with an
emphasis on issues involving assertiveness. Assist the adolescent in understanding
situations that did not go as planned, and together discuss other behaviors that might have
worked better. Also discuss how sometimes, no matter how hard we try, things just do not
go our way. Reinforce the adolescent’s attempts at this exercise. Discuss any additional
situations in which the adolescent either struggled with assertiveness or practiced
assertiveness skills.
2. Acknowledge Last Skills Session and Review Progress
 Acknowledge that this session marks the end of the Skills-building phase of treatment.
Review with the adolescent the work she has done in building and practicing skills to cope with
her feelings, deal with difficult situations, and get along with others. Reinforce strengths and
positive feelings about the adolescent’s hard work and accomplishments.
 Congratulate the adolescent on her hard work and progress during Skills-building. Try to
highlight the details of the adolescent’s progress. The therapist may praise the adolescent
with comments such as, “You have been really motivated to work on some tough issues,”
“You seem to be able to control your anger more effectively,” “You have really made an
effort to do your homework regularly. “ Even praising an adolescent’s improvement in
attendance and timeliness can be immensely helpful at this time. Ask the adolescent for
her own thoughts about her progress. Discuss the areas in which she has continued to
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grow and improve, and let her know that you will continue to build and practice skills during
the next phase of treatment.
R is a 17- year-old adolescent girl who has difficulty controlling her anger and tends to lash
out at people close to her when she feels threatened and vulnerable. During therapy, R recognized
how her angry feelings interfered with her relationship goals and led her to act in ways that she
later regretted. While reviewing her progress, R’s therapist pointed out to her, “In the past, you
tended to get really angry at people when you felt hurt and disappointed. Often, you wanted to cut
off your relationship with them completely. Do you remember when your boyfriend said something
you did not like and you immediately wanted to break up? Now, you seem to manage your angry
feelings much better. You do not feel as if you have to walk away from relationships when
something happens to upset you. You seem more able to identify your goals in relationships, weigh
the pros and cons of the situation and tell the person how you’re feeling in an assertive way.”
3. Provide a Brief Rationale of Narrative Storytelling (NST)
 Remind the adolescent that in the next phase of treatment, your work will shift toward
helping her to make sense of her traumatic memories. She will accomplish this by talking
about her traumatic memories repeatedly and understanding their meaning for her now.
Explain to the adolescent that in the past, she may have avoided thinking about these
memories because they felt overwhelming and upsetting. Avoiding these thoughts and
feelings, however, prevented her from understanding and making sense of these painful
experiences. The symptoms she currently experiences, such as flashbacks, difficulty
sleeping and upsetting feelings and thoughts, are signs that she still has some “unfinished
business” related to the trauma. The storytelling work (NST) will allow her to explore some
of these feelings and process them in a safe and comfortable environment with the
therapist, while using the relaxation and coping skills she learned in the first phase of
treatment.
 Some adolescents may be very anxious at the idea of talking about their abuse, especially
in detail. The therapist may explain that the work will begin slowly. The adolescent will first
talk about the memories that are least upsetting, and then gradually work up to more
difficult ones. Also, emphasize that the work will be collaborative, that the adolescent will
determine the pace of the work and stop if she needs to. Reassure the adolescent that she
also developed new coping skills during the first phase of the treatment to help her with
NST. Reiterate once again what those skills are, and how they can be helpful in relieving
upsetting feelings.
4. Elicit Questions and Concerns about Transition to NST
 Many adolescents have worked hard at putting the past behind them so that the idea of
talking about traumatic memories can feel very threatening. This is particularly true of
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adolescents whose memories of the abuse may still be painfully raw. Other adolescents
may have had upsetting experiences related to sharing their abuse and are therefore
skeptical about how NST can be helpful. Ask the adolescent whether she has any questions
or concerns about transitioning to NST. Does she understand the rationale and procedure
for NST? What are her concerns and fears about starting to do NST? Encourage the
adolescent to be up-front about her concerns. Let her know that she will have time in the
next session to discuss any additional questions or concerns she may have about NST.
Challenges
Many adolescents are very hesitant about beginning the storytelling work. It is common for
an adolescent to skip the next session as a way to avoid dealing with painful feelings about the
abuse. If the therapist thinks there is a possibility that the adolescent may “no-show” the following
week, it is often helpful to bring this up during session. The therapist may say, “It is very
understandable for you to be nervous when talking about these painful issues. I am wondering if
one way you are thinking about coping with your feelings is to not come for our session next week.”
Some adolescents feel frightened about the storytelling work because they may have been
upset in the past when they tried to talk about the abuse. One adolescent reported, “When I tried
talking to my parents about what happened, they just got upset with me and told me not to talk
about these things. I never said another word. After awhile, I think I was able to convince myself
that it didn’t happen.” In order to reassure an adolescent, the therapist may say, “ I know that other
people may have told you to ignore your feelings and not to talk about them, but therapy is a place
where you can feel safe and comfortable exploring these painful feelings and memories.”
Some adolescents do not want to do the storytelling work because they are afraid that the
painful feelings will overwhelm them if they talk about their abuse. An adolescent may say, “The
last time I talked about what happened to me, I got so depressed I couldn’t get out of bed or go to
school for a week.” Another adolescent may have attempted suicide in the past and is afraid that
she will become so upset that she may try to hurt herself again. The therapist may try to reassure
the adolescent by saying, “Bringing up these memories can be very frightening at first and you may
feel more upset than usual while doing storytelling work. However, understanding and making
sense of what happened to you is an important step in helping you to feel better over time. In order
to make sure that you feel safe and comfortable during the storytelling, you can control the pace
and decide which memories will be the easiest for you to start with. If you feel that you might
become overwhelmed, we can take a break and stop for a bit.”
 The adolescent should continue to practice using either the Dealing with Others or
Challenging Schemas sheet. Encourage her to think about the next phase of treatment
between sessions and bring in any questions or concerns to the next session.
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7. Assess and Review PTSD Symptoms
 Now that the adolescent has completed Phase I of the treatment and is ready to begin
Phase II, the therapist or clinical evaluator should administer the CAPS-CA to assess current
symptoms of PTSD. The therapist or evaluator should review the adolescent’s symptoms
with an eye toward noting progress or improvements and to clarify areas that may still be
problematic. The therapist may administer the CAPS-CA at the end of session 10. It is a
good idea to make plans in advance to let the adolescent and parent/guardian know that
she will be in your office for an additional twenty to thirty minutes on that day.
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Session 11: Introduction to NST
*Note to Therapist: Using the SUDS Rating Scale
Subjective Units of Discomfort (SUDS) refers to the intensity of an emotional experience.

For example, an adolescent may indicate that she feels “just a little upset” when her mother scolds
her at home; however, she may feel “very upset” when a peer at school teases her. The SUDS
Rating Scale includes ranges of numbers from 0-100 (see attached SUDS Rating Scale). These
ratings help the adolescent to establish anchors that she can use to rank her severity of distress
during NST. Each adolescent will have her own unique rating system based on her personal life
experiences. Hence, one adolescent may report experiencing a SUDS of 50 when describing a
memory of sexual abuse, whereas another adolescent may report experiencing a SUDS of 90 when
describing a very similar experience. The SUDS rating scale is valuable to treatment because it
allows the adolescent and therapist to “speak the same language”, and have a mutual
understanding of the adolescent’s subjective emotional experience. This is particularly important
during NST because it allows the adolescent and therapist to track changes in her level of distress
to detect hot spots and monitor habituation.
Agenda

2. Review Safety Plan with the Adolescent
3. Rationale for NST
4. Elucidation of Memories
5. Review Difficulties Concerning Coping Skills and Relationships
6. Assign Between-Session Work: Mastery and Competency Activity
1. Review Between-Session Work (Dealing with Others handout or Challenging Schemas handout,
address questions or concerns about NST)
 Review the adolescent’s Dealing with Others or Challenging Schemas handout. Assist the
adolescent in understanding situations that did not go as planned, and together discuss
other behaviors that might have worked better. Also, discuss how sometimes, no matter
how hard we try, things just do not go our way. Reinforce the adolescent’s attempts at this
exercise. Invite the adolescent to discuss any questions or concerns she has about her
transition to NST.
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2. Review Safety Plan with the Adolescent
 Ask the adolescent if she still has her safety card handy in her backpack, wallet, or pocket.
If she does not, create a new one. Review the three-point plan so that you are both clear on
the plan as you enter this next phase of treatment. In addition, the therapist and
adolescent should review this plan the end of each session going forward.
3. Rationale for NST
 The first goal of this session is to re-introduce the rationale for NST. Again, it is natural for
the adolescent to be anxious about beginning this new phase of treatment. Many
adolescents say they feel it is time for them to “face their fears” and deal with their
traumatic memories. However, when phase II approaches; they may feel that they are not
ready. It is important to normalize the adolescent’s fears at this time. The therapist may
say, “I know you may be frightened, or think that you may not be able to handle this.
Remember that working with your traumatic memories is one of the reasons you came into
treatment. During our last session, we talked about how this part of the treatment may be
painful, but in the long run, it will help you feel better about yourself and your relationships.
It can help you deal with stressful things that come up in your day to day life.”
 The therapist should explain the purpose of NST in a clear and understandable manner.
Explain to the adolescent that the purpose of NST is to have her relive some of her
childhood abuse memories.
The therapist may say, “It is not easy to understand and make sense of traumatic
experiences. When you think about the abuse, or something reminds you of it, you may feel
upset. The abuse was very upsetting, so you may want to push away or avoid the painful
memories. You may tell yourself, “I just have to forget about it”. However, as you have
already discovered, no matter how hard you try to push away thoughts about the abuse,
they come back to haunt you through nightmares, flashbacks, and upsetting thoughts and
feelings. These symptoms tell you that the abuse is still “unfinished business.”
“In fact, trying to avoid memories of the abuse can make you feel more anxious and upset
about the memories. This is because avoidance keeps you from making sense of the
thoughts and feelings that go along with the memories. After something happens, your
mind starts to organize all of the pieces into a story. When your mind puts all of the pieces
together, your feelings are easier to deal with. However, if your mind misses some of the
pieces because you avoid the upsetting parts, it never gets to finish the story. When this
happens, your feelings can be strong and overwhelming.”
“The goal of this treatment is to help you put all the pieces of your memories together by
remembering the abuse. Staying with these memories rather than running away from them
may be very upsetting at first. This is a normal reaction. However, over time, it will help you
feel less anxious and afraid than you felt when it happened. It is normal to want to avoid
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memories, feelings and situations that remind you of the abuse. However, the more you
avoid dealing with the memories, the more they bother you.”
“As a child, you may have tried to tell others what was happening to you. You may have
found that people you tried to tell about the abuse did not believe you or did not want to
listen. Someone may have told you to pretend it was not happening, or to try to forget about
it. Today, you might not want to talk about it because it might make people feel
uncomfortable. In this therapy, you are in a very different situation where it is safe to talk
about what happened. I want to hear all about your experiences and will be a good
listener.”
 As noted in Session 10, many adolescents feel afraid to talk about the abuse and have a
hard time starting the storytelling work. At this point, it is very important to talk about any
concerns the adolescent has about this phase of the treatment.
4. Elucidation of Memories
 During the adolescent’s initial assessment, she may have provided a brief and general
description her abuse without going into details about her most disturbing memories. To
prepare for NST, the therapist will need more specific and detailed information about the
abuse memories. The therapist’s role is to assist the adolescent in describing the
memories that she will use in the storytelling. Adolescents’ memories of their abuse
experiences vary greatly. Some adolescents may only have one memory, whereas others
have many. For this treatment program, ask the adolescent to identify her most disturbing
memories that affect her most in her daily life.
 Before you begin, explain to the adolescent: “We will begin doing the storytelling in the
next session. In the meantime, we will prepare for it several ways. You have begun to learn
how to cope with some upsetting feelings by using the skill of deep breathing. I want to
encourage you to continue to practice this skill. Another thing we need to do to prepare for
the storytelling is to pick which memories you will talk about. To do this, I need to know
more about your memories of abuse. I would like you to describe any specific memories
you have of the abuse you experienced as a child. Please tell me about the memories that
stand out for you the most, the memories that haunt you regularly during the day or night,
the images that you find difficult to get out of your mind. What specific memory first comes
to your mind? Tell me what you recall.”
 The therapist should record the adolescent’s memories on the Memory Elucidation form.
The adolescent should report a maximum of 3 memories to make sure that she will have
enough time to tell her memory in detail many times over the next few sessions. However,
the therapist may only get to 1-2 memories during NST, depending upon how long it takes
the adolescent’s symptoms to decrease, and to deal with any potential resistance to this
intervention.
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 The adolescent’s reporting of her traumatic memories should be brief. It is important that
the therapist not probe for excessive details about the adolescent’s traumatic experiences
during this task. Rather, the adolescent should merely identify a few clear memories she
has of her traumatic experiences. The adolescent will have time to describe her memories
in detail during the actual storytelling. For example, the adolescent may report a memory
of a time her mother hit her so hard that she had to go the hospital. The therapist should
not probe for details about where she was hit, with what she was hit, how she got to the
hospital, etc. during this session.
The purpose of completing the Memory Elucidation form is to compose a record of

memories that the adolescent will use in the subsequent NST sessions. If the adolescent
begins to provide excessive details, the therapist may gently stop her by saying, “You are
able to remember a lot of things about this experience. I do want to hear more about it and
I will make sure that you have a lot of time to tell me about this memory over our next
several sessions. For now, I just want to make a list of your memories so that we can pick
which ones you need to talk about most.”
 After the adolescent has finished describing a memory, ask her to assign a SUDS
(Subjective Units of Discomfort) rating based on her level of anxiety while describing that
event. Your task is to evaluate which memories cause the greatest anxiety for the
adolescent. The amount of anxiety the adolescent experienced during the abuse is of less
relevance. Similarly, details that the adolescent has a hard time remembering are of less
importance, since those details are less likely to affect her daily symptoms (e.g., intrusive
images) or functioning.
 After reviewing the specific traumatic incidents, spend a few minutes discussing with the
adolescent which memories cause the most anxiety, and which one is the most difficult to
manage. Usually, the most difficult memory has the highest SUDS rating. Some
adolescents give more than one incident the highest rating. The adolescent should decide
which memory is most upsetting; however, you may share your observations of her behavior
while she described the events to assist her. When determining which memories are most
upsetting, both memories related to childhood abuse as well as the other traumatic
memories should be included.
Challenges
While describing one experience of abuse, the adolescent may remember another incident,
and shift topics. Gently redirect the adolescent back to describing the first event. Tell her that you
will make a note of the second incident, and will return to it after she completes the first one. After
you obtain a SUDS rating for the first event, you can then ask the adolescent to describe the second
event.
When reviewing the adolescent’s memories of abuse, she may identify other traumatic
events (e.g., witnessing the death of a relative or close friend). You should make note of these
events and plan to assess them after completing your assessment of the childhood abuse
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experiences, following the same procedures. If significant traumatic events have occurred, it is
critical that these events be included in the assessment.
5. Review Difficulties Concerning Coping Skills and Relationships
 Review any problems or issues that arose during the past week with regard to using coping
skills. Emphasize to the adolescent that although she has entered into the next phase of
treatment, it is very important for her to continue practicing and using the skills she learned
throughout therapy.
6. Assign Between-Session Work: Mastery and Competency
 Mastery and Competency: Discuss with the adolescent her talents and/or activities she
enjoys. Help her to identify a personal strength (e.g., writing, sports, academics, artistic
ability, or musical interest). Make a weekly plan with the adolescent to practice this activity
to help her gain a sense of mastery and control, and improve self-esteem. For example, if
an adolescent likes to write poetry, have her begin a notebook of poems and bring the book
to session each week to show you. If she feels comfortable, she can read poems aloud in
session, or consider submitting one to a local newspaper for publication. If an adolescent is
interested in sports, she can set a specific goal such as trying out for the school basketball
team or working up to 30 minutes of running every other day by the end of treatment.
 Record the adolescent’s choice of activity and goal on the Mastery and Competency Activity
form. Tell her that you will review her progress towards this goal over the next 6 weeks of
treatment.
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* Note to Therapist: Orientation of Therapist to NST
Adolescents are often reluctant to fully relive the abuse and confront feared images. The
adolescent can overcome her reluctance by controlling the pace and intensity of the process. In the
first few sessions of storytelling, the adolescent may need more guidance to follow through with
the exercise. After several sessions, the adolescent should become more familiar with the
procedure and feel less anxious. As this happens, the therapist may use fewer directive statements
to bring out descriptions of the childhood abuse memories.
The therapist will begin with a practice storytelling, using an imagery scene unrelated to the
abuse (e.g., a walking tour of the adolescent’s home or some other safe place). This familiarizes
the adolescent with the procedure and gives her control of the exercise before she talks about the
abuse. In the first attempt to relive the abuse, help the adolescent to approach the memory
gradually and determine the appropriate level of detail. This also enhances the adolescent’s sense
of control. In subsequent episodes of storytelling, encourage the adolescent to experience the
event in greater depth by probing for the emotional and physical reactions that went with the
abuse.
It is essential that the adolescent not end a storytelling session with a high level of anxiety.
It is particularly desirable for the adolescent’s SUDS level at the end of the storytelling to be lower
than it was at the height of the session, even if only slightly. This permits the therapist to draw
attention to the fact that the anxiety is habituating. The therapist should plan sessions so that
there is enough time at the end to evaluate the adolescent’s level of distress and, when necessary,
practice deep breathing to reduce anxiety. It is very important to encourage the adolescent to talk
about her reactions to reliving the abuse and to discuss new details and associations that emerge.
The therapist may incorporate these into future storytelling sessions.
Forms to use During NST
SUDS Rating Scale: The therapist should provide the adolescent with a copy of this scale to
use as a guide when she provides SUDS ratings during NST. If the adolescent is unfamiliar with the
form, the therapist should spend a few moments reviewing the score ranges and asking for
examples (not related to abuse) from the adolescent. For example, an adolescent may give a SUDS
rating of 30 to having a disagreement with a friend and a rating of 60 to watching a scary movie.
Therapist NST Recording Form: The therapist uses this form to track the adolescent’s SUDS
ratings at various times throughout the storytelling. The therapist should record a brief description
of the memory at the top of this sheet, as identified during the Memory Elucidation task. The
therapist should ask the adolescent for a SUDS rating before she begins storytelling of the memory
and record this on the “Pre-NST” line. Once the adolescent begins storytelling, the therapist should
request additional SUDS ratings approximately every 5 minutes to monitor the intensity if her
emotions. This allows the adolescent and therapist to identify hot spots and monitor habituation.
Lastly, the therapist should request a SUDS rating after the adolescent completes her storytelling
and record this on the “Post-NST” line.
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It is helpful for the therapist to record notes about the content of the storytelling along with the
SUDS ratings, as well as any behavioral observations. The therapist may share this information
with the adolescent during the debriefing phase of the session.
Therapist Form for Post NST Emotional State: The therapist uses this form to record the
intensity of the adolescent’s emotions during NST. Since it may be difficult for the adolescent to
identify and articulate feeling states during NST, this form can help her consider different emotions
that traumatized adolescents often experience, particularly when re-experiencing events. The
therapist completes this form after the adolescent finishes her storytelling of a memory. The
therapist may ask, “As you were describing this memory, how angry did you feel?” If the adolescent
reports different levels of intensity throughout the NST, record the highest rating for that memory.
Lastly, the therapist asks the adolescent to identify the strongest feeling she experienced during
the storytelling. Again, this provides useful information for the therapist and adolescent to discuss
during the debriefing phase of the session.
Potential Problems During NST
Avoidance: In order to maintain control during the storytelling phase of treatment, the
adolescent may engage in avoidance behavior. For example, she may become quiet or turn to the
side while avoiding extremely upsetting memories such as the perpetrator’s face, having someone
threaten her verbally or physically, or force her to perform sexual acts. If the adolescent has
difficulty verbalizing during NST, gently encourage her to refocus on the memory and continue
speaking.
Avoidance can range from changing or blocking the image, to minimizing its emotional
impact, to dissociation. When you notice signs that the adolescent may be using avoidance
strategies during NST, you should ask, “What is happening?” and gently encourage her to confront
the difficult image. For adolescents who are prone to dissociation during storytelling, you may want
to develop a non-verbal cue that she can use to sign if avoidance is moving toward dissociation. If
the adolescent is unable to confront a particular scene without dissociating, you may need to work
with less threatening material in the beginning. You may reduce the intensity of the storytelling
exercise by not asking for a great depth of detail until the adolescent is able to tolerate lower levels
of anxiety.
Another effective technique that can be helpful here is the slow-motion technique. This
involves focusing on the image and asking the adolescent to express her thoughts, feelings and
physical reactions. If she has difficulty expressing her feelings, the therapist can say in an
encouraging tone, “Allow all your feelings to be present – sadness, anger, guilt, fear.”
Behavior Changes: Some adolescents display behaviors such as rhythmic shaking,

huddling, or a childish tone of voice during NST. Such behaviors typically indicate that the
adolescent is fully immersing herself in reliving the abuse. It is important to carefully observe
these behaviors and maintain verbal contact with the adolescent. Remind her that it is still safe
with you here and that she is doing well in facing the memories. Touching the adolescent’s arm or
hand also can be helpful to ground the adolescent in the present; however, it is important to ask
permission ahead of time before using touch. The behaviors will likely diminish within and across
sessions. It is not necessary to discuss these behaviors with the adolescent. Doing so may make
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the adolescent feel self-conscious and hold her back from reliving the experience. Sudden
reductions in this type of behavior may signal that the adolescent is starting to use avoidance
strategies or even dissociating.
Therapist Discomfort: NST will likely include the adolescent describing events that you
may find unpleasant. Moreover, the adolescent’s distress can itself be upsetting for you. You may
want to minimize the level of detail and the degree of anxiety the adolescent experiences. You
may even want to terminate the session prematurely to spare yourself and the adolescent the
discomfort, distress and embarrassment of reliving the experience. You should anticipate feelings
of distress and revulsion and keep in mind the importance of letting the adolescent’s habituation
occur. Terminating an NST session prematurely can sometimes slow the habituation process. You
must be prepared to guide the adolescent through the story gently. It may be helpful to develop
coping self-statements of your own to help you tolerate the painful material. If you are having
difficulty with this, it is essential that you seek peer support or supervision.
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Session 12: Storytelling of First Memory
Agenda

2. Review Rationale for NST
3. Practice Storytelling of Neutral Memory
4. Conduct First Storytelling
5. Terminate Storytelling
6. Debriefing
1. Review Between-Session Work (Mastery and Competency)
 The therapist should check in with the adolescent about her selected mastery and
competency activity. Ask how often she practices the activity, how she feels while
performing the activity, and any resulting beliefs about herself. The therapist should use
this opportunity to praise and reinforce the adolescent. Encourage the adolescent to track
her progress on the Mastery and Competency sheet.
2. Review Rationale for NST
 Before beginning the first storytelling, review the rationale for NST and the nature of the
“debriefing “ which will follow the storytelling work:
“Today you are going to spend the first half of the session reliving some of your memories of
childhood abuse.
The goals of this treatment are to help you make sense of your memories of the abuse and
put them together into an organized story. We do this by having you remember and talk
about your memories for an extended time. Staying with the memories rather than running
away from them may be very upsetting at first. This is a normal reaction to those hurtful
events. However, over time, it will help reduce the anxiety and fear that you have with the
memories. As we have already discussed, the more you avoid dealing with the memories,
the more they disturb your life.
As you face the memories and the strong feelings that go with them, the feelings will
become less upsetting. It is important that you repeat your story a few times in session
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because as you repeat it, you will find that you feel less upset over time. I understand that
the idea of doing this may be scary to you. I want to assure you that your braveness and
sticking to it will pay off. Telling your story and allowing yourself to experience all of your
feelings related to it will help reduce your fear and upsetting feelings. Keeping this in mind
will help you to fight the urge to avoid the upsetting images and feelings that are part of the
storytelling. Before we begin, do you have any questions about anything that I have said?
Immediately after a traumatic event, people often report feeling numb, then extremely sad
and pained, and sometimes angry. All of these feelings are part of a natural process that
people may experience after a traumatic event. In fact, it is important to experience all
feelings that are connected to a trauma to make sense of them and get to a point at which
the memories are not so upsetting.”
 The therapist may find it helpful to summarize the rationale for this treatment with the
following points. Again, the therapist should strive to communicate these points to the
adolescent using as simple language as possible:
Habituation: Repeated reliving of the experience for long periods will lower anxiety. The
more often and longer you do it, the better it will work.
Emotional Processing: Reliving a trauma memory will incorporate safety information into
your memory. You will learn that remembering the trauma is not dangerous and that
being anxious or upset also is not dangerous.
Repetition: Repetition and long storytelling episodes are necessary because the trauma
was so severe, and the fear so intense. It takes longer to process this kind of memory and
to habituate to the fear.
Thought Suppression: Pushing the thoughts away will not work, given the re-experiencing
symptoms the adolescent has. A useful example to use is: “Let me show you what I mean.
For the next 10 seconds, I want you to think about that which comes into your mind EXCEPT
one thing. Whatever you do, DO NOT think about a pink elephant floating above my head
for the next 10 seconds. Did it work?” Make the point that it is difficult, if not impossible,
to push powerful images and memories out of one’s mind, and that focusing on the images
and memories can be helpful.
3. Practice Storytelling of Neutral Memory
 To give the adolescent a sense of how to do the storytelling exercises, conduct a practice
storytelling of a neutral memory. You may introduce the exercise in the following way:
“It may be helpful for you to close your eyes so you won’t be distracted. However, if that
makes you feel uncomfortable, you may keep your eyes open during the storytelling. (If you
choose to keep your eyes open, you may find it helpful to focus on a spot on the wall.) Let’s
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first practice with a scene from your life now that is not related to your childhood abuse.
Most people are able to imagine their home or some other familiar and safe place quite
easily. I would like you to get comfortable and guide me through a safe and familiar place.
Tell me what is happening as you walk through this place.”
 Use probes to help the adolescent describe what she sees, hears, smells, feels and thinks
while walking through the safe place. Encourage her to speak in first person. Also, probe
for feeling states and physiological reactions. For example:
“What do you smell in the kitchen? What do you notice in your body? What sounds do you
hear? What are you thinking?”
 End the practice storytelling after a few minutes and discuss the experience with the
adolescent. Ask the adolescent if she has any questions about storytelling. Offer her praise
for completing the exercise. For example:
“You did a great job staying in the present tense. I felt like I was right there with you as you
were describing your house. You did a nice job paying attention to your thoughts, feelings,
and what was happening in your body. That’s exactly what I want you to do as we shift to
talking about the abuse.”
4. Conduct First Storytelling
 Have the adolescent begin storytelling with a moderately upsetting trauma memory
identified during Session 11. It is typical for adolescents to be somewhat hesitant as they
begin storytelling work. It will be important for you to provide reassurance, encouragement,
and demonstrate confidence in the effectiveness of this technique.
“Now you are going on a journey back in time. I am going to ask you to remember the
memories of the abuse you experienced as a child. I will ask you to recall these painful
memories in as much detail as possible, as if the events are actually happening to you. Try
to relive the experience; see, hear, smell, taste and feel everything as if you are there.
Although this can be scary, in the back of your mind you will know that you are safe here in
my office. You will be in charge of reliving the abuse by describing the experience aloud. I
do not want you to tell a story about the abuse in the past tense. I would like you to
describe a story in the first person and present tense, as if it were happening now, right
here. If you are having trouble bringing the events back to life, I will help guide you by
focusing your attention on details of the experience.”
“In our last session we spent some time reviewing some of your memories of your
childhood abuse. Among those different memories, you said that you found the time in
which [briefly describe the incident] to be moderately upsetting. I would like to start
working on that memory today.”
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“I want you to tell me what happened during that experience in as much detail as you
remember. If you start to feel too uncomfortable and want to run away or avoid it by leaving
the image, I will help you to stay with it. You can signal me by [e.g., raising your right
forefinger] if your upsetting feelings become so overwhelming that you are unable to stay
with the image. From time to time, while you are reliving the experience, I will ask you for
your anxiety level on the 0 to 100 SUDS scale. Please respond with your ratings quickly and
don’t leave the image.”
 If the adolescent needs additional reassurance, you may say something like:
“I imagine the thought of doing this is very scary. In fact, we even have a word for this --
anticipatory anxiety. Often the anticipatory anxiety is worse than the experience itself.
Eventually, imagining the abuse and talking about it will become easier for you. The way we
get to that point is through repeated practice. In the beginning, reliving the abuse may
make you anxious. The upsetting feelings you have are a signal that you are beginning to
process the memories of your abuse. That feels bad at first, but it is a sign that you are
finally working through these unfinished memories and putting them to rest. I will be here
to help you get through this. This type of treatment has helped many survivors of childhood
abuse and it will become easier with time.”
 Proceed with the trauma memory. Be prepared to modify the adolescent’s first disclosure
as necessary to control the intensity of the first storytelling session. For example, if the
adolescent has difficulty tolerating a moderately upsetting memory, try a less upsetting
one.
 Use the Storytelling Therapist Record to Record the Adolescent’s SUDS Ratings regularly
during the storytelling exercise.
 During the adolescent’s first description of her traumatic memory, it is best to keep probe
questions, requests for clarification, etc. to a minimum. Allow her to describe her
experience with little interruption. Most trauma survivors with PTSD experience very high
levels of anticipatory anxiety before their first storytelling session, not only about their own
reactions, but also uncertainty about the therapist’s behavior. By minimizing the number of
interruptions with probes and clarifying questions in the first telling of the event (or first
several reviews), the adolescent will adjust to the storytelling procedure more quickly. This
will facilitate the habituation of her anxiety to the memory of the traumatic event.
 During the adolescent’s first telling of her memory, you should demonstrate good active
listening skills by occasionally saying, “Uh-huh,” “I see,” etc. to reassure the adolescent that
you are listening. It is best not lead the adolescent by suggesting feeling states or reactions
to the trauma which she has not yet identified (e.g., “That must have been frightening”,
“Were you angry?”). Rather, questions should be open-ended (e.g., “How are you feeling?
What happens next?”) If the adolescent reports a feeling, you can paraphrase her response
to show empathic listening skills. If the adolescent has a strong emotional response, such
as crying, you should respond empathically (e.g., “I understand that must have been very
difficult to experience”) and praise her for her strength and bravery in being able to deal
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with the experience (e.g., “It takes a lot of courage to confront your memories this way. You
are doing a very good job”).
Without many probes, the first storytelling often takes only few minutes, usually ranging
between 3 and 15 minutes. After the adolescent completes her description, request that
she describe the event again, just as before. It is best if the therapist communicates this in
a matter-of-fact manner, such as by saying, “You did a good job. Can you describe your
experience again, just as you did the first time? As before, describe any sensations,
thoughts or feelings you can recall related to your experience at the time.”
 Some adolescents have a hard time staying focused on describing the traumatic event, as
evidenced by prolonged silence, talking about irrelevant details, or switching the topic to
another abusive incident. When this occurs, gently refocus her on the selected memory
with statements or questions such as, “What happens next?”, or, “I’ll make a note of the
incident you just mentioned and we can get back to it at a later time. For now, I’d like you
to return to the situation you were describing earlier, and pick up at the point when...” The
therapist may use other encouraging comments, such as:
“You are doing fine, stay with the image.”

“Stay with your feelings.”
“I know this is difficult. You are doing a good job.”
“Stay with the image, you are safe here.”
“Feel safe and let the feelings happen.”
“You are getting through it.”
5. Terminate Storytelling
 Terminate the exercise by having the adolescent open her eyes and practice her deep
breathing skills. If the adolescent’s anxiety does decrease within the session of storytelling,
comment as follows:
“You see, your anxiety decreases if you just continue to stay in the situation.”
“I want you to notice that you are much less anxious now than you were at the
beginning of the storytelling.”
“I can see that you are more relaxed now than the last time when you faced this
upsetting memory. As you can see, the more you face this memory, the less it
makes you feel anxious.”
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“You see, you confronted the fearful memories and nothing terrible happened.
Although it is still a very upsetting memory, with each storytelling it will become
less scary.”
 If the adolescent’s anxiety does not decrease within the session of storytelling, comment as
follows:
“You were feeling very anxious today during the storytelling. You did a great job
facing the memory. You were not sure that you would be able to do this. You can
give yourself a big pat on the back.”
6. Debriefing
 Debriefing is a key part of the storytelling work. The therapist should always allow
adequate time for this following the storytelling itself, before moving on to work on coping
and relationship skills. First, the therapist should ask the adolescent what it was like to
complete the storytelling. In order to increase the adolescent’s sense of mastery and
control, the therapist should validate the adolescent's efforts during the storytelling.
Emphasize that the adolescent is taking control of the memories rather than the memories
controlling her.
 Practice Coping Skills: The therapist should encourage the use of coping skills to restore a
sense of calmness (e.g., deep breathing) and help the adolescent to regain her composure
after storytelling. As this phase of the treatment continues, the therapist should continue to
encourage the adolescent to use these skills and help her to realize that she now has the
tools to manage upsetting feelings related to her memories.
 Explore Meaning of the Storytelling Narrative: Second, it is important to work with the
adolescent to use the information gained during storytelling to understand her current
beliefs and feelings. Work with the adolescent to understand how her abuse experiences
have shaped her beliefs about herself and others, or her behavior in relationships with
others. Discuss how she can use information gained during the storytelling to alter those
schemas or behaviors.
An adolescent sexually abused by her stepfather for several years developed a schema that
she was worthless and “dirty.” During storytelling, she recalled that after raping her, her stepfather
would spit at her and say, “You dirty whore, you wanted it.” During debriefing, the therapist and
adolescent focused on this aspect of her memory. The therapist helped the adolescent to incorporate
it into a less self-critical and harsh attitude towards herself. The adolescent accomplished this by
recognizing that although her stepfather blamed her for his actions, she was not responsible for the
rape and that, at such a young age, there was nothing she could do to prevent it from happening.
Having come to this understanding, the adolescent was able to shift her sense of herself as worthless
and dirty and focus on her inner strength that it required to survive this experience.
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 Mastery and Competency: The adolescent should practice her identified competency
activity.
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Sessions 13-15 Continued Work on Storytelling
*Note to Therapist: Planning Referrals
As the therapy approaches its last few weeks, the therapist should begin to think about
whether the adolescent will require additional treatment. The therapist may wish to consult with a
supervisor or treatment team to develop a plan for the adolescent, and begin to identify
appropriate services based on the adolescent’s needs. The therapist should begin to discuss this
plan at least 3 weeks in advance of termination to address individualized needs (i.e. the adolescent
requires therapy in a particular area, the adolescent requires free treatment, the adolescent needs
to check on insurance coverage). The therapist should work these details out prior to termination
to allow a smooth transition.
Agenda

2. Continuing NST
3. NST with Multiple Traumas
4. Moving to Another Memory
5. Selecting the Next Memory
1. Review Between-Session Work (Competency Activity)
2. Continuing NST
 In sessions 13-15, the therapist and adolescent continue to work on storytelling. For many
adolescents, the first NST session is the most difficult one. Often, adolescents have
significant anticipatory anxiety prior to the first NST session that is no longer present at the
second. In addition, many adolescents experience at least some reduction in anxiety during
the first session, and this can encourage them to continue the storytelling work. Even when
adolescents do not experience a significant reduction in anxiety, the therapist may bolster
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their commitment to work hard by pointing out their success in enduring the storytelling
session without any harmful effects. Therefore, it is often best to plunge back into NST in
the following session without a review of the rationale or a detailed discussion of the
procedure. The session should begin with the same event that was the focus of the
previous session.
Although many adolescents do not require additional preparation before resuming NST,
some do. For example, adolescents who became very distressed, or had a difficult time
due to anxiety that did not habituate or dissociation during NST may benefit from a review
of the rationale for NST. They may also require additional reassurance that the procedure is
in the adolescent’s best interest. These are some examples of statements the therapist
can make to these adolescents:
“I know that the last storytelling session was not easy for you and you felt really upset in the
beginning. Being upset is normal and expected when a person begins to talk about
traumatic memories such as the abuse. Since you never had a chance to talk about and
make sense of these traumas, they tend to come up at unexpected times without you
understanding what triggers them. These upsetting memories can be very scary and
disturbing because they seem to come out of nowhere. You may feel you have no control
over them. You have fought hard to escape these memories, but the more you have tried to
ignore these memories, the more upsetting they have become to you.”
“By focusing on your memories of the abuse on purpose instead of avoiding them, they will
begin to come together and form a story that makes sense to you. As you tell the complete
story of your abuse, you will also experience many of the painful feelings that you have
avoided for a long time. Letting yourself feel these feelings will allow you to get used to
them, and finally file the complete story away with the rest of your memories. Then, these
memories will no longer be random and uncontrollable. They will no longer cause you to
feel such strong and overwhelming feelings.”
“I know that these feelings are painful. As a child, you formed ways to escape these
feelings. When you were younger, you did not have the skills to cope with such
overwhelming feelings. You also may not have had anyone to support you through this.
Although this avoidance helped you to survive as a child, avoiding your upsetting feelings
has made them worse and has made it difficult to do many things in life.”
“Now that you are older, you have chosen to confront not only the memories, but also the
painful feelings that go with them. Now you can deal with upsetting feelings better. In this
program, you are learning coping skills that you never had before because of your abuse. I
know that you might feel more upset for a short time in order to feel better later. This may
help you to cope with these feelings and to continue the storytelling we started in our last
session.”
“Today we will do another storytelling exercise. Again, I will ask you to give me your SUDS
rating every few minutes. When I ask for your SUDS, please call out your rating as quickly
as possible, and without leaving the image. As I said earlier, I will encourage you to
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experience the events in more detail than in the last session. However, you are always in
control of the storytelling and you should let me know if you feel you must end the session
early.”
 After the first storytelling of a memory, the therapist often takes a more active role in
guiding subsequent episodes of the storytelling of that memory. The therapist can use
probe questions and hot spots to deepen the processing of the memory.
Probe Questions. As the adolescent repeats storytelling of a traumatic event, usually at

least two to three sessions, her anxiety decreases substantially (e.g., SUDS ratings below
60). It is helpful to probe for sensory, cognitive and other cues that may trigger anxiety
related to the memory. These probes often result in a temporary increase in anxiety when
they trigger an important cue for the adolescent. Following this increase in anxiety,
however, the adolescent is often able to reach an even lower level of anxiety than before.
Examples of these probe questions include:
Where are you now? Feel the bed under you.

What do you notice around you?
Notice what he smells like.
Can you feel his weight on you?
What are you thinking?
How does it feel?
Hot Spots. When the adolescent’s anxiety over a trauma memory declines, it is often useful
to probe for hot spots of the memory that are most disturbing. Usually, the hot spot is
obvious because it has the highest SUDS rating within the story (e.g., SUDS rating 15-20
points higher than other parts of the story). Examples of hot spots are the moment of
penetration, experiencing physical pain, or the start of an upsetting sex act. After
identifying a hot spot, the therapist should make sure there is enough time to talk about
this part of the memory. The therapist may request that the adolescent repeat the hot spot
again several times (as many as six or seven), immediately after identifying it (e.g., not
waiting until the adolescent has completed the whole story).
 The therapist should provide the adolescent with a copy of the SUDS Rating Scale and
continue to track the content of her memories, as well as her SUDS ratings, on the
Therapist NST Recording Form. The therapist should complete the Therapist Form for Post
NST Emotional State as part of the processing phase at the end of the session.
3. NST with Multiple Traumas
 Most adolescents abused as children will have more than one memory of their abusive
experiences. In addition, some may have experienced traumatic events recently, which are
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contributing to their PTSD symptoms. For example, many of these adolescents have grown
up in neighborhoods in which they witness community violence on a regular basis. In many
cases, successful treatment of PTSD in these adolescents will require you to focus on more
than one traumatic memory. There are two critical issues to address when determining the
pace of treatment of multiple traumatic memories: 1) at which point the therapist should
move on from one memory to another; and, 2) which memory to select next for NST.
4. Moving to Another Memory
 The decision to begin treating the memory of another traumatic event assumes that: 1) the
therapist and adolescent identified at least one more traumatic event in Session 11; and 2)
the adolescent has a high SUDS rating with that event (e.g., SUDS over 70). You must use
your own judgment to determine the potential benefit from treating other traumatic
memories with lower SUDS ratings.
 This treatment protocol includes 4 storytelling sessions. When working with adolescents
who have multiple memories of trauma, you should plan to focus on two or three
memories. The decision to move on from one memory to another should be based on
these criteria:
1. The adolescent has experienced a significant improvement in SUDS ratings.

You anticipate little additional gain by staying with this memory (e.g., final SUDS
ratings are below 40).
2. The adolescent has experienced some reduction in SUDS ratings, but SUDS
remain higher than optimal (e.g., 40-80). The rate of improvement, however,
has been slow or has hit a plateau. You expect little additional improvement in
the short-term.
3. The adolescent has experienced little or no improvement in SUDS ratings,

despite several sessions devoted to one traumatic event.
 Among the four storytelling sessions, no more than two should be devoted to one event for
adolescents with multiple memories unless you determine that that memory is much worse
than the others are.
5. Selecting the Next Memory
 The first memory to address in NST must be one based in the experience of childhood
abuse. However, additional memories that are the focus of NST do not need to relate to
childhood abuse. For example, you may target traumatic memories of non-sexual events
that occurred in childhood or more recently.
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 After completing work on one memory, select the next memory based on which is currently
associated with the highest distress level. The therapist may review the SUDS ratings the
adolescent assigned to her memories in Session 11. However, do not assume that the
second most distressing traumatic memory will still be just as distressing after the
adolescent completes storytelling of the first memory. It is common for habituation to one
traumatic memory to generalize to another memory, especially if the two memories share
similar features.
In order to select the next memory for NST, the therapist should conduct another
assessment, using the same procedures as in Session 11. Evaluate only those memories
associated with the most distress again. Then, as before, the memory with the highest
SUDS should be the focus of NST.
 Use the same procedures used in NST for the first memory for subsequent memories.
Proceed with storytelling for 10-30 minutes, recording SUDS on the Therapist NST
Recording Form. In general, it is preferable to select memories for NST that are as different
as possible, provided they are all associated with high levels of distress. In addition, when
beginning work on a new memory, it is helpful to begin the session with a review of
previous memories treated with NST. This ensures that distress related to memories does
not rebound when work shifts to another memory.
 Mastery and Competency: The adolescent should practice her identified competency
activity.
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Session 16: Reviewing Progress and Saying Goodbye
Agenda

2. Review Skills Learned in Treatment and Progress of Competency Activity
3. Identify Remaining Goals
4. Say Good-bye and Provide Referrals
5. Present Certificate of Completion
1. Review Between-Session Work (Competency Activity)
2. Review Skills Learned in Treatment and Progress of Competency Activity
 During the final session, the therapist should review the adolescent’s progress in therapy.
Review with the adolescent the work she has done in building and practicing skills to cope
with her feelings, deal with difficult situations, get along with others, and make sense of her
abuse history. Reinforce strengths and positive feelings about the adolescent’s hard work and
accomplishments.
 Congratulate the adolescent on the hard work and progress she made in treatment.
Highlight the details of the adolescent’s progress. The therapist may praise the adolescent
with comments such as, “Talking about what happened to you took a lot of strength and
courage”, “You have learned to manage your anger more effectively,” and “You seem like
you are able to express your needs better and tell people what is on your mind.”
Melissa is a 15- year-old adolescent girl physically abused by her mother from ages 5 to 10.
In therapy, she realized that it was difficult for her to identify her basic emotions such as anger and
sadness. Instead, she tried to avoid her feelings by locking herself in her room and avoiding talking
to her family and friends. During therapy, Melissa realized how avoiding her upsetting feeling was
not helping her to deal with her past or get her needs met in her current relationships. Over time,
she was able to identify her feelings and use the coping skills she learned in therapy to manage her
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upsetting feelings in a healthier way. Melissa’s therapist pointed out, “In the past, you used to tune
out when you felt hurt and avoid talking to people you were close to. Now, not only are you able to
pay attention to and recognize your feelings, but you also know how to deal with them and make
yourself feel better.”
 Ask the adolescent for her own thoughts about the progress she has made and about her
overall experience in this phase of treatment. Discuss the areas in which she may continue
to grow and improve.
 Discuss the adolescent’s progress in her selected competency activity, reminding her of
where she began and where she is now. Review any difficulties or barriers to progress.
Reinforce positive behaviors. Together make a plan for continued progress (e.g., continue to
practice singing every week and attend an upcoming audition).
3. Identify Remaining Goals
 Discuss with the adolescent personal goals that she would like to continue to work on after
this phase of treatment. The therapist may make suggestions for continued practice and
use of coping skills. For example, the therapist may say, “You have worked really hard on
learning to express your needs in an assertive manner with your boyfriend. You can
continue to work on this goal by practicing these new skills in situations with others such
as your classmates at school.”
4. Say Good-bye and Provide Referrals
 Discuss with the adolescent her feelings about ending treatment. Some adolescents may
feel unsure of their readiness to continue their recovery without the therapy. The therapist
should convey that this is a natural and understandable concern, but that people continue
to improve after therapy as they come across new opportunities to practice their skills and
mastery. The therapist may say, “It is very natural to feel worried and nervous when
therapy ends. However, many people continue to feel better by continuing to practice the
skills they have learned in treatment.”
 For other adolescents, especially those with multiple traumas, the work accomplished
during the therapy may seem like a "drop in the bucket," or there may still be significant
PTSD symptoms. In such cases, the therapist should assess the adolescent’s clinical
status and make referrals for continuing treatment. Make sure to convey the need to seek
further treatment in positive terms. The therapist should emphasize what progress the
adolescent made and stress that additional therapy may provide her with the opportunity
to relieve her symptoms further and strengthen gains.
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C is a 17-year-old adolescent living in a group home. She has a history of sexual abuse by
her brother. Prior to therapy, C rarely spoke about her abuse because she feared that no one would
listen to her or believe what she said. Although she was initially skeptical of treatment, over time,
C was able to learn new coping skills that improved her ability to deal with upsetting feelings and
get along with others.
During NST, C was gradually able to deal with the upsetting feelings related to talking about
her memories of the abuse. She was just beginning to make sense of her intense feelings of
helplessness and anger. In the last session, C expressed her anxiety about ending treatment by
saying, “How can we stop now? It’s not fair - I just started to feel comfortable talking about this
stuff and now it’s over. ” The therapist acknowledged that it was very difficult for C to end
treatment and reassured her of the progress that she made. She said, “It is very understandable to
be upset about ending therapy. You have put in a lot of hard work and are beginning to express
your intense feelings about what happened to you. Even though our work together is ending, you
can continue to talk about these painful feelings and memories with your close friends and your
therapist at the group home. You have made a lot of progress and can continue to use the skills
you have learned here.”
5. Present Certificate of Completion
 The therapist should present the adolescent with a certificate of completion to reinforce the
hard work she has done, and the tremendous advances she made in therapy.
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Appendix A: Safety Guidelines and Procedures for Emergent Patients
I. If an adolescent is in immediate danger, call 911.
II. If an adolescent reveals active suicidal or homicidal ideation, it is important for the
clinician to assess:
a. Intent and means (i.e., conditions under which the adolescent would act on ideations).
b. Lethality of intent (Has the adolescent acted on ideations before? Is there a history of
taking steps to harm herself? Does the adolescent have access to stated means?).
c. Adolescent’s openness to discussing topic (Can she verbalize why she would not act on
ideations? What might she do if home alone and experienced suicidal thoughts or
urges to harm herself?).
d. Safety at home and availability of support (Presence of family members and/or
friends; someone who can serve as contact person).
e. Medication supervision, if applicable (Consult with and/or notify the adolescent’s
psychiatrist).
III. After assessing the situation in the above manner, if suicidal/homicidal intent is present:
a. Develop safety plan for reference outside of therapy session.

b. Ensure that the adolescent knows where the ER is? (Or the ER closest to home).
c. Contract for safety.
d. Contact the adolescent’s parents/caregiver (there is no confidentiality when an
adolescent is suicidal or homicidal).
e. If the adolescent needs to be admitted immediately, call 911 for transport.
f. Call ER. Give brief background on the adolescent and estimated time of arrival.
SUICIDE HOTLINE:
National Suicide Hotline: 1-800-SUICIDE (1-800-784-2433)

Suicide Prevention Hot Line: 1-800-827-7571
IV. Special Circumstances:
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a. Child Abuse:
In cases of suspected or confirmed child abuse (including adolescent witnessing

domestic violence), the clinician, being a mandated reporter, is required by law to
report the case.
OUTLINE of PROCEDURES for MANDATED REPORTING of CHILD ABUSE AND NEGLECT
in NYS (New York State Office of Children and Family Services)
If there is reasonable cause to suspect that the adolescent is being abused or

neglected it must be reported immediately. Reports of child abuse and neglect can
be made 24 hours a day, 7 days a week by calling the New York State Central
Register (SCR) Child Abuse and Maltreatment Hotline.
NYS Central Register of Child Abuse and Maltreatment, Mandated Reporter #1-800-
635-1522
Include in report:
 Subjects of report (i.e., child, parent, other family/household members)

 Name & address, age, gender, race
 Nature and extent of injuries, abuse, maltreatment
 Person responsible for injury, abuse, maltreatment
 Source of report and person making report
 Any additional information that may be helpful
5 Essential Elements of a Report:
 Child under 18 years of age

 Jurisdiction in New York State
 Demographics
 Allegations
 Person legally responsible for child
A signed, written report (LDSS 2221A - attached) must be filed by mandated

reporters within forty-eight hours of an oral report. The written report should be
submitted to the appropriate local child protective service. The address of the
investigative district may be requested from the child protective specialist at the
time of making the oral report to the State Central Register of Child Abuse and
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Maltreatment. Mail a Written Report, form DSS 2221-A, to county Child

Protective Services.
Legal Protections:
 Immunity from civil or criminal liability

 Confidentiality
A Willful Failure to Report can lead to:
 Class A Misdemeanor
 Civil Liability for Damages
For information or help, call: Prevent Child Abuse New York Prevention Information
& Parent Helpline: 1-800-342-7472.
All calls are confidential. The SCR relays calls to ACS to begin an investigation when
appropriate.
Inquiring About the Report:

A mandated reporter can receive, upon request, the findings of an investigation
made pursuant to his or her report. This request can be made to the State Central
Register at the time of making the report or to the appropriate local CPS at any
time thereafter. However, no information can be released unless the reporter's
identity is confirmed.
If the request for information is made prior to the completion of an investigation of
a report, the released information shall be limited to whether the report is
"indicated" (i.e., substantiated), "unfounded," or "under investigation," whichever
the case may be.
If the request for information is made after the completion of an investigation of a
report, the released information shall be limited to whether a report is "indicated"
or, if the report has been expunged, that there is "no record of such report,"
whichever the case may be.
b. Domestic Violence
These Hotlines help the adolescents:
24-Hour Hot Line: 1 (800) 621-4673
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Spanish-speaking 24-Hour Hot Line: 1 (800) 942-6908
Hearing Impaired 24-Hour Hotline: TDD: 1 (800) 810-7444
Gay and Lesbian Anti-Violence Project: (212) 807-0197
c. Self-Harming Behaviors
24- Hour Hot Line: 1-800-dontcut (366-8288)
d. Crisis
1. HELPLINE'S Language Bank (212) 532-2400
This 24-hour hotline helps people who want to sort out a problem, to put their
lives in perspective or who want to talk to a sympathetic person. It also assists
people who are contemplating suicide.
2. National Youth Crisis Hotline (800) 448-4663
This 24-hour hotline is available to children from the ages of 12 to 18. This
deals with problems such as drugs, teen pregnancy, physical, emotional and
sexual abuse, homelessness, prostitution, suicide and more.
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LifeSKillsLifeStory Manual

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Treating Multiply Traumatized Girls

Life Skills/Life Story:

Marylene Cloitre, Ph.D.

Phase I – Life Skills

Session 1: Introduction to Treatment 12

Provide Psychoeducation about PTSD and Common Reactions to Trauma

Session 2: Identification and Labeling of Feelings

Discuss the Adolescent’s Reaction to the First Session

*Optional Session to Prepare for Coping Skills Addressed in Session 3:

Note to Therapist: Rationale for Optional Session

Session 3: Coping with Upsetting Feelings

Review Between-Session Work

Session 4: Dealing with Upsetting Situations

Review Between-Session Work

Session 5: Coping Strategies for Dealing with Upsetting Situations

Session 6: Using Positive Imagery to Deal with Upsetting Feelings

Review Between-Session Work

Session 7: Relationships with People: Behavior and Communication

Review Between-Session Work

Review Coping Skills and Safety Plan

*Optional Session to Expand on Relationship Work Addressed in Session 7:

Note to Therapist: Rationale for Optional Session

Session 8: Introduction to Role-playing: Feelings vs. Behavior

Review Between-Session Work

Session 9: Role-playing with Focus on Assertiveness

Review Between-Session Work

Session 10: Review of Skills Learned and Transition to Narrative Story

Review Between-Session Work

Review Coping Skills and Safety Plan

Phase II – Life Story - Narrative Storytelling (NST)

Session 11: Introduction to NST

Note to Therapist: Using the SUDS Rating Scale

*Note to Therapist: Orientation of Therapist to NST

Session 12: NST of First Memory

Review Between-Session Work

Sessions 13– 15: Continued Work on NST

Note to Therapist: Planning Referrals

Worksheet: SUDS Rating Scale

Sessions 16: Reviewing Progress and Saying Good-Bye

Review Between-Session Work

Appendix A: Safety Guidelines for Emergent Patients

About This Treatment (Life Skills/Life Story)

This manual addresses cognitive, behavioral, interpersonal, emotional and developmental

Maintaining sensitivity towards an adolescent’s level of cognitive functioning is essential for

Overview of the Treatment

Life Story (Narrative Storytelling or NST)

Use of this Manual

As in all cognitive-behavioral treatments, weekly homework, or between-session work, is

General Attitudes and Behavior

Session 1: Introduction to Treatment

1. Re-experiencing: People re-experience traumatic events by remembering or thinking about

2. Provide Rationale and Overview of the Treatment

PHASE I: SKILLS TRAINING

PHASE II: NARRATIVE STORYTELLING (NST)

3. Help the Adolescent to Compile a List of Personal Goals for Treatment

2. Create a Safety Plan and Safety Card with the Adolescent

 Examples of Safety Cards:

Safety Card for Potentially Suicidal Adolescents

Safety Card for Dissociative Adolescents

5. Discuss Plans to Meet with the Caregiver Next Session

Session 2: Identification and Labeling of Feelings

1. Discuss the Adolescent 's Reactions to the First Session

1. Discuss the Adolescent’s Reactions to the First Session

When you ____, I feel _ because_________