Clinical Benefits of RT: - PowerPoint Presentation

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Clinical Benefits of RT:

Trauma Reactive, Sexually Aggressive, and Commercially Sexually Exploited Children

DOLLY WILLIAMS, LRT/CTRS, LPC/NCC

NEW HOPE CAROLINAS

ROCK HILL, SCSlide2

Female ProgramsTransformations I & II: Trauma-focused residential program for adolescent females with significant mental health, para-suicidal behaviors, substance abuse, and/or behavior-management difficultly.Safe Harbor:

Intellectually and/or developmentally disabled (I/DD) female adolescents who present with significant emotional and/or behavioral issues.Male ProgramsTriad: Intellectually and/or developmentally-disabled (I/DD)males who have demonstrated a pattern of offensive sexual behavior.Starting Pointe: Adolescents who exhibit offensive sexual behavior.

New Choices:

Adolescents with mild cognitive and/or developmental impairment who present with significant emotional and/or behavioral issues.Waypoint: Adolescents with significant emotional and/or behavioral issues.Turning Point: Short –term stabilization and assessment service. Program intended for 30 days or less, and provide comprehensive behavioral health assessment, that includes psychiatric, psychological (including objective testing), academic, nursing, nutritional, recreational, substance abuse and speech/language assessments/screenings, along with diagnoses and recommendations for treatment/supervision. Located in Rock Hill, SCWebsite: www.newhopetreatment.com

New Hope Carolinas

150 bed PRTFSlide3

ADD/Attention DisordersBehavior DisordersOppositional Defiant Disorder Conduct DisorderMood DisordersTrauma and Stress Related DisordersReactive Attachment Disorder (RAD)Acute Stress Disorder (ASD)Child Physical, Sexual, Psychological Abuse and NeglectSubstance-Related and Addictive Disorders

Intellectual DisabilityParaphiliasExhibitionism: Exposing genitalsFetishism: Sexual attraction to non-living objectsFrotteurism: Touching or rubbing a non-consenting personPedophilia: Focus on prepubescent childrenSexual Sadism: Inflicting humiliation or sufferingSexual Masochism: Receiving humiliation or suffering

Transvestic

Fetishism: Cross-dressingVoyeurism: Observing sexual activityCommon Diagnosis at New Hope CarolinasSlide4

WHAT IS TRAUMA???Slide5

How we respond to trauma is mediated by the structures of the brain and mind we have in place at the time of a traumatic experience.

-Bergemann (2013)Slide6

What is in the studyThere are 10 types of childhood trauma measured in the ACE Study Five are personal: physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect. Five are related to other family members: a parent who’s an alcoholic, a mother who’s a victim of domestic violence, a family member in jail, a family member diagnosed with a mental illness, and the disappearance of a parent through divorce, death or abandonment.

Each type of trauma counts as one. So a person who’s been physically abused, with one alcoholic parent, and a mother who was beaten up has an ACE score of three.Slide7

Some neuroscience believe that trauma work may not be well served by traditional talk therapy alone and in fact, asking victims to just retrieve their traumatic events may poorly serve them by creating flooding and flashbacksThe language centers of the brain have been impaired by a cascade of biochemical responses, set loose by our built in biologically driven survival reaction at the time of the traumatic event itself Often traumatic memories are not absorbed by the thinking brain, the way of ordinary memories; rather they are shelved in disconnected-sensory fragments, somatic sensations and muscular impulses. As a result, they are often disconnected from awareness and inaccessible to cognition

Its not that talk therapy is bad. It’s just that it is not enoughSlide8

4 Core Principles That Comprise Trauma Informed Care Trauma is a defining life event2. The victim’s complaints, behaviors, and symptom are coping mechanisms3. The primary goals of services are empowerment and recovery

4. The service relationship is collaborativeSlide9

The most universal sources of possible traumatic reactions, including falls, accidents, and invasive medical/surgical procedures, occur with such frequency that a conscious link between later symptoms and precipitating incident is rarely made. Often these events have no lasting ill effects. Having said this, the wisdom of “an ounce of prevention being worth a pound of cure” could not be truer when startling things happen. –Trauma Through A Child’s Eye’s Let’s look at a few examples of how common events can affect children adverselySlide10

Although each “event” was very different, what these youngsters have in common is that each experienced feelings of overwhelm. Each youngster was traumatized by what happened. How do we know? the answer is quite simple. Each child carried on in life, some way, as if the event were still happening. They were “stuck” or fixated in time, as their bodies responded to an alarm that was set at the traumatic moment. Although memory may not be consciously connected to the event, the children’s play, behavior, and physical complaints reveal their struggle to deal with internal turmoil. –Trauma Through A Child’s EyesSlide11

TF-CBT

TRAUMA FOCUSED COGNITIVE BEHAVIOR THERAPYSlide12

Trauma Focused- Cognitive Behavior TherapyTF-CBTPsycho-education about childhood trauma and PTSD

Parenting component including parent management skillsRelaxation skills individualized to the child and parent Affective modulation skills adapted to the child, family and cultureCognitive coping: connecting thoughts, feelings, and behaviors related to the traumaTrauma narrative: assisting the child in sharing a verbal, written, or artistic narrative about the trauma(s) and related experiences, and cognitive an affective processing of the trauma experiences

In-vivo practical application-being confronted by the trigger and showing they can work through it

Conjoint parent-child sessions to practice skills and enhance trauma-related discussionsEnhancing future personal safety and enhancing optimal developmental trajectory through providing safety and social skills trainingSlide13

DBT

DIALEICAL BEHAVIOR THERAPYSlide14

Dialectical Behavior TherapyDBT

Dialectics are the art of holding two things in balance that are in conflict, contrary, or mismatched: feelings and thoughts, being right and making mistakes, wanting to live and wanting to die…It was developed by Marsha Linehan to deal with BPD (Borderline Personality Disorder). Saw that “traditional” CBT did not work, needed to change things. Added more Eastern philosophy to her treatment…..it worked.Studies have shown it works with adults and adolescents with emotional regulationproblems.Slide15

DBTSix difficult problems clients faceEmotional vulnerabilitySelf-invalidation-failure to recognize one's own emotional response, thoughts, beliefs, and behaviors. Usually stems from invalidating environments

Unrelenting crises-frequent, stressful, negative environmental events, disruptions, and roadblocksActive passivity-tendency to use a passive interpersonal problem-solving style, involving failure to engage in solving own life problems-learned helplessness and hopelessnessInhibited grieving –inhibit and over control negative emotional responsesApparent competence-appear deceptively more competent than they are. Failure to display adequate nonverbal cues of emotional distressSlide16

WHAT IS S.A.Y.???

SEXUALLY AGGRESSIVE YOUTHSlide17

GOOD LIVES

& SELF REGULATION MODELSSlide18

Good Lives ModelModel works towards recognizing the identity, values and beliefs with which the offender identifies so that he/she can work towards personal fulfillment and the development of pro social skills.Focus is not solely upon risk reduction, but also upon enhancing the residents capacity to improve his/her life.Slide19

Good Lives and Self Regulation Good Lives-assumes any number of primary goals/ goods may be directly or indirectly sought through sexual offending (love, friendship, happiness, autonomy, etc.)Self Regulation-specifies the conditions under which individuals have failed to obtain these primary goods. Goals and the manner in which they came to offend.Used together, these models can help the therapist and resident make sense of the behavior and begin to target meaningful interventions.Slide20

Evidenced Based Interventions& Clinical Benefits of RTSelf Regulation

Avoidant PassiveAvoidant ActiveApproach AutomaticApproach

Explicit

Want to avoid offendingThey are actively trying to avoid offending, just using wrong strategiesEasily ActivatedSexualizedOffense appears impulsiveIntact/good regulationConscious, explicit planningUsually impulsiveGenerally okay coping skillsLack ambivalence in feeling states at post or pre offense evaluation and use that to increase motivation to change goalPlanning usually involved-but will take advantage of any opportunityExpect little to no motivation to change or give up lifestyleLack coping skillsRP should work. Problem is not a lack of motivation-problem is primarily skill deficits. Teach risk and helpful active strategiesActively tries to control urges

Total lack of awareness of offense chain. Over learned sexual scripts at the core, with under regulation strategies, May require trauma resolution up front

Victim empathy/impact type assignments, perspective taking in general-specific to sex crimes

Tries to manage desire, triggers through denial/or simplistic attempts to distract (ignore, watch TV)

Chooses ineffective strategies (drugs/alcohol, masturbation)

Cognitive re-structuring the sense of entitlement

Involves over-learned sexual scripts-usually resulting from trauma or exposure to porn or sexual violence

Positive affective states before,, during and after

Post offense

eval

.-(negative)

Negative affective states/cognitions

Post offense

eval

.-(negative)

Post offense

eval

.-(negative/positive)

Tends to go with the flow

Post offense

eval

.-(positive)

no one understands, no regrets, relish the sexual experience/deviance

See themselves as victims/blames their abusive behavior on life experiences or others

Negative affective states or cognitions/angry at self

Work to improve overall regulating/impulsivity. Expect lapses; sexualized nature

Life revolves around sexual offending/Lives in a world all their own

Trapped hopeless about future, under regulated or disinhibited

May appear confident, capable but easily confused/angry when faced with challenge

May consider SSRIs or other meds to lower sex drive

Opportunist acts

Takes satisfaction in their ability to offend

Low self esteem/out of control

May describe life of general frustration

Target and teach specific active strategies; arousal reconditioning, RP, Good lives

Will gladly re-tell every offense in great detail

Poor ability to relate to others, shallow relationships

Target and teach specific active strategies, likely to need long term arousal reconditioning, Good lives

History of impulsivity or careless disposition

Trauma work is likely essential up front

Basic Ed/SO

Foster hobbies/strengths, clubs, sports, etc.

Not good at evaluating consequences

Undoing deviant sexual interest. Use anything at your disposal except RP

Mood management, Brain Gym, anger management, classic RP strategies

Holistic changes to core cognitive schema are requiredSlide21

Evidenced Based Interventions & Clinical Benefits of RTGood Lives

Good Lives ApproachSeeking out that which is goodOpposite of Relapse PreventionPromoting a healthy life style

Good Lives Model

Functions as an overarching rehabilitation frameworkProvides guidance to therapist on how to treat sexually aggressive residentsOutlines fundamental aims, etiological assumptions, and critical practice elements of effective therapy

A Strengths Based Approach

Takes residents personal preferences and values-the things that matter most to them in the world-and draws upon these primary goods to motivate individuals to lead better lives

Primary goods definition: Activities, experiences or situations that are sough for their own sake, and that benefit individuals and increase their sense of fulfillment and happinessSlide22

Evidenced Based Interventions& Clinical Benefits of RTSelf Regulation

Focus of Therapy GLMEmbrace the persons’ strengths and personal goalsIdentify unmet needs/primary goals not metWork to shore up or improve their ability to achieve all primary goods (life, knowledge, self-directness, intimacy, happiness)

Treatment should add to the repertoire of personal functioning-not simply restrict activities (i.e.-RP model)

Practice Implications GLMBy equipping the resident with the skills, values, attitudes, and resources necessary to lead a different kind of life, therapy can improve the persons overall level of functioning, while reducing their risk for future criminal/sexually offensive behaviorThe model represents a humanistic and holistic approach to the treatment of sexual aggression or general rehabilitationSlide23

Primary Treatment Issues For Children With Sexual BehaviorsStopping abusive or “hurting” types of touchDeveloping affective and behavioral regulation in response to the environment

Experience nurturing, safe, “non-abusive” relationshipsUnderstanding the needs that are met by their abusive behaviorFinding non-abusive ways to meet those needs Slide24

Miner and Crimmins (1997) report that although juvenile sexual offenders do not differ significantly than non-sexual juveniles delinquents in either attitude or behavior, they were significantly more isolated from family than non-delinquent youth and more socially isolated from peers than juvenile non-sexual delinquents.Miner and Munns (2005) conclude that juvenile sexual offenders experience a deeper level of social isolation that non-sexual juvenile delinquents and non-offenders, and suggest that the inability to experience satisfaction in social relationships

may turn some adolescents to younger children to meet sexual and social needs.SAY Adolescent and Social ConnectionsSlide25

Why Using Touch Is ImportantClinically appropriate and ethical use of touch with survivors of childhood abuse can be invaluable in helping them heal and recover from their traumatic experiences (Hunter, Struve, 1998).Once a strong therapeutic alliance has been formed, “the use of touch” will evoke, address and hopefully help correct experiences and distortions such as: deprivation and neglect, over stimulation, intrusion and bodily violations, and sexualization (Cornell, 1997).

Touch is an essential component to human development -Harlow (1958): Infant monkeys required touch as much as food in their development. -At times the monkeys preferred tactile stimulation to food even when hungry.-Spitz (1945): Children in orphanages deprived of touch failed to develop normally even when physical needs were met.Slide26

A child’s need for contact will not go awayDistinguishing “sexualized” and “non-sexualized” touch needs to be learned from experienceIf children do not learn from us, who do they learn from?

Experiencing “nurturing” relationshipsAttachment develops from attunement responsiveness, touch, movement, and other non-verbal interactionsTreatment Issues and TouchSlide27

ResiliencyWhat Keeps Kids Safe and Avoid RelapsePro-social attitudePositive family functioningEmotional maturityPositive peer groupCommitment to schoolPositive community activitiesIntelligence, lack of comorbidity and other developmental influencesSlide28

Base rate for recidivism is low-avg. 7%Even better rates associated with treatmentSexuality in adolescence is fluid and dynamicThe Good NewsSlide29
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Americas Daughtergoogle Americas daughter to get the videoSlide32

12-14 years old is the average entry age into pornography and prostitution in the United States, according to the U.S. Dept. of Justice.100,000 to 300,000 children in America are at risk for sex trafficking each year, according to the National Center for Missing Children.

In the U.S., the sale of child pornography is a $3 billion annual industry; 55% of child pornography on the Internet comes from the U.S.Slide33

Are you or someone you know being trafficked? Is human trafficking happening in your community? Recognizing potential red flags and knowing the indicators of human trafficking is a key step in identifying more victims and helping them find the assistance they need.

Common Work and Living Conditions: The individual(s) in questionIs not free to leave or come and go as he/she wishesIs under 18 and is providing commercial sex actsIs in the commercial sex industry and has a pimp / managerIs unpaid, paid very little, or paid only through tipsWorks excessively long and/or unusual hoursIs not allowed breaks or suffers under unusual restrictions at workOwes a large debt and is unable to pay it offWas recruited through false promises concerning the nature and conditions of his/her workHigh security measures exist in the work and/or living locations (e.g. opaque windows,

boarded

up windows, bars on windows, barbed wire, security cameras, etc.)Poor Mental Health or Abnormal BehaviorIs fearful, anxious, depressed, submissive, tense, or nervous/paranoidExhibits unusually fearful or anxious behavior after bringing up law enforcementAvoids eye contactPoor Physical HealthLacks health careAppears malnourishedShows signs of physical and/or sexual abuse, physical restraint, confinement, or tortureLack of ControlHas few or no personal possessionsIs not in control of his/her own money, no financial records, or bank accountIs not in control of his/her own identification documents (ID or passport)Is not allowed or able to speak for themselves (a third party may insist on being present and/or translating)OtherClaims of just visiting and inability to clarify where he/she is staying/addressLack of knowledge of whereabouts and/or do not know what city he/she is inLoss of sense of timeHas numerous inconsistencies in his/her storySlide34
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CultureMost common form is pimping. Pimping has become a social norm, and in some arenas is a glorified or glamorous lifestyle. RecruitmentPimps recruit and groom vulnerable persons into the lifestyle by selling the “dream”. They create a fictitious lifestyle that is attractive, appealing, and specifically tailored to the intended target. For example, a pimp may appeal to a young girl by offering her a ticket to Hollywood in order to help her launch her acting career.

Types of pimpsBoyfriend Pimp-appear to be the ideal “boyfriend” and carries himself as such. Victims will refer to their trafficker as their boyfriend and are convinced that they are in a legitimate relationship with the individual that is exploiting him/her.Gorilla Pimp is known for his/her “heavy hand” and is brutally abusive and violent with his victims.Lover Boy Pimp- A Dutch slang term for a type of pimp who seduces individuals towards victimization. This trafficker will often use charm and finesse to engage the victim towards exploitation and throughout the process of her victimization. Often times the victim will struggle to understand the trauma as the level of manipulation and coercion is intense.

Branding

Branding is a method of identity disassociation used in the process of control over the exploited person. This further forces the victim to detach from his/her former life and adopt the fictionalized world created by their trafficker as reality. In pimp controlled trafficking, and example of branding would include a tattoo and/or an actual brand mark on the victim with the pimp’s name on it or a symbol, sign or writing symbolizing property to the pimp. This is also so that others know to whom he/she belongs to. LifestyleThe pimping lifestyle is all about glamor that is accompanied with a level of indoctrination into what pimps term “the game.” This lifestyle, similar to gangs is controlled by specific rules, a unique set of vocabulary, and customs. The victims are given new names as a form of dissociation as wellOperationOperations are very transient and often entail traffickers moving their criminal behavior city to city, or state to state. Emphasis on technology-based means of advertising, as well as common street-walking. LoyaltySimilar to the Stockholm syndrome or domestic violence, the relationship of love created by the trafficker creates a sense of loyalty that envelope the victim. The victim is often times “in love” with the trafficker, which makes it extremely difficulty to break the trauma bond GroomingThe grooming process can be very long and extensive. It can take days or even months depending on the victim. The pimp knows to invest in this process in order to insure unconditional and total loyalty. Grooming exist so that the pimp can earn the victims love, trust and loyalty. It may begin as courting, wining and dining, expensive gifts and false promises. It then turns into the breakdown of the victims mind, body and spirit where the pimp begins to enforce dominance through force, fear and coercion.

Quote taken from an instruction manual on pimping available n the internet on how to play “The Game.”

You'll start to dress her, think for her, own her. If you and your victim are sexually active, slow it down. After sex, take her shopping for one item. Hair and /or nails is fine. She’ll develop a feeling of accomplishment. The shopping after a month will be replaced. The love-making turns into raw sex. She'll start to crave the intimacy and be willing to get back into your good graces. After you have broken her spirit, she has no sense of value. Now pimp, put a price tag on the item you have manufactured.”

Types of Exploitation

Pimp ControlledSlide36

CultureCommonly disguised as massage parlors, restaurants, strip clubs or bars. They can also be set up in a home located in urban or suburban neighborhoods. A brothel is a way of facilitation sexual services to the masses. Victims can live in the brothel or come in as directed by their trafficking.RecruitmentVictims are recruited as employees of that particular establishment and sometimes live there. They are offered employment and wages that appear to be legitimate. In other cases, if the brothel is set up by a gang or family, recruitment occurs as it would within the culture of that particular form of trafficking.

BrandingBranding can occur as it would in pimp-controlled trafficking situation. It continues to be a method of dissociating the victim from his or her reality and into the new life/LifestyleOften run like normal business with extremely poor working conditions and the victims/workers are often told to surrender their identification, passports or legal documents, however this is not always necessary if the victims are not living there and are not foreign born.OperationA brothel is usually set up by the trafficker who can be a pimp, the owner of the establishment, a gang member or family member. It is very common to have a female run the brothel who is referred to as “the madam.” A buyer comes in and appears to be purchasing a massage or other services but in reality he/she is well aware that they are purchasing sex.

Loyalty

The concept of loyalty is different within the brothel because grooming was not done for this purpose. In most traditional brothel scenarios, the victims are kept against their will and held captive.GroomingIn the traditional brothel, scenario, grooming many not exist as it does in the previous examples. The victim can be groomed to form a bond or loyalty to the trafficker. Grooming also may not occur and someone could be forced into a situation.Types of ExploitationBrothelSlide37

CultureControlled just like gang culture itself, the gang becomes the victim’s family, and the words to live by are “family over everything.” The gang represents; love, loyalty, protection, and provision. Understanding the concept of family and loyalty as it relates to gang-controlled sex trafficking is key to effectively treating this population.RecruitmentTrafficking recruitment within a gang is similar to gang membership recruitment. It can occur in a subtle way, by the victim first associating with the gang, starting to talk with gang members, going to parties, and then slowly being introduced to the life. Recruitment also occurs through social media sites such as Facebook. In many instances, the victims are chosen and then pursued based on personal attributes, vulnerability, home life, etc. The gang knows how to target their victims. Those being trafficked can be actual members or associates.

BrandingGangs brand their victims similar to pimps. A branding within the gang context consists of marking to show allegiance/belonging to the particular gang, not to a particular person.LifestyleThe gang lifestyle is controlled by a system of rules, vocabulary and customs. There is a hierarchy that exist to enforce rules, execute orders and ensure that the unit functions properly. Gang members live their life by “the code of the streets.” Do not talk to law enforcement or talk about anything that happens.

Operation

Gangs operate differently in that in most cases there is not just one trafficker. Usually they trafficking occurs by the gang leaders or between certain designated members. They work and function as a unit and not independently. The victims are often trafficked within the gang. Among gang members is the exchange for basic needs such as food, shelter, clothing, and drugs and then sold for sex. Gang members have been known to set up brothels in lower-income neighborhoods where they buyers come to purchase sex. They have also been known to set up a door-to-door system where they send the girls out and have them knock on different doors soliciting sex. Gangs will also set up “skipping parties” or other gatherings where the victims are exploited during the event itself. It is very common for the victim to be exploited regularly by gang members and gang leaders in exchange for food, drugs or shelter. Victims are often threatened with death or serious harm if they every speak about what happens within the gang to law enforcement or other outsiders. It is an extremely high profit enterprise and low risk of prosecutionLoyaltyThis is probably one of the most important concepts in the gang culture. Victims show and extreme amount of loyalty because the gang has become their family. The connection and trauma bond is no only tied to one person, it is tied to an entire family unit and lifestyle. the gangs expectation is to remain loyal at all times and live by the “code of the streets,” again to never talk to law enforcement or anyone else. GroomingCan be short or extensive depending on the victim. In most cases, once the victim is “chosen” by the gang, a gang member befriends her and becomes her “boyfriend.” The gang will first try to sell ‘the story’ to the victim and then gain her love, affection and loyalty. The ‘boyfriend’ acts as her savior and quickly gains her trust. She is introduced to drugs and alcohol in order to form a dependency. She may or may not be given nice things at first. As time goes on, the romance fades and she begins to be mistreated, disrespected, belittled, and abused. This is where she begins to dissociate and believe she is nothing more than property and a piece of garbage. The victim does not belong to one specific gang member. She belongs to all of them.

Types of Exploitation

GangSlide38

CultureVictims are exploited within his or her own family. The traffickers are either parents or other family members. The exploitation begins when the victims are very young. This group is not obvious to the public, as they may engage in normal activities such as taking their child to school or attending school plays. They try to maintain an appearance of normalcy to avoid suspicion. RecruitmentNo recruitment is needed as the victim being exploited within his or her own family. The traffickers are either parents or other family members. The exploitation begins when the victims are very young. There have been cases of victims as young as 1-2 years of age. In some cases the exploitation continues into their adolescence.

BrandingThis practice is not common in familial exploitationLifestyleThese situations are not always obvious to the public. The family may partake in normal activities such as taking their child to school or attending school plays. They try to maintain an appearance of normalcy to avoid suspicion. The children are raised and trained on how to behave in social situations as well as what to say if they are every questioned by anyone.OperationWithin familial exploitation, it is most common practice for the ‘johns’ or buyers to come to the home. The victims are then exploited as often as necessary to meet the family’s quota. In many cases, these victims, to the outside world, are leading normal lives.

Loyalty

This is family, which represents everything to the victim. The family is all the victim has ever known. They are trained to love, respect and show loyalty.GroomingThis is not necessary as the victim has already been raised in the life and knows no other way of existence. As they grow older, they are taught and trained on what to say, how to act, and how to answer when questioned. Types of ExploitationFamilial ExploitationSlide39

Victim Warning SignsChanges in peer groupEntire social network begins to change because the pimp/trafficker has begun to isolate them from their friends and family. It should also be noted that changes in peer group may not always occur. Offenders often teach victims to not change their behavior and social structure in order to reduce suspicion.

Behavioral changesThey may become runaways, skip school (truancy), or begin to engage in high-risk behaviors including drug use. Drugs are an essential component because the trafficker can exploit the victim while he/she is under the influence, which reduces resistance. Branding/tattoo/markingsIt is a constant reminder of their slavery and acts as a key component in the dissociating process. The ‘marking’ can either be a traditional brand with a hot object, a tattoo with the traffickers name on it, the victims ‘new name,’ some type of scar induced by cutting or carving on the skin.New clothing/unexplained itemsThis is usually part of the grooming process. Purchasing clothing articles for the victim can also be a strategy to get the victim to start dressing differently, such as in a more provocative way or to the traffickers taste.

Other common factors seen in the majority of cases include:

1.Conflict in the home-A dysfunctional family life often provides a greater incentive for many individuals to leave the home. Home was not a safe place and self worth has begun to break down. This makes her an easy target for traffickers and makes ‘selling the story’ easier.2. Being a runaway or throwaway-Humans are wired for love, bonding and connections and if they can't find this at home, they will set off to try and connect with it somewhere else. .. Once the trafficker offers that love and connection, the victim is sold and the bond begins to take place.3. Psychological or emotional problems-Victims dealing with depression, posttraumatic stress, anxiety, oppositional defiant disorder, reactive attachment disorder, etc. These conditions can impair their ability to have sound judgment and make good choices. 4. Promiscuous vs. Exploitation-many people will confuse promiscuity with exploitation and use the terms interchangeably, however this is not the case. Fear, force and coercion play a role and are key in distinguishing the two terms. 5. Buyers-studies reveal that men who buy women in prostitution come from all nationalities, races, and walks of life.Slide40

More InformationPolaris Project

National Human Trafficking Resource Center1-888-373-7888www.TraffickingResourceCenter.org Slide41

CBT

COGNITIVE BEHAVIOR THERAPYSlide42
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CBTEach area strongly influence each other and creates patterns of thoughts, behaviors and emotions. Automatic thoughts are an integral part of all our thinking processes and many will reflect underlying beliefs that we have about ourselves and about the world in general. Thoughts are closely linked to our mood and our mood is closely linked to our thoughts.If we feel anxious we will experience anxious thoughts, and if we are having anxious thoughts we will feel anxious.Our physical responses and our behavior also change in response to our thoughts and mood and these in turn influence our thoughts and mood.

Purpose/goal of CBT=is to identify and change patterns in order to secure immediate benefit and to understand how these patterns emerged in order to maintain improvement in the long term. Treatment goals directly target distressing symptoms, reduce distress, help re-evaluate thinking patterns and beliefs, and promote helpful behavioral responses by promoting solution focused interventions.Slide44

How Does

RECREATIONTie Into EachInterventionSlide45

Areas of Focus for RT

TRAUMASAYCSECTeach relaxation skills/ techniquesHelp w/ affective and behavioral regulations

Develop effective skills to address emotional difficulties

Help w/ affective modulation trough participationDecrease hyper vigilanceHelp w/ alterations in consciousnessHelp decrease Impaired thoughts, feelings, and behaviorsDecrease destruction of property (keeping busy) Help w/ self perceptionImprove impaired self validationDecrease emotional deficits through self expression activitiesLearn to replace negative behaviors with positive/adaptive behaviorsDecrease interpersonal deficits

Decrease deficits in communication

Decrease alterations in relationships with others through positive interactions

Reduce stress levels

Increase body awareness

Decrease alterations in systems of meaning

Increase pro-social skills

Distinguishing sexual and non sexualized touch

Develop awareness of how thoughts, feelings and values influence their behaviors

Decrease unrelenting crisis states

Increase attunement ( bring into harmony

; a feeling

of being “at one “

w/another being)

Enhance personal growth, self esteem and responsible sexuality to promote the development of a healthy identity

yHelp

understand learned helplessness and ways to overcome

Increase appropriate social interactions and decrease socially isolative behaviors

Develop appropriate interactions, appropriate communication and adaptive social skills

Help build trust and empathy

Increase leisure awareness- what they can and can not do to reduce risk of reoffendingSlide46

Evidenced Based Interventions&Clinical Benefits of RTTF-CBT

PRAC:

Coping Skills Phase

P: Psycho EducationP: Parenting SkillsR: Relaxation SkillsA: Affective Modulation SkillsC: Cognitive Coping SkillsT:Trauma Narrative and Processing PhaseT: Trauma Narrative & Processing

ICE:

Treatment Consolidation and Closure Phase

I: In vivo Mastery of Trauma Reminders

C: Conjoint Youth-Caregiver Sessions

E: Enhancing SafetySlide47

Evidenced Based Interventions&Clinical Benefits of RTDBT

Skill Training(5modes: Individual-Phone Consultation- Skills Training-Consultation Team-Ancillary TreatmentMindfulness: (taking control of your attention and thoughts) States of mind-what skills-how skills-observing and describing thoughts-noticing and managing judgment.Distress Tolerance: (getting through painful situations without making them worse-crisis

survival strategies) self soothe with the 5 senses-improve the moment-thinking of pros and cons-urge management-observing your breath-half smile-awareness-radical acceptance-reality acceptance-willingness-management of obsessions.Emotional Regulation: (keeping my balance) healthy perspectives on emotions-about emotions-how (all emotions help us with our unique response-knowing the difference-naming emotions-the way emotions work.Interpersonal Effectiveness: (getting along well in my community) Asking for what you want or refusing a request-how to get what you want-guidelines for self-respect and keeping respect for yourself-factors reducing effectiveness.Slide48

Evidenced Based Interventions&Clinical Benefits of RT

Avoidant PassiveAvoidant ActiveApproach Automatic

Approach

ExplicitImprove social competenceHelp w/ relationship buildingHelp w/ self regulation strategiesEducate-reality about healthy leisure outlets (what and where they can go and can not go)Help w/ mood managementHelp w/ problem solvingOpportunity for perspective takingEmpathy activitiesGive them active strategies to keep busy (not watching TV, etc.)Help w/ communication skillsHelp increase interactions w/ others. Issues with under regulation (friendships, use of leisure, etc.)Increase social interactions to help get them out of the mind-set that the world revolves around themHelp overhaul social skills

Education and research hobbies (leisure awareness)

Help w/ cognitive restructuring (empathy and perspective taking)

Activities that

education and challenge

c

ognitive

thinking errors

Good LivesSlide49

Evidenced Based Interventions&Clinical Benefits of RTCBT

Making the thought- feel linkSpotting errors in the way you thinkTackling toxic thoughtsBehavioral experiments-testing the validity of your thoughts to help clarify problem areasRefocusing and Retaining your awareness (how to manage your thoughts) Exploring emotionsDefining problems and setting goalsTackling anxiety –fear-depression-obsessions-low self-esteem- angerLooking backwards and moving forwardDevelop healthy attitudes/self-esteem

Phases of Sex Trafficking Treatment

(Introduction/Screening/Evaluations- Self Awareness/Self Recognition-Education of Exploitation- Honesty & Responsibility-Self Esteem/Acting Out-Negative Peer Association-Substance Abuse-Trauma Prevention-Aftercare)Self Awareness/Self Recognition: acknowledge negative behaviors-sexual history, etc. Look in depth at significant life events, important relationships and discloses other negative and criminal behaviors.Honesty & Responsibility: expected to be fully invested in treatment and learn to be honest and take full responsibility for him/herself.Self Esteem/Acting Out: understand rationale for behaviors. This includes but not limited to contributing factors to acting out behaviors, motivation to associate with a particular group, self esteem issues, image, etc.Negative Peer Association: explore the history of association with a negative peer group. This can include gang affiliation/membership. This means specially, understanding the reason for association/memberships in order to foster the idea of a positive support group.Slide50

Affect Expression and Modulation ActivityA good way to tell how we feel and how others feel is by noticing facial expressions. Have them draw the feelings in the circles to show how we express our feelings on our faces. Can leave black circles to allow the resident to pick an emotion that was not already talked about. Have them rate intensity levels of various emotions.Role play appropriate feelings displayed in various situations.

Basic identification of emotions.Help them understand the rationale for emotions.Can play a game of feelings charades. Sounds so simple and basic, but a lot of teenagers are not in touch with emotions or able to identity how they feel.At the end of the session, you can process- how they are presently feeling. Slide51

TF-CBTAffect Expression and Modulation

while role playing various emotions-practice stopping and changing the emotion RT INTERVENTIONSTrauma ReactiveHAPPY

SAD

ANGRYSCAREDNERVOUSEXCITEDCONFUSED SHOCKEDPROUD

BRAVESlide52

RT INTERVENTIONSTrauma ReactiveDBTDistress Tolerance SkillsSelf-SootheThis skill is about self-soothing when you are having a bad day or dealing with a lot of stress. Self-soothing provides comfort and reassurance. It can help you stay grounded in your body and in the present moment. It can serve as a distraction from the difficulties you are dealing with.

The “Self-Soothe” skill is about using all 5 of your senses to “Self-Soothe”: Seeing, hearing, smelling, touching, & tasting.I can “Self-Soothe” with vision by: Pictures, Art, Stargazing, etc.I can “Self-Soothe” with sound by: Music, Nature Sounds, etc. I can “Self-Soothe” with smells by: Fragrance, food aromas, etc.

I can “Self-Soothe” with

touch by: Fabric, rocks, hands, pets, etc.I can “Self-Soothe” with taste by: Sweet, sour, chewy foods, etc.The ways in which you choose to “Self-Soothe” will need to be effective and not cause additional problems for you. For example, if you tend to over eat, then you might not want to “Self-Soothe” with food.Slide53

RT INTERVENTIONSSEXUALLY AGGRESSIVE YOUTHGood Lives Self RegulationADD A GOOD LIVES ACTIVITYLego activity (sitting back to back)

Incorporating a minimal amount of touch can be huge with the offender population Slide54

Communication GameThis activity allows you to use touch along with building communication skills. (When you allow them to sit back to back, it becomes less intrusive) Residents have to sit back to back with one another or you could have 3 in a group sitting shoulder to shoulder.One person describes the picture given. Can add various twist to the game. For example:

-Person can only ask open ended questions -No questions at all -Can ask unlimited questionsSlide55

Past –Present-Future HopscotchHave patients form several lines to make the waiting time shorter. The first student in each queue moves in “hopscotch” fashion (alternating between hopping on one and two feet.” The game starts by having the patients name an event as they hop. If the event is in present time, they hop and land on both feet. If the event they name reflects the past, they hop backwards on one foot. If the event is in the future, they hop forward on one foot. The idea is to keep thoughts and feelings moving, rather than being stuck in the past. Hopping in place on both feet: “I’m playing hopscotch now.”

Hopping backwards on one foot: “Last week my hamster died.”Hopping in place on both feet: “I’m having fun now.”Hopping forward on one foot: “We’re having a party on Friday.”If a patient states only unpleasant experiences on every turn, epically for the future, suggest that they alternate between pleasant and unpleasant future images. For example, a child whose parents are going through a divorce might say: “Today my parents are fighting-yesterday they were fighting-tomorrow they will still be fighting”. Perhaps the next round, if they are still preoccupied with the divorce, you might suggest something the patient might like to do for fun. Only give this guidance when a patient is “stuck” in the past or see a grim future. Encourage them to imagine some things that might make them feel better if this does not happen spontaneously.Slide56

Thinking Errors Activity

All-or-nothing: You evaluate yourself and events that happen in your life in extremes, it’s either totally black or totally white.Example: “ Your boy/girl friend must behave exactly to your expectations, or they are not the right one.”To beat this cognitive distortion: Has there ever been a time when it was NOT that way?EXAMPLE: _________________________________________________________________________________________________________________________________________________

NEW THOUGHT:_____________________________________________________________________________________________________________________________________________

Overgeneralization: You conclude that a thing that happened to you once will occur over and over again. Example: “I will never get a girlfriend… (Based on one rejection).”To beat this cognitive distortion: Say to yourself, “just because one event happened, does not necessarily mean I am (or you are or he/she is…(some way of being).”EXAMPLE: _________________________________________________________________________________________________________________________________________________

NEW THOUGHT:_____________________________________________________________________________________________________________________________________________

Mental filter

:

You pick out a negative detail in any situation and dwell on it, thus perceiving the whole situation as negative.

Example: “Because I got one low grade on one test (but all the other grades in that class are good) it means I am doing a lousy job.”

To beat this cognitive distortion

: Count up your (-) ad your (+). For every negative event, stack up a positive against it. Make a list of both (-) and (+).

EXAMPLE: _________________________________________________________________________________________________________________________________________________

NEW THOUGHT:_____________________________________________________________________________________________________________________________________________

Disqualifying the positive:

It’s about the unwanted ability of your mind to transform neutral and maybe even positive events into negative ones. You don’t just ignore positive experiences; you cleverly and swiftly turn them into their nightmarish opposite.

Example: “You get a compliment and your mind starts questioning the compliment.” “The good stuff doesn’t count because the rest of my life sucks!”

To beat this cognitive distortion

: Accept compliments with a simple, “Thank you.”

Ask yourself, “so what does count?”

EXAMPLE: _________________________________________________________________________________________________________________________________________________

NEW THOUGHT:_____________________________________________________________________________________________________________________________________________

Jumping to conclusions

: Two subtypes: Mind reading and Fortunetelling: You assume something negative when there is actually not evidence to support it.

Mind reading: assume the intentions of other. Fortunetelling-anticipating that things will turn out badly.

Example: “You make assumptions

that other people are looking down on you, and you’re so sure about this that you don’t even bother to check it out and talk with other people.”

To beat this cognitive distortion

: When based on prior cause, ask yourself, “What evidence do you have to support your notion.” When based on future consequence, ask yourself, “how does this conclusion serve you?” and “if you continue to think that way…{what will happen to you}?” and “image 5 years from now…”

EXAMPLE: _________________________________________________________________________________________________________________________________________________

NEW THOUGHT:_____________________________________________________________________________________________________________________________________________Slide57

Thinking Errors Activity

Magnification and minimization: You either blow things out of proportion or shrink them. Magnification commonly occurs when you look at your own errors, fears or imperfections, and exaggerate their importance. Of course if you magnify your imperfections and minimize your good points, you’re guaranteed to feel inferior.Example: “Getting a mediocre evaluation proves how inadequate I am. Getting High marks doesn't mean I’m smart.”To beat this cognitive distortion: Ask yourself, “What would happen if you did…..” Ask yourself, “how specifically is {this/that/he/she} so good/too much/too many/etc. or so bad/not good enough/too little/etc.?”

EXAMPLE: _________________________________________________________________________________________________________________________________________________

NEW THOUGHT:_____________________________________________________________________________________________________________________________________________Emotional reasoning: You take your emotions as evidence for the truth. Because things feel so negative to you, you assume they are true. Example: “I know I do a lot of things well at school, but I still feel as if I’m a failure.” To beat this cognitive distortion: Interrupt anything negative: “X makes me mad” How does what I do cause you to choose to feel mad?” “How could you believe that?”

EXAMPLE: _________________________________________________________________________________________________________________________________________________

NEW THOUGHT:_____________________________________________________________________________________________________________________________________________

Should statements:

You try to motivate yourself with statements like “I should do this”, “I must do that” etc. These statements cause you to feel pressured and resentful. When the reality of your own behaviors falls short of your standards, your “

shoulds

” and “

shouldn’ts

” create self-loathing, shame and guilt.”

Example: “I should be able to get better grades.”

To beat this cognitive distortion:

Ask, “What would it feel like, look like, sound like if you could/did or could not/did not?” “What rule or law says you/I should?” or “Why should I?”

EXAMPLE: _________________________________________________________________________________________________________________________________________________

NEW THOUGHT:_____________________________________________________________________________________________________________________________________________

Labeling and mislabeling

: Labeling means creating a completely negative self-image based on your errors. It’s an extreme form of overgeneralization. Labeling means that you have a fixed mindset.

Example: “I’m a born loser.”

To beat this cognitive distortion

: “What could be a better way of looking at this that would truly empower you/me?” or, “Is there another possible more positive meaning for this?”

EXAMPLE: _________________________________________________________________________________________________________________________________________________

NEW THOUGHT:____________________________________________________________________________________________________________________________________________

Personalization

:

You assume responsibility for a negative event or thing, even where there is no basis for doing so.

Example: “The teacher was short with me because I did something wrong.”

To beat this cognitive distortion

: Ask yourself, realistically how much of this problem is actually my responsibility.” Ask yourself, “Who/what else is involved in this problem.”

EXAMPLE: _________________________________________________________________________________________________________________________________________________

NEW THOUGHT:_____________________________________________________________________________________________________________________________________________Slide58

Thoughts, Feelings, and ActionsSituation A: I am sitting in the kitchen when a car pulls into the driveway. I hear a loud crunch. I remember I that I left my bicycle in the driveway.I would feel _______________________________________________I would think ______________________________________________

I would act ________________________________________________Situation B: I was just informed that my family is moving to a new town.I would feel _______________________________________________I would think ______________________________________________I would act ________________________________________________Situation C: I am home alone at night, and I hear a strange noise.I would feel _______________________________________________I would think ______________________________________________I would act ________________________________________________Situation D: My dog chews up one of my new shoes.

I would feel _______________________________________________

I would think ______________________________________________I would act ________________________________________________Situation E: Make up your own situation.I would feel _______________________________________________I would think ______________________________________________I would act ________________________________________________ Slide59

Brain GymMidline movements that focus on skills necessary for easy two-sided (left-right) movement across the midline of the body.Because Brain Gym works on connecting the left and right sides of the brain, and would be a beneficial activity to use with all three populations Slide60

The Hook-UpsHook-ups connect the electrical circuits in the body, containing and thus focusing both attention and disorganized energy. The mind and body relax as energy circulates through areas blocked by tension. The figure 8 pattern of the arms and legs (Part One) follows the energy flow lines of the body. The touching of the fingertips (Part Two) balances and connects the two brain hemispheres.Teaching Tips

Sitting, the student crosses the left ankle over the right. Extend arms, before crossing the left wrist over the right. Then interlace fingers and draw hands up toward chest. May now close eyes, breathe deeply, and relax for about a minute.When ready, uncrosses legs. Touch fingertips of both hands together, continuing to breathe deeply for about another minute.VariationsCan be done while standingActivates The Brain For GroundingIncreased attentionSlide61

Belly BreathingBelly Breathing reminds the student to breathe instead of holding their breath during focused mental activity or physical exertion. The breath should expand the rib cage front to back, left to right, and top to bottom, including the abdomen. When breathing is shallow, lifting only the rib cage, the oxygen supply to the brain is limited. When one breathes correctly, there is abundant oxygen for higher brain functions.Teaching Tips

The student inhales through the nose and initially cleanses the lungs with one long exhalation, released in short puffs through pursed lips (may imagine keeping a feather afloat.) Thereafter, the outbreath is also through the nose.The hand rest on the lower abdomen, rising on inhalation and falling on exhalation. Inhale to a count of three, hold breath for three, exhale for three, hold for three. Repeat. For an alternate rhythm, inhale for two, exhale for four, with no holding.Ideally, rhythmic breathing is automatic, Rhythmic music may help, so that counting isn’t needed. When doing activities like lifting, kicking, or pushing, remember to exhale on the exertion.Variations

Lie flat with a book on the belly. The abdomen should rise on inhalation and lower on exhalation.

Walk and Belly Breathe at the same time.Activates The Brain ForThe ability to cross the midlineCentering and groundingRelaxation of the central nervous systemSlide62

Brain ButtonsThe Brain Buttons (soft tissue under the clavicle to the left and right of the sternum) are massaged deeply with one hand while holding the navel with the other hand.Teaching TipsThe student stimulates these points for twenty to thirty seconds, or until any tenderness is released.

The Brain Buttons may be tender at first; over a few days to a week, the tenderness subsides. Then, even holding the points will activate them.The student may change hands to activate both brain hemispheres.VariationsInclude horizontal tracking (for example, across the floor or ceiling line.)Do “Butterfly 8s” on the ceiling while holding the points: the student extends an imaginary paintbrush from his nose and paints a “Butterfly 8” on the ceiling. (Note: Butterflies are in the forward visual field, not straight overhead; the head should not be tilted back to block the “open throat” position.)Rather than holding the navel, massage the points to the left and right of it.

Activates The Brain For

Sending messages from the right brain hemisphere to the left side of the body, and vice versa.Slide63

The ElephantThe grace and balance for which elephants are known inspired this movement. A bull elephant of the Indian species might weigh over 9,000 pounds, yet every square centimeter of it’s large foot pad carries only twenty-one pounds of weight (a one hundred twenty-pound woman, by comparison, might exert as much as four and one-half pounds on every square centimeter of her high-heeled shoes.) The ears of the East African elephant account for one-third of his total body-surface area. His auditory ability may account in part for his well-developed intelligence. The Elephant movement activates the inner ear for improved balance and equilibrium and also integrates the brain for listening with both ears. It releases tight neck muscles, with often tense in reaction to sound or to excessive lip movement during silent reading. In the Elephant movement, the torso, head, and pointing arm and hand function as a single unit. This unit moves around a distant, imaginary Lazy 8, eyes focusing beyond the hand. The whole body moves without any separate arm movements.

Teaching TipsShow the student where to paint the 8 before beginning. Relate the center and sides of the 8 to a shape in the environment (e.g., the center line of the chalkboard.)The student stands with knees comfortably bent, facing the center of the Lazy 8.Pre-and post-test the student's ease of head-turning before and after the movement.While keeping both eyes open, the student projects the 8 onto a distant lateral plane with the center of the Lazy 8 at the midline. No body twist is involved.

The head is ‘glued’ to the shoulder (holding a paper between the head and shoulder helps with this skill.)

The student aims with their hand, looking past the hand into the distance (the hand will appear double or out of focus if both eyes are correctly processing information.)VariationsThe student may do the Elephant while sitting.The student may point their arm into different visual fields, relaxing different areas of tension.Activates The Brain ForCrossing the auditory midline (including skills of attention, recognition, perception, discrimination, and memory.)Short-and long-term memory.Slide64

Double DoodleDouble Doodle is a bilateral drawing activity which is done in the midfield to establish direction and orientation in space relative to the body. When the learner has developed a sense of left-and-right discrimination, as they draw and write they experience themselves in the center, and movement toward, way from, up, and down is interpreted in relationship to that center. Prior to developing this sense, the child fumbles to recreate a shape from memory. The Double Doodle is best experienced with the large muscles of the arms and shoulders. Stand behind the student and guide arms and hands through a few simple movements. Teach the student to refer to their physical midline for directional reference. Say “Out, up, in, and down” as you guide the student to draw squares with both hands simultaneously. Set the student free when both hands are able to move together, mirroring each other easily.

Teaching TipsBegin by allowing the student to freeform “scribble” with both hands together (as in finger-painting.) The student starts with large arm movements, neck and eyes relaxed, working at a large board.Emphasize the process, not the product. Avoid making either positive or negative judgments.Encourage relaxed head and eye movements.Have samples of Double Doodle shapes that others have done.

Encourage innovation and experimentation.

Double Doodling of actual shapes, like circles, triangles, stars, hearts, trees, or faces, is most fun when done spontaneously.VariationsProgress from the large board to a smaller piece of paper taped to the desk or floor.Offer different tools for doing Double Doodle (e.g., chalk, paint, markers, crayons.)Double Doodle in the air as a group activity.Double Doodle touching different fingers to the thumbs (releasing thumb/index finger tensions.)Doodle in the air with shoulders, elbows, wrist, or feet (relaxes tensions.)Quadroodle Doodle: Doodle with hands and feet at the same time.Activates The Brain ForHand eye coordination in different visual fieldsSpatial awareness and visual discriminationCrossing the kinesthetic midlineSlide65

RT INTERVENTIONSCOMMERICALLY SEXUALLY EXPLOITED CHILDRENCBT A Vicious Flower of Panic

Key thoughts and meanings: I’m going to be forced to go back, and I am unsafe Behaviors: Run away, freeze, erratic/ unpredictable behavior

Emotions:

Anxiety, panic , guilt Attention focus: Focusing on feeling dizzy and wondering if I am safePhysical sensations: Knot in my stomach, legs fell wobbly, heart racing, trembling handsTrig

Trigger:

While out shopping I smelled cologne that reminded me of my exploiterSlide66

CBT A Vicious Flower of PanicThe vicious flower exercise is a way of putting together different elements of your problem to aid your understating of how your problem is maintained.

1. In the trigger box, write down the trigger that makes you feel anxious or upset. 2. In the central circle, write down the key thoughts and meanings you attach to the trigger. 3. In the flower petals, write down the emotion, behavior, and sensations you experience when your uncomfortable feeling is triggered. In the top petal, write down what you tend to focus on.Key negative thoughts, attitudes, or beliefs are the heart of your vicious flower. The petals are your attention, emotion, physical, and behavioral responses to the meaning you have attached to the trigger.One of the most important aspects of building a vicious flower is to think through how the petals affect the thought or “meaning” that underpins your emotional problem. For example, the effect of anxiety on your thinking is to make you more likely to interpret experiences as more dangerous than they really are. The effect of depression is to make your thinking more gloomy and negative.

Focusing your attention on a sensation usually makes the sensation feel more intense. Acting upon an unhelpful thought or meaning usually makes the meaning seem more real. Unpleasant physical sensations accompanying your reaction can make upsetting thoughts seem even more real.

The ‘physical sensations’ petals is the aspect of your problem that you’re least able to change directly because physical sensations are outside your immediate conscious control. However, you can minimize the impact of physical sensations by learning to tolerate them while you overcome your problem, and to interpret them as no more dangerous than they really are.Slide67

dollyw@newhopetreatment.com