The CCT Square builds on the CBT triangle (emotions-thoughts-behavior) to add a fourth domain: physiological reactions. CCT addresses all four corners of the square: if we change one corner, the other three are altered.
Cues—also known as trauma reminders—are formerly neutral stimulus that, through a process of classical conditioning, come to activate the trauma response and symptoms. Cues are idiosyncratic: they are specific to a person and the context of trauma. Each cue is linked to a particular square, i.e., an initial response pattern.
In CCT, we do not attempt to change the child’s trauma responses, but we help the child create new, more adaptive responses. This is visually represented with the CCT CUbE.
Each individual cue is linked to a particular square, which represents the initial response pattern. Through CCT, we’ll create new responses, new squares, over time. Every new square gets layered on top of the previous ones so that the initial trauma-response square becomes a three-dimensional cube, with multiple layers representing different reaction patterns and response options.
The CCT Square becomes the CCT CUbE over time
It is important to emphasize that in CCT, we are not trying to change the original square—the initial response pattern—but to add more squares on top of that over time. The rationale for this is that the responses in the original square were adaptive at one point in time, they were protective, and they may even prove effective in the future in the case of additional trauma exposure, despite being maladaptive in some current contexts. Thus, it may be counterproductive to eliminate strategies that children feel can keep them safe; they might fight us on it.
Instead, through the creation of new responses in CCT, we are empowering children to come to their own conclusion about which responses best work for them, and in what situation. In other words, children come to the realization that the new responses work better than the old ones without us having to jump to immediately “fix” the old response. The resultant CUbE provides more options for choosing adaptive responses over maladaptive ones. Rather than focusing on “right” versus “wrong” responses, CCT aims to promote flexibility and adaptability in responses, depending on the situation.
The prefrontal cortex is a control center for human emotions, thoughts, behavior, and physiological reactions. In conditions of stress and trauma, the emotional center of our brain, or limbic system (i.e., the amygdala and hippocampus), takes over and activates neuroendocrine responses, resulting in the ‘fight-or-flight-or-freeze’ reactions.
“Fight, Flight, or Freeze”
If the body is exposed to stress continuously for too long, neuroregulatory mechanisms become overactivated, which manifests as posttraumatic stress symptoms (PTSS). Posttraumatic symptoms feed on avoidance and will get worse if left untreated.
The association between the level of stress and mind-body performance is represented as an inverted U-shaped curve (Yerkes-Dodson law). Initially, the higher the stress, the better the performance, until stress passes the apex of peak performance, at which point more stress impairs performance.
The Yerkes-Dodson Law
The accumulation of trauma and other stressors across the lifespan is known as allostatic load.
If stress is too high for too long, it becomes ‘toxic.’ Neuroendocrine stress responses become over-sensitized, which leads to changes in the function of the brain and organ systems.
Dr. Kletter explaining the stress continuum to Tasha and her mother
Tasha and her mother enter the room but stay standing near the door. Tasha’s dark eyes dart here and there—her anxiety is palpable.
“Hi Tasha, how are you doing today?” you ask warmly.
“Okay,” she shrugs.
You smile and motion Tasha and her mother toward their seats. “How has everything been since the last time we spoke?”
“Just stressed,” she mumbles. “As usual.”
“Okay. Well, today we were going to take time to talk about stress—what it is and how it develops. What do you think?”
Tasha returns your gaze, but doesn’t respond.
“I’d like to start by asking if you can describe to me what you think stress is.”
Tasha fidgets in her seat and scrunches her forehead. “Stress is, like… when you’re very worried?”
“Mm-hmm, tell me more. Can you give me an example of a time when you felt stressed?”
“I don’t know, I feel weird like that all the time,” Tasha blurts. “Ugh which can make me think I’m going crazy.”
You remain still.
Tasha sighs. “It’s like a tension. I can’t breathe, and I feel shaky. I don’t know, it’s upsetting because I don’t have any control over it.”
She looks away and crosses her arms. “Those are very common signs of stress,” you explain, “not something crazy or ‘weird.’ People can have many different reactions to stress: thoughts, or a feeling, or a physical sensation, or even behavior.” Tasha’s gaze continues to trace the ceiling. “Has there ever been a time when you experienced stress, but it was helpful to you?”
Tasha looks at you. “Helpful? I don’t think so…”
“You know, a small amount of stress, believe it or not, can actually do some good,” you say with a bright smile. “It can motivate us. It can help us adapt.”
“Well,” Tasha uncrosses her arms. “I guess at school, when I have a test…I get stressed about it, so I study to try to get an A.”
“That’s a great example! What if we think about the other extreme? What if you were studying too much for the exam? Staying up all night, and skipping breakfast to study?” Tasha turns her face to you with curiosity. “How do you think you’d do on the day of the test?”
“I’d… probably be too tired.”
“That’s right, and your brain might be totally fried, wouldn’t it? Even if you know the information.”
Tasha nods emphatically.
“So too much stress can also be bad for us,” you continue, producing a pen and notepad to hold up in front of Tasha. “Imagine stress as occurring along a curve. On one side, there’s a positive stress response, the beneficial kind. But then, on the other side, there’s toxic or traumatic stress.”
Tasha focuses intently on the paper.
“All that stress we carry adds up, like a weight that we call ‘allostatic load.’ Sometimes the weight of the allostatic load over time can get to be too much—there’s a limit to how much stress we can handle.”
“Allostatic load.” Tasha repeats to herself. “Is that what happened to me? My ‘allostatic load’ is too much?”
“That’s correct,” you answer softly. “You explained that you’ve had a few major things that happened in your life, with your uncle and your cousins. Those weren’t normal day-to-day stressors. They were traumatic events. When those happen, they pile up and up until your mind and body tell you, ‘This is too much!’ So it makes total sense that this kind of compounding stress over time would eventually take a toll.”
“I don’t know,” Tasha mutters, “I wish I could be stronger.”
“Everyone’s limit is different. These things really depend on your biology and genetics, even past experiences. Some people are better at managing stress than others, sometimes because they’ve had more practice or help, other times because the people around them practice healthy coping. But none of this is to say that you’re doing a worse job than others.”
Psychoeducation is a crucial part of CCT intervention with a child. It occurs in Session 1, after the assessment is completed, and should be conducted with both the child and caregiver.
For younger children, an additional session may be needed to convey this information better.
Goals of Psychoeducation
Help the child and the caregiver understand: – What trauma is and how it develops – The normal stress response – Trauma symptoms – Development of cues through classical conditioning
Give the child hope for healing and recovery
Introduce CCT treatment: – Components – Format – Expectations
CCT is structured over 15 sessions with the flexibility to add extra sessions in each phase. Although we recognize the value of having a caregiver in therapy, experience has taught us that this is not always possible. Hence, CCT has been designed to maximize the active engagement of the child, while not requiring the presence of a caregiver in all sessions.
The intervention is standardized for children age 8 to 18 years, but can be adapted to the child’s age, developmental level, background, and current functioning. It can also be adapted to maximize the therapist’s strengths and approach. In essence, CCT is appropriate for any type of trauma, but emphasis is on ongoing, chronic trauma experiences.
In our online course, we will be covering CCT topics and strategies through a series of clinical vignettes. To demonstrate its application to diverse backgrounds, age, and traumatic experiences, these vignettes will center around four characters: Tasha, Nelson, Brian, and Michelle.
You will be introduced to each character through a graphic novel style story. You can listen to the story by selecting the blue audio play button in the top right corner of the slide player. You will advance through the graphic novel by selecting the forward arrow just next to the slide number (e.g., “1 / 4”) below the player. The arrows on the bottom right corner allow you to expand to full screen for a better viewing experience.
Each lesson is followed by a clinical vignette, referred to as a “Chapter.” The chapter also has an audio player if you prefer to listen in to the session or read along with the written text. The audio player for the chapters appears as a grey bar. There is a play/pause button and sound level adjustment.
At the end of each module, there will be a short recap and a quiz that you can take to assess your formative learning. The link to the quiz will be in a red box at the bottom of the lesson page, just like the one at the bottom of this page. If you select the quiz icon or quiz name it will advance to the first question.
References to additional resources and guides are embedded through the course. Page numbers for the Cue-Centered Therapy manual (available in both English and Spanish) are included for each module, so you can follow along. We strongly recommend using this course in conjunction with the Cue-Centered Therapy manual given that it is referenced throughout and provides access to the session worksheets, and contains additional content beyond the course.
The worksheets and coping tool scripts used in this course are copyrighted by Carrion, VG: Cue-centered therapy for youth experiencing posttraumatic symptoms: a structured multimodal intervention, therapist guide. New York: Oxford University Press; 2016 and reproduced with permission of Oxford Publishing Limited through PLSclear.
The entire course will take approximately 7–8 hours to complete. Please take a break after finishing the section for each CCT session, and have your favorite writing implement nearby so you can follow prompts to practice note-taking.
CCT consists of 15 sessions organized into 4 phases of intervention, plus a series of take-home activities meant to practice skills in preparation for everyday utilization.
In Phase 1, we provide psychoeducation and introduce coping tools. Child and caregiver perspectives on trauma symptoms may differ, so we discuss them during psychoeducation.
In Phase 2, we build a life timeline—placing traumatic events into the greater context of the child’s life—and have the child narrate their traumatic experience. During the timeline and narrative exercises, we identify emotions, cognitive distortions (i.e., unhelpful thoughts), cues, and memory gaps. We then help to restructure these unhelpful thoughts.
In Phase 3, we do gradual exposure to cues—starting with imaginary, followed by in-session and in-vivo.
Phase 4 represents integration of learned skills while revisiting the trauma experiences, making sure that intervention effects are maintained after termination.
BETA TESTERS: Please complete our quick feedback survey here: Beta Tester Survey on The Stress Continuum. This will open in a new tab. Then you can complete the quiz below.
The prefrontal cortex is a control center for human emotions, thoughts, behavior, and physiological reactions. In conditions of stress and trauma, the emotional center of our brain, or limbic system (i.e., the amygdala and hippocampus), takes over and activates neuroendocrine responses, resulting in the ‘fight-or-flight-or-freeze’ reactions.
“Fight, Flight, or Freeze”
If the body is exposed to stress continuously for too long, neuroregulatory mechanisms become overactivated, which manifests as posttraumatic stress symptoms (PTSS). Posttraumatic symptoms feed on avoidance and will get worse if left untreated.
The CCT Square builds on the CBT triangle (emotions-thoughts-behavior) to add a fourth domain: physiological reactions. CCT addresses all four corners of the square: if we change one corner, the other three are altered.
Cues—also known as trauma reminders—are formerly neutral stimulus that, through a process of classical conditioning, come to activate the trauma response and symptoms. Cues are idiosyncratic: they are specific to a person and the context of trauma. Each cue is linked to a particular square, i.e., an initial response pattern.
In CCT, we do not attempt to change the child’s trauma responses, but we help the child create new, more adaptive responses. This is visually represented with the CCT CUbE.
