Treating Complex Trauma in Adolescents and Young Adults

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John N. Briere & Cheryl Lanktree

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    Acknowledgments

    We would like to acknowledge and thank the many individuals who were involved in the development of the ITCT-A treatment model or worked as ITCT-A therapists. These include former MCAVIC staff (Barbara Adams, Psy.D.; Juan Carlos Aguila, Ph.D.; Lorraine Al-Jamie, M.F.T.; Tracey Burrell, Ph.D.; Laura Benson; Karianne Chen, M.F.T.; Nicole Farrell, M.S.W.; Susana Flores, M.S.; Sara Hernandez, Psy.D.; Jeff McFarland, M.S.; Stephen Neal, Ph.D.; Maria Pannell, Ph.D.; Eric Rainey-Gibson, Ph.D.; Andrea Sward, M.A.; Laurie Trimm, B.S.; and Kathleen Watkins, Ph.D.), the MCAVIC-USC program evaluator and consultant (Carl Maida, Ph.D.), USC Psychological Trauma Program staff and fellows based at MCAVIC (Wendy Freed, M.D.; Natacha Godbout, Ph.D.; and Monica Hodges, Ph.D.), William Saltzman, Ph.D., Patricia Lester, M.D., and the many psychology interns, externs, and volunteers who supported the mission at MCAVIC. We also express appreciation to the MCAVIC-USC Expert Panel on Cultural Issues, including Veronica Abney, Ph.D., L.C.S.W.; Meghan Berthold, Ph.D., L.C.S.W.; Thema Bryant-Davis, Ph.D.; Renda Dion, Ph.D.; and Russell Jones, Ph.D., who provided feedback on the appropriateness of ITCT for different cultural and demographic groups. (Any remaining errors are our own.)

    We are further indebted to those clinicians, researchers, and friends who provided support and input on this book at various points in its development. This includes many of the people just thanked, as well as Colleen Friend, Ph.D., L.C.S.W.; Anne Galbraith, M.F.T.; David Kim, M.F.A.; Barbara Maida, Ph.D.; Sebastien Malette, Ph.D.; and Sage Publications reviewers Eric J. Green, Ph.D.; Victoria White Kress, Ph.D.; and Anna Mercedes Caro, Psy.D. We also thank our colleagues at the National Child Traumatic Stress Network, in particular John Fairbank, Ph.D.; Mandy Habib, Psy.D.; Victor LaBruna, Ph.D.; Jenifer Maze, Ph.D.; Robert Pynoos, M.D.; and Alan Steinberg, Ph.D., as well as members of the ITCT Learning Community, for their support.

    Special appreciation is due Malcolm Gordon, Ph.D., for his support and feedback as the project officer on our second Substance Abuse and Mental Health Service Administration (SAMHSA) grant, as well as those governmental and private entities who funded the development, assessment, and application of ITCT-C and ITCT-A, including SAMHSA, U.S. Department of Health and Human Services; Office of Criminal Justice Planning, State of California; UniHealth Foundation; Long Beach Memorial Medical Foundation; In-and-Out Burger Foundation; Mark McGwire Foundation for Children; Ralph M. Parsons Foundation; and the California Community Foundation.

    Finally, we thank our various family members, who provided so much caring and support, especially the Brieres (Adelle, Danny, and Eugene), Lanktrees (Beryl, Bruce, Jean, and Roy), and Mansons (Harald and Lynda), as well as the next generation and their partners (Andrew, Allison, Dave, Ethan, James, Tayler, Matt, Laura, Mike, Ellen, Sarah, and Jason).

  • Initial Trauma Review: Adolescent/Young Adult Version (ITR-A)

    This semistructured interview allows the clinician to cover the primary forms of trauma potentially experienced by adolescents (i.e., those between the ages of 12 and 21). The clinician may wish to paraphrase these questions in order to make them “fit” better into the session. However, (1) try to use the behavioral descriptors (don't just ask about “abuse” or “rape”), and (2) only ask as many questions at a given time period as is tolerated by the adolescent. Remaining questions can be asked at later points within the first few sessions. The question How old were you the first time? usually indicates whether or not the trauma was a form of child abuse. The questions When this happened, did you ever feel very afraid, horrified, or helpless? and Did you ever think you might be injured or killed? indicate whether the trauma meets Criterion A2 for DSM-IV PTSD or ASD.

    • [Childhood physical abuse] “Has a parent or another adult who was in charge of you ever hurt or punished you in a way that left a bruise, cut, scratches, or made you bleed?”
      • Yes
      • No

      If yes,

      • “How old were you the first time?”_______________
      • “How old were you the last time?”_____________

      “When this happened, did you ever feel very afraid, horrified, or helpless?”

      • Yes
      • No

      “Did you ever think you might be injured or killed?”

      • Yes
      • No
    • [Sexual abuse] “Has anyone who was five or more years older than you ever done something sexual with you or to you?”
      • Yes
      • No

      If yes,

      • “How old were you the first time?”________________
      • “How old were you the last time?”________________

      “When this happened, did you ever feel very afraid, horrified, or helpless?” [NOTE: For sexual abuse only, this part is not necessary for PTSD Criterion A]

      • Yes
      • No

      “Did you ever think you might be injured or killed?” [NOTE: For sexual abuse only, this part is not necessary for PTSD Criterion A]

      • Yes
      • No
    • [Peer sexual assault] “Has anyone who was less than five years older than you ever done something sexual to you that you didn't want or that happened when you couldn't defend yourself (for example, when you were intoxicated or asleep)?”
      • Yes
      • No

      If yes,

      • “How old were you the first time?”_________
      • “How old were you the last time?”_________

      “When this happened, did you ever feel very afraid, horrified, or helpless?”

      • Yes
      • No

      “Did you ever think you might be injured or killed?”

      • Yes
      • No
    • [Disaster] “Have you ever been involved in a serious fire, earthquake, flood, or other disaster?”
      • Yes
      • No

      If yes,

      • “How old were you the first time?”___________
      • “How old were you the last time?”___________

      “When this happened, did you ever feel very afraid, horrified, or helpless?”

      • Yes
      • No

      “Did you ever think you might be injured or killed?”

      • Yes
      • No
    • [Motor vehicle accident] “Have you ever been involved in a serious automobile accident?”
      • Yes
      • No

      If yes,

      • “How old were you the first time?”________
      • “How old were you the last time?”________

      “When this happened, did you ever feel very afraid, horrified, or helpless?”

      • Yes
      • No

      “Did you ever think you might be injured or killed?”

      • Yes
      • No
    • [Partner abuse] “Have you ever been slapped, hit, beaten, or hurt in some other way by someone you were dating or who you were in a sexual or romantic relationship with?”
      • Yes
      • No

      If yes,

      • “How old were you the first time?”_______________
      • “How old were you the last time?”_______________

      “When this happened, did you ever feel very afraid, horrified, or helpless?”

      • Yes
      • No

      “Did you ever think you might be injured or killed?”

      • Yes
      • No
    • [Nonintimate peer assault] “Have you ever been physically attacked, assaulted, stabbed, or shot at by someone who wasn't a parent, date, or sexual partner?”
      • Yes
      • No

      If yes,

      • “How old were you the first time?”_______________
      • “How old were you the last time?”_______________
      • “When this happened, did you ever feel very afraid, horrified, or helpless?”
      • Yes
      • No

      “Did you ever think you might be injured or killed?”

      • Yes
      • No
    • [Torture—if the adolescent is an immigrant from another country] “In the country where you used to live, were you ever tortured by the government or by people against the government?”
      • Yes
      • No

      If yes,

      • “How old were you the first time?”_______________
      • “How old were you the last time?”_______________
      • “When this happened, did you ever feel very afraid, horrified, or helpless?”
      • Yes
      • No

      “Did you ever think you might be injured or killed?”

      • Yes
      • No
    • [Police trauma] “Have you ever been hit, beaten, assaulted, or shot by the police or other law enforcement officials?”
      • Yes
      • No

      If yes,

      • “How old were you the first time?”_______________
      • “How old were you the last time?”_______________
      • “When this happened, did you ever feel very afraid, horrified, or helpless?”
      • Yes
      • No

      “Did you ever think you might be injured or killed?”

      • Yes
      • No
    • [Medical trauma] “Have you ever been in the hospital because you were very sick or very hurt?”
      • Yes
      • No

      If yes,

      • “How old were you the first time?”_______________
      • “How old were you the last time?”_______________
      • “When this happened, did you ever feel very afraid, horrified, or helpless?”
      • Yes
      • No

      “Did you ever think you might die?”

      • Yes
      • No
    • [Witnessing trauma] “Have you ever seen someone else get killed, badly hurt, or sexually assaulted?”
      • Yes
      • No

      If yes,

      • “How old were you the first time?”_______________
      • “How old were you the last time?”_______________
      • “When this happened, did you ever feel very afraid, horrified, or helpless?”
      • Yes
      • No

      “Did you ever think you might be injured or killed?” [NOTE: Not required for PTSD Criterion A]

      • Yes
      • No
    • [Other trauma] “Has any other very bad or upsetting thing ever happened to you?”
      • Yes
      • No

      If yes, what was it? (If more than one, pick the worst other thing that happened)

      _________________________________________________________________________

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      • “How old were you the first time it happened?”_______________
      • “How old were you the last time it happened?”_______________
      • “When this happened, did you ever feel very afraid, horrified, or helpless?”
      • Yes
      • No

      “Did you ever think you might be injured or killed?”

      • Yes
      • No

    ITCT-A Assessment Locator

    ATF-A ItemAssessment (Tests applicable only for relevant age ranges)
    1. Safety—environmentalAdolescent self-report in session (A-S), parent/ caretaker report in session (C-R)
    2. Caretaker support issuesA-S, C-R, and clinical impressions during parent interview
    3. AnxietyA-S, C-R, CBCL, BASC-2, PAI-A, MMPI-A, TSCC, TSSA, TSI, TSI-2
    4. DepressionA-S, C-R, CBCL, CDI, BDI-II, BASC-2, TSCC, TSSA, TSI, TSI-2
    5. Anger/aggressionA-S, C-R, BASC-2 (parent report), CBCL, PAI-A, TSCC, TSSA, TSI, TSI-2
    6. Low self-esteemA-S, C-R, BASC-2, TSCS
    7. Posttraumatic stressA-S, C-R, PAI-A, MMPI-A, TSCC, TSSA, TSI, TSI-2, DAPS, UPID
    8. Attachment insecurityA-S, C-R, BASC-2, TSI-2, TSSA
    9. Identity issuesA-S, C-R, IASC, TSI, TSI-2
    10. Relationship problemsA-S, C-R, BASC-2, CBCL, TSSA
    11. SuicidalityA-S, C-R, TSCC, PAI-A, TSI-2, TSSA, DAPS, SIQ(Continued)
    12. Safety—risky behaviorsA-S, C-R, TSCC, BASC-2, TSI, TSI-2
    13. DissociationA-S, C-R, TSCC, TSSA, DAPS, TSI, TSI-2
    14. Substance abuseA-S, C-R, BASC-2, PAI-A, TSI, TSI-2, DAPS
    15. GriefA-S, C-R
    16. Sexual concerns and/or dysfunctional behaviorsA-S, C-R, TSCC, TSSA, TSI, TSI-2
    17. Self-mutilationA-S, C-R

    Assessment-Treatment Flowchart: Adolescent/Young Adult Version (ATF-A)

    Client Name:_______________________________________________

    Priority ranking (circle one for each symptom):

    • 1 = Not currently a problem: no treatment currently necessary
    • 2 = Problematic, but not an immediate treatment priority: treat at lower intensity
    • 3 = Problematic, a current treatment priority: treat at higher intensity
    • 4 = Most problematic, requires immediate attention
    • (S) = Suspected, requires further investigation

    Assessment Period: ___________________________________________

    Problems-to-Components Grid (PCG)

    Problem (from ATF-A)Treatment component that may be useful (in approximate order of importance)
    1Safety—environmentalSafety training, system interventions, psychoeucation
    2Caretaker support issuesFamily therapy, intervention with caretakers
    3AnxietyDistress reduction/affect regulation training, titrated exposure, cognitive processing, medication
    4DepressionCognitive processing, relational processing, relationship building and support, group therapy, medication
    5Anger/aggressionDistress reduction/affect regulation training, trigger identification/intervention, cognitive processing
    6Low self-esteemCognitive processing, relational processing, group therapy, relationship building and support
    7Posttraumatic stressDistress reduction/affect regulation training, titrated exposure, cognitive processing, psychoeducation, relationship building and support, trigger identification/intervention, medication
    8Attachment insecurityRelationship building and support, relational processing, group therapy, family therapy
    9Identity issuesRelationship building and support, relational processing, group therapy
    10Relationship problemsRelationship building and support, relational processing, cognitive processing, group therapy
    11SuicidalitySafety training, distress reduction/affect regulation training, cognitive processing, systems intervention
    12Safety—risky behaviors and tension-reduction behaviorsPsychoeducation, safety training, cognitive processing, titrated exposure, trigger identification/intervention, distress reduction/affect regulation training
    13DissociationDistress reduction/affect regulation training, affect regulation training, emotional processing, trigger identification/ intervention
    14Substance abuseTrigger identification/intervention, distress reduction/affect regulation training, titrated exposure
    15GriefCognitive processing, relationship building and support, psychoeducation, titrated exposure
    16Sexual concerns and/or dysfunctional behaviorsDistress reduction/affect regulation training, psychoeducation, safety training, cognitive processing, titrated exposure, trigger identification/intervention
    17Self-mutilationDistress reduction/affect regulation training, trigger identification/intervention, cognitive processing, titrated exposure

    Written Homework About my Trauma

    This homework has to do with the trauma that you and your therapist agreed that you should write about. There might be a lot of traumas in your life, so, remember, this is just about the trauma that you and your therapist picked this time. After each question, write an answer in as much detail as you can, in the amount of space you have. When you are done, save this homework, and bring it to your next session so that you and your therapist can read it together. You don't have to answer all these questions at the same time. You can put it down and then start on it again later. If it is too upsetting to finish, you can stop and talk to your therapist about it in your next session.

    • What happened to you?

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    • What were your feelings when it was happening?

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    • What was the worst feeling after it happened?

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    • What did you think when it was happening?

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    • What did you think after it was over?

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    • What did you do after it happened?

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    • What was the worst thing about what happened?

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    • Is there anything about what happened that has made you stronger or better or smarter?

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    What Triggers Me? (the Trigger Grid]

    What Is a Trigger?

    _____________________________________________________________________

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    Times I Have Been Triggered

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    What Kinds of Things Trigger Me? (What Are My Triggers?)

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    What Happened After I Got Triggered?

    Trigger #What I Thought After This TriggerWhat I Felt After This TriggerWhat I Did After This Trigger
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    How I Know I've Been Triggered

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    What I Could Do So That I Wouldn't Get Triggered

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    What I Could Do After I Get Triggered That Would Make It Better and I Wouldn't Get So Upset or Mad

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    Outlines for Two ITCT-A Therapy Groups

    As described in Chapter 19, ITCT-A therapy groups can be adapted for different settings and to meet the specific needs of different trauma survivors. Presented here are outlines for two such groups: one for sexual abuse survivors in an outpatient clinic and one for traumatized adolescents in a school setting. In both cases, although specific topics and activities are presented, the general principles of trauma-focused group therapy outlined in Chapter 19 should be adhered to.

    ITCT-A Group for Adolescent Female Sexual Abuse Survivors

    This group intervention for sexually abused younger adolescents, aged 12 to 15, was initially developed by Hernandez and Watkins (2007), and further expanded here. Prerequisites for participation in this 12-week group were recent and/or current ITCT-A individual therapy, ability and commitment to attend all weekly sessions, interest in further processing traumatic experiences, and sufficient affect regulation skills to cope with the possibility of being triggered by others in group sessions.

    • Screening

      Once referrals are received, prospective members are interviewed and, if accepted into the group, asked to complete relevant pregroup assessment measures, such as the TSCC.

    • Session 1: Introduction to the Group

      Topics and activities: Introductions, overview of the group, confidentiality, and rapport/trust building. Group leaders note that all of the girls are in the group because they have been sexually abused but generally do not expand further during the first session. In some cases, especially when individual therapy has occurred or is continuing through the course of the group sessions, group members may wish to share briefly in this initial session what sexual abuse experiences they have had. This can reduce anxiety associated with having to disclose their traumatic experiences. Rules of confidentiality are reviewed, since some of the girls may attend school together or associate with each other in other contexts. They are asked not to talk about the group outside of the group, although this cannot always be prevented. If outside communication occurs between group members, it is important that they discuss these contacts within the group setting. No sexual relationships between group members are permitted. Although this might seem unlikely for this age group, externalized sexual behavior is not especially uncommon among younger sexual abuse survivors.

      In order to reduce anxiety associated with introductions, group members interview each other, in pairs, and then share with the group what that member told her about herself. Group members may also draw self-portraits representing how they feel at the start of group therapy. These self-portraits are kept by the cotherapists and then are compared with self-portraits completed at the end of group therapy. In addition, group members may wish to write personal goals they hope to accomplish with their participation in the group. These are kept by cotherapists, but a copy is returned to the group member so that they can refer to them and revise as needed as they proceed through the group sessions.

    • Session 2: Learning About Sexual Abuse

      Topics and activities: Psychoeducation regarding common reactions to sexual abuse. Members are presented with psychoeducation about the thoughts and feelings often experienced by sexual abuse survivors. Group members are asked to share symptoms that they have observed in themselves and in other sexual abuse survivors. Materials relevant to their trauma experiences, especially child sexual abuse and peer sexual assault, may be distributed and discussed. Materials must be age-appropriate and reviewed by the cotherapists prior to distribution. For example, excerpts from Don't Give It Away! (Vanzant, 1999), My Body, MyselfThe What's Happening to My Body Book for Girls (Madaras & Madaras, 2000) and, for male groups, the What's Happening to My Body Book for Boys (Madaras & Madaras, 2007) may be used. Sometimes clients also will want to share the names of books or movies relevant to sexual abuse, such as I Know Why the Caged Bird Sings (Angelou, 1969) and Push (Sapphire, 1996), made into the movie Precious.

    • Session 3: Learning About and Expressing Feelings Related to the Trauma

      Topics and activities: Activities to explore and express feelings, especially how clients felt before, during, and after the abuse, and upon disclosure, if relevant. Clients who are more reticent about directly expressing their feelings verbally can be invited to write a letter to the perpetrator or person who did not protect her (with explicit instructions not to send it, at least at that time), write a poem about her feelings, or simply list, on paper, the feelings she had before, during, and after the abuse ended or was disclosed (as for many trauma survivors, the disclosure may be delayed until well after the abuse ended). Group members may choose to use an art activity such as Color-Your-Life (O'Connor, 1983), using different colors in an abstract fashion to depict feelings about the abuse.

    • Session 4: Specific Exploration of Trauma-Related Perceptions

      Topics and activities: Collage or art depicting how they believe others see them, how they view themselves “on the inside,” and their feelings about how they were affected by the abuse. For example, group members have made collages with pictures and words depicting the alcoholism of their perpetrator; unseeing, disbelieving, and unprotective family members; other related abuse (physical abuse, domestic violence, community violence); the perpetrator, represented symbolically (e.g., by male in black-and- white-striped prison garb, as a devil or other threatening figure); and other symbols of their trauma and the impacts on them. This tends to be a session where clients focus on visual expression of their experiences, through art, which can then lead to exploration of their trauma narrative and deeper emotional processing. Group members also may create a box with drawings, photos, and words glued on the outside to depict how they believe others see them. Then, in the same fashion, they can draw and/or glue photos and words on the inside of the box to depict how they perceive themselves.

    • Session 5: Specific Exploration of Traumatic Events Experienced

      Topics and activities: Writing a narrative of their abuse history. Generally, per Chapter 12, group members write about their trauma exposure and then read it to the group. Another approach is the “hat game,” involving all group members and coleaders writing questions concerning sexual abuse experiences, which are then placed in a container or hat. Each group member draws a question and answers it, after which all other group members also answer the question. If a group member declines to answer, he or she is not pressured to do so but is asked to express the feelings he or she is having and why it is difficult to answer the question. This process often helps the recalcitrant group member to address the question in some manner and, sometimes, to disclose more specific details regarding their experiences and feelings. Especially for less verbal group members, this can be the beginning of the development of a more detailed trauma narrative.

    • Session 6: Specific Exploration of Trauma (Continued)

      Topics and activities: Sharing trauma narratives with the group, per Session 5. This session can begin with a meditation or relaxation period, whereby group members focus on their breath and pay attention to their thoughts (see Chapter 11 for the specific exercise). As they further share their narratives and related feelings, the courage of each member and of others in the group is emphasized. The cotherapists typically invite all group members, before the session ends, to mention something positive that they noticed about each other in the processing of their trauma narrative. As this is also the midpoint of the group, and may involve new trauma-related material, the group therapists may debrief with clients' individual therapists (with completed consent for information, if needed). Group members are also encouraged to evaluate their progress in the group and how they are working toward meeting their goal(s).

    • Session 7: Addressing Thoughts and Feelings About Sex and Sexuality

      Topics and activities: Group members use their narrative to help them talk about sexuality and to integrate their experiences into their lives. It is common during this session for group members to share feelings of being coerced by peers to have sex, difficulties they may have in enjoying consensual sexual experiences with partners, sexual identity issues, and other concerns related to difficulties with intimacy. Older adolescents sometimes disclose that they have increased flashbacks and nightmares when they are engaged in a sexual relationship, even with a partner with whom they feel safe. Psychoeducation materials normalizing sexual feelings and sexual development, describing safer sexual behaviors, and covering other related topics are often helpful at this point.

    • Session 8: Begin Exploring Problem Solving

      Topics and activities: This session relates in particular to affect regulation and affect tolerance. A general discussion is facilitated about whether there are things survivors can do to improve their lives, decrease the likelihood of further victimization, and get through times when their feelings are triggered. It may be helpful during this session for group members to work on their trigger grids (Chapter 13), as they identify situations that activate memories and feelings, and discuss what they can do to take care of themselves at such times. Group members may also identify those whom they can turn to for support and how they can expand their repertoire of coping skills outside the group (e.g., physical activity, art, music, reading, journal writing, etc.).

    • Session 9: Learning About Boundaries and Safety

      Topics and activities: Developing a specific safety plan regarding the possibility of future abuse or other relational trauma. Adolescents often benefit from discussing potential dangerous situations in their lives that might result in additional physical and sexual assaults. This may also include who they identify as safe versus unsafe in their families, as well as those who can help to keep them safe, such as supportive peers, coaches, teachers, neighbors, etc. Because so much of abuse and neglect occurs within attachment relationships and family systems, this can also be a session wherein group members explore, through family genograms (Chapter 17), how risks to safety, and boundary violations, have occurred intergenerationally within their family. They can then identify ways to change these patterns and be safer in the future.

    • Session 10: Focusing on Self-Esteem

      Topics and activities: Exploring and identifying a client's positive qualities. This session involves discussion of potentially “positive” outcomes of experiencing abuse (e.g., how it has made them stronger, the idea that “If I got through that, I can deal with this….”).

      Leaders of groups where self-esteem issues are especially paramount may choose to adjust the sequence of session topics, so that this session occurs at an earlier stage. It is often a helpful strategy to include an activity at the beginning and/or end of this session, wherein group members share their perceptions of positive attributes of the other group members. It is especially important that no one be overlooked during this activity.

      An example of an activity to increase self-esteem and feelings of being accepted by others, as well as increasing compassion for—and appreciation of—one another, is the “balloon game.” This activity is particularly helpful for younger group members and those who are less verbal. Each group member writes one supportive message for each of the other group members, along with one self-care message for themselves, on a piece of paper. Group members fold and insert the piece of paper into a deflated balloon, blow it up, and toss it around the room. Each member then takes one balloon (not their own) and pops it. They then read aloud the messages and discuss any feelings associated with these messages.

    • Session 11: Building Positive Coping Strategies for Painful Memories

      Topics and activities: Learning to avoid being triggered and, if it can't be avoided, what can be done to cope with triggered states (both what they identified on the trigger grid described in Chapter 13 and Appendix VI, as well as additional options they have come up with since completing the grid). In addition to trigger identification and discussion, group members also discuss how to handle relationships so that they can be safe and how to avoid being revictimized in general. Depending on the level of affect regulation capacities in the group, members will sometimes benefit from this session being conducted earlier in the sequence, so that they can be better prepared to do trauma processing later on. If group members are having particular difficulty with this material, cotherapists and group members may wish to extend this topic to more than one session.

    • Session 12: Termination Group

      Topics and activities: Overview/recap of the group. In the last group meeting, members make individual disclosures about what they gained from the group. Members may also create a self-portrait to be compared with the one they created in the first session, review their goals and what they have accomplished or gained from being in the group, as well as review any other material representing their progress in the group, such as music, journal writing, artwork, etc. Group members are encouraged to describe their goals for the future. It is also important that all group members share in a celebration during this session, which typically involves special food brought from home or that the coleaders have provided. At this time, clients can complete post-group measures, such as the TSCC.

      If the leaders and the group members so desire, the group may be extended for another four sessions. In such cases, additional topics may include sex roles, stereotypes, and gender issues (using collages, role-plays, and exploration of non-gender-stereotypic behaviors), as well as more on family relationships, including exploration of primary-attachment relationships, caretaking failures and disappointments, role models, and those who did provide nurturance.

    School-Based Group for Traumatic Loss/Community Violence

    Often, adolescents in school settings with complex trauma exposure and symptoms are not clinically referred, because they have not been identified as traumatized. In other cases, parents or guardians are not amenable to their treatment in a clinical setting, but will consent to school-based group sessions. The following is a general group session outline for younger adolescents (aged 12–14 years) attending middle school who have experienced traumatic loss (e.g., of a parent or close friend) and community violence (e.g., witnessing shootings). The first version of this model was developed at MCAVIC by Karianne Chen, M.S., M.F.T. and Kathleen Watkins, Ph.D., with earlier contributions from other MCAVIC therapists who provided school-based interventions. This model has been further expanded here to include additional components. A version of this model has also been used in an alternative education setting (Neale & Aguila, 2004) with more emphasis on behavior management in the classroom, crisis intervention, acute problem solving, reducing at-risk behavior in the community, and expanding choices. Clients in this environment were fairly guarded and less likely to disclose the full nature of their trauma exposures.

    This model is aimed toward younger adolescents because it is difficult to coordinate a weekly school-based group for older youth (i.e., those attending high school)—primarily due to the constraints of academic schedules and difficulties removing students from academic classes. However, this model can be applied to older adolescents in programs where there is a specific focus on assisting troubled youth, for example, residential treatment-oriented schools or day treatment programs that include an academic component.

    It is not unusual for youth attending school-based groups to disclose new, or additional, child abuse and neglect experiences, thereby necessitating reports to child protection agencies. For this reason, any school-based intervention like ITCT-A should have a built-in procedure for dealing with child maltreatment reporting, as well as, when possible, an option to refer especially traumatized children to individual therapy.

    Presented here is the ITCT-A model for school-based intervention. As was true of the previous group model, the specific topics and activities—as well as the order in which they are applied—may vary according to the specific needs of the youth involved.

    • Screening

      Once referrals are received, prospective members are interviewed and, if accepted into the group, asked to complete relevant pregroup assessment measures, such as the TSCC-A or CBCL.

    • Session 1: Introduction to the Group

      Topics and activities: Introductions, overview of the group, group rules and guidelines that are posted at each group, confidentiality, rapport/trust building, and creating a safe therapeutic environment. Clients are asked to make a brief statement about why they are attending the group (e.g., “I saw a cousin get shot” or “I told my teacher that my dad hits me”). Cotherapists introduce the use of a behavioral chart (this is not always needed for older adolescents) to monitor each member's positive behaviors and means for reinforcement (e.g., stars or stickers for behaviors, then a pizza party for the group when their goal is reached).

      Because the group is held at a school site, confidentiality is discussed, including the limits of confidentiality when there is a need to report suspected child abuse or danger to self or others. Group members are instructed to not discuss what is shared in group sessions outside of group. To build cohesiveness, members agree on a group name and make a banner that is posted at each session. Adolescents interview each other in pairs (per the sexual abuse group) and then describe to the other members what they learned about the group member he or she interviewed. Self-portraits are completed and discussed in terms of the client's self-perceptions and feelings regarding participating in the group. Group members describe and/or write their goals for participating in the group. Icebreakers to help build trust and rapport among group members may be used, such as a board game, art therapy, or physical activity such as role-playing a favorite place, animal, or person/hero.

    • Session 2: Building Cohesion and Trust

      Topics and activities: Activities related to identity development, safety in the group, and increasing connection and comfort with other group members. Group members share briefly why they are in the group and typically participate in activities such as drawings, collages, and/or writing exercises as well as role-plays to facilitate self-expression and reinforce a sense of safety and boundaries. These activities are focused on describing who they are and their interests, likes, and dislikes. Group members each share at least one positive impression about all other group members. Group and individual goals are discussed further and revised as needed.

    • Session 3: Identifying Feelings and Emotions

      Topics and activities: Activities related to identifying and processing feelings associated with traumatic experience(s). Group members typically have not had an opportunity to explore and express their feelings in a supportive environment. They are encouraged to identify their feelings, including those associated with the traumatic experience(s), and explore how they are, in fact, normal reactions to an abnormal/distressing situation (e.g., witnessing community violence, experiencing a traumatic loss). Members connect feelings to their traumatic experiences using games (e.g., Ungame), art (e.g., self-portraits), and writing exercises (e.g., letter to the person they lost, a description of how they felt before the loss versus after). Group members may also role-play distressing situations so they can act out how they express and/or manage feelings. This session begins the process of learning more adaptive ways to express and manage feelings.

    • Session 4: Learning About Trauma and Loss

      Topics and activities: Psychoeducation regarding different types of trauma and their impacts, focusing primarily on community violence and traumatic loss. Information is provided by cotherapists regarding common trauma experiences in the locale where the members live, and trauma-related reactions such as posttraumatic stress, anxiety, depression and sadness, anger, and dissociation that group members might be experiencing. Members are encouraged to begin discussing their past and current reactions to their traumatic experiences. As the majority of group members are likely to have experienced a traumatic loss that may also be related to community violence, they are encouraged to discuss how the commonly acknowledged stages of grief—denial, anger, bargaining, depression, and acceptance—relate to them.

    • Session 5: Anger Management/Affect Regulation

      Topics and activities: Psychoeducation and activities that help group members to identify when they may feel triggered and how to cope with triggeredfeelings. Since group members attending school-based group sessions typically have not had a course of individual therapy, it is important that they develop affect regulation skills before engaging in cognitive or emotional processing of their actual trauma experiences. Group members identify ways that they get triggered and react (using the trigger grid presented in Appendix VI) and engage in role-plays that help them to understand the perspective of others and explore alternative ways of responding. Group members may also create collages, write, or engage in art activities that address these questions: What makes them angry? How does their behavior affect others? How can they respond differently so that there are no negative consequences? In one storefront group, members viewed videos of admired professional athletes behaving aggressively toward others while playing a sport. Members then discussed the negative consequences for these role models and alternative ways they might have dealt with their anger. Group cotherapists instruct group members in affect regulation skills such as relaxation exercises, breath training, and/or introduce them to meditation (see Chapter 11). This session may be repeated an additional time if group members appear to require further focus on affect regulation skills.

    • Session 6: Specific Exploration of Trauma Events

      Topics and activities: Creating a trauma narrative through drawings, writing, collages, and other group activities. Group members create collages or drawings that relate to their traumatic experiences. Members may also use the “hat game” (see Session 5 in the previous group outline), using questions about traumatic experiences written by group members and coleaders that are then placed in a hat or container. As previously described, each group member draws a question that he or she responds to, with the other members then taking turns answering the question (e.g., “Where were you when your friend/loved one died?”). This intervention has been especially effective with groups in which members are processing more violent, or intrusive, experiences and are having difficulty directly verbalizing them. Group members also may write a letter to the perpetrator or person who did not protect them or support them. Younger group members may also use a board game such as the Ungame to facilitate discussion of specific experiences and feelings.

    • Session 7: Further Processing of the Trauma Narrative

      Topics and activities: Group members further process their trauma narrative per Session 6. Group members add more details to their narrative, including how they are reminded of their traumas, the worst moments of the trauma, and trauma-related symptoms and feelings. Members also may honor the memory of their lost loved one through a poem, drawing, song, or letter. Throughout this and the previous session, group members are encouraged to describe their current feelings when describing what happened to them.

    • Session 8: Cognitive Processing

      Topics and activities: Group members describe cognitions associated with trauma experiences and provide feedback to each other. Group members identify negative beliefs and cognitions related to their trauma narrative. Discussion is focused on cognitive reframing/reconsideration (see Chapter 12), exploring beliefs and distortions about the trauma, and addressing feelings of self-blame, guilt, fears, and powerlessness. Group members provide supportive feedback to each other and, in some groups, engage in role-plays to enact situations associated with distorted cognitive beliefs (e.g., witnessing a friend being shot in a drive-by shooting and realizing that they could not have prevented their friend's death).

    • Session 9: Staying Safe and Recognizing Positive Aspects of Their Lives. [Note: If there are immediate safety issues for group members, this session may be scheduled earlier in the sequence of sessions.]

      Topics and activities: Group members explore ways that they can be safe, including expanding positive coping skills. Some group members may have lost family members or close friends to violence, so they will need to explore ways that they are and can continue to be safe. Group members discuss how they can build a safety repertoire—expanding coping skills and their support systems and developing a safety plan (see Chapter 9). Members may role-play unsafe situations and problem-solve ways to seek help. They may explore ways in which they can prevent further traumatic experiences, by identifying risky situations and dangerous environments and discussing ways to avoid risk of trauma (e.g., avoid a particular neighborhood, prevent risk of gang-related involvement by engaging in an after-school sport or other extracurricular activity).

    • Session 10: Building Self-Esteem and Social Skills

      Topics and activities: Group members participate in activities focused on improving self-perceptions, self-capacities, and a greater sense of empowerment. This session focuses on group members becoming more self-aware and mindful through meditation exercises (see Chapter 11) and “checking in on” their internal states. They may share with each other their responses to statements such as “I am good at …,” “I can help others by …,” and/or create a collage depicting “I am …,” thereby incorporating self-awareness and meaning that has been developed from prior trauma processing. They may also review their trauma narrative in the context of strengths gained, and skills learned, from the trauma. More severely traumatized adolescents often have difficulty forming relationships with others and feeling empathy for others' experiences. As members are able to process their traumatic experiences, feel supported by others, and gain more positive self-identities, they are likely to be more emotionally available to others, have greater empathy, and be able to form stronger relationships, thereby increasing their self-esteem. Group members are encouraged to increase their relatedness with others by listening to other group members share their self-perceptions and by verbalizing positive qualities they observe in each other.

    • Session 11: Caring for Others and Positive Coping

      Topics and activities: Group members explore further ways to increase their relatedness to others and positive coping strategies. Discussion and activities focus on increasing their ability to empathize with others, manage their own reactions, and recognize the gains that they have made. This session is particularly focused on relational aspects of their coping and may also connect to work they are doing (or have done) in individual and/or, occasionally, family therapy. Group members also explore through discussion their current family and peer relationships. Group members may role-play common challenging situations so that they can generate more options for positive coping.

    • Session 12: Making Plans for the Future and Celebration

      Topics and activities: In this session, members review what they have gained in participating in the group and discuss their goals for the future. Group members share stories, journals, artwork, and music reflecting what they have learned about themselves through the group. In some groups, the therapists may keep a folder of each member's artwork, writing exercises, collages, etc., until the last session, when they take their folders home. Group members discuss the extent to which they have been able to process their trauma experiences and related feelings and any changes in self-esteem, coping ability, sense of empowerment, or safety that they have experienced. Members review their initial goals for the group and whether they achieved them, and offer supportive feedback to each other. They discuss plans and goals for the future. To celebrate the group and the work accomplished, members usually choose to share a pizza or cake and ice cream, or they bring a favorite dish to the final session. Group members complete postgroup assessment measures and self-portraits at this final session.

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    About the Authors

    John N. Briere, Ph.D., is an associate professor of psychiatry and psychology at the Keck School of Medicine, University of Southern California, and director of the Psychological Trauma Program at LAC+USC Medical Center. He is a past president of the International Society for Traumatic Stress Studies and recipient of the Outstanding Contributions to the Science of Trauma Psychology Award from the American Psychological Association. Designated as a “Highly Cited Researcher” by the Institute for Scientific Information, he is the author or coauthor of a number of books, articles, chapters, and psychological tests in the areas of trauma, child abuse, and interpersonal violence. His website is http://www.johnbriere.com.

    Cheryl B. Lanktree, Ph.D., is a licensed clinical psychologist in private practice and a clinical associate professor of psychiatry and the behavioral sciences at the Keck School of Medicine, University of Southern California. She was the principal investigator for the federally funded program that piloted the treatment model described in this book. Dr. Lanktree has published various papers and chapters, as well as two treatment manuals, on the assessment and treatment of trauma in children and adolescents. The developer of Integrative Treatment of Complex Trauma (ITCT), she provides workshops and trainings nationally and internationally. Her website is http://www.cblanktree.com.


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