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In the realm of mental health there are still underserved populations not being provided with the needed mental health resources and care. One such population is adolescents dealing with complex trauma. One way that the needs of this population could be met is the implementation of trauma-focused cognitive behavioral therapyin school settings. Some behavior problems that arise within the school are correlated with complex trauma during childhood. The goal is to serve these students to prevent further negative symptomatology from their traumas. Group therapy provides insight for intrapersonal and interpersonal maladaptations. In order to implement such a group effectively it is important to understand the theoretical approach taken, the population in question, and how to best bring both together in a group process.
Starting with a theoretical foundation for therapy is always important whether it be individual or group-based work. In reviewing the recent scholarly literature on theories of group work, specifically with clients who have a history of trauma, three theoretical approaches stood out. The first is narrative theory and its use of narrative exposure therapy. There is also behavioral theory with its STAIR approach and cognitive behavioral theory with its trauma focused approach. Narrative TheoryOne major type of group therapy that looks at trauma-based group work is narrative therapy. According to Kwok (2016), narrative therapy recognizes the significance of individuals needing to be able to tell their own stories, as these are the stories that people live by and with throughout their lives. Narrative therapy believes that people’s stories give their lives meaning, direction, and effect interpersonal relationships (Kwok, 2016). This is what makes it easy to integrate narrative therapy into trauma therapy, as all of these aspects of story are especially true for a person’s trauma narrative.
According to Mauritz et al. (2016), one specific type of therapy that is used for higher risk groups is “narrative exposure therapy (pg. 3). ” Narrative exposure therapy (NET) was created to help those suffering from post-traumatic stress disorder (PTSD) and those dealing with repeated trauma histories (Mauritz et al. , 2016). The NET looks to combine aspects of both individual counseling and group counseling in its approach. Specific components of NET start with developing an “active chronological reconstruction of the autobiographical memory (Mauritz et al. , 2016, pg. 3). ” The next component focuses on individual prolonged exposure therapy (Mauritz et al. , 2016). Then the group attempts to find significant connections and integrate regulation of the body, mind, and emotions for stabilization (Mauritz et al. , 2016). The fourth component involves thinking through patterns of behavior and a revaluation of the trauma story through processing those difficult memories in a new light (Mauritz et al. , 2016). It is then important to “revisit positive life experiences” and regain dignity through ownership of the trauma story (Mauritz et al. , 2016, pg. 4). However, drawbacks of NET are that within the narrative therapy realm, NET is relatively new and still being researched (Mauritz et al. , 2016). Therefore, NET can still be useful but should be used with caution. There is also no adaptation of the therapy specifically for adolescents (Mauritz et al. , 2016). Narrative therapy has its limitations; therefore other theories are also being addressed.
Another theory that deals with group work specifically related to trauma is behavioral theory. According to Seon-Rye, Han-Hong, and Seoul-Hee (2017), behavioral theory does not necessarily focus on the behavior, but what is behind the function of the behavior. “Behavior is affected by intention and perceived behavior control, intention is determined by the attitude of the behavior, subjective norm and perceived behavior control (Seon-Rye et al. , 2017, pg. 8316). ” Gudiño et al. , (2014) notes that within behavior theory and behavior therapy is a group trauma-informed treatment known as “skills training in affective and interpersonal regulation” or STAIR (pg. 496). The STAIR approach works in phases and has been developed in a form specifically for adolescents (Gudiño et al. , 2014). The therapy looks to focus on stabilization, functioning, symptom reduction, and safety for the clients (Gudiño et al. , 2014).
The first module of this trauma-focused treatment begins with psychoeducation on trauma and the way past-trauma can play a role in present issues the clients may be experiencing (Gudiño et al. , 2014). The second module then looks at coping skills and tries to help clients evaluate their feelings. In order to do so clients are asked to look at ways they currently try to cope. Then the counselor looks at helping clients learn new, more adaptive ways of coping (Gudiño et al. , 2014). The last module of this theory looks at communication and helping clients develop better skills in that area. The first step of the module is to become aware of current obstacles to communication, and the next step looks at developing new, more effective ways of communication (Gudiño et al. , 2014). Finally, the group focuses on how to become more flexible in relationships and how to be more aware of what they are communicating to others (Gudiño et al. , 2014). Cognitive behavioral theory enhances the work of behavioral theory.
Similar to the structure of behavioral theory is cognitive behavioral theory (CBT). While behavioral therapy has its strengths, O’Donnell et al. (2014) talks about the stronger evidence base and more established approaches in CBT in the realm of trauma. This was one of the major reasons CBT was the chosen approach for thetrauma-group. Visser et al. (2015) confirms that trauma focused CBT (TF-CBT) is a form of treatment that has shown to be effective specifically with adolescents dealing with trauma. The components of TF-CBT were standardized for adolescents to help parents learn how to be part of the healing process for their children (Visser et al. , 2015). One of the advantages of this standardization according to Sachser, Keller & Goldbeck (2017) is the manualization of the treatment. The manulization makes it easier to implement TF-CBT, especially in a school setting.
Particularly helpful with CBT is how the theory looks at trauma and what goes into trauma’s development. According to Ridings, Moreland & Petty (2018) and Scher, Suvak & Resick (2017), predisposing factors often include low socio-economic environment, low levels of resilience, negative attachment style, and frequency of exposure to traumatic experiences. A mixture of these factors often set the stage for a child or adolescent to late experience acute or complex trauma. The precipitating factor for trauma is associated with the traumatic experience that triggers the trauma-related symptoms and the way that this experience shifts the person’s way of thinking and interpreting information through the filter of that trauma (Scher et al. , 2017). This shift often negatively affects their view of either themselves or the world around them (Scher et al. , 2017).
Along with predisposing and precipitating factors are perpetuating factors. Perpetuating factors can include poor family functioning, the parental figure having their own mental health issues, substance abuse, low self-esteem, and negative schema formed from trauma experience or experiences (Ridings et al. , 2018). Other factors can include a heightened sense of threat due to hypervigilance, the development of “inaccurate meanings of the trauma experience,” and poor emotional regulation (Scher et al. , 2017, pg. 751). Many of the other theories that work with trauma agree that cognitions are an important piece of what go into and maintain the symptoms of traumatic disorders such as PTSD (Scher et al. , 2017). CBT attempts to consider all of these moving pieces and influencing factors. This is completed through implementing practical therapy which attempts to target and restructure many of the thoughts and beliefs that seem to work against the individual dealing with trauma (Ridings et al. , 2018).
The components of TF-CBT work in a phased approach similar to the previously mentioned behavioral therapy (Visser et al. , 2015). There are three phases that make up TF-CBT (Sachser et al. , 2017). The modules of the different phases are arranged around the acronym “P. R. A. C. T. I. C. E” which do not only touch on CBT but include aspects of behavioral theory, family theory, and attachment theory (pg. 161). This integration of other theories is part of what set CBT apart when deciding which theory to move forward with in group therapy. The first phase looks at psychoeducation regarding trauma and to help clients work on basic skills of stabilization (Visser et al. , 2015). Phase one is made up of the first four sessions and then phase two focuses on working through the trauma story in the next three to four sessions (Sachser et al. , 2017). The final phase that is made up of the last three sessions is focused on developing a sense of safety and looking to the future with the new sense of self development through ownership of the trauma story (Sachser et al. , 2017). It is important to note that these phases are not seen as linear and that not all participants are able to move from one phase to the other in a chronological order (Ridings et al. , 2018).
Session one of manualized CBT starts with psychoeducation in relation to trauma symptoms, etiology, and parental support for children and adolescents dealing with trauma (O’Donnell et al. , 2014). The next session deals with relaxation techniques, mood regulation, and triggers that may be associated with the trauma (O’Donnell et al. , 2014). The third session of the manualized CBT focuses on cognitive coping skills such as ABCD model through worksheets that challenge maladaptive thoughts. The fourth session opens up the idea of the trauma narrative and what that looks like in general terms (O’Donnell et al. , 2014). Sessions five through eight look to focus on the individual trauma narratives of each individual involved while also including individual sessions where the trauma story can be explored with the adolescent and parental figure (O’Donnell et al. , 2014). The final three to four sessions focus on dealing with the loss that is associated with the trauma story and then a movement to the new sense of self. The goal is to hold onto the positive memories and then look to the future for new positive relationships (O’Donnell et al. , 2014). Cognitive behavior theory is the focus of the group work with adolescents, as it is one of the best serves for clients dealing with trauma.
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