Group therapy is a helpful addition to ITCT-A, although it is not used with all traumatized adolescents.
Typically, group treatment augments individual therapy; it is generally not used in isolation6. This is because many adolescent survivors of complex trauma suffer from relatively intense symptomatology, including posttraumatic stress and painful relational memories – phenomena that, along with the specific activities of trauma group therapy, can be triggered by interactions with other group members. Without concomitant individual therapy, these triggered cognitive and emotional states may become problematic for the client and for the group.
Especially triggering may be descriptions of abuse incidents that prematurely expose the client to his or her own unprocessed memories, often before he or she has sufficient affect regulation capacities to handle such material. Unfortunately, the result may be that the youth becomes so flooded by negative internal states that he or she either redirects the group leaders’ (and the group’s) attention to his or her responses alone (thereby altering group dynamics), or leaves the group session in an emotionally compromised state. In the absence of an individual therapist to whom the client can go for support and further intervention, the net effect of group therapy for such individuals may be negative.
Assuming that individual therapy is also available, group therapy can be a powerful tool in the adolescent survivor’s recovery. Below are some central principles and parameters, as well as an example of an adolescents’ group. The reader is referred to Briere and Lanktree (2011) for more information on the group component of ITCT-A, including an additional 12-session group that can be used for youth in school settings.
It is suggested that all groups be comprised of adolescents of a single sex (i.e., separate groups for males and females). This is because mixed gender trauma groups tend to involve two challenges:
- First, heterosexual members of such groups tend to respond to the presence of opposite sex members with behaviors associated with sexual-romantic issues, including showing off, flirting, or discussions of male-female differences in social contexts. Lesbian, gay, bisexual, or transgendered youth may evidence the same issues in same sex groups, but various factors (including the smaller ratio of such adolescents to their specifically heterosexual peers) typically reduce the prevalence or intensity of this issue. Sexual and romantic discussions and behaviors are a healthy part of adolescent development and socialization, regardless of the individual’s gender or sexual orientation. This however, may easily distract members from talking about, and processing, their traumatic pasts.
- Second, survivors of trauma generally often have less difficulty exploring their pasts when in the presence of same-sex group members. This is especially true of those with sexual abuse histories, who may experience greater shame or, in some cases, even triggered memories when disclosing in the presence of opposite-sex group members. The typical preference for disclosing to same-gender groups is often equivalent regardless of sexual orientation. The issue of transgendered youth sometimes presents a problem, although this can be negotiated within the group. Often, the transgendered adolescent will choose to attend sessions with members of his or her assigned sex, as opposed to biological one.
The clinician should consider limiting groups to members of specific age ranges, for example, 12 to 15 year olds versus 16 years or older. In general, there should be no more than a three year difference between the youngest and oldest member. This is because younger adolescents often differ from older ones in several respects: (1) they may be less mature emotionally and cognitively, such that they have different needs and capacities that affects how group treatment should occur, (2) it may be that exposure to the abuse/victimization stories of older adolescents will be too activating, and perhaps even traumatizing, and (3) younger members may be intimidated by the presence of older youth in the same group, leading to a decreased willingness to be vulnerable and open about trauma issues. Conversely, older group members often do better in groups of their peers, where they can openly discuss their concerns and issues, and where they may feel more understood by other members.
It is sometimes helpful to run groups with individuals who have certain issues or experiences in common. Examples of such groups are those who share histories of specific traumas (e.g., sexual abuse, hate crimes, refugee experiences) or who are especially identified with certain stressors or orientations (e.g., substance-abusing adolescents, homeless youth, or those who identify themselves as gay, bisexual, or transgendered). Race-specific groups are sometimes conducted, to the extent that members have experienced oppressive circumstances that require discussion and processing without dominant-race participants. In each of these cases, the issue is typically one of shared experience: the adolescent survivor may feel most safe and most comfortable with other youths who have been through similar experiences, as opposed to group members who cannot relate to their specific concerns, or even represent a group who has done them harm. In all cases, however, the therapist should consider the downside of homogenous groups, especially the possibility that opportunities for cross-cultural or cross-demographic discussions and/or rapprochements are missed.
Matching on Affect Regulation Capacity
Groups should ideally consist of clients with relatively equivalent abilities to tolerate emotional distress (Briere, 1996). As noted earlier, those with very little affect regulation capacities often do better in groups with others at similar levels; generally because the therapist can make sure that the focus and process of the group is less likely to be overwhelming. When group members have been screened for similar affect regulation skills, the trauma disclosures and processing activities of any one group member is less likely to trigger another member into an excessive emotional or cognitive state; in other words, all members share generally equivalent therapeutic windows, such that undershooting or overshooting is less common.
Although affect regulation matching is generally a good idea, in some cases there will not be sufficient potential members available to sort them into such groups. As a result, the clinician may have to include clients of differing levels of emotional regulation capacity, and thus may have to pay special attention to the possibility that some members may become overwhelmed if other members fully process their trauma. Unfortunately, this means that a given therapy group may be less helpful for some members than others; especially those whose capacities support the activation and processing of very distressing material, since they will necessarily have to be constrained to some extent in groups with individuals who have less ability to modulate strong emotional experiences. In such situations, the best that the clinician may be able to do is to screen out those adolescents with especially poor affect regulation capacity, so that (a) they will not be overwhelmed by other clients’ emotional processing, and (b) group members will have greater opportunities to discuss and respond to abuse memories without worrying about – and/or stigmatizing – those who might be especially overwhelmed by such material.
In general, whenever possible, there should be two group leaders, both of the same gender as the group participants. Group work with trauma survivors is often quite intense, and it is rarely sufficient that only one clinician be present. Two therapists allows the clinicians to “share the work:” backing each other up when necessary, but also providing two sets of eyes and ears so that subtle and/or important group dynamics are less likely to be missed.
In contrast to the practices of some agencies, it is also important that at least one group member be an experienced clinician who has led groups for trauma survivors in the past. Because group therapy for trauma survivors can be challenging, leadership of such groups should not be an entry-level job for newly trained or accredited therapists, unless close supervision is available and one co-therapist is experienced in treating traumatized youth. In the worst case, employing an untrained therapist in group treatment, without an experienced co-facilitator, can result in negative outcomes for both group members and the clinician.
Group Structure and Focus
Group treatment can be open or structured. Open or “drop-in” groups admit members at any time, often do not have a specific number of sessions planned, and typically do not address a single specific issue in any given session – whatever the group members wish to discuss, as long as it is trauma-related, is accepted. Group sessions usually last for 1 to 1 1/2 hours, although some may be constrained to a lesser amount of time.
Structured group therapies usually consist of a specific series of content-related sessions, and are closed to new members – members are recruited to attend the full number of sessions. Often, these groups meet for somewhere between eight and 16 sessions, although some agencies and clinicians offer longer session series. See Briere (1996) for a detailed discussion of open versus closed groups in the treatment of sexual abuse survivors.
An ITCT-A group for young adolescent females
Presented here is a structured, 12 week group for female sexual abuse survivors, aged 12 to 15, initially developed by Hernandez and Watkins (2007), and further expanded by Briere and Lanktree (2011). This group can be adapted for adolescent males in the same age range with only minor changes. Older adolescent groups may follow the same general format (i.e., addressing the same session areas), but should be altered to eliminate materials and activities that are less developmentally appropriate (e.g., psychoeducation using books for younger children; some art activities and games), and adding, instead, reading materials for older adolescents, and more discussions and attention to more mature topics (e.g., greater attention to dating, sexuality and safer sex, and substance abuse issues).
Pre-requisites for participation in this 12-15 year old group are (a) recent or current ITCT-A individual therapy, (b) a commitment to attend all weekly sessions, (c) interest in further processing of traumatic experiences, and (d) sufficient affect regulation skills to cope with the possibility of being triggered by the disclosures of other group members.
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 on this further during the first session. However, group members may, if they wish, share briefly — without describing in detail — what sexual abuse experiences they have had. Early, limited disclosure can reduce anxiety associated with having to share their traumatic experiences at a later point. 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 adolescent sexual abuse survivors.
In order to reduce anxiety associated with introductions, group members interview each other, in pairs, then share with the group what that member told her about herself. Group members may also draw self-portraits depicting how they feel at the start of group therapy. These self-portraits are kept by the co-therapists, and then are compared with self-portraits completed at the end of group therapy. If time permits, group members may create a list of personal goals they hope to accomplish with their participation in the group. These are kept by co-therapists, but a copy is returned to the group member so that she 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 written information 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 co-therapists prior to distribution. For example, commonly used are excerpts from My Body, Myself – the What’s Happening to My Body Book for Girls (Madaras & Madaras, 2000) and, for male groups, the My Body, Myself – What’s Happening to My Body Book for Boys (Madaras & Madaras, 2007). Sometimes clients will also 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 (2009).
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 are invited to write a letter to the perpetrator or person who did not protect them (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. 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,” their feelings about how they were affected by the abuse .
Group members may make collages with pictures and words depicting the alcoholism of their perpetrator; unseeing, disbelieving, and nonprotective 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 or folder with drawings, photos and words glued on the outside, to depict how they believe others see them, then in the same fashion, draw and/or glue photos and words on the inside of the box or folder to depict how they perceive themselves.
Session 5: Specific exploration of traumatic events experienced.
Topics and activities: Writing a narrative or “story” of their abuse history.
Generally as per Chapter 10, group members write about their trauma exposure, and then read it to the group. Another approach is the “hat game,” involving all group members 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, they are not pressured to do so, but are asked to express the feelings they are having and why it is difficult to answer the question. This process can often help the recalcitrant group member answer 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, as per Session 5 .
This session can begin with a relaxation exercise, whereby group members focus on their breath and pay attention to their thoughts (see Chapter 7). As they further share their narratives and related feelings, the courage of each member and of others in the group is emphasized. The co-therapists 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 disclosure of new trauma-related material, the group therapists may debrief with the clients’ individual therapists, if relevant. Group members are also encourage to evaluate their progress in the group, and how they are working toward meeting their goals.
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 be experiencing in enjoying being sexual with partners when they wish to be, sexual identity issues, and other issues related to difficulties with intimacy. Older adolescents sometimes disclose that they have flashbacks and nightmares when they are engaged in a sexual relationship, even with a partner with whom they feel safe. Psychoeducational material is often helpful at this point, normalizing sexual feelings and sexual development, describing safer sexual behaviors, and covering other related topics.
Session 8: Begin exploring problem solving.
Topics and activities: This session relates in particular to safety and affect regulation/tolerance .
A general discussion is facilitated about whether there are things that the group members could 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 11), 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 also may wish to identify those whom they can turn to for support, and explore how they can expand their repertoire of coping skills outside the group (e.g., physical activity, art, music, reading, writing in journals, 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 .
Group members describe situations where there might be a danger of physical or sexual assault. This discussion typically also includes 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, or neighbors. Because child abuse and neglect often occurs within attachment relationships and family systems, this also can be a session wherein group members explore, through family genograms (Chapter 15), how risks to their safety, and boundary violations, have occurred across generations in their family. They can then identify ways to change these patterns and be more safe in the future.
Session 10: Focusing on self-esteem.
Topics and activities: Exploring and identifying client’s positive qualities .
This session involves discussion of any posttraumatic growth that may have occurred after 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 each other, 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. She then reads aloud the message, and discusses any feelings associated with the message.
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 in Session 8 , as well as additional options they have come up with since completing the grid).
Group members also discuss how to handle relationships so that they can be safe, and how to avoid being re-victimized in general. Depending on the level of affect regulation in the group, members will sometimes benefit from this session being conducted earlier in the sequence, so that they can feel greater affect regulation and self-capacities, and be better prepared to do trauma processing later on. If group members are having particular difficult with this material, co-therapists and group members may wish to extend this topic to more than one session.
Session 12: Terminating 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 which is 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 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 co-leaders have provided.
If the leaders and group members wish, the group may be extended for another 2 to 4 sessions. In such cases, additional topics might include sex roles, stereotypes, and gender issues (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.