Trauma-Centered Group Psychotherapy for Women

A Clinician's Manual

Hadar Lubin, David Read Johnson

• Éditeur: Routledge
• Année: 2012
• ISBN:
  9781136862335
• Édition: 1
• Sujet: Psicologia
• Sous-sujet: Storia e teoria della psicologia

Learn effective PTSD group treatment The awareness of psychological trauma has grown exponentially in the past decade, and clinicians in many areas have increasingly found themselves confronted with the need to provide trauma-related services to clients. Still, there remains a serious lack of manuals that guide clinicians using group therapy to treat posttraumatic stress disorder (PTSD). Trauma-Centered Group Psychotherapy for Women: A Clinician's Manual is the important, "how-to" resource that fills this void with a successful theory-based, field-tested model of group therapy for traumatized women. Concise and full of clinical examples, this helpful text includes a session-by-session guide for clinicians and a workbook for clients. Comprehensive and practical, Trauma-Centered Group Psychotherapy for Women: A Clinician's Manual not only describes the theory, method, and rationale for this effective treatment, but also offers a complete, step-by-step clinician's manual and client workbook to help implement the model and establish effective practice. Explained in-depth are unique methods such as the use of testimonial and ceremonial structures to heighten the therapeutic impact and case examples of individual client histories and progress through treatment. In addition, appendices detailing a treatment contract and a script for a trauma program "Graduation Ceremony" are also included. Chapters in Trauma-Centered Group Psychotherapy for Women cover:

• concepts of group therapy with traumatized populations
• developmental theory of trauma and posttraumatic stress disorder
• usefulness and challenges of various formats of group therapy
• session-by-session instructions for clinicians
• session-by-session workbook for clients
• guidance in handling difficult treatment and clinical situations
• group therapy procedures and rules
• managing traumatic re-enactments
• empirical support for TCGP
• and much more!

With a detailed bibliography and numerous diagrams, charts, and tables for visualizing information, Trauma-Centered Group Psychotherapy for Women is an ideal resource for mental health clinicians of all types, graduate students and educators, state mental health commissions and agencies, libraries, hospitals, and clinics.

Part I.

The Trauma-Centered Group Psychotherapy Model

Chapter 1

Objectives and Rationale

Despite advances in the treatment for posttraumatic stress disorder for women, there remains a significant need to address the interpersonal ramifications of traumatic experience; there is no better place to do so than in group therapy. Trauma is pervasive, intrusive, and lingers near the heart—it takes time for all of its tendrils to wither. After desensitization, education, and medication, comes practice; learning how to apply new means of coping with trauma in a group setting can be a crucial step for women on their journey to recovery. The connection to others that occurs in groups consolidates progress: struggling together with the arising remnants of traumatic schemas, confronting the need to forgive and move on and its counterpart, never forgetting, are the challenges and benefits of group therapy.

Having participated in groups with traumatized women for many years, we know about the triumphs and the failures, and the hard work that goes into both. Acknowledging the profound alterations in perception, personality, and relationships that traumatic experience causes is indeed humbling. The barriers to recovery may seem at times impenetrable, but with time and persistence, we have seen these walls come down. Though this also occurs in individual therapy, engaging the potential power of the group in this task often shows impressive benefits.

The objective of the trauma-centered group psychotherapy (TCGP) model, therefore, is to utilize the power of group dynamics to penetrate the maladaptive patterns of trauma victims. This is accomplished with persistent application of focused techniques, addressing the traumatic events without hesitation, and always showing a deep respect for the strength and tenacity of the distorted traumatic schemas.

This method has been formerly called “interactive psycho educational group therapy,” but has now been renamed to more accurately portray its methodological principles. The group therapy model is situated within a broader clinical model that we have developed.

Trauma-Centered Psychotherapy

Our general method of trauma treatment is rooted in a developmental theoretical foundation (see Chapter 2) that locates the fundamental injury in an impairment of the capacity for differentiation, in sensory, affective, cognitive, and social spheres. Distorted traumatic schemas arise out of this impairment in differentiation. The repair of this injury occurs when distorted schemas are confronted while the client is in a state of imagined exposure to her original traumatic experiences. Due to the continuous and pernicious operation of avoidance, the client’s responses to stressors in her current life are shaped by the distorted schemas, leading her into ever-expanding cycles of dysfunctional behavior. The perceived emergencies in her current life are too often fueled by linkages with the pool of fear and anxiety from her original traumatic experiences.

The treatment strategy is based on the assumption that the client, and to some extent the therapist, are continuously using avoidant strategies that must be overcome, as well as its corollary that at any given point the client’s narrative of her experience is incomplete. The therapist is guided by three basic principles: immediacy, engagement, and emotionality. Immediacy means that the therapist does not wait or hesitate to begin an inquiry about the client’s traumatic experiences. Though this inquiry at all times respects the client’s perspective, the therapist indicates that accessing the traumatic experience is paramount to successful treatment. Engagement means that the therapist demonstrates to the client an active and engaged interest in her traumatic experiences, and a willingness to be available to the client in her path toward recovery. Emotionality means that treatment is expected to arouse emotion and that the therapist is not fearful of emotional expression. These principles of treatment are applied in individual, family, and group therapies. We now turn to an examination of the unique aspects of group therapy in the amelioration of traumatic stress.

Critical Elements of Group Therapy

The group environment is very relevant for traumatized individuals due to their experience of isolation and separation from communal supports that occurs in the midst of trauma (Abbott, 1995). The group serves as a symbolic societal witness to the victim’s experience, as it is retold and relived in the group process. Fundamental societal functions, (e.g., securing safety, sharing affective distress, determining basic attributions of responsibility, and welcoming the victim back home) are replayed within the group interaction (Foy et al., 2001; Klein & Schermer, 2000; van der Kolk, 1987). Group therapy provides a corrective emotional experience of the victim’s “homecoming,” in which inevitable dynamics of self-blaming, loss of credibility, and silencing of the victim are evoked and then worked through (Cather all, 1989; Johnson et al., 1997). The group’s intrinsic multiplicity of perspective will highlight differentiated perceptions of each member’s traumatic experience, which will allow the individual the important opportunity to integrate her unique history into a revised sense of self without feeling cut off, misunderstood, or rejected by others.

Generally, models of group treatment have varied according to several critical issues: (1) what degree of homogeneity among members is desired, (2) what degree of exposure to traumatic memories is demanded, (3) how structured are the treatment sessions, and (4) the extent of psychopathology that is tolerated. Let us place the TCGP model within these categories.

Homogeneity

Most clinicians agree that the treatment of posttraumatic stress disorder (PTSD) should begin in a highly homogeneous treatment environment, in which clients experience the safety and security afforded by exposure to others who have had highly similar experiences (Bloom, 1997; Herman, 1992b; Marmar, Foy, Kagan, & Pynoos, 1993; Parson, 1985; Scurfield, 1993). Feelings of isolation, mistrust, and shame among trauma victims may be more readily overcome in the early stages of treatment within homogeneous environments (Parson, 1985). Learning that one is not alone or crazy appears to be of prime importance in the recovery process, and is facilitated by a high degree of similarity among members. Significant differences in experience among members place too great a strain on individual members’ capacities for accommodation, and may lead to a high dropout rate (Parson, 1985). Homogeneity helps keep the focus on the trauma, encourages more detailed recall, authorizes the feedback provided by other group members, and minimizes the “we-they” split that often cripples the treatment group (Scurfield, 1993).

Despite the advantage of enhancing group cohesion, highly homogenous groups may also have some negative aspects. Clients may become attached to their identities as victims, delaying their adaptation to the normal world (Brende, 1983; Nicholas & Forrester, 1999; van der Kolk, 1987). Collusive group interactions may occur in order to protect individual members from being singled out, preventing members from taking responsibility or acknowledging certain realities (Parson, 1985). Appreciating member differences and engaging in appropriate interpersonal conflicts are important means toward greater individuation. A group consisting of similarly victimized clients may become too insular, unintentionally increasing the alienation of the clients from their families and society at large (Johnson, Feldman, Southwick, & Charney, 1994; van der Kolk, 1987). Helping victims differentiate their own experiences from others without feeling intense shame or fear may be more likely to occur in heterogeneous groups.

In view of these considerations, a number of authors have proposed treatment models that progress from homogeneous to heterogeneous stages. For example, Herman (1992b) proposes a three-stage model of safety, remembrance/mourning, and reconnection. She recommends individual work in the first stage, homogeneous groups in the second stage, and heterogeneous groups in the third stage. Another model aims to gradually increase members’ psychological differentiation and individuation, in which differences among group members are increasingly identified and explored (Parson, 1985). VanDeusen and Carr (2003) have designed a two-stage model that incorporates first supportive and then trauma-focused formats. Johnson et al. (1994) have identified first- and second-generation models for inpatient PTSD treatment, characterized by homogeneity and heterogeneity, respectively. First-generation programs are sanctuarial environments highly responsive to clients’ expressed needs (Bloom, 1997), while second-generation programs encourage transactions across various societal and family boundaries, deemphasizing inter-member bonding.

Trauma-centered group psychotherapy utilizes a heterogeneous treatment environment, and thus is aligned with second-generation approaches. The idea behind the formation of a heterogeneous trauma group is to emphasize differences among individuals and to depathologize their experience of the trauma. Traumatized individuals are forced to over accommodate to the challenges posed during the traumatic moment. Later in their life they tend to continue utilizing over accommodation as a coping strategy. This behavior is more easily targeted in the context of a diverse group where other group members with different trauma experiences can see the maladaptive aspects of the same coping strategies they are using (Meyer, 2000). The common denominator, hence, is not centered in the type of trauma but rather in the clients’ experiences. The more diverse the group the more likely is the possibility to connect to each other based on social principles rather than victim perspectives.

Exposure

Another important consideration in the group work is the timing of the trauma disclosure. It has been a common practice to delay trauma disclosure to a later phase of the treatment after group cohesion and sense of trust have been established. More recently, a number of trauma-focused models have been proposed (Foy, Ruzek, Glynn, Riney, & Gusman, 2002; Spiegel, Classen, Thurston, & Butler, 2004). Empirical research comparing efficacy of trauma-focused versus present-focused models has begun (Classen, Koop man, Nevill-Manning, & Spiegel, 2001; Saxe & Johnson, 1999; Schnurr et al., 2003; Zlotnick et al., 1997).

In the TCGP model, trauma disclosure occurs as early as the first session. An early disclosure prior to the development of group cohesion is possible due to the strong containment experienced in the group through its psycho educational structure. We believe that the early disclosure not only reduces anticipatory anxiety by overcoming avoidance, but also results in enhancing group cohesion. The experience of safe disclosure so early in the group development sets the norm for trauma-centered work. Because every group member is fully preoccupied with her trauma prior to the commencement of the group, immediately addressing this preoccupation reduces the anticipatory anxiety associated with such treatment. Our experience over the past ten years shows a very small dropout and attrition rate, which we believe is due in part to the use of early disclosure.

Structure of Sessions

Group models vary according to the degree that sessions are structured. Generally, the greater the structure (i.e., attention to time boundaries, use of lecture, homework, written assignments, organization, and so on), the greater the containment of affect and the greater control the therapist has over the flow of the group (Fallot & Harris, 2002; Margolin, 1999). On the other hand, greater structure requires a task-oriented approach that may interfere with the therapists’ ability to listen to the clients, and may suppress important information from them.

The TCGP model falls in the middle on this issue: The beginning and ending of the session are highly structured and controlled by the therapist, while the central period is more open for spontaneous interaction and expression of affect. The therapist intentionally titrates the level of structure during the session to maintain a working level of affect.

Extent of Psychopathology

Many models exclude clients with more severe psychopathology during the screening process in order to ensure greater stability in the group (Foy et al., 2000). These kinds of clients typically have dissociative symptoms, severe personality disorders, a history of early childhood abuse, and usually qualify for the diagnosis of disorders of extreme stress, not otherwise specified (DESNOS) (Pelcovitz et al., 1997). Yet these clients are often in the most need of treatment. The challenge is to be able to provide them with trauma treatment in a group context in which they will be able to function successfully (Cloitre & Koenen, 2001).

Our model attempts to provide for (such) clients with multiple traumas and a broad range of symptoms. Clearly, any client whose status is actively psychotic, behaviorally violent or out of control, and who is recently in and out of the hospital, is not a good candidate for any form of group therapy, including TCGP. However, the more highly structured group format of TCGP seems to provide sufficient holding capacity to include clients who have chronic and severe symptoms. We have recently successfully extended the use of the TCGP model to clients who have comorbid diagnoses of schizophrenia and bipolar disorder in a community mental health center.

Chapter 2

A Developmental Theoretical Framework

We have found that a developmental perspective is most informative of the alterations in adaptation, personality, and behavior we have observed in our clients with psychological trauma. Although other perspectives (such as biological, learning, and information processing models) provide important insights, the developmental perspective has provided the most flexibility and scope required in our clinical work.

Our developmental model is based on the pioneering work of Bruner (1964), Piaget (1962), Werner (1948), and Werner and Kaplan (1963), and influenced by developmental object relations theorists (Jacobson, 1964; Kohut, 1977; Mahler, Pine, & Bergman, 1975; Winnicott, 1953). Previous references to this developmental perspective are contained in Johnson, Feldman, Southwick, and Charney (1994), Lubin and Johnson (1997), and Johnson and Lubin (2000). We have also been deeply influenced by many of our colleagues in the trauma field who have applied developmental concepts, especially Briere, 1992; Figley, 1985; Green, Wilson, and Lindy, 1985; Herman, 1992b; Horowitz, 1976; Krystal, 1988; Lifton, 1988; McCann and Pearlman, 1990; Roth, Dye, and Lebowitz, 1988; and van der Kolk, 1987.

Normal Development and the Processes of Accommodation and Assimilation

We propose that PTSD symptoms and other sequelae of trauma are best viewed as the result of the organism’s inability to adapt to the traumatic stressor. An understanding of the nature of the traumatic injury, therefore, must explain the observed alterations in the person’s capacity for adaptation. We will primarily utilize the ideas of Piaget (1962), who analyzes adaptation in terms of two constituent processes: accommodation, in which the individual modifies established schemas (motoric, symbolic, and cognitive) in response to environmental stimuli and objects, and assimilation, in which the individual incorporates external objects, symbols, or ideas into previously learned schemas. Accommodation leads to learning new schemas, while assimilation leads to new uses of objects. Accommodation represents the primacy of the external world over the internal, and is accomplished largely through imitation. Work is an adult activity that emphasizes accommodation by the person to the demands of the roles and tasks established by the organization. Assimilation, on the other hand, represents the primacy of the internal world over the external, and is accomplished largely through play and fantasy. Imagination and creativity are adult activities that rely on assimilation.

Successful adaptation occurs when these two processes are relatively balanced, providing what Piaget identifies as “the mobility and reversibility of thought” (1962, p. 284). The balanced interaction between self and environment allows for both to be transformed in ways that provide integration of experience, as for example in the development of comprehended language. The elements of language (i.e., letters, words, grammar) are learned through imitation (i.e., accommodation), but are given meaning by linking them to personal associations and images (i.e., assimilation). The result is that one person can communicate inner states of feeling and thought to another. Mobility and reversibility of thought are the basis for concrete operations, by which relations among internal images and external objects can be transformed and manipulated. Through such capacities, the individual develops essential differentiations in perception, being able to perceive different stimuli both as distinct, and as parts of a larger whole. A differentiated perception consists of making partial distinctions among feelings, ideas, or events, such that one simultaneously acknowledges...

Table des matières

• Cover Page
• Half Title page
• The Haworth Press®
• Title Page
• Copyright Page
• About the Authors
• Contents
• Foreword
• Preface
• Acknowledgments
• PART I. The Trauma-Centered Group Psychotherapy Model
• Chapter 1 Objectives and Rationale
• Chapter 2 A Developmental Theoretical Framework
• Chapter 3 Group Therapy Procedures and Rules
• Chapter 4 Managing Traumatic Reenactments
• PART II. Session-By-Session Lecture Series
• Chapter 5 Phase I Sessions
• Chapter 6 Phase II Sessions
• Chapter 7 Phase III Sessions
• Chapter 8 The Graduation Ceremony
• PART III. Ensuring Success with Trauma-Centered Group Psychotherapy
• Chapter 9 Therapist Competencies and Challenges
• Chapter 10 Empirical Support for Trauma-Centered Group Psychotherapy
• Chapter 11 Conclusion
• Appendix A Handout for the Graduation Ceremony
• Appendix B Workbooks
• Appendix C Women's Trauma Program
• References
• Index