Chapter Three – Treatment Overview

This chapter briefly outlines the primary foci of ITCT as it is applied to adolescents, above-and-beyond the specific components of therapy described in Chapters 5 to 14.

Assessment-focused therapy

As indicated in the last chapter, ITCT-A is assessment-based; initial and repeat assessments determine, as represented on the ATF-A, which intervention components are utilized in treatment. Consider an example of how ATF-A data (presented as Figure 1. on next page) might initially determine, and then alter treatment focus:

Based on psychological testing, as well as the adolescent’s verbal self-report in the evaluation session, his parents’ feedback, and the therapist’s clinical impressions, three symptom clusters, anxiety, depression, and posttraumatic stress, are prioritized as 4s (Most problematic, requires immediate attention). Two additional problems (anger/aggression, dissociation) are prioritized as 3s (Problematic, a current treatment priority), and the remainder of ATF-A items are rated as 2s ( Problematic, but not an immediate treatment priority) or 1s (Not currently a problem (re-evaluate at each interval): Do not treat).

As treatment progresses, the client shows clinical improvement in anxiety, depression, and dissociation at assessment period 1 (i.e., at three months), leading the clinician to prioritize these problems as, respectively, “3,” “2,” and “2” at the next assessment period (presented as Figure 2. on following page). Further, one problem (“identity issues”) is downgraded from a “2” to a “1.” However, additional stressors in the client’s life and other undetermined factors have resulted in increased risky behaviors and, therefore, a new rating of “3.” Thus, at intake the highest level of treatment attention was anxiety, depression, and posttraumatic stress, whereas at the next assessment period the focus shifts to posttraumatic stress, followed by anger/aggression and safety – risky behaviors.

Figure 1.

Figure 2.

Problems-to-Components Grid

Based on the next treatment planning tool, the Problems-to-Components Grid (see Table 2), the various problems and symptoms described the previous chapters are linked to specific ITCT-A components (e.g., cognitive processing, therapeutic exposure, psychoeducation) outlined in the following chapters. In this way, assessment and treatment, followed by repeat assessment and further treatment, are directly linked. Treatment of a specific issue only occurs if it is assessed to be a problem (i.e., has a higher ranking on the ATF-A), and treatment for that issue only occurs as long as assessment indicates it is still problematic. As a result, treatment for two different clients may differ significantly as a function of initial test or interview data, collateral input, and response to treatment or external circumstance.

Table 2. Problems-to-Components Grid

The Primacy of the Therapeutic Relationship

Although modern trauma treatment is characterized by a number of specific techniques – many of which are presented in the Problems-to-Components Grid – research and clinical experience suggest that a positive therapeutic relationship is one of the most important components of successful therapy (Cloitre, et al., 2006; Cloitre, Stovall-McClough, Miranda, & Chemtob, 2004; Lambert & Barley, 2001; Pearlman & Courtois, 2005). This is probably especially true for multiply traumatized adolescents, whose life experiences have taught them to mistrust authority and to expect maltreatment in relationships. This dynamic can be further intensified for youth who live in deprived and marginalized social environments, and/or who have experienced racism or other discrimination on a regular basis.

In this complex psychosocial matrix, client trust and openness becomes less likely at the very time it is especially needed. Some level of vulnerability and trust is necessary before the traumatized adolescent can meaningfully revisit and process painful memories. If the therapist maintains a consistently positive, caring demeanor, and indicates by his or her behavior that he or she will not maltreat, disrespect, discriminate against, exploit, or otherwise harm the client, the multiply-besieged youth may slowly come to realize that there is no immediate danger, gradually reducing his or her defenses and avoidance behaviors, and eventually enter into a more therapeutic connection with the clinician.

For some especially traumatized and maltreated adolescents, this process may take time, requiring considerable patience on the part of the therapist. The client may test the clinician in various ways regarding his or her actual feelings and intentions for the client. There may be an expressed attitude of disinterest, or even disdain, even though the adolescent may actually be hungry for connection and validation. The client may challenge or, conversely, attempt to pacify the therapist in various ways that have proved helpful with powerful others in the past. Only when the therapist does not “take the bait” and become angry, dangerous, exploitive, seductive, or rejecting, may the youth begin to perceive the therapist, and the therapeutic relationship, as benign.

Beyond the need for the client to participate in treatment, and thus lower his or her defenses against expectations of maltreatment, the experience of a safe and caring client-therapist relationship is often a technical requirement of trauma therapy (Briere & Scott, 2012; Pearlman & Courtois, 2005). Almost inevitably, the therapeutic relationship will trigger memories, feelings, and thoughts associated with prior relational traumas, as well, in some cases, as more recent social maltreatment (e.g., experiences of racism, sexism, or homophobia). As noted in Chapter 4, when these activations and expectations can be processed in the context of a safe, supportive relationship, their power over the adolescent survivor often diminishes. In this regard, as the client experiences reactivated rejection, abandonment fears, misperception of danger, or authority issues at the same time that he or she perceives respect, caring, and empathy from the therapist, such intrusions may gradually lose their generalizability to current relationships and become counterconditioned by current, positive relational feelings. In this sense, a good therapeutic relationship is not only supportive of effective treatment, it is technically integral to the resolution of major relational traumas.

Customization

In actual clinical practice, clients vary significantly in their sociocultural backgrounds, presenting issues, comorbid symptoms, and the extent to which they can utilize and tolerate psychological interventions. For this reason, therapy is likely to be most effective when it is tailored to the specific characteristics and concerns of the individual person. Above-and-beyond the differing symptomatic needs of one client relative to another, treatment may require adjustment based on a number of other relevant variables. Presented below are several factors that should be taken into account when providing trauma therapy to adolescent trauma survivors.

Age

Although it is sometimes implied that adolescence is a single developmental stage, in actuality the usually cited age range for this category (ages 12 to 21) comprises several smaller developmental periods. In addition, any given adolescent may be “a young” X-year-old or “an old” one, psychologically and/or physically. Further, childhood abuse may delay some children’s psychological or physical development and accelerate others, and some environments may demand “older” psychosocial functioning than others.

A common error made by clinicians working with traumatized youth is to intervene as if the adolescent is older or younger than his or her actual psychological age. The older adolescent may feel that “my counselor treats me like a baby,” whereas the younger (or more cognitively impaired) adolescent may not fully understand the clinician’s statements, or may feel insufficient emotional connection with the therapist because the clinician is interacting with him or her in a way that is too abstract or intellectualized. Such potential problems highlight the need to provide developmentally sensitive and appropriate treatment to adolescents with trauma histories.

Gender

Although adolescent males and females experience many of the same traumatic events and suffer in many of the same ways, it is also clear that some traumas are more common in one sex than the other, and that sex-role socialization often affects how such injuries are experienced and expressed. These differences have significant impacts on the content and process of trauma-focused therapy for adolescents.

Research indicates that girls and women are more at risk for victimization in close relationships than are boys and men, and are especially more likely to be sexually victimized, whereas boys and men are at greater risk than girls and women of physical abuse and assault (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Yehuda, 2004). In addition to trauma exposure differences, young men and women tend to experience, communicate, and process the distress associated with traumatic events in somewhat different ways (Briere & Scott, 2012). These sex-role related differences in symptom expression and behavioral response often manifest themselves during trauma-focused psychotherapy. As a result, the therapist should be alert to ways in which traumatized youth express or inhibit their emotional reactions based on sex-role-based expectations. Although the clinician should not respond to clients in a sex-role stereotypic manner, he or she should be sensitive to how gender-related socialization influences the client, and respond accordingly. In some cases, he or she may be able to offer perspectives or role modeling that allow the client to be less affected by sex-roles or gender-based assumptions.

Sociocultural matrix

Although many North American therapists are firmly rooted in the middle class, with the assumptions and perspectives that go along with that context, a significant proportion of mental health service consumers, including many adolescent trauma survivors, are embedded in a different psychosocial matrix – one that includes a range of cultural or subcultural experiences, expectations, and rules of interpersonal engagement, and that is often characterized by marginalization due to poverty, race, culture, gender, or sexual orientation (e.g., Bryant-Davis, 2005). As a result, the traumatized adolescent may present with a variety of issues beyond his or her specific trauma history; not only will he or she have been hurt by physical or sexual violence, he or she may have experienced the direct and indirect effects of social maltreatment, and may view the world from a cultural lens that differs substantially from that of the therapist (Abney, 2002; Cohen, Deblinger, Mannarino, & De Arellano, 2001; Jones, Hadder, Carvajal, Chapman, & Alexander, 2006; Marsella, et al., 1996). This is especially relevant to work with adolescents recently immigrated to the United States from Mexico or Central America, many of whom are separated from their caretakers or families.¹

Sociocultural and experiential differences between clients and therapists may easily extend to inherent disagreements regarding the requirements and process of therapy. Although the therapist may assume that the client feels safe, understood, and supported in treatment, these beliefs may not always be accurate. Further, the client may not subscribe to the clinician’s perspective on what constitutes therapy. There may be differing expectations about how private issues are discussed during treatment, the extent to which therapy is focused on practical (as opposed to more psychological) issues in the client’s life, the importance of regularly scheduled weekly sessions, or even the role of eye contact or therapist self-disclosure (e.g., Abney, 2001; Ford, 2007; Marsella, Friedman, Gerrity, & Scurfield, 1996). Differences in client versus therapist class or culture may result in clinician errors, such as the treatment provider’s belief that the adolescent female client’s late or missed sessions represent “resistance” or “acting out,” when, in fact, the client may have multiple impinging concerns (e.g., childcare issues, a changing work schedule, or difficulties in arranging transportation) and/or a different perspective on the relative importance of being “on time”. Similarly, the client may assume that the therapist is uninvolved or uncaring, when, in fact, the therapist is quite concerned about the client, but his or her culture (or training) dictates less emotional expression or visible interpersonal closeness.

The impacts of social discrimination and cultural differences are not things that the clinician can overlook when working with many traumatized adolescents. Minimally, the therapist should take into account (1) the adverse conditions and additional trauma exposure that the client may have experienced, (2) the anger and/or anxiety that he or she may feel when in contact with a therapist whose social characteristics are more representative of the dominant (i.e., White, middle class) culture, (3) differences in world-views and experiences often associated with different socioeconomic strata or cultural/subcultural membership, and (4) the actual characteristics of, and impediments in, the physical and social environment in which the client is embedded.

Affect regulation capacity

Not only should treatment be customized based on the client’s symptomatic presentation and sociodemographic/cultural characteristics, there is an important psychological variable that frequently affects how therapy is delivered: the client’s level of affect regulation – his or her relative capacity to tolerate and internally reduce painful emotional states. Adolescents with limited affect regulation abilities are more likely to be overwhelmed and destabilized by negative emotional experiences – both those associated with current negative events and those triggered by painful memories. Since trauma therapy often involves activating and processing traumatic memories, those with less ability to internally regulate painful states are more likely to become highly distressed, if not emotionally overwhelmed, during treatment, and may respond with increased avoidance, including “resistance” and/or dissociation (Briere & Scott, 2012; Cloitre, Koenen, Cohen, & Han, 2002). Such responses, in turn, reduce the adolescent’s exposure to traumatic material and to the healing aspects of the therapeutic relationship. As described in Chapter 7, treatment of those with impaired affect regulation capacities should proceed carefully, so that traumatic memories are activated and processed in smaller increments than otherwise might be necessary. Often described as titrated exposure or “working within the therapeutic window” (Briere, 2002), this involves (1) adjusting treatment so that trauma processing that occurs within a given session does not exceed the capacities of the survivor to tolerate that level of distress, and, at the same time, (2) providing as much processing as can reasonably occur.

Advocacy and System Intervention

Traumatized youth often have issues that extend beyond psychological symptomatology, per se. Some of these concerns are associated with a lack of financial and/or social resources. Others arise from ways in which the adolescent’s trauma history, family difficulties, and living environment may have affected his or her interactions with external systems, such as the schools, law enforcement, juvenile justice, child protection, and social welfare agencies. The client may be involved in gang activity, prostitution, significant substance use or abuse, theft, revictimization, or violence against others.

In such situations, psychotherapy – by itself – may not be enough. For this reason, ITCT-A and other approaches to multi-problem youth typically include a social advocacy/systems intervention component. This may involve dealing with “red tape” in health or social welfare bureaucracies so that the client can receive needed services or funding, advocating for the client in a judicial hearing, helping the client to apply for U.S. resident status, or working with school personnel to keep the client in the educational system. It may include filling out forms, writing letters, making phone calls, or completing reports.

In addition, for clients who are economically disadvantaged and have limited resources, ITCT-A providers with sufficient resources or funding may offer an optional range of extra-therapeutic services (e.g., Lanktree, 2008), including

• Transportation to therapy sessions, through taxi vouchers, bus passes, or an agency van;
• Food and clothing;
• Advocacy and referrals for legal support and housing. In some cases, such financial assistance can significantly change the survivor’s life by ending homelessness or moving him or her to a safer neighborhood;
• Emergency financial assistance for youth and families when starting back to school and for holidays;
• Access to community after-school programs and participation in organizations in the neighborhood, such as Big Brothers and Big Sisters, or the Boys and Girls Club – caretakers may not be aware of free services in their community and these resources can supplement the advantages of ongoing therapy.

These various activities provide real-world support to the adolescent trauma survivor in the most basic and important ways, involving food, shelter, financial support, social integration, and physical/social protection; conditions that typically must be met before meaningful progress on psychological issues can be made.