Treating Complex Trauma in Adolescents and Young Adults

John N. Briere, Cheryl B. Lanktree

• Publisher: SAGE Publications, Inc
• Year: 2011
• ISBN:
  9781483342191
• Edition: 1
• Topic: Psicología
• Subtopic: Trastorno de estrés postraumático (TEPT)

Treating Complex Trauma in Adolescents and Young Adults is the first empirically-validated, multi-component manual to guide practitioners and students in the treatment of multi-traumatized adolescents and young adults. Best-selling author, John Briere, and renowned clinician, Cheryl Lanktree, outline a hands-on, culturally-sensitive approach to the most challenging of young clients: those suffering from complex trauma histories, multiple symptoms, and, in many cases, involvement in a range of problematic behaviors. This model, Integrated Treatment of Complex Trauma for Adolescents (ITCT-A), integrates a series of approaches and techniques, which are adapted according to the youth's specific symptoms, culture, and age. Components include relationship-building, psychoeducation, affect regulation training, trigger identification, cognitive processing, titrated emotional processing, mindfulness training, collateral treatments with parents and families, group therapy, and system-level advocacy.

1

Introduction

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This guide has been developed to help clinicians evaluate and treat adolescents and young adults who have experienced repeated, extended, and/or severe traumatization. We take the clinician through the process of assessment, target prioritization, selection of appropriate treatment components, and the actual conduct of therapy. The approach described in this book, Integrative Treatment of Complex Trauma for Adolescents (ITCT-A), is inherently customizable: its various treatment components are meant to be adapted to the specific history, symptoms, and problems experienced by each given client. Yet, although it does not assume that “one size fits all,” it provides a specific, organized approach to the treatment of complex trauma, regardless of which components are ultimately applied. In the appendices of this book are various forms, handouts, and group treatment examples that will assist the clinician in using ITCT-A with his or her clients. Some of these materials are also available at no charge at johnbriere.com in a slightly larger format.

Background

Complex trauma usually involves a combination of early and late-onset, sometimes highly invasive traumatic events, usually of an ongoing, interpersonal nature, frequently including exposure to repetitive childhood sexual, physical, and/or psychological abuse (Briere & Scott, 2006; Cook et al., 2005). As described in Chapter 2, the impacts of complex trauma are substantial, ranging from anxiety and depression to posttraumatic stress, interpersonal problems, and dysfunctional or self-endangering behaviors.

Especially as they present themselves in mental health clinics, schools, hospitals, and residential treatment contexts, complex trauma effects are often complicated by adverse social circumstances. Social and economic deprivation—as well as racism, sexism, homophobia, and homelessness—not only produce their own negative effects on children and adults (e.g., Bassuk et al., 2003; Carter, 2007), but also increase the likelihood of trauma exposure and often intensify the effects of such victimization (e.g., Breslau, Wilcox, Storr, Lucia, & Anthony, 2004; Chen, Keith, Airriess, Wei, & Leong, 2007). Social marginalization also means that many traumatized youth have reduced access to appropriate mental health services (e.g., McKay, Lynn, & Bannon, 2005; Perez & Fortuna, 2005; Rayburn et al., 2005).

It is a general finding of the clinical literature that people with lesser social status are more likely than others to be victimized (Briere & Scott, 2006). Among the traumas more common among those with lower socioeconomic status, in addition to child abuse, neglect, and witnessing domestic violence, are sexual and physical assaults by peers, gang or community violence, “drive-by” shootings, robbery, sexual exploitation through prostitution, trauma associated with refugee status, and loss associated with the murder of a family member or friend (e.g., Berthold, 2000; Breslau, Davis, & Andreski, 1991; Farley, 2003; Giaconia et al., 1995; Macbeth, Sugar, & Pataki, 2009; Schwab-Stone et al., 1995; Singer, Anglin, Song, & Lunghofer, 1995; Sugar & Ford, in progress).

However, despite the prevalence of complex trauma in economically deprived and socially marginalized youth, it is also true that higher-socioeconomic-status adolescents are not protected from abuse and neglect by parents and other caretakers, nor are more-advantaged schools and social environments free of interpersonal violence by adults or other young people. Noteworthy is the prevalence of sexual and physical abuse among those of higher socioeconomic status (e.g., Smikle, Satin, Dellinger, & Hankins, 1995) and the substantial risk of sexual victimization for girls and young women in university or college (Fisher, Cullen, & Turner, 2000). Even in economically less-impacted neighborhoods, adolescents run significant risk of physical assault, threats of harm, and gang activity (Singer et al., 1995). The potential presence of violence and maltreatment at all socioeconomic levels and in all cultural or ethnic groups highlights a point we will make multiple times in this book: child abuse, peer assaults, and other forms of trauma are broadly prevalent in North America and elsewhere; no child, adolescent, or young adult is necessarily exempt from such experiences, and the effects of such maltreatment permeate our entire society.

Unfortunately, although complex trauma and its effects are common, there are few empirically informed treatments specifically developed for multiply traumatized children or adolescents. This is partially due to the challenging nature of the problem—the range of these impacts often requires a multimodal, multicomponent treatment strategy. Treatment approaches that are limited to a single modality (e.g., exposure therapy, cognitive therapy, or psychiatric medication) can sometimes be insufficient—especially if the intervention approach is not adapted to the specific experiences, psychological needs, and cultural matrix of the affected youth.

The MCAVIC-USC Experiment

This book describes an integrated, multicomponent approach to the psychological and social issues faced by young people exposed to complex trauma. It is an adaptation and expansion of a treatment model developed by a joint project of the Miller Children’s Abuse and Violence Intervention Center (MCAVIC) at Miller Children’s Hospital, Long Beach, California, and the Psychological Trauma Program of the University of Southern California, Department of Psychiatry and the Behavioral Sciences—hereafter referred to as the MCAVIC-USC Child and Adolescent Trauma Program. This four-year (2005–2009) experiment in providing culturally relevant, multidisciplinary outreach and treatment services to multiply traumatized, socially marginalized youth, was supported by the U.S. Substance Abuse and Mental Health Administration, who funded MCAVIC-USC as a Category II Center of the National Child Traumatic Stress Network (NCTSN). The resultant treatment model, Integrative Treatment of Complex Trauma, has been adapted for two different age groups: ITCT for Adolescents (ITCT-A) and ITCT for Children (ITCT-C), the first of which is the focus of this book. Both ITCT-C and ITCT-A guides were adapted and revised over the lifetime of this project, with input from MCAVIC and USC staff, members of MCAVIC-USC’s Expert Panel of Cultural Issues, members of the community, and attendees from a nationwide NCTSN Learning Community on ITCT. Recent analyses of treatment outcome data indicate the efficacy of both ITCT-C and ITCT-A, as presented in Chapter 21 and Lanktree et al. (2010).

Overview of ITCT-A

The core components of the adolescent version of ITCT include the following:

 

• Assessment-driven treatment, using an interview-based symptom review measure (the Assessment-Treatment Flowchart [ATF; see Chapter 4]) and, when possible, trauma-specific tests, administered at three-month intervals
• Attention to complex trauma issues, including posttraumatic stress, behavioral and affect dysregulation, and interpersonal difficulties
• Customization, involving application of different treatment components for each client, based on his or her own particular history, needs, symptoms, and cultural context
• Multiple treatment modalities, including cognitive therapy, exposure therapy, affect regulation training, and relational treatment in individual, group, and caretaker therapy
• Focus on a positive working relationship with the therapist, deemed crucial to the success of therapy for complex trauma
• Attention to attachment difficulties associated with early, developmental trauma
• Cultural adaptations of treatment components to maximize their relevance to clients from different social and ethnocultural groups
• Early focus on immediate issues such as acute crisis and self-endangering behaviors
• Skills development, in terms of building emotional regulation and problem-solving capacities
• Titrated therapeutic exposure and exploration of trauma within a developmentally appropriate and safe context, balanced with attention to the client’s existing affect regulation capacities
• Advocacy and interventions at the system level to establish healthier functioning and to address safety concerns
• A flexible time frame for treatment, since the multiproblem nature of complex trauma sometimes precludes short-term therapy

Because this multimodal treatment takes into account a range of psychological, social, and cultural issues, its effectiveness rests on the therapist’s previous training, skill, sensitivity, creativity, and openness to the client. Although specific interventions and activities are described here, this is not a “how-to” manual. Instead, we offer a semistructured approach that can be adapted on a case-by-case basis by the therapist in order to meet the youth or young adult’s specific developmental level, psychological functioning, and cultural/ethnic background.

SECTION I

Complex Trauma Outcomes and Assessment

2

Complex Trauma in Adolescence and Young Adulthood

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In this chapter, we provide a brief overview of the social context and psychological outcomes associated with complex trauma in adolescents and young adults. Most traumatized youth will not experience all of the difficulties described here; many, nevertheless, will encounter a significant combination of adverse effects. More detailed discussions of the psychosocial contexts and effects of complex trauma relevant to adolescents and others can be found in Briere and Spinazzola (2005), Cook et al. (2005), and Courtois and Ford (2009).

Risk and Endangerment

Although many of the effects of trauma exposure are chronic in nature, and may not require rapid intervention, others are more severe and potentially endanger the client’s immediate well-being, if not his or her life. Some of these issues reflect the youth’s environment; his or her victimization may be ongoing, as opposed to solely in the past, and his or her social context may continue to be invalidating or dangerous. Other issues may involve the impact of trauma on the client’s personality, internal experience, and relationships with others: he or she may be suicidal, abusing major substances, or involved in various forms of risky behavior.

Environmental Risks

When complex trauma has occurred within the context of socioeconomic deprivation or social marginalization, it is unlikely that conditions will have changed substantially at the time of treatment. The adolescent who was abused in the context of caretaker neglect or nonsupport, or who was assaulted as a result of gang activity—and who lives with poverty, inadequate schools, social discrimination, and/or hard-to-access medical and psychological resources—is often struggling not only with a trauma history and social deprivation, but also with the likelihood of future adversities. The fact that negative economic and social conditions increase the risk of interpersonal victimization has direct implications for treatment: as we will discuss later in this guide, optimal assistance to such youth often requires not only effective therapy, but also advocacy, collaboration, and systems intervention (e.g., Saxe, Ellis, & Kaplow, 2007).

The traumatized adolescent’s environment also may be noteworthy for the continued presence of those involved in his or her victimization. If the client was sexually or physically victimized by an adult or peer, there is often little reason to assume that the danger from such individuals has passed. Hate crimes such as assaults on minorities, the homeless, and gay, lesbian, or transgendered youth may not stop merely because law enforcement has been notified. As is true for adverse social conditions, the continued presence of perpetrators in the adolescent’s environment may require the clinician to do more than render treatment—ultimately, the primary concern is the client’s immediate safety.

Self-Endangerment

In addition to dangers present in the social and physical environment, the adolescent may engage in behaviors that threaten his or her own safety. Although the youth may appear to be “acting out,” “self-destructive,” “borderline,” or “conduct-disordered,” these behaviors often represent adaptations to, or effects of, prior victimization (Runtz & Briere, 1986; Singer et al., 1995).

The primary self-endangering behaviors seen in youth suffering from complex trauma exposure are suicidal behavior, intentional (but nonsuicidal) self-injury, major substance abuse, eating disorders, dysfunctional sexual behavior, excessive risk-taking, and involvement in physical altercations (Briere & Spinazzola, 2005; Cook et al., 2005). The traumatized adolescent or young adult may not only seek out violent ways to externalize distress, but also may be further traumatized when others fight back (e.g., the aggression-retaliation cycle associated with gang activity) or may become involved in the juvenile justice system, with its own potential negative effects. He or she also may experience less obviously endangering relational difficulties, such as poor sexual-romantic choices and inadequate self-protection—including passivity or dissociation—in the face of dangerous others.

Some of these difficulties involve what is referred to in the literature as revictimization: those who were severely maltreated as children have an elevated risk of also being assaulted later in life (Classen, Palesh, & Aggarwal, 2005). This phenomenon can result in a scenario well known to clinicians who work with traumatized youth: the abused and/or neglected child may, as he or she matures, engage in various activities and defenses (e.g., substance abuse, dysfunctional sexual behavior, or aggression) as a way to reduce posttraumatic distress, only to have such coping strategies ultimately lead to even more victimization and, perhaps, even more self-endangering behavior (e.g., Koenig, Doll, O’Leary, & Pequegnat, 2004). In this regard, self-endangerment—as well as dangerous environments—requires the clinician to focus on safety as much as symptom remission and increased capacities.

Longer-Term Trauma Outcomes

In addition to immediate endangerment, many adolescent trauma survivors suffer the chronic, ongoing psychological effects of previous adverse experiences. Arising from traumas that may have begun in early childhood (e.g., abuse) and continued into adolescence (e.g., victimization by peers or adults), such impacts may emerge as relatively chronic psychological symptoms, sometimes presenting as one or...