COHORT C GROUP COUNSELING PROPOSAL
Running head: COHORT C GROUP COUNSELING PROPOSAL
Running head: COHORT C GROUP COUNSELING PROPOSAL
In this document, we will provide our proposal for a counseling group to help adolescent female victims of sexual abuse. We will share our rationale and supporting evidence for our cognitive-behavioral theory (CBT) approach to help members. Our proposal consists of practical group considerations for implementation from screening to termination, including a definition of goals, strategies to achieve goals, and evaluation plans to measure progress towards those goals.
The population of the proposed group consists of female survivors of sexual abuse. Members will be restricted to ages 14 to 18. The United States Department of Justice (2017) describes sexual assault or abuse as any type of sexual contact or behavior that occurs without the consent of the recipient, such as rape, fondling, and attempted rape.
Establishing a safe environment that provides support is crucial and justifies limiting group membership to females. Adolescence is developmentally marked by instability and anxiety, with body changes, sexual development, and establishing independence (Broderick & Blewitt, 2014). Add in the challenges of dealing with sexual abuse, and adolescents are at a severe disadvantage with potential long-term consequences. Peers are an increasingly important source of support in adolescence, a factor involved in a female survivor’s decision to disclose unwanted sexual experiences (Kogan, 2004). The significance of peers for adolescents makes group intervention a good fit for females at this age of development (Tourigny & Hebert, 2007).
Prevalence & Risk Factors
Sexual abuse is widespread among adolescent girls, during a developmental phase when sexual exploration is common. Recent findings suggest 20–26% of young girls experience childhood sexual abuse (Finkelhor, Shattuck, Turner, & Hambly, 2014). However, these findings likely underestimate the actual impact of sexual abuse on adolescent females, as only 1 in 20 estimated cases of sexual abuse are identified and reported to authorities (Horner, 2010).
Today’s culture of advanced technology and media-portrayed sexualized behaviors influence adolescent behaviors. Research shows nearly one out of four high-school-aged girls living in a high-poverty community have sent a “sext” (Tichen, Maslyanskaya, Silver, & Coupey, 2018). Tichen et al. (2018) also note such behavior is independently associated with abuse within sexual relationships.
Adolescent girls who experienced sexual abuse are more likely to develop depressive symptoms, posttraumatic stress disorder (PTSD), eating disorders, anxiety, and suicidal ideation or attempts (Alix, Cossette, Hebert, Cyr, & Frappier, 2017; Hall & Hall, 2011). They are more likely to engage in maladaptive coping strategies including substance use, dissociative behaviors, suicidal or self-injurious behavior, aggression, over- and under-sexualized behaviors, and even poor self-esteem to minimize or avoid emotions caused by the abuse (Ross & O’Carroll, 2004). Without effective coping mechanisms, Alix et al. (2017) addressed the high potential for self-blame and shame which can result in an increased chance for revictimization or high-risk type behaviors.
Type of Group
Our proposed group is a closed group, leveraging a CBT approach to help female victims of sexual abuse cope with their experiences and promote adverse symptom reduction and positive personal growth. The group will be closed, following the recommendation by Corey et al. (2018) to support cohesion. There will be fifteen sessions total with one session per week, which will allow members and the group enough time to reach established goals.
The research literature is clear in the prevalence of sexual abuse and its role in physical, psychological, and social problems that follow the individual (Smith & Kelly, 2008). Group therapy is beneficial for this population because it allows members to be reassured, connect with other victims, and reduce stigma and isolation (Smith & Kelly, 2008). Research findings also suggest sexual abuse-specific cognitive-behavioral theory is more effective than nondirective, supportive treatment, reducing self-reported levels of trauma and depression for most participants (Smith & Kelly, 2008). Given the prevalence of sexual abuse and its impact, it’s critical to have effective, evidence-based group treatment to reduce the negative consequences for the victimized individual and society in general.
Support for CBT Approach
Research supports a CBT group approach for the selected population goals and measures that focus on improving PTSD symptoms, dealing with anxiety, and building self-esteem. Avinger and Jones (2007) reviewed outcome studies for group treatment of sexually abused adolescent females, finding that trauma-focused group models demonstrated significant reductions in self-reported anxiety symptoms and increased self-esteem (Avinger & Jones, 2007). The results also suggest symptoms of PTSD (avoidance of reminders, arousal/agitation, irritability, hypervigilance, re-experiencing) and internalizing (depression and anxiety) may be efficiently addressed by such a group approach (Avinger & Jones, 2007).
Research conducted by Benuto and O’Donohue (2015) assessed 77 studies to offer evidence-based treatment recommendations for children and adolescents who were victims of CSA. The results concluded CBT is superior to other theoretical models for this population, demonstrating moderate positive effects on PTSD and anxiety symptoms. Study outcomes data suggest sessions should be brief (from 8-20 groups), and administered in an agency setting, with an emphasis on upfront clinical assessment and psychometric evaluation (Benuto & O’Donohue, 2015). Group leader planning should identify the group duration, goals, and measurement to increase treatment effectiveness (Benuto & O’Donohue, 2015).
Group goals should reflect what the needs are among the group population (Corey et al., 2018). Our group goals and objectives include:
Group Goals and Objectives
|Members will regain positive decision making and coping skills enabling them to have healthier behavior patterns.||Members will reduce the number of unmanageable PTSD, anxiety, and/or depressive episodes from 3 to 5 times per week (estimated baseline) to 2 times per week or less by 15 weeks.|
|Members will increase their knowledge of the traumatic effects of their abuse and cease abuse reactive behavior to enhance their social interactions and relationships with others.||Members will have no more than 2 verbal outbursts with caretaker/s or peers per week for 5 consecutive weeks by week 15.|
Group leaders must address practical considerations including recruitment, screening procedures, informed consent, and group rules (Corey et al., 2018). Defined logistics include time, location, and frequency of meetings. Other considerations include necessary community resources to support the group members during the group and after termination.
Members will include court referred clients, parental referrals, and self-submitted clients. We will market to and seek referrals from counselors in the community who are focused on teen populations. Teachers and school counselors may refer potential members. Best practice from the ASGW states potential members should have access, preferably in writing, to group information (Corey et al., 2018). Due to privacy concerns with social media, we will create a simple, mobile-optimized website to serve as a hub to promote program information.
Abuse survivors may not be quick to trust (Corey et al., 2018). The screening process is critical to establish a foundation for a trusting relationship. Therefore, group leaders will conduct private screening sessions with potential members. The screening will focus on diversity and composition of members, to consider shared experiences, but provide for different perspectives and backgrounds. When possible, it is preferred to meet independently with parent(s) as part of the screening process. There may be homework, behavior changes, and other areas requiring support outside of the group context.
A professional disclosure statement and confidentiality agreement will be signed by members and copies provided to them (Corey et al., 2018). Information on group goals and policies, member/leader expectations, rights and responsibilities, group logistics, participation expectations, and disclosure will be provided (Corey et al., 2018). Depending on the state, minors may require parental or court-ordered informed consent to engage in group counseling (Sori & Hecker, 2015).
The sessions will run 1.5 hours weekly. Meeting more frequently for shorter periods is more suited for adolescents (Corey et al., 2018). Corey et al. (2018) recommend 15 weeks as an ideal length for adolescents. The program will have a fixed time-limit of 15 weeks, which parallels a school semester and is long enough to develop trust and work towards behavioral change. Having a set time frame allows participants to gauge their commitment to expectations, maintain motivation, and track progress along the path.
An ideal size is 6 to 8 members for an adolescent group (Corey et al., 2018). Other research suggests 8 members to allow for diversity within the group composition (Chard, Weaver, & Resick, 1997). 8 people will be our target, which is large enough to be inclusive and provide for diversity, but not so large where there will not be a sense of cohesion and involvement.
The setting will be a community mental health setting, rather than a school, to support member safety and confidentiality. There is often fear and stigma associated with seeking help, especially if seeking help is conspicuous in any way. Social responses of victim-blaming serve to keep victims silent and compound trauma. Our ethical commitment to confidentiality could be undermined simply by an awareness of participation in the group.
Necessary Community Resources
TLC4Teens is an Internet-based resource where teens can connect to web resources including hotlines, organizations, suicide prevention, and mental health information (TLC4teens, n.d.). The Rape, Abuse & Incest National Network (RAINN) provides tools like a secure online chat hotline, to connect individuals with specialists for crisis intervention who can offer resources, referrals, and guidance (RAINN, n.d.). Circle of 6 is an app focused on preventing violence, allowing users to connect to trusted adults or friends, hotlines, and local emergency numbers when they find themselves in a risky or uncomfortable situation (Circle of 6, n.d.).
It is important to have a defined outline of each session. Although flexibility and adapting to group sessions is essential, structure ensures group goal adherence (Corey et al., 2018). Included below is the proposed group session roadmap.
|1||Group Introduction||· Member introductions and icebreaker activity
· Review group rules, expectations, confidentiality
· Leaders provide an overview of the process
|2||Defining Trauma||· Trauma/PTSD/CBT psychoeducation
· Sharing personal perceptions of trauma
· Homework: find a quote that resonates
|3||Body Responses||· Group reviews quotes and emotional responses
· Relaxation/mindfulness practice
|4||Emotional Responses||· Discuss emotional expression, generate a list of the range of emotions, members circle feelings experienced during trauma and discuss
· Homework: journal one positive/one negative emotion experienced during the week
|5||Introduce Cognitive Coping||· Share journal experiences, emotions, triggers
· Introduce interrelationships between thoughts, feelings, and behaviors
· Homework: journal automatic thoughts and determine if accurate or inaccurate
|6||Cognitive Coping||· Discuss identifying problematic thoughts, practice replacement thoughts
· Create cognitive coping cards
· Homework: practice skills in response to triggers
|7||Explore Sexual Abuse Experience||· Create and share visual collages from magazines/newspapers to express trauma experience through art|
|8||Trauma Story||· Provide trauma story overview
· Members each prepare their own title, introduction, and “just the facts” of their trauma experience
|9||Sharing Trauma Experiences||· Members deepen their trauma story, focusing on thoughts and feelings
· Willing members share their trauma stories
|10||Sharing Trauma Experiences||· Willing members share their trauma stories|
|11||Sharing Trauma Experiences||· Members discuss what they’ve learned about the trauma and themselves|
|12||Boundaries and Safety||· Review coping skills
· Discussion of challenging future scenarios and solutions
|13||Preparing for Termination||· Discuss emotions surrounding group ending|
|14||Contracts||· Members create own contracts to document how they will implement what they’ve learned in daily life moving forward|
|15||Graduation & See You Later||· Leaders conduct graduation ceremony, presenting certificates of completion
· Group members make and sign cards for each other as a reminder of what they’ve learned
· Leaders will share a date for reunion within 3-6 months
Strategies and Interventions
Group leaders with employ general strategies and interventions, informed by a CBT approach, throughout the group sessions. Leaders will work to establish rapport and trust within group, model and teach alternate behaviors, and increase awareness of trauma and how sexual abuse impacts feelings of self-worth and ability to establish healthy personal/interpersonal relationships through discussion. Leaders will facilitate emotional exploration through discussion or structured activities regarding daily situations that produce overwhelming and/or intense emotions. Members will increase awareness of the connection between thoughts and feelings, problem-solve intense emotions, practice relaxation and coping techniques, work through various tools and worksheets, and participate in role-play or role-reversal techniques.
A culturally skilled group practitioner recognizes the power and value different perspectives can bring while also surfacing universal human themes that can unite members. Supporting diversity begins with the group planning process, delivering awareness of the group and access to individuals from different backgrounds and cultures. Our group size target allows for a diverse group member composition. We’ve also selected a community setting rather than a school location to welcome individuals from various neighborhoods and schools.
In our population, cultural factors may shape the expression of symptoms, coping styles, or willingness to disclose. Group practitioners must be aware of their own personal values, beliefs, biases, and prejudices (Corey et al., 2018). They must have general knowledge of how diversity affects the group process and skilled to adapt interventions appropriately for the group members’ different life experiences (Corey et al., 2018). A willingness to address how diversity is helping or impeding group participation, and shifting the group process accordingly, is needed to transition into productive, trusting, and culturally respectful interactions.
This group will prepare for termination starting in session 13 with a discussion of feelings related to the group process coming to an end. Members benefit from having time to reflect on the group experience and address any concerns about the group ending (Corey, Corey, & Haynes, 2014). Addressing the termination early enables the adolescent clients time to process saying goodbye, supported by processes such as contract and graduation that emphasize moving forward after the group. Establishing a reunion in the near-future provides ongoing structure for accountability and community following the group’s conclusion.
To ascertain psychotherapeutic gains on measures, the members and parents will complete the assessment instruments following the last session. Research conducted by Jaberghaderi, Greenwald, Rubin, Zand, and Dolatabadi (2004) suggests referrals and further treatment for participants with any outcome measure are in the clinical range at post-treatment.
Evaluation of the Group Experience
An evaluation of the group experience assists in assessing individual and group progress against goals and help improve the design of future groups (Corey et al., 2018). The group will utilize a weekly, informal questionnaire with ratings of a few key metrics and an opportunity for members to explain meaningfulness and perceptions of the experience. The survey provides a quick indication of a level of satisfaction to identify trends for each group session (Corey et al., 2018).
A satisfaction questionnaire will be given at the last session for participants to express their perceptions of the group experience and effectiveness. We will use the OQ Group Questionnaire (OQ-GQ), a 30-item, Likert-scale self-report measure of the therapeutic relationship across three structural dimensions: member-member, member-leader, and member-group (Thayer & Burlingame, 2014). Research supports the OQ-GQ as an empirically valid instrument to measure the quality of the group therapeutic relationship, identified as one of the most significant general mechanisms of change in group psychotherapy (Thayer & Burlingame, 2014; Johnson, Burlingame, Olsen, Davies, & Gleave, 2005).
Evaluation of Measured Progress Toward Group Goals
Measurement of member symptoms pre- and post-participation will be used to determine changes and progress against group goals. The members of this group will be administered the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI-II) and Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5). Parents of the adolescents will be asked to complete the Child Behavior Checklist (CBCL).
The BAI is a 21-question, self-report inventory to measure the severity of anxiety. Four BAI validity studies suggest a cutoff score of 16, sensitivity of .62, a mean specificity of .69, a mean PPP of .52, and a mean NPP of .85, which resulted in an estimated percentage of correct classification of approximately 65% (Bardhoshi, Duncan, & Erford, 2016). The results demonstrate the diagnostic reliability and validity of the BAI with the DSM-5.
The BDI-II is a 21 item self-report inventory used to quantify levels of depressive symptoms. In one study, the Cronbach’s alpha for the BDI-II total score was 0.89, the correlation between the BDI-II and the PHQ-9 was strong (r=0.75), and anxiety-related measures were 0.68 and 0.71, which were also in the high range (Lee, Lee, Hwang, Hong, & Kim, 2017). The BDI-II was shown to be a reliable and valid tool for measuring the severity of depressive symptoms in adolescents.
The PCL-5 is a self-report measure of 17 items corresponding to the PTSD symptom criteria in the DSM-5. The PCL-5 has been extensively validated and scores have shown excellent psychometric properties, including test-retest reliability (ranging from .66 to .96), internal consistency (α ranging from .83 to .98), convergent validity (correlations with other PTSD measures ranging from .62 to .93), discriminate validity (correlations with measures of related constructs below .87), and diagnostic utility (diagnostic efficiencies ranging from .58 to .83) (Blevins, Weathers, Davis, Witte, & Domino, 2015). Therefore, the PCL-5 is a reliable and valid test for measuring PTSD symptoms.
The research literature on psychological measurement highlights the value of including multiple informants, particularly parents, in youth assessments (Saywitz, Mannarino, & Berliner, 2000). Parents will complete the CBCL, one of the most extensively used parent-report measures of youth symptoms, to assess a wide range of emotional, behavioral, and social problems (Barbosa, Tannock, & Manassis, 2002). The CBCL is normed with a large number and variety of children and adolescents, demonstrates good criterion validity, test-retest reliability, inter-rater reliability and internal consistency (Carrion & Hull, 2010).
COHORT C GROUP COUNSELING PROPOSAL
Female, adolescent victims of sexual abuse are a population particularly suited to group counseling, likely to benefit from the proposed evidence-based CBT approach to reduce adverse symptoms of anxiety, depression, and PTSD. From the initial screening to termination strategy, this proposal is a blueprint for a counseling process that provides a safe place, supportive community, and practical tools for member growth by leveraging the power of group dynamics. The proposed 15-week group counseling program includes evaluation of the group experience and effectiveness, providing outcome measurements regarding group and member progress and informing future, similarly-focused groups.
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