Handbook of Cognitive-Behavior Group Therapy with Children and Adolescents [2 ed.] 081538047X, 9780815380474

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Handbook of Cognitive-​B ehavior Group Therapy with Children and Adolescents

Now in its second edition, the Handbook of Cognitive-​Behavior Group Therapy with Children and Adolescents offers a review of cognitive-​behavior therapy fundamentals, evidence-​based group interventions, and practical guidelines for group psychotherapy. This extensive guide presents innovative and evidence-​based treatments for the challenges faced by today’s youth. Each chapter covers areas such as assessment, case conceptualization, group selection, cultural considerations, protective factors, and detailed strategies and treatment protocols for use in clinical practice. This handbook combines theoretical foundations with practical application, highlighting the authors’ personal experiences through case studies and therapeutic vignettes. This book is an invaluable reference for professionals providing therapeutic intervention to children and adolescents. Ray W. Christner, Psy.D., NCSP, ABPP, is a licensed psychologist in Pennsylvania, a nationally certified school psychologist, and a nationally registered health service psychologist. He is board-​ certified in behavioral and cognitive psychology. Jessica L. Stewart, Psy.D., is a licensed clinical psychologist in Massachusetts and Rhode Island. She maintains a private practice in Providence, Rhode Island, focusing on personal empowerment and distress tolerance through transitional challenges. Christy A. Mulligan, Psy.D., is an assistant professor in the School Psychology Program in the Derner School of Psychology at Adelphi University.

Handbook of Cognitive-​B ehavior Group Therapy with Children and Adolescents

Second edition

Edited by Ray W. Christner, Jessica L. Stewart, and Christy A. Mulligan

Designed cover image: © Getty Second edition published 2024 by Routledge 605 Third Avenue, New York, NY 10158 and by Routledge 4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2024 selection and editorial matter, Ray W. Christner, Jessica L. Stewart, and Christy A. Mulligan; individual chapters, the contributors The right of, Ray W. Christner, Jessica L. Stewart, and Christy A. Mulligan to be identified as the authors of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identification and explanation without intent to infringe. First edition published by Routledge 2007 ISBN: 9780815380474 (hbk) ISBN: 9780815380481 (pbk) ISBN: 9781351213073 (ebk) DOI: 10.4324/​9 781351213073 Typeset in Times New Roman by Newgen Publishing UK

Thanks to my family for continuing to support me taking on another project, even when I say, “This is the last one!” I dedicate this book to my dear friend and colleague, Dr. Rosemary Mennuti, whose relationship provides me with energy, knowledge, and the desire for more connection. Ray W. Christner I dedicate this book to the three Bien Men. Dan, thank you for your never-ending support, picking up the slack so I could commit my time to this project, and being my best friend in this chaos we call life. Josh and Colby, thank you for your patience, your grace, and for being more independent when I had to spend way more time in my office than any of us wanted. Jessica L. Stewart I dedicate this book to my parents, who have supported me through all my educational aspirations. Thank you for all you do and for all you are. Christy A. Mulligan

Contents

Author Biographies

ix

PART I

Essentials of Cognitive-​Behavior Group Therapy

1

1 Finding Strength in Numbers: An Introduction to Cognitive-​Behavior Group Therapy (CBGT) with Youth

3

JESSICA L. STEWART AND RAY W. CHRISTNER

2 Leading Effective Groups for Children and Adolescents: Change Through Connection

23

CRAIG HAEN AND SETH ARONSON

3 Legal and Ethical Issues in Providing Group Therapy to Minors

40

LINDA K. KNAUSS

4 Useful Techniques in Group Cognitive Behavioral Therapy with Youth: Helping Youth See Things from Wing to Wing

60

ROBERT D. FRIEDBERG, ISABELLA XIE, CALLIE GOODMAN, JOEE ZUCKER, MEGAN NEELLEY, RUNZE CHEN, ANDREA NOBLE, AND TIA LEE

5 Setting Considerations for Group-​Based Cognitive Behavior Therapy for Children and Adolescents

73

AYNSLEY SCHEFFERT

PART II

Presenting Problems

85

6 Cognitive-​Behavior Group Therapy for Anxiety Disorders

87

ELLEN FLANNERY-​S CHROEDER AND CHELSEA TUCKER

7 CBT Groups for PTSD ANNIE KIPKE, DANIELLE CITERA, HALLE THURNAUER, AND PAUL SULLIVAN

111

viii Contents

8 Using CBGT with Youth Depression

128

COURTNEY L. LEONE AND HANNAH BRIMKOV

9 Improving Coping for Angry and Aggressive Youth

145

JOHN E. LOCHMAN, NICOLE POWELL, CAROLINE BOXMEYER, ANNIE DEMING, AND LAURA E. LARSEN

10 Modern Group Eating Disorder Treatment: Inclusion from a Cognitive Behavioral Perspective

165

EMILY L. WINTER, RACHEL BAUMANN, AND ERIN DEMAIO

11 Group CBT for Youth Experiencing Grief

178

MICAELA THORDARSON

12 Building Healthy Media and Device Habits: A CBT-​Based Roadmap

193

JESSICA L. STEWART, RAY W. CHRISTNER, CHRISTY A. MULLIGAN, AND EMILY FOX

13 Running Multi-​Family Skills Training Groups in DBT for Adolescents

221

JILL H. RATHUS

14 CBT Groups with LGBTQ Youth

239

JOHANNA DE LEYER-​T IARKS

15 Building Team Cohesion and Optimal Performance

254

JASON VON STIETZ

16 Providing Positive Psychology Interventions in Group Counseling

270

SHANNON M. SULDO, SARAH A. FEFER, AND KAI ZHUANG SHUM

PART III

Conclusions and Future Considerations

293

17 Epilogue: Future Considerations in CBT Group Treatment

295

CHRISTY A. MULLIGAN

Index

303

Author Biographies

Seth Aronson, Psy.D., is the Director of Curriculum, Training and Supervising Analyst at the William Alanson White Institute. He also teaches in the doctoral program at Long Island University, supervising doctoral students there and at Teachers College, Columbia University. He maintains a private practice in New York City. Rachel Baumann, M.A., S.Y.C., NCSP, LPC, is a licensed therapist and Nationally Certified School Psychologist in Connecticut, working with children, adolescents, adults, and families. An OCD and Trauma specialist, she uses ERP, TF-​CBT, PE, and ACT to help clients reach their goals and live a life driven by their values. Caroline Boxmeyer, Ph.D., is Associate Dean for Academic and Faculty Affairs in the College of Community Health Sciences at the University of Alabama and Professor in the Department of Psychiatry and Behavioral Medicine. She oversees medical and interdisciplinary training programs and provides direct services. Her research focuses on social–​ emotional programming. Hannah Brimkov, M.Ed., is a doctoral candidate in the Ph.D. program in School Psychology at the Indiana University of Pennsylvania. Runze Chen, MS., is a doctoral student at PAU-​Stanford PsyD Consortium. Runze is passionate about working with individuals with diverse and intersecting identities and treating mood and anxiety disorders using culturally tailored interventions. Ray W. Christner, Psy.D., NCSP, ABPP, is a licensed psychologist, certified school psychologist, and an elected Fellow of the Association of Behavioral Cognitive Therapies (ABCT). He is the President of Cognitive Health Solutions in Pennsylvania. His work includes neuro/​psychological testing, case conceptualization, diagnosis, cognitive-​behavior therapy (CBT), and psychotherapy integration. Danielle Citera, Ph.D., is a postdoctoral fellow at Stony Brook University. She treats children, adolescents, and emerging adults. Clinically, she is interested in trauma-​focused treatment, exposure-​based treatments, and acute care settings. Danielle’s research focuses on sexual assault, social reactions to disclosure, and rape myth acceptance. Johanna de Leyer-​Tiarks, Ph.D., NCSP, is an assistant professor at Pace University and Director-​ Center for Education and Intervention Research (CEIR) Psychology Department, NYC. She is a licensed psychologist and certified school psychologist. Her research includes evidence-​based interventions to promote positive behavioral, academic, social–​emotional, and physical health outcomes.

x  Author Biographies

Erin DeMaio, M.A., is a school psychology Ph.D. candidate at the University of Connecticut. Erin has a particular interest in providing comprehensive psychological assessment and consultation to children and families and wishes to continue exploring pathways toward equitable service delivery in educational/​clinical settings as an early career psychologist. Annie Deming, Ph.D., is the Clinical Director of Pediatric Behavioral Health with Intermountain Health in Salt Lake City, UT. She is also an adjunct faculty in the Department of Psychiatry at the University of Utah. Sarah A. Fefer, Ph.D., is a professor and Associate Director of the Center for Youth Engagement at the University of Massachusetts, Amherst. She is also the Associate Dean for Research and Faculty Development. Ellen Flannery-​Schroeder, Ph.D., ABPP, is a licensed psychologist who specializes in childhood anxiety disorders. She earned her doctorate in Clinical Psychology at Temple University and is the Dr. Glenda L. Vittimberga ’88 Endowed Professor of Psychology and Director of the Clinical Psychology program at the University of Rhode Island. Emily Fox, B.S., is a third-​year school psychology PsyD candidate in the Derner School of Psychology at Adelphi University. She is a clinical extern at Neuropsychologic Associates, PLLC, and was previously a student psychotherapist at the Derner Hempstead Child Clinic. Annie Kipke, M.A., is a Ph.D. candidate in the Clinical Psychology program at Hofstra University. Annie has experience treating children, adolescents, and young adults with anxiety disorders, depressive disorders, eating disorders, disruptive behavior disorders, selective mutism, obsessive-​compulsive disorder, and PTSD. Robert D. Friedberg, Ph.D., ABPP, ACT, is a licensed clinical psychologist, board-​certified diplomate in CBT, a Founding Fellow of the Academy of Cognitive Therapy, and a Fellow of ABCT and APA Div 53 (Clinical Child Psychology). He now trains professionals in CBT at the Altamont Cognitive Therapy Training Institute in San Jose, CA. Callie Goodman-​Doughty, B.A., is a graduate of the University of California, Berkeley, completing a Ph.D. in Clinical Psychology at Palo Alto University. She is passionate about the intersections of medical disorders and accountability within pediatric behavioral health care to attend to the whole child’s health. Craig Haen, Ph.D., RDT, CGP, LCAT, is a private practitioner in White Plains, NY, and co-​ founder/​training director of the Kint Institute. He is co-​editor with Seth Aronson of the Handbook of Child and Adolescent Group Therapy. Andrea Noble, M.A., is a Ph.D. candidate in Clinical Psychology at Palo Alto University. Linda K. Knauss, Ph.D., is a professor at Widener University’s Institute for Graduate Clinical Psychology and a private practitioner. She is the chair of the Ethics Committee for the American Board of Professional Psychology. Knauss has taught courses and workshops and published widely on a variety of ethical issues. Laura E. Larsen, Ph.D., is a mental health professional specializing in child and adolescent clinical assessment and intervention, particularly in the areas of anxiety and child trauma, with most recent experiences in community mental health, elementary and middle schools, and university medical centers. Tia Lee is a doctoral candidate at PGSP-​Stanford PsyD Consortium. Her clinical and research interests include children, adolescents and families, anxiety and trauma-​related disorders, autism, and LGBTQ+​populations.

Author Biographies xi

Courtney L. Leone, Ph.D., NCSP, is a professor in the Psychology Department at Indiana University of Pennsylvania. She directs the Ph.D. program in School Psychology. John E. Lochman, Ph.D., ABPP, is the Saxon Professor Emeritus of Psychology at the University of Alabama and a senior fellow at the Alabama Life Research Institute. He was the founding Director of the Center for Prevention of Youth Behavior Problems (now the Center for Youth Development and Intervention). He is the recipient of numerous awards for his work. Christy A. Mulligan, Psy.D., is an assistant professor in School Psychology in the Derner School of Psychology at Adelphi University. She also serves as Assistant Editor for the New York Association of School Psychologists (NYASP) newsletter. Megan Neelley is a Ph.D. candidate in Clinical Psychology at Palo Alto University. Nicole Powell, Ph.D., MPH, is a research psychologist at the University of Alabama’s Center for Youth Development and Intervention. Jill H. Rathus, Ph.D., is Professor of Psychology at Long Island University/​C.W. Post Campus in Brookville, New York, and Co-​Director of the Family Violence Program at C.W. Post. Aynsley Scheffert, Ph.D., LICSW, is an assistant professor of Social Work at Bethel University. In her practice, Scheffert has worked with children, adolescents, and adults and provided individual, group, and family therapy in a community mental health setting. Kai Zhuang Shum, Ph.D., is an assistant professor in the School Psychology Program at the University of Tennessee, Knoxville. Her research includes initiating and sustaining culturally inclusive school mental health research and services. Jessica L. Stewart, Psy.D., is a clinical psychologist in private practice in Providence, Rhode Island, providing psychotherapy with adolescents and adults, conducting neuro/​psychological evaluations, and consulting with local schools. Her expertise includes anxiety, ADHD, executive functioning, cognitive-​behavior therapy, case conceptualization, and building emotional competency and resilience through challenging transitions. Shannon M. Suldo, Ph.D., is a professor of School Psychology and a licensed psychologist at the University of South Florida. Her research interests are in positive psychology and how they relate to children and adolescents. Paul Sullivan, Ph.D., is the current Unit Chief of the Adolescent Inpatient Unit at Bellevue Hospital Center, in addition to being an assistant clinical professor at NYU Langone Health. Sullivan is a graduate of Palo Alto University and specializes in working with patients who present in acute care settings. Micaela Thordarson, Ph.D., is a clinical child psychologist and manages an adolescent intensive outpatient program at Children’s Health of Orange County. Thordarson is passionate about disseminating evidence-​based treatments and mental health education to all stakeholders in the lives of children. Halle Thurnauer, Ph.D., is a clinical psychologist in the Child and Adolescent Partial Hospital Program at Bellevue Hospital Center and is an assistant clinical professor in the Department of Child and Adolescent Psychiatry at NYU Langone Health. Chelsea Tucker, Ph.D., is a licensed psychologist specializing in the cognitive-​behavioral treatment of anxiety disorders. Tucker earned her doctorate in Psychology at the University of Rhode Island in 2017 and currently practices at the New England Center for Anxiety. She is the founder of the consulting firm High Performance Parenting.

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xii  Author Biographies

Jason von Stietz, Ph.D., is a psychologist in group practice at CBT SoCal specializing in OCD, insomnia, and sports psychology. He provides team building and mental skills training to athletes and performers of all levels. Emily L. Winter, Ph.D., NCSP, is a Connecticut and Nationally Certified School Psychologist. She is an assistant professor of clinical psychology at Touro University’s School of Health Sciences in their Psy.D. program. In her clinical practice, Winter works with children, adolescents, and their families by offering comprehensive psychoeducational testing. Isabella Xie is a Clinical Psychology Ph.D. student at Palo Alto University, focusing on pediatric behavioral health care. Isabella holds a B.A. in Psychology and a B.S. in Cognitive Science from Johns Hopkins University. She currently trains at both the Neurodevelopmental Services Program at Pacific Clinics and the Child Mind Institute. Joee Zucker, B.A., is a Ph.D. candidate in Clinical Psychology at Palo Alto University.

Part I

Essentials of Cognitive-​B ehavior Group Therapy

Chapter 1

Finding Strength in Numbers An Introduction to Cognitive-​B ehavior Group Therapy (CBGT) with Youth Jessica L. Stewart and Ray W. Christner

The application of cognitive-​behavior therapy (CBT) with children and adolescents has proven to be a valuable and effective approach to providing therapeutic intervention for multiple disorders, ethnicities, formats of delivery, and treatment settings. CBT is a well-​established and efficacious therapeutic modality for anxiety, depression, obsessive-​compulsive disorders, autism spectrum disorders, externalizing disorders, and posttraumatic stress (Friedberg & Thordarson, 2018). Not only has CBT been applied to numerous presenting problems experienced by youth, but there is also growing implementation of CBT interventions in a variety of settings outside of traditional mental health offices, such as primary care settings, schools, juvenile detention centers, and other community settings (e.g., churches, non-​profit organizations). Most CBT resources for youth clients primarily center on delivering individual treatment services. Yet, many professionals in the field face greater time constraints and increasing numbers of referrals. This is especially true over the last few years with significant increases in mental health concerns for youth, which the COVID-​19 global pandemic has exacerbated. Clinicians must adapt their practice and think beyond providing traditional individual therapy to meet these increased needs. One such option is group therapy –​an alternative or enhancement for providing effective evidence-​based services to youth. Since the first edition of this Handbook, there continues to be a growing evidence base for delivering CBT within a group format to children and adolescents. Cognitive-​behavior group therapy, or CBGT, has shown positive outcomes with youth for a variety of issues, including anger and aggression (Lochman, Boxmeyer, Gilpin, & Powell, 2021; Tavakoli & Mirghaemi, 2023), depression (Nardi, Massei, Arimatea, & Moltedo-​Perfetti, 2016), anxiety (Flannery-​Schroeder & Kendall, 2000; Wolgensinger, 2015; Villabø et al., 2018), and autism spectrum disorders (Scarpa, Williams, White, & Attwood, 2013). Our goal when deciding to develop this Handbook in the early 2000s was to fill the void for a comprehensive resource that not only presents the theoretical foundations of CBT and group psychotherapy but also captures the innovative practices of CBGT with various presenting problems while considering essential aspects of service delivery. This revision expands on the original volume by including updated research and practice on the original topic areas while also considering emerging applications where CBGT is showing promise. We are excited to present this updated volume to help guide professionals in expanding their roles and practices to include CBGT. Now, more than ever, this essential means of delivery is critically needed. Readers would benefit from having a basic understanding of CBT before reading this book. However, each chapter will provide a fundamental review of the components of CBT relevant to the treatment being discussed and direction on how to apply them effectively in group therapy with youth. For those needing a more thorough understanding of the underlying tenets of CBT, consider Dr. Judy Beck’s Cognitive Therapy: Basics and Beyond, Third Edition (2020) and Dr. Robert Friedberg and Dr. Jessica McClure’s Clinical Practice of Cognitive Therapy with Children and DOI: 10.4324/9781351213073-2

4  Jessica L. Stewart and Ray W. Christner

Adolescents: The Nuts and Bolts, Second Edition (2015). In this chapter, we will outline key considerations, benefits, and challenges when providing therapy to youth within a group format, outline a framework for conceptualizing issues through a cognitive-​behavioral lens, and present a general understanding of the “what to do when” and how to structure goals and interventions for the effective practice of CBGT.

Considerations for the Provisions of Group Therapy Service Accessibility A primary benefit to the group modality is simply the capability to reach a large number of children and adolescents at one time. For some professionals, this has become a primary modality as a matter of necessity, based on healthcare limitations and resource restrictions, rather than a desire to work with groups of clients. Yet for other clinicians, group interventions allow them to deliver therapy to multiple clients within a limited timeframe, thus maximizing efficiency while not compromising effectiveness. This is convenient from time, space, staffing, and financial standpoints, and groups also (and more importantly) allow clinicians to begin seeing clients sooner to prevent further decline in their well-​being that may occur during extended wait periods for service. This issue of convenience can also have some disadvantages as well. For instance, although clinicians may be able to see individuals in groups sooner, it also means that there will be less direct time devoted to each client.

Social Comparison and Support According to Festinger’s (1954) social comparison theory, change is internally motivated and occurs more readily when relevant others are available for social comparison, particularly in the presence of an ambiguous situation. The situations that typically produce emotional and behavioral disturbances for young people are often new and ambiguous to them, as they are largely unaware of their mental processes (Reinecke et al., 2003). Observing and hearing others experiencing similar problems, symptoms, or circumstances affords group members reference points that can offer information and increase motivation to adapt to their challenges and difficulties while normalizing what makes members feel “different” or alone. Yalom and Leszcz (2020) note that “normalizing behavior” promotes a sense of universality, one of group therapy’s most helpful features. Given the common tendency for patients, especially when working with adolescents, to challenge a therapist’s ability to understand what they are “going through,” the group setting limits the ability of members to dismiss the observations of others who currently share similar problems. Generally, this is an excellent benefit of group interventions, though we must also be aware that there can be a negative impact on some youth. We can recall group members who, in comparing themselves with their group mates, dismiss their growth and progress or become discouraged if they perceive that others are making more obvious or notable gains. For them, this can reinforce negative self-​talk, including “I am a failure” or “I am not capable of changing.” To minimize and overcome this risk, we recommend both naming at the outset that change will be different (in both rate and degree) for each member and also setting specific goals for each child so they have a target to meet for themselves. This necessitates celebrating the moments when each member achieves steps leading to their goal, which clinicians must intentionally monitor and highlight for the group.

Finding Strength in Numbers 5

Opportunities for Observations Many child and adolescent clients presenting for therapy are experiencing, to some degree, difficulties interacting with others. This may manifest for some through social anxiety. In contrast, it may relate to being disruptive or disturbing to others, as is the case with children with anger problems or difficulty with behavioral inhibition. In individual therapy, we often face the problem of skills not generalizing outside of the therapeutic setting. Goldstein and Goldstein (1998) suggested that interventions must occur in an environment near where the problem occurs. In this way, a group format offers an ideal opportunity for clinicians to directly observe participants’ emotional and behavioral reactions and interactions with peers. This affords valuable information regarding group members’ repertoire of interpersonal responses and skills (e.g., decision-​making, coping, problem-​solving, communication, and so on) and their abilities to implement those skills successfully. Clinicians can use this information to refine their ongoing conceptualization of the client and monitor their progress. For children or adolescents with social problems, monitoring can occur with specific skills (e.g., listening to others when they are talking, making eye contact, turn-​taking) by establishing a baseline during the initial first group sessions and then collecting data on the skills via observations across sessions over time. This information can be tracked and compared to baseline data to measure growth. Natural Laboratory As noted earlier, group therapy settings offer a unique opportunity for clients to interact and practice skills in a safe environment. The group therapy setting is a natural laboratory where members can “test out” their beliefs and newly acquired strategies and skills learned during the skill acquisition phase. This “testing out” phase, or skill implementation, provides members the opportunity and setting to experiment with new behaviors in general, especially those that specifically relate to navigating the social world. This can occur naturally during group interactions or through role-​play and practice activities the therapist facilitates, which offers an excellent opportunity before trying new skills in the “real world.” It provides a way to observe, give feedback, and help refine these skills. Group members may practice any number of skills within the group. However, it is especially beneficial for experimenting with effective coping strategies (e.g., emotional regulation, relaxation, feeling identification and tracking, behavioral regulation, goal setting, problem-​solving) and interpersonal skills (e.g., social awareness, appropriate self-​disclosure, effective communication and listening skills, developing empathy, conflict management). As participants often model the behaviors of other group members or therapists, group facilitators must be mindful of the potential for ineffective or dysfunctional thoughts and behaviors to be repeated and strengthened or adopted by other members. Group therapy requires clinicians to have strong management skills to avoid being sidetracked and be mindful of –​and able to interrupt –​negative patterns occurring within the group. Cohesiveness and Shared Responsibility Effective CBGT with children and adolescents promotes collaboration between members through goal setting, establishing group rules, agenda setting, feedback and sharing of ideas, role-​playing, and practice exercises. These ongoing opportunities for members to work together for the betterment of each other promote cohesiveness, which facilitates each member taking an active role and a personal investment in their success and that of the group and other participants. Ideally, this investment leads each member to share responsibility for the group’s maintenance, progression, and successful completion. Facilitators should monitor the degree to which members are actively

6  Jessica L. Stewart and Ray W. Christner

collaborating and portraying an interest in working together, offering positive (and constructive) feedback to others, and working to meet group goals so that challenges to group cohesion may be detected and addressed early and directly. Some members may be less willing (or able) than others to assume responsibility for their progress, let alone the group’s growth. However, others may be quick to show self-​awareness and positive leadership attributes. Facilitators must be conscious of the motivation or resistance of these members to participate in the change process actively. This will be evident if the conceptualization of each group member’s presentation and the group dynamics are adjusted for accuracy throughout the process of group therapy. Assessment and Group Inclusion A thorough assessment of group members is crucial to developing and starting any group therapy process. This assessment may vary based on the setting or presenting problem, and thus, readers are encouraged to review guidance within specific chapters in this Handbook. Clinicians must consider multiple factors that may influence group composition and make-​up (e.g., developmental level, individual experiences, aspects of identity, and so on), in addition to the presenting symptoms and severity, desired goals for treatment, and readiness to engage in the therapeutic process. Assessment should include standardized objective measures (both comprehensive, broadband measures, and more narrow, problem-​specific questionnaires), observations (when possible), and an extensive interview with potential group members, their families, teachers, etc. Samples of broadband measures that might be useful during the initial assessment include the Behavior Assessment System for Children, Third Edition (BASC-​3™; Reynolds & Kamphaus, 2015), Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001), and the forthcoming Christner Behavior and Adaptability Assessment System (C-​BAAS™; Christner, in progress). The information gathered from these rating scales helps the clinician formulate a thorough and accurate conceptualization of each member’s needs, skill deficits, competencies, and strengths through the CBGT framework. Once an individual is determined appropriate for inclusion in the group, additional baseline data not included in the initial assessment that relates to the presenting problem must be considered for progress monitoring, such as problem-​specific measures given at periodic intervals (e.g., depression, anxiety, anger). Readers are referred to individual chapters in this book for problem-​specific rating scales and measures that can be used in assessment and progress monitoring. CBT Group Formats One factor that can majorly impact cohesion and sharing is the type of CBT group. Traditionally, groups are designated as “closed” or “open” groups. Closed groups often have a set number of sessions or timeframe (e.g., eight weeks), and once they begin, no new members are added to the group. There is a greater chance for group unity in this case, and the therapist can sequentially progress through topics. With open groups, conversely, new members may be continuously added. While this may impact group cohesion, it has its benefits of offering group members an opportunity to move from new to experienced members and practice new skills, such as teaching new members what they have learned. Open groups are more likely to be seen in short-​term settings, such as inpatient or hospital units. Another option for a group format is a rotating group. In rotating groups, therapists design the group based on an 8-​to 12-​week cycle, and each session serves as a treatment module. No matter when a new member enters, they remain in the group until they complete the entire course of sessions. This format is ideal in specific settings. For instance, we have used this approach in schools as an alternative to suspension. Students would be assigned to the group for certain disruptive behaviors (e.g., anger outbursts). They would be required to attend the entire eight-​week program,

Finding Strength in Numbers 7

which consisted of eight distinct lessons, including (1) relaxation training, (2) understanding and modifying negative thoughts, (3) social problem-​solving, (4) self-​monitoring, (5) self-​instruction, (6) stress management, (7) communication skills, and (8) setting goals for your future. No matter where the student began the group, they continued until they completed all modules. It should be noted that with rotating groups, therapists must be skilled at introducing and making new members part of the group. Having time set aside each session to introduce new group members is encouraged. Virtual Group Therapy Especially since the COVID-​19 global pandemic, therapeutic intervention is now more commonly provided within a virtual/​remote setting than ever. Whether members and facilitators are meeting from different classrooms within the same school building or the comfort of their own homes, virtual group therapy has become more commonplace, making this treatment modality more accessible. Group format may still be open, closed, or rotating. However, facilitators of virtual services will need to establish clear rules and expectations for confidentiality (e.g., recording images, audio, or video of meetings, not having others in the room) and member participation (e.g., camera on or off, phones away and hands visible, sharing openly or in the chat). Clinicians will need to be more creative in delivering lessons, assessing members’ acquisition of knowledge and skills, and facilitating the practice and implementation of strategies. For example, getting any required physical materials to group members before the start of each lesson will be necessary. Even the flow of the lesson and member interactions will be different when virtual, requiring more support and proactive direction from the facilitator. For example, whereas when in-​person members can go around a circle to share out, we have experienced the long and awkward pause when members are invited to share their progress on homework, but they do not know in what order they may be required to “go next” (e.g., because there is no circle, they are not sure in what order their “square” may be on the facilitator’s screen). Facilitators will need to be more direct about how they call on or solicit member involvement and how they intentionally foster cohesion when members are not physically in each other’s presence. Promoting group member interaction or collaboration may also be more challenging (e.g., members cannot pair off for “turn and talks”). If there are multiple facilitators, options like break-​out rooms or side chats may be possible but should be closely monitored for member safety and appropriate engagement. Even technological aspects of virtual group therapy may prove challenging, such as a lag in a member’s feed requiring more patience and tolerance from the facilitator and other members, links not working, and so on. Social Loafing Whether related to compliance with homework or in-​session exercises, the social psychology concept of social loafing is critical to consider within the group modality. Essentially, facilitators must be aware of the possibility that when involved in a group, each member may experience the perception that they do not need to engage in an activity because other members will, which will be enough to guide the exercise. This concept of social loafing exists given that, by the nature of a group, each member’s identity is lessened to the extent that they contribute to the group’s identity as a whole. Therefore, the sense of individual responsibility or contribution is also decreased, as the emphasis typically shifts to the group’s production as a whole. It is important for facilitators to actively address members’ perceptions of their accountability to individual growth and goal attainment and the simultaneous contribution to the success of other members. By being cognizant of drawing attention to individual contributions and gains and helping members stay accountable to

8  Jessica L. Stewart and Ray W. Christner

the goals they set at the start of the group, facilitators help minimize the likelihood that members will engage in social loafing. One way we have found to encourage participation from all members is to use the members’ real-​life experiences for group problem-​solving but to do so in a manner that gives all members a chance –​even those who may not be that outgoing. We use a technique called This is My Life (Christner, 2006), in which all group members are given a 3 × 5 card as they come into the group session and have to briefly write down one recent personal situation related to the topic being discussed (e.g., “Write down a situation that made you angry this week.”). All the cards are then placed into a paper bag (or any object), randomly selected, and read aloud to the group without identifying the group member. As a group, they begin talking about thoughts, feelings, and behaviors (both positive and negative) related to the chosen situation and work collaboratively to produce a positive thought–​feeling–​behavior connection. This is a form of group problem-​solving. Then, we invite the individual who wrote the situation to identify themself and describe what they did in the situation and then evaluate how they think the group’s suggestions would help next time they are in a similar situation. Readiness to Change The idea of readiness to change is not a new concept to psychotherapy, as it has been supported in the literature for many years (Prochaska & DiClemente, 1982; Prochaska, DiClemente, & Norcross, 1992) and has been applied to many psychological, psychosocial, and medical issues (see Prochaska et al., 1994). Freeman and Dolan (2001) provided a revision to the original model, including the following ten stages: (1) Noncontemplation, (2) Anticontemplation, (3) Precontemplation, (4) Contemplation, (5) Action Planning, (6) Action, (7) Prelapse, (8) Lapse, (9) Relapse, and (10) Maintenance. See Freeman and Dolan (2001) for a thorough review of these stages. The group context presents an additional dynamic, as each member’s change stage potentially influences the stages of others (both in positive and negative directions). In a positive way, for example, a member who is just thinking about the need to change but has yet to take action may move more quickly toward the action planning and action phases by observing the successes of other group members. However, we have seen instances where the opposite has occurred, and members’ reluctance to attempt change strategies results from a negative report of another member. The therapist must be aware of this possible dynamic and use session time to problem-​solve less than positive experiences and to encourage further attempts for all members to move forward. Challenging Group Members When we think of challenging group members, “resistant” often comes to mind. Malekoff (2015) noted that resistance could manifest in many ways, including denial of the problem, superficial compliance, testing the limits, silence, blaming others, etc. However, while these resistant behaviors appear planned and deliberate on the surface, in many cases, these behaviors stem from sources outside of awareness (Yalom & Leszcz, 2020). Although resistance is a commonly used word, we feel it is pejorative and implies intentionality to the client’s behavior, which instead may be protective or defensive reactivity to pressures involved in change. Thus, we prefer to use the term challenging. In our experiences, disruptive and difficult group behaviors may result from several cognitive errors or distortions at work. For instance, the group member who needs to be “the center of attention.” This child responds to every question, but they do so in a manner that is disruptive and often superficial (e.g., from the perspective “If I look like I know this stuff, I won’t get put on the spot.”). Sometimes, however,

Finding Strength in Numbers 9

another need is being met for this child, such as “I need to be noticed, or people will forget about me.” Another common presentation within child and adolescent groups is the silent challenger. This child attends every group but rarely responds; if they do, it is usually, “I don’t know.” These children often have concerns regarding social perception in the group (e.g., “I don’t want to embarrass myself or look stupid”). However, in our work, we have seen other children and adolescents whose silence was because they did not believe the intervention would work for them. We remember one teenage girl in a school-​based resilience group who, while talking with the facilitator about her lack of active engagement, shared aloud her thoughts that she has “tried these things before, and this is just the way it is, I can’t change anything about my life,” and that “I’m just never going to be happy anyway.” By addressing the underlying, distorted cognitions, we were able to collaborate with her to alter her perceptions that were serving as barriers to her participation and treatment. Finally, there is the active challenger. This is the client who is more actively noncompliant and often disruptive. Again, it is essential to consider what thought pattern may be contributing to the observable behavior. We have had some clients who expressed thoughts like “If I change, I will be weak (or vulnerable)” or “If I try in the group, I’m admitting I have a problem.” These are just a few examples, and we encourage therapists to explore the cognitive factors that may be at the root of challenging behavior individually with the group members. In addition, while individual factors are often looked at when a client’s behavior is challenging, we encourage therapists to consider other potential factors that impede change. These can include family factors, systems or setting factors, peer factors, and provider factors (e.g., teachers, nurses, physicians, and so on), to name a few –​including aspects related to the facilitators themselves. Each of these, and others, should be considered when a client presents as challenging in a group. Keeping an open mind and exploring a range of factors, we can often identify the root of the challenge and work with the child or adolescent to overcome the difficulty, facilitating greater success for each member within the group experience. Cultural Considerations The impact of cultural factors will always be present to some degree within the group context, given the diversity of elements present in group dynamics, and specifically impact how individual members engage in the therapeutic process. Clinicians must remain aware of the certainty that underlying beliefs and norms unique to the identities and experiences of each group member will impact their nonverbal communication (e.g., eye contact), willingness to share, ways they may interact with facilitators and other group members, ability to follow-​through with tasks outside of the group, and their openness to discussing emotions and psychological experiences within the group. Clinicians need to possess knowledge of specific cultural differences, experiences, and considerations to keep in mind within a therapeutic process throughout assessment, goal setting, intervention, communication, and evaluation. However, a general sense or knowledge of specific cultural tendencies or characteristics is insufficient. Facilitators must especially understand that culturally informed and sensitive assessment and treatment consider these individual factors and the therapist–​client (and client-​group) interactive cultural context (Tanaka-​Matsumi, 2022). This is especially critical when assessing and treating youth (and interacting with family members) of historically isolated, marginalized, and harmed populations since their experiences (including generational trauma) impact members’ thinking, emotions, and behaviors that will influence not only symptom presentation but also members’ ability to engage comfortably in, and thus benefit from, the therapeutic process. For example, how racism-​related stress may be an added factor in the emotional challenges of youth of color should be understood to the best of the clinician’s ability. We refer readers to the work of DeLapp and Gallo (2022) for more information and

10  Jessica L. Stewart and Ray W. Christner

examples to help inform the clinician’s conceptualization of the member’s presentations within the group. Because belief systems are shaped by experiences that are unique to the individual, it is important during the assessment process to understand both the illness narrative and desired therapy goals through the lenses of each specific client and their family, not simply their identified or perceived cultural backgrounds. Pedersen and Pope (2016) emphasized the importance of inclusive cultural empathy, which “involves increased awareness to prevent false assumptions, increased knowledge to protect against incomplete comprehension, and increased skill to promote right actions” (p.28). So, at a minimum, facilitators need to appreciate that there will be belief systems interacting within the group therapy context that are influenced by cultural experiences and perspectives and appreciate that these dynamics cannot be understood from simply a fact-​based perspective alone. Some examples include beliefs about emotional matters and mental health (e.g., stigmas about help-​seeking, what should be kept private or shared, vulnerability versus “weakness”); power, authority, and the trustworthiness of the medical profession (especially if a facilitator appears to be of the White majority and a group member does not identify as such); responsibility to the collective group benefit versus individual growth (particularly of emphasis in some cultures); issues of privacy and loyalty regarding disclosing family experiences; spiritual belief systems; etc. Maintaining this appreciation, without judgment or assumption, and including these considerations within the overall conceptualization of each member’s presentation, strengths, and needs –​ as they relate to achieving individual goals and the larger group process –​is critical to supporting the effectiveness of group therapy for each member. Facilitators need to make the process emotionally safe for all youth –​those who are comfortable actively participating and those who may not be –​so that all members can benefit from each component of treatment (e.g., psychoeducation, skills practice, social support, the modeling or context others may provide, and so on). Clinicians should be mindful to include storytelling and careful dialogue that can transcend cultural issues or experiences when they look to teach the social–​emotional skills and competencies we know youth need to develop so that all children can benefit and the group process will be effective. Each problem-​specific chapter that follows will include cultural considerations specific to assessing and treating that presenting problem. Readers are also encouraged to familiarize themselves with research-​based information and guidance for providing culturally informed and sensitive (and therefore more effective) counseling, such as the classic and multiple works of Sue, Sue, Neville, and Smith (2019) and Pedersen, Lonner, Draguns, et al. (2015), among others. In addition, the International Association for Cross-​Cultural Psychology (IACCP) sponsors the Online Readings in Psychology (ORPC), which consists of free resources for anyone interested in the interrelationships between psychology and culture. Articles grouped in Unit 10 (Health/​Clinical Psychology and Culture) “demonstrate the importance of developing the interface between psychology and culture, particularly about counseling and psychotherapeutic activities in a cultural context” (Tanaka-​Matsumi, 2022). Therapist Cognitions When conceptualizing the presenting problems, strengths, needs, participation, and progress of each group member, facilitators must be familiar with the influence of their cognitions and biases. Just as the schemas, automatic thoughts, and resulting emotional and behavioral responses of members influence each other and the group as a whole, so do the same factors of the group facilitator impact dynamics within the group therapy process. As clinicians, we often take for granted that we are just as likely to possess less-​than-​entirely-​accurate or helpful perceptions that may negatively impact our responses to those with whom we interact. In addition to our cultural context (as noted above), it is crucial to be mindful of our beliefs related to our competencies and

Finding Strength in Numbers 11

abilities, and to the intentions, motivations, behaviors, and skills of others (e.g., group members, family members). The group setting presents a unique situation with additional challenges, which may activate underlying schema that would otherwise be less of an issue in a one-​to-​one situation. For example, clinician beliefs related to incompetence are more salient in the group setting, as the idea of making a mistake or not being skilled enough is far more threatening given an audience of six to eight children instead of one. We must be aware of our reactions to particular kinds of group dynamics that may stem from our upbringing (e.g., position within a multi-​child household, experiences with complicated peer relationships) and play out in the group. For example, reactions to unkindness, dominance, and learned helplessness within group dynamics may urge us to intervene in ways that undermine members’ ability to develop skills for navigating these situations in the real world (e.g., regulating their emotional arousal, finding their voice to practice assertiveness). We must remain focused on managing these group dynamics to ensure members’ safety and skill building, not necessarily to assuage our comfort. Facilitators may also possess beliefs related to their ability to work with a cofacilitator, which is often a benefit or even, at times, a necessity in specific group programs. But this may introduce concerns for professional judgment from one’s colleague, “power” dynamics around seniority or experience discrepancies, and differences in style that can impact the sense of cohesiveness. Clinicians must monitor their thought–​feeling–​behavior responses and regulate them in real time to limit their impact on members’ group experience and progress. We must especially monitor our beliefs about the intentions or motivations of youth in our group to avoid biases that impact our ability to deliver the most effective treatment for the betterment of all members. This includes biases regarding member backgrounds and identities (e.g., ethnicities, race, religion, culture, sexuality, gender, abilities, socioeconomic status, family make-​up, or experiences) and reactions to member personality traits or behaviors. For example, we may assume that adolescents of certain backgrounds would resist engaging in role-​play exercises and, therefore, be less likely to assign these practice situations –​which would deny members access to a highly effective, well-​established intervention tool. Maintaining an awareness of the impact that our own beliefs, assumptions, emotions, and behavioral reactivity may have on the dynamics of the group or the participation and progress of individual members is crucial to ensure the effectiveness of therapy.

Cognitive-​B ehavior Group Therapy: The “What” There has been much written over the years discussing the fundamental aspects of the CBT model. It is beyond the scope of this chapter to take a deep dive into CBT theory. Therefore, we refer readers to several seminal texts to obtain a solid footing in CBT, including Cognitive Therapy and The Emotional Disorders (Beck, 1976) and Cognitive Behavior Therapy: Basics and Beyond, Third Edition (Beck, 2020). For an outstanding reference of the use of CBT with children and adolescents, we direct readers to Clinical Practice of Cognitive Therapy with Children and Adolescents: The Nuts and Bolt (Friedberg & McClure, 2018). However, before using the resources provided within this Handbook, we feel it is important to offer a brief review of the basic goals, structure, and components of CBT, specifically as they relate to group therapy with children and adolescents. Brief Overview of CBT The aim of CBT, in general, is to identify and restructure irrational or distorted beliefs and schema related to the self, others, and the world that produce emotional distress and maladaptive behavior (Beck, Rush, Shaw, & Emery, 1979; Beck, 2020). This same fundamental goal is maintained for

12  Jessica L. Stewart and Ray W. Christner

each participant when CBT is provided in a group format. However, the group modality offers the additional benefits of support, peer modeling, a sense of commonality, and an environment in which to practice the variety of skills acquired (as discussed above). Through CBT and CBGT, everyone in the group is encouraged to be active in the collaborative process of therapy, even younger children. However, it remains necessary, especially in a group setting, for the clinician to guide sessions and group processes. Traditionally, CBT is viewed in a linear manner, in which situations, thoughts, feelings, and behaviors are connected in that sequence. For instance, a child who is afraid to be in their bedroom (situation) begins to think that someone will break into the house (thought), and subsequently, they become nervous and afraid (feelings) and refuse to be in their bedroom alone (behavior). While this functional view can be helpful as a starting point, we have not always found this connection to be as simplistic, clear, or direct. Instead, rather than simply a linear approach, these factors tend to influence each other in a multidirectional manner. We encourage clinicians to think and view the interactions of situations, thoughts, feelings, and behaviors less as a linear process and instead more as one whereby each aspect affects the others. Mennuti and Christner (2012) offered a visual illustration of this process in Figure 1.1. In general, the CBT model postulates that the way a child responds to situations depends on the ways in which they interpret those experiences (Friedberg & McClure, 2015) and that these interpretations and responses can affect each other. Distorted thinking will, naturally, result in irrational and unnecessary emotional reactions and exaggerated behavioral responses. These are usually the symptoms that result in referral for psychological intervention and, in this case, inclusion in group psychotherapy. CBT aims to use the therapeutic situation to identify distorted thinking and

Figure 1.1 Multidirectional Model of CBT. © 2010 R. W. Christner and R. B. Mennuti.

Finding Strength in Numbers 13

responding and to modify both. The identification of distorted perceptions and beliefs may be direct or indirect, depending on the age and cognitive flexibility of group members (discussed in more detail below). Modification of beliefs can be through various cognitive techniques and means or through behavioral experiments that result in “evidence” that counters or corrects distorted thinking. Similarly, ineffective emotional and behavioral responses can be modified through behavioral techniques and interventions that aim to build more effective coping skills. The inherent benefits of the group setting highlighted above support the objectives of identifying and restructuring distorted perceptions and beliefs and facilitating the development of more effective skills, making the group modality a natural extension of individual CBT. As the name implies, there are two primary elements in CBT –​(1) cognition and (2) behavior. The CBT literature uses numerous terms to describe the various levels of cognition: core beliefs, schema, intermediate beliefs, irrational beliefs, cognitive distortions, automatic thoughts, etc. To simplify these terms for use in working with young people, we suggest using three terms –​ schema, automatic thoughts, and cognitive distortions. Schemas are an individual’s basic beliefs or assumptions through which individuals perceive and interpret various events (Freeman et al., 2004; Friedberg & McClure, 2015; Young, Klosko, & Weishaar, 2006). They are shaped by our life experiences and are often reinforced throughout our development. They are, essentially, the lenses through which people view themselves, others, the world, events, and interactions. Schema are not easy to identify in younger children, and in many cases, their schema are just developing. However, it is much easier to identify automatic thoughts, which are the immediate, superficial level of cognition (Beck, 2020; Freeman et al., 2004). Automatic thoughts are situation-​specific and occur spontaneously without cognitive effort. Essentially, automatic thoughts “pop” into our minds in response to what just happened or what may be happening in the future. We can have many automatic thoughts in a short amount of time. These thoughts typically produce immediate emotional or behavioral responses, are usually easy to identify, and provide a basis for understanding the patterns in thinking that are generated by our schemas to target for change. When a youth’s thinking affects their behavior, there are two possible cognitive explanations –​ cognitive deficiencies and cognitive distortions (Kendall & MacDonald, 1993). Cognitive deficiencies refer to a deficit in a child’s or adolescent’s cognitive processing ability. For instance, consider the child who responds impulsively without thinking in social situations, and this results in social conflict. Cognitive distortions generally refer to errors or inaccuracies in thinking (Freeman et al., 2004). These errors lead to the individual misperceiving or misinterpreting a situation that subsequently alters their emotions and actions. For example, a teenager is in class and the teacher, with a stern look on their face, glances in their direction. The adolescent thinks, “Ms. Jones must be upset with me; maybe I failed the quiz,” without considering other more reasonable options, such as “Ms. Jones is thinking and making a face.” It should be noted that not all cognitive distortions are negative, though we will alter incoming information to fit our underlying schema. Several experts in the field have identified a number of cognitive distortions or errors in thinking common to a number of disorders (Beck, 2020; Burns, 1999; Freeman et al., 2004). These distortions invalidate or modify information that poses a threat to a person’s existing schematic framework (even if that framework is irrational or maladaptive) so that the incoming information is, instead, compatible with what the person already believes. In Table 1.1, we offer a sample of common cognitive distortions we have seen in our work with children and adolescents in both individual and group settings. Not only may the cognitive distortions of youth clients influence their feelings and behaviors in general, but they may also affect the youth’s group participation (e.g., “If I say the wrong thing, the group will make fun of me,” “The other students are going to think my problems are silly,” and so on).

14  Jessica L. Stewart and Ray W. Christner Table 1.1 Common Cognitive Distortions of Children and Adolescents 1. C  atastrophizing –​ The individual predicts that future situations will be negative and treats them as intolerable catastrophes. For example, “I’m going to fail my test and never graduate.” 2. C omparing –​ The individual compares their performance to others. Oftentimes, the comparison is made to higher performing or older individuals. For example, “I can’t run as fast as my older brother. He is a better athlete than me.” 3. D ichotomous thinking –​ The individual views situation in only two categories rather than on a continuum. The world is either black or white with no shades of gray. For example, “People either love me or hate me.” 4. D isqualifying the positive –​ The individual discounts positive experiences that conflict with their negative views. For example, “Doing well on my homework was just because my mom helped me.” Or “I suck for missing that shot” (ignoring the 18 shots they blocked). (This is also called maximizing the negative and minimizing the positive.) 5. E motional reasoning –​ The individual assumes that their feelings or emotional reactions reflect the true situation. For example, “I feel lonely, so no one wants to be with me.” 6. L abeling –​ The individual attaches a global label to describe themself rather than looking at behaviors and actions. For example, “I’m a failure” rather than “Boy, I had a bad game last night.” 7. M ind reading –​ The individual believes they know what others are thinking about them without any evidence. For example, “I just know that my friends are mad at me.” 8. O vergeneralization –​ The individual sees a current event as being characteristic of life in general, instead of one situation among many. For example, “Because she didn’t invite me to the party, I’ll never be invited to anyone else’s either.” 9. P ersonalization –​ The individual assumes that they are the cause of negative circumstances. For example, “Juan wouldn’t talk to me in the hall today. I must have done something that made him angry.” 10. S elective abstraction –​ The individual focuses attention on one detail (usually negative) and ignores other relevant aspects. For example, “My teacher gave me an unsatisfactory on the last assignment, so this means I must be one of his worst students!” 11. S  hould statements –​ The individual uses should or must to describe how they or others are to behave or act. For example, “I must always get good grades.” Or “she shouldn’t have said that to me.”

The other element of CBGT is the focus on behaviors. This also can be broken down into two areas: skills deficits and skills deficiencies. Children with skills deficits are viewed as not yet having particular skills that would support more adaptive functioning, and through skills acquisition exercises in groups, they will learn new ways to approach situations. The simplest example is what we see in typical social skills groups. However, we often use acquisition interventions that also focus on building executive function skills, such as task monitoring, self-​regulation, organization, and emotional regulation. Skills deficiencies, on the other hand, are seen in children who have acquired a given skill and can use it effectively in certain situations (e.g., the child who can use diaphragmatic breathing well in the session), yet they do not apply it consistently to general situations. For children at this level, skills implementation exercises are essential for them to make progress. While these are also conducted in group sessions, the use of “homework” or between-​ session work is essential in improving implementation and generalizing from the therapy room to real-​life situations. Process Considerations of CBGT: The “How” We are often asked, “What makes a successful group?” Of course, specific, research-​based interventions to treat a given problem are critical components of CBGT that result in positive and sustainable change for group members. But clinicians also need to understand several key aspects of

Finding Strength in Numbers 15

the structure and process of CBGT that work together to facilitate change and, further, to appreciate the context within which change and growth occur in CBT groups. Therapeutic Relationship Perhaps the most important tool a therapist can utilize is the working relationship. Those not familiar with cognitive-​behavioral approaches often assume CBT or CBGT ignore the “therapeutic relationship,” yet this is not accurate. In fact, Beck and his associates (1979) stressed the importance of active interaction between patient and therapist and stressed that not attending to the relationship is a common error in therapy. When referring to relationships, this goes beyond getting along with those with whom we work. The relationship between clinician and client is empowering and empathetic. The therapeutic connection creates a safe space in which youth can be seen, heard, and understood, which is often a new experience for them. The ways in which we interact will open the opportunity for children to explore and voice their true thoughts, feelings, and needs in a manner that helps move them into action. On a basic level, Bordin (1979), in his influential work, identified the “working alliance” to include three important components to its effectiveness –​(1) an agreement on goals, (2) an agreement on assigned tasks, and (3) the development of a personal bond. While the first two are important, the idea of bond or connection is essential, and our role as therapists is to ensure that the connection we have with youth is empathetic, validating, and empowering. This is accomplished through collaboration, and in group settings this relationship extends beyond patient and clinician to include the relational dynamic between group members as well. We must be aware of connection and disconnection that occur, and in groups, ensure that the disconnection is not passed over but addressed as part of the process. As we attend to and address the ruptures in real time, we can create increased energy and trust in the group process while further increasing understanding and providing a sense of self-​worth for all members. Session Structure Setting and following an agenda. No matter which group type or format you use, consistent with individual CBT, CBGT relies on the use of session agendas, though some alterations will be necessary. The agenda helps structure the group format and flow, but clinicians must be flexible to allow content and processes to emerge. It is important to have a basic idea of the agenda for each session, and some specific group formats may be more structured than others (e.g., modules to provide education and skills instruction/​practice in a particular way). However, sessions should include aspects that are established and implemented collaboratively so members feel a sense of shared responsibility for the session’s success. Some common elements of CBGT include “checking in” since the last session, reviewing between-​session work, discussing specific topics or skills of the session, obtaining feedback from the members, setting new between-​session work, and adjourning. While some clinicians may want to allow members to have much more influence in determining the group agenda, we caution this could be counterproductive with youth clients and result in a loss of critical time that could be spent on the work at hand. Instead, we suggest that therapists using CBGT with children and adolescents have a relatively standard agenda but allow for the opportunity for the group to discuss and negotiate tasks to accomplish the goals of the session. In Table 1.2, we offer a suggested agenda format for various stages of group therapy. This is a guideline that therapists can use in planning their sessions. In-​session skills practice. As noted above, a major goal of CBGT is to develop greater awareness in members of the interaction between their thoughts, feelings, behaviors, and physiological perceptions and to facilitate the development of more effective and adaptive ways of operating

16  Jessica L. Stewart and Ray W. Christner Table 1.2 Example of CBGT Agendas First session

Middle sessions

Last session

Introductions Setting the agenda Clarifying group rules Getting to know your activity Socializing to CBT Providing a summary Developing between-​ session work Eliciting feedback Adjourning

Greeting and check-​in Setting agenda Eliciting feedback from last session Reviewing between-​ session work Conducting skills building Obtaining examples from group Providing summary Developing between-​ session work Eliciting feedback Adjourning

Greeting and check-​in Setting agenda Eliciting feedback from last session Reviewing between-​ session work Developing a maintenance plan Identifying group members “plans for success” Providing summary Eliciting feedback Adjourning

through education, modeling, and skills implementation exercises. A critical component of sessions, therefore, is the opportunity for group members to not only ask questions and engage in discussion that makes concepts more meaningful, relatable, and attainable but also to see skills implemented –​ both poorly and successfully, for juxtaposition –​ and practice skills themselves while supportive, affirming, and corrective feedback can be provided. Again, CBGT aims to use the therapeutic situation to identify distorted thinking that contributes to exaggerated emotional experiences and maladaptive or ineffective behaviors and modify each of these interconnected elements of members’ experiences to help them improve their overall functioning and well-​being. Therefore, it is critical that sessions are not merely didactic but rather provide members with the chance to experience concepts directly, uncover underlying thought patterns, see ineffective or even maladaptive behaviors as no longer helpful, and feel the cognitive dissonance that results from evolving beliefs that do not align with existing behavior patterns. It is this dissonance that helps to facilitate change –​so long as group members are shown and given the opportunity to practice healthier and more effective skills. Through shared, lived experiences that include emotion and often humor, the material will be more easily remembered, as experiential learning is typically more impactful –​even if it is contrived within group activities. Homework. The inclusion of between-​session practice (typically referred to as “homework” in CBT) is a primary component of the CBGT model, given that the emphasis is on skill building, with the goals of making newly learned skills automatic, generalizing skills across settings, and altering the ways in which group members perceive events. Essentially, homework attempts to “put in action” the skills discussed and learned in group therapy, but in real-​life situations. Homework is often first practiced within a group session, then planned for additional practice between sessions, and finally reviewed in the following session. Members work together to learn and practice skills and then support and provide feedback to one another on the success or failure of homework completion. Homework in CBGT has particular value, as it offers members the chance to learn from one another’s experiences when between-​session work is reviewed as a group. An important consideration for facilitators beyond the assignment of meaningful homework is how to handle when group members fail to follow-​through with between-​session work. This consideration cannot be underscored enough, as it contributes to the perceptions and beliefs that members have about themselves, others, and the process of therapy. Suppose a particular member is having compliance difficulty. In that case, the facilitator must seek to accurately understand their difficulty rather than automatically attributing noncompliance to behavioral difficulties or

Finding Strength in Numbers 17

resistance (as discussed as a caution above). Some group members may have difficulty with follow-​ through because of a lack of support or resources outside of the group (e.g., a reliable adult to help facilitate the assigned activities, a lack of opportunities to generalize the skills, and so on). Others may be experiencing self-​doubt, feelings of incompetence, or confusion about the assignment that must be understood as part of the conceptualization of the automatic thoughts and schemas of the individual members at work within the group. Reasons for missed homework must be accurately and directly ascertained and addressed by facilitators within the group to prevent the members from perceiving that homework is not important (i.e., if they observe that Beth continually does not do her between-​session work and the facilitator does not address this with her or do anything to “make her,” they may begin to discredit the importance of the work). Also, understanding the reason for noncompliance can be an assessment tool to help determine factors that may hinder or impede an individual client’s change process. In addition, the group could work to help one member by sharing ideas to overcome particular obstacles. When a therapist does not address issues related to non-​completion of between-​session work, it may lead to members feeling that the therapist “doesn’t care.” For example, consider a socially rejected child who is not completing assignments, but the clinician does not directly address the issue. The child may perceive, “She really doesn’t care that I am a member of the group” or “She doesn’t even notice me.” These perceptions result from and, worse, reinforce his beliefs that he is worthless, dispensable, and lacks value in the eyes of others. Time limitations. The amount of time available for conducting each group meeting will likely depend on the setting and the purpose of the group. For example, groups conducted in the school setting may be limited by class period scheduling (e.g., 45 minutes), while inpatient groups may be 60–​90 minutes. Likewise, groups that include lengthy aspects of exposure treatment may require more time. Regardless, we feel it is important to include the key components of CBGT still, even if that means some aspects are shorter to allow for more time spent, for example, on skill acquisition and implementation practice. Facilitators will need to use clinical judgment as to how best to budget time given their unique circumstances and be mindful that this may not be the same budget from week to week. Early on in the process, for example, more time may need to be spent on rapport building (for group cohesion and trust to develop), and practical activities to promote member interest and motivation as they experience change more directly. Case Conceptualization The use of case conceptualization or case formulation is common in CBT (Beck, 2020), and it has been discussed widely when working with children and adolescents (Murphy & Christner, 2012; Manassis, 2014; Friedberg & McClure, 2015). When using case conceptualization in group CBT it refers to the structured and systematic understanding of not only the individual’s presenting concerns but also how each member’s concerns relate within the context of the group environment. This process involves gathering comprehensive information about the individual’s cognitive, behavioral, and emotional patterns and integrating this knowledge into a comprehensive understanding of the individual and the broader group dynamics. A well-​formed conceptualization assists clinicians in tailoring interventions not only to the individual’s needs but also in a manner that optimizes the therapeutic benefits of the group setting. Christner (2022) provides a list of different components for clinicians to consider when formulating an understanding of a child or adolescent, which is shown in Table 1.3. Within the group context, it is imperative to consider how individual patterns of cognition and behavior influence and are influenced by the different dynamics seen within group therapy. For instance, an individual with social anxiety might interpret benign comments from other members as critical or hostile, which in turn might affect group cohesion. By thoroughly understanding these nuances through case conceptualization, clinicians have a greater potential to preempt challenges

18  Jessica L. Stewart and Ray W. Christner Table 1.3 Components of Case Conceptualization Identifying Data/​Personal Information Reported Concerns Antecedents/​Triggers Developmental Considerations Ethnoracial Considerations Wellness and Resiliency Factors Barriers to Progress Readiness to Change Factors Relevant Assessment Data Working Hypothesis(es) Diagnostic Impression/​E ducational Classifications Goals/​Treatment Considerations ©2022 Ray W. Christner

and use group dynamics to foster change. By weaving these insights into the group process, clinicians can foster richer, more diverse discussions and learning experiences to broaden outcomes. Each of the problem-​specific chapters in this volume will provide valuable insight and important considerations to guide case conceptualization unique to that issue. Goals and Objectives The CBGT approach is both goal-​driven and time-​limited. It emphasizes the creation of distinct objectives to steer the application of its techniques. Such a method is vital in every therapeutic setting, but it becomes even more crucial in group therapy. While some group sessions might have predefined goals before the attendees begin the group (e.g., CBGT for alleviating social anxiety), it is essential to also set individual objectives for each participant. By doing so, each member feels more invested in the group therapy process, having a clear personal target rather than measuring success against others. When determining goals, we will have the overarching therapeutic goals (e.g., “Reduce John’s anxiety so he can approach others in conversation 8 out of 10 times”), and also support youth to come up with personal and highly motivating goals (e.g., “I will improve my anxiety level so I can go with my friends to SkyZone.”). We use many metaphors, analogies, and references to pop culture in our work with children and adolescents, especially when discussing goals and the process to reach them. For example, highlighting the process by which Taylor Swift became a global sensation, we consider that her first goal was likely not to sell out stadiums but instead to first write a song, then another, record them, then get people to listen, then get a record label, etc. A common metaphor we use involves thinking of goals as a map or a GPS –​to find your way, you must first know where you want to go. For younger children, we use a strategy, “The Captain’s Map to the Chest of Success” (Christner, 2023). We liken the process of goal setting to a pirate going on a journey to find the treasure of a lifetime –​Feeling Success. If you are a pirate not knowing where you want to go, you might wander aimlessly, unsure of your direction. But with a map that has an “X” that marks the spot (the goal), you can chart a course toward your desired destination, adjusting as necessary when obstacles or new paths emerge. Intervention Selection: The What to Do When When selecting interventions to use in CBGT, there are several options to consider. CBT has been refined over the years to address the multifaceted nature of psychological disorders, resulting in

Finding Strength in Numbers 19

various programs, approaches, and interventions. While there are some distinctions between different approaches, it is important to remember that all approaches are grounded in the foundational principles of CBT and are developed with the aim of providing efficient and effective treatments. Throughout the forthcoming chapters, you will see these different methods and approaches brought to life based on the specific problem areas discussed. These chapters will include specific, “apply tomorrow” interventions we know readers look forward to. However, we want to take a moment here to discuss the frameworks clinicians have when choosing different ways to identify interventions for use within a group. One approach that clinicians may be familiar with is the use of manualized therapy. Multiple published manuals and programs exist for delivering CBGT to youth for a variety of concerns, several of which are discussed in chapters within this book and other publications on CBGT (see Christner & Bernstein, 2017). While some may view manualized programs as rigid, they offer clearly defined, step-​by-​step procedures to follow and specific activities to use in session. This is ideal for new clinicians but can also be of benefit to seasoned practitioners working in larger organizations or schools, where different providers might run the same group. The concern of manualized approaches being rigid has been challenged more recently, and we recommend clinicians using treatment manuals review Phillip Kendall’s book, Flexibility within Fidelity: Breathing Life into a Psychological Treatment Manual (2021), for inspiring ideas in using manuals in group therapy. The two other main options for formatting intervention seek to increase adaptability and move away from the idea of a “one-​size-​fits-​all” method. The second approach is the use of unified protocols. The goal of unified protocols is to address commonalities across anxiety and mood disorders, focusing on the core underlying factors rather than the specific diagnostic labels. This is referred to as transdiagnostic treatment, which highlights the shared emotional and cognitive processes across many clinical presentations, and how they contribute to an array of disorders. The adaptability of unified protocols is through this transdiagnostic lens. Clinicians aim to target underlying contributing factors, such as emotional dysregulation and cognitive distortions, and less attention is focused on the specific disorder, per se. Thus, group members might have differing diagnoses, but the goal of therapy is to address and build skills in those common areas. Those interested in unified protocols with children and adolescents are referred to the work of Ehrenreich-​May and colleagues (2018) for specific guidance and strategies in using this approach. Finally, there is the use of modular-​based therapy, which promotes adaptability by allowing clinicians to select from a set of modules or components tailored to the patient and their unique problems and needs. The use of modular-​based therapy relies on the clinician using good case conceptualization skills to understand the child and the group (Mennuti & Christner, 2012). Chorpita and Weisz (2009) offer an excellent application of the modular approach using MATCH-​ADTC (Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems). MATCH-​ADTC consists of core and supplemental modules to meet each patient’s unique presenting concerns. Beyond using a program such as MATCH-​ADTC, clinicians well versed in CBT and integrative psychotherapy could use effective case conceptualization to identify a youth’s critical knowledge and skill gaps and then develop an appropriate treatment plan, consisting of intervention components that guide the group work. While the modules or components of practice differ based on the core presenting problem(s), Table 1.4 offers a list of common modules that are seen in transdiagnostic literature. It is necessary to note that with each of these approaches, there remains an emphasis on the importance of empirical evidence. Their foundations lie in evidence-​based practices, with each program, module, or element in these treatments having strong research backing. Selecting interventions using one of these methodologies ensures that patients and groups receive CBT treatments

20  Jessica L. Stewart and Ray W. Christner Table 1.4 Sample of CBT Modules for Children and Adolescents Activity Scheduling (Activation) Assertiveness Training Cognitive Interventions (e.g., refocusing, reframing, restructuring, and so on) Communication Skills Confronting Physical Sensations Emotional Self-​M onitoring Emotional Regulation Goal Setting Interoceptive/​E motion Exposure Maintaining Motivation

Maintenance Strategies (relapse prevention) Modeling Parental Education (e.g., response cost, differential reinforcement) Problem-​S olving Psychoeducation Relaxation Self-​Reward/​P raise Social Skills Training Understanding Emotions

that are not only tailored to their needs but are also rooted in scientifically proven methods. The key to all good group therapy approaches is that they involve adaptability, personalization, and evidence-​based practice. Summary CBGT provides a systematic, theoretically driven model that aids in understanding each patient’s unique information within the context of the group’s dynamics. This model helps clinicians anticipate challenges and select structured intervention methods. Throughout this chapter, we have underscored the significance of having a flexible understanding of each group member, taking into account their cultural contexts individually and when interacting within the group –​including interactions with facilitators –​to meet clearly defined goals and objectives. It is crucial to see each member’s needs and objectives through the lens of the CBGT model. This way, facilitators can grasp the thoughts, emotions, perceptions, and behaviors exhibited by each child and the group as a whole. This aids in shaping the group’s program, choosing relevant and effective interventions, and monitoring each member’s progress in the change process. Facilitators must also be conscious of their thoughts and actions and how they influence the group’s dynamic. With the interplay of thoughts, emotions, perceptions, and behaviors in CBGT, numerous simultaneous reactions influencing each other are ever present in a group setting. We hope readers will understand from this Handbook that while facilitating CBGT with children and adolescents comes with its unique set of considerations (and even challenges at times) in comparison to individual therapy, it also offers numerous benefits and rewards. These challenges are manageable within the group context, provided facilitators stay attentive to potential hurdles, remain true to core principles of CBT, consistently evaluate factors impacting group dynamics, and guide the group toward achieving well-​defined goals and objectives for both individual patients and the group collectively. We are excited to present readers with subsequent chapters, written by a diverse team of thoughtfully chosen experts in the field, that provide a more in-​depth exploration of the use of CBGT with specific problems facing youth. References Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA school-​age forms & profiles. Burlington, VT: University of Vermont, Research Center. Beck, A. T. (1976). Cognitive therapy and the emotional disorders. Madison, CT: International Universities Press. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy for depression. New York: Guilford Press.

Finding Strength in Numbers 21 Beck, J. S. (2020). Cognitive therapy: Basics and beyond (2nd ed.). New York: Guilford Press. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–​260. https://​doi.org/​10.1037/​h0085​885 Burns, D. D. (1999). Feeling good: The new mood therapy (Rev. ed.). New York: Avon. Chorpita, B. F., & Weisz, J. R. (2009). MATCH-​ADTC: Modular approach to therapy for children with anxiety, depression, trauma, or conduct problems. Satellite Beach, FL: PracticeWise. Christner, R. W. (in progress). Christner behavior and adaptability assessment system (C-​BAAS™). Lutz, FL: PAR, Inc. Christner, R. W. (2023, September). Better interventions, better outcomes: CBT to enhance student success. Presented at the North Dakota Association of School Psychologists Fall 2023 Conference in Minot, ND. Christner, R. W. (2022, October). Beyond diagnosis: Using test data for case conceptualization. Presented for the PARtalks series for Psychological Assessment Resources (PAR). [Virtual] Christner, R. W. (2006). Fundamentals of psychotherapy with children and adolescents: Overlooked variable and effective strategies. Invited workshop presented at Midwestern Intermediate Unit, Grove City, PA. Christner, R. W., & Berstein, E. R. (2017). Cognitive-​behavioral group therapy. In C. Haaen & S. Aronson (Eds.), Handbook of child and adolescent group therapy: A practitioner’s reference (pp. 110–​123). New York: Routledge. DeLapp, R. C. T, & Gallo, L. (2022). A flexible treatment planning model for racism-​related stress in adolescents and young adults. Journal of Health Service Psychology, 48, 161–​173. November 2022. https://​doi. org/​10.1007/​s42​843-​022-​00073-​6 Ehrenreich-​May, J., Kennedy, S. M., Sherman, J. A., Bilek, E.L., Buzzella, B. A., Bennett, S. M., & Barlow, D. H. (2018). Unified protocols for transdiagnostic treatment of emotional disorders in children and adolescents: Therapist guide. New York: Oxford. Festinger, L. (1954). A theory of social comparison processes. Human Relations, 7, 117–​140. Flannery-​Schroeder, E. C., & Kendall, P. C. (2000). Group and individual cognitive–​behavioral treatments for youth with anxiety disorders: A randomized clinical trial. Cognitive Therapy and Research, 24(3), 251–​ 278. https://​doi.org/​10.1023/​A:100550​0219​286 Freeman, A., & Dolan, M. (2001). Revisiting Prochaska and DiClemente’s stages of change theory: An expansion and specification to aid in treatment planning and outcome evaluation. Cognitive and Behavioral Practice, 8, 224–​234. Freeman, A., Pretzer, J., Fleming, B., & Simon, K. M. (2004). Clinical applications of cognitive therapy. New York: Plenum Press. Friedberg, R. D., & McClure, J. M. (2015). Clinical practice of cognitive therapy with children and adolescents: The nuts and bolts (2nd ed.). New York: The Guilford Press. Friedberg, R. D., & Thordarson, M. A. (2018). Cognitive behavioral therapy. In J. L. Matson (Ed.), Handbook of childhood psychopathology and developmental disabilities of treatment (pp. 43–​55). Cham: Springer International Publishing. Goldstein, S., & Goldstein, M. (1998). Managing attention deficit hyperactivity disorder in children: A guide for practitioners (2nd ed.). New York: Wiley. Kendall, P. C. (2021). Flexibility within fidelity: Breathing life into a psychological treatment manual. New York: Oxford University Press. Kendall, P. C., & MacDonald, J. P. (1993). Cognition in the psychopathology of youth and implications for treatment. In K. S. Dobson & P. C. Kendall (Eds.), Psychopathology and cognition (pp. 387–​430). San Diego, CA: Academic Press. Lochman, J. E., Boxmeyer, C. L., Gilpin, A., & Powell, N. P. (2021). Cognitive-​behavioral intervention for aggressive children: The anger coping and coping power programs. In M. Feinberg (Ed.), Designing effective prevention and public health programs (pp. 9–​21). Oxon: Taylor and Francis and Routledge. Manassis, K. (2014). Case formulation with children and adolescents. New York, NY: Guilford Press. Malekoff, A. (2015). Group work with adolescents: Principle and practices (3rd ed.). New York: Guilford Press. Mennuti, R. B., & Christner, R. W. (2012). An introduction to cognitive-​behavioral therapy with youth. In R. B. Mennuti, R. W. Christner, & A. Freeman (Eds.), Cognitive-​behavioral interventions in educational settings: A handbook for practice (2nd ed., pp. 3–​24). New York: Routledge Publishing.

22  Jessica L. Stewart and Ray W. Christner Murphy, V. B., & Christner, R. W. (2012). A cognitive-​behavioral case conceptualization approach for working with children and adolescents. In R. B. Mennuti, R. W. Christner, & A. Freeman (Eds.), Cognitive-​ behavioral interventions in educational settings: A handbook for practice (2nd ed., pp. 81–​ 115). New York: Routledge Publishing. Nardi, B., Massei, M., Arimatea, E., & Moltedo-​Perfetti, A. (2016). Effectiveness of group CBT in treating adolescents with depression symptoms: A critical review. International Journal of Adolescent Medicine and Health, 29(3), 20150080. /​j/​ijamh.2017.29.issue-​3/​ijamh-​2015-​0080/​ijamh-​2015-​0080.xml. https://​ doi.org/​10.1515/​ijamh-​2015-​0080 Pedersen, P. B., & Pope, M. (2016). Toward effectiveness through empathy. In P. B. Pedersen, W. J. Lonner, J. G. Draguns, J. E. Trimble, & M. R. Scharron-​del Rio (Eds.), Counseling across cultures (7th ed., pp. 13–​30). Thousand Oaks, CA: SAGE Publications. Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research & Practice, 19(3), 276–​288. https://​doi.org/​10.1037/​h0088​437 Prochaska, J. O., DiClemente, C. C., & Norcross J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102–​1114. http://​dx.doi.org/​10.1037/​0003-​066X.47.9.1102 Prochaska, J. O., Redding, C. A., Harlow, L. L., Rossi, J. S., & Velicer, W. F. (1994). The transtheoretical modal and HIV prevention: A review. Health Education Quarterly, 21, 471–​486. Reinecke, M. A., Dattilio, F. M., and Freeman, A. (Eds.). (2003). Cognitive therapy with children and adolescents: A casebook for clinical practice (2nd ed.). New York: Guilford Press. Reynolds, C. R., & Kamphaus, R. W. (2015). Behavior assessment system for children (3rd ed.). Bloomington, MN: Pearson. Scarpa, A., Williams White, S., & Attwood, T. (2013). CBT for children and adolescents with high-​functioning autism spectrum disorders. New York: Guilford Press. Sue, D. W., Sue, D., Neville, H. A., & Smith, L. (2019). Counseling the culturally diverse: Theory and practice (8th ed.). Hoboken, NJ: Wiley. Tanaka-​Matsumi, J. (2022). Counseling across cultures: A half-​century assessment. Journal of Cross-​Cultural Psychology, 53(7–​8), 957–​975. https://​doi.org/​10.1177/​002202​2122​1111​810 Tavakoli, M. N., & Mirghaemi, T. S. (2023). The effectiveness of cognitive-​behavioral group therapy anger and assertiveness of adolescents. International Journal of Education and Applied Sciences, 3(4), 20–​28. doi:10.22034/​injoeas.2023.365081.1038 Villabø, M. A., Narayanan M., Compton S. N., Kendall P. C., & Neumer S. P. (2018). Cognitive-​behavioral therapy for youth anxiety: An effectiveness evaluation in community practice. Journal of Consulting and Clinical Psychology, 86, 751–​764. Wolgensinger, L. (2015). Cognitive behavioral group therapy for anxiety: Recent developments. Dialogues in Clinical Neuroscience, 17, 347–​351. doi:10.31887/​DCNS.2015.17.3/​lwolgensinger Yalom, I., & Meszcz, M. (2020). The theory and practice of group psychotherapy (6th ed.). Cambridge, MA: Basic Books. Young, J. E., Klosko, J. S., & Weishaar, M. E. (2006). Schema therapy: A practitioner’s guide. New York: Guildford Press.

Chapter 2

Leading Effective Groups for Children and Adolescents Change Through Connection Craig Haen and Seth Aronson

As we write this chapter, the United States is in the midst of what has been deemed a mental health crisis for children and adolescents. It is estimated that over 140,000 children in this country lost a parent or grandparent caregiver during the first 15 months of the COVID-​19 pandemic (Hillis et al., 2021). Protective measures of lockdowns and remote schooling, as well as uncertainty about illness transmission and disruption to regular rhythms and routines, were connected to increased anxiety, depression, somatization, phobias, sleep disturbance, and distress among youth and families (De France et al., 2022; Patrick et al., 2020; Rosen et al., 2021; Viner et al., 2022). The long-​ term toll of this public health crisis is currently being measured in terms of developmental delays and learning loss (Goldhaber et al., 2022; González et al., 2022). The pandemic highlighted existing societal imbalances, with already vulnerable groups bearing the greatest hardship. Widespread racial disparities were prominently illustrated by data on disease transmission, mortality rates, healthcare access and quality, unemployment, and related stressors (Brown et al., 2020; Chavira et al., 2022; Mude et al., 2021). These data call us to reckon with structural and systemic factors as powerful determinants of youth mental health (Rostad et al., 2023). They also implore us to consider whether our clinical practices are well-​suited to addressing the varied needs of children and adolescents. Such self-​examination is necessary, as meta-​analyses show that (a) existing treatment approaches for youth are only moderately effective in aggregate (Weisz et al., 2017) and generally yield small to medium effect sizes at 12-​month follow-​up (Pilling et al., 2020); and (b) the development of empirically supported treatments has not improved the effectiveness of child/​adolescent therapy for several key problem areas, including anxiety and Attention-​Deficit/​Hyperactivity Disorder (ADHD), while outcomes have worsened for depression and conduct problems (Weisz et al., 2019). Group therapy has a vital role in supporting child and adolescent mental health, particularly in its capacity to increase the reach of services by virtue of having multiple young people participate at the same time, making it both cost-​ and time-​efficient (Yalom & Leszcz, 2020). Accumulated evidence suggests that group therapy is at least as effective as individual therapy (Burlingame & Jensen, 2017; Rosendahl et al., 2021). However, quality group treatment is not about simply providing individual therapy on a wider scale. Groups offer the possibility for interpersonal learning, relationship-​building, and peer support that are not readily available within individual formats (Kealy & Kongerslev, 2022). Groups also show promise for remedying disconnection among youth during a time when the impact of loneliness on physical health, mental health, and academic progress is becoming increasingly understood and appreciated (Hards et al., 2022; Hawkley, 2022; Yildiz & Duan, 2022). These generative aspects of group therapy are important for both children (who often lack the understanding that others share their feelings) and adolescents (for whom peer relationships are an important source of identity, influence, and belonging).

DOI: 10.4324/9781351213073-3

24  Craig Haen and Seth Aronson

Group therapy recently became recognized in the field of psychology as a specialty practice, highlighting the need for group leaders to have distinctive skills and training (Whittingham et al., 2021). As Hahn et al. (2022) noted, Not knowing what one is doing in a group can harm not just one but many patients and can create a situation in which patients are worse off than when they started. Conversely, knowing what one is doing can provide maximum therapeutic benefit. (p. 692) When harnessed within structured approaches such as cognitive-​behavioral therapy (CBT), the therapeutic factors of group can have a synergistic effect that enhances shared sense of purpose among members and leaders, motivation to engage in exercises and tasks, and positive reinforcement of clinical gains (Christner & Bernstein, 2017; Kealy & Kongerslev, 2022). In this chapter, we will discuss elements of effective group work with children and adolescents that are rooted in both research and practice-​based evidence. Beyond technique or approach, these process components are at the heart of engaging young people in group therapy, forging connections, and facilitating change. Our focus on group dynamics, structure, and leadership dimensions is aligned with recent efforts to determine evidence-​based principles of group psychotherapy that are integrative and transtheoretical (Haen, 2017; Kaklauskas & Greene, 2020), as well as the movement toward identifying empirically supported principles of change in youth psychotherapy that can be customized to treat a broad range of mental health challenges for children and adolescents with diverse identities (Fitzpatrick et al., 2023; Weisz & Bearman, 2020). The Relationships Are the Thing Ask young people what they value most about their group therapy experience, and they are less likely to tell you about what they did or talked about during sessions than they are to focus on their relationships and sense of belonging within the group (Haddad & Shechtman, 2020; Harpazi et al., 2020; Pingitore & Ferszt, 2017; Shechtman & Gluk, 2005). This is perhaps not surprising. As Tasca and Marmarosh (2023) noted, the therapeutic alliance—​which refers to the bond between therapist and patient and their concordance on the tasks and goals of treatment—​is one of the most robust predictors of outcome in both adult (Flückiger et al., 2018) and child/​adolescent psychotherapy (Cirasola & Midgley, 2023; Roest et al., 2023). As important as relationship factors are within individual treatment, they may be paramount in group therapy, acting as the central mechanisms of change for young people. In a recent randomized controlled trial of 182 children and adolescents diagnosed with anxiety disorders, Bjaastad et al. (2023) found that the therapeutic alliance correlated to long-​term outcomes in group CBT. Interestingly, this same correlation was not found for participants who received individual CBT, where only therapist adherence to the treatment model was positively related to outcome (a finding that, conversely, did not apply to the groups). The emphasis that CBT therapists place on a collaborative stance appears to be key to fostering the therapeutic alliance (Cirasola et al., 2022). In group CBT, the role of the leader can be likened to that of a coach who engages the members in problem-​solving, learning and practicing coping strategies, and applying those acquired skills outside of session (Christner & Bernstein, 2017). A solid therapeutic alliance, which child/​adolescent therapists are tasked with establishing with both young people and their parents (Cirasola & Midgley, 2022), can help with (a) building trust and overcoming initial reticence (Kapp et al., 2017); (b) increasing children and adolescent’s confidence in their capacity to change and bolstering motivation (Nuñez et al., 2022); (c) providing containment and safety as well as setting the emotional tone for the group (Pingitore & Ferszt,

Leading Effective Groups for Children and Adolescents 25

2017); and (d) keeping youth engaged and attending sessions, even adolescents struggling with depression, substance misuse, and personality disorders, for whom treatment dropout is common (Harris et al., 2012; Hauber et al., 2020; O’Keeffe et al., 2020). While the alliance-​outcome association tends to be less robust in CBT compared to other group approaches, it remains a significant process variable that can be capitalized upon by a skilled group leader (Lo Coco et al., 2022). In group therapy, the alliance is multidimensional, as there are often two therapists facilitating a group, and members may have different bonds with each of them. In addition to bonding with the therapist(s), group members also form relationships with one another and the group-​as-​a-​whole, reflecting three levels of process that are all important to the effectiveness of group therapy. These multilayered relationships are captured by two related concepts: cohesion and group climate. We will review each of these process variables and how they intersect with group development, group leader intervention, and the effectiveness of group therapy with children and adolescents. Group Cohesion While definitions have varied across the literature, cohesion generally refers to the connections between group members that draw them toward one another and promote a sense of unity or “we” (Rosendahl et al., 2021; Tasca & Marmarosh, 2023). Cohesion can be observed in the ways that young people move from noticing what makes them different from other group members to identifying similarities; becoming invested in being part of the group; expressing interest in each other and forming connections; and experiencing shared and reciprocal interactions such as encouragement, support, and empathy that evoke positive emotions (Bryde Christensen et al., 2021; Forsyth, 2021; Lo Coco et al., 2022). In cohesive groups, young people generally feel seen and appreciated by others, have a sense of belonging, and share a desire to “stick together” (Gray & Rubel, 2018). Yalom and Leszcz (2020) asserted that cohesion is “not only a potent therapeutic force in its own right; it is a precondition for other therapeutic factors to function optimally” (p. 77). Cohesion seems to have an even greater connection to group therapy outcomes than the therapeutic alliance, exhibiting a moderate effect size in meta-​analysis (Burlingame et al., 2018). Summarizing the substantive research on this topic, Tasca and Marmarosh (2023) reported that increased cohesion has been found to have a positive relationship with group attendance, commitment, participation, tolerance of conflict, and quality of empathy between members. Group interventions that aim to build cohesion are therefore empirically supported (Hahn et al., 2022). However, most research on cohesion has focused on adult groups. Shechtman, in conducting three studies on child/​adolescent groups (Shechtman & Katz, 2007; Shechtman & Leichtentritt, 2010; Shechtman & Mor, 2010), found a high correlation between bonding with the therapist and bonding with the group, leading her to conclude that children may have greater difficulty differentiating these two sets of relationships (Shechtman, 2017). Her data suggest that alliance and cohesion have a similar impact on outcomes in children’s groups. As children age into adolescence, though, peer relationships take on increasing importance. Consistent with this developmental shift, relationships between adolescent group members tend to supersede their relationships with the group leader (Gray & Rubel, 2018; Hauber et al., 2020; Shechtman & Leichtentritt, 2010; Steen et al., 2022). Given its fundamental nature, cohesion-​building is particularly important during initial group sessions in order to set the stage for what’s to come, particularly in CBT approaches where members will be asked to engage in more emotionally challenging activities that evoke resistance, such as exposure and behavioral activation, in subsequent sessions (Lebowitz & Zilcha-​Mano, 2022). Kealy and Kongerslev (2022) noted that cohesion “can be a force for keeping patients engaged in such activities, with members rallying around those who struggle and celebrating those who report

26  Craig Haen and Seth Aronson

progress at the next group session” (p. 1562). The encouragement, sharing, and feedback group members provide to one another “may be particularly important for amplifying treatment effects in a relatively short time-​frame” (Kealy & Kongerslev, 2022, p. 1562). As Shechtman (2017) emphasized, a “focus on relationships does not happen by itself” in child/​ adolescent groups (p. 59). Group therapists working with young people have to take an active and deliberate approach to fostering cohesion. The idea that you get what you invest in within group therapy is supported by recent meta-​analyses, showing that the cohesion-​outcome relationship is stronger in any approach in which there is a leadership focus on group process or facilitation of interactive engagement between members (Burlingame et al., 2018; Rosendahl et al., 2021). Initially, group leaders catalyze cohesion through their leadership style. This ideally means balancing the expression of warmth, humor, caring, a nonjudgmental presence, and genuine enthusiasm for the group and its individual members with the provision of structure and responsible authority that will create a sense of safety and allow for connections to happen (Gray & Rubel, 2018; Haen & Webb, 2019; Shechtman, 2017). Co-​leaders model building relationships through the ways in which they relate to one another while demonstrating collaboration and working through differences within the group (Yalom & Leszcz, 2020). As children and adolescents often need greater scaffolding and direction to begin to self-​disclose and form connections, group facilitators can promote cohesion through the use of games and creative activities that offer structured and playful ways of engaging (Wang et al., 2023). Exercises that allow for identifying similarities and gradually learning to share about oneself (Haen & Webb, 2019); arts activities and the use of stories, films, or poems that provide a degree of distance and foster reciprocal positive emotions (Haen & Webb, 2019; Shechtman, 2017); and games that involve partnering and finding common strengths and shared capacities (Harris et al., 2012) have all been utilized successfully. Recent research has also found that physiological synchrony increases cohesion (Tomashin et al., 2022). As such, activities that include shared movement or simultaneous action—​such as singing, chanting, or drumming—​as well as those involving joint decision-​making or collaborative problem-​solving are useful tools for fostering connections. In addition to activities, Leichtentritt and Shechtman (1998) found open questions to be the most useful for promoting self-​disclosure in children’s groups. They also identified encouragement, interpretation, and judicious self-​disclosure by the therapist as successful verbal interventions that contribute positively to outcomes (Shechtman & Leichtentritt, 2010). Compared to facilitation of adult groups, child/​adolescent group leaders have to work overtime to form connections with group members and to help them feel seen and heard. In adolescent groups, effective leaders have been found to place emphasis during the initial sessions of the group on stimulating conversations and interpersonal interactions, showing interest in members by asking questions, providing validation for what they have said by paraphrasing it, and encouraging turn-​taking by drawing out and engaging less verbal members (Arias-​Pujol & Anguerra, 2017, 2020). Management of structural considerations that protect the group and its space can also foster cohesion. These can include reinforcing consistent boundaries around start and end times; developing familiar rituals for beginning the group; minimizing disruptions from outside the group room in chaotic settings like schools and hospital units; preparing members to transition from the group when sessions end; managing confidentiality and the transfer of information to parents and other providers; and being thoughtful about whether, when, and how to accept new members once the group is in motion (Creeden & Haen, 2017; Gray & Rubel, 2018; Hurster, 2017). Group size and duration have also been found to impact the relationship between cohesion and outcomes. Burlingame et al. (2018) found that groups of five to nine members had the strongest cohesion-​ outcome correlation, while groups with more than nine people had the weakest. Effects of cohesion seem to grow over time, with long-​term groups of 20 sessions or more showing the most robust

Leading Effective Groups for Children and Adolescents 27

connection to outcomes. However, it is important to note that these results are largely based on adult groups. We will discuss issues of group size further in considering group composition. As cohesion increases, the unique benefits of group therapy get activated, allowing for peer modeling and universality, or the sense that one is not so alone with their problems and worries (Yalom & Leszcz, 2020). In groups, positive steps such as self-​disclosure and bravery shown by one member tend to open the door for others to do the same, particularly when leaders encourage joining and subgrouping. In this sense, groups can become a social laboratory for trying on new behaviors, testing out faulty beliefs, and buffering hopelessness by witnessing others succeed (Friedberg et al., 2017). This phenomenon has been called mutual influence, capturing the way that perceptions, behaviors, and treatment outcomes are dynamically and reciprocally shaped by members of the group (Kivlighan & Narvaez, 2021). Mutual influence may be direct as described above, when one member’s actions, beliefs, or perceptions elicit the same in another member; or indirect, when the influence evokes something different in another member. For example, a child may feel a greater sense of connection to the group by virtue of seeing a member they admire continue to attend. While it is generally true that increased cohesion is a good thing, it is worth noting that there are instances in which it can also lead to negative outcomes including dependence and conformity, as well as members uniting against the therapeutic purpose of the group (Nitsun, 2015). For example, in groups for young people with aggressive and externalizing behaviors, an adolescent who is perceived as cool and brags about their transgressions can have a direct influence by encouraging boasting from other members. This might ultimately cause increased problematic behaviors outside of the group, a phenomenon known as deviancy training (Poulin et al., 2001). Such posturing can also have an indirect influence by causing other members to feel less safe in the group and perhaps stop attending. This is where the clinical skills of group leaders and their capacity to leverage the therapeutic alliance can come into play to mitigate iatrogenic effects. In examining CBT groups for children with aggressive behaviors, Lochman et al. (2019) found that when group leaders were (a) able to remain emotionally regulated, responding to behavioral challenges with warmth and positivity (rather than frustration or anger), and (b) were less rigid in their implementation of structured CBT exercises, children showed fewer behavior problems at one-​and four-​year follow-​up points. It is likely that one of the mediators in these groups was the preservation of a positive and safe atmosphere. As Hogue et al. (2021) noted, mutual influence can be bidirectional, so peers who are at higher risk for externalizing behaviors and acting-​out can also be influenced to change within a positive group climate, which is established by the group leader and then sustained by the members. Group Climate Group climate refers to the experience of the interpersonal environment (MacKenzie, 1983), or the emotional atmosphere, of the group in terms of members’ engagement, avoidance, and levels of conflict. This construct has been applied not just in psychotherapy groups, but also in residential treatment and correctional settings (e.g., Sonderman et al., 2021), where the milieu is central to the intervention. The components of group climate provide a useful barometer of the group’s development, as they tend to shift over time (Ogrodniczuk et al., 2021). Studies of online groups for young people are still needed, but research on adult groups suggest that group development follows a similar trajectory in the virtual format as it does within in-​person groups (Arrow et al., 2021), and that relationship factors of cohesion, climate, and therapeutic alliance remain important to outcomes (Gentry et al., 2019; Gullo et al., 2022). While patterns have differed across studies, generally effective short-​term groups with children and adolescents involve increased engagement over the course of the group, with decreased

28  Craig Haen and Seth Aronson

avoidance, and levels of conflict that either remain consistently low or that begin low but then rise and subsequently fall during the middle sessions (Christian et al., 2019; Nickerson & Coleman, 2006; Shechtman, 2007; Wang et al., 2023). Most models of group development capture a sequential process in which members coalesce after challenging authority and pushing back on the rules and structure of the group. Aronson (2002) proposed that after initial exploration, or pre-​affiliation, there is a period of resolving power and control issues, before proceeding to the working phase of the group, followed by separation and termination. Dies (2000) highlighted the importance of the period of storming and differentiation in her model of adolescent group development by dividing it into two phases, sequenced as initial relatedness, testing the limits, resolving authority issues, working on self, and moving on. Shechtman (2007) referred to this middle period in which conflict rises as a transition stage, during which acting-​out behaviors, resistance, and emotional outbursts are more common. As discussed, group leaders’ ability to provide structure, limit-​setting, and psychological holding during this phase can help ease anxiety and pave the way for greater self-​disclosure and interpersonal connections (Kivlighan & Tarrant, 2001; Letendre & Davis, 2004). It can be helpful for group leaders to bear the storm of rebellion by remembering that they’re supporting a healthy process through which members take greater ownership of the group and develop stronger cohesion. In studying a manualized, semi-​structured, short-​term group therapy intervention with a diverse sample of adolescents in state custody, Kivlighan and Tarrant (2001) found that group climate mediated between group leadership and outcomes. As engagement increased, the teens perceived the groups to be more beneficial, and as conflict decreased the members reported greater satisfaction in their relationship with the therapist. Similarly, Wang et al. (2023), who examined 41 groups of elementary and middle school students, found that members who perceived consistently high levels of engagement and low levels of conflict relative to other group members had better outcomes in emotion regulation. What is notable is that both interventions focused on fostering interpersonal interaction, affective expression, and here-​and-​now group process as central to administering the curricula. In the first study, when leaders deviated from this focus to instead attempt to provide individual therapy within the group, it negatively impacted how the members felt about the leader (Kivlighan & Tarrant, 2001). What the body of research tells us is that when group therapists focus on promoting a safe atmosphere, it increases member engagement. Active engagement or involvement is particularly important in child/​adolescent therapy, given the motivational challenges that result from young people often being compelled to attend treatment by adults in their lives (Braswell et al., 1985; Weisz et al., 2021). Group leaders should bear in mind that there are a variety of ways young people engage, informed by their personality, developmental level, and personal challenges. Quieter members who are nevertheless actively listening and watching others in the group derive benefits while more verbal members who are replicating unhelpful interpersonal patterns from life outside the group can deteriorate (Haen, 2019; Pingitore & Ferszt, 2017). Likewise, it is valuable to think about the perceptions of group climate that are held by both individual members and the group-​as-​a-​whole (Wang et al., 2023). While these two sets of perspectives can interact in complex ways, a clinically useful metric is for group leaders to note whether there are any members whose view of the group is different from that of the majority of the members. For example, when group leaders attend to a child who is alone in viewing the group as rife with conflict, they can help this outlier to develop greater tolerance or feel safer and more connected within the group. Creating a New Group Culture Yalom and Leszcz (2020) proposed that one of the primary features of group therapy is that, as groups come together, they form a social microcosm; meaning, members will re-​enact patterns

Leading Effective Groups for Children and Adolescents 29

from their life outside of the group room with the members and leaders of the group. These behaviors reflect young people’s general interpersonal styles (traits) and also the ways in which their interactions vary over time and across contexts (states; Lebowitz & Zilcha-​Mano, 2022). When these patterns play out, they offer live behavioral demonstrations that not only provide data for group leaders on where intervention is most needed, but also present a number of here-​and-​now opportunities to facilitate a different experience. Research by Kivlighan et al. (2021) supported the social microcosm theory and showed that members can be guided to experience themselves differently in groups. When they tried on new interpersonal behaviors during sessions that contrasted with their typical way of being, group members were more likely to generalize these behaviors to interactions outside of session. These findings have been captured in studies of children’s groups, which have suggested that it can be useful for group leaders to think about the roles different members play within session (who becomes the main focus of the action, who engages in conflict, and who is merely a bystander to these interactions) so they can encourage them to take on new roles (Haen, 2014). Likewise, when young people feel positive emotions, such as gratitude and acknowledgment, in conjunction with experiences of agency, connectedness, and competency, they report greater well-​being (Wei et al., 2021). At the member level, this means that group leaders should encourage youth to try on new ways of behaving, either through the use of experiential exercises or by actively intervening to coach different ways of responding (Kivlighan et al., 2021). At the group level, facilitators should work with the members to create a new group culture that is healthier and provides corrective experiences for the hurtful interactions that shape young people’s lives. Group Composition The building of a new culture begins with consideration of who to welcome to the group. It is widely accepted that a group’s composition is critical to its success, although there will be some settings where leaders will have less control over these decisions. Composition is usually framed in terms of patient factors such as age, gender, and diagnosis; as well as less obvious factors such as interpersonal style, capacity for relatedness and engagement, previous group experience, and developmental level (Haen & Webb, 2019; Leszcz, 2018). Groups that are specific in focus (for anxiety or trauma, for example) tend to benefit from homogeneity, while more open-​ended groups may require greater variety in composition (Kealy et al., 2016). Kivlighan et al. (2017) discovered that diversity of attachment styles helped reduce interpersonal conflict in groups, leading to greater cohesion. Gender is another important consideration for the group leader. Garcia et al. (2015) found that adolescent girls showed greater benefit from being in groups with all female-​identified members, while boys benefited more from mixed-​gender group experience. The implication is that girls may feel freer to self-​disclose and be vulnerable without the presence of males, while boys are likely to be positively influenced by their female peers’ capacity to express emotions. These findings have been supported by Shechtman (2017), and in adult group work as well (Burlingame & Strauss, 2021). However, the gender composition of the group may also be dictated by the age of the group members as well as the focus of the group. Attachment style has been shown to be another important consideration in group composition (Shechtman, 2017). Patient attachment style can be a predictor of outcomes and a moderating variable that impacts cohesion, climate, and levels of self-​disclosure (Burlingame & Strauss, 2021). Furthermore, having group members with secure attachment styles can aid in repairing the inevitable ruptures that occur in groups, which will be discussed further. As Shechtman (2017) noted, it’s best to have some mix of attachment styles in group; for example, having too many avoidantly attached youth who eschew relationships and empathic connection can create an imbalance that is detrimental to cohesion and climate.

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In planning for groups, group readiness is best assessed via a screening interview. Given the wide range of development among youth, consideration must be given to the young person’s chronological age as well as developmental level. For example, many developmental theorists divide adolescence into early (11–​14 years), middle (14–​17 years), and late (17+​) stages, with different attributes and developmental tasks connected to each stage. Too wide a range of ages and developmental levels is likely to have an adverse impact on the group. The screening interview also provides the leader with an opportunity to prepare each member for the group (Grunblatt, 2017). In this interview, diagnosis can be assessed as well as previous group involvement, and information regarding logistics (time, location, attendance) can be provided. Young people are often unfamiliar with what it might mean to be a group member, so this meeting is an important time for sharing more about how the group works and what can be expected as a member, as well as answering questions and addressing worries or resistances (Kaklauskas & Greene, 2020). The bounds and limitations of confidentiality should be emphasized, including how therapist–​parent communication will operate, and preliminary treatment goals can be delineated. Although research on adult groups suggest the optimal size for group to be five to nine members (Burlingame & Jensen, 2017), the general recommendation for child/​adolescent groups is five to ten young people, depending on the developmental level and self-​regulatory capacity of the members, with seven to nine being ideal (Berg et al., 2018; Finneran et al., 2017). Kivlighan et al. (2012) found that, as adolescent therapy groups become larger, levels of engagement can decrease and conflict can rise. However, they also found that this trend was mitigated by the presence of a co-​leadership team. Having two leaders who could attend to members and make interventions was particularly useful in a sample of “multiproblem” adolescents. In this study, teens in co-​led groups perceived them as more beneficial than teens who were in groups with just one facilitator. When two therapists facilitate a group together, they can balance attending to individual members and the group-​as-​a-​whole, as well as providing a model of a healthy relationship. However, the success of a group can depend on the complementary personalities and collaborative proficiency of the co-​leaders (Yalom & Leszcz, 2020), as well as their capacity to manage mistrust, competitiveness, power struggles, and disagreement about interventions (Chang-​Caffaro & Caffaro, 2021). The co-​leader relationship requires development through feedback and ongoing processing between sessions. Rupture and Repair The importance of attachment paradigms in group work, as well as the utility of groups for building healthy relationships, has led to a research focus on rupture and repair processes (Lo Coco et al., 2019; Tasca & Marmarosh, 2023). The concept of (dis)ruption and repair has its origins in intersubjective studies of the caregiver–​infant dyad (Beebe & Lachmann, 2014). It is predicated on the notion that the infant comes to expect certain behavioral contingencies and becomes distressed when these contingencies are violated for whatever reason. Such disruptions are inevitably a part of the human encounter; what is key is the ability of the individual to bring about repair and resolution. The group therapy literature in this area has focused more on adults, but the implications for children and adolescents can be clearly drawn, particularly given how adult leaders may evoke associations with caregivers and authority figures for young people. One key factor predicting the ability to repair rupture is the therapeutic alliance (O’Keeffe et al., 2020), as noted previously. The therapist’s role is critical to how well group members might negotiate what they experience to be a rupture (for example, misattunement, misunderstanding, or nonrecognition) in their connection to the group. The therapist’s contribution to rupture may be relational or technical. In the relational realm, therapists who are viewed by members as critical

Leading Effective Groups for Children and Adolescents 31

or defensive often do not provide the necessary safety for members to view the group as a secure space. In addition, therapists experienced as too distant or non-​directive can also lead members to feel disconnected by virtue of not feeling there is an adult holding the safety of the group. Group leaders are challenged with striking a balance between providing guidance, structure, and containment while also being responsive to what emerges in the group and not being too intrusive. In the technical realm, a group therapist who is viewed as being too inflexible can also lead to rupture. A non-​directive, too silent child/​adolescent group leader could potentially lead to children withdrawing or dropping out, as they may feel the leader is hiding behind “the rulebook” and not bringing their genuine self to the group experience, and the group can come to feel directionless. It is easy to see how these leadership styles that evoke rupture map onto parenting styles. The group leader can bring clarity of purpose to a group by forming an agreement with the members (and the group-​as-​a-​whole) about the goals and tasks of the group, solidifying their understanding of what they will work on together. Ruptures may take the form of angry confrontation or silent withdrawal. The young person who feels misunderstood or that the therapist is too removed may express overt dissatisfaction through angry complaints or provocation. On the other hand, a member may instead withdraw, becoming silent and gradually refusing to participate in or attend sessions. Ruptures expressed in this way are often more subtle and difficult for the group leader to detect, especially if they are overshadowed by more dominant members’ engagement in the group. O’Keeffe et al. (2020) found that a relational approach was the best way to counter these ruptures and facilitate repair. In groups, this means renegotiating the tasks and goals of the group, as well as addressing the interpersonal dynamics in a balanced, nonjudgmental way that allows for therapeutic work to proceed. The therapist may require consultative help in identifying the ruptures and subsequent strategies to help re-​engage the group member(s). Complicating the process of rupture and repair is the multiplicity of “players” in group therapy. Thus, there can be a rupture between group members (impacting cohesion), between group members and leaders (impacting the therapeutic alliance), and between group members and the group itself (impacting the climate). Ruptures can occur between co-​leaders as well (Chang-​Caffaro & Caffaro, 2021). At the same time, there is a bystander or audience effect in that group members who aren’t directly involved in a rupture are nevertheless observing and impacted by seeing what happens and how it’s worked through (Tasca & Marmarosh, 2023). Expanding the Circle Despite clear evidence of the disproportionate impact of poverty, illness, systemic inequities, and racial trauma on the mental health of BIPOC (Black, Indigenous, and People of Color) children and adolescents, as well as disparities in treatment access and utilization in these communities (Alegría et al., 2022), white youth are grossly overrepresented in psychotherapy research. Most quantitative studies feature samples that are over 90% white, with so few racially minoritized participants that comparisons of treatment outcome by race are largely not possible (Mullarkey & Schledier, 2021). Indeed, many of the studies cited in this chapter suffer from lack of diversity. Reckoning with this reality challenges us to investigate how our practices can best meet the underaddressed needs of BIPOC youth. While the research base is lacking, we believe that group therapy presents a clinical opportunity for effectively serving BIPOC children and adolescents by drawing on many of the ideas outlined in this chapter. Cheng et al. (2020) pointed out that group therapy is well-​suited to working with African American adolescents because it is aligned with the communal nature of Black culture and presents a potential venue for feeling seen, heard, and empowered—​a notion that can be applied to many other BIPOC communities. If group psychotherapy is to function as a social microcosm,

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then all children and adolescents benefit from being in groups whose composition mirrors that of the communities in which they live. By eliminating barriers to participation for marginalized youth and welcoming them with cultural humility, group therapists take on a social justice orientation that is rooted in ethical obligation (Brabender & MacNair-​Semands, 2022). Given that the success of group begins with the therapeutic alliance, “It is imperative that therapists expand their knowledge of their patients’ cultural background and worldview and gain awareness of how their (therapists and patients) assumptions, beliefs, and values may impact the process of alliance formation and maintenance” (Lebowitz & Zilcha-​Mano, 2022, p. 141). Pregroup meetings are an important venue for understanding more about how a young person’s race, ethnicity, culture, gender identity, religion, socioeconomic status, or other identity factors have impacted their life and that of their family, as well as inquiring about past experiences of marginalization or discrimination (Kaklauskas & Green, 2020). Therapeutic relationships that model a valuing of different experiences and identities lay the foundation for an inclusive group climate. Because members tend to unite around similarities in early sessions, it might appear that it would be difficult to build cohesion in racially or culturally diverse groups. However, when leaders facilitate exercises that emphasize similarities, it can help young people look beyond visible differences to connect more fully with one another (Marmarosh & Sproul, 2021). As groups become a social microcosm, ruptures in the form of microaggressions, biases, and discrimination are likely to arise. These moments provide leaders with an opportunity to facilitate corrective experiences that replace misunderstanding and ostracism with deeper recognition and belonging. Group members who hold societal privilege can be guided to explore how their actions impact others, while members who are socially marginalized can be offered experiences of feeling connected and valued, and of having their agency and voice supported (Marmarosh et al., 2022). When groups coalesce, particularly in the presence of shared emotions, prejudice can be reduced as a sense of “us” and “them” gets replaced by a sense of “we” (Haen, 2019). Parent Involvement Including family members in the child/​adolescent’s therapy is a well-​known tenet of work with youth. As Shechtman (2017) aptly stated, “children do not live in a vacuum” (p. 63). It is a generally held belief that parental involvement in children’s treatment helps, yet is not often given full consideration (Jäderberg et al., 2020). The consensus is that a youth’s interpersonal relationships and difficulties at home and in school, inevitably involve the family. In addition, young people often do not bring themselves for therapy, so the family’s engagement is key to ensuring attendance. Parent involvement in group therapy may take many forms, from receiving general updates from the leaders on the themes and directions of the group to participating in concurrent parent groups, in which caregivers receive concrete advice, psychoeducation, and support (Mitchell et al., 2017). When caregivers view their relationship with the group therapist as positive and see themselves as co-​facilitators of change, greater therapeutic gains are reported by both parent and child (Nuñez et al., 2022). When parents, youth, and therapists all converge positively in their assessment of the relationship and course of treatment, it correlates with greater efficacy and satisfaction, even in challenging clinical endeavors such as trauma treatment (Zorzella et al., 2017). In the event that parents do not expect to be involved in their children’s treatment, there is evidence of limited ability to reflect on their children’s experience and some premature withdrawal from therapy (Karver et al., 2018). By contrast, Schlimm et al. (2021) found in CBT work with adolescents, that when parents realized the significance of the teen developing a trusting relationship with the therapist (and recognized their role in helping to promote this), treatment was more effective. Although most of these studies focused on individual therapy, the implications for group work are clear.

Leading Effective Groups for Children and Adolescents 33

Conclusion As we as a global society confront the mental health crises brought on by the immediate and long-​ term effects of the pandemic, as well as other factors such as inequity in the delivery of mental health services, it is critical to ascertain how to best provide services for children and adolescents. Group therapy plays an important role due to its cost-​effectiveness and ability to reach multiple young people at one time. Groups also provide opportunities for interpersonal learning and relationship building, as well as assuaging loneliness. Key factors in making groups effective for children include a strong therapeutic alliance, group cohesion and positive climate, thoughtfulness paid to group composition, attention to increasing equity and inclusion, and efforts to involve parents in the treatment process. With attention paid to the factors outlined in this chapter, group therapy with children and adolescents can not only address current mental health challenges, but also provide experiences of connection, belonging, and shared humanity that have important ramifications as young people grow into adulthood. References Alegría, M., O’Malley, I. S., DiMarzio, K., & Zhen-​Duan, J. (2022). Framework for understanding and addressing racial and ethnic disparities in children’s mental health. Child and Adolescent Psychiatric Clinics of North America, 31(2), 172–​191. https://​doi.org/​10.1016/​j.chc.2021.11.001 Arias-​Pujol, E., & Anguera, M. T. (2017). Observation of interactions in adolescent group therapy: A mixed methods study. Frontiers in Psychology, 8, Article 1188. https://​doi.org/​10.3389/​fpsyg.2017.01188 Arias-​Pujol, E., & Anguera, M. T. (2020). A mixed methods framework for psychoanalytic group therapy: From qualitative records to a quantitative approach using t-​pattern, lag sequential, and polar coordinate analysis. Frontiers in Psychology, 11, Article 1922. https://​doi.org/​10.3389/​fpsyg.2020.01922 Aronson, S. (2002). The group treatment process. In S. Aronson & S. Scheidlinger (Eds.), Group treatments of adolescents in context: Outpatient, inpatient, and school (pp. 37–​54). International Universities Press. Arrow, K., Yap, K., & Chester, A. (2021). Group climate in online cognitive behaviour therapy predicts treatment outcomes. Clinical Psychologist, 25(2), 153–​163. https://​doi.org/​10.1080/​13284​207.2020.1829​944 Beebe, B., & Lachmann, F. M. (2014). The origins of attachment: Infant research and adult treatment. Routledge. Berg, R. C., Landreth, G. L., & Fall, K. (2018). Group counseling: Concepts and procedures (2nd ed.). Routledge. Bjaastad, J. F., Gjestad, R., Fjermestad, K., Ӧst, L.-​G., Haugland, B. S. M., Kodal., A., Heiervang, E. R., & Wergeland, G. J. (2023). Adherence, competence, and alliance as predictors of long-​term outcomes of cognitive behavioral therapy for youth anxiety disorders. Research in Child and Adolescent Psychopathology, 51, 761–​773. https://​doi.org/​10.1007/​s10​802-​023-​01028-​1 Brabender, V., & MacNair-​Semands, R. (2022). The ethics of group psychotherapy: Principles and practical strategies. Routledge. Braswell, L., Kendall, P. C., Braith, J., Carey, M. P., & Vye, C. S. (1985). “Involvement” in cognitive-​ behavioral therapy with children: Process and its relationship to outcome. Cognitive Therapy and Research, 9, 611–​630. Brown, S. M., Doom, J. R., Lechuga-​Peña, S., Watamura, S. E., & Koppels, T. (2020). Stress and parenting during the global COVID-​19 pandemic. Child Abuse & Neglect, 110, Article 104699. https://​doi.org/​ 10.1016/​j.chi​abu.2020.104​699 Bryde Christensen, A., Wahrén, S., Reinholt, N., Poulsen, S., Hvenegaard, M., Simonsen, E., & Arnfred, S. (2021). “Despite the differences, we were all the same”: Group cohesion in diagnosis-​specific and transdiagnostic CBT groups for anxiety and depression: A qualitative study. International Journal of Environmental Research and Public Health, 18(10), Article 5324. https://​doi.org/​10.3390/​ije​rph1​8105​324 Burlingame, G., & Jensen, J. (2017). Small group process and outcome research highlights: A 25-​year perspective. International Journal of Group Psychotherapy, 27(sup1), S194–​S218. https://​doi.org/​10.1080/​ 00207​284.2016.1218​287

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36  Craig Haen and Seth Aronson Kaklauskas, F. J., & Greene, L. R. (2020). Core principles of group psychotherapy: An integrated theory, research, and practice training manual. Routledge. Kapp, C., Perlini, T., Jeanneret, T., Stéphan, P., Rojas-​Urrego, A., Macias, M., Halfon, O., Holzer, L., & Urben, S. (2017). Identifying the determinants of perceived quality in outpatient child and adolescent mental health services from the perspectives of parents and patients. European Child & Adolescent Psychiatry, 26(10), 1269–​1277. https://​doi.org/​10.1007/​s00​787-​017-​0985-​z Karver, M. S., De Nadai, A. S., Monahan, M., & Shirk, S. R. (2018). Meta-​analysis of the prospective relation between alliance and outcome in child and adolescent psychotherapy. Psychotherapy, 55(4), 341–​355. https://​doi.org/​10.1037/​pst​0000​176 Kealy, D., & Kongerslev, M. T. (2022). Structured group psychotherapies: Advantages, challenges, and possibilities. Journal of Clinical Psychology, 78, 1559–​1566. https://​doi.org/​10.1002/​jclp.23377 Kealy, D., Ogrodniczuk, J. S., Piper, W. E., & Sierra-​Hernandez, C. A. (2016). When it is not a good fit: Clinical errors in patient selection and group composition in group psychotherapy. Psychotherapy, 53(3), 308–​313. https://​doi.org/​10.1037/​pst​0000​069 Kivlighan, D. M., Jr., Gullo, S., Giordano, C., Di Blasi, M., Giannone, F., & Lo Coco, G. (2021). Group as a social microcosm: The reciprocal relationship between intersession intimate behaviors and in-​session intimate behaviors. Journal of Counseling Psychology, 68(2), 208–​218. https://​doi.org/​10.1037/​cou​ 0000​495 Kivlighan, D. M., Jr., Lo Coco, G., Gullo, S., Pazzagli, C., & Mazzeschi, C. (2017). Attachment anxiety and attachment avoidance: Members’ attachment fit with their group and group relationships. International Journal of Group Psychotherapy, 67(2), 223–​239. https://​doi.org/​10.1080/​00207​284.2016.1260​464 Kivlighan, D. M., Jr., Miles, J. R., & London, K. (2012). Are two heads better than one? The relationship between number of group leaders and group members, and group climate and group member benefit from therapy. Group Dynamics: Theory, Research, and Practice, 16(1), 1–​13. https://​doi.org/​10.1037/​a0026​242 Kivlighan, D. M., III, & Narvaez, R. C. (2021). Mutual influence in group psychotherapy: A review and application to group psychology. In C. D. Parks & G. A. Tasca (Eds.), The psychology of groups: The intersection of social psychology and psychotherapy research (pp. 191–​206). American Psychological Association. https://​doi.org/​10.1037/​0000​201-​011 Kivlighan, D. M., Jr., & Tarrant, J. M. (2001). Does group climate mediate the group leadership-​group member outcome relationship?: A test of Yalom’s hypotheses about leadership priorities. Group Dynamics: Theory, Research, and Practice, 5(3), 220–​234. https://​doi.org/​10.1037/​1089-​2699.5.3.220 Lebowitz, E. R., & Zilcha-​Mano, S. (2022). Not so common anymore?: Beyond the common factor understanding of the role of alliance in youth psychotherapy. Clinical Psychology: Science and Practice, 29(2), 140–​142. https://​doi.org/​10.1037/​cps​0000​088 Leichtentritt, J., & Shechtman, Z. (1998). Therapist, trainee, and child verbal response modes in child group therapy. Group Dynamics: Theory, Research, and Practice, 2(1), 36–​47. https://​doi.org/​10.1037/​ 1089-​2699.2.1.36 Leszcz, M. (2018). The evidence-​based group psychotherapist. Psychoanalytic Inquiry, 38(4), 285–​298. https://​doi.org/​10.1080/​07351​690.2018.1444​853 Letendre, J., & Davis, K. (2004). What really happens in violence prevention groups? A content analysis of leader behaviors and child responses in a school-​based violence prevention project. Small Group Research, 35(4), 367–​387. https://​doi.org/​10.1177/​10464​9640​4263​271 Lo Coco, G., Gullo, S., Albano, G., Brugnera, A., Flückiger, C., & Tasca, G. A. (2022). The alliance-​outcome association in group interventions: A multilevel meta-​ analysis. Journal of Consulting and Clinical Psychology, 90(6), 513–​527. https://​doi.org/​1037/​ccp​0000​735 Lo Coco, G., Tasca, G. A., Hewitt, P. L., Mikail, S. F., & Kivlighan, D. M., Jr. (2019). Ruptures and repairs of group therapy alliance: An untold story in psychotherapy research. Research in Psychotherapy: Psychopathology, Process and Outcome, 22(1), Article 352. https://​doi.org/​10.4081/​rip​ppo.2019.352 Lochman, J. E., Glenn, A. L., Powell, N. P., Boxmeyer, C. L., Bui, C., Kassing, F., Qu, L., Romerro, D. E., & Dishion, T. (2019). Group versus individual format of intervention for aggressive children: Moderators and predictors of outcomes through 4 years after intervention. Development and Psychopathology, 31, 1757–​1775. https://​doi.org/​10.1017/​S09545​7941​9000​968

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38  Craig Haen and Seth Aronson Rosen, M. L., Rodman, A. M., Kasparek, S. W., Mayes, M., Freeman, M. M., Lengua, L. J., Meltzoff, A. N., & McLaughlin, K. A. (2021). Promoting youth mental health during the COVID-​19 pandemic: A longitudinal study. PLoS One, 16(8), Article e0255294. https://​doi.org/​10.1371/​jour​nal.pone.0255​294 Rosendahl, J., Alldredge, C. T., Burlingame, G. M., & Strauss, B. (2021). Recent developments in group psychotherapy research. American Journal of Psychotherapy, 74, 52–​59. https//​doi.org/​10.1176/​appi.psycho​ ther​apy.20200​031 Rostad, W. L., Ports, K. A., Merrick, M., & Hughes, L. (2023). The moment is now: Strengthening communities and families for the future of our nation. Children and Youth Services Review, 144, Article 106745. https://​doi.org/​10.1016/​j.chi​ldyo​uth.2022.106​745 Schlimm, K., Loades, M., Hards, E., Reynolds, S., Parkinson, M., & Midgley, N. (2021). ‘It’s always difficult when it’s family … whereas when you’re talking to a therapist …’: Parents’ views of cognitive-​behaviour therapy for depressed adolescents. Clinical Child Psychology and Psychiatry, 26(4), 1018–​1034. https://​ doi.org/​10.1177/​135910​4521​1013​846 Shechtman, Z. (2007). How does group process research inform leaders of counseling and psychotherapy groups? Group Dynamics: Theory, Research, and Practice, 11(4), 293–​304. https://​doi.org/​10.1037/​ 1089-​2699.11.4.293 Shechtman, Z. (2017). Bridging the gap between research and practice: How research can guide group leaders. In C. Haen & S. Aronson (Eds.), Handbook of child and adolescent group therapy: A practitioner’s reference (pp. 52–​65). Routledge. Shechtman, Z., & Gluk, O. (2005). An investigation of therapeutic factors in children’s groups. Group Dynamics: Theory, Research, and Practice, 9(2), 127–​134. https://​doi.org/​10.1037/​1089-​2699.9.2.127 Shechtman, Z., & Katz, E. (2007). Therapeutic bonding in group as an explanatory variable of progress in the social competence of students with learning disabilities. Group Dynamics: Theory, Research, and Practice, 11(2), 117–​128. https://​doi.org/​10.1037/​1089-​2699.11.2.117 Shechtman, Z., & Leichtentritt, J. (2010). The association of process with outcomes in child group therapy. Psychotherapy Research, 20(1), 8–​21. https://​doi.org/​10.1080/​105033​0090​2926​562 Shechtman, Z., & Mor, M. (2010). Groups for children and adolescents with trauma-​ related symptoms: Outcomes and processes. International Journal of Group Psychotherapy, 60(2), 221–​244. https://​ doi.org/​10.1521/​ijgp.2010.60.2.221 Sonderman, J., Van der Helm, G. H. P., Kuiper, C. H. Z., Roest, J. J., Van de Mheen, D., & Stams, G. J. J. M. (2021). Differences between boys and girls in perceived group climate in residential youth care. Children and Youth Services Review, 120, Article 105628. https://​doi.org/​10.1016/​j.chi​ldyo​ uth.2020.105​628 Steen, S., Melfie, J., Carro, A., & Shi, Q. (2022). A systematic literature review exploring achievement outcomes and therapeutic factors for group counseling intervention in schools. Professional School Counseling, 26(1a), 118–​136. https://​doi.org/​10.1177/​215675​9X22​1086​739 Tasca, G. A., & Marmarosh, C. (2023). Alliance rupture and repair in group psychotherapy. In C. E. Eubanks, L. W. Samstag & J. C. Muran (Eds.), Rupture and repair in psychotherapy: A critical process for change (pp. 53–​71). American Psychological Association. https://​doi.org/​10.1037/​0000​306-​003 Tomashin, A., Gordon, I., & Wallot, S. (2022). Interpersonal physiological synchrony predicts group cohesion. Frontiers in Human Neuroscience, 16, Article 903407. https://​doi.org/​10.3389/​fnhum.2022.903​407 Viner, R., Russell, S., & Saulle, R. (2022). School closures during social lockdown and mental health, health behaviors, and well-​being among children and adolescents during the first COVID-​19 wave: A systematic review. JAMA Pediatrics, 176(4), 400–​409. https://​doi.org:10.1001/​jam​aped​iatr​ics.2021.5840 Wang, L.-​f., Kivlighan, D. M., Jr., Wei, M., Kivlighan, D. M., III, Hung, Y.-​L., & Koay, E. Y. Y. (2023). Changes in group counseling engagement and conflict and growth in emotional cultivation for children and adolescents. Journal of Counseling Psychology, 70(2), 159–171. https://​doi.org/​10.1037/​cou​0000​648 Wei, M., Wang, L.-​f., & Kivlighan, D. M., Jr. (2021). Group counseling change process: An adaptive spiral among positive emotions, positive relations, and emotional cultivation/​regulation. Journal of Counseling Psychology, 68(6), 730–​745. https://​doi.org/​10.1037/​cou​0000​550 Weisz, J. R., & Bearman, S. K. (2020). Principle-​guided psychotherapy for children and adolescents: The FIRST program for behavioral and emotional problems. Guilford.

Leading Effective Groups for Children and Adolescents 39 Weisz, J. R., Fitzpatrick, O. M., Venturo-​Conerly, K., & Cho, E. (2021). Process-​based and principle-​guided approaches in youth psychotherapy. World Psychiatry, 20(3), 378–​380. https://​doi.org/​10.1002/​wps.20887 Weisz, J. R., Kuppens, S., Ng, M. Y., Eckshtain, D., Ugueto, A. M., Vaughn-​Coaxum, R., Jensen-​Doss, A., Marchette, L. S. K., Chu, B. C., Weersing, V. R., & Fordwood, S. R. (2017). What five decades of research tell us about the effects of youth psychological therapy: A multilevel meta-​analysis and implications for science and practice. American Psychologist, 72(2), 79–​117. https://​doi.org/​10.1037/​a0040​360 Weisz, J. R., Kuppens, S., Ng, M. Y., Vaughn-​Coaxum, R. A., Ugueto, A. M., Eckshtain, D., & Corteselli, K. A. (2019). Are psychotherapies for young people growing stronger?: Tracking trends over time for youth anxiety, depression, attention-​deficit/​hyperactivity disorder, and conduct problems. Perspectives on Psychological Science, 14(2), 216–​237. https://​doi.org/​10.1177/​17456​9161​8805​436 Whittingham, M., Lefforge, N. L., & Marmarosh, C. (2021). Group psychotherapy as a specialty: An inconvenient truth. American Journal of Psychotherapy, 74(2), 60–​66. https://​doi.org/​10.1176/​appi.psycho​ther​ apy.20200​037 Yalom, I. D., & Leszcz, M. (2020). The theory and practice of group psychotherapy (6th ed.). Basic Books. Yildiz, H., & Duan, V. (2022). Effect of group work on coping with loneliness. Social Work with Groups, 45(2), 132–​144. https://​doi.org/​10.1080/​01609​513.2021.1990​192 Zorzella, K. P. M., Rependa, S. L., & Muller, R. (2017). Therapeutic alliance over the course of child trauma therapy from three different perspectives. Child Abuse and Neglect, 67, 147–​156. https://​doi.org/​10.1016/​ j.chia​mbu.2017.02.032

Chapter 3

Legal and Ethical Issues in Providing Group Therapy to Minors Linda K. Knauss

Two important factors combine to highlight the importance of ethical issues in group therapy with children and adolescents. The first is the fact that groups are a powerful force, and the second is the fact that children and adolescents are especially influenced by peer pressure (Terres & Larrabee, 1985). In addition, group treatment strategies have been rapidly expanding to apply to a variety of populations and disorders, including grief, depression, physical and sexual abuse, substance abuse, and eating disorders. In many settings, group interventions are the primary treatment modality (Glass, 1998). This chapter will highlight a sample of ethical and legal concerns that often arise when conducting group therapy with minors. These issues include: (1) ethical decision-​making, (2) competence, (3) diversity, (4) recruitment of group members, (5) screening and selection, (6) consent to treatment, (7) informed consent, (8) confidentiality, (9) child abuse, (10) record keeping, and (11) telehealth. Ethical Decision-​M aking Ethical dilemmas usually arise in an interpersonal context. This makes ethical decision-​making in practice much more difficult than on an exam. Many considerations compete for the group therapist’s attention and inclination. Thus, it is essential to understand the personal and interpersonal nature of ethics. Most therapists do not plan to engage in unethical behavior. Violations most often occur because of poor judgment, insensitivity to ethical standards, or as a means to justify one’s actions. There are many available ethical codes and guidelines to help therapists resolve ethical dilemmas. Some of these codes have been developed by professional organizations such as the Ethical Principles of Psychologists and Code of Conduct (American Psychological Association, 2017), the ACA Code of Ethics (American Counseling Association, 2014), and the NASW Code of Ethics (National Association of Social Workers, 2017). Additional codes have been developed by organizations devoted to the advancement of group therapy, such as the American Group Psychotherapy Association (AGPA, 2002) and Guiding Principles for Group Work of the Association for Specialists in Group Work (ASGW, 2021). Regardless of the specificity of existing ethical guidelines, there will always be situations that go beyond the written code or pit one ethical standard against another (Brabender, 2002). Typically, most ethical dilemmas are ambiguous, which gives clinicians discretion in determining an ethical course of action. The course that is chosen is influenced by the therapist’s training, moral standards, and prevailing values of the community (Yanagida, 1998). Thus, therapists need to be familiar with a model of ethical decision-​making to further aid in making appropriate choices.

DOI: 10.4324/9781351213073-4

Legal and Ethical Issues in Providing Group Therapy to Minors 41

Many ethical decision-​making models exist (Abeles, 1980; Eberlein, 1987; Haas & Malouf, 2005; Koocher & Keith-​Spiegel, 2016; Kitchener, 1984; Rest, 1982; Tymchuk, 1986). The model that will be presented here is both systematic enough to include all of the relevant information and flexible enough to apply to a variety of situations. This model, developed by Knapp and VandeCreek (2003), is comprised of five steps that are common across most of the models. 1 Identification of the problem. This includes obtaining information from the parties involved and from relevant sources. It also includes consulting existing guidelines or ethics codes such as those mentioned earlier in this chapter. This process may lead to contradictions, or there may be no relevant standard. However, it is important to take this step so one does not disregard existing policy. 2 Development of alternatives. This includes considering whether there is a reason to deviate from an existing standard, perhaps because the standard is vague or, in a particular case, it may lead to more harm than benefit by adhering to the standard. It is also necessary to evaluate the rights, responsibilities, and welfare of all affected parties. When generating alternatives, all possible actions should be included. A decision that was initially unacceptable may later be the most feasible. 3 Evaluation of alternatives. At this time, it is important to list the risks and benefits of making each decision as well as evaluate the probability that those risks and benefits will actually occur. Often, there is no evidence to help make this decision. The alternative that results in the optimum resolution for the greatest number of interested parties should be chosen. 4 Implementation of the best option. It is not enough to be aware of what needs to be done. Being ethical requires action and taking responsibility for the consequences of those actions. These decisions should also be documented both for the protection of the practitioner and for future use. 5 Evaluation of the results. One way to evaluate the decision is to ask if it was satisfactory to the needs and preferences of the affected parties. It can also be helpful to ask: Would you recommend that everyone do this? Thinking about how to advise another person to act in a similar situation provides an opportunity to reflect on a particular choice. The shortcoming of any cognitive model of ethical decision-​making is that it does not require therapists to consider emotional or situational factors affecting their decisions. Also, it is necessary to have time to reflect on the ethical problem (Knapp & VandeCreek, 2003). In order to improve ethical decision-​making in crisis situations, it is helpful to anticipate the type of problems that might occur and develop an action plan for high-​probability situations. Competence Competence to provide group therapy to minors encompasses several areas: competence as a therapist, competence as a group therapist, and competence to work with children. In addition, group therapists must be competent to work with racially and culturally diverse clients and may need to be competent to work with special populations such as eating disorders or substance abuse. Competence as a Therapist Competence may refer to the use of a technique (assessment, hypnosis), skills in working with particular problem areas (substance abuse), a particular population (children), or emotional stability (emotional competence). To become proficient in a certain area of practice, psychologists or other therapists submit their work to external feedback. This occurs when students attend graduate programs and receive feedback from faculty and clinical supervisors. It is more difficult

42  Linda K. Knauss

for individuals in practice to demonstrate competence in new areas or with new techniques (Knapp & VandeCreek, 2003). It is not considered sufficient to read a book or attend a workshop to gain competence in a new domain of practice. This is because neither of those activities guarantees that therapists have acquired the knowledge and skills necessary to provide intervention in the new domain. Competent performance in an area of practice requires skills that take practice rather than just factual knowledge (Knapp & VandeCreek, 2003). Working with children and leading therapy groups are both areas that require skills, practice, and feedback to perfect. Competence as a Group Therapist Group therapists come from very diverse backgrounds. Preparation for leading groups ranges from no formal training to graduate-​level training with supervised experience. Some group leaders have been in groups as members, while others have not. Sometimes, leaders are individuals who have been diagnosed with the disorder being treated. This is especially true in the area of substance abuse. The assumption is that having experienced the problem is an essential leader qualification. In contrast, some professionals may possess an advanced degree and a license to practice, but they have no training or supervised experience in leading groups (Glass, 1998). According to Brabender (2002), “organized training in group therapy has not been prevalent in graduate training programs in the mental health professions” (p. 250). In comparison to training in individual therapy, group therapy is given minimal treatment in most programs. However, many mental health professionals are called upon to lead groups in their jobs. Some are clinical groups, such as groups for children with diabetes, and others are administrative groups, such as treatment teams. Most agencies or organizations do not provide training opportunities in this valuable skill to make up for weaknesses in graduate training (Brabender, 2002). Thus, individuals are responsible to spend their own resources of time and money to ensure competence. Many professional organizations, such as the American Psychological Association and the AGPA, provide training experiences in group therapy (Brabender, 2002). As was mentioned previously, didactic training alone is not enough. Brabender (2002) notes, “To achieve competence the group therapist will require competent supervision” (p. 251). Co-​therapy provides the most ideal opportunity for supervision because the supervisor has access to all of the interventions made by the supervisee, as well as nonverbal cues such as posture and head nodding. When co-​therapy is not possible, process notes, audio tapes, and videotapes provide various amounts of information (Brabender, 2002). Specific guidelines for the training of group therapists have been developed by professional organizations such as the AGPA and the ASGW. Both organizations specify a combination of knowledge, skills, and experience competencies to prepare therapists to lead groups adequately (Glass, 1998). However, the requirements of the two organizations differ with respect to minimum expectations for group participation and supervision. Because guidelines provided by professional organizations can only provide models for consideration, individuals who conduct group therapy need to be aware of their own strengths and weaknesses in the areas of knowledge, skills, and experience and seek means to strengthen any deficiencies. Competence to Work with Children Numerous ethical and legal issues confront group therapists that are unique to working with children and adolescents. Often, groups are designed for children of divorced parents, physically ill

Legal and Ethical Issues in Providing Group Therapy to Minors 43

parents, children who have been abused, or children with developmental delays. While in most situations in which therapists work with children, their work is not monitored, some situations may place them under professional scrutiny by the courts (Koocher & Keith-​Spiegel, 1990). A group therapist could be asked to testify in a child custody case or a case involving child abuse. Similar to the situation with group therapy, there are no written guidelines in the area of child or family work with respect to establishing a basic threshold of competence. It is possible to complete a doctoral degree in psychology as well as advanced training in social work, psychiatry, and other mental health fields without ever assessing or treating a child. Due to the lack of training standards or guidelines for working with minors, Koocher and Keith-​ Spiegel (1990) have made the following suggestions. Therapists who are planning to pursue assessment or intervention with children or adolescents should have completed formal course work in developmental psychology or human development, including educational components on physical, social, and personality development as well as psychopathology of childhood and adolescence. In addition, practitioners should have completed formal supervised experience such as a practicum or internship in a setting where they have the opportunity to work with children. This is an ideal way to combine training in group work with training in working with minors because many educational and agency settings offer group therapy or specialized groups for children and adolescents. It is especially important for anyone working with minors to be aware on a continuing basis of the statutes or regulations in the state or agency that apply to minors (such as child abuse reporting laws). Therapists must also maintain an awareness of and sensitivity to the effects of their own emotional needs and reactions when working with children and adolescents. Sexual abuse of child and adolescent clients or providing illegal substances in an effort to build rapport and be liked by clients are not rare or isolated events (Bajt & Pope, 1989; Koocher & Keith-​Spiegel, 1990). For this reason, it is also important to be alert for indications of possible sexual abuse by prior therapists when working with children and adolescents. If a child client does behave in a manner that suggests that abuse may have occurred in a professional relationship, the current therapist must explore the situation and make a report of abuse if warranted. Although it may not always be possible to avoid all dual-​role situations, it is very important to consider the potential effect of such relationships when working with children and adolescents. Dual-​role relationships may also grow out of relationships with people other than the identified client. These types of relationships often go unnoticed until a crisis occurs. These suggestions by Koocher and Keith-​Spiegel (1990) are especially valuable because they focus attention on the most common ethical dilemmas that are faced by therapists working with children and adolescents. Specialty Populations Often, therapy groups, especially groups for children and adolescents, are developed for a specific purpose. For example, there are groups for children who have been sexually abused, groups for clients with eating disorders or substance abuse, groups for children with cancer, diabetes, or terminal illnesses, and groups for children who have lost a parent. It is necessary to have adequate training in the etiology, typical needs, common symptom patterns, and interpersonal capabilities of these clients to develop an effective group design (Glass, 1998). It is not possible to address the needs of such diverse client populations through a generic group design. To practice competently, the group therapist must be familiar with the client population they will be serving. This can be accomplished through reading, observations, co-​leading a group, consultation, or supervision (Glass, 1998). In many employment settings, there is a great deal of pressure to provide services to new or emerging clinical populations. Glass (1998) notes,

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Administrators and supervisors often assume that the professionals they hire ought to be capable of carrying out every professional task the agency may require. To decline such an assignment may put the professional in the position of appearing either uncooperative or incompetent. (p. 102) However, professionals in this situation should indicate their willingness to do group work with the specified client population but only after the appropriate experience. Additional Considerations Self-​care is an important component of competence for mental health professionals. This is magnified for group therapists who work simultaneously with multiple clients as well as for therapists working with children and adolescents. There is growing literature on the stressors facing healthcare professionals, according to Knapp and VandeCreek (2003). In addition, individuals and institutions should attempt to help reduce distress, prevent impairment, and assist in making the workplace as pleasant and desirable as possible. In recent years, there has been a focus on general self-​care, meaning anticipating and learning to handle stressors and focusing on positive self-​care. The focus on positive self-​care is especially important for mental health professionals, where emotional competence is directly related to the quality of their work (Knapp & VandeCreek, 2003). The APA Ethical Principles of Psychologists and Code of Conduct (2017) have two standards related to impairment (2.06 a&b). These standards state that impairment is grounds for disciplinary actions, and psychologists who are impaired have a responsibility to stop practicing or seek supervision to ensure the quality of their work. In fact, every ethical code of mental health professionals includes a provision or two about the need for self-​care. The National Association of Social Work Code of Ethics (NASW, 2017) advises practitioners to monitor their performance, warns against practicing while impaired, and recommends “remedial action by seeking professional help, making adjustments in workload, terminating practice, or taking any other steps necessary to protect clients and others.” The American Counseling Association’s Code of Ethics (ACA, 2014) proactively instructs counselors to “engage in self-​care activities to maintain and promote their own emotional, physical, mental, and spiritual well-​being to best meet their professional responsibilities.” At times, therapists may find it helpful or necessary to participate in their own personal therapy. For group therapists, involvement in a therapy group may be especially helpful (Brabender, 2002). In addition, many state and provincial psychological associations have created colleague assistance programs designed to help psychologists who are having difficulties (Barnett & Hillard, 2001). Stress or other personal or situational factors may cause a noticeable decline in effectiveness that does not cause one to become impaired or incompetent. However, a reduced ability to empathize with clients or to handle countertransference feelings may result in a decline in positive patient outcomes (Knapp & VandeCreek, 2003). Life-​long learning is another important aspect of competence. The research base of group therapy and techniques for working with children and adolescents is continually expanding, as are empirically supported treatments. Other knowledge becomes obsolete over time. Both formal and informal continuing education is needed to keep pace with the latest developments in the field. Many licensing boards require continuing education as a condition of licensure renewal. However, this represents a minimal requirement. Life-​long learning is fundamental to ensure that teaching, research, and clinical practices have an ongoing positive effect on clients (Fisher, 2017). Diversity Society is becoming increasingly multi-​ethnic. To work effectively with ethnic and culturally diverse clients, it is necessary for therapists to understand not only racial, ethnic, and gender

Legal and Ethical Issues in Providing Group Therapy to Minors 45

issues but also to develop an increased awareness of their values and attitudes. In addition, mental health professionals will work more effectively with diverse individuals if they recognize the impact of their cultural heritage on their assumptions (Knapp et al., 2017). According to Corey et al. (2017), “Effective delivery of group counseling services must take into account the impact of the client’s culture” (p. 299). They go on to say that culture influences the client’s behavior and the group therapist’s behavior, whether or not one is aware of this process. The APA Ethical Principles of Psychologists and Code of Conduct (2017) address diversity in standard 2.01b. Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in Standard 2.02, Providing Services in Emergencies. Despite the best intentions to create effective, cross-​cultural ethical guidelines, it is difficult to do this effectively. One reason for this is that the process of defining what constitutes correct, appropriate, and ethical behavior in any ethics code reflects the values and norms of the dominant culture (Glass, 1998). Cultural differences can be magnified in group therapy. For example, not all cultures value insight. Thus, in an insight-​oriented therapy group, a client’s lack of success may be related to cultural factors (Brabender, 2002). Leong (1992) cites other examples of ethnocentrism that can be detrimental in group therapy. These include the belief that emotional openness is better than emotional inhibition and the belief that independence and self-​sufficiency are signs of maturity in contrast to interdependence and group loyalty. Other behaviors, such as expecting verbalizations of thoughts and feelings, confrontations and conflicts, and asking questions to probe feelings, can be uncomfortable for members of various cultural groups (Hurdle, 1991). However, it is equally important not to stereotype minority clients using broad generalizations such as, “Asian clients are always quiet.” An additional challenge for the group therapist working with culturally diverse children and adolescents is the tendency of children to identify and exaggerate differences in negative ways. Thus, it is important to discuss issues of diversity in the group and hopefully begin the process of intercultural acceptance and understanding (Glass, 1998). Group leaders also need to be aware of their personal feelings and model appropriate behavior of respect and acceptance. In general, group therapy can be easily adapted to a multicultural population. There is nothing inherent in group approaches that makes them inappropriate for any culture. Thus, group therapy does not require major alterations of general principles of group process to work with clients of a non-​majority culture. Group therapists should find culturally inviting ways to include members of diverse populations in their therapy groups. Thus, it is important for group therapy practitioners to examine their attitudes, assumptions, and values to become as effective as possible in working with clients from multicultural backgrounds (Glass, 1988). Recruitment Recruitment is the first stage in the process of group therapy. Groups for children and adolescents may be held in schools, community agencies, or be run by private practitioners. Recruitment begins by advertising the group or soliciting referrals from parents, teachers, or other therapists. In a school setting, the school counselor could put a notice on the bulletin board, send a memo to teachers asking for referrals, or put a notice in handbooks and newsletters that go to parents, inviting them to nominate their child for a particular group (Ritchie & Huss, 2000). In community agencies,

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therapists could notify other therapists in their agency or related agencies of their intention to begin a group on a particular topic. They can also form groups from their caseloads by starting a group with several children and adolescents with similar concerns. Therapists in a community agency or private practice can work with school counselors for referrals. They also advertise groups through direct mail, radio, newspapers, and the internet (Ritchie & Huss, 2000). Often, well-​intentioned school counselors solicit members for groups on a wide range of topics, such as children of divorce, children of alcoholics (COA), and attention-​deficit/​hyperactivity disorder (ADHD), by asking teachers to identify potential members. Unfortunately, this can create ethical problems. Receiving a referral from a concerned or observant teacher is not unethical, but labeling students who exhibit problem behaviors with a diagnosis of ADHD or even COA or “at risk” can be problematic. The primary ethical issue in the recruitment of minors for participation in a group experience is privacy. This refers to both the therapeutic relationship and being identified as a client. This right to privacy also extends to people before the therapeutic relationship begins, such as those who are interested in becoming a group member or people who have been recommended to be a group member. Thus, group therapists in schools or community agencies need to be careful that their recruitment process does not label potential group members and violate their rights and the rights of their parents to privacy (Ritchie & Huss, 2000). Based on the literature and ethical guidelines, Ritchie and Huss (2000) suggest the following guidelines for recruitment and advertising for minors for group therapy. First, do not give the group a name that might label children or imply a diagnosis. Next, it is best not to have a pre-​group meeting in school at an announced time and place, especially if COA or divorced parents are being recruited. This would compromise the privacy of anyone seen in that area. It would be preferable to have students make an appointment with the therapist at their discretion to discuss their interest in the group. Finally, if the group therapist gives teachers a checklist of observable behaviors, it is best not to identify those behaviors as characteristic of a particular label. This is also true of checklists included in newsletters or other communications to parents for recruitment. In most cases, the lists of behaviors are very similar regardless of the issue of which they are supposed to be symptomatic (children of divorce, COA, at risk, and so on). Although recruitment for group members often takes place in schools, and minors can be referred or express interest in participation, they cannot become group members without the consent of their parent or legal guardian and a thorough informed consent process. Screening and Selection A critical element of success for any therapy group is the appropriateness of the group experience for the specific child or adolescent. The ASGW (2021) Guiding Principles for Group Work states that group therapists select group members whose needs and goals are compatible with the goals of the group, who will not impede the group process, and whose well-​being will not be jeopardized by the group experience. Although there are several possible options for pre-​group screening, individual interviews with potential members are the most effective. The primary purpose of pre-​group screening is to determine the appropriateness of the potential member for the group. However, a pre-​group interview also allows the group leader to discuss the purpose and procedures of the group as well as identify the needs, expectations, and commitment of the potential group member (Couch, 1995). Group interviews, which require less time than individual interviews, also allow the group leader to observe communication and interaction skills of potential members (Ritchie & Huss, 2000). The group interview can take the form of an activity, such as having each child interview another child and introduce that child to the group. This provides an opportunity for children to talk

Legal and Ethical Issues in Providing Group Therapy to Minors 47

about themselves, listen to others, and sit quietly while listening. One drawback to this method is that children may not be as forthcoming about their concerns in a group interview as they would be individually (Ritchie & Huss, 2000). Although the consent of a parent or legal guardian may not be necessary in certain situations at the pre-​screening level of group therapy, it is advisable to have parental (legal guardian) consent whenever one is working with a minor. In selecting children and adolescents to participate in group therapy, the group leader must judge the suitability of potential members, not only regarding the selection criteria but also based on the probability that the child will cooperate in the group setting. Ritchie and Huss (2000) suggest that “Group leaders should be aware of specific client characteristics that would warrant exclusion from the group” (p. 152). Selection criteria are usually obvious in groups that are established for a specific purpose, such as children of divorced parents. Several client characteristics have been identified as desirable for group membership. These include interest in the group, the capacity for empathy, and age-​appropriate social skills. These characteristics can be evaluated during pre-​screening. It is also important for children and adolescents to be available at the time the group is scheduled. Contraindications for outpatient or school-​based group therapy include children or adolescents who present a danger to themselves or others, who are overly aggressive, or those who are overly sensitive to criticism (Toseland & Siporin, 1986). However, groups for children and adolescents in residential facilities or inpatient settings are often composed of individuals with difficult behaviors and complex treatment needs. In general, the goal of the screening and selection process is to include children and adolescents who will benefit from the group therapy experience, who will not be harmed by the experience, and whose participation will not be harmful to others. Consent to Treatment The concepts of consent to treatment and informed consent are different, but they have many overlapping elements. The law and society presume that children are not able to make major life decisions on their own, and the rules that exist to deny children the right to make decisions independently generally serve to protect them (Koocher & Keith-​Spiegel, 1990). When a decision is to be made on behalf of minors, it is usually made by a parent or legal guardian. This is the person who consents to treatment for the child. It is assumed that the adult is acting in the child’s best interest, although situations do arise that question this assumption. Courts traditionally respect the sanctity of the family unit and seldom become involved unless there is abuse, severe neglect, or other dramatic reasons. Thus, decisions that may not be in the child’s best interest, especially with regard to mental health treatment, often do not rise to the level of intervention (Koocher & Keith-​Spiegel, 1990). It is also important to differentiate between the concepts of consent, permission, and assent. Consent implies the ability to understand the facts and consequences relative to a decision and be able to make that decision voluntarily. The idea of informed consent indicates that all the data needed to reach a thoughtful decision have been both considered and understood. In many jurisdictions, a person must meet a legal age requirement, usually age 18 (but in some states, as young as age 14), for their decision to be considered legal or binding. Thus, it is imperative for mental health professionals working with children or adolescents to know the legal age of consent in their locale. In addition, there can be many subtle nuances in laws regarding the age of consent. For example, some states may have different ages for consent to inpatient or outpatient treatment. Or there could be different circumstances related to consent to treatment versus release of information. Many state professional organizations can be helpful in providing this information and in offering continuing education in this area. Consent is sometimes defined as a decision that one can only make for oneself. Thus, parents or legal guardians are those from whom permission must be sought as both a legal and ethical requirement before providing mental health services to minors (Koocher & Keith-​Spiegel, 1990). Assent is used to mean that although minors may not be able to give consent because of their age and

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accompanying developmental level, they are still able to have and express a preference. However, exercising this power usually can only be done in the negative by refusing to participate, such as in individual or group therapy. It is also disrespectful to solicit the assent of a child if refusal would not be honored (Corrao & Melton, 1988). Assent involves the minor in the decision-​making process, although the child’s level of participation is limited. In general, adults are considered competent, and minors are considered incompetent in almost all legal contexts. Unfortunately, the law has seldom been guided by psychological principles. Because minors are considered incompetent, even if they are determined to be competent for a particular purpose, such as to stand trial as an adult, they are still considered incompetent in other decision-​making situations, such as consenting to their medical treatment. The status as an “emancipated minor” can be given at a court hearing. This status, which is seldom based on the cognitive or reasoning ability of the minor, gives them some rights of the majority, such as the right to consent to medical care, but not all rights, such as voting or consuming alcohol (Koocher & Keith-​ Spiegel, 1990). Conflicts of interest can arise among various parties, including the child, parents, and mental health professionals. However, it is the ethical responsibility of the professional to obey the law and protect the best interests of the client while delivering competent services (Koocher & Keith-​Spiegel, 1990). This can be a difficult task. Children are usually brought to therapy by adults who have a definite agenda in mind (my child is disruptive, uncooperative, or lazy). Although the adult’s agenda may be consistent with the child’s, it would be an error just to assume this to be true. In assessing minors for appropriateness to participate in group therapy, group leaders need to recognize that different family members may have different goals for the same child. Any treatment plan that is developed should take into consideration the best interests of all parties. Accomplishing this goal may require assertiveness and strong mediation skills. When providing mental health services to minors, therapists always have two clients, the minor and their parent(s) or legal guardian. Services should not be provided to any minor without the knowledge and consent of the parents or guardian unless it is an emergency or the child is old enough to give consent on their own. It is the duty of every mental health professional “to know and understand the legal obligations and responsibilities that apply when children are clients” (Koocher & Keith-​Spiegel, 1990, p. 17). This is especially true regarding the age at which a person can consent to treatment. Informed Consent Informed consent for group therapy with minors takes place between the parents, child or adolescent, and the therapist. It is important for the minor to hear all the information that is part of the informed consent process and to give their assent. The purpose of informed consent is to provide an adequate basis for deciding whether or not to give permission for the child to join a particular group and to enable minors to decide on their level of participation once they are in the group (Brabender, 2002). Informed consent generally includes the qualifications of the leader; the purpose and goals of the group; expectations of members; methods and procedures to be used; potential risks and benefits of participation; confidentiality and its limits; times, location, and duration of the group; fees for participation; and the ability to withdraw from the group at any time (ASGW, 2021; Corey et al., 2017, Gladding, 1999). The information needs to be presented in language that is understandable, including in the client’s native language, if that is different from the language used by the group leader. Group leaders also need to be able to explain their reasons for recommending group therapy as the treatment of choice (Glass, 1998) and compare and contrast group therapy with other possible treatment options (Brabender, 2002).

Legal and Ethical Issues in Providing Group Therapy to Minors 49

Informed consent can be either written or verbal. If informed consent is given verbally, this should be documented in the client’s record. Sometimes, verbal informed consent is used when there is not enough time to get written consent. If this is the case, written informed consent should follow later. Written informed consent provides evidence that the person has consented; however, a signature is not proof that the person truly understood the conditions of treatment. Thus, the therapist needs to make every effort to ensure that the client understands the information in the informed consent document (Brabender, 2002). This can be accomplished by asking the client questions about what they understand or by asking them to explain in their own words the informed consent information. This is also a good time to address any questions or misconceptions about the group process. Group membership may not be voluntary on the part of a minor when a parent or guardian gives consent. However, the group member is always empowered to make choices about their behavior during the group, including how much and what information to share (Brabender, 2002). This is one reason for including minors in the informed consent process. They need to know whether their behavior will be the basis for any decision-​making process, such as custody decisions or probation. The minor also needs to know the limits of confidentiality, both to their parents and any other parties, such as teachers, school administrators, or probation officers. A very important part of the informed consent process involves a discussion of the risks and benefits of participation in the particular therapy group. The therapist does not necessarily need to share every possible risk. Some risks, although possible, are extremely unlikely, while others are much more common. Thus, the therapist needs to consider the probability that a potential risk may occur in deciding whether to discuss it as part of informed consent. Therapists who are overly inclusive run the risk of discouraging clients who would benefit from group therapy. According to Glass (1998), “Some group leaders prefer to focus on the positive benefits of group participation and are reluctant to detail possible, but unlikely risks” (p. 112). Research data on the probability of various risks in group treatment is extremely limited (Brabender, 2002). However, the most common risk seems to be violations of confidentiality by other group members. This will be discussed in detail in the next section. Other possible risks include receiving negative feedback, physical aggression, and lack of progress toward treatment goals. Even if the group’s process can be accurately explained to minors and their parents, this cognitive level of understanding is still very different from the actual experience of group participation. Even with the best intentions of providing thorough informed consent, exact information about what will happen in the group and how other group members will behave cannot be accurately predicted (Glass, 1998). It is not possible to prepare anyone for all the possibilities that may occur during group treatment. However, despite these limitations, group leaders are ethically bound to do the best job possible of informing clients as fully as possible. Although not every possible consequence can be anticipated, prospective members (and their families in the case of minors) deserve a realistic and comprehensive overview of the nature of group therapy and the expectations for the specific group being considered. Confidentiality Two of the most common questions asked by children and adolescents about group therapy are, “What can I say in the group?” and “Can I really trust the other group members with my problems?” (Ohlsen, 1974). These questions indicate that confidentiality is central to effective group therapy. Group participants, especially children and adolescents, are not going to reveal themselves in a meaningful way unless they feel sure that they can trust both the group leader and the other group members to respect what they say (Corey et al., 2014). One of the most important tasks of a group leader is to clearly define confidentiality as well as to help group members recognize how important and, at times, difficult it can be to maintain confidentiality.

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The best time to discuss confidentiality, as well as the limits to confidentiality, is during the informed consent process. As in all therapy situations, there are legally mandated limits to confidentiality. These exceptions to confidentiality include threats of physical harm to oneself or others (including the duty to warn identifiable victims), mandated reporting of child abuse, and responding to a court order. Thus, therapists should never imply that everything that is shared in the context of therapy is confidential. This is especially true in group therapy, where the therapist–​client relationship is not the only variable. In group therapy with minors, there are certain unique dimensions of confidentiality. One dimension has to do with information that is shared with parents or legal guardians in contrast to information that is shared with other parties. Although the dimension of therapist–​client confidentiality is shared with other forms of therapy, client-​to-​client confidentiality is unique to group therapy. From a legal perspective, children do not have the same rights as adults. In most circumstances, parents or legal guardians make all decisions regarding confidentiality for children under 18 years of age. This includes signing for the release of information, accessing school or hospital records, and learning the content of therapy sessions. Koocher and Keith-​Spiegel (1990) observe, “In the strictest legal sense, children are not generally entitled to have secrets from their parents unless the parents permit it” (p. 81). Thus, it is very important for group therapists to discuss the limits of confidentiality with both parents and their children before beginning treatment. Autonomy and privacy are concerns of great importance to adolescents. In establishing a trusting, therapeutic relationship, treating children and adolescents with honesty, respect, serious consideration, and involvement in goal setting is more important than the promise of absolute confidentiality (Koocher, 1976). Minors need to know the nature and extent of information to be shared with others as well as the reasons for sharing it. Although it is not legally or ethically required to get the permission of a child client before disclosing confidential information, it is clinically wise to do so. If it is not likely that the child will give his or her permission, it is good clinical practice to tell the child what information you will be disclosing and to whom, rather than doing this without the child’s knowledge. This connotes a level of respect for the child’s cognitive, social, and emotional level of functioning (Koocher & Keith-​Spiegel, 1990). Thus, it is best to discuss the “ground rules” of confidentiality in advance with parents and children together. Information that is ordinarily confidential from other parties is usually not confidential from parents or guardians of children under the age of 18. However, it is important for group leaders to know the laws of the jurisdiction in which they are practicing. For example, in some states, the right to confidentiality may extend to children as young as age 14 years. When conducting groups with children and adolescents, therapists may be confronted with issues of illegal substance use, sexual activity, pregnancy, or tobacco use. Again, it is important to know the laws regarding age limits of confidentiality in the area in which one is practicing. For example, in some locations, minors of any age may seek treatment for substance abuse in a facility licensed for this purpose, and this treatment is confidential, including confidentiality from parents and legal guardians. Generally, when working with children and adolescents, treatment may not be successful if children are concerned that everything they say will be shared with their parents or guardians. Therapists can develop “agreements of confidentiality” with parents where parents agree to restrict their access to the information obtained by the therapist from or about the child. This is a voluntary agreement between the therapist, parent, and minor that limits the amount of information the therapist will tell the parents without the consent of the child. The purpose of such agreements is to encourage the child to disclose more in therapy. Of course, information regarding danger to self,

Legal and Ethical Issues in Providing Group Therapy to Minors 51

others, and mandated reporting of child abuse are always disclosed to parents. Parents can limit the information they want to know to danger to self, others, and child abuse, or they can include sexual activity, substance use, or any other category in which they are interested. However, the minor would know in advance what information will be shared with parents and can make their disclosures accordingly. Group leaders may adhere to strict standards of confidentiality themselves, but confidentiality in a therapy group cannot be guaranteed. Information that is discussed in a group format is shared by many people, so the leader alone cannot ensure confidentiality. According to Brabender (2002), “Whereas the therapist’s inappropriate disclosures about a group member can lead to stiff legal and professional sanctions, with some rare exceptions such consequences do not exist for group members” (p. 260). The burden of responsibility rests with the group leader to establish a confidentiality rule by which group members agree to protect the identities of the other group members and agree not to share material discussed in the group context with individuals outside of the group. Unfortunately, therapists have very little power to enforce this rule. Therefore, group leaders need to educate members on the importance of maintaining confidentiality (Glass, 1998). Children and adolescents may need to be reminded frequently of the importance and necessity of confidentiality. It is helpful to include examples of how violations of confidentiality can be hurtful both to individual group members and to the effectiveness of the group. Confidentiality is especially difficult when groups are conducted in institutions, agencies, or schools where members know each other and have frequent contact with each other outside of the group. In these settings, the idea that group members should not have contact with one another except during group is not practical. Although no group therapist can promise group confidentiality, five steps have been identified by Brabender (2002) that can be taken to increase the probability that members will protect each other’s confidentiality. This must become part of the group process. The first step is to obtain a commitment from the minor before entering the group to observe confidentiality. Before the child makes that promise, the therapist should explain that the child must not talk about what they hear in group with anyone outside of the group, even a close friend. It is also important to specify that confidentiality should be maintained even after the group has ended. The second step is to let all group members know the consequences of violations of confidentiality. The consequences need to be stringent enough to discourage breaches of confidentiality yet flexible enough to account for the various ways in which violations occur. Some group leaders terminate group membership for a violation of confidentiality, but this is not effective with children and adolescents who are often not highly motivated to participate in the group. The third step is to provide regular reminders to the group about the need for confidentiality. This is especially important when working with children and adolescents. It cannot be assumed that because confidentiality has been discussed once in a group, it will be thoroughly understood or remembered (Terres & Larrabee, 1985). An important discussion to have in group therapy is how members should act when they meet each other outside of the group (when this is not a frequent or regular occurrence). There is a natural tendency to greet people that one knows; however, when it is another group member, this may not be in their best interest. If the person is with colleagues or friends, it may create an awkward situation or a compromise of that person’s confidentiality if someone asks how they know each other. In contrast, a group member may be concerned that ignoring another group member outside of the group may be considered impolite or cause the other person to feel slighted or rejected. This situation is easier to rectify by subsequently discussing it in the group. It can usually be explained as an effort to respect the person’s confidentiality and prevent an awkward moment. Experienced group leaders are aware of the probability of out-​of-​group

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encounters, although group members may not anticipate them. Therefore, group leaders should provide the opportunity for the group to discuss unexpected encounters before they occur and develop guidelines for handling them (Brabender, 2002). The fourth step is to be sure to discuss thoroughly within the group any violations of confidentiality that do occur. Violations of confidentiality can interfere with the functioning of the group, even if the violation has not caused any harm outside of the group (Brabender, 2002). Group members may feel betrayed and become less likely to participate in the group process. By discussing the issue in an open and honest manner, group members can gain empathy for both sides of the situation and hopefully progress to an even higher level of functioning while becoming more sensitized to the issue in the future. Finally, it is important to stress that group leaders should model ethical behavior, especially regarding confidentiality. Group therapists may be more aware of the types of issues that can compromise confidentiality, but nonetheless, ethical dilemmas do arise. One example of this situation may occur when group leaders are asked for information about a group member by a third party. Although receiving the necessary release of information from a parent or guardian may be time-​ consuming and cumbersome, it is an ethical obligation. There are several additional considerations regarding confidentiality. Audio or video recording of group sessions may be useful for training or supervision purposes. Prior consent of group members and their parents or guardians is required, as well as an understanding of how this material is to be used. Written consent is recommended in this situation. Also, consent is needed if someone such as a student or intern will be observing the group or using information from the group for research, training, or supervisory purposes (Glass, 1998). When third parties such as teachers, probation officers, or referral sources need to know about a minor’s progress or participation in group therapy, this either needs to be agreed to as part of the informed consent process, or a release of information form needs to be completed. Clients or their legal guardians can always have information about their progress in therapy shared with outside parties through the release of information process. This may be necessary for insurance reimbursement or coordination of care if the minor is also being seen in individual therapy or by a psychiatrist. Thus, every effort is made to protect the confidentiality of information that is shared in group therapy, except when disclosure is legally mandated or requested by the client. Mandating Reporting of Child Abuse Group therapists who work with minors are likely to encounter a situation of suspected child abuse in their careers. The decision to report suspected abuse is always difficult and is sometimes referred to as an ethical dilemma. The reasons that therapists find it difficult to report abuse fall into three general categories: violations of confidentiality, the consequences of reporting, and diluting the professional role (Kalichman, 1999). Mandated reporting of child abuse is an exception to confidentiality. Therefore, it needs to be thoroughly discussed as part of the informed consent process. Many therapists fear that by telling clients, especially children and adolescents, that they are mandated reporters, the minors will not talk about abuse if it is occurring. This may be true in certain situations, so it is best that clients know the consequences of their behavior and can choose accordingly. However, many minor clients do reveal abuse in therapy with the knowledge that the therapist is a mandated reporter. This is an appropriate method to obtain protection and assistance. One reason that therapists are reluctant to report abuse is that they believe reporting suspected abuse will have a negative effect on therapy. Specifically, they fear that the client will terminate treatment and may also be reluctant to seek treatment in the future. However, failure to report suspected abuse is illegal, and it puts vulnerable children at risk. There is no guarantee that keeping

Legal and Ethical Issues in Providing Group Therapy to Minors 53

a minor or even their family in treatment will prevent further abuse (Koocher & Keith-​Spiegel, 1990). However, reporting does not have to result in the termination of the therapeutic relationship. In a study by Harper and Irvin (1985), it was found that when cases were reported in the context of ongoing therapy, clients were unlikely to terminate treatment. Watson and Levine (1989) found that reports of suspected abuse tend to occur early in the course of treatment. In this study, a careful review of the cases showed that most cases of mandated reporting did not have negative effects on the therapeutic relationship. Even when it is clear that a report needs to be made, the therapist has a number of clinical options regarding how the report is made. There are ways to reduce the negative effects of a child abuse report. When the therapist learns of abuse, remind the client (and their parents) that it must be reported. This follows from the discussion of mandated reporting during informed consent. From a clinical perspective, it is best if the client makes the report. This can be done from the therapist’s office, or the client can make the report on their own. However, if the report is not made in the presence of the therapist, after being informed that the report was made, the therapist should check with the agency where the report was given to be sure the suspected abuse was reported. Even if the client makes the report, the therapist is still responsible for the abuse getting reported. If the report was not made, it can be made at this time. If the client does not want to make the report, the therapist should make the report with the client present. In this way, the client (and their parents, who should also be present) knows exactly what was said. This is very important to the therapeutic relationship. If the client and legal guardian are not present when the report is made, it is helpful if they are informed that a report will be made. Although it is both legal and ethical to make a report of suspected child abuse without the client being present or informed, this is the least preferable choice from a therapeutic perspective. Nonetheless, there may be times, based on the specifics of a particular case, when this is the best option. Concerns about the adverse effects on therapy are not the only reason therapists are reluctant to report suspected abuse. Another significant factor is concern about a lack of enough evidence to report abuse (Kalichman, 1999). Some therapists struggle with the decision of whether or not abuse has occurred, especially when working with young children. Other professionals who suspect abuse may feel that having a reasonable suspicion, which is the standard set by most child abuse reporting laws, is not enough to make a report. According to Kalichman (1999), Human service professionals also find themselves in a precarious situation of seeking further information to justify reporting in response to vague statutes, despite the fact that the law does not require them to do so and that such actions may compromise their roles as helping professionals. (p. 42) Thus, with respect to mandated child abuse reporting laws, therapists need to understand the threshold for making a formal report. The use of professional discretion as a rationale for not reporting is not ethically acceptable (Koocher & Keith-​Spiegel, 1990). There is little evidence to support the perception that reporting abuse has detrimental effects on the quality and efficacy of professional services. When facing an ethical dilemma, it is often helpful to consult a colleague. This is also useful when considering making a report of suspected child abuse. Discussing the circumstances of the specific case with a colleague brings an additional perspective to the situation. Kalichman and Brosig (1993) found that many practicing psychologists discuss cases of suspected child abuse with colleagues. In addition, therapists who discuss cases with colleagues more consistently make reports of child abuse (Kalichman, 1999). In contrast to the position that reporting suspected child

54  Linda K. Knauss

abuse is an ethical dilemma, when therapists discuss the limits of confidentiality and report all cases of suspected abuse, they have met both their legal and ethical obligations. Consistently reporting suspected abuse also eliminates the temptation to seek additional information to validate the occurrence of abuse beyond the legal standard of suspicion. Thus, mandatory reporting laws limit the use of clinical judgment when child abuse is suspected. As with many other legal issues discussed here, mandated reporting laws vary from state to state. Group therapists need to be familiar with the laws governing the jurisdiction in which they practice. Record Keeping The central dilemma regarding record keeping in group psychotherapy is whether to keep records separately for each group member or to keep one record for the group as a whole (Knauss, 2006). If records are kept for the group as a whole, which may correspond more closely to the way the therapist experiences and thinks about the group session, it creates a problem of confidentiality with regard to access to records by group members, release of the record to third parties, and subpoenas of the entire record if a court proceeding involves one of the group members. However, if records are kept for each group member, it may be difficult to capture the context of a group member’s comments and how they relate to the other group members. The challenge is to maintain the confidentiality of group members while still being able to follow the flow of the session. This makes record keeping more complex for group therapists than for individual therapists. Many authors (Brabender et al., 2004; Leupker, 2022; Slovenko, 1998) recommend writing individual notes about each group member after each meeting to be kept in the individual’s file. No reference to other group members in a manner that would identify them should be included in any individual chart. This includes specific characteristics of background and behavior as well as the person’s name. Many factors determine the content of session notes. The following are commonly included: Date of Service, Diagnostic Impression, Treatment Goals, and Progress toward achieving those goals. Group therapists may also include the theoretical orientation of the group, the relationship between the group member’s behavior and their presenting problems, and any significant feedback the member received from others in the group (Brabender et al., 2004). Group therapists cannot predict who might want to read their records. It may be the client, their parents, a teacher, or an attorney. Progress notes may also be read in court. It is for these reasons as well that it is preferable to keep individual files for participants in group therapy rather than creating an integrated record of the whole group. Although an integrated group progress note can better capture the focus and themes of the group sessions, it would be difficult to include an adequate amount of detail about each individual in such a note. In addition to the issue of the content of session notes, each group therapy participant needs to have an individual client record file with identifying information such as name, address, telephone number, birth date, legal guardian, school, billing and financial information, relevant history, medical history, presenting problem, testing or school reports, and records of any consultations about the client. Other factors that may influence the content of a group member’s record are requirements of third-​party payers such as insurance and managed care companies, as well as requirements of schools or probation officers when relevant (Brabender et al., 2004). In order to ensure confidentiality, convenient access to records, and proper release of information, group therapists need to maintain separate documentation in individual charts on each group member. Although it is easier and more convenient to write a single comprehensive note about the entire group session, it is worth the extra time after each group meeting to write individual notes to protect each group member’s confidentiality. It takes skill and practice to write individual notes that capture important group-​level issues.

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Telehealth Mental health professionals have been providing services through telehealth for many years, long before COVID-​19. However, in response to this pandemic, there was an unprecedented increase in the use of telehealth services in the entire healthcare system, including in mental health care (Kneeland et al., 2021). Using telehealth to provide mental health services has many advantages, including providing services to people who live in rural areas, providing services to people who are having difficulty finding a provider who specializes in their area of need, and providing accessible care to people who cannot come to an office. In addition, studies report comparable outcomes between telehealth and in-​person therapy for a range of issues (Fletcher et al., 2018; Gros et al., 2013). However, the practice of telehealth presents new challenges in the areas of technological competence, informed consent, confidentiality, and establishing a therapeutic relationship. Until 2013, there was little specific guidance to ensure the quality of care. That year, the Guidelines for the Practice of Telepsychology (2013) were approved by the American Psychological Association Council of Representatives, the Association of State and Provincial Psychology Boards Board of Directors, and the American Insurance Trust Board of Directors. These guidelines have been widely disseminated to mental health practitioners. Technological competence includes knowledge on the part of the therapist as well as group members regarding needed hardware, software, and a secure internet connection. Safeguards and security precautions are also needed to ensure client privacy (Barnett & Kolmes, 2016). It may also be necessary to provide instruction to clients (or their parents) on the technology used. It is important to prepare clients for potential loss of sound, video, or internet connection during sessions and have a backup plan for making contact or following up after the session (Barnett & Kolmes, 2016). Audio and visual challenges are unique to telehealth. When conducting group therapy, it may be difficult to see and hear participants effectively. Faces are usually in small boxes on the screen, making it difficult, if not impossible, to detect non-​verbal behavior or even to know who is speaking. In group therapy, it is important to ensure that all participants have an opportunity to participate in the group discussions. It may be necessary for group members to raise their hands to help the group leader identify who is speaking (Kneeland et al., 2021). Security considerations are another technological issue. The potential for unintentional disclosure of information is a potential weakness of telehealth services. In addition to using a Health Insurance Portability and Accountability Act of 1996 (HIPAA)-​compliant platform for group sessions, it is essential that only authorized participants attend. This can be done by having the sessions password protected or using a waiting room feature where the group leader individually admits group members into the therapy sessions. There are also new aspects of informed consent and confidentiality when providing group therapy by telehealth. Clients should be aware of the benefits and risks of telepsychology so they can make an informed decision about participation in this form of treatment. In addition, the therapist cannot guarantee confidentiality. Computer viruses, hackers, and theft of technology devices are just some of the potential threats. It is recommended that clients keep their cameras on during sessions. It is important to be in a quiet, private space that is free of distractions (including cell phones or other devices) during the session and use a secure internet connection rather than public Wi-​Fi. Therapists need to know the location of each client, as well as contact information and an emergency contact for each client (Barnett & Kolmes, 2016). Individual therapy using telehealth with children and adolescents is challenging, and group therapy is even more challenging. There are a multitude of distractions in each child’s environment, making it especially difficult to maintain the attention and concentration of each group member. It is also more difficult to establish a therapeutic relationship remotely. It is more difficult to discuss

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mental health issues on a computer screen with individuals whom you have never met in person. One strategy to help children and adolescents establish rapport and get to know each other is to use ice-​breaker exercises or other informal discussions at the beginning of the group to increase comfort (Kneeland et al., 2021). Didactic and psychoeducational groups also need to be adapted to the telehealth format. When group members are completing worksheets, it is important to ask at regular intervals whether they have any questions or are having any difficulty completing the task. The use of telehealth to provide mental health services, including group therapy, is likely to expand in the future. Therapists need to keep up to date on the ever-​evolving technological changes and the standards of care regarding the use of telehealth (Campbell et al., 2018). Additional Considerations Peer pressure can have a negative effect on group members, especially in groups for children and adolescents. Group leaders have an ethical obligation to respond to undue peer pressure toward any group member. It is always a judgment call to achieve a balance between appropriate pressure and unethical coercion. One technique for dealing with peer pressure in group therapy is to make it the topic of group discussion. This acknowledges the feelings of the group members who are exerting pressure and hopefully reframes those feelings in a more productive direction. It is also the role of the leader to remind the group of the need to respect the wishes of an unwilling member (Corey et al., 2014). Group members also must have the freedom not to participate in activities or discussions. This information should be part of the informed consent process, and frequent reminders during group may be helpful. In addition, group leaders need to demonstrate that it is acceptable for members to choose not to participate at times. This is especially true for minors because many times, they have been referred by parents or teachers and are especially reluctant to participate. Similarly, when group members are discussing a particular issue, they can decide to stop at any point. The leaders may explore their reason for stopping and let them know that if they want to continue the discussion later, to let the leader know. In contrast to peer pressure, group leaders can also abuse their power. This can take the form of excessive focus on one member, pressuring a minor to reveal certain information, or making group members feel defensive. When these techniques are used, clients tend to withdraw and stop participating. Thus, it has the opposite of the intended effect. Other group members may also model abuse toward a client by the group leader. This causes a serious disruption in the functioning of the group and destroys any atmosphere of trust. Instead of giving thoughtful answers to questions, a client who feels attacked will try to find the “right” answer to get the questions to stop. Although confrontation can be an effective therapeutic technique, it needs to be done carefully and with concern for the client being confronted (Corey et al., 2014). Giving group members the freedom to leave the group is a difficult decision when working with minors, especially because, in some circumstances, it is not the minor’s choice to be a member of the group. Regardless of how the group leader wishes to handle this issue, it should be discussed as part of informed consent so that group members are aware of what is expected of them. If group members have the option to leave the group and wish to do so, they also have a responsibility to inform the group members and leader of their intention to leave as well as their reasons for wanting to leave. It can be therapeutic for the person who plans to leave to tell the group what they considered negative in the experience if this is the reason for leaving. Also, if the child or adolescent is leaving because of feedback they have received, this discussion provides the opportunity to clarify any misunderstanding that may have taken place. Other group members may feel that the child is leaving because of something they said or did. Corey and colleagues (2014) point out that when the person who is leaving provides reasons to the group, it gives the other members a chance to verify

Legal and Ethical Issues in Providing Group Therapy to Minors 57

any concerns they may have about their responsibility for that person’s decision. In most groups, members are expected to attend all sessions and inform the leader if they plan to miss a session or withdraw. When members choose to leave the group, it does have a significant effect on the whole group, especially if they do so without discussing their reasons. If a child who is still in need of mental health services chooses to leave group therapy, it is good practice to provide their parents with a referral for additional treatment. Summary and Conclusion There are many legal and ethical issues that confront group therapists working with minors. It is the responsibility of the group leader to both act ethically and create an ethical climate in the group (Glass, 1998). Although there are ethical guidelines and codes to aid group therapists in making good decisions, they do not provide answers for all ethical dilemmas. Thus, in addition to knowing the ethics code of the group leader’s profession and the laws of their specific jurisdiction, it is helpful to have an ethical decision-​making framework to use in resolving ethical dilemmas (Brabender, 2002). This chapter presented the model developed by Knapp and VandeCreek (2003), which is made up of five steps that are common across most ethical decision-​making models. The area of competence was discussed from several perspectives, such as competence as a therapist, competence as a group therapist, competence to work with children, competence with specialty populations, and competence to work with a diverse clientele. The importance of life-​long learning in maintaining competence throughout one’s career was also stressed. Recruitment, screening, and selection of minors for participation in group therapy were also addressed. Some of the issues discussed included the negative effects of labeling children and adolescents in the recruitment process, how to best involve teachers and parents, and how to identify children who will benefit from group treatment. The next area focused on is consent to treatment of minors. In most jurisdictions, when a decision is to be made on behalf of a person who has not yet reached the age of 18, it is usually made by a parent or legal guardian. Even though group therapy clients under the age of 18 cannot legally consent to treatment, it is important to obtain their assent or willingness to participate in the group. Informed consent is a very important part of the group therapy process. Informed consent provides the basis for parents to make the decision about whether their child should participate in group treatment. The elements of adequate informed consent were discussed, including the risks and benefits of group participation. Confidentiality is central to all mental health treatment. Group therapy with minors presents many challenges in the area of confidentiality. For example, the amount of information to be shared with parents needs to be negotiated and agreed on in advance. Also, in group therapy, the leader can control therapist–​client confidentiality but not client-​to-​client confidentiality. Children and adolescents need frequent reminders of the importance and necessity of confidentiality. Five steps were discussed that can be taken by group leaders to increase the probability that group members will respect each other’s confidentiality. Mandated reporting of child abuse was included because group therapists working with minors are likely to encounter a situation that requires reporting. Knowing the reasons that therapists are reluctant to make a report is as important as knowing when and how to report suspected child abuse. Options were provided to reduce the negative effects on treatment of making a child abuse report. Records of group therapy sessions can be written either about the entire group or about each individual member. The pros and cons of each format were discussed, and recommendations were made to maintain the confidentiality of group members.

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Using telehealth to provide mental health services has many advantages as well as challenges, including technological competence, informed consent, confidentiality, and establishing a therapeutic relationship. The use of telehealth to provide mental health services, including group therapy, is likely to expand in the future, requiring therapists to keep up to date in this rapidly evolving area. Finally, the issues of peer pressure in group therapy, the freedom not to participate in group activities or discussions, and the freedom to leave the group were presented. These topics are especially important when working with children and adolescents who are easily influenced by the behavior of others. Ethical dilemmas arise when they are least expected and most inconvenient. It is beneficial to discuss ethical issues with colleagues and to provide necessary training to graduate students and interns. Consultation in complex situations provides an additional perspective (Glass, 1998). “The group therapist can deliver effective treatment only by acting ethically and within the limits of the law” (Brabender et al., 2004, p. 202). References Abeles, N. (1980). Teaching ethical principles by means of value confrontation. Psychotherapy: Research and Practice, 17, 384–​391. American Counseling Association. (2014). ACA Code of Ethics. Retrieved from www.cou​nsel​ing.org/​Resour​ ces/​aca-​code-​of-​eth​ics.pdf American Group Psychotherapy Association. (2002). AGPA and IBCGP Ethics in Group Therapy. Retrieved from AGPA: Ethics in Group Therapy: www.agpa.org/​home/​pract​ice-​resour​ces/​eth​ics-​in-​group-​ther​apy American Psychological Association. (2017). Ethical Principles of Psychologists and Code of Conduct (2002, Amended December 2016). Retrieved from: www.apa.org./​eth​ics/​code/​eth​ics-​code-​2017.pdf Association for Specialists in Group Work. (2021). Guiding principles for group work. Alexandria, VA: American Counseling Association. Bajt, T. R., & Pope, K. S. (1989). Therapist-​patient sexual intimacy involving children and adolescents. American Psychologist, 44, 455. Barnett, J. E., & Hillard, D. (2001). Psychologist distress and impairment: The availability, nature and use of colleague assistance programs for psychologists. Professional Psychology: Research and Practice, 32, 205–​210. Barnett, J. E., & Kolmes, K.K. (2016). The practice of tele-​mental health: Ethical, legal, and clinical issues for practitioners. Practice Innovations, 1(1), 53–​66. Brabender, V. (2002). Introduction to group therapy. Hoboken, NJ: Wiley. Brabender, V. A., Fallon, A. E., & Smolar, A. I. (2004). Essentials of group therapy. Wiley. Campbell, L. F., Millan, F., & Martin, J. N. (2018). A telepsychology casebook: Using technology ethically and effectively in your professional practice. Washington, DC: American Psychological Association. Corey, G., Corey, M. S., Callanan, P., & Russell, J. M. (2014). Group techniques (4th ed.). Boston, MA: Cengage Learning Brooks/​Cole. Corey, M. S., Corey, G., & Corey, C. (2017). Groups: Process and practice (10th ed.). Boston, MA: Cengage Learning Brooks/​Cole. Corrao, J., & Melton, G. B. (1988). Legal issues in school-​based behavior therapy. In J. C. Witt, S. N. Elliot, & F. M. Gresham (Eds.), Handbook of behavior therapy in education (pp. 377–​399). New York: Plenum. Couch, R. D. (1995). Four steps for conducting a pre-​group screening interview. Journal for Specialists in Group Work, 20, 18–​25. Eberlein, L. (1987). Introducing ethics to beginning psychologists: A problem-​solving approach. Professional Psychology: Research and Practice, 18, 353–​359. Fisher, C. B. (2017). Decoding the ethics code: A practical guide for psychologists (4th ed.). Sage. Fletcher, T. L., Higan, J. B., Keegan, F., Davis, M. L., Wassef, M., Day, S., & Lindsay, J. A. (2018). Recent advances in delivering mental health treatment via video to home. Current Psychiatry Reports, 20(8), 56. Gladding, S. T. (1999). Groundwork: A counseling specialty (3rd ed.). Hoboken, NJ: Prentice Hall.

Legal and Ethical Issues in Providing Group Therapy to Minors 59 Glass, T. A. (1998). Ethical issues in group therapy. In R. M. Anderson, T. L. Needels, & H. V. Hall (Eds.), Avoiding ethical misconduct in psychology specialty areas (pp. 95–​126). Springfield, IL: Charles C. Thomas. Gros, D. F., Morland, L. A., Greene, C. J., Acierno, R., Strachan, M., Egede, L. E., Tuerk, P. W., Myrick, H., & Frueh, B. C. (2013). Delivery of evidence-​based psychotherapy via video telehealth. Journal of Psychopathology and Behavioral Assessment, 35(4), 506–​521. Haas, L. J., & Malouf, J. L. (2005). Keeping up the good work: A practitioner’s guide to mental health ethics (4th ed.). Sarasota, FL: Professional Resource Exchange. Harper, G., & Irvin, E. (1985). Alliance formation with parents: Limit setting and the effect of mandated reporting. American Journal of Orthopsychiatry, 55, 550–​560. Hurdle, D. E. (1991). The ethnic group experience. In K. L. Chau (Ed.). Ethnicity and biculturalism: Emerging perspectives of social group work (pp. 59–​69). Haworth Press. Joint Task Force for the Development of Telepsychology Guidelines for Psychologists. (2013). Guidelines for the practice of telepsychology. American Psychologist, 68, 791–​800. Kalichman, S. C. (1999). Mandated reporting of suspected child abuse: Ethics, law, and policy (2nd ed.). Washington, DC: American Psychological Association. Kalichman, S. C., & Brosig, C. L. (1993). Practicing psychologists’ interpretations of and compliance with child abuse reporting laws. Law and Human Behavior, 17, 83–​93. Kitchener, K. S. (1984). Intuition, critical evaluation and ethical principles: The foundation for ethical decisions in counseling psychology. Counseling Psychologist, 12(3), 43–​55. Knapp, S., & VandeCreek, L. (2003). A guide to the 2002 revision of the American Psychological Association’s ethics code. Professional Resource Press. Knapp, S., VandeCreek, L., Fingerhut, R. (2017). Practical ethics for psychologists: A positive approach (3rd ed.). Washington, DC: American Psychological Association. Knauss, L. K. (2006). Ethical issues in record keeping in group psychotherapy. International Journal of Group Psychotherapy, 56(4), 415–​430. Kneeland, E. T., Hilton, B. T., Fitzgerald, H. E., Castro-​Ramirez, F., Tester, R. D., Demers, C., & McHugh, R. K. (2021). Providing cognitive behavioral group therapy via videoconferencing: Lessons learned from a rapid scale-​up of telehealth services. Practice Innovations, 6(4), 221–​235. Koocher, G. (Ed.) (1976). Children’s rights and the mental health profession. Wiley-​Interscience. Koocher, G. P., & Keith-​Spiegel, P. C. (1990). Children, ethics, and the law: Professional issues and Cases. Lincoln, NE: University of Nebraska Press. Koocher, G. P., & Keith-​Spiegel, P. (2016). Ethics in psychology and the mental health professions: Standards and cases (4th ed.). New York: Oxford University Press. Leong, F. T. L. (1992). Guidelines for minimizing premature termination among Asian American clients in group counseling. Journal for Specialists in Group Work, 17(4), 218–​228. Leupker, E. T. (2022). Record keeping in psychotherapy and counseling (3rd ed.). New York: Routledge. National Association of Social Workers. (2017). Code of Ethics: English. Retrieved from NASW: Code of Ethics: www.social​work​ers.org/​About/​Eth​ics/​Code-​of-​Eth​ics/​Code-​of-​Eth​ics-​Engl​ish Ohlsen, M. M. (1974). Guidance services in the modern schools. San Diego, CA: Harcourt Brace Jovanovich. Rest, J. R. (1982). A psychologist looks at the teaching of ethics. Hastings Center Report, pp. 29–​36. Ritchie, M. H., & Huss, S. N. (2000). Recruitment and screening of minors for group counseling. Journal for Specialists in Group Work, 25(2), 146–​156. Slovenko, R. (1998). Psychotherapy and confidentiality: Testimonial privileged communication, breach of confidentiality, and reporting duties. Springfield, IL: Charles C. Thomas. Terres, C. K., & Larrabee, M. J. (1985). Ethical issues and group work with children. Elementary School Guidance and Counseling, 19(3), 190–​197. Toseland, R. W., & Siporin, M. (1986). When to recommend group treatment: A review of the clinical and the research literature. International Journal of Group Psychotherapy, 36, 171–​201. Tymchuk, A. J. (1986). Guidelines for ethical decision making. Canadian Psychology, 27, 36–​43. Watson, H., & Levine, M. (1989). Psychotherapy and mandated reporting of child abuse. American Journal of Orthopsychiatry, 59, 246–​256. Yanagida, E. H. (1998). Ethical dilemmas in the clinical practice of child psychology. In R. M. Anderson, T. L. Needels, & H. V. Hall (Eds.), Avoiding ethical misconduct in psychology specialty areas (pp. 47–​77). Springfield, IL: Charles C. Thomas.

Chapter 4

Useful Techniques in Group Cognitive Behavioral Therapy with Youth Helping Youth See Things from Wing to Wing Robert D. Friedberg, Isabella Xie, Callie Goodman, Joee Zucker, Megan Neelley, Runze Chen, Andrea Noble, and, Tia Lee

Introduction I hid in the crowded wrath of the crowd; But when they said, sit down, I stood up; Ooh, growin’ up; Well, the flag of piracy flew from my mast; My sails were set wing to wing. (Bruce Springsteen, Growin' Up, 1973).

The COVID-​19 pandemic launched a new normal in pediatric behavioral health care. Racine and her colleagues (2021) noted that one in five children and adolescents reported anxious symptoms and approximately 25 percent of youth worldwide indicated they were suffering from depressive symptoms. Not surprisingly, a tsunami of clinical referrals is expected (Liang et al., 2020). However, the existing care delivery system is not prepared for the tidal wave of new cases (Friedberg, 2021b). Accordingly, multiple organizations such as the American Psychological Association, American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, Children’s Hospital Association, and the U.S. Surgeon General warned about a crisis in pediatric behavioral health care. The flood of incoming patients will quickly exceed the capacity for individual therapy. Therefore, delivering an evidence-​based approach such as cognitive behavioral therapy (CBT) via group modalities is a suitable way to manage the influx of cases. Group interventions offer multiple clinical advantages. Group modalities offer increased access, efficiency, a sense of universality, and scalability of interventions (Cumba-​Avilés, 2017; Santesteban-​Echarri et al., 2018; Wolgensinger, 2022). Additionally, Cumba-​Avilés (2017) noted that group cognitive behavioral therapy (GCBT) yields cost savings, readily provides partners for skill practice, and facilitates learning from others. Hence, GCBT emerges as first-​line option for mitigating emotional and behavioral problems in young people. Finding yourself is a pervasive theme in Bruce Springsteen lyrics and represents a core goal in GCBT. Expanding children’s and adolescents’ cognitive, emotional, and behavioral flexibility is key in treatment. In this chapter, we address several pertinent issues. The chapter begins with a brief review of the empirical research supporting clinical applications of GCBT with various populations. In the second larger section, the core processes and practices in GCBT designed to broaden young patients’ perspectives are delineated. Multiple examples are presented, and resource tables are provided. Clinical Applications GCBT enjoys successful applications to youth experiencing a myriad of problems (Christner & Bernstein, 2017). Additionally, GCBT appears acceptable, feasible, and effective with diverse youth (Cardemil et al., 2002; Cardemil et al., 2007; Craig et al., 2021; Cumba-​Avilés, 2017; Eshikawa et al. 2019; Ginsburg & Drake, 2002; Wong et al., 2018). More specifically, GCBT shows

DOI: 10.4324/9781351213073-5

Useful Techniques in Group Cognitive Behavioral Therapy  61

promising results for children and adolescents experiencing depressive symptoms (Cardemil et al., 2002; Cardemil et al., 2007; Cumba-​Avilés, 2017; Keles & Idsoe, 2018; Keles et al., 2021). In their meta-​analysis, Keles and Idsoe found that GCBT was effective at both post-​test and follow-​ up evaluation points. The Penn Resiliency Program for adolescents (PRP-​A; Gillham et al., 2012) yielded decreased depression and hopeless in adolescents. African-​American and Latino youth who initially reported symptomatic levels of depression experienced reductions in symptoms after GCBT (Cardemil et al., 2007). Anxiety disorders are also effectively treated through group-​based interventions (Asbrand, 2020; Donovan et al., 2015; Jónsson et al., 2015; Kendall & Peterman, 2015; O’Shannessy et al., 2023) The Coping Cat (Kendall & Hedtke, 2006) program is the most extensively evaluated group treatment for youth. A recent review showed that Coping Cat was superior to wait-​list control, active contrast conditions, and demonstrated impressive treatment generalization as well durability (Friedberg, 2021a). Additionally, Jónsson and colleagues (2015) implemented a GCBT intervention (e.g., Cool Kids) with youth ages 7–​16 years and found it resulted in decreased self and clinician-​reported anxious symptoms. Several studies examined the impact of GCBT on both anxiety and depressive symptoms (Barron-​Linnankoski et al., 2022; Bilek & Ehrenreich, 2012; Haugland et al., 2020; Kim et al., 2018; Scaini et al., 2022). Bilek and Ehrenreich declared that their GCBT resulted in improved depression and anxious symptoms. In a school-​based GCBT intervention with adolescents, both parents’ and teens’ reports of anxiety and depression decreased (Barron-​Linnankoski et al., 2022). Another school-​based GCBT program addressing depression and anxiety in youth with problematic internet use found lowered symptoms in their participants at post-​intervention evaluations (Kim et al., 2018). Finally, children’s self-​reported anxiety and depression was reduced by the Cool Kids GCBT program (Scaini et al., 2022). GCBT for youth challenged with disruptive behaviors, irritability, anger, and aggression is yielding beneficent results (Derella et al., 2020; Lochman, 2022; Lochman et al., 2015; Sukhodolsky et al., 2016; Waxmonsky et al., 2016). Derella et al. (2020) showed their GCBT resulted in decreased irritability, oppositional behavior, and defiance as well as improved emotional regulation. Coping Power is a widely researched and empirically supported group intervention for youth showing disruptive behavior problems (Lochman et al., 2015; Lochman, 2022; Stromeyer et al., 2020). In randomized clinical trials, Coping Power resulted in reduced disruptive behaviors, hostile attributions, and beliefs that aggression leads to goal attainment (Lochman, 2022). Moreover, this progress showed sustainability at one-​year follow-​up points. The Unified Protocol for Children (Ehrenreich-​May et al., 2018) was deployed with 19 children ages 8–​12 years old who were diagnosed with disruptive behavior problems and accompanying irritability (Hawks et al., 2020). The results revealed that parents’ ratings of their children’s disruptive behavior improved over the course of treatment. Recent research yields promising results for GCBT with youth diagnosed on the Autism Spectrum (Blakely-​Smith et al., 2021: Reaven et al., 2012, 2018, 2020). More specifically, Reaven and colleagues (2012) demonstrated that the Facing Your Fears (FYF) GCBT program decreased anxiety in teens diagnosed on the Autism Spectrum. Recently, Blakely-​Smith and her team (2021) found that the FYF program was effective with adolescents diagnosed with autism and comorbid intellectual disabilities. The literature is certainly promising but practice in treatment-​as-​usual settings is often difficult and proper implementation of GCBT is challenging. Consequently, faithful adherence to fundamental CBT process and principles as well as flexible application of clinical practices is crucial. The following section offers several recommendations for effective GCBT with youth.

62  Robert D. Friedberg et al.

Putting the Techniques in Context via 3P: Core Principles, Processes, and Practices GCBT is best applied in a personalized manner that appreciates individual group members’ particular contexts. Core principles, processes, and practices (3Ps) enables this flexible and adaptable approach. In this section, collaborative empiricism, guided discovery, and working with fidelity and flexibility are explained. Additionally, building session structure, multi-​tasking, and promoting experiential learning are delineated. Collaborative Empiricism, Guided Discovery, as well as Practicing with Fidelity and Flexibility Similar to individual CBT, GCBT is punctuated by collaborative empiricism and guided discovery (Beck et al., 1979). Collaborative empiricism fuels the transparency characterizing CBT. There are no mysteries since rationales, goals, procedures, and progress markers used in treatment are explicitly shared with patients. In this way, youth are informed partners throughout the treatment process. Guided discovery refers to the practice of using empathy, socratic dialogues, and behavioral experiments to build a database upon which patients form their own conclusions. The goal is not to smash children’s and adolescents’ belief through interrogation, refutation, or disputation but rather to create cognitive dissonance. Finally, delivering a dose of CBT with a mix of fidelity to the theoretical model and sufficient flexibility to appreciate individual patients’ circumstances is a contemporary clinical imperative (Kendall & Frank, 2018; Kendall et al., 2008). Building Session Structure Adhering to session structure is an imperative to all CBT modalities (Beck et al., 1979; Beck, 2021). Mood check-​ins, homework review (HWR), agenda setting, processing session content, homework assignment (HWA), and feedback/​summaries are prototypical session components. Mood check-​ins are done either informally (e.g., How was your mood since our last session?) or via objective symptom measures. Past homework assignments are perused and discussed. Agenda setting enables genuine informed consent, identification of clinical priorities, and efficient allocation of time. Following a collaborative agreement on the agenda, items are then therapeutically processed with an eye on both skill acquisition and application. Homework assignments based on the session content are then mutually decided upon. The session then concludes with group members providing feedback on what was helpful and not helpful in the day’s session as well as a summary of the work completed. Skills Required for Leading GCBT Groups: Multi-​t asking Is Crucial! Certainly, therapists planning to lead GCBT sessions are well-​advised to be fully trained in CBT core competencies (Friedberg, 2015; Newman & Kaplan, 2016). Newman and Kaplan (2016) stated the essential features of competent CBT practice include case conceptualization, cultural alertness, managing the working alliance, competence in collaboration and guided discovery, capacity to adhere to prototypical session structure, technical proficiency (skillfulness self-​monitoring, behavioral activation, relaxation, cognitive restructuring [CR], exposure, etc.), and ability to craft homework assignments. Effective CBT is marked by attending to both skill acquisition and skill application (Friedberg & McClure, 2015). As previously noted, patients learning coping skills is a fundamental task of

Useful Techniques in Group Cognitive Behavioral Therapy  63

therapy. In order for skills to be applied to modify thoughts, feelings, behaviors, and situations, they must first be acquired. However, many novice therapists neglect this step. Skill acquisition requires direct instruction and repeated practice. Therefore, group therapists are well-​advised to allocate time in session to teach and rehearse various skills. Skill acquisition is best done experientially and in a systematic manner. The basic rationale of a coping strategy is simply explained, core elements are demonstrated, and then practiced in an emotionally neutral context. Skill application on the other hand is enacted in emotionally charged situations. Implementing acquired tools when emotions are ignited enables greater generalization. Simultaneously attending to therapeutic structure, content, and process is another important practice. Therapeutic structure refers to clinical tasks such as agenda setting, eliciting feedback, homework assignments, daily thought records, and all the various cognitive behavioral procedures. Therapeutic content includes the material generated via the structure. Finally, treatment process reveals the way group members navigate through structure and content. For instance, some group members may react to interventions with enthusiasm, opposition, avoidance, anxiety, irritability, and so on. Addressing all of these responses is clinically important. Focus on Experiential Learning: The Group as a Social Learning Laboratory Beck’s Cognitive Therapy is fundamentally a phenomenological approach. In his earlier writing, Beck (1976) cogently noted, “the experiential approach exposes the patient to experiences that are in themselves powerful enough to change misconceptions” (p. 214). The group milieu is viewed as a here and now social learning laboratory. Accordingly, the interpersonal environment offers a ripe context for acquiring and applying skills. Immediacy in session is highly valued and thoughts/​ images from the past, present, and future are dealt with in the here and now. According to Friedberg and Gorman (2007), “psychotherapeutic moments are charged with urgency and genuine emotional experience in present tense and real time” (p. 189). For instance, the group represents a ready-​made arena for testing out interpersonal biases, fears of rejection, and inaccurate beliefs about oneself. Judgments such as “Other kids will reject me” or “People think I am a loser” are appropriate fodder for group processing. Additionally, angry youths’ hostile attributional biases (“Kids are always trying to get over on me”) are similarly good treatment foci. Moreover, in vivo demonstration of social skills is enabled via the group milieu. Accordingly, children get practice giving and getting feedback via group work. Despite the advantages of group treatment, Lochman (2022) warned about iatrogenic effects. Iatrogenic effects refer to increased illnesses or other adverse complications due to treatment. In GCBT, these untoward outcomes might be due to contagion effects or group members colluding with each other to propel problematic behavior (Dishion et al., 2001). For example, teens in group treatment for non-​suicidal self-​injury (NSSI) might learn new ways to cut or burn themselves. Additionally, youth in groups for conduct disorders could learn more ways to violate various norms without being caught. Therefore, groups demand particular clinician skillfulness to avoid iatrogenic effects (Lochman, 2022). There are several ways for clinicians to obviate these iatrogenic effects. First, beginning with the first group session and continuing with a review in subsequent sessions, group therapists are well-​advised to establish group rules and set limits. Second, adhering to the prototypical GCBT session described above is recommended. Finally, firmly practicing a skills-​oriented approach that focuses on adaptive problem-​solving and productive coping strategies is elementary to good work.

64  Robert D. Friedberg et al.

Stocking the CBT Treasure Chest for Group Work: Change-​m aking Techniques Building coping skills is rudimentary in CBT. Further, CBT is being increasingly delivered in modules (Chorpita & Weisz, 2009; Friedberg & Thordarson, 2018). Modules refer to conceptual categories grouping similar procedures together. For the purposes of this chapter, psychoeducational, progress metrics, basic behavioral tasks (BBTs), CR, and exposure-​based techniques are delineated as modules. Psychoeducational interventions teach patients about their diagnosis, treatment options/​strategies, and the course of treatment. Progress metrics estimate movement toward therapeutic goals. BBTs are initial methods that focus on specific straightforward action patterns. CR procedures target thought content as well as processes through priming, self-​instruction, problem-​ solving, and rational analysis. Finally, exposure and experiments represent experiential learning opportunities where youth apply their acquired coping skills. Modular Elements Psychoeducation. Psychoeducational interventions involve providing verbal information, written material, as well as audio and video recordings that improve group members’ knowledge and mitigate power imbalances. Handouts describing CBT and its various procedures may be distributed. The MATCH-​ADTC (Chorpita & Weisz, 2009) package contains a stockpile of handouts for young patients. Additionally, self-​help workbooks may also be used. Table 4.1 lists some favorite books/​ workbooks for children and adolescents. A number of video recordings are also very helpful. For instance, the Child Mind Institute, On Our Sleeves, and Sesame Street websites offer engaging videos illustrating CBT-​oriented practices. The use of optical illusions to introduce CBT to children and adolescents is common to several treatment manuals (Ehrenreich-​May et al., 2018; Lochman et al., 2008). The classic optical Table 4.1 Psychoeducation Materials Resource

Age range

Huebner, D. (2007a). What to do when you grumble too much. American Psychological Association. Huebner, D. (2007b). What to do when your temper flares. American Psychological Association. Huebner, D. (2005). What to do when you worry too much. American Psychological Association. Wagner, A. P. (2013). Up and down the worry hill. Lighthouse Press. Stallard, P. (2019). Think good, feel good: A cognitive behavioral workbook for children and adolescents (2nd Ed.). Wiley. Vernon, A. (1989a). Thinking, feeling, behaving (grades 1–​8 ). Research Press. Vernon, A. (1988). The passport program (Grades 1–​5 ). Research Press. Pill, E. (2005). Everybody gets angry. The Bureau for At-​R isk Youth. Vernon, A. (2002). What works when with children and adolescents. Research Press. Feindler, E.L., & Sita-​M olz, G. (2021). Teen anger management education. Research Press. Tompkins, M.A. (2023). Stress less: A teen’s guide to calm, chill life. Magination Press. Tompkins, M.A. (2022). The anxiety and depression workbook for teens. New Harbinger. Tompkins, M.A. (2020). Zero to 60: A teen’s guide to manage frustration, anger, and everyday irritations. Magination Press.

6–​1 2 years 6–​1 2 years 6–​1 2 years 6–​1 1 years 8–​1 8 years 6–​1 4 7–​1 1 7–​1 3 6–​1 8

years years years years

13–​1 8 years 13–​1 8 years 13–​1 8 years 13–​1 8 years

Useful Techniques in Group Cognitive Behavioral Therapy  65

illusion familiar to most students in undergraduate psychology classes is the Young Lady/​Old Hag drawing. Since optical illusions are unfamiliar to most children and adolescents, they are very intriguing to group members. When we implement this exercise, we show an optical illusion and ask the group members to write down what they see. Members are asked to share their perceptions and of course some people see one thing and others identify something else. We then ask, “How can people see different things in one picture?” as a way to illustrate the point that where you place your attention shapes what you see. Naming the distortion is a psychoeducational procedure that is well-​suited for GCBT. First, the group members are taught the various cognitive distortions. Mid-​sized sandwich bags are labeled with the cognitive errors (e.g., all or none thinking, overgeneralization, emotional reasoning, catastrophizing, and so on). Multiple automatic thoughts are written on two sets of index cards (e.g. “I’m a loser,” “Nothing works out for me,” “Emotions are scary,” and so on). The group members are divided into two teams. Each team gets an automatic thought and then they must place the index card in the bag labeled with the proper distortion. Progress metrics. Various assessment tools are useful for tracking group members progress during GCBT, a sample of which are provided in Table 4.2. The critical part is to select relatively brief but tractionable measures that gauge relevant progress. The Pediatric Symptom Checklist-​17 (PSC-​17) is a favorite broadband instrument. For depression, we recommend the Beck Depression Inventory-​2 (BDI-​2), Children’s Depression Inventory-​2 (CDI-​2), and the Table 4.2 Sample of Assessment Tools Measure

Reference

Intolerance of Rifkin, L. S., & Kendall, P.C. (2020). Intolerance of uncertainty in Uncertainty Index-​A youth: Psychometrics of the Intolerance of Uncertainty Index-​A for for Children Children. Journal of Anxiety Disorders, 71, 102197. Patient Health Nandakumar, A.L., Vande Voort, J.L., Nakonezny, P.A., Orth, S.S., Questionnaire-​9 A Romanowicz, M., Sonmez, A.I., Ward, J.A., Rackley, S.J., Huxahl, (PHQ-​9 A) J.E., & Croarkin, P.E. (2019). Psychometric properties of the Patient Health Questionnaire-​9 modified for Major Depressive Disorder in adolescents. Journal of Child and Adolescent Psychopharmacology, 29, 34–​4 0. GAD-​7 Spitzer, R.L., Kroenke, K., Williams, J.B., &, Lowe B. (2006). A brief measure for assessing generalized anxiety disorder: the GAD-​7 . Archives of Internal Medicine, 166, 1092–​1 097. SCARED Birmaher, B., Khetarpal, S., Brent, D., Cully, M., Balach, L., Kaufman, J., & Neer, S.M. (1997). The Screen for Child Anxiety Related Emotional Disorders: Scale construction and psychometric properties. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 545–​5 53. Revised Child Anxiety Chorpita, B.F., Yim, L., Moffitt, C., Umemoto, L.A., & Frances, S.E. and Depression (2000). Assessment of DSM-​IV anxiety and depression in children; Scale A Revised Child and Anxiety Depression Scale. Behaviour Research and Therapy, 38, 835–​8 55. Eyberg Child Behavior Eyberg, S.M. (1974). Eyberg Child Behavior Inventory. Psychological Inventory Assessment Resources. Pediatric Symptom Gardner, W., Murphy, M., Childs. G., Kelleher, K., Pagano, M., Jellinek, Checklist M.S., McInerny, T.K., Wasserman, R.C., Nutting, P., & Chiapetta, L. (1999). The PSC-​1 7: A brief Pediatric Symptom Checklist with psychosocial problem subscales; A report from the PROS and ASPN. Ambulatory Child Health, 5, 225–​2 36. School Refusal and Kearney, C.A., & Silverman, W.K. (1993). Measuring the function of Avoidance Scale school refusal behavior: The School Refusal Assessment Scale. Journal of Clinical Child Psychology, 22, 85–​8 6.

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Patient Health Questionnaire-​9 Adolescent Form (PHQ-​9A). We recommend the GAD-​7 for anxiety and the School Refusal and Avoidance Scale is very helpful for this specific problem. The Revised Child Anxiety and Depression Scale (RCADS) evaluates both presenting complaints. For disruptive behavior problems, the Eyberg Child Behavior Inventory (ECBI) is a good option. Further, since intolerance of uncertainty is a transdiagnostic pathway, adding the Intolerance of Uncertainty Index-​A for Children is suggested. Finally, Becker-​Haimes and colleagues (2020) collated and evaluated a wide array of brief, reliable, and valid measures for youth. Basic behavioral tasks (BBTs). BBTs commonly include relaxation training, social skills instruction, mindfulness exercises, behavioral activation, and contingency contracting. There are a variety of relaxation methods available such as controlled breathing, guided imagery, and progressive muscle relaxation. CBT-​oriented group work also frequently involves social skills training. Semple and Williard (2019) created engaging mindfulness exercises for children and adolescents. These procedures are especially good for group work. Two excellent examples are A Cup of Mindfulness and Mindful Music. A cup of mindfulness requires group members to sit in a circle. Group leaders should bring three Styrofoam cups filled halfway with water, and a water pitcher to the session. The three cups are passed around the circle carefully with the members trying not to spill. Next, the cups are filled completely and then passed around the circle without spilling. As Semple and Williard explain, greater mindfulness is required in phase two. The therapist then debriefs the exercise with the group (e.g. How did you feel in the first part? The second part? What went through your mind in the first part? The second part? When were you more mindful? What was it like for you to be more mindful?) Mindful hearing (Semple & Williard, 2019) is another nice group technique. In this exercise, group members listen to a 30–​60-​second piece of music. They record whether they like or dislike the music. Additionally, they construct a title for the piece. Semple and Williard emphasize this procedure centers on group members’ here and now experiences. Social skills training is best accomplished in a group setting. Bierman (2004) created a very engaging, accessible, and fun practice exercise which involves making a trail mix. Each group member is given an individual family-​size package of ingredients (M and Ms, raisins, peanuts, pretzel, nuts, etc.). Of course, group therapists should make sure there are no food allergies. The group is told that their task is for each of them to make a trail mix that includes all of the ingredients. Consequently, they have to request ingredients from each other as well as respond to others wishes for trail mix fixings. The procedure is a here and now experience where children practice asking for things, complying with requests, dealing with rejection, and negotiating potential conflicts. The group process often yields multiple in vivo teaching moments for group leaders. Finally, there is a built-​in reward since children get a trail mix at the end of the session. The use of popular games are also well-​founded vehicles for teaching social skills in groups. Ginsburg and colleagues (2006) deployed the ETCH-​A-​SKETCHTM toy in their study. In GCBT, the toy is used to foster cooperation, reciprocity, and communication with children who are controlling and demanding. The exercise is conducted in dyads. One child is in charge of the horizontal knob and the second member is assigned the vertical control knob. They are instructed to work together to make a design. However, they are allowed to only use their respective knobs. Thus, in order to complete the task, the children must communicate with each other, exercise patience, and tolerate surrendering a level of control. PasswordTM is a board game that is suitable for GCBT. This exercise targets perspective-​taking, flexibility, and egocentricity. In Passsword, children are divided into dyads; one member is the clue-​giver and the other is the guesser. Dyads take turns giving and receiving clues. A secret word

Useful Techniques in Group Cognitive Behavioral Therapy  67

is given and can be selected based on the group members’ vocabulary levels. Success in the game depends on adopting teammates’ perspectives. If a player maintains a narrow self-​focused perspective, they are unlikely to win the game. Similar to the Trail Mix technique, real-​time feedback by the group leader is enabled. Additionally, we have found recording feedback on index cards and distributing them to individual group members valuable. Cognitive restructuring (CR). CR in group therapy is somewhat different than in individual CBT. Of course, the main difference is that multiple individuals are simultaneously engaged in the process rather than one individual completing the task. Typically, CR procedures include priming exercises, problem-​solving, self-​instruction, and rational analysis techniques. Priming procedures ready young patients for more advanced cognitive change by working to increase flexibility and perspective-​taking. Problem-​solving is a very familiar method for most practitioners. Self-​ instruction focuses on changing one’s private speech whereas rational analysis addresses thought processes. Two of our favorite self-​instructional exercises to use with groups of young patients are Changing Your Tune (Friedberg et al., 2001) and Shake it Off (McClure et al., 2019). We prefer these for several reasons. First, they are experiential self-​instructional techniques. Second, they are very active and prompt engagement in therapy. Third, both exercises include music and are fun! Changing Your Tune is focused on re-​engineering group members’ habitual distressing thoughts. The procedure employs the metaphor of repetitive song lyrics that people cannot get out their heads. When presenting the metaphor to youth, we recommend therapists emphasize negative automatic thoughts are like song lyrics that go over and over in people’s heads and become automatic. Therapists begin by asking group members if they ever had song lyrics regularly running through their head and could not yank them out of their minds. The children then are encouraged to offer some examples The next phase involves the experiential part. The therapist introduces the Change Your Tune game. First, a relatively familiar song with repetitive lyrics is selected. A few examples are Baby Shark, Call Me Maybe, You’re So Golden, Jingo La Ba, and Send Me on My Way. The therapist explains the task (e.g., I am going to play a song where the lyrics play over and over. I want you to raise your hand when you first hear the repetitive lyric). The recording is played, and children try to identify the repetitive lyric as quickly as they can. The second step invites members to listen for the repetitive lyric and then sing along with the recording as soon as they recognize the repeated words. The third part adds one more component. The recording is played again, and members are instructed to identify the lyric, sing along, and perform a dance move while sitting in their chair. Following these three steps, the therapist guides the group through a debriefing process fueled by a socratic dialogue. Group therapists might employ questions such as “What did you have to do to catch the repetitive lyric?”, “What did you have to have to do in the last stage?”, and “When have you done these dance moves to this song before?”. Finally, the Change Your Tune worksheet is distributed, and the members identify the old tunes (negative automatic thoughts) they want to change and work to create new tunes (coping thoughts). Shake it Off is another CR method and is based on the iconic Taylor Swift song. Group members and their therapist write their negative thoughts on post-​it notes. The therapist then asks, “How many of you have heard of Taylor Swift’s song Shake it Off. Well, we are going to do what Taylor says with your thoughts. “How does that sound?” Next, the group members and the therapist stick the post-​it notes with the automatic thoughts on their sleeves. The therapist proceeds telling the children they are going to do what Taylor sings. The song is played and when the words “Shake it Off!” are heard, the therapist and group members flap their arms feverishly to rid themselves of the negative thoughts. After the post-​it notes fall to the floor, the recording is stopped, and the therapist says, “Well, we cannot leave these thoughts on the floor. We have to pick them

68  Robert D. Friedberg et al.

up and write a talk back thought on this new post-​it note.” After the group members construct their counterthoughts, they paste the two post-​it note back to back. In this way, they have a ready-​ made coping card. Exposure/​Behavioral experiments. Exposures and behavioral experiments are the sine qua non in CBT. These procedures teach a patient to “Show that I can” (Kendall & Hedtke, 2006). Bandura (1977), in his seminal book, explained “performance accomplishments provide the most dependable source of self-​efficacy expectations because they are based on one’s own personal experience” (p. 81). Exposures and experiments are presented in a graduated manner via a hierarchy. In-​session exposures need to approximate the circumstances which evoke distress and be repeatedly practiced in order to generalize. Inhibitory learning models state that the goal of these procedures is for new approach behaviors to block maladaptive escape/​avoidance responses. These procedures need to be explicitly processed. Group members make predictions about what they think will happen prior to attempting the experiment, collect data about the exposure, analyze what they observe/​experienced, and form a conclusion based on the comparison between what they hypothesized and what they found. Introducing exposure and behavioral experiments is a crucial first step with youth especially in group work. Clinicians must remember that anxious patients see avoidance as the solution rather than the problem. Metaphors are often useful. I (RDF) typically use a basic metaphor to explain exposures. In particular, Batman’s origin story is helpful in this regard. As a boy, Bruce Wayne fell into a cave filled with tons of bats and later developed chiroptophobia (Nolan, 2005). Then as a budding superhero, Bruce forced himself to re-​enter the cave and remain in place while a frenzied cloud of bats surrounded him. Thereafter, he adopted the bat, a previous signal of his fear and weakness, now as a sign of his courage. Fear made Bruce Wayne the Batman. He showed that he could manage his fear. Seeing a hero such as Batman approach rather than avoid scary things often fuels willingness to experiment with coping skills. Most traditional exposure procedures are readily implemented in GCBT. Lochman and colleagues (2008) include a substantial exposure component in their well-​researched Coping Power protocol. The Self-​Control Dominoes Game is an excellent example of one of their procedures. The exercise is especially well-​suited to youth with impulse control problems, low frustration tolerance, and aggressive behavior. The exposure enables practice in keeping cool when things do not go your way and others tease you. To play the game, group members take turns building a domino tower in 30 seconds with their non-​dominant hand while the peers tease them. Therapists may elect to graduate this experience by having the youth build the tower in initial trials and then add to the difficulty level with the teasing. Improv theatre exercises are well-​suited for behavioral experiments and exposures. These theatre games are unscripted, spontaneous, and action-​oriented activities (Felsman et al., 2023; Gao et al., 2019). Increased flexibility, empathy, tolerance for uncertainty, emotional regulation, and divergent thinking are treatment goals (Felsman et al., 2023). In a recent clinical trial, Felsman and colleagues’ results revealed that improv theatre increased tolerance for uncertainty and social anxiety. Karaoke is another fun type of exposure for those who are anxious, intolerant of uncertainty, and socially fearful. Graduated trials are recommended. Early exposures might include shorter songs that are familiar to the youth. Later trials involve longer, more unfamiliar lyrics. Minute to Win It games are excellent ways for group members to practice frustration tolerance, impulse control, and anger management. These exciting and emotionally evocative games are completed within one minute. Although these procedures are fun, Minute to Win It activities are also very challenging. They readily spark problematic emotions, cognitions, and behaviors. Accordingly, Minute to Win It games facilitate here and now opportunities to practice acquired coping skills.

Useful Techniques in Group Cognitive Behavioral Therapy  69

Conclusion The current crisis in pediatric behavioral health care highlights a critical need for effective, accessible, and scalable interventions for children and adolescents seeking help for emotional and behavioral problems. Group CBT demonstrates efficacy in preventing and treating a wide range of disorders and shows promising results with diverse youth. Compared to individual treatment, GCBT offers benefits in terms of accessibility, cost, efficiency, universality, and scalability. Moreover, the group environment provides an opportunity for social learning in the present moment, where children can practice and learn from each other. While the COVID-​19 pandemic presents challenges to pediatric behavioral health care, GCBT appears to be a feasible solution to address the growing demands of patients around the nation. Successful delivery of GCBT relies on adherence to its core processes and principles, as well as flexibility from the clinician in adapting to group dynamics and context. This chapter provides practical guidance for adapting CBT to a group format, including detailed examples and techniques to use with young patients in each step of the five modules: psychoeducation, progress metrics, BBTs, CR, and exposure-​based techniques. The core elements of GCBT help expand the young patient’s cognitive, emotional, and behavioral flexibility, making it an effective intervention to address a variety of different issues. Using collaborative empiricism, guided discovery, session structure, and the cache of powerful change-​ makers, GCBT clinicians escort young people along their journey of growing up, finding themselves, and seeing things from wing to wing. References Asbrand, J. (2020). Experience versus report: Where are changes seen after exposure-​based cognitive-​ behavioral therapy? A randomized controlled group treatment of childhood social anxiety disorder. Child Psychiatry, 51, 427–​441. Bandura, A. (1977). Social learning theory. Prentice-​Hall. Barron-​Linnankoski, S., Raaska, H., Bergman, P., Närvänen, E., Elovainio, M., & Laasonen, M. (2022). Effectiveness of group CBT on internalizing and externalizing symptoms in children with mixed psychiatric disorders. Children, 9(11), 1602. https://​doi.org/​10.3390/​chil​dren​9111​602 Beck, A. T. (1976). Cognitive therapy and the emotional disorders. Madison, CT: International Universities Press. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York, NY: Guilford. Beck, J. S. (2021). Cognitive behavior therapy: Basics and beyond (3rd Ed.). New York, NY: Guilford. Becker-​Haimes, E. M., Tabachnick, A. R., Last, B. S., Stewart, R. E., Hasan-​Granier, A. & Beidas, R. S. (2020). Evidence base update for brief, free, and accessible youth mental health measures. Journal of Clinical Child & Adolescent Psychology, 49, 1–​17. Bierman, K. L. (2004). Peer rejection: Developmental processes and intervention strategies. New York, NY: Guilford. Bilek, E. L., & Ehrenreich-​May, J. (2012). An open trial investigation of a transdiagnostic group treatment for children with anxiety and depressive symptoms. Behavior Therapy, 43(4), 887–​897. Blakely-​Smith, A., Meyer, A. T., Boles, R. E., & Reaven, J. (2021). Group cognitive behavioral treatment for anxiety in autistic adolescents with intellectual disability: A pilot and feasibility study. Journal of Applied Research in Intellectual Disabilities, 34, 777–​778. Cardemil, E. V., Reivich, K. J., Beevers, C. G., Seligman, M. E. P., & James, J. (2007). The prevention of depressive symptoms in low-​income, minority children: Two-​year follow-​up. Behaviour Research and Therapy, 45, 313–​327. Cardemil, E. V., Reivich, K. J., & Seligman, M. E. P. (2002). The prevention of depressive symptoms in low-​ income minority middle school students. Prevention & Treatment, 5. Retrieved from http://​journ​als.apa. org/​pre​vent​ion/​volu​me5/​pre0​0500​08a.html

70  Robert D. Friedberg et al. Chorpita, B. F., & Weisz, J. R. (2009). Modular approach to therapy for children with anxiety, depression, trauma or conduct problems (MATCH-​ADTC). Satellite Beach, FL: PracticeWise. Christner, R. W., & Bernstein, E. R. (2017). Cognitive behavioral group therapy. In C. Haen, & S. Aronson (Eds.). Handbook of child and adolescent group therapy (pp. 110–​123). New York: Routledge. Craig, S. L., Iacono, G., Pascoe, R., & Austin, A. (2021). Adapting clinical skills to telehealth: Applications of affirmative cognitive-​behavioral therapy with LGBTQ+​youth. Clinical Social Work Journal, 49, 471–​483. Cumba-​Avilés, E. (2017). Cognitive-​behavioral group therapy for Latino youth with Type 1 diabetes and depression: A case study. Clinical Case Studies, 16, 58–​75. Derella, O. J., Burke, J. D., Romano-​Verthelyi, A. M., Butler, E. J., & Johnston, O. G. (2020). Feasibility and acceptability of a brief cognitive-​behavioral group intervention for chronic irritability in youth. Clinical Child Psychology and Psychiatry, 25, 778–​789. Dishion, T. J., Poulin, F., & Burrastron, B. (2001). Peer group dynamics associated with iatrogenic effect in group interventions with high-​risk adolescents. New Directions for Child and Adolescent Development, 91, 79–​92. Donovan, C. L., Cobham, V., Waters, A. M., & Occhipinti, S. (2015). Intensive group-​based CBT for child social phobia: A pilot study. Behavior Therapy, 46, 350–​364. Ehrenreich May, J., Kennnedy, S. M., Sherman, J. A., Bilek, E. L., Buzzella, B. A., Bennett, S. M., & Barlow, D. H. (2018). Unified protocols for transdisagnostic treatment of emotional disorders in children and adolescents [therapist guide]. New York: Oxford University Press. Eshikawa, S. Kikula, K., Sakai, M., Mitamura, T., Motomura, N., & Hudson, J. (2019). A randomized controlled trial of a bidirectional cultural adaptation of cognitive behavior therapy for children and adolescents with anxiety disorders. Behaviour Research and Therapy, 120, 103432. Felsman, P., Seifert, C. M., Sinco, B., & Himle, J. (2023). Reducing social anxiety and intolerance of uncertainty in adolescents with improv theatre. The Arts in Psychotherapy, 82, 101985. https://​doi.org/​10.1016/​ j.aip.2022.101​985 Friedberg, R. D. (2015). Where’s the beef: Concrete elements in supervision with CBT with youth. Journal of the American Academy of Child and Adolescent Psychiatry, 54, 527–​531. Friedberg, R. D. (2021a). Pediatrician-​friendly perspectives on cognitive behavioral therapy for anxious youth: Current status and clinical implications for the next normal. World Journal of Clinical Pediatrics, 9, 112–​123. Friedberg, R. D. (2021b). We’re not in Kansas anymore: Reimagining a new yellow brick road to treating youth and their families in the peri–​and post-​pandemic periods. Practice Innovations, 6, 275–​287. Friedberg, R. D., Friedberg, B. A., & Friedberg, R. J. (2001). Therapeutic exercises with children. Sarasota, FL: Professional Resource Press. Friedberg, R. D., & Gorman, A. A. (2007). Integrating psychotherapeutic processes with cognitive behavioral procedures. Journal of Contemporary Psychotherapy, 37, 185–​193. Friedberg, R. D., & McClure, J. M. (2015). Clinical practice of cognitive therapy with children and adolescents (2nd Ed.). Guilford. Friedberg, R. D., & Thordarson, M. A. (2018). Suite lessons: Pointers for private practitioners. In T. H. Ollendick, S. White, & B. White (Eds.). Oxford handbook of clinical child psychology (pp. 685–​695). New York, NY: Oxford Press. Gao, L., Peranson, J., Nyhof-​Young, J., Kapoor, E. & Rezmovitz, J. (2019). The role of “improv” in health professional learning: A scoping review. Medical Teacher, 41, 561–​568. Gillham, J. E., Reivich, K. J., Brunwasser, S. M., Freres, D. R., Chajon, N. D., Kash-​MacDonald, V. M., Chaplin, T. M., Abenavoli, R. M., Matlin, S. L., Gallop, R. J., & Seligman, M. E. P. (2012). Evaluation of a group cognitive-​behavioral depression prevention program for young adolescents: A randomized effectiveness trial. Journal of Clinical Child and Adolescent Psychology, 41, 621–​639. Ginsburg, G. S., & Drake, K. L. (2002). School-​based treatment for anxious African-​American adolescents: A controlled pilot study. Journal of the American Academy of Child & Adolescent Psychiatry, 41(7), 768–​775. Ginsburg, G. S., Grover, R. L., Cord, J. J., & Ialongo, N. (2006). Observational measures of parenting in anxious and non-​anxious mothers: Does type of task matter? Journal of Clinical Child and Adolescent Psychology, 35, 323–​328.

Useful Techniques in Group Cognitive Behavioral Therapy  71 Haugland, B. S., Haaland, Å. T., Baste, V., Bjaastad, J. F., Hoffart, A., Rapee, R. M., Raknes, S., Himle, J. A., Husabø, E., & Wergeland, G. J. (2020). Effectiveness of brief and standard school-​based cognitive-​ behavioral interventions for adolescents with anxiety: A randomized noninferiority study. Journal of the American Academy of Child & Adolescent Psychiatry, 59, 552–​564. Hawks, J. L., Kennedy, S. M., Holzman, J. B. W., & Ehrenreich-​May, J. (2020). Development and application of an innovative transdiagnostic treatment approach for pediatric irritability. Behavior Therapy, 51(2), 334–​349. Jónsson, H., Thastum, M., Arendt, K., & Juul-​Sørensen, M. (2015). Group cognitive behavioral treatment of youth anxiety in community based clinical practice: Clinical significance and benchmarking against efficacy. Journal of Anxiety Disorders, 35, 9–​18. Keles, S., Bringedal, G., & Idsoe, T. (2021). Assessing fidelity to and satisfaction with the “Adolescent Coping With Depression Course” (ACDC) intervention in a randomized controlled trial. Journal of Rational-​ Emotive and Cognitive-​Behavior Therapy, 40, 583–​602. Keles, S., & Idsoe, T. (2018). A meta-​analysis of group cognitive behavioral therapy (CBT) interventions for adolescents with depression. Journal of Adolescence, 67, 129–​139. Kendall, P. C., & Frank, H. E. (2018). Implementing evidence-​based treatment protocols: Flexibility within fidelity. Clinical Psychology: Science and Practice, 25, e12271. Kendall, P. C., Gosch, E., Furr, J. M., & Sood, E. (2008). Flexibility within fidelity. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 987–​993. Kendall, P. C., & Hedtke, K. A. (2006). Coping cat workbook. Workbook Publishing. Kendall, P. C., & Peterman, J. (2015). CBT for adolescents with anxiety: Mature yet still developing. American Journal of Psychiatry, 176, 519–​530. Kim, S.-​H., Yim, H.-​W., Jo, S.-​J., Jung, K.-​I., Lee, K., & Park, M.-​H. (2018). The effects of group cognitive behavioral therapy on the improvement of depression and anxiety in adolescents with problematic internet use. Journal of the Korean Academy of Child and Adolescent Psychiatry, 29, 73–​79. Liang, L., Ren, H., Cao, R., Hu, Y., Qin, Z., Li, C., & Mei, S. (2020). The effect of COVID-​19 on youth mental health. Psychiatric Quarterly, 91, 841–​852. Lochman, J. E. (2022). Tailoring of evidence-​ based group intervention with children with disruptive behavior: Implications for therapists and researchers. Salud Mental, 44, 257–​260. Lochman, J. E., Dishion, T. J., Powell, N. P., Boxmeyer, C. L., Qu, L., & Sallee, M. (2015). Evidence-​based preventive intervention for preadolescent aggressive children: One-​year outcomes following randomization to group versus individual delivery. Journal of Consulting and Clinical Psychology, 83, 728–​735. Lochman, J. E., Wells, K. C., & Lenhart, L. A. (2008). Coping power: Facilitator guide. New York: Oxford. McClure, J. M., Friedbert, R., Thordason, M., & Keller, M. (2019). CBT express: Effective 15-​minute techniques for treating children and adolescents. New York: Guilford Press. Newman, C. F., & Kaplan, D. A. (2016). Supervision essentials for cognitive-​behavioral therapy. Washington, D.C: American Psychological Association. Nolan, C. (Director) (2005). Batman begins [Motion Picture]. Warner Brothers. O’Shannessy, D. M., Waters, A. M., & Donovan, C. L. (2023) Feasibility of an intensive, disorder-​specific, group-​based cognitive behavioural therapy intervention for adolescents with social anxiety disorder. Child Psychiatry and Human Development, 54, 546–​557. doi.org/​10.1007/​s10578-​021-​01265-​9 Racine, N., McArthur, B. A., Cooke, J. E., Eirich, R., Zhu, J., & Madigan, S. (2021). Global prevalence of depressive and anxiety symptoms in children and adolescents during COVID-​19. JAMA Pediatrics, 175, 1142–​1150. Reaven, J., Blakely-​Smith, A., Leuthe, E., Moody, E., & Hepburn, S. (2012). Facing your fears in adolescence: Cognitive-​behavioral therapy for high functioning Autism Spectrum Disorder and Anxiety. Autism Research and Treatment, https://​doi.org/​10.1155/​2012/​423​905 Reaven, J., Moody, E., Klinger, L., Keefer, A., Duncan, A., O’Kelley, S., Meyer, A., Hepburn, S., & Blakely-​ Smith, A. (2018). Training clinicians to deliver group CBT to manage anxiety in youth with ASD: Results of a multi-​site trial. Journal of Consulting and Clinical Psychology, 86, 205–​217. Reaven, J., Reyes, N., Pickard, K., Tanda, T., & Morris, M. A. (2020). Addressing the needs of diverse youth with ASD and anxiety in public schools: Stakeholders input on adaptations of clinic-​based facing your fears. School Mental Health, 12, 308–​322.

72  Robert D. Friedberg et al. Santesteban-​Echarri, O., Hernández-​Arroyo, L., Rice, S. M., Güerre-​Lobera, M. J., Serrano-​Villar, M., Espín-​ Jaime, J. C., & Jiménez-​Arriero, M. A. (2018). Adapting the brief coping cat for children with anxiety to a group setting in the Spanish public mental health system: A hybrid effectiveness-​implementation pilot study. Journal of Child and Family Studies, 27, 3300–​3315. Scaini, S., Rossi, F., Rapee, R. M., Bonomi, F., Ruggiero, G. M., & Incerti, A. (2022). The Cool Kids as a school-​based universal prevention and early intervention program for anxiety: Results of a pilot study. International Journal of Environmental Research and Public Health, 19(2), 941. Semple, R. J., & Williard, C. (2019). The Mindfulness Matters Program for children and adolescents. Guilford. Stromeyer, S. L., Lochman, J. E., Kassing, F., & Romero, D. E. (2020). Cognitive behavior therapy with angry and aggressive youth: The Coping Power program. In R. D. Friedberg & B. J. Nakamura (Eds.). Cognitive behavior therapy in youth: Tradition and Innovation (pp. 109–​124). Humana. Sukhodolsky, D. G., Smith, S. D., McCauley, S. A., Ibrahim, K., & Piasecka, J. B. (2016). Behavioral interventions for anger, irritability, and aggression in children and adolescents. Journal of Child and Adolescent Psychopharmacology, 26, 58–​64. Waxmonsky, J. G., Waschbusch, D. A., Belin, P., Li, T., Babocsai, L., Humphery, H., & Pelham, W. E. (2016). A randomized clinical trial of an integrative group therapy for children with severe mood dysregulation. Journal of the American Academy of Child and Adolescent Psychiatry, 55, 196–​207. Wolgensinger, L. (2022). Cognitive behavioral group therapy for anxiety: Recent developments. Dialogues in Clinical Neuroscience, 17, 347–​351. Wong, D. F. K., Kwok, S. Y. C. L., Low, Y. T., Man, K. W., & Ip, P. S. Y. (2018). Evaluating effectiveness of cognitive–​behavior therapy for Hong Kong adolescents with anxiety problems. Research on Social Work Practice, 28, 585–​594.

Chapter 5

Setting Considerations for Group-​ Based Cognitive Behavior Therapy for Children and Adolescents Aynsley Scheffert

Introduction This chapter will provide additional information on setting specific considerations for the use of cognitive-​behavior group therapy approaches with children and adolescents. Considerations for various settings such as school-​based, outpatient, inpatient, residential, and transitional living settings will be explored. Cognitive-​behavior therapy (CBT) for children and adolescents will be examined for group identification, implications for progress monitoring, and setting-​based obstacles for group therapy based on setting considerations. Overview As with other treatment approaches, the setting and situational factors impacting the group are essential considerations when designing, developing, and implementing a group-​based treatment (Toseland & Rivas, 2017). Based on the setting, group identification, practices for group admission, and methods for monitoring group progress will vary to allow for greater utilization of the setting for specific enhancement to group protocols (Alsalamah, 2020; Ziomek-​Daigle & Heckman, 2019). Different settings allow for additional information to be obtained from a wider array of sources, for example in school settings teacher feedback is more available and specific examples of target behaviors are more accessible for treatment monitoring (Anaby et al., 2019; Ziomek-​Daigle & Heckman, 2019). Enhanced support for skill development may also be available depending on the setting, such as additional coaching in residential settings outside of the treatment group itself (Black et al., 2022). In addition to the enhanced supports that can be available in different settings, there are also setting-​based barriers. Identifying group composition in a school, residential, or inpatient setting may require reduced group homogeneity due to the availability of group members (Dean et al., 2020; Stichter et al., 2019; Toseland & Rivas, 2017). This may require the group to be composed of more loosely aligned presenting concerns or a wider range of group members’ ages, backgrounds, or developmental stages (Stichter et al., 2019). This reduced group homogeneity then requires an adaptation of the group curriculum and skill development to be applicable to all group members (Dean et al., 2020). Other setting-​specific complications can include time-​based obstacles, such as the length of time a group may run in terms of the length of each group session or the number of sessions allotted for the group program (Crocker et al., 2023; Gee et al., 2021). For example, in school-​based settings, a group may only be able to run over a quarter or may need to be shortened to a 40-​minute session due to time-​constraints of the school year or schedule. The next section will examine the setting considerations related to group identification, assessment, progress monitoring, and evaluation in detail for multiple settings. Setting specific considerations for schools, outpatient, inpatient, residential, and telehealth will be explored to aid in group development and programming. DOI: 10.4324/9781351213073-6

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Outpatient Settings Engaging children and adolescents in group work in outpatient environments has multiple benefits. Outpatient settings, due to the variation of presenting concerns, may be one of the few settings where the clinician can tailor the group composition to both developmental levels and treatment goals (Kennedy et al., 2023). Additionally, parent involvement is more likely to be achieved in outpatient settings, further enhancing the efficacy of the group intervention for children and adolescents (Fjermestad et al., 2020). In the outpatient setting, group composition can be thoughtfully and intentionally identified (Hickie et al., 2019). Closed groups can be developed in the outpatient setting and expectations for ongoing participation with associated consequences of missing scheduled sessions should be clearly explained prior to beginning the group intervention (Toseland & Rivas, 2017). Key considerations for outpatient group settings for children and adolescents include developmental stage, social and self-​regulation skill level, presenting concern, and identified treatment goals (Calloway et al., 2021). As closed groups are an option in outpatient settings, group interventions with scaffolding of skill development and interactive components to aid in group cohesion should be prioritized (Marmarosh & Sproul, 2021; Toseland & Rivas, 2017). In the outpatient setting, assessment for inclusion in a group intervention must identify the appropriateness of the child or adolescent for a group intervention model (Sperling, 2022; Yohannan et al., 2022). Assessments should identify the child or adolescent’s developmental stage with a focus on cognitive development for intervention planning and self-​regulation skills (Yohannan et al., 2022). For example, an individual with low self-​regulation skills or attention control may first need individual treatment to increase executive functioning performance before adding group-​ based treatment models. Additionally, specific concerns related to social and emotional skill development should be noted as well as how these might contribute to group cohesion (Marmarosh & Sproul, 2021; Toseland & Rivas, 2017). For example, a child described as shy may have increased needs that can be better addressed in the group setting, with intervention strategies designed to aid in social skill development while also addressing presenting concerns, such as anxiety or low mood. As closed groups allow for scaffolding of skill development, ongoing evaluation can also be planned into the group intervention design (Hickie et al., 2019; Brennan et al., 2022). The evaluation of learning goals and progress can be undertaken using multiple methods (Lewis et al., 2019). Self-​report measures can provide the child or adolescent perspective regarding their progress on identified goals, with parents and occasionally teachers also adding their perspectives on skills development and progress. This allows for a triangulated evaluation thus providing a more objective approach to the evaluation (Lewis et al., 2019). The extent to which group members increase their use of targeted skills in the group can also be used to evaluate the effectiveness of the group as an intervention (Hickie et al., 2019; Jonsson et al., 2019). Evaluation may consist of increases in knowledge about concepts, skills, or topics included in the group curriculum. It may also include the group facilitator’s observations of the use of interpersonal or self-​regulation skills being utilized by participants in the group during the session or applied outside of a group session (Toseland & Rivas, 2017). When possible, a combination of evaluation methods will provide the most efficacious feedback and identify next steps (Hickie et al., 2019; Lewis et al., 2019). School Settings Over the past 20 years, school-​based mental health services have expanded significantly (Arora et al., 2019; Crocker et al., 2023; Love et al., 2019). The increased access to mental health care for youth, as well as the addition of mental health professionals to the interdisciplinary team in school

Setting Considerations for Group-Based Cognitive Behavior Therapy 75

settings has driven this growth (Arora et al., 2019; Crocker et al., 2023; Fjermestad et al., 2020; Park et al., 2020). The increased ease of collaboration with school personnel and support for integration of mental health practices into the classroom further support the efficacy of school-​based mental health programming (Fjermestad et al., 2020; Park et al., 2020). The identification of group members, ease of access for youth, and incorporation of mental health care into the youth’s school day schedule makes group-​based treatment viable in the school setting (Crocker et al., 2023; Fjermestad et al., 2020). Group composition in the school setting can be determined by a number of factors including developmental stage, presenting concern, grade level, current levels of interpersonal and social skills, and gender (Rivas & Toseland, 2017). In some school settings, group-​based CBT programming may be beneficial for a similar presenting concern such as impulsive or disruptive behavior, or based on diagnosis, such as autism spectrum disorder (Zaheer et al., 2019). Group homogeneity may be achieved by identifying youth in the same classroom or grade, or may be across grade levels but by inclusion based on gender or presenting problem (i.e., a third–​fifth grade boys with autism social skills group) (Rivas & Toseland, 2017). In a school-​based cognitive-​behavioral group treatment program, limitations of the school setting may take priority when developing and assessing a group program (Crocker et al., 2023; Gee et al., 2021). The amount of time devoted to each meeting is determined by the agreement with the school for a mutually acceptable time period the students would be available for a group session (Gee et al., 2021). In the school setting, students are often referred to school-​based mental health or counseling services through teacher or administrative recommendation, which allows for greater assessment of school-​based behavioral and emotional concerns, but the involvement of parents is limited due to the setting (Anaby et al., 2019: Witte et al., 2023). Psychological testing as part of special education may be available and offer enhanced evaluation as a part of the assessment process. Observational data in the classroom setting can provide baseline levels of specific targeted behaviors which can then later be used for evaluation of progress (Anaby et al., 2019; Connors et al., 2021). As noted above, the nature of the setting can determine the composition of the group, assessment factors, treatment focus, and methods for progress monitoring. In addition to the role of the setting in determining the composition of the group, as well as assessment factors impacting treatment focus of the group, setting also informs methods for progress monitoring (Anaby et al., 2019; Arora et al., 2019; Crocker et al., 2023; Gee et al., 2021). Similar to assessment, progress monitoring for school-​based groups may rely on teacher reporting more regularly than parent or caregiver reports (Gee et al., 2021; Park et al., 2020; Witte et al., 2023). Timing for the group may also need to help inform progress monitoring and evaluation, both in terms of the timing of the group within the school year and the time of day (Gee et al., 2021). Inpatient Settings In psychiatric inpatient settings, assessment is completed by a multidisciplinary team and incorporates medical considerations which may impact the presenting concern (Leffler et al., 2020; Milliard et al., 2020; Tanguturi & Turner, 2022). Children and adolescents admitted into an inpatient psychiatric setting are often experiencing mental health crises or acute symptoms (Tanguturi & Turner, 2022; Ugueto & Zeni, 2021). For group interventions in the hospital setting, assessment should include evaluation of coping and distress tolerance skills specific to the presenting concerns (Kennedy et al., 2023; Tanguturi & Turner, 2022). In hospital settings, avenues for normalization through the group process as well as basic mental health psychoeducation activities should be geared toward building skills for managing acute symptoms and coping skills (Chiu et al., 2022; Milliard et al., 2020). Group-​based CBT provides

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a medium for skill development and activities should focus on providing references for continued skill building following hospital discharge (Feder et al., 2022; Tanguturi & Turner, 2022). For children and adolescents, art or game-​based activities and shortened sessions provide enhanced engagement in skill building and are often the most appropriate for children and adolescents in the hospital setting (Kennedy et al., 2023; Beard et al., 2019). Evaluation in the hospital setting focuses on reduction of acute symptomology. The review of presented material for application in the outpatient setting is used to provide treatment recommendations and safety planning for discharge (Tanguturi & Turner, 2022). Children and adolescents should demonstrate their understanding of identified coping skills through discussion of events that would prompt the use of these skills in daily life. Due to the constraints of the hospital setting, it is often difficult to involve family members directly in the group intervention process. Typically, though, inpatient programs incorporate family engagement and education in some capacity as part of the youth’s treatment. Intentional inclusion of family members in skill development and review before discharge is necessary in order for skills to be utilized in the home setting or in further treatment settings (Tanguturi & Turner, 2022). Residential Settings The use of cognitive-​behavioral groups in residential settings has comparable benefits to those in school-​based settings. Group interventions are often part of residential treatment programming and are incorporated into daily scheduling (Lanier et al., 2020). Unlike school-​based cognitive behavioral group programs which may identify groups mainly by general targeted behavior with group composition being largely age or grade-​specific, therapy groups in residential treatment programming are often diagnosis-​specific or based on presenting concerns (Chiu et al., 2022; Lanier et al., 2020). Although the homogeneity of the group based on presenting problem and developmental stage may seem evident at first glance, the skill levels of group members as well as group members’ abilities to utilize group-​based interventions are highly variable (Chiu et al., 2022). In a residential setting, assessment is completed as part of a multidisciplinary team (Childs & Connors, 2022). This has several advantages as the multidisciplinary team has additional tools at their disposal. Further assessment measures and tools, including psychological testing and monitoring of medication and vitals, provide greater guidance and information in order to inform ongoing assessment and treatment planning (Childs & Connors, 2022; Lavender et al., 2022). This additional assessment can also help to identify nuanced treatment goals based on the child or adolescent’s interpersonal skills, distress tolerance skills, or coping skills as part of treatment planning (Lavender et al., 2022). Another consideration for group-​based cognitive behavioral interventions in residential treatment settings is the length of the group. Residential treatment programs often allow for ongoing admissions and discharges from programming based on progress and availability (Chiu et al., 2022). This becomes an important consideration when planning a group-​based CBT intervention, as an open-​group does not allow for skills scaffolding (building upon previously learned material in a linear curriculum) (Toseland & Rivas, 2017). However, in a residential treatment settings, a skills-​based cognitive-​behavior group intervention with targeted skills identified for each session allows for increased flexibility to accommodate group members at different stages of treatment. These skills-​based cognitive behavioral group interventions also encourage group members to identify experiences of their use of targeted skills both in the group and outside of the group. This reflective activity encourages skill mastery and the incorporation of group members’ examples of application of group material in discussion encourages newer group members through the modeling of their peers (Toseland & Rivas, 2017). This may mean revisiting previous content in a

Setting Considerations for Group-Based Cognitive Behavior Therapy 77

new or novel way to enhance the flexibility of the group process. Group programming may have multiple activities which capture a specific skill or allow for an intervention to be tailored to specific group members or introduced and reviewed as needed for the group composition of that time (Toseland & Rivas, 2017; van Wijk-​Herbrink et al., 2021). Group-​based CBT is a natural fit for the residential setting, given that groups are often incorporated into the treatment programming and occur on a more frequent basis (Lanier et al., 2020). In residential settings, individual clients may participate in groups multiple times per day and groups may occur multiple times per week (Lanier et al., 2020). Variations in activities can appeal to different learning styles and offer increased engagement and review of material (Toseland & Rivas, 2017). Additionally, the increased frequency of group sessions can provide enhanced interpersonal skill development as the group’s cohesion increases (van Wijk-​Herbrink et al., 2021). The group setting then also provides alternative social interactions to those that youth may have previously experienced in their interpersonal relationships (van Wijk-​Herbrink et al., 2021). Evaluation in the residential treatment setting is often determined through observations within the group process and personal relationships between group members, as well as skill development observed outside of the group setting (Childs & Connor, 2022; van Wijk-​Herbrink et al., 2021). Evaluation is also enhanced within residential treatment settings as goals can be monitored closely throughout the week through observations of multiple staff and providers. Progress on treatment goals can be measured through self-​report, as well as monitored through group participation, and other treatment planning activities throughout the week (Childs & Connor, 2022). One potential obstacle or disadvantage of group treatment in residential settings is the potential for conflict between group members outside the group setting (van Wijk-​Herbrink et al., 2021). The risk of the loss of confidentiality can also be difficult to manage in a residential treatment setting. The rules of the group, including confidentiality and what this means in the residential group setting, should be discussed with the group as part of the initial rapport building process (Toseland & Rivas, 2017). Transitional Living Settings Transitional settings include domestic violence, youth housing, and homeless shelters –​settings that are often left unacknowledged in the literature. However, group-​based programming is highly utilized in these settings due to the high needs of the population (Bani-​Fatemi et al., 2020). Children and adolescents in these transitional settings tend to have higher than average exposure to adverse childhood events and potentially traumatic events than those in other settings, such as outpatient or school-​based (Woollett et al., 2020). These exposures increase the complexity of presenting concerns and highlight the need for programming and intervention for this group (Bani-​Fatemi et al., 2020). As transitional settings have high rates of turnover, open groups are a necessity as children and adolescents may be in this environment for a few days, up to months, or years, and may have multiple stays at different time points (Spiegel et al., 2022). The open group should be formed around general psychoeducation surrounding basic mental health, coping, and self-​regulation skills, and may touch on psychoeducation surrounding trauma as a general overview in order to avoid potential triggering (Spiegel et al., 2022; van der Hoeven et al., 2022). Group composition may vary widely between developmental stages based on the population utilizing the shelter setting at that time (Spiegel et al., 2022; van der Hoeven et al., 2022). Homogeneity within the group will then focus on areas of concern and the creation of a sense of community through interpersonal interaction within the group programming (Spiegel et al., 2022). Taking into account the potentially high levels of exposure to traumatic events, whenever possible, group membership should be

78  Aynsley Scheffert

gender-​based and separate groups should be provided for males and females, with gender nonconforming individuals being allowed to identify the group setting they are most comfortable in (Bani-​Fatemi et al., 2020). Allowing individuals who do not identify with their gender assigned at birth, or who identify as gender non-​conforming, to choose their preferred group composition provides a method to respect and respond to their social positioning (Bani-​Fatemi et al., 2020; Matsuno & Israel, 2018). Given the variation in developmental stages, assessment for inclusion in group intervention should focus on current coping and self-​regulation skills, level of reactivity, trauma history, and potential for dysregulation following exposure to the group (Spiegel et al., 2022; van der Hoeven et al., 2022). Individuals who become flooded following the perceived triggering of traumatic memories are unlikely to benefit from group material and high levels of dysregulation may cause harm or attrition from the group (van der Hoeven et al., 2022). Assessment should then focus on the child or adolescent’s ability to maintain emotional equilibrium and utilize coping and self-​ regulation skills following potential distress (Spiegel et al., 2022). Similar to programming in residential and inpatient settings, group programming in transitional settings should allow for flexibility and introduction and review of targeted skills or concepts within a session. This allows for individuals who may only be present for a session to benefit from programming and allows for skill development over time for those who attend numerous sessions, as skills or concepts are introduced and then reviewed (Toseland & Rivas, 2017). New group members may apply content by identifying situations where the targeted skill may be useful while more senior members of the group provide examples of their use of the skills in daily life (Toseland & Rivas, 2017). This also allows for specific skills to be introduced and reviewed based on current events or concerns the clinician is aware of for children and adolescents within the transitional housing setting (Woollett et al., 2020). This method of presentation of information also allows for modeling of skills by older individuals for the younger individuals and application examples can be tailored to the developmental stages of individuals in the group (Toseland & Rivas, 2017). Evaluation in these settings is dependent on the situation of each child or adolescent (Spiegel et al., 2022; Woollett et al., 2020). If an individual is only present for a month of group, evaluation may be based on their reported understanding of group skills or concepts. The review of skills or concepts in a later session for individuals who have been participating in the group for longer periods of time will provide an enhanced evaluation of knowledge and skill development as the group facilitator can assess progress in understanding and in the group member’s description of their use of the targeted skill in daily life (Toseland & Rivas, 2017). For example, a senior group member may be able to provide an example of challenging a negative automatic thought from their daily life, thereby allowing newer members to have a practical example of application and allowing the facilitator to evaluate the senior group member’s use of the skills outside of a group session. Telehealth-​b ased Group Settings Telehealth-​based group settings are relatively recent for cognitive-​behavioral groups for children and adolescents (Ros-​DeMarize et al., 2021). The impact of the COVID-​19 pandemic on health care due to the need for social distancing and isolation early in the pandemic required a rapid shift to online platforms for mental and behavioral health care delivery (Ros-​DeMarize et al., 2021). Out of necessity, individual and group therapies were telehealth-​based leading to an examination of the risks and benefits of the modality. One of the main benefits of the telehealth setting for group therapies includes the increased accessibility of group programming for clients (Banbury et al., 2018; Castro et al., 2022). The ease of access from the home, school, or other locations allows individuals who may not have been

Setting Considerations for Group-Based Cognitive Behavior Therapy 79

able to participate otherwise more realistic (Holland et al., 2021). For group composition, using telehealth as the group setting allows for greater access and potentially increased homogeneity in group members as more individuals may be willing to consider the option of cognitive-​behavioral groups (Banbury et al., 2018; Castro et al., 2022). Although some concerns related to the risks to privacy have been raised as it is difficult to ascertain if the group member is alone or in a private space, individuals engaged in group treatments through telehealth do not endorse significant concerns with privacy or confidentiality with telehealth sessions. Clear expectations for individuals using telehealth for group-​based treatment should be identified prior to group members beginning telehealth-​based groups and ongoing reminders of these expectations should be provided (Banbury et al., 2018; Kneeland et al., 2021). Investigations into the differences between in-​person and telehealth-​based groups have found similar outcomes for both modalities (Castro et al., 2022). Group cohesion and rapport building are both accomplished through telehealth-​based groups and group processes have not been found to be significantly impacted (Banbury et al., 2018). As telehealth-​based groups are frequently hosted through video conferencing platforms, psychoeducation and group norm building should include a focus on the communication strategies specific to online environments (Ros-​DeMarize et al., 2021). This may include expectations for keeping cameras on for the duration of the group session, muting and unmoving, use of the chat feature, or other group norms for keeping members engaged in an online venue. Another unique consideration for telehealth-​based group programming can be included in the assessment for the appropriateness of telehealth-​based treatment for the individual (Holland et al., 2021). Individuals who may be at higher risk for self-​harm may not be eligible for online sessions. The ability for the individual to connect to sessions consistently based on their access to sufficient internet bandwidth is also a necessity and should be explored to determine eligibility. Telehealth-​based groups offer increased access to group-​based treatment for individuals from rural areas, those with transportation concerns, or individuals who may struggle to commit to in-​person group programming for various reasons (Banbury et al., 2018; Holland et al., 2021). Telehealth-​based groups can be assessed similarly to other in-​person groups depending on the other setting factors and offer a feasible alternative to in-​person groups (Banbury et al., 2018; Castro et al., 2022). Case Example In school settings, the flexibility of an intervention model is often a key consideration when identifying a group treatment (Crocker et al., 2023; Gee et al., 2021). The flexibility of the group curriculum provides enhanced options for delivery to accommodate shortened group sessions, smaller or larger group sizes, or the need to revisit content throughout the course of the group’s process (Toseland & Rivas, 2017). Children who miss one group session, sometimes due to illness or absence and others due to conflicts in scheduling or needs within the classroom, should be able to return to the group and still have the opportunity to be introduced to topics or skills from previous group sessions (Crocker et al., 2023; Gee et al., 2021; Toseland & Rivas, 2017). In a school-​based setting, the developmental levels of students may vary considerably, but the presenting problem or the focus of the group may have more uniformity (Zaheer et al., 2019). In school-​based settings, groups may be used to build emotional regulation skills for managing aggressive behavior in early school-​aged children (Fite et al., 2020). The following example highlights a group-​based cognitive behavioral intervention to begin developing anger management skills. As this group is geared toward a younger audience, one main aspect of the intervention

80  Aynsley Scheffert

is geared toward emotion identification and anger triggers. Students whose emotional regulation skills are impacted by trauma or PTSD are not likely to respond fully to a group designed for anger management skills and will likely continue to have emotional reactions due to the underlying PTSD (Fondren et al., 2020). A school clinician receives multiple referrals from the four kindergarten teachers for interventions related to disruptive behaviors and anger management skills. As the presenting concern for all six kindergarten students relates to impulsive acting out behaviors in response to situations in which the children do not have control (i.e., being told “no”, given a direction they do not like, and so on), a group-​based intervention is appropriate as learning can be shared and enhanced skill development can take place within the group setting through practice in game-​based activities (Fite et al., 2020). The intervention portion of the group begins with psychoeducation regarding emotions and then engages youth in reading a social story and asking group members to identify the feelings of the characters. This session provides important information on the topic, begins to develop vocabulary on emotional identification, and provides application in the form of a social story. Beginning with third-​person identification provides the opportunity for the application of concepts in a non-​ threatening manner as it is as it relates to the feelings of someone else and does not ask the child to self-​disclose this early in the group process (Toseland & Rivas, 2017). Further group sessions provide activities geared toward different aspects of both emotion identification and anger triggers. For example, one group session may focus on the completion of a worksheet where they draw an example of one of their anger triggers (Njardvik, 2022). Another group session will focus on the physical sensations they experience as they begin to get angry and ways they can recognize these sensations as they arise. A variety of activities, including drawing, role-​play, videos, social story reading, and games will address various learning strategies. Turn-​ based games are particularly helpful in these types of groups as this allows for the practice of anger management skills in the group setting. For example, games such as Chutes and Ladders or Sorry! can be helpful in practicing anger management as the winner is continually changing throughout the game. Evaluation of progress can consist of both in-​group behaviors and observations of improved anger management in the group setting. Knowledge-​based evaluation can also be provided through the group process. As noted above, an advantage of the school setting for evaluation and progress monitoring is the availability of various forms of feedback. In schools, feedback from teachers, paraprofessionals, or administrators related to classroom behavior, lunchroom or playground behaviors, or disciplinary referrals can provide an evaluation of progress and use of target skills in daily life. Summary Group-​based CBT can be utilized across settings with diverse presenting concerns, developmental levels, and setting-​specific considerations. The situational factors that impact group-​based interventions vary by setting and should be a key consideration in the process of developing, designing, and implementing a group treatment intervention (Toseland & Rivas, 2017). Group composition, assessment, design, and evaluation may all vary based on setting and it is essential to identify potential obstacles for group-​based interventions for the intervention model to be successful (Alsalamah, 2020; Ziomek-​Daigle & Heckman, 2019). In order to successfully plan a group intervention, a thorough understanding of the setting is needed. Multiple settings have specific time-​based barriers for group treatment. In school settings, this may be related to the length of time each group session can take or related to time-​based

Setting Considerations for Group-Based Cognitive Behavior Therapy 81

considerations of the school calendar including breaks, school holidays and days off, and the number of weeks remaining in the school year (Gee et al., 2021). In a transitional housing or inpatient setting, individuals may only be present for group-​based interventions for short periods of time (Crocker et al., 2023; Gee et al., 2021). It is also essential to identify the open or closed nature of the group based on the setting. In residential treatment or transitional housing settings, open groups with flexible programming are required due to the high rates of turnover with ongoing admission of new members (Spiegel et al., 2022; Woollett et al., 2020). Closed groups in outpatient or school-​based settings can allow for increased group cohesion and can be especially important in groups designed to increase social or interpersonal skills or target the normalization of symptomology (Marmarosh & Sproul, 2021). Assessment and evaluation may also be dependent on the setting. In schools, the assessment will likely include data from multiple sources, including parents, teachers, or other school personnel (Arora et al., 2019; Crocker et al., 2023; Fjermestad et al., 2020; Park et al., 2020). In outpatient treatment, the assessment may consist of parent and child reports, as well as information provided for diagnostic considerations or reason for referral, but further information may be difficult to obtain (Hickie et al., 2019; Brennan et al., 2022). In inpatient and residential settings, assessment and evaluation data will likely have contributions from the multidisciplinary team (Leffler et al., 2020; Milliard et al., 2020; Tanguturi & Turner, 2022). Cognitive-​behavior group interventions have utility in a variety of settings and allow for adaptation as needed to accommodate setting-​ based constraints. These characteristics make cognitive-​behavior group interventions efficacious and feasible. References Alsalamah, A. (2020). Supporting students with or at risk of emotional disturbance within the response to intervention model: A systematic review. Journal of Education and Practice, 11(36). https://​doi.org/​ 10.7176/​JEP/​11-​36-​08 Anaby, D. R., Campbell, W. N., Missiuna, C., Shaw, S. R., Bennett, S., Khan, S., … & GOLDs (Group for Optimizing Leadership and Delivering Services). (2019). Recommended practices to organize and deliver school-​based services for children with disabilities: A scoping review. Child: Care, Health and Development, 45(1), 15–​27. Arora, P. G., Collins, T. A., Dart, E. H., Hernández, S., Fetterman, H., & Doll, B. (2019). Multi-​tiered systems of support for school-​based mental health: A systematic review of depression interventions. School Mental Health, 11, 240–​264. Banbury, A., Nancarrow, S., Dart, J., Gray, L., & Parkinson, L. (2018). Telehealth interventions delivering home-​based support group videoconferencing: Systematic review. Journal of Medical Internet Research, 20(2), e25. Bani-​Fatemi, A., Malta, M., Noble, A., Wang, W., Rajakulendran, T., Kahan, D., & Stergiopoulos, V. (2020). Supporting female survivors of gender-​based violence experiencing homelessness: Outcomes of a health promotion Psychoeducation group intervention. Frontiers in Psychiatry, 11, 601540. Beard, C., Rifkin, L. S., Silverman, A. L., & Björgvinsson, T. (2019). Translating CBM-​I into real-​world settings: Augmenting a CBT-​based psychiatric hospital program. Behavior Therapy, 50(3), 515–​530. Black, K. R., Collin-​Vézina, D., Brend, D., & Romano, E. (2022). Trauma-​informed attitudes in residential treatment settings: Staff, child and youth factors predicting adoption, maintenance and change over time. Child Abuse & Neglect, 130, 105361. Brennan, E., Bailey, K. J., Biggs, B. K., Cunningham, M. L., Dammann, J. E., Reneson-​Feeder, S. T., … & Whiteside, S. P. (2022). An uncontrolled investigation of the feasibility of parent-​coached exposure therapy for youth with anxiety disorders. Journal of Child and Family Studies, 2, 1–​13. Calloway, A., Fleischer, N., & Creed, T. A. (2021). Cognitive behavioral therapy for children and adolescents with internalizing disorders. In A. Wenzel (Ed.), Handbook of cognitive behavioral therapy: Applications

82  Aynsley Scheffert (pp. 725–​ 750). Washington, DC: American Psychological Association. https://​doi.org/​10.1037/​0000​ 219-​023 Castro, M. J., Rodriguez, R. J., Hudson, B., Weersing, V. R., Kipke, M., Peterson, B. S., & West, A. E. (2022). Delivery of cognitive behavioral therapy with diverse, underresourced youth using telehealth: Advancing equity through consumer perspectives. Evidence-​Based Practice in Child and Adolescent Mental Health, 8, 1–​15. Childs, A. W., & Connors, E. H. (2022). A roadmap for measurement-​based care implementation in intensive outpatient treatment settings for children and adolescents. Evidence-​Based Practice in Child and Adolescent Mental Health, 7(4), 419–​438. Chiu, A. W., Falk, A., Pelcovitz, M., Zendegui, E., & Bennett, S. M. (2022). Considerations for implementing evidence-​based practices for youth anxiety in an acute psychiatric care setting. Professional Psychology: Research and Practice, 53(3), 286. Connors, E. H., Prout, J., Vivrette, R., Padden, J., & Lever, N. (2021). Trauma-​focused cognitive behavioral therapy in 13 urban public schools: Mixed methods results of barriers, facilitators, and implementation outcomes. School Mental Health, 13, 772–​790. Crocker, J., Whitcomb, S., Megginson, A., & Pearrow, M. (2023). District-​level school mental health workforce development: Lessons learned from Methuen Public Schools. In Handbook of School Mental Health: Innovations in Science and Practice (pp. 329–​342). Cham: Springer International Publishing. Dean, M., Williams, J., Orlich, F., & Kasari, C. (2020). Adolescents with autism spectrum disorder and social skills groups at school: A randomized trial comparing intervention environment and peer composition. School Psychology Review, 49(1), 60–​73. Feder, M. A., Brodman, D. M., Yang, Z. C., Ng, V. Y., Glickman, S., Smith, J., … & Verduin, T. L. (2022). I’m coming home: Providing parent training to support inpatient discharge programs. The ADHD Report, 30(5), 1–​7. Fite, P. J., Cooley, J. L., & Williford, A. (2020). Components of evidence-​based interventions for bullying and peer victimization. In: R. G. Steele & M. C. Roberts (Eds.), Handbook of Evidence-​Based Therapies for Children and Adolescents: Bridging Science and Practice (pp. 219–​234). Cham: Springer International Publishing. Fjermestad, K. W., Wergeland, G. J., Rogde, A., Bjaastad, J. F., Heiervang, E., & Haugland, B. S. M. (2020). School-​based targeted prevention compared to specialist mental health treatment for youth anxiety. Child and Adolescent Mental Health, 25(2), 102–​109. Fondren, K., Lawson, M., Speidel, R., McDonnell, C. G., & Valentino, K. (2020). Buffering the effects of childhood trauma within the school setting: A systematic review of trauma-​informed and trauma-​responsive interventions among trauma-​affected youth. Children and Youth Services Review, 109, 104691. Gee, B., Wilson, J., Clarke, T., Farthing, S., Carroll, B., Jackson, C., … & Notley, C. (2021). Delivering mental health support within schools and colleges–​a thematic synthesis of barriers and facilitators to implementation of indicated psychological interventions for adolescents. Child and Adolescent Mental Health, 26(1), 34–​46. Hickie, I. B., Scott, E. M., Cross, S. P., Iorfino, F., Davenport, T. A., Guastella, A. J., & Scott, J. (2019). Right care, first time: A highly personalised and measurement-​based care model to manage youth mental health. Medical Journal of Australia, 211, S3–​S46. Holland, M., Hawks, J., Morelli, L. C., & Khan, Z. (2021). Risk assessment and crisis intervention for youth in a time of telehealth. Contemporary School Psychology, 25, 12–​26. Jonsson, U., Olsson, N. C., Coco, C., Görling, A., Flygare, O., Råde, A., … & Bölte, S. (2019). Long-​term social skills group training for children and adolescents with autism spectrum disorder: a randomized controlled trial. European Child & Adolescent Psychiatry, 28, 189–​201. Kennedy, S. M., Wilkie, D. P., Henry, L., Moe-​Hartman, J., Townson, K., Anthony, L. G., & Hawks, J. L. (2023). The unified protocols for children and adolescents in partial hospitalization: Using implementation science frameworks to guide adaptation. Cognitive and Behavioral Practice, 30(3), 367–​383. https://​doi. org/​10.1016/​j.cbpra.2022.04.006 Kneeland, E. T., Hilton, B. T., Fitzgerald, H. E., Castro-​Ramirez, F., Tester, R. D., Demers, C., & McHugh, R. K. (2021). Providing cognitive behavioral group therapy via videoconferencing: Lessons learned from a rapid scale-​up of telehealth services. Practice Innovations, 6(4), 221.

Setting Considerations for Group-Based Cognitive Behavior Therapy 83 Lanier, P., Jensen, T., Bryant, K., Chung, G., Rose, R., Smith, Q., & Lackmann, L. (2020). A systematic review of the effectiveness of children’s behavioral health interventions in psychiatric residential treatment facilities. Children and Youth Services Review, 113, 104951. Lavender, J., Benningfield, M. M., Merritt, J. A., Gibson, R. L., & Bettis, A. H. (2022). Measurement-​based care in the adolescent partial hospital setting: Implementation, challenges, & future directions, evidence-​ based practice. Child and Adolescent Mental Health, 7(4), 439–​451, doi:10.1080/​23794925.2021.1981178 Leffler, J. M., & D’Angelo, E. J. (2020). Implementing evidence-​based treatments for youth in acute and intensive treatment settings. Journal of Cognitive Psychotherapy, 34(3), 185–​199. Lewis, C., Boyd, M., Puspitasari, A., Navarro, E., Howard, J., Kassab, H., … & Kroenke K. (2019). Implementing measurement-​based care in behavioral health: A review. JAMA Psychiatry, 76(3), 324–​335. doi:10.1001/​jamapsychiatry.2018.3329. PMID: 30566197; PMCID: PMC6584602. Love, H. E., Schlitt, J., Soleimanpour, S., Panchal, N., & Behr, C. (2019). Twenty years of school-​based health care growth and expansion. Health Affairs, 38(5), 755–​764. Marmarosh, C. L., & Sproul, A. (2021). Group cohesion: Empirical evidence from group psychotherapy for those studying other areas of group work. In: C. D. Parks & G. A. Tasca (Eds.), The psychology of groups: The intersection of social psychology and psychotherapy research (pp. 169–​189). American Psychological Association. https://​doi.org/​10.1037/​0000​201-​010 Matsuno, E., & Israel, T. (2018). Psychological interventions promoting resilience among transgender individuals: Transgender resilience intervention model (TRIM). The Counseling Psychologist, 46(5), 632–​655. Milliard, B. (2020). Utilization and impact of peer-​support programs on police officers’ mental health. Frontiers in Psychology, 11, 1–​8. https://​doi.org/​10.3389/​fpsyg.2020.01686 Njardvik, U., Smaradottir, H., & Öst, L. G. (2022). The effects of emotion regulation treatment on disruptive behavior problems in children: A randomized controlled trial. Research on Child and Adolescent Psychopathology, 50(7), 895–​905. Park, S., Guz, S., Zhang, A., Beretvas, S. N., Franklin, C., & Kim, J. S. (2020). Characteristics of effective school-​based, teacher-​delivered mental health services for children. Research on Social Work Practice, 30(4), 422–​432. Ros-​ DeMarize, R., Chung, P., & Stewart, R. (2021). Pediatric behavioral telehealth in the age of COVID-​ 19: Brief evidence review and practice considerations. Current Problems in Pediatric and Adolescent Health Care, 51(1), 100949. Sperling, J. (2022). The role of intolerance of uncertainty in treatment for pediatric anxiety disorders and obsessive-​compulsive disorder. Evidence-​Based Practice in Child and Adolescent Mental Health, 8(4), 429–​438.. Spiegel, J. A., Graziano, P. A., Arcia, E., Cox, S. K., Ayala, M., Carnero, N. A., … & Sundari Foundation. (2022). Addressing mental health and trauma-​related needs of sheltered children and families with trauma-​ focused cognitive-​behavioral therapy (TF-​CBT). Administration and Policy in Mental Health and Mental Health Services Research, 49(5), 881–​898. Stichter, J. P., Herzog, M. J., Malugen, E., & Schoemann, A. M. (2019). Influence of homogeneity of student characteristics in a group-​based social competence intervention. School Psychology, 34(1), 64. Tanguturi, Y., & Turner, C. (2022). The adolescent unit. Textbook of Hospital Psychiatry, 67. Toseland, R. W., & Rivas, R. F. (2017). An introduction to group work practice (8th ed.). Boston, MA: Pearson Education, Inc. Ugueto, A. M., & Zeni, C. P. (2021). Patterns of youth inpatient psychiatric admissions before and after the onset of the COVID-​19 pandemic. Journal of the American Academy of Child and Adolescent Psychiatry, 60(7), 796. van der Hoeven, M. L., Widdershoven, G. A., van Duin, E. M., Hein, I. M., & Lindauer, R. J. (2022). A resilience enhancing trauma-​informed program for children and mothers in domestic violence shelters: A qualitative study. Child & Family Social Work, 28(2), 515–​526. van Wijk-​Herbrink, M. F., Arntz, A., Broers, N. J., Roelofs, J., & Bernstein, D. P. (2021). A schema therapy based milieu in secure residential youth care: Effects on aggression, group climate, repressive staff interventions, and team functioning. Residential Treatment for Children & Youth, 38(3), 289–​306. Witte, A. L., Garbacz, S. A., & Sheridan, S. M. (2023). Preparing the school mental health workforce to engage in partnership approaches to address children’s needs. In: S. W., Evans, J. S., Owens, C. P., Bradshaw, &

84  Aynsley Scheffert M. D., Weist (Eds.), Handbook of School Mental Health: Innovations in Science and Practice (pp. 357–​ 374). Cham: Springer International Publishing. Woollett, N., Bandeira, M., & Hatcher, A. (2020). Trauma-​informed art and play therapy: Pilot study outcomes for children and mothers in domestic violence shelters in the United States and South Africa. Child Abuse & Neglect, 107, 104564. Yohannan, J., Carlson, J. S., & Volker, M. A. (2022). Cognitive behavioral treatments for children and adolescents exposed to traumatic events: A meta-​analysis examining variables moderating treatment outcomes. Journal of Traumatic Stress, 35(2), 706–​717. Zaheer, I., Maggin, D., McDaniel, S., McIntosh, K., Rodriguez, B. J., & Fogt, J. B. (2019). Implementation of promising practices that support students with emotional and behavioral disorders. Behavioral Disorders, 44(2), 117–​128. Ziomek-​Daigle, J., & Heckman, B. D. (2019). Integrating behavioral and social/​emotional supports within the response to intervention (RtI) model. Journal of Professional Counseling: Practice, Theory & Research, 46(1–​2), 27–​38.

Part II

Presenting Problems

Chapter 6

Cognitive-​B ehavior Group Therapy for Anxiety Disorders Ellen Flannery-​Schroeder and Chelsea Tucker

Introduction Anxiety disorders represent one of the most common forms of psychopathology among children and adolescents with onset typically in childhood and adolescence (Bandelow & Michaelis, 2015). While the onset age often differs among specific anxiety disorders, it is generally before age 15 (Kessler et al., 2005; Lijster et al., 2017). Research suggests that anxious children may experience difficulties in their social relations (e.g., Settipani & Kendall, 2013), academic achievement (e.g., Mychailyszyn et al., 2010), and future emotional health (e.g., Copeland et al., 2014; Merikangas et al., 2010). The course of anxiety disorders has been shown to remain relatively stable, with childhood anxiety predicting adolescent anxiety, and adolescent anxiety, in turn, predicting adult anxiety (e.g., Cohen et al., 2018; Essau et al., 2018; Pine et al., 1998). Risk factors for the development of an anxiety disorder include female gender, having a parent with an anxiety disorder, behavioral inhibition (i.e., a temperament or personality style associated with a fearful or avoidant response to novel stimuli), and stressful life events (e.g., Broeren et al., 2014; Clauss & Blackford, 2012; Kessler et al., 2012; Lawrence et al., 2019; van Nierop et al., 2015). Having a parent with an anxiety disorder raises the risk of an anxiety disorder nearly twofold (Lawrence et al., 2019), while behavioral inhibition raises it sevenfold (Clauss & Blackford, 2012). In addition, a national survey of LGBTQ youth demonstrated that this population may be at particular risk for anxiety disorders (The Trevor Project, 2021). Moreover, anxiety disorders have been found to represent a substantial economic burden (Fineberg et al., 2013; Yang et al., 2021). A strong association exists between anxiety and affective disorders and a less significant but notable association with substance use disorders (Michael et al., 2007). Research appears to suggest that anxiety disorders precede the development of both these disorders (e.g., Kessler et al., 2005; Michael et al., 2007). In response to increasing recognition of the debilitating nature of childhood anxiety disorders and their economic burden, treatment research has flourished, and cognitive-​ behavioral interventions have been demonstrated to be effective for both children and adolescents (see Banneyer et al., 2018; Higa-​McMillan et al., 2016; and Schwartz et al., 2019 for reviews). Cognitive-​behavioral treatments for anxiety disorders have a significant research base and have been deemed well established (Kendall et al., 2018). Cognitive-​behavioral treatments have been extended from individual formats to family and group formats. Cognitive-​behavioral group treatments may confer unique benefits including, but not limited to, improved cost-​benefit ratios, social interactions with peers (e.g., positive peer modeling), and opportunities to be exposed to multiple anxiety-​provoking situations. Cognitive-​ behavioral group treatments for anxiety will be the focus of the present chapter. This chapter provides an overview of childhood anxiety disorders, their prevalence, phenomenology, and comorbidity patterns. Commonly used assessment techniques and instruments for

DOI: 10.4324/9781351213073-8

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anxiety are presented, followed by a cognitive-​behavioral conceptualization of anxiety disorders in childhood and the rationale for group treatment. The remainder of the chapter will describe a cognitive-​behavioral group treatment protocol, a review of the extant literature on the efficacy of cognitive-​behavioral group approaches, and a summary of potential considerations inherent in group CBT. Finally, a case study will be presented as an example. Overview of Childhood Anxiety Disorders Anxiety disorders are the most common of all psychiatric disorders in adulthood (e.g., Bandelow & Michaelis, 2015; Kessler et al., 2009; Walter et al., 2020). This statistic also holds true for children and adolescents (Bitsko et al., 2022; Bernstein & Borchardt, 1991; Fergusson et al., 1993; Kashani & Orvaschal, 1990), for whom prevalence rates have been found to range from approximately 7% to 13% (e.g., Costello et al., 2003; Polanczyk et al., 2015, U.S. Department of Commerce, 2021), with rates in adolescence as high as 31% (Merikangas et al., 2010; Silva et al., 2020). In a surveillance report on child and adolescent mental health from 2013 to 2019, 1 in every 11 children and adolescents was found to have a diagnosed anxiety disorder (Bitsko et al., 2022). Likely, these rates are currently underestimated, provided recent evidence suggesting that the number of youth with anxiety symptoms has doubled since the start of the COVID-​19 pandemic (Racine et al., 2021). Research consistently finds prevalence rates of anxiety disorders in females to be approximately twice as high as in males (e.g., Bandelow & Michaelis, 2015; Cohen et al., 2018). This difference is detectable as early as age six, despite the absence of gender differences in age of onset (e.g., Lewinsohn et al., 1998). It is worth noting, however, that research on gender differences in anxiety has typically used binary gender constructs in parent/​caregiver –​and self-​reports. Thus, future research must expand the definitions of gender to allow for the identification of the many types of gender identities. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders –​Text Revision (DSM-​5-​TR; American Psychiatric Association, 2022) classifies the following anxiety disorders: separation anxiety disorder, selective mutism, generalized anxiety disorder (GAD), social anxiety disorder, specific phobia, and panic disorder. Many children “worry,” but most often, the worry is transitory and does not cause substantial impairment. If, however, the worry is excessive and uncontrollable, regards several life domains, and persists for six months or more, a diagnosis of GAD may be warranted (American Psychiatric Association, 2022). School, health, disasters, social relationships, achievement, and the future are among the most common domains of worry among children and adolescents (Hunter et al., 2022; Songco et al., 2020; Weems et al., 2000). Worrying often occurs in the absence of a precipitating event, occurs more days than not, and may be accompanied by physical symptoms such as muscle tension, fatigue, and irritability. Children with GAD are often highly perfectionistic, eager-​to-​please, and demonstrate cognitive distortions in which small errors are perceived as utter failures. These traits are socially desirable within Western culture, potentially complicating the identification of the problem. Many adults with GAD report being anxious for as long as they can remember (American Psychiatric Association, 2022). The age of onset for GAD is late compared with other anxiety disorders; the mean age of onset has been reported to be early –​to mid-​30s (Solmi et al., 2022; Lijster et al., 2017). Interestingly, GAD is also not gender-​specific until adolescence, at which point more females than males are diagnosed –​a trend also found in adults (Kessler et al., 2012; Ruscio et al., 2017). Separation anxiety disorder involves a fear of being separated from a parent, caregiver, or loved one. A child with separation anxiety fears that, upon separation, something bad is likely to happen to them, the attachment figure, or both. For example, a child may refuse to visit a friend’s house on their own because they fear the parent might be in an accident, kidnapped, or killed, and thus,

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they will not be reunited with their parent. Alternatively, the child may fear something terrible will happen to them and prevent them from seeing their parent(s) again. Often, separation anxiety manifests as refusal to attend school or extra-​curricular activities, frequent trips to the school nurse’s office, multiple calls home from school, and an inability to sleep alone in one’s bed. It is certainly true that some separation concerns are developmentally normative, and some cultures value family-​member interdependence; however, separation anxiety disorder involves significant distress and impairment that is no longer age –​or stage-​appropriate. As with GAD, physical symptoms such as nausea and headaches may manifest when separation occurs or is anticipated. Repeated nightmares involving themes of separation are also common. Age of onset is found to be the earliest of all anxiety disorders (median age under 11; Bandelow & Michaelis, 2015; Lijster et al., 2017) and may be diagnosed in childhood, adolescence, or adulthood (American Psychiatric Association, 2022). Separation anxiety is the most common anxiety disorder among children under age 12, with prevalence rates around 4% for children and 1.6% among adolescents (American Psychiatric Association, 2022). Twelve-​month prevalence rates among adults approximate 1% (Silove et al., 2015). In social anxiety disorder, a child fears social or performance-​based situations. The child worries that, in these situations, he or she may do something others perceive as stupid or dumb, resulting in embarrassment, humiliation, or rejection. While in social or performance-​based situations, the child may exhibit symptoms that mirror a panic attack, such as sweating, heart racing, or shortness of breath. As a result, a child will often avoid the situation altogether or may endure it with considerable distress. Social anxiety may result in missing out on strategic developmental interactions with peers and others. Common manifestations of the disorder include poor friendship development and refusal to talk in class, give presentations, eat in public, or interact with teachers or peers. The age of onset is typically early to middle adolescence but may occur as early as age eight (e.g., Solmi et al., 2022), and the development of the disorder has a very strong association with behavioral inhibition in early childhood (e.g., Luis-​Joaquin et al., 2020; Sandstrom et al., 2020). Selective mutism involves a consistent inability to speak and communicate effectively in specific social situations (e.g., school), despite both the expectation to communicate within the setting and the competence to do so as demonstrated in other contexts (e.g., home). The lack of speech interferes with educational or social functioning and persists for more than one month (not limited to the first month of school) (American Psychiatric Association, 2022). While symptoms of selective mutism are often present before age five, the failure to speak typically becomes apparent when the child begins school and fails to acclimate to the new setting (White & Cheung, 2021). While more common in childhood and adolescence, selective mutism may also be diagnosed in adulthood. Prevalence rates typically range from .03% to 1.9% (Carbone et al., 2010; Muris & Ollendick, 2015; Viana et al., 2009), with a median age of onset ranging from 2.7 to 4.1 years (Cunningham et al., 2004; Garcia et al., 2004; Kristensen, 2000). Despite the early onset, the condition may go undiagnosed for months to years. Though some specific fears and worries (e.g., monsters, bugs, the dark, water, needles) are quite typical in a child’s development, excessive or persistent worries that result in significant distress or avoidance are suggestive of a specific phobia. Prevalence rates of specific phobias are extremely variable but higher in girls than in boys, particularly during adolescence (Steinsbekk et al., 2022), with age of onset around age eight (Wardenaar et al., 2017). The DSM-​5-​TR classifies specific phobias into the following categories: Animal Type, Natural Environment Type, Blood-​Injection-​ Injury Type, Situational Type, and Other Type (e.g., choking, contracting an illness, vomiting). Both the animal and natural environment types typically have childhood onsets, whereas the onset of the situational subtype is bimodal, with one peak in childhood and another during the mid-​20s (American Psychiatric Association, 2022).

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Finally, panic disorder is characterized by recurrent and unexpected panic attacks. The symptoms and significance placed upon panic attacks vary across cultures (Lewis-​Fernández et al., 2010). Panic disorder is infrequent during childhood, with a prevalence rate of less than .4% (Craske et al., 2010). Rates gradually increase during adolescence, reaching 1% (Baker & Waite, 2020) and peaking in adulthood at around 2%–​3% (e.g., Merikangas et al., 2010). By age 14, a gender difference is apparent in which more girls develop the disorder (Nelemans et al., 2014). Anxiety disorders are highly comorbid with other childhood psychiatric disorders. Anxiety disorders frequently co-​occur with other anxiety disorders, with comorbidity rates estimated to be upwards of 50% (e.g., Benjamin et al., 1990; Goldstein-​Piekarski et al., 2016; Kashani & Orvaschel, 1990; Mobach et al., 2019). Comorbidity rates for anxiety and depression have been reported to be between 10% and 73% (Curry et al., 2004; Hudson et al., 2015); comorbidity rates for anxiety and disruptive behavior disorders (e.g., Attention Deficit Hyperactivity Disorder, Oppositional Defiance Disorder, Conduct Disorder) appear to range from 10% to 37% (e.g., Anderson et al., 1987; Geller et al., 1996; Last et al., 1992; Hudson et al., 2015; Spence et al., 2017). Additionally, substance abuse has been shown to be comorbid with Post Traumatic Stress Disorder (PTSD), Obsessive Compulsive Disorder (OCD), Social Phobia, and Generalized Anxiety Disorder (GAD; Curry et al., 2004; Essau et al., 2018). Assessment of Anxiety Accuracy in assessment is critical to proper screening, diagnosis, case formulation, treatment planning, and evaluation. Assessment is a practice that is useful not only in screening for disorders and in the initial stages of treatment (e.g., case conceptualization, treatment planning) but also important during and after treatment (e.g., evaluations of treatment progress and outcomes). Within the past decade, great strides have been made in developing reliable and valid measures of psychological constructs. These research advances have included the development of several measures designed to assess child anxiety. Given the covert nature of anxious distress, children’s self-​reports are deemed crucial to accuracy in assessment. There is considerable debate, however, about who is able to report most accurately regarding a child’s distress –​ parent/​caregiver or child. High levels of discrepancy among reports are well documented (e.g., Sawyer et al., 1992). Given this, a multi-​method assessment approach is recommended to increase the reliability and validity of the assessment (Kraemer et al., 2003). The combination of child, parent, teacher, and peer reports of child behaviors across contexts and varying assessment methods (e.g., diagnostic interview, rating scales, behavioral observations) will likely provide the most comprehensive clinical assessment. For a meta-​analytic review, see De Los Reyes et al. (2015). Screening In October 2022, the US Preventive Services Task Force recommended that primary care providers screen all children and adolescents aged 8–​18 for anxiety disorders (US Preventive Services Task Force, 2022). The Task Force concluded that the evidence was insufficient to extend the recommendation to children younger than 8 and that such screening has a “moderate net benefit.” The recommendation was based on evidence that screening and early treatment of anxiety, for which psychotherapy has shown a positive benefit, improves health outcomes in children and adolescents. Diagnostic Interviews A diagnostic interview is often considered the most critical piece of a clinical assessment. Diagnostic interviews may be structured or unstructured, the latter permitting flexibility in questioning to

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gather additional information as necessary. Diagnostic interviewing allows for the collection of rich clinical data derived from the interviewee’s verbal reports as well as observations of behavior and interpersonal interactions. However, one of the limitations of such interviews is the time required to complete them. Structured and semi-​structured interviews will vary in length depending on several variables (e.g., talkativeness of the interviewee, the extent of clinical symptomatology, and interviewer experience) (Velting et al., 2004). The Anxiety Disorders Interview Schedule for DSM-​5, Child and Parent Versions (ADIS-​5 C/​PV; Kerns et al., 2023a, 2023b) is a semi-​structured interview designed to assess anxiety disorders in children and adolescents. The ADIS-​5 is conducted separately with parents/​caregivers and the child. Although designed for the diagnosis of anxiety disorders, the inclusion of other disorders (e.g., dysthymia, attention deficit hyperactivity disorder, panic disorder) allows for differential diagnoses and the assessment of comorbid conditions. Clinician severity ratings are assigned to each diagnosis and permit an assessment of the impairment associated with the disorder. Studies of the previous ADIS for DSM-​IV (Silverman & Albano, 1996a; 1996b) suggest high interrater reliability (r =​.98 for parent interview and r =​.93 for child interview; Silverman & Nelles, 1988) and retest reliability (k =​.76 for parent interview; Silverman & Eisen, 1992). The ADIS-​5 yielded adequate 7–​14-​day retest reliability for the child (k =​.61–​.80), parent (k =​.65–​1.00), and combined (k =​.62–​1.00) diagnoses (Silverman et al., 2001). At the time of this writing, the ADIS-​5 is in pre-​ release; thus, psychometric properties are unavailable for this version. Other structured diagnostic interviews have been used to assess anxiety disorders in children and adolescents. These include the Diagnostic Interview for Children and Adolescents (DICA-​ R; Herjanic & Reich, 1997), the Kiddie Schedule for Affective Disorders and Schizophrenia for School-​Age Children –​Present and Lifetime Versions (K-​SADS-​PL; Kaufman et al., 1997), and the National Institute of Mental Health Diagnostic Interview Schedule for Children (NIMH DISC-​ IV; Shaffer et al., 2000). The DICA-​R, K-​SADS, and NIMH DISC-​IV are all designed to assess a broad range of childhood disorders, including anxiety. The ADIS-​5 is the only interview specifically designed for assessing anxiety disorders. As such, it is often considered the “gold standard” in assessing anxiety disorders in children and adolescents (Greco & Morris, 2004). Nonetheless, collective evidence suggests that structured diagnostic interviews provide reasonably accurate data regarding children’s anxious distress (Schniering et al., 2000). Questionnaire Measures of Anxiety Typically, self-​report measures provide information ancillary to diagnoses. They are used to garner additional information on children’s thoughts, feelings, and behaviors, allow for more discrete responses, and are generally quick, easy, and less costly to administer. Questionnaire measures may be global in nature, assessing anxiety as a broad construct, or they may be syndrome-​specific, assessing specific symptoms of anxiety or anxiety within certain contexts or situations (e.g., social anxiety). A thorough and comprehensive assessment often incorporates information garnered from not only the child but also the parent/​caregiver, teacher, and other informants’ perspectives, permitting a more thorough picture of the problem. Global measures. For many years, the Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1985), Fear Survey Schedule for Children-​Revised (FSSC-​R; Ollendick, 1983), and the State-​Trait Anxiety Inventory for Children (STAIC; Spielberger, 1973) were the instruments of choice in global assessments of anxiety. These global measures of anxiety are downward extensions of corresponding adult versions. While the RCMAS, FSSC-​R, and the STAIC have not been found to adequately distinguish between anxiety disorders or between anxiety disorders and other disorders (e.g., Hodges, 1990; Hoehn-​Saric et al., 1987; Strauss et al., 1988), these measures have been found to adequately distinguish children with anxiety disorders from nonclinical controls (Ollendick, 1983; Perrin & Last, 1992; Stark et al., 1993).

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More recent attempts to measure the global construct of anxiety have tried to address some of these limitations. Multidimensional scales typically assess symptoms of specific anxiety disorders while providing a total anxiety score. The Multidimensional Anxiety Scale for Children –​Second Edition (MASC-​2; March, 2013) and the Screen for Anxiety and Related Emotional Disorders (SCARED; Birmaher et al., 1997) were specifically designed to serve as sensitive and specific screening tools for anxiety disorders in childhood and adolescence. The MASC-​2 is a 50-​item, 4-​point Likert-​type child-​report measure with four main factors: physical symptoms; social anxiety; harm avoidance; separation anxiety, obsessions, and compulsions, as well as a GAD index. The MASC-​2 has demonstrated strong psychometric properties in epidemiological and clinical studies. The SCARED (Birmaher et al., 1999) is a 66-​item, 3-​point Likert-​type child-​report measure consisting of nine DSM-​IV-​linked subscales: panic disorder, GAD, social phobia, separation anxiety disorder, obsessive-​compulsive disorder, specific phobia (animal, blood-​injection-​injury, and environmental–​situational types), and traumatic stress disorder. A parent/​caregiver report version is also available. Both versions of the SCARED have demonstrated excellent internal reliability and good retest reliability in clinical samples (Birmaher et al., 1997; Birmaher et al., 1999) and in a community sample (Muris et al., 1998). Similarly, the Spence Children’s Anxiety Scale (Nauta et al., 2004; Spence et al., 2003) is designed to produce an overall anxiety score as well as specific symptom subscale scores, including generalized anxiety, panic/​agoraphobia, social anxiety, separation anxiety, obsessive-​compulsive disorder, and specific phobia. The measure consists of 44 items using a 4-​point scale. A 38-​item parent/​caregiver version is also available. The child and parent/​caregiver versions have been demonstrated to have good psychometric properties (Nauta et al., 2004). While most of the available and oft-​used scales have been based on earlier editions of the DSM, the Youth Anxiety Measure for DSM-​5 (YAM-​5; Muris et al., 2017) was developed out of the need for measures that align with the DSM-​5. The YAM-​5 was developed as a screening tool to assess for DSM-​5 anxiety disorders in youth aged 8–​18. The questionnaire is composed of 28 items measuring major anxiety disorders, including separation anxiety disorder, selective mutism, social anxiety disorder, panic disorder, and GAD, and 22 items that measure specific phobias and agoraphobia. Both child and parent/​caregiver versions demonstrate good internal consistency and test–​retest reliability as well as content, construct, convergent, divergent, and concurrent validity (Çanakya & Cevik, 2019; Muris et al., 2017; Simon et al., 2017). For reviews of youth –​and parent-​report measures of anxiety, see Etkin, Shimshoni, et al. (2021), Etkin, Lebowitz, et al. (2021), and Spence (2018). Syndrome-​specific measures. Numerous inventories assess the specific syndromes associated with anxiety. Social anxiety symptoms are assessed by the Social Phobia and Anxiety Inventory for Children (SPAI-​C; Beidel et al., 1995) and the Social Anxiety Scale for Children (SASC-​R; La Greca, 1998; La Greca et al., 1988). Items on the SPAI-​C are theory-​driven and, as such, do not directly correspond to DSM criteria (Greco & Morris, 2004). The SPAI-​C comprises three subscales: fear of negative evaluation, generalized social avoidance and distress, and social avoidance and distress with new or unfamiliar peers. Items on the SASC-​R more directly correspond to DSM criteria. Both measures have demonstrated excellent internal consistency and high retest reliability (La Greca, 1998; Beidel et al., 1995). Other syndrome-​specific measures include the Penn State Worry Questionnaire for Children (PSWQ-​C; Chorpita et al., 1997) and the Childhood Anxiety Sensitivity Index (CASI; Silverman et al., 1991), the latter of which measures fear of anxiety-​related somatic symptoms. Behavioral Observations Behavioral observations can be a useful supplement to interview and questionnaire measures. They may be structured or naturalistic and often involve notations of children’s verbalizations,

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body posture, body movements, facial expressions, and the like. Observational assessments can be useful in assessing the level of fear when a child is exposed to an anxiety-​provoking object, situation, or event, particularly when interview or questionnaire assessments may be unreliable. Two examples of structured observations are the Behavioral Avoidance Task (BAT) and the Youth Speech Sample. The BAT involves requiring a child to confront a feared object, situation, or event and recording the behavioral features of the child’s performance (e.g., self-​reported fear levels, proximity to the feared stimulus, physiological reactions, latency to respond). Though they may provide ancillary information difficult to obtain through interview and self-​report formats, BATs may be difficult to implement with particular types of fears, lack standardization, and may not generalize to naturalistic settings. Cognitive-​B ehavioral Conceptualization The cognitive-​behavioral model posits three dimensions of anxiety: physiological, cognitive, and behavioral –​all of which may be considered adaptive emotional responses. On a physiological level, anxiety may alert a child to impending danger via activation of the autonomic nervous system (ANS). When the ANS is activated, physiological responses such as sweating, tightening of the muscles, increased breathing rate (which can lead to headaches), and digestive changes (which can lead to stomachaches) may occur as a child’s body prepares for “fight or flight” (Hyde et al., 2019). Cognitively, a child may perceive the dangerousness of the situation through estimations of their own ability to cope. When a child does not believe that they can cope, these beliefs may manifest behaviorally through avoidance of anxiety-​provoking situations, tantrums, or crying. Maladaptive levels of anxiety have several etiological explanations. Four pathways to the development of anxiety symptoms and disorders have been proposed: (1) direct learning (e.g., classical conditioning), (2) indirect or vicarious learning (e.g., modeling, negative information transfer), (3) biological preparedness (e.g., faster fear acquisition to stimuli that are larger threats to one’s survival), and (4) non-​associative or non-​specific learning (e.g., one cannot identify a direct event leading to the onset of anxiety) (Coelho & Purkis, 2009; Nebel-​Schwalm & Davis, 2013). Numerous twin studies have demonstrated that genetics accounts for approximately 30%–​40% of the variance in anxious symptomatology and disorder (e.g., Hettema et al., 2001). Several studies appear to suggest the inheritance of a general predisposition rather than the heritability of individual disorder(s) (e.g., Andrews et al., 1990; Hettema et al., 2001; Kendler et al., 1992; Thapar & McGuffin, 1997). Behavioral inhibition, a temperamental feature characterized by irritability in infancy, fearfulness in toddlerhood, and shyness, wariness, and withdrawal in childhood, has also been associated with an increased vulnerability to anxiety disorder(s) (e.g., Biederman et al., 1993; Kagan, 1989, 1997; Rosenbaum et al., 1993; Luis-​Joaquin et al., 2020; Sandstrom et al., 2020). A recent meta-​analysis of 27 studies demonstrated that behavioral inhibition increases the likelihood of developing an anxiety disorder with an odds ratio of 2.8. Odds ratios for individual anxiety disorders ranged from 1.49 for specific phobias to 5.84 for social anxiety disorders (Sandstrom et al., 2020). Resounding evidence suggests that behavioral inhibition is a strong risk factor for the development of anxiety, especially the development of social anxiety disorder. Adverse childhood experiences (ACEs), defined as potentially traumatic, stressful, and uncontrollable life events, have been identified as factors that may precipitate anxious distress. Children and adolescents with four or more ACEs have been demonstrated to have a two-​to five-​fold increased risk for anxiety disorders compared with children and adolescents exposed to fewer than four ACEs (Bomysoad & Francis, 2020; Elmore & Crouch, 2020). Childhood exposure to trauma is now, unfortunately, common. Lifetime exposure to potentially traumatic

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experiences in US adolescents is 61.8% (McLaughlin et al., 2013). In fact, US schools are increasingly implementing multi-​tiered systems of trauma-​informed support in an effort to respond to the rise in the number of trauma-​exposed youth (Fondren et al., 2020; Franklin et al., 2017; Overstreet & Chafouleas, 2016). As such, group treatments are now commonly implemented in schools to address student anxiety symptoms that interfere with school functioning (Herrenkohl et al., 2019). Group Treatment Cognitive-​behavioral therapy (CBT) is effective for anxious children (e.g., Conley et al., 2023; Weisz & Kazdin, 2010). The two most common forms of treatment for anxiety disorders in childhood and adolescence are individual CBT (ICBT and group CBT (GCBT) (Guo et al., 2021). While ICBT may permit greater tailoring of treatment to the individual needs and characteristics of the child, GCBT offers cost-​and time-​efficiency as well as significant social benefits (e.g., normalization, social support, positive peer modeling). The rationale for the use of a group format involves several factors. First, group treatment for childhood anxiety disorders appears to have a theoretical basis. Anxiety disorders often have a dysfunctional social and often evaluative component (particularly social anxiety and GAD). Groups provide unique opportunities for social interactions with peers (e.g., practice in initiation and maintenance of relationships, positive peer modeling, peer reinforcement, and peer feedback), social reward, normalization, and multiple exposures to feared interpersonal contexts, objects, and situations (Albano et al., 1995; Flannery-​Schroeder & Kendall, 2000; Heimberg et al., 1990). Further, group treatments are often more cost-​and time-​efficient than individual therapy formats, an important consideration for any intervention. Virtual delivery of GCBT may further enhance cost-​and time-​efficiency and has been showing promise with anxious youth (Spence et al., 2006; Jones et al., 2015). Regardless of treatment format, most studies use treatment protocols that include similar components. The vast majority of cognitive-​behavioral treatments include psychoeducation about anxiety, cognitive restructuring, and exposure. The cognitive model is used to conceptualize the development and maintenance of anxiety by helping clients to understand the relationship between feelings, thoughts, and behaviors. Exposure-​based strategies are used to enable the practice of learned coping skills in the management of anxiety-​provoking situations and anxiety-​related sensations that are currently avoided or endured with great distress. Some treatment protocols also use relaxation, mindfulness, problem-​solving, or strength-​based strategies. There is no consensus on what components should be included and in what order for CBT treatment to be most effective (Higa-​McMillan et al., 2016). A sample GCBT whose overall goal is to provide children with the skills necessary to effectively cope in various anxiety-​provoking situations is described below. The group treatment is divided into two segments: a skill-​building segment and a practice segment. In addition, the therapist meets separately with parents/​caregivers of group members periodically throughout treatment. Individual sessions are arranged for any group members absent from group sessions or struggling to keep up with the group’s pace. The first half of GCBT treatment (skill-​building segment) comprises the educational and cognitive components of the treatment. Cognitive-​behavioral strategies are presented sequentially to the children, beginning with developing awareness of bodily reactions to feelings and recognizing those reactions in response to anxiety. The children are trained to use those physical reactions as cues to the presence of anxiety. Second, the children are encouraged to focus on their self-​statements and, third, to modify their “self-​talk” as appropriate. Emphasis is placed on the need to devise a

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“plan” for more effective coping in the anxiety-​provoking experience. Additionally, the children are assigned homework to reinforce the information presented during the sessions, and “buddy” assignments (i.e., homework to make brief social contacts with fellow group members in-​between sessions) are used to increase group cohesion as well as hone group members’ social skills. The second half of GCBT treatment (practice segment) consists of applying the newly acquired skills in various graduated exposures to anxiety-​eliciting situations. These situations are tailored to the individual fears of the children. Within any group, there may be a great deal of variability in the worries and concerns of the children. The therapist must be sensitive to each child’s individual needs and work on a more global or group level. The practice segment begins with exposures taking place within the group, then progresses to exposures involving the group as a whole, and then to exposures involving individual group members. Application of strategies to in vivo situations provides success experiences that are incompatible with previous expectations and provides evidence (to the child, group, and others) that change is taking place. The final session aims to consolidate the information learned throughout the treatment, reinforce each child’s participation within the group, and plan for future exposures to be completed independently after the conclusion of the group treatment. In sum, the treatment consists of helping the children recognize signs of anxious arousal and use these as cues for using the anxiety management strategies proposed in the treatment program. Noteworthy, too, are the group-​based strategies which are emphasized in order to encourage responsibility, problem-​solving, and cohesion among group members: (1) group participation in a sequence of learning tasks and assignments, with the form of participation, varied to fit with each group member’s level of readiness and social skill; (2) therapist structuring of session format to encourage the expression of anxious affect within an atmosphere of tolerance and respect for the uniqueness of each member’s experience; (3) the setting of goals for the group as well as for the individual members; (4) the use of cohesion-​building tasks and games to strengthen the ties among group members; and (5) homework assignments designed to enhance group cohesion (“Buddy” assignments). Of note, typical group treatment protocols are rooted in Western ideals, and cultural adaptations are indicated. Modifications may involve changing one or more main components, including treatment format while maintaining other core elements. For example, a cultural norm in Japan is for children to attend medical appointments with a parent, thus making the group CBT format for children and adolescents native to Japan culturally incongruous. Ishikawa et al. (2019) culturally adapted the Coping Cat group protocol (Flannery-​Schroeder & Kendall, 1996) to include top-​down and bottom-​up modifications, such as holding all sessions with child and parent(s) jointly and using culturally specific illustrations, respectively. Khan and colleagues (2020) recently found it feasible to adapt the Coping Cat protocol (Kendall, 2000) for the GCBT treatment of Pakistani children with anxiety disorders to include cultural adaptations of language, as well as workbook pictures and characters. Sensitivity to cultural values, beliefs, and attitudes in psychotherapy has been demonstrated to enhance both client engagement in therapy and treatment outcomes (Pumariega et al., 2013). Cultural beliefs about anxiety and mental health influence the way disorders present themselves, whether an individual seeks treatment, the type of treatment, and the efficacy of treatment. In addition, cultural beliefs can determine what symptoms are reported and how they are described (Rausch, 2019). Given that CBT was born of cognitive therapy, developed in the United States in the 1960s by Aaron T. Beck, much of CBT’s existence has been Western-​centric, posing issues of cultural relevance (Rathod et al., 2017). Within the United States, psychological research has a historical bias toward majority groups, and subsequent treatments have been developed in light of these research results. The cultural diversity of the population, as well as increasing globalization,

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requires psychological treatment delivery rooted in cultural sensitivity, cultural competence, and cultural humility (Al-​Rodhan, 2006; Rathod et al., 2015). While the efficacy of ICBT for the treatment of childhood anxiety has long been demonstrated, the efficacy of group delivery formats has been established more recently (e.g., McKinnon et al., 2018). Research on the efficacy of GCBT is strong (e.g., Hudson et al., 2015; McKinnon et al., 2018). Numerous reviews have evaluated the efficacy of ICBT versus GCBT and generally find no differences between the two formats (e.g., Guo et al., 2021; James et al., 2015; James et al., 2020; McKinnon et al., 2018). However, in a subgroup analysis of age, ICBT demonstrated greater efficacy at post-​treatment for adolescents (Guo et al., 2021). At least one meta-​analytic review of randomized controlled trials for treating childhood anxiety found larger effect sizes in ICBT versus GCBT on child reports of anxious symptoms (Reynolds et al., 2012). Yet, a more recent meta-​ analysis comparing different types of psychotherapies as well as different treatment delivery formats for youth anxiety found GCBT to be significantly more effective than other psychotherapies in the study, concluding that psychotherapy using a group format may generally result in better outcomes than individual formats (Zhou et al., 2019). Given these conflicting findings, the efficacy of ICBT versus GCBT remains unclear. Emerging research suggests that there may be some disorder-​specific responses to treatment format. While McKinnon and colleagues (2018) found no differences between ICBT and GCBT among children with GAD, separation anxiety disorder, or social anxiety disorder, they noted that the clinical severity of specific phobia was significantly reduced following ICBT compared to GCBT. Yet, remission rates were comparable across treatment formats for these same children. It is notable, however, that at the follow-​up assessment, no significant differences were found between ICBT and GCBT. Alternatively, despite the theoretical advantage of treating social anxiety in group formats owing to numerous opportunities for social interactions, the research literature is inconclusive. Some studies find ICBT to be superior to GCBT for social anxiety (e.g., Manassis et al., 2002; Ingul et al., 2014), while others find GCBT to be more effective (e.g., Liber et al., 2008 [father informants only]; Villabø et al., 2018). Still, others find no differences between ICBT and GCBT for youth with social anxiety (e.g., Herbert et al., 2009). Some studies have found ICBT to be more effective than GCBT for youth with GAD but only based on parent-​report (Manassis et al., 2002; Wergeland et al., 2014), although the difference was no longer significant at a two-​year follow-​up (Wergeland et al., 2014). Considerations for GCBT Several factors should be considered when implementing group cognitive-​behavioral interventions with anxious children. First, one must determine whether it is feasible to conduct group cognitive-​ behavioral treatment at all. That is, is the flow of patient referrals within the treatment clinic sufficient to form therapy groups? If recruitment of group participants is slow, delays in the formation of groups may result in unwanted participant attrition (Himle et al., 2003). Second, several decisions regarding group composition must be made. The age of group members is an important consideration. “What is the optimal age for group treatment?” and “Should groups be composed of similar or varied ages?” are questions that need to be addressed. The use of cognitive strategies in group treatment typically determines the lower limits of age as children younger than six or seven have not yet developed the ability to engage in metacognition (i.e., think about one’s own thinking), a skill necessary for successful use of cognitive strategies. The decision to include similar or dissimilar ages remains the purview of the therapist. It may be that groupmates similar in age have more in common, resulting in more effective interventions; however, dissimilarly aged group mates may benefit if the older children serve as “coaches” or

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“leaders” for younger ones. In the latter case, older children stand to gain leadership skills and a deeper understanding of session material, while younger children may benefit if the older children represent more effective models of coping techniques. Caution is warranted, however, in the case of dissimilarly aged groups. Attention must be paid to the developmental appropriateness of session content and materials (e.g., therapy workbooks). If seven-​year-​olds are grouped with 11-​year-​ olds, for example, care must be taken to ensure that the session content is pitched neither too low for the older children nor too high for, the younger children. Future research is needed to enable therapists to make empirically informed decisions regarding group members’ ages. Similarly, the gender of group members and the size of groups represent issues to consider. Treatment outcome studies have tended to evaluate mixed-​gender groups. The potential advantages and disadvantages of mixed-​gender groups, however, remain unclear. Additionally, “What group size is optimal?” and “Does group size interact with gender and age composition?” remain questions unanswered in the literature. Group cognitive-​behavioral studies have evaluated groups typically ranging in size from three to six members. Eight group members appear to represent the maximum size researchers consider due to concerns about anxious children’s fears concerning large groups (Mendlowitz et al., 1999). There may be a clinical rationale for choosing a small versus large group size. For example, it could be argued that certain anxiety disorders (e.g., social anxiety) are better treated in smaller groups. The converse, however, could be argued as well. It may be that children with social anxiety are better treated in larger groups, given the increased social interaction opportunities afforded by such. Again, future research is needed to determine which group sizes are most advantageous for which children. With empirically established group CBT protocols for children and adolescents with anxiety disorders in place, the field is primed for more cultural-​adaptation research, or “ethno-​CBT” (Naeem et al., 2019). Treatment protocols must be sensitive to all group members’ cultural backgrounds to ensure equitable and just practices. Studies suggest that standard group CBT protocols can be effective when culturally adapted for children and adolescents with anxiety disorders who are from underrepresented populations (Ishikawa et al., 2019). Maintaining confidentiality within a group of children or adolescents presents special challenges. It is often the case that group mates are referred from the same local area. Thus, there stands a good chance that group mates may be acquainted with one another, share a friend in common, or be likely to cross paths in the near future. It is advisable to discuss the importance of confidentiality and its limits before initiating the first group session. Group members may develop a deepened appreciation and respect for the maintenance of confidentiality if they (and their parents/​ caregivers) complete agreements of confidentiality at the outset of therapy. This will help to ensure that everyone feels free to disclose within group sessions. Given the nature of anxiety, however, it would be expected that some group members would find discussing their experiences embarrassing or humiliating when in a group setting. This reluctance would be especially heightened for group members with dissimilar anxious symptomatology in an otherwise homogeneous group. Another potential difficulty exists in the ability of the therapist to address group members’ individual needs. As most cognitive-​behavioral group sessions run approximately 90 minutes, a mere 18 minutes can be devoted to each member in a five-​person group. This leaves little time to develop a personalized treatment plan for each group member. Additionally, some cautions against the use of group treatment involve concerns that group members may either learn or trivialize the symptoms exhibited by other group members. Anxious children, in particular, may develop complicity in insisting that particular anxiety-​provoking situations are indeed dangerous despite a therapist’s attempts to use cognitive-​restructuring techniques or in vivo exposures to demonstrate the contrary. Conversely, teasing may occur within a group, leading to various untoward outcomes (e.g., lowered self-​esteem, discouragement, embarrassment).

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Case Example Aisha, a ten-​year-​old Black girl, was referred by the school psychologist to the child anxiety clinic for problems attending school. Aisha refused to get ready for school each morning, would miss the school bus, and often refused to get in her mother’s car to go to school. Aisha’s mother expressed concern about the impact Aisha’s anxiety was having on family relations and on the well-​being of Aisha’s two younger siblings, who have now also begun to show signs of school refusal. According to the school psychologist, Aisha reported an intense dislike of school, had few friends, was exceedingly shy, and appeared sullen and withdrawn much of the school day. Aisha’s mother reported that Aisha routinely avoided social situations and hated having any amount of attention focused on her. However, she also felt left out when her friends proceeded with sleepovers without her. Upon a structured clinical interview, Aisha met the criteria for Social Anxiety Disorder (Generalized Type) and Major Depressive Disorder. Maya, an eight-​year-​old White girl, was referred to the child anxiety clinic by her parents as a result of Maya’s unwillingness to remain alone, even for brief moments. Maya’s parents reported that Maya had “meltdowns” whenever she and either of her mothers were to be apart. Over the course of the last school year, Maya made frequent trips to the school nurse complaining of stomach aches, which abated upon reuniting with a parent. Most recently, Maya had surgery to correct a heart defect, and while in the hospital, she refused to allow her mother, Margaret, to leave her side, even to use the bathroom. Maya’s mothers also reported issues with Maya’s behavioral self-​control and inattention, as well as an extreme fear of spiders, which interfered with outdoor activities. Upon a structured diagnostic interview, Maya was diagnosed with Separation Anxiety Disorder, ADHD, and a Specific Phobia. Nevaeh, an 11-​year-​old multiracial (Native American and Black) girl, was referred by her parents due to concern about her worrying and perfectionistic behaviors. Nevaeh worried about making mistakes in her schoolwork and felt excessively nervous about tests and oral reports. Within the past year, she had begun earning Bs and Cs, down from As, due to failure to complete several key homework projects. Nevaeh believed that if she was unable to complete the homework perfectly, it was not to be done at all. Nevaeh had tremendous difficulty managing her frustration in the face of challenging schoolwork and frequently lost emotional control after making minor errors. Additionally, Nevaeh had difficulty sleeping independently at night and required a parent to lie down with her until she fell asleep. Her parents reported that bedtime was especially difficult because Nevaeh’s worries would escalate then. Her concerns about a test the next day would soon turn to worries about her performance in the next grade, progressing rapidly to fear of leaving home upon adulthood, having enough money to live independently, and anxiety about her parents dying despite their current good health. Using a structured diagnostic interview, Nevaeh received a diagnosis of GAD. Aisha, Maya, and Nevaeh were treated in an 18-​week, clinic-​based group cognitive-​behavioral treatment for children with anxiety disorders. The development of group cohesion was a primary goal during the initial sessions. To facilitate group unity and rapport among group members, the girls were encouraged to choose a name for their group. They settled upon “Sassy Squad” and made a poster emblazoned with the name they colored and hung in the therapy room during sessions. Each session began with an individual review of homework, during which the therapist modeled positive feedback, tolerance, and respect for group members. The homework tasks allowed session content to be personalized to each child’s unique manifestation of anxiety. The group members were assigned highly structured “buddy tasks,” which involved contacting each other between sessions to build group cohesion and provide social skills practice.

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The first session focused on building rapport among the group members, introducing them to the treatment program, and encouraging participation. The girls played a get-​to-​know-​you game, decorated their homework journals, established group norms, and took a group tour of the clinic to facilitate group interaction. Early in treatment, Aisha was quiet during sessions but answered questions when group members or the therapist asked. Maya was social, extraordinarily talkative, and frequently out of her seat and sidling herself up next to her group mates. She frequently interrupted group members during the homework review to relay her own experiences; this ultimately generated much laughter and interpersonal ease among all members. The next few sessions focused on affective education, particularly the identification of one’s own somatic reactions to anxiety and subsequent relaxation training. Group members distinguish between anxiety and other feelings noting how each made their bodies feel. Among other affective education tools, the therapist introduced the “feelings thermometer,” a large picture of a thermometer with ratings from 0 to 10 that identify low to high anxiety levels, to help the girls identify how much anxiety they felt in different situations. The “thermometer” emphasized the distinctions among varying levels of fear and worry and provided useful language for describing the degree of their emotional distress. Maya began to create a list of anxiety-​provoking situations involving separation from a parent in which she used the feelings thermometer to rank order the difficulty levels associated with each (e.g., staying upstairs while her parent is downstairs =​3, parent arriving late to pick up Maya after a session =​7, sleeping over at her grandmother’s house =​10). Nevaeh’s list of anxiety-​provoking situations included a progression of situations in which she made larger and more serious mistakes (e.g., making a mistake on a non-​graded class assignment =​4, making a mistake on a graded homework assignment =​8, making a mistake on a test =​10) as well as some situations involving sleeping independently (e.g., parents staying with her at bedtime for ten minutes =​4, parents staying for five minutes =​7). Later sessions focused on identifying and modifying self-​talk, problem-​solving skills training, and self-​rating and reward. In the session focusing on modifying anxious self-​talk to coping self-​talk, Maya reported thinking that “something bad will happen” to her mothers when she is separated from them. In particular, Maya worried about the possibility of her mothers being involved in a motor vehicle accident. The therapist and group mates helped Maya to develop coping thoughts, including, “Both my mothers know how to take care of themselves,” “My parents are both good drivers,” and “If one of my parents does get into an accident, it will most likely be just a fender-​bender.” In the problem-​solving session, the group focused on learning the steps to solving a problem. As an example, Aisha devised ways to cope when she experienced fear and worries in the mornings before school. She and her group mates generated a list of potential solutions without regard for their potential utility. After all ideas were exhausted, the group evaluated each potential solution. Those deemed unlikely to help were eliminated, while those deemed promising were highlighted. In Aisha’s case, the group’s initial list included solutions such as “concentrate on the things you like about school,” “fake sick,” “call your buddy from the group,” and “meet a friend at the school’s front door.” Aisha’s final plan included meeting up with a friend, taking time for deep breathing and relaxation before school, and focusing on the day’s high points (e.g., art class or journal club). The final skill taught was self-​reward. The group members received instruction on how to rate their own attempts to cope on a 0–​10 scale, with 10 signifying maximum effort. The therapist emphasized the importance of rewarding effort and not merely positive results. The group members each made “reward menus” in which they listed both material and social incentives for use in rewarding efforts to cope with anxiety. Sample rewards included colorful pens, sports equipment, staying-​up-​late privileges, time with parent(s), sleepovers, and ice cream outings.

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Throughout the sessions in the first half of treatment, Nevaeh demonstrated concern with staying on task and accomplishing the goals of the session. She frequently reprimanded group mates for off-​task behavior and chastised them for infractions of session “rules.” While Nevaeh demonstrated complete mastery of all session content, as well as “perfectly” completed homework, Maya demonstrated difficulty with staying on task, remembering session content, and had a propensity to arrive at sessions with lost, incomplete, or forgotten homework. Aisha, initially reticent, slowly warmed to the group and, by mid-​treatment, was actively engaged in sessions and demonstrated good social interactions with the other group members. In the second half of treatment, the group members applied the newly acquired skills in various graduated exposures to anxiety-​eliciting situations. Group cooperation was critical in this phase of treatment. The anxiety-​eliciting situations were tailored to the individual fears of the children as these varied across the group. The therapist also strove to address concerns shared by group members by developing group exposures. The practice segments began with imaginal exposures taking place within the group, then progressed to in vivo exposures involving the group as a whole, then to in vivo exposures involving individual group members. In the group in vivo phase, the group members accomplished superordinate goals together. For example, one group in vivo exposure involved a scavenger hunt in a nearby park. Maya, the group member with separation anxiety, was responsible for leading the group to the park with minimal directions, Nevaeh was to make intentional errors during the group quest (e.g., returning to the therapist with an incorrect item), and Aisha, the group member with social anxiety, had to report back to the therapist and provide an oral review of the group’s activities during the scavenger hunt. Thus, each child’s unique anxieties were tapped in a task that could not be accomplished without each group member’s cooperation and courageous behaviors. Group members with similar fears were paired to accomplish various tasks for some exposures. For example, Aisha and Nevaeh shared social anxiety symptoms. One in vivo exposure required the pair to prepare and administer a survey on the usefulness of mistake-​making. In this exposure, Aisha received practice in approaching and asking questions of strangers while Nevaeh designed the survey and, ultimately, benefited from the “data” gathered. This data, when summed, demonstrated that most survey participants reported seeing value in making mistakes, acknowledged the universality of mistake-​making, and exhibited a tolerance for the mistakes of others. In this manner, both girls’ fears were targeted through a single task. The final phase of exposure involved each member tackling in vivo exposures independently. Aisha completed a series of social exposures –​she gave speeches, initiated conversations with peers and adults (familiar and unfamiliar), joined an art class, and began riding the school bus to and from school. Maya completed a series of exposures that increased the degree of separation required –​she remained home alone for short periods, independently entered convenience stores to make purchases, and slept over at a cousin’s house without her parents. In addition, Maya worked on overcoming her fear of spiders by progressing from exposures to pictured spiders to plastic spiders to live but contained spiders. Nevaeh tackled exposures that targeted her perfectionism as well as other concerns (e.g., tardiness and sleeping independently). Group mates offered creative ideas and support during the pre-​exposure preparation, observed during the exposures (where possible), and offered hearty congratulations upon their successful completion. Summary Anxiety disorders in children are prevalent, impairing, and often of long-​standing duration. However, we can now add “treatable” to this list. Cognitive-​behavioral treatments have shown real promise in the treatment of anxiety disorders in childhood and adolescence. Though individual and

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family formats have received a good deal of research attention to date, the literature on the efficacy of group cognitive-​behavioral treatments for childhood anxiety is compelling. There appear to be distinct advantages for the use of group approaches with anxious children and adolescents. Group formats may afford more plentiful opportunities for peer modeling, peer interaction, and peer support and reinforcement of treatment-​induced changes. They may help to normalize and destigmatize the experience of anxiety, as well as to increase the generalization of therapy-​learned techniques due to a wider exposure to varying anxiety symptoms and concerns. Furthermore, groups parallel the social milieu for most children, and especially adolescents, in that the importance of peers and social groups is paramount during these years. Last, few can deny the cost and time savings inherent in group treatments. Though the research on group cognitive-​behavioral treatments holds great promise, we remain unclear on exactly how or why and for whom such groups work. Researchers must ascertain those conditions in which group cognitive-​behavioral formats are preferred and those in which they are less preferred or inadvisable. References Albano, A. M., Marten, P. A., Holt, C. S., Heimberg, R. G., & Barlow, D. H. (1995). Cognitive-​behavioral group treatment for social phobia in adolescents: A preliminary study. Journal of Nervous and Mental Disease, 183, 649–​656. Al-​Rodhan, N. R., & Stoudmann, G. (2006). Definitions of globalization: A comprehensive overview and a proposed definition. Program on the Geopolitical Implications of Globalization and Transnational Security, 6, 1–​21. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). Arlington, VA: American Psychiatric Publishing. https://​doi.org/​10.1176/​appi.books.978089​ 0425​787 Anderson, J. C., Williams, S., McGee, R., & Silva, P. A. (1987). DSM-​III disorders in preadolescent children. Archives of General Psychiatry, 44, 69–​76. https://​doi.org/​10.1001/​archp​syc.1987.018​0013​0081​010 Andrews, G., Stewart, G. W., Morris-​Yates, A., Holt, P., & Henderson, A.S. (1990). Evidence for a general neurotic syndrome. British Journal of Psychiatry, 157, 6–​12. https://​doi.org/​10.1192/​bjp.157.1.6 Baker, H. J., & Waite, P. (2020). The identification and psychological treatment of panic disorder in adolescents: A survey of CAMHS clinicians. Child and Adolescent Mental Health, 25(3), 135–​142. https://​ doi:10.1111/​camh.12372 Bandelow, B., & Michaelis, S. (2015). Epidemiology of anxiety disorders in the 21st century. Dialogues In Clinical Neuroscience, 17(3), 327–​335. https://​doi: 10.31887/​DCNS.2015.17.3/​bbande​low Banneyer, K. N., Bonin, L., Price, K., Goodman, W. K., & Storch, E. A. (2018). Cognitive behavioral therapy for childhood anxiety disorders: A review of recent advances. Current Psychiatry Reports, 20, 1–​8. https://​ doi.org/​10.1007/​s11​920-​018-​0924-​9 Beidel, D. C., Turner, S. M., & Morris, T. L. (1995). A new inventory to assess childhood social anxiety and phobia: The Social Phobia and Anxiety Inventory for Children. Psychological Assessment, 7, 73–​79. https://​doi.org/​10.1037/​1040-​3590.7.1.73 Benjamin, R. S., Costello, E. J., & Warren, M. (1990). Anxiety disorders in a pediatric sample. Journal of Anxiety Disorders, 4, 293–​316. https://​doi.org/​10.1016/​0887-​6185(90)90027-​7 Bernstein, G. A., & Borchardt, C. M. (1991). Anxiety disorders of childhood and adolescence: A critical review. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 519–​532. https://​doi.org/​ 10.1097/​00004​583-​199107​000-​00001 Biederman, J., Rosenbaum, J. F., Bolduc-​Murphy, E. A., Faraone, S. V., Chaloff, J., Hirshfeld, D. R., & Kagan, J. (1993). A 3-​year follow-​up of children with and without behavioral inhibition. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 814–​821. https://​doi.org/​10.1097/​00004​583-​ 199307​000-​00016

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Cognitive-Behavior Group Therapy for Anxiety Disorders 107 Muris, P., Simon, E., Lijphart, H., Bos, A., Hale, W., & Schmeitz, K. (2017). The Youth Anxiety Measure for DSM-​5 (YAM-​5): Development and first psychometric evidence of a new scale for assessing anxiety disorders symptoms of children and adolescents. Child Psychiatry & Human Development, 48, 1–​17. https://​ doi.org/​10.1007/​s10​578-​016-​0648-​1 Mychailyszyn, M. P., Méndez, J. L., & Kendall, P. C. (2010). School functioning in youth with and without anxiety disorders: Comparisons by diagnosis and comorbidity. School Psychology Review, 39(1), 106–​121. https://​doi.org/​10.1080/​02796​015.2010.12087​793 Naeem, F., Phiri, P., Rathod, S., & Ayub, M. (2019). Cultural adaptation of cognitive–​behavioural therapy. BJPsych Advances, 25(6), 387–​395. https://​doi.org/​10.1192/​bja.2019.15 Nauta, M. H., Scholing, A., Rapee, R. M., Abbott, M., Spence, S. H., & Waters, A. (2004). A parent-​ report measure of children’s anxiety: psychometric properties and comparison with child-​report in a clinic and normal sample. Behaviour Research and Therapy, 42(7), 813–​839. https://​doi.org/​10.1016/​ S0005-​7967(03)00200-​6 Nebel-​Schwalm, M. S., & Davis, T. E. (2013). Nature and etiological models of anxiety disorders. In E. Storch and D. McKay (Eds.), Handbook of treating variants and complications in anxiety disorders (pp. 3–​21). New York: Springer. https://​doi.org/​10.1007/​978-​1-​4614-​6458-​7_​1 Nelemans, S. A., Hale, W. W., Branje, S. J., Raaijmakers, Q. A., Frijns, T., van Lier, P. A., & Meeus, W. H. (2014). Heterogeneity in development of adolescent anxiety disorder symptoms in an 8-​year longitudinal community study. Development and Psychopathology, 26(1), 181–​202. https://​doi.org/​10.1017/​S09545​ 7941​3000​503 Ollendick, T. H. (1983). Reliability and validity of the Revised Fear Survey Schedule for Children. Behaviour Research and Therapy, 21, 685–​692. https://​doi.org/​10.1016/​0005-​7967(83)90087-​6 Overstreet, S., & Chafouleas, S. M. (2016). Trauma-​informed schools: Introduction to the special issue. School Mental Health, 8, 1–​6. https://​doi.org/​10.1007/​s12​310-​016-​9184-​1 Perrin, S., & Last, C. G. (1992). Do childhood anxiety measures measure anxiety? Journal of Abnormal Child Psychology, 20, 567–​578. https://​doi.org/​10.1007/​BF0​0911​241 Pine, D. S., Cohen, P., Gurley, D., Brook, J., & Ma, Y. (1998). The risk for early-​adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Archives of General Psychiatry, 55(1), 56–​64. https://​doi.org/​10.1001/​archp​syc.55.1.56 Polanczyk, G. V., Salum, G. A., Sugaya, L. S., Caye, A., & Rohde, L. A. (2015). Annual research review: A meta-​analysis of the worldwide prevalence of mental disorders in children and adolescents. Journal of Child Psychology and Psychiatry, 56(3), 345–​365. https://​doi.org/​10.1111/​jcpp.12381 Pumariega, A. J., Rothe, E., Mian, A., Carlisle, L., Toppelberg, C., Harris, T., Gogineni, R. R., Webb, S., & Smith, J. (2013). Practice parameter for cultural competence in child and adolescent psychiatric practice. Journal of the American Academy of Child and Adolescent Psychiatry, 52, 1101–​1115. Racine, N., McArthur, B. A., Cooke, J. E., Eirich, R., Zhu, J., & Madigan, S. (2021). Global prevalence of depressive and anxiety symptoms in children and adolescents during COVID-​19: A meta-​analysis. JAMA Pediatrics, 175(11), 1142–​1150. https://​doi.org/​10.1001/​jam​aped​iatr​ics.2021.2482 Rathod, S., Kingdon, D., Pinninti, N., Turkington, D., & Phiri, P. (2015). Cultural adaptation of CBT for serious mental illness: A guide for training and practice. John Wiley. Rathod, S., Pinninti, N., Irfan, M., Gorczynski, P., Rathod, P., Gega, L., & Naeem, F. (2017). Mental health service provision in low-​and middle-​income countries. Health Services Insights, 10, 1178632917694350. https://​doi.org/​10.1177/​11786​3291​7694​350 Rausch, R. (2019). Narrative matters: The role of culture in the treatment of childhood anxiety. Child and Adolescent Mental Health, 24(4), 350–​351. https://​doi.org/​10.1111/​camh.12341 Reynolds, C. R., & Richmond, B. O. (1985). Revised Children’s Manifest Anxiety Scale (RCMAS): Manual. Los Angeles, CA: Western Psychological Services. Reynolds, S., Wilson, C., Austin, J., & Hooper, L. (2012). Effects of psychotherapy for anxiety in children and adolescents: A meta-​analytic review. Clinical Psychology Review, 32(4), 251–​262. https://​doi.org/​10.1016/​ j.cpr.2012.01.005 Rosenbaum, J. F., Biederman, J., Bolduc-​Murphy, E. A., Faraone, S. V., Chaloff, J., Hirshfeld, D. R., & Kagan, J. (1993). Behavioral inhibition in childhood: A risk factor for anxiety disorders. Harvard Review of Psychiatry, 1, 2–​16. https://​doi.org/​10.3109/​106732​2930​9017​052

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Cognitive-Behavior Group Therapy for Anxiety Disorders 109 Songco, A., Hudson, J. L., & Fox, E. (2020). A cognitive model of pathological worry in children and adolescents: A systematic review. Clinical Child Family Psychology Review, 23(2), 229–​249. https://​doi.org/​ 10.1007/​s10​567-​020-​00311-​7 Spence, S. H. (2018). Assessing anxiety disorders in children and adolescents. Child and Adolescent Mental Health, 23(3), 266–​282. https://​doi.org/​10.1111/​camh.12251 Spence, S. H., Barrett, P. M., & Turner, C. M. (2003). Psychometric properties of the Spence Children’s Anxiety Scale with young adolescents. Journal of Anxiety Disorders, 17(6), 605–​625. https://​doi.org/​ 10.1016/​S0887-​6185(02)00236-​0 Spence, S. H., Holmes, J. M., March, S., & Lipp, O. V. (2006). The feasibility and outcome of clinic plus internet delivery of cognitive-​behavior therapy for childhood anxiety. Journal of Consulting and Clinical Psychology, 74(3), 614–​621. https://​doi.org/​10.1037/​0022-​006X.74.3.614 Spence, S. H., Zubrick, S. R., & Lawrence, D. (2017). A profile of social, separation and generalized anxiety disorders in an Australian nationally representative sample of children and adolescents: Prevalence, comorbidity and correlates. Australian & New Zealand Journal of Psychiatry, 52(5), 446–​460. https://​doi. org/​10.1177/​00048​6741​7741​981. Spielberger, C. (1973). Manual for the State-​Trait Anxiety Inventory for Children. Palo Alto, CA: Consulting Psychologists Press. Stark, D., Kaslow, N. J., & Laurent, J. (1993). The assessment of depression in children: Are we assessing depression or the broad-​band construct of negative affectivity? Journal of Emotional and Behavioral Disorders, 1, 149–​159. Strauss, C. C., Last, C.G., Hersen, M., & Kazdin, A.E. (1988). Association between anxiety and depression in children and adolescents with anxiety disorders. Journal of Abnormal Child Psychology, 16(1), 57–​68. https://​doi.org/​10.1007/​BF0​0910​500 Steinsbekk, S., Ranum, B., & Wichstrøm, L. (2022). Prevalence and course of anxiety disorders and symptoms from preschool to adolescence: A 6-​wave community study. Journal of Child Psychology and Psychiatry, 63(5), 527–​534. https://​doi.org/​10.1111/​jcpp.13487 Thapar, A., & McGuffin, P. (1997). Anxiety and depressive symptoms in childhood: A genetic study of comorbidity. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 38, 651–​656. https://​doi. org/​10.1111/​j.1469-​7610.1997.tb01​692.x The Trevor Project. (2021). 2021 National Survey on LGBTQ Youth Mental Health. West Hollywood, CA: The Trevor Project. U.S. Department of Commerce. (2021). 2020 National Survey of Children’s Health: Topical Frequencies. Washington, DC: U.S. Census Bureau. US Preventive Services Task Force. (2022). Screening for Anxiety in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA, 328(14), 1438–​1444. https://​doi.org/​10.1001/​ jama.2022.16936 van Nierop, M., Viechtbauer, W., Gunther, N., van Zelst, C., de Graaf, R., ten Have, M., van Dorsselaer, S., Bak, M., & van Winkel, R. (2015). Childhood trauma is associated with a specific admixture of affective, anxiety, and psychosis symptoms cutting across traditional diagnostic boundaries. Psychological Medicine, 45(6), 1277–​1288. https://​doi.org/​10.1017/​S00332​9171​4002​372 Velting, O. N., Setzer, N. J., & Albano, A. M. (2004). Update on and advances in assessment and cognitive-​ behavioral treatment of anxiety disorders in children and adolescents. Professional Psychology: Research and Practice, 35, 42–​54. https://​doi.org/​10.1037/​0735-​7028.35.1.42 Viana, A. G., Beidel, D. C., & Rabian, B. (2009). Selective mutism: A review and integration of the last 15 years. Clinical Psychology Review, 29, 57–​67. https://​doi:10.1016/​j.cpr.2008.09.009 Villabø, M. A., Narayanan, M., Compton, S. N., Kendall, P. C., & Neumer, S. P. (2018). Cognitive–​behavioral therapy for youth anxiety: An effectiveness evaluation in community practice. Journal of Consulting and Clinical Psychology, 86(9), 751–​764. https://​doi.org/​10.1037/​ccp​0000​326 Walter, H. J., Bukstein, O. G., Abright, A. R., Keable, H., Ramtekkar, U., Ripperger-​Suhler, J., & Rockhill, C. (2020). Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 59(10), 1107–​1124. https://​doi.org/​10.1016/​j.jaac.2020.05.005

110  Ellen Flannery-Schroeder and Chelsea Tucker Wardenaar, K. J., Lim, C. C., Al-​Hamzawi, A. O., Alonso, J., Andrade, L. H., Benjet, C. D., Bunting, B., de Girolamo, G., Demyttenaere, K., Florescu, S. E., Gureje, O., Hisateru, T., Hu, C., Huang, Y., Karam, E., Kiejna, A., Lepine, J. P., Navarro-​Mateu, F., Oakley Browne, M., … & De Jonge, P. (2017). The cross-​ national epidemiology of specific phobia in the World Mental Health Surveys. Psychological Medicine, 47(10), 1744–​1760. https://​doi.org/​10.1017/​S00332​9171​7000​174 Weems, C. F., Silverman, W. K., & LaGreca, A. M. (2000). What do youth referred for anxiety problems worry about? Worry and its relation to anxiety and anxiety disorders in children and adolescents. Journal of Abnormal Child Psychology, 28, 63–​72. https://​doi.org/​10.1023/​A:100512​2101​885 Weisz, J. R., & Kazdin, A. E. (Eds.). (2010). Evidence-​based psychotherapies for children and adolescents. New York, NY: Guilford Press. Wergeland, G. J. H., Fjermestad, K. W., Marin, C. E., Haugland, B. S. M., Bjaastad, J. F., Oeding, K., Bjelland, I., Silverman, W. K., Öst, L., Havik, O. E. & Heiervang, E. R. (2014). An effectiveness study of individual vs. group cognitive behavioral therapy for anxiety disorders in youth. Behaviour Research and Therapy, 57, 1–​12. https://​doi.org/​10.1016/​j.brat.2014.03.007 White, K. S., & Cheung, V. (2021). Cognitive behavioral therapy for anxiety disorders. In A. Wenzel (Ed.), Handbook of cognitive behavioral therapy: Applications (pp. 33–​65). Washington, DC: American Psychological Association. https://​doi.org/​10.1037/​0000​219-​002 Yang, X., Fang, Y., Chen, H., Zhang, T., Yin, X., Man, J., Yang, L. & Lu, M. (2021). Global, regional, and national burden of anxiety disorders from 1990 to 2019: Results from the Global Burden of Disease Study 2019. Epidemiology and Psychiatric Sciences, 30, e36. https://​doi.org/​10.1017/​S20457​9602​1000​275 Zhou, X., Zhang, Y., Furukawa, T. A., Cuijpers, P., Pu, J., Weisz, J. R., Yang, L., Hetrick, S. E., Del Giovane, C., Cohen, D., James, A. C., Yuan, S., Whittington, C., Jiang, X., Teng, T., Cipriani, A., & Xie, P. (2019). Different types and acceptability of psychotherapies for acute anxiety disorders in children and adolescents: A network meta-​analysis. JAMA Psychiatry, 76(1), 41–​50. https://​doi.org/​10.1001/​jam​apsy​chia​ try.2018.3070

Chapter 7

CBT Groups for PTSD Annie Kipke, Danielle Citera, Halle Thurnauer, and Paul Sullivan

At all levels of pediatric healthcare, trauma and stress-​related presentations are an increasingly prevalent concern that mental health providers must be ready to identify and treat (Cohen et al., 2008; Copeland et al., 2007; Felitti et al., 1998; Zhao, 2023). A percentage of these children and adolescents who present for trauma-​related treatment will be formally diagnosed with posttraumatic stress disorder (PTSD; Alisic et al., 2014). However, there is a dearth of available mental health clinicians who are formally trained in specialized trauma-​informed care, leaving many children and adolescents with PTSD on long clinic wait lists, unable to access providers, or with inferior non-​targeted care (Owens et al., 2002). Group-​based trauma-​focused cognitive behavioral therapy (TF-​CBT; Cohen et al., 2006) is a manualized treatment with growing empirical support for child and adolescent populations (Thielemann et al., 2022). Youth group TF-​CBT offers individuals the opportunity to understand their symptomatology, learn to manage their emotions, change emotionally laden cognitive distortions, develop a safety plan, and create a corrective narrative of their traumatic event. Group-​based interventions also offer the opportunity for support from group members who may have experienced similar life circumstances. Additionally, TF-​CBT offers a concurrent nonoffending caregiver group to provide caregivers with a sound knowledge base, a better understanding of how to support the child, and allow them to be an active part of treatment. This chapter intends first to provide a concise overview of PTSD and then discuss the application of group-​based trauma-​informed treatment. We will provide special considerations structurally and conceptually within this type of intervention in the pediatric population. Structural considerations include how to compose a group as well as identify group members, offer guidance on how to monitor clinical progression, and how to navigate treatment-​interfering obstacles. Additionally, racial, ethnic, and gender considerations for youth populations will be highlighted to assist clinical implementation. From a conceptual lens, a cognitive-​behavioral perspective of child and adolescent PTSD will be discussed. Modules of group-​based TF-​CBT, specifically those within the child and adolescent sessions, will be explicated to provide depth and understanding of the intervention. To showcase the implementation and flexibility of group-​based TF-​CBT, a real-​world clinical case will be used to bring to life how practical CBT intervention could be used in this format. Additional trauma-​informed, evidence-​based group treatments will also be discussed. Overview of Youth PTSD Within the Diagnostic and Statistical Manual of Mental Disorders (DSM-​5-​TR; APA, 2022), under the Trauma-​and Stressor-​Related Disorders lies the criterion for PTSD. A diagnosis of PTSD may occur in response to exposure to a stressor that includes actual or threatened death, serious injury, or sexual violence by direct experience, witnessing the event, learning of the event in relation to a caregiver or friend, or repeated exposure to an adverse event. Children and adolescents may be DOI: 10.4324/9781351213073-9

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chronically exposed to bullying or neglect, leading to PTSD presentations (Gerson & Heppell, 2019). The symptomatology of PTSD is divided into four main categories: intrusion symptoms, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. Intrusion symptoms that an individual may report are flashbacks, intrusive dreams, as well as physical reactivity. Within child presentations, flashbacks and nightmares may occur during their play, and children may not be able to recall the contents of dreams that may be influenced by trauma (American Psychiatric Association, 2022). Avoidance symptoms are the evasion of any external stimuli (school, people, places) or internal stimuli (feelings, thoughts) associated with any trauma reminder. Alterations in mood and thoughts may include negative self-​perceptions, excessive blame of self/​others, isolation, anhedonia, and inability to experience positive affect. Arousal and reactivity may be seen by alterations in sleep schedule, increases in risky behaviors, irritability, concentration issues, hypervigilance, and heightened startle responses. Youths with PTSD may also experience dissociative symptoms that can take either the form of depersonalization or derealization. Research shows that traumatized young females are more likely to present with dissociative symptoms than boys with PTSD (Alisic et al., 2014; Hagan et al., 2018; Hulette et al., 2011). Depersonalization is when one feels detached from their body or thought process, whereas derealization is a sense of unreal or dreamlike state. Clinicians working with trauma-​informed groups need to be mindful of these symptoms during sessions as they can impede clinical progress and thus interfere with treatment (Chu & Bowman, 2000). Dissociative symptoms in adolescents may take the form of PNES and are typically associated with more functional impairments in academic and social life in those with trauma (Myers et al., 2019). Group Identification and Progress Monitoring Group delivery of CBT for traumatized children and adolescents may be an especially effective format for treatment, particularly due to its ability to reach large numbers of youths in the aftermath of widespread natural disasters or war-​related events. Additionally, group treatment may be necessary in settings in which specialized resources are limited, such as low-​income, rural, and international locations. Clinicians in these settings may opt to deliver group treatment via telehealth to avoid lengthy delays in commencing treatment. It is recommended that weekly groups be composed of four to five youths for clinicians without prior experience delivering trauma-​informed care in a group format; six to eight youths may be appropriate for clinicians with more experience (Deblinger et al., 2016). All group members should be at roughly the same developmental level. Both same-​and mixed-​gender groups have demonstrated success in clinical trials. Groups should focus on one type of trauma; alternatively, group participants may have diverse trauma histories with at least one common trauma type or “unifying experience” such as foster care (Deblinger et al., 2016). McMullen and colleagues (2013) conducted a randomized controlled trial (RCT) of TF-​CBT in the Democratic Republic of the Congo; they found that TF-​CBT was effective for youths presenting with moderate to severe levels of PTSD. In a RCT examining the effectiveness of TF-​CBT for Congolese girls exposed to rape or sexual abuse, exposure to the traumatic event served as the eligibility criteria, as opposed to symptomatology (O’Callaghan et al., 2013). Still, researchers reported significant reductions in PTSD, depression, and anxiety symptoms for participants from pre-​ to post-​treatment. Clinicians should conduct psychosocial interviews with participants prior to treatment commencement. Standardized assessments should be administered to obtain pre-​and post-​treatment levels of PTSD and related symptoms to better assess treatment outcomes. Deblinger and colleagues

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(2016) advise that symptom measures aid clinicians in recommending more intensive individual treatment for the small number of youths who are less responsive to group-​delivered trauma treatment. Additional progress monitoring should occur via homework activities assigned to group participants between sessions. Monitoring of between-​session practice will allow clinicians to determine skill generalization. Cognitive-​B ehavioral Conceptualization of PTSD Childhood trauma exposure can lead to several outcomes depending on a variety of factors, including the type of trauma experience, number of trauma exposures, degree of resilience, caregiver or adult support, understanding of the traumatic events, and nature of trauma symptoms. The complex constellation of these variables may manifest in the clinical diagnosis of PTSD; however, the impact of trauma is often more insidious and evades the narrow categorical diagnostic criteria of the diagnosis. These traumatic experiences can have a long-​lasting impact on sense of self, ability to maintain and enjoy interpersonal relationships, beliefs about the world, and overall quality of life. Cognitive behavior therapy (CBT) conceptualizes trauma symptoms as occurring across several symptom domains, including affective, behavioral, and cognitive, all of which interact to precipitate and maintain trauma symptoms (Cohen et al., 2016). Children who experience traumatic events often initially respond with the emotions of fear, diffuse anxiety, and sadness. It is expected that when children are exposed to a traumatic event or experience a threat in their environment that they will instinctively respond with fear. However, a trauma response occurs when the child begins to generalize this fear to other ostensibly harmless stimuli (e.g., people or places) despite the absence of a real threat. For example, a child who experienced a traumatic car accident might begin to avoid cars or all modes of road transportation entirely. Avoidance may also look like a child who experienced interpersonal trauma via emotional abuse by a primary caregiver who does not respond well to authority and combatively confronts teachers, caregivers, police officers, etc. While the child may be engaging with others, albeit in a maladaptive way, they are avoiding opportunities to be vulnerable, cared for, or helped by an adult figure who has the potential to be a source of survival rather than an adversary or future perpetrator of further abuse. Overgeneralization and other cognitive distortions such as binary thinking, a sense of impending doom, an over-​inflated sense of control over the traumatic event, belief that they were somehow responsible for the trauma, blaming oneself for not being able to avoid the event (e.g., if only I had done something differently) may emerge in the child’s effort to make sense of traumatic experiences in the absence of any logical explanation. Alternatively, children may develop a more generalized irrational cognition that they are globally bad or deficient in some way that somehow justifies the trauma they experienced. This allows them to maintain that the world is still organized and predictable, yet that they are the anomalous variable that deserves to have experienced such horror. In addition to the development of distorted or inaccurate cognitions, children may also develop accurate yet unhelpful cognitions. While these beliefs may actually reflect reality, they may also lead to significant emotion dysregulation and maladaptive behaviors in the absence of context. For example, while the cognition that “dangers lurk in the shadows of dark alleys” might be true, it also might lead to drastic functional interference, such as avoidance of being out past dark. In other words, the cognition is accurate but unhelpful. In order to cope with the overwhelming emotions associated with trauma responses, children often develop behaviors to protect themselves from having to re-​experience those emotions. A behavior often observed in traumatized children is avoidance; children may do whatever it takes to stay away from reminders of their traumatic experiences, whether it be places, people, thoughts, or situations that trigger a reminder. In the same way that anxiety generalizes to non-​threatening

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situations, avoidance also tends to occur in any situation that has the potential to remind the child of the traumatic event or threaten to elicit the associated emotion. For example, a child who has experienced ongoing interpersonal trauma might go on to avoid all close relationships. A child who was in a car accident might avoid all modes of road transportation, not just to avoid the reminders but also the associated emotions of fear and shame. If avoidance is ineffective or physically not possible, the child may then resort to psychological modes of avoidance, including emotional numbing or dissociation. These behaviors, influenced and maintained by intense emotions and cognitive distortions, can lead to significant problems in school attendance, ability to develop and maintain relationships, and overall quality of life. Cultural and Racial Considerations The experience of trauma is different in several ways based on cultural, ethnic, and racial factors. These differences are related to what is considered to be traumatizing, how trauma symptoms present, and how to approach treatment. Trauma symptoms are culture-​bound and require special attention based on a child’s various intersectional identities (Marsella, 2010; Bryant-​Davis, 2019). Furthermore, the clinician’s perceptions of trauma based on their cultural backgrounds are other variables to consider in trauma treatment (Ennis et al., 2019). Several cultural factors leave some groups at higher risk of experiencing trauma, such as race, ethnicity, or socioeconomic status (SES). For example, income inequality and low SES in childhood have been associated with childhood maltreatment such that children growing up in low-​ income families are more likely to have experienced physical, sexual, or emotional abuse or neglect (Eckenrode et al., 2014). Related to race, it has been demonstrated that Black children experience more childhood maltreatment than White and Hispanic children; however, this disparity in maltreatment disappears when controlling for income. This suggests that racial disparities in maltreatment are due to disproportionate risks in poverty between Black and White Americans (Kim & Drake, 2018). These differences between racial/​ethnic and socioeconomic groups have implications for access to care and the ways that these groups interact with the mental healthcare system. When working psychotherapeutically with children of cultural, ethnic, and racial backgrounds that diverge from both the micro and macro culture of the clinician or community at large, it is imperative to consider several domains within the therapy. These factors include language, expression of psychological symptoms (e.g., somatic symptoms versus verbalized expression of feeling states), conceptualizations of mental anguish, familial perspectives on trauma/​mental health, perspectives on Western medical philosophies and intervention, and self-​construal. Therapists must consider the differences between their own cultural identities and those of their patients and have an openness and respect for those cultural differences. Further, therapists working with traumatized children must take into account sociocultural factors such as access to care, cultural congruence of the treatment intervention, and understanding of both diagnosis considerations and treatment interventions (Bryant-​Davis, 2019). Researchers and clinicians alike have sought to adapt widely known evidence-​based practices to address some of the differences in perceptions and drivers of trauma as well as cultural meaning and values (Bernal et al., 2009). These alterations include surface adaptations such as changes in language, translation, use of pictures, level of complexity, and pace of the intervention, as well as deep adaptations including the addition of spirituality to the case conceptualization, changing how relationships are interpreted, inclusion of other community members (e.g., family, teachers, spiritual leaders), altering time in treatment, use of drawing/​toys, and degree of therapist self-​disclosure (Ennis et al., 2019). For example, it has been demonstrated that adapting the Western-​developed TF-​CBT for Zambian children through the use of local lay people as counselors, tailoring parenting

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psychoeducation, and the use of culturally appropriate metaphors have been successfully implemented (Murray et al., 2013). These results highlight the feasibility of making both surface and deep adaptations of evidence-​based practices better to serve a child’s intersectional identities in trauma treatment. Group CBT for Traumatized Youth: Sample Interventions Trauma-​Focused Cognitive-​Behavioral Therapy (TF-​CBT; Cohen et al., 2016) Several CBT interventions for treating traumatized youths have been created or adapted for group implementation. Of these, TF-​CBT is one of the most empirically supported, with over 16 RCTs to date (Deblinger et al., 2016). TF-​CBT was created to help children and adolescents ages 3–​18 recover from the negative impact of traumatic experiences. Studies examining the efficacy of TF-​CBT at reducing symptoms of PTSD in traumatized youths have been conducted in several countries with various age ranges and clinical presentations, and results consistently indicate significant improvements in PTSD symptoms among traumatized youths as compared to a wait-​list control condition (Cohen et al., 2016). Although originally tested for use in individual treatment, several RCTs have tested the efficacy of group TF-​CBT (Deblinger et al., 2001; McMullen et al., 2013; O’Callaghan et al., 2013). TF-​CBT groups have been growing in popularity in recent years, possibly due to the increasing demand for mental health services for traumatized youths, as well as the cost-​effectiveness and accessibility of group therapy. The group modality also promotes a sense of community and support for patients, which often destigmatizes and relieves the sense of shame that many youths experience who have experienced trauma. Caregiver groups are run concurrently to youth groups, both of which typically run for approximately 10–​14 sessions (Cohen et al., 2016), typically one to two hours per session. Providing simultaneous treatment to caregivers enables them to understand better what their traumatized youths have experienced and act as support for their children throughout treatment. Ideally, two clinicians are running the youth group, and at least one is leading the caregiver group. When appropriate, youth and caregiver groups will come together for conjoint session time at the end of separate sessions. Caregiver and youth groups follow the same topics in parallel, including Psychoeducation and Parenting, Relaxation, Affect expression and modulation, Cognitive coping, Trauma narrative and processing, In vivo mastery, Conjoint sessions, and Enhancing safety and future development, also known as the PRACTICE components. Each of these components is described below as they would be covered in youth group sessions. Homework assignments are often given to caregivers and youths to encourage the application of skills being learned in group. An overview of topics discussed in youth, caregiver, and conjoint sessions can be found in Table 7.1. Session-​b y-​S ession Breakdown of Youth Groups in TF-​C BT Session 1. Psychoeducation: The first session typically begins with introductions and the establishment of group rules (collaboratively created with therapists and group members), including setting appropriate boundaries and confidentiality. Information is provided about the nature of this trauma-​ focused treatment, followed by psychoeducation about trauma and PTSD. Ideally, the session will end with a group activity or game to facilitate introductions and rapport among group members. A relaxation exercise may also be introduced at the end of group if time permits. Session 2. Relaxation: Group rules are once again reviewed, followed by providing psychoeducation about the nature of trauma (i.e., physical abuse, sexual abuse, death, domestic violence, and so on) and common responses. Therapists can facilitate gradual exposure by providing members with appropriate language to use when speaking about trauma. Therapists can also model

116  Annie Kipke et al. Table 7.1 Group TF-​C BT Session Outlines Session No.

Youth session

Caregiver session

Joint session

1

• Introductions • G roup rules • P sychoeducation about trauma, PTSD symptoms, and treatment overview

• Introductions • W hat brought caregivers to treatment (gradual exposure)? • P sychoeducation about trauma, PTSD symptoms, treatment overview, and role of parents

• Joint introductions of children and caregivers • T herapists model appropriate group behavior, including praise for introductions • Treatment overview provided

2*

• R  eview group rules • P sychoeducation • Introduce relaxation strategies • A ssign homework

• P  arent skill: specific and labeled praise, engage in positive activities together • Relaxation strategies introduced • H ow to use skills in response to trauma (gradual exposure)

• C  ollaborative discussion of relaxation strategies • C hildren teach skills to caregivers • C aregivers provide praise to children

3*

• R  eview homework • A ffect expression and modulation; coping toolkit • Identifying feelings experienced during trauma • A ssign homework

• A  ffect expression and modulation: caregivers encouraged to share and praise expression of feelings • Parenting skill: reflective listening

• C  hildren share one non-​ trauma-​r elated positive and negative emotion with caregivers • C aregivers practice reflective listening and praise

4

• R  eview homework and coping skills • C ognitive coping • A ssign homework

• P  arenting skills: reflective listening • C ognitive coping • U se of skills in response to trauma reminders

• G  ame or activity in which children teach caregivers about emotions and cognitive coping • C aregivers demonstrate selective attention and praise

5

• R  eview homework and coping skills • C ognitive coping • P sychoeducation group activity or game • A ssign homework

• C  ognitive coping • Parenting skill: increasing cooperativeness from children, establishing family rules, natural consequences

• P  sychoeducation • C aregivers demonstrate selective attention and giving praise

6

• R  eview homework and • Review parenting and coping skills coping skills • Trauma narrative • Introduce trauma introduction (age narrative rationale and appropriate) concept • B rainstorm title and introduction chapter to trauma narrative • A ssign homework

• C  hildren share coping toolkit with caregivers • C aregivers demonstrate praise

CBT Groups for PTSD 117 Table 7.1 (Continued) Session No.

Youth session

Caregiver session

Joint session

7–​1 0

• ( Individual) Trauma narrative • (Group) review coping skills, cognitive processing, add to toolkit, discuss how to talk about trauma with peers, art project relating to trauma • In vivo mastery (when appropriate)

• R  eview parenting and coping skills • P repare for trauma narrative sharing

• C  hildren may share art projects • ( Individual) Sharing of trauma narrative, if indicated • M utual exchange of praise

11

• P  ractice safety skills • In vivo mastery • P repare for graduation

• R  eview safety skills • P repare for graduation

• C  hildren demonstrate safety skills to caregivers • C aregivers practice praise

12

• R  eview safety skills • P ractice skills and plan for future trauma reminders • A cknowledgment and celebration of progress

• R  eview skills and plan for future trauma reminders • A cknowledgment and celebration of progress

• R  eview skills and plan for future trauma reminders • G raduation celebration • Awarding of certificates

Note. *Sessions 2 and 3 can be switched based on clinical appropriateness and need for affect modulation prior to relaxation strategies; PTSD =​ posttraumatic stress disorder; TF-​C BT =​ trauma-​focused cognitive behavioral therapy.

destigmatizing trauma by giving information about its prevalence, impact, and various types of traumas. Clinical judgment should be used to provide this information in an age-​appropriate manner. Relaxation strategies should be taught, typically beginning with deep breathing, progressive muscle relaxation, imagery, and mindfulness techniques. Session 3. Affect expression and modulation: Psychoeducation continues to be discussed in this session, followed by an introduction to affect expression. Group members are then asked to list as many feelings as they can, followed by engaging in an activity providing explanations and examples of various feelings while also being taught how to manage such emotions effectively. As part of gradual exposure, children may be asked to identify emotions from the list that they experienced at the time of/​in response to the trauma(s). “Feelings Charade” and “Feelings Jeopardy” are two activities that can be utilized as interactive ways of teaching emotions. Next, therapists help children brainstorm a list of skills that can be used to manage distressing emotions (i.e., deep breathing, listening to music, talking to a peer, and so on). This “toolkit” can be referenced and added to throughout treatment. For homework, group members may be asked to share their feelings with caregivers, as well as record the use of new skills to manage emotions throughout the week. Session 4. Cognitive coping: The session begins with a review of coping skills previously learned and praise for youth’s efforts to both verbalize and cope with emotions between sessions. The session then focuses on cognitive coping with thoughts and feelings, starting with an example unrelated to trauma. Cognitive coping tools should be developmentally appropriate, with younger children being taught basic relationships between thoughts and feelings and older adolescents learning the interconnectivity between thoughts, feelings, and behaviors using the cognitive triangle. This is a great opportunity to engage in a group conversation about everyday stressors

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and the automatic thoughts that come up in response. Group members are then able to discuss as a group whether certain automatic thoughts are helpful or unhelpful in how they influence emotions and behaviors. When age-​appropriate, youths can complete an automatic thought record throughout the week as a homework assignment. These thought records can be added to the coping skills toolkit each child began compiling last session. Session 5. Continued cognitive coping: Development of cognitive coping skills and integration of skills learned thus far often requires more than one session, and it is important to ensure each group member’s understanding of the material before moving to the next stage of treatment. Therefore, this session consists of reviewing automatic thought records if they were completed for homework and engaging in additional cognitive coping group activities. Therapists can also help group members practice identifying unhelpful thoughts and brainstorming more adaptive replacement thoughts through cognitive restructuring. Older adolescents may be asked to continue this restructuring in their automatic thought records as a homework assignment. Session 6. Introduction to trauma narrative and processing: The session begins with an introduction of a trauma narrative and example in the format of a story, handout, or published narrative that aligns with the type of trauma(s) experienced by group members. Children are then encouraged to come up with a title and brief introduction similar to the format of the story they just heard. Younger children may engage in this exercise in a fill-​in-​the-​blank format if needed. If implementation of coping skills has been done successfully, group members can continue to create outlines of their individual trauma narratives. Further work on trauma narratives will be done in individual sessions. Sessions 7–​10. Trauma narrative and processing, In vivo mastery, Conjoint sessions: Most of the trauma narrative work takes place in individual breakout sessions with one of the therapists and the child or adolescent, while the other therapist is guiding the rest of the group through coping skills practice, building upon their coping toolkit, and group activities reflecting on treatment. Given the time limitations of the individual work based on the group session time frame, trauma narratives may be more limited than in longer-​term individual therapy. Identifying incidents of traumatic exposure in which the child felt the greatest shame, sadness, or fear can help determine which incidents (when more than one has occurred) are important to include in the narrative. Additionally, it can be therapeutic for children to include traumatic situations that they thought they would never tell anyone about, as well as positive memories, personal strengths, or support received from loved ones throughout the trauma. The final session of the narrative is a chance for children to reflect on what they have learned about themselves, the world, and trauma. The therapist should use clinical judgment in determining the importance of sharing the narrative with a caregiver and only do this when appropriate and clinically indicated. If children are observed to be engaging in trauma-​related avoidant behaviors throughout treatment, including after processing their narrative, more individualized in-​vivo work should be done with the child and their caregiver to decrease avoidance. Session 11. Enhancing safety and future development: Children have typically shared and processed their trauma narratives with caregivers by this point in treatment. As therapists prepare for the end of treatment, focus shifts to personal safety and consolidation of skills. Developmentally appropriate role plays involving things like calling 911 can be a helpful way to teach this material. Young children may review “okay” and “not okay” touching, while older children or adolescents may focus on sex education (when caregivers provide consent). Therapists also begin preparing children for the end of treatment and may elicit ideas from the group about how to celebrate completing treatment. Session 12. Graduation/​Final session: The final session may begin with a review of safety skills discussed in Session 11, including a practice exercise or role play that ideally incorporates other

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skills learned throughout treatment. Age-​appropriate graduation celebrations can be arranged, and children may choose to present a project (individual or group) to their caregivers about what they learned regarding trauma and their experiences. Children are encouraged to praise both their hard work and their caregivers’ participation throughout the treatment. In addition to TF-​CBT, a number of other evidence-​based interventions have been shown to be effective at treating traumatized youths. An important consideration when working with this population is accessibility to care. Although the availability of trauma-​focused treatment has increased in recent years, there is still a shortage of treatment options, considering the demand. The ability to provide trauma treatment in a variety of settings with differing levels of acuity is an essential element in increasing accessibility to care. Described below are three cognitive-​behavioral group interventions for traumatized youths, each typically implemented in differing acuity settings. Cognitive Behavioral Intervention for Trauma in Schools (CBITS) CBITS was created as an in-​school treatment of youths 11–​15 who have experienced one or more traumatic event and who display symptoms of posttraumatic stress or depression (Jaycox, 2004). CBITS is a skills-​based intervention primarily provided in a group setting; however, individual and parent sessions also take place over the course of treatment. Treatment consists of six main components, which are covered over approximately ten 60-​minute weekly sessions. Additional sessions include one to three individual sessions, dependent on need, two-​parent education sessions, and one teacher education session. Psychoeducation is prioritized at the start of treatment to present youths with a treatment rationale and understanding of the connections between thoughts, feelings, and actions. PTSD is introduced as a disorder that can be treated rather than a group of symptoms that are uncontrollable and will last forever, destigmatizing the symptoms one may experience following trauma and instilling a sense of hope in youths (Jaycox, 2004). Examples of traumatic experiences and their impact on our thoughts, feelings, and actions can be elicited by the group and provided by the therapist. One example that can be used is as follows: Jane got attacked by a dog and had to get stitches. It was a very stressful and scary event. When she sees dogs on the street, she feels shaky, nervous, and upset. She thinks that all dogs are dangerous and could try to hurt her. When friends who have pet dogs invite Jane over to their houses, she declines the invitation because she doesn’t want to be around dogs. Relaxation strategies such as controlled breathing and progressive muscle relaxation are introduced early on in treatment and recommended to be practiced independently between sessions. These skills help reduce anxiety and anger symptoms and provide youths with a sense of control over their emotional experiences. Additionally, research suggests that experiencing stress or trauma changes certain assumptions individuals make about themselves and the world, specifically that the world is more dangerous and that the traumatized individual is less able to cope (Jaycox, 2004). Youths are taught to identify maladaptive ways of thinking and replace them with more realistic and objective thoughts. Cognitive therapy is an essential part of CBITS treatment and is typically introduced in session three. As with most behavioral treatments of anxiety or stress, exposure and response prevention are utilized to decrease avoidance and increase adaptive functioning. Youths work with therapists to identify a list of trauma-​related situations that are feared and avoided and are then encouraged to work with their caregivers to confront these situations in a controlled manner. An example list, also known as a fear hierarchy, can be found in Table 7.2.

120  Annie Kipke et al. Table 7.2 Sample Fear Hierarchy for Real-​L ife Exposure Practice Feared scenario Feeding an unleashed dog a treat from my hand Petting an unleashed dog for 15 seconds Being in a room with an unleashed dog for one minute Standing next to a sitting, leashed dog for 15 seconds Standing five feet away from a dog for 30 seconds Watching a video of a dog jumping on a person Watching a cartoon movie about dogs Looking at pictures of dogs for three minutes

Anxiety rating (0–​1 0) 10 9 8 7 6 5 3 2

In individual sessions, therapists guide youths through imaginal exposures to the stress or trauma they experienced. Subsequent exposures will take place in the group setting using drawings or the creation of stories, which can then be shared with the group to enhance the exposure exercise further. Coping skills are introduced and practiced throughout these sessions, and the pace of exposure work is dictated based on the individual needs of each child or adolescent. Lastly, social problem-​solving techniques are taught to challenge the anger, aggression, and impulsivity that often follow a traumatic event. Social problem-​solving is intended to help improve the overall functioning of youths who have experienced trauma by decreasing their reactivity in interpersonal situations or conflicts. CBITS is intended to be an interactive intervention, and activities are used in each session to consolidate skill acquisition and promote generalization of newly learned material. Practice activities will be assigned at the end of each group and reviewed at the start of the subsequent session. Therapists should be mindful of the goals of each group member throughout treatment and problem-​solve with youths and caregivers if practice assignments are not being completed. Despite being a group-​based intervention, individual conceptualization of group members is a vital piece to ensuring each youths gets the most possible out of treatment. Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS) SPARCS is a 16-​session weekly 60-​minute group treatment for traumatized youths ages 12–​21 suffering in several domains of functioning as a result of past or ongoing stress. SPARCS is based on three empirically informed interventions: Dialectical Behavior Therapy for Adolescents (Miller et al., 2006), Trauma Adaptive Recovery –​Group Education and Therapy (Ford & Russo, 2006), and School-​Based Trauma/​Grief Group Psychotherapy Program (Layne et al., 2001). This present-​focused intervention aims to help adolescents manage current life stressors, identify individual strengths, and increase hopefulness for the future while addressing problems in emotional regulation, somatization and physical health, attention and information processing, self-​perception, interpersonal relationships, and sense of meaning/​purpose in life. While this treatment has been implemented in a variety of settings, it is recommended that treatment is done in a setting where adolescents can remain in treatment through the completion of the intervention. To accommodate this, sessions can be conducted twice weekly or divided in half in duration. The broad treatment goals of SPARCS have been defined by its creators as “the four Cs”: cultivate awareness, cope more effectively, connect with others, and create meaning (DeRosa et al., 2006). Cultivating awareness is done through the use of mindfulness techniques such as blowing bubbles, mindful eating, and listening to music in order to increase attentional control and

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awareness of present internal states. Youths are also taught how the environment and external experiences may impact how they feel, think, and behave, thus fostering awareness of potential triggers. These mindfulness strategies emphasize the importance of remaining present in the moment and observing without action or judgment. To enhance coping, psychoeducation is provided regarding common responses to stress and trauma, including various adaptive and maladaptive coping skills often used by adolescents. Unhelpful coping skills may include substance use, excessive risk-​taking, and self-​harm, and are known in the treatment as “MUPS” or things that “mess you up.” Adolescents are taught how these behaviors often perpetuate existing problems and often create new ones (DeRosa and Pelcovitz, 2009). Replacement coping skills deriving from Dialectical Behavior Therapy’s distress tolerance and mindfulness modules are introduced (Habib et al., 2013). Effective communication skills and adequate social support are essential elements of helping adolescents cope with trauma. As such, SPARCS engages group members in role-​play activities to improve social functioning and practice communication skills. Specifically, the acronym MAKE A LINK (be Mindful, Act confident, Keep a calm and gentle manner, Express interest, Ask for what you want, Let them know you get their point of view, Include your feelings, Negotiate, Keep your self-​respect) is utilized to help youths effectively manage social interactions. Finally, adolescents are encouraged to create meaning by reframing traumatic experiences and building upon current adaptations to the trauma to construct a sense of meaning and purpose in their lives. Skills Training in Affective and Interpersonal Regulation for Adolescents (STAIR-​A) STAIR-​A is a brief intervention designed for multiple traumatized adolescents reporting a history of physical and sexual abuse, community and domestic violence, and multiple other traumas (Cloitre et al., 2012). The treatment, comprised of three 60-​minute sessions, is skills-​focused and was designed for implementation in a psychiatric inpatient setting. Primary treatment goals include enhancing competency and functioning in everyday life by providing youths with tools to effectively manage feelings, interpersonal conflicts, and decrease symptoms of PTSD. The treatment manual has been divided into three versions designed to meet differing developmental, emotional/​ behavioral, and cognitive functioning of participants. Described below is an overview of each session as it is written in Version A, which is the most structured and visual of the three and is often recommended for adolescents who are new to treatment. Session 1, titled “Identification and Labeling of Feelings,” provides an overview of common emotional experiences and the impact of trauma on emotions. After discussing several various emotions and corresponding situations in which those emotions may be important, therapists then lead the group through a conversation regarding the impact of trauma on coping with feelings. Trauma is defined, followed by an overview of common posttraumatic stress symptoms such as intrusion, avoidance, negative thoughts/​mood, and hyperarousal. To practice naming and recognizing emotions, therapists can engage the group in a game of “Feelings Charade.” Youths are then asked to practice identifying and labeling their own emotions by completing a self-​monitoring form, an example of which can be found in Figure 7.1 (Clotire et al., 2012). Relaxation strategies are then introduced as tools that can be used to cope with difficult or upsetting emotions. Each session thereafter ends with a relaxation practice exercise and the construction of a safety plan to cope with distress throughout the week. The second session focuses on identifying, evaluating, and, when necessary, replacing coping skills for managing difficult emotions. Simply titled “Coping with Upsetting Feelings,” the session often begins with psychoeducation about how emotion impacts our mind, body, and behavior. The following example can be used to illustrate this idea:

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Figure 7.1 Sample Self-​M onitoring Form. Source: From Cloitre et al. (2015).

Imagine a time recently when you felt angry. A lot of us start to notice our bodies becoming energized when we feel angry, and notice thoughts like “I hate everyone!” and “this is so unfair!”. People may slam doors or throw things, which will make them angrier because they know they might get in trouble for throwing something, and just continue feeling more and more angry! The conversation then shifts to how to stop emotions from escalating by introducing new coping skills and determining in which settings they are most appropriate. Adolescents may lack models for appropriately regulating emotions and thus have ineffective or maladaptive coping methods. Specific coping skills to be discussed in this session include positive self-​talk, self-​care and relaxation, and deep breathing. It is important to emphasize the necessity of different coping skills in different situations. Group members can be provided with a list of several coping skills and asked to select one to practice between sessions. Once again, the session concludes by reviewing relaxation practice and adding to safety plans. The third and final session, “Skills for Clear Communication,” aims to identify barriers that may interfere with appropriate communication and help adolescents build skills to facilitate more effective communication. A helpful activity to cover this material can be handing out a worksheet with three brief problems (i.e., someone you like steps on your toe while you are talking to them) and asking group members how they would respond to the situation. Acknowledge the variability in people’s responses and how different responses would likely lead to different outcomes. Similarly, explain how communication skills will be taught in this group to deal with problems

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so that the chances of a positive outcome are increased. Barriers to effective communication are then discussed, followed by an overview of specific strategies for communication (Cloitre et al., 2012). Group leaders should leave time for role-​play activities to practice newly learned skills and promote generalization, followed by relaxation practice and review of safety plans to conclude the session. These sessions do not necessarily need to be taught in order, and participants may enter the program at any point and may attend sessions more than once based on need. Overcoming Potential Obstacles of Group Treatment for PTSD In group settings, allotting equal time to all participants poses a challenge; this may be increasingly difficult in caregiver sessions. Agenda-​setting should be incorporated to combat this challenge, as well as having more than one group leader when possible. Safety concerns among youths may also pose a potential challenge for clinicians; group leaders may exercise flexibility in delivering safety enhancement sessions earlier in the group series if multiple participants present with safety concerns. Alternatively, clinicians may choose to address safety issues in individual sessions with youths. Clinicians may have difficulty navigating youths’ externalizing behaviors in group settings, which have the potential to interfere with treatment for other group members. To combat this potential challenge, it is recommended that clinicians present behavioral guidelines or ground rules at the start of each group session. It is recommended that group activities are carefully selected and allow for physical movement when appropriate. Clinicians should utilize praise generously and may consider implementing visual aids, behavior charts, and point systems to enhance motivation and compliance. With younger children, clinicians may choose to implement time-​out in group sessions; if utilized, procedures surrounding time-​out should be clearly explained to both youths and caregivers and delivered in an educational and non-​punitive manner. To minimize the risk of vicarious trauma or retraumatization for group members, clinicians should conduct trauma narration in individual sessions that occur in parallel with group-​based work. Group discussion of cognitive distortions, however, may occur in the group setting to promote peer support and reduce stigmatization (McMullen et al., 2013). Deblinger and colleagues (2001) found that discussion of specific details related to their children’s sexual trauma was beneficial for nonoffending caregivers enrolled in a TF-​CBT group. Specifically, these detailed discussions were hypothesized to contribute to reductions in anxiety and distorted thinking among caregivers. Case Example Note: It is important to note that throughout youth group-​based CBT, there is substantial caregiver involvement. For this chapter, we will focus primarily on Melody’s treatment within the youth modules of care. To display the usefulness of group-​based TF-​CBT with complex presentations of PTSD, we will describe the case of “Melody.” Melody was a 15-​year-​old Black Indigenous People of Color (BIPOC) female who was referred for group TF-​CBT after her first psychiatric hospitalization for suicidal ideation and experiencing Psychogenic non-​epileptic seizures (PNES) episodes at school in which she began to seize during a test. During her hospitalization, she disclosed that her suicidal ideation was primarily a function of her trauma. She disclosed that she had been sexually assaulted by an adult family member during a family gathering three years prior, and had never shared this information due to concerns that her family members would not believe her. Melody disclosed that she had been experiencing recurrent nightmares about the incident, avoidance of any family gatherings, panic attacks, and sleeping with a bat under her bed to protect herself from similar events.

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Essential components of the initial session of TF-​ CBT groups include Assessment and Engagement, which was of extreme importance for Melody entering a group, as well as setting expectations for participation, behavioral rules, and confidentiality guidelines for the group. When developing rules, soliciting ideas from the group members themselves can be particularly helpful; one rule that Melody suggested was no jokes inside or outside of group about other members’ triggers. Additionally, group members were instructed on how to respond to Melody’s PNES episodes by not intervening and allowing group leaders to handle any situation that arose. Child participants should all ideally be at about the same developmental level. Both same-​gender and mixed-​gender groups have been successful, though single-​gender groups can often be more culturally sound (Deblinger et al., 2016). Groups can also consist of participants who have experienced similar trauma, if possible. Developmentally appropriate interventions such as charades, two truths and a lie, card games, and other icebreaker activities can help build rapport among patients, their peers, and clinicians. Concurrently, Melody’s mother participated in a caregiver group, which provided education and support to help her assist Melody in her recovery. Melody was given a UCLA Child/​Adolescent Reaction Index in the first session to achieve a baseline of her symptoms, on which she obtained a score of 40, exceeding the clinical severity cutoff score of 35 (APA, 2022). As previously described, treatment progressed according to the PRACTICE components of TF-​ CBT (Delinger et al., 2012). The Psychoeducation (P) sessions were helpful for both Melody and her mother to understand the difficulties Melody had been experiencing. Melody’s mother used conjoint sessions to discuss ways to assist Melody in using her coping skills. To highlight the flexibility of group-​based TF-​CBT, group leaders felt that based on the overall presentation of the participants of the group and need for greater insight into emotions, Affective Modulation (A) was taught before Relaxation strategies (R). Games such as the Talking, Feeling, Doing (Gardner, 1983), and Feelings Jenga were helpful in providing a greater understanding of emotions as well as their physiological impact. These games were also helpful in the creation of Coping Index cards as group members shared skills and distractions they found particularly helpful. Cognitive coping (C) was a particular stuck point for Melody as she vocalized not feeling comfortable in a group format sharing her thoughts among her peers and her mother in conjoint sessions. Common cognitive stuck points for victims of physical abuse include trust and control, for sexual abuse are safety and guilt for those who have experienced sexual abuse, and those who have experienced physical violence are commonly guilt, esteem, and difficulties with trust for those who have endured physical violence (Botsford et al., 2019). Melody’s mother was supported in the caregiver group in how to validate Melody’s emotions and provided with supportive and corrective statements to offer Melody after Melody vocalized her worries about her mother not believing her and forever viewing her as flawed. Discussing these distortions and creating positive self-​statements were a helpful bridge to prepare both Melody and her mother for the Trauma narrative (T). Within the group session, the participants read A Terrible Thing Happened (Holmes et al., 2000) and were then directed to create their own title and chapter subjects and to share them in group. Melody labeled her title as “Family Flaws” with her middle chapter named “Blame Game” based on her cognitions surrounding self-​blame of the events. Her last chapter was named “Hiding” based on her years of not sharing what had happened. The trauma narrative is created with each child individually in between group sessions by scheduling individual sessions. The length and number of chapters are limited by the duration of group sessions and can be continued further within individual sessions. During the narrative portion in the caregiver group, Melody’s mother created coping statements to encourage Melody to share her work and to visit family members Melody had been avoiding since the trauma event. Leading up to sessions in which Melody shared her narrative (In Vivo exposure [I]‌) with her mother (Conjoint [C]), it was decided that specifics of the event would not be shared with Melody’s mother as Melody felt that certain aspects of the trauma would not be beneficial for her mother to be aware of despite encouragement from group

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leaders and other peers. It was agreed in the conjoint session that sharing these details would be one of Melody’s future treatment goals. The remaining sessions of Melody’s group TF-​CBT sessions were focused on building upon the safety plan she created when she was first hospitalized and adding on new skills she had learned throughout treatment (Enhancing safety; E). Melody and other group members engaged in role-​ play activities where Melody practiced asking her mother if Melody could skip certain family holidays when she felt uncomfortable attending. In the final graduation session, Melody requested and played the song ‘Battle Scars’ by Lupe Fiasco and related it to her own experiences by explaining that though she experienced a traumatic event, she felt that her process of healing had begun. At the conclusion of treatment, Melody’s UCLA Child/​Adolescent Reaction Index was 31 (down from a pre-​treatment score of 40), which was in the subclinical range. Summary In the aftermath of exposure to stressors involving actual or threatened death, serious injury, or sexual violence, youths may meet the criteria for a diagnosis of PTSD, demonstrating symptoms of intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. Due to a shortage of mental health providers trained in specialized trauma-​informed interventions, youths exposed to trauma are often faced with long clinic wait lists or inferior non-​targeted care (Owens et al., 2002). Group-​based treatment is an effective solution to increase access to care for traumatized youths. Several evidence-​based manualized trauma interventions exist for working with children and adolescents. Group trauma treatment often focuses on psychoeducation, challenging maladaptive thought patterns relating to traumatic experiences, developing healthy coping strategies when faced with trauma triggers, and effective processing and conceptualization of the trauma. Due to growing numbers of children and adolescents presenting in the healthcare system with trauma and stress-​related symptoms, it is imperative that clinicians are trained and informed on how to best implement trauma-​ informed care. References Alisic, E., Zalta, A. K., van Wesel, F., Larsen, S. E., Hafstad, G. S., Hassanpour, K., & Smid, G. E. (2014). Rates of posttraumatic stress disorder in trauma-​exposed children and adolescents: Meta-​analysis. British Journal of Psychiatry, 204(5), 335–​340. https://​doi.org/​10.1192/​bjp.bp.113.131​227 American Psychiatric Association & American Psychiatric Association, APA. (2022). Diagnostic and Statistical Manual of Mental Disorders: DSM-​5-​TR. Van Haren Publishing. Bernal, G., Jiménez-​Chafey, M. I., & Domenech Rodríguez, M. M. (2009). Cultural adaptation of treatments: A resource for considering culture in evidence-​based practice. Professional Psychology: Research and Practice, 40(4), 361–​368. https://​doi.org/​10.1037/​a0016​401 Botsford, J., Steinbrink, M., Rimane, E., Rosner, R., Steil, R., & Renneberg, B. (2019). Maladaptive post-​ traumatic cognitions in interpersonally traumatized adolescents with post-​traumatic stress disorder: An analysis of “stuck-​points”. Cognitive Therapy and Research, 43, 284–​294. Bryant-​Davis, T. (2019). The cultural context of trauma recovery: Considering the posttraumatic stress disorder practice guideline and intersectionality. Psychotherapy, 56(3), 400–​408. https://​doi.org/​10.1037/​pst​ 0000​241 Chu, J. A., & Bowman, E. S. (2000). 20 years of study and lessons learned along the way. Trauma and Dissociation, 1(1), 5–​20. https://​doi.org/​10.1300/​J229v0​1n01​_​02 Cloitre, M., Weis, J. R., Marr, M., & Sullivan, B. (2012). Skills Training in Affective and Interpersonal Regulation for Adolescents (STAIR-​A) Brief Version–​Revised [Print]. NYU Langone Medical Center and Bellevue Hospital.

126  Annie Kipke et al. Cohen, J. A., Kelleher, K. J., & Mannarino, A.P. (2008). Identifying, treating, and referring traumatized children: the role of pediatric providers. Archives of Pediatrics & Adolescent Medicine, 162(5), 447–​452. Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2016). Treating Trauma and Traumatic Grief in Children and Adolescents (2nd ed.). The Guilford Press. Copeland, W. E., Keeler, G., Angold, A., & Costello, E. J. (2007). Traumatic events and posttraumatic stress in childhood. Archives of General Psychiatry, 64(5), 577–​584. Deblinger, E., Behl, L. E., & Glickman, A. R. (2012). Trauma-​focused cognitive-​behavioral therapy for children who have experienced sexual abuse. In P. C. Kendall (Ed.), Child and adolescent therapy: Cognitive-​ behavioral procedures, (4th ed., pp. 345–​375). New York, NY: Guilford. Deblinger, E., Pollio, E., & Dorsey, S. (2016). Applying trauma-​focused cognitive–​behavioral therapy in group format. Child Maltreatment, 21(1), 59–​73. https://​doi.org/​10.1177/​10775​5951​5620​668 Deblinger, E., Stauffer, L. B., & Steer, R. A. (2001). Comparative efficacies of supportive and cognitive behavioral group therapies for young children who have been sexually abused and their nonoffending mothers. Child Maltreatment, 6(4), 332–​343. https://​doi.org/​10.1177/​1077​5595​0100​6004​006 DeRosa, R., Habib, M., Pelcovitz, D., Rathus, J., Sonnenkler, J., Ford, J., et al. (2006). Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS): A trauma-​focused guide. Manhasset, NY: North Shore University Hospital. DeRosa, R., & Pelcovitz, D. (2009). Group treatment for traumatized adolescents. In: Brom D, Pat-​Horenczyk R, Ford JD, (eds.). Treating traumatized children: Risk, resilience, and recovery. New York: Routledge. Eckenrode, J., Smith, E. G., McCarthy, M. E., & Dineen, M. (2014). Income Inequality and child maltreatment in the United States. Pediatrics, 133(3), 454–​461. https://​doi.org/​10.1542/​peds.2013-​1707 Ennis, N., Shorer, S., Shoval-​Zuckerman, Y., Freedman, S., Monson, C. M., & Dekel, R. (2019). Treating posttraumatic stress disorder across cultures: A systematic review of cultural adaptations of trauma-​focused cognitive behavioral therapies. Journal of Clinical Psychology, 76(4), 587–​611. https://​doi.org/​10.1002/​ jclp.22909 Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine, 14(4), 245–​258. https://​doi.org/​10.1016/​ s0749-​3797(98)00017-​8 Ford, J. D., & Russo, E. (2006). Trauma-​focused, present-​centered, emotional self-​regulation approach to integrated treatment for posttraumatic stress and addiction: Trauma adaptive recovery group education and therapy (TARGET). American Journal of Psychotherapy, 60(4), 335–​355. Gardner, R. (1983). The talking, feeling, and doing game. In C. Schaefer & K. O’Connor(Eds.), Handbook of Play Therapy (pp. 259–​267). John Wiley. Gerson, R., & Heppell, P. (2019). Beyond PTSD: the complexity of diagnosis and treatment for teens in child welfare custody. Psychiatric News, 54(7). https://​doi.org/​10.1176/​appi.pn.2019.4a25 Habib, M., Labruna, V., & Newman, J. (2013). Complex histories and complex presentations: Implementation of a manually-​guided group treatment for traumatized adolescents. Journal of Family Violence, 28(7), 717–​ 728. https://​doi.org/​10.1007/​s10​896-​013-​9532-​y Hagan, B. O., Wang, E. A., Aminawung, J. A., Albizu-​Garcia, C. E., Zaller, N., Nyamu, S., Shavit, S., Deluca, J., Fox, A. D., & Transitions Clinic Network (2018). History of solitary confinement is associated with post-​traumatic stress disorder symptoms among individuals recently released from prison. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 95(2), 141–​148. https://​doi.org/​10.1007/​ s11​524-​017-​0138-​1. Holmes, M. M., Mudlaff, S. J., & Pillo, C. (2000). A Terrible Thing Happened (1st ed.). Magination Press. Hulette, A. C., Kaehler, L. A., & Freyd, J. J. (2011). Intergenerational associations between trauma and dissociation. Journal of Family Violence, 26, 217–​225. Jaycox, L. (2004). CBITS: Cognitive Behavioral Intervention for Trauma in Schools (1st ed.). Sopris West. Kim, H., & Drake, B. (2018). Child maltreatment risk as a function of poverty and race/​ethnicity in the USA. International Journal of Epidemiology, 47(3), 780–​787. https://​doi.org/​10.1093/​ije/​dyx​280 Layne, C. M., Pynoos, R. S., Saltzman, W. R., Arslanagić, B., Black, M., Savjak, N., ... & Houston, R. (2001). Trauma/​grief-​focused group psychotherapy: School-​based postwar intervention with traumatized Bosnian adolescents. Group Dynamics: Theory, Research, and Practice, 5(4), 277.

CBT Groups for PTSD 127 Marsella, A. J. (2010). Ethnocultural aspects of PTSD: An overview of concepts, issues, and treatments. Traumatology, 16(4), 17–​26. https://​doi.org/​10.1177/​15347​6561​0388​062 McLaughlin, K. A., Koenen, K. C., Hill, E. D., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C. (2013). Trauma exposure and posttraumatic stress disorder in a national sample of adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 52(8), 815–​830.e14. https://​doi.org/​ 10.1016/​j.jaac.2013.05.011 McMullen, J., O’Callaghan, P., Shannon, C., Black, A., & Eakin, J. (2013). Group trauma-​focused cognitive-​ behavioural therapy with former child soldiers and other war-​affected boys in the DR Congo: A randomised controlled trial. Journal of Child Psychology and Psychiatry, 54(11), 1231–​1241. https://​doi.org/​10.1111/​ jcpp.12094 Miller, A. L., Rathus, J. H., & Linehan, M. M. (2006). Dialectical behavior therapy with suicidal adolescents. Guilford Press. Murray, L. K., Dorsey, S., Skavenski, S., Kasoma, M., Imasiku, M., Bolton, P., Bass, J., & Cohen, J. A. (2013). Identification, modification, and implementation of an evidence-​based psychotherapy for children in a low-​ income country: The use of TF-​CBT in Zambia. International Journal of Mental Health Systems, 7(1), 24. https://​doi.org/​10.1186/​1752-​4458-​7-​24 Myers, L., Trobliger, R., Bortnik, K., Zeng, R., Segal, E., & Lancman, M. (2019). Dissociation and other clinical phenomena in youth with psychogenic non-​epileptic seizures (PNES) compared to youth with epilepsy. Seizure, 70, 49–​55. https://​doi.org/​10.1016/​j.seiz​ure.2019.06.028 O’Callaghan, P., McMullen, J., Shannon, C., Rafferty, H., & Black, A. (2013). A randomized controlled trial of trauma-​focused cognitive behavioral therapy for sexually exploited, war-​affected Congolese girls. Journal of the American Academy of Child & Adolescent Psychiatry, 52(4), 359–​369. https://​doi.org/​ 10.1016/​j.jaac.2013.01.013 Owens, P. L., Hoagwood, K., Horowitz, S. M., Leaf, P. J., Poduska, J. M., Kellam, S. G., & Ialongo, N. S. (2002). Barriers to children’s mental health services. Journal of the American Academy of Child & Adolescent Psychiatry, 41(6), 731–​738. https://​doi.org/​10.1097/​00004​583-​200206​000-​00013 Thielemann, J., Kasparik, B., König, J., Unterhitzenberger, J., & Rosner, R. (2022). A systematic review and meta-​analysis of trauma-​focused cognitive behavioral therapy for children and adolescents. Child Abuse & Neglect, 134, 105899. https://​doi.org/​10.1016/​j.chi​abu.2022.105​899 Zhao, Y. (2023). The effects of acute stress reaction on trauma-​related symptoms and relevant factors. Journal of Education, Humanities and Social Sciences, 8, 163–​168. https://​doi.org/​10.54097/​ehss.v8i.4243

Chapter 8

Using CBGT with Youth Depression Courtney L. Leone and Hannah Brimkov

Introduction Depression is among the top psychological disorders present in children and adolescents worldwide and has been found to correlate with negative outcomes, including decreased academic performance, decreased social and emotional functioning, and increased risk for suicide. Children and adolescents who suffer from depression also have been found to struggle with substance abuse and obesity in adolescence (Thapar et al., 2012). Left untreated, depressive symptoms that exist in childhood and adolescence can persist into adulthood. Despite effective treatments being available, many children and adolescents do not receive the care they need to manage their symptoms. By introducing children and adolescents to evidence-​based cognitive behavioral therapies (CBTs) at an early age, they can learn coping strategies and tools to prevent depressive symptoms or manage symptoms they already have. Delivery of cognitive behavioral interventions in a group therapy format has been found to be advantageous to clients for many reasons, including easier generalization outside of session and within peer-​to-​peer relationships. This chapter describes the evidence-​based use and application of group-​based CBT as a prevention and treatment for depression in children and adolescents. The benefits of group therapy specific to depression and the direction that the field is going involving the use of technology to deliver these interventions are also discussed. This chapter intends to provide readers with a “go-​to” resource with all the foundational information a professional would need for preparing CBT group-​based preventions and interventions that target depressive symptoms. Overview of the Problem Although depression is one of the more common psychological disorders in adolescence, it may go undiagnosed because it appears differently in childhood than it does in adulthood. In children and adolescents, depression may manifest as irritability, drastic mood shifts, behavior problems, disinterest in activities that used to be enjoyable, and physical symptoms, such as problems with eating that induce rapid weight loss or weight gain. Symptoms may be categorized as internalized or externalized emotions. Commonly, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition with Text Revisions (DSM 5-​TR) and the International Classification of Diseases-​ 10 (ICD-​10) are used to define symptomology and diagnose depression. Both the DSM 5-​TR and ICD-​10 have similar definitions and criteria for depression. The DSM 5-​TR specifies details regarding the presentation of symptoms in children and adolescents. Depressive Disorders in Children and Adolescents Two disorders are often used to classify depressive symptoms in adolescents. These include Major Depressive Disorder (MDD) and Persistent Depressive Disorder. As previously mentioned, DOI: 10.4324/9781351213073-10

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identifying adolescents with depression can be difficult because of how symptoms can appear in children and adolescents. The DSM 5-​TR specifies that for children and adolescents, some symptoms may be personal recounts from the parent or child, or they may be objective observations from another individual who spends sufficient time with the child. Below are the DSM 5-​TR diagnostic classification criteria for MDD and Persistent Depressive Disorder in children and adolescents. Major Depressive Disorder (MDD). According to the DSM 5-​TR, to receive a diagnosis of MDD, five or more of the following symptoms must be present during the same two-​week period and represent a change from previous functioning. The symptoms are: (1) depressed mood most of the day, nearly every day, or irritability in children; (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day nearly every day; (3) in a child, the failure to make their expected weight gain; (4) insomnia or hypersomnia nearly every day; (5) observed restlessness or being slowed down; (6) fatigue or loss of energy nearly every day; (7) feelings of worthlessness or excessive or inappropriate guilt nearly every day; (8) diminished ability to think or concentrate, or indecisiveness, nearly every day; or (9) recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. In addition, at least one of the symptoms must be either depressed mood or loss of interest or pleasure. Diagnosis also requires that the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The depressive episode may not be attributable to the physiological effects of a substance or another medical condition. At least one major depressive episode may not be better explained by other psychotic disorders. There also should never have been a manic episode or hypomanic episode (APA, 2022). Persistent Depressive Disorder. In the DSM 5-​TR, a diagnosis for persistent depressive disorder includes the following symptoms: (1) depressed mood for most of the day, for more days than not, and in children this can show as irritability for at least a year; (2) presence of two or more of poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-​esteem, poor concentration or difficulty making decisions, or feelings of hopelessness; (3) during the one year period of the disturbance the child has never been without the previously stated symptoms for more than two months at a time; (4) criteria for a major depressive disorder may be continuously present for two years; (5) there has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder; (6) the disturbance is not better explained by another psychotic disorder; (7) the symptoms are not attributable to the physiological effects of a substance or other medical condition; and (8) the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (APA, 2022). Although these two disorders have similarities, it is important to note the key differences when making a diagnosis. In addition, because diagnosing adolescents may be difficult, ruling out other diagnoses is imperative for effective treatment. Common comorbid and differential diagnoses include generalized anxiety disorder, eating disorders, or adjustment disorders with depressed mood. Like depressive disorders, these differential diagnoses have similar symptoms, such as sadness, loss of interest, changes in appetite, and feelings of worthlessness or guilt. What sets these diagnoses apart from depressive disorders is that major depression disorder has more persistent symptoms that last longer, while the other disorders may have distinct differences that are fleeting symptoms (APA, 2022). Prevalence. The prevalence of depression and depressive episodes has been steadily increasing for over ten years in adolescent populations. Daly (2022) completed a study of national trends from 2009 to 2019 to find the prevalence of depression in adolescents aged 12 to 17 years old. The study focused on the analysis of the gender, race and ethnicity, and income of the participants. Over 160,000 adolescent participants self-​reported through computerized interview systems their levels of depressive symptoms. While the evidence showed both male and female participants experienced depressive symptoms, female participants reported more often. His findings showed

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that the prevalence of major depressive episodes nearly doubled from 8.1% in 2009 to 15.8% in 2019 among adolescent girls. According to a meta-​analysis completed during the COVID-​19 pandemic, 6.3% to 71.5% of children and adolescents across 19 studies struggled with mental health symptoms associated with depression (Oliveira et al., 2022). This alarming information gives sufficient evidence that the promotion of preventative measures and intervention is needed throughout the United States (Daly, 2022). Due to the overwhelming increase in the prevalence of depression, professionals in the field have been working to learn more about these changes and evidence-​based strategies to combat them. Symptoms associated with depression are categorized as biological, environmental, or psychological factors (Selph & McDonagh, 2019). Possibilities for the more recent increase have been theorized to include higher rates of victimization and bullying, use of social media and technology, reduced quality and quantity of sleep, and higher expectations of achievement from younger populations (Daly, 2022). Depressive episodes may also be a sign of dysfunction at home and in the family, problems in school, or problems with peers (Idsoe et al., 2019). When the problems a child is facing are inescapable, it may make it even harder to stay positive and improve outcomes. Difficulty concentrating and low energy may contribute to academic difficulty. These compounding problems may cause even more stress on the client and impact their daily living (Sander et al., 2015). Other research has been investigating how trauma exposure impacts depression in adolescents. Adolescents who have more than one factor contributing to their depressive symptoms should not only have even more preventative work but should also receive trauma-​specific interventions (Sbrilli et al., 2020). By knowing the causes of depression, treating the symptoms may be more effective and manageable. Moreover, the symptoms may be preventable in some cases. For some children and adolescents, school-​based services are provided, which often assist clients in attending most sessions and reduce financial and transportation stressors on families. Identification, Forming Groups, and Progress Monitoring While often, a parent or guardian is the first to recognize something is wrong with a child or adolescent, professionals play a key role in assisting in identifying some of the more pertinent problems or concerns. Therefore, it is critical professionals, such as pediatricians, teachers, and school mental health professionals, are educated about common symptoms that should raise concerns. All these key adults in a child or adolescent’s life must work together to communicate about symptoms and related monitoring. A depressive disorder should be identified using clinical interviewing with the parent, teacher, and child in combination with norm-​referenced rating forms provided by the clinician to key people, including the child or adolescent, teachers, and parents/​caregivers. Once the child has been identified as having symptoms, they may be assigned to an appropriate group for treatment. Interviews As mentioned above, clinical interviewing is one way to gather information on the child and to understand the symptoms. Asking the parents or guardians and teachers general questions will help, but there are several structured clinical interviews (SCIs) that clinicians may use to gather this information as well. A structured interview approach is standardized, systematic, and comprehensive in gathering information about a person’s developmental and medical history, as well as their symptoms, experiences, and behaviors. Commonly used SCIs include the Behavior Assessment System for Children, Third Edition Structured Developmental History (BASC-​3 SDH; Reynolds & Kamphaus, 2015) and the Diagnostic Interview Schedule for Children, Fourth Edition (DISC-​IV; Shaffer et al., 2000).

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While empirically supported and evidence-​based assessments like the BASC-​3 SDH and DISC-​ IV are the best choice for identifying children and adolescents, cost and efficiency also need to be considered. Measures that are efficient and regularly used in school and community settings are rating scale screeners. The rating scales may be given to parents and teachers, and the client may self-​report. These rating scales will often screen clients for several issues to categorize them into groups where they may receive intervention. There are two common methods to identify children and adolescents: narrowband and broadband measures. Broadband measures. Prior to identifying depressive symptoms specifically, the clinician may use broadband measures that pinpoint the areas where the child is experiencing problems. These measures use a wide range of symptoms to diagnose. These raters consider a variety of symptoms, such as anxiety, irritability, sleep disturbance, or eating disturbance, in addition to the symptoms used by narrowband raters. Examples of broadband measures include rating scales such as the Behavior Assessment System for Children, Third Edition (BASC-​3; Reynolds & Kamphas, 2015), Beck Youth Inventories, Second Edition (BYI-​2; Beck et al., 2005), Behavior and Symptom Identification Scale (BASIS-​32; Eisen et al., 2019), Mood and Feelings Questionnaire (MFQ; Angold et al., 1987), Youth Self-​Report (YSF; Achenback & Rescorla, 2001), and Patient Health Questionnaire for Adolescents (PHQ-​A; Johnson et al., 2002). Narrowband measures. Assessment tools used to identify specific criteria for depression are narrow measures. These raters use a limited set of symptoms, such as sadness, hopelessness, and loss of interest, to identify cases of depression. The advantage of narrowband measures is that they are more reliable and have a higher degree of diagnostic accuracy than broad measures. Examples of narrowband measures that are used for identifying depression in children and adolescents include the Children’s Depression Inventory (CDI; Kovacs, 2010), Reynolds Adolescent Depression Scale (RADS; Reynolds, 2019), Beck Depression Inventory for Youth (BDI-​Y; Beck et al., 2005), and the DISC-​IV (Shaffer et al., 2000). Group Assignment Less than half of all children and adolescents who are identified in the school system with a mental health impairment receive treatment. Those who do receive treatment from a community health professional do not receive nearly enough sessions to ensure success (Hoover & Bostic, 2021). Most children and adolescents would benefit from receiving the help they need from the school system itself to improve accessibility and reduce costs. By implementing a multi-​tiered system of support for mental health in schools, children may be identified using universal screening and then categorized by their level of need and support. Clients who are at a low level of risk may be placed into prevention programs. Children in prevention groups may spend time focused on psychoeducation about emotional regulation or teaching skills using games that promote positive behaviors (i.e., The Good Behavior Game). Clients who are at a moderate level of risk may be appropriate for group therapy to work on prevention and symptom reduction. Clients who are at a high level of risk also may be appropriate for group therapy, but interventions focus on the treatment of symptoms. Not all clients are appropriate for group therapy; therefore, individual therapy may be a better fit. Clients who are not appropriate for the group may (1) not be comfortable sharing with peers, (2) not be able to maintain confidentiality, or (3) not have goals that align with the goals targeted for the group intervention. While relying on the school system as a support for adolescents, additional support from the community outside of school hours will ensure a higher rate of success for the child. If a child is at level two or level three, it will be effective to recommend outside support from the community. With outside support, the child will experience more individualized treatment, and the professionals they are working with may include family therapy to involve the parents in helping the child. By having a holistic systems approach, the child will have thriving conditions to manage their symptoms.

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Progress Monitoring Progress monitoring tools are instruments used to assess and track the improvement of children and adolescents with depression over time. These tools are used in combination with other assessments, such as symptom rating scales, behavioral observations, and SCIs, to gain a comprehensive understanding of the child or adolescent’s depression and to evaluate the effectiveness of treatment. Initially, to identify children and to place them into groups, broadband measures are used to determine the need for treatment. Then, once the child is identified and either placed into a group or recommended for individual therapy, narrowband measures are used to understand the specificities and severities of the individual’s symptoms. In doing this, the professional may track the progress of the child’s symptoms using these narrowband measures. For example, if a child initially takes the BYI-​2 at the start of the treatment and is at high risk for depression, then the child may be given the BYI-​2 at the end of the treatment to see if they report less symptomatology than from the beginning of treatment. Not only may self-​report measures be used, but it is also important to track changes in overall well-​being by considering information from outside sources, such as a parent or guardian. Cognitive Behavioral Therapy (CBT) Conceptualization of the Problem CBT is a psychological treatment that focuses on changing thinking patterns. The key focus of CBT is that psychological problems, such as depression, are partly based on unhelpful thought and behavioral patterns. By using CBT, an individual can learn how to cope with these symptoms and learn behaviors so that they may have a more effective lifestyle (APA, 2017). Aaron Beck first developed CBT in the 1960s when he noted some of his depressed patients were verbalizing thoughts that were lacking in validity. He categorized these thoughts as cognitive distortions. When CBT was first being developed, Beck was looking at the relationship between cognition, emotion, and behavior. When using CBT, the three key aspects of cognition that are focused on include automatic thoughts, cognitive distortions, and core beliefs. Automatic thoughts are the immediate analysis of an event or situation. These automatic thoughts shape a person’s emotional response to what is happening around them (Chand et al., 2022). With depression, these thoughts are often assumptive, exaggerated, and negative (Idsoe et al., 2019). A therapist may help a person change their thought and behavior patterns in a few key ways. The psychologist may first help the individual identify their distortive thoughts and then bring to light how the client may realistically change in an everyday situation. The individual will need to understand these depressive, automatic thoughts better so they may develop problem-​solving skills for when such thoughts occur. If the individual can create a sense of confidence in their abilities, then they may be able to cope easier with these thoughts. This approach will require them to be able to calm their mind and body to conquer depressive episodes (APA, 2017). Cognitive distortions are errors in logic that lead individuals to distorted thinking. Overgeneralizing is a type of cognitive distortion. When overgeneralizing, an individual with depression takes the outcome of one situation and applies it to all similar situations. Another common cognitive distortion is dichotomous thinking. Dichotomous thinking is common with depression, as it categorizes thinking as black and white with nothing in between. Someone with depression may take an all-​ or-​nothing approach to things, from one extreme to another. An individual with depression often has the distorted thought of minimization as well. With minimization, the individual may take a positive or good experience and treat it as small or insignificant (Chand et al., 2022). Adolescents have high expectations of who they should be and what they should be accomplishing. Setting these high standards may make failure a tough topic to confront.

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In CBT, the theory is that clients who are depressed think differently than non-​depressed people. The foundation of their thinking is within their core beliefs, which often are related to thoughts of helplessness, unlovability, and worthlessness. The goal of many prevention and intervention programs, including group-​based programs for children and adolescents, is to guide and support them to recognize their thinking patterns so that they can change them to improve their feelings. Understanding these core beliefs helps professionals and clients to understand their patterns better as they work to create positive changes. The clinician uses similar strategies with each patient, but ultimately, the psychologist works with the individual on what skills will work best for them. CBT is meant to be a solution-​focused type of therapy that is short term so that the client gains the skills and becomes a therapist for themself. Since CBT is a solution-​focused type of treatment, the psychologist focuses on the present and the future instead of dwelling on past thoughts and behaviors. The client not only works on skills and techniques with the psychologist in session, but they are also given skills to work on outside of treatment by the psychologist. This is a practice used so the individual knows how to continue to use the skills learned in session and apply them to daily life (APA, 2017). CBT is a versatile therapy that has been used individually and in group settings. Although the original patients that Dr. Aaron Beck worked with were adults, CBT has been proven to be effective with adolescents. In a study where 470 participants were identified with depressive symptoms, after 20 sessions of CBT, there was a decrease in depressive symptoms. CBT was also modified to be a brief measure, and this produced similar results (Srinivasan et al., 2019). In addition to CBT being effective for individual treatment with adolescents, CBT has also been proven effective in settings using CBT-​focused programs for groups (Idsoe et al., 2019). The CBT sessions can be customized for a particular problem for an individual or a group, but the overall structure of the sessions looks similar in both settings. Before the sessions begin, a conversation about the main problems and goals of treatment should be discussed with the individual or group members. It is also important to discuss with the client or group how each session will look. The sessions normally begin with a declaration of what their current mood is. In youth populations, mood declaration may be done effectively using a mood scale rating. The next step in the session is a brief overview of what was covered in the previous session or evaluating homework that was assigned to the individual or group. Going over the previous session provides a flow of treatment and continuity from one session to the next. Once an overview of the previous session has been completed, the next steps into another problem begin. Most sessions end with a summary of the session and an assignment of homework for the next session (Chand et al., 2022). Individuals with depression may be experiencing feelings of hopelessness, sadness, and overall decreased mood. This may cause the individual to not feel like themself and to not participate in activities and events as they once would. In a CBT setting, the therapist may focus on reintroducing positive activities that the individual once found pleasurable. In doing this, positive emotions and thoughts are being reproduced. In a group setting, having others who are in a similar situation may be motivating and encouraging to reframe thoughts and patterns. Because CBT involves strategies and techniques that are brief, focused, and easy to learn, these tools may also be provided as a prevention strategy or as an initial intervention for individuals who are identified early (Sander et al., 2015). Utilization of Technology and Treatment of Depression Although the use of technology in treatment has been controversial in various ways, it is undeniable that technology has made treatment more accessible and increased the capacity at which individuals receive treatment. The efficacy of treatment also depends on the individual’s willingness to

134  Courtney L. Leone and Hannah Brimkov

interact with and receive feedback from the therapist. Given the versatility and effectiveness associated with CBT, professionals have begun to use this therapy for online treatment services. In the field, this is referred to as internet-​based CBT (iCBT; Andersson & Titov, 2014) or computerized CBT (C-​CBT; Andersson, 2009). Largely, iCBT has been researched in adult populations, but it has begun to emerge in studies for adolescents. So far, the research is promising, but more research is needed to understand the impact fully. For many adolescents, it has been documented that they are avid users of technology and thrive from communicating with messaging systems (i.e., online chats). Although there is a preference from adolescents for online programs that are brief and do not require interaction with a therapist, these types of programs do not show as many positive outcomes as programs that are blended with some online face-​to-​face interaction. Studies have found that adolescents respond well to immediate feedback. Thus, a format that includes some form of real-​time interaction from a therapist will likely be more successful because the therapeutic relationship often brings value to the overall development in sessions (Topooco et al., 2018). In turn, internet-​based or computerized programs using CBT will have more positive outcomes when there is more therapist–​client interaction (Grist et al., 2019). One suggestion for using technology-​ delivered CBT is to use computerized therapy to narrow the gap for a child waiting to receive in-​ person treatment. Because it may be difficult to find a therapist within an appropriate time frame or the waiting lists at community agencies may be long, using a computerized therapy that requires less face-​to-​face time from a therapist as an alternative will allow the child to receive treatment while they wait for in-​person treatment. While some computerized interventions that target depression are in the literature (i.e., SPARX and “Space from Depression”), none appear to be “group-​ based.” Given the satisfaction initially reported by individuals participating in these interventions, this is an area of development the field needs to consider (Merry et al., 2012; Richards et al., 2016). Cultural, Ethnic, and Racial Considerations Historically, since the 1960s and 1970s, CBT has been used with clients struggling with depression. The world has changed since the mid-​twentieth century when CBT was initially introduced. The globalization of the United States has made the country more diverse in culture, socialization, politics, and religion. Cultural aspects that should be considered in CBT include spiritual concepts, language, customs, norms, values, experiences, and our internalized belief systems. Because of mass globalization, CBT must also continue to evolve to maintain its evidence-​based credibility and to address the needs of the people who inhabit the country (Naeem, 2019). Many psychosocial treatments were originally invented and introduced by Caucasian males of Western cultures. With the diversity in the United States, CBT-​based interventions need to be carefully critiqued to ensure they fit the identity and culture of the individuals being treated (Naeem et al., 2019). For example, in a non-​Western culture, there is more sense of community; most problems are not expected to be solved individually and often are reasoned with spiritual explanations. Non-​Western communities that follow monotheistic religions believe that things in life are more predetermined, which can impact how they approach problems. For example, people who are Hindu believe in “karma” or “what goes around comes around”; Buddhists follow Confucius’s teachings, and Taoism follows a more naturistic view of how to live life (Naeem et al., 2019). Because CBT is such a versatile therapy, it can easily be modified and adapted to fit different genders, races, ethnicities, religions, and cultures to suit the client better, provided the professional is informed and educated about the culture of all the adolescents and children included in a group. It is known that the relationship the therapist has with their client affects the success of treatment. If the culture of the children and adolescents included in a group is ignored or neglected, it may have a negative impact. Moreover, with CBT and many other treatments, the client

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response and the treatment itself will be more efficacious when the therapist shows a level of competence in the client’s culture (Hall et al., 2016). Cultural adaptations to CBT may be achieved in a multitude of ways. As the therapist begins treatment, a more direct approach may be helpful. After the client becomes more comfortable, a collaborative approach may be used to achieve the goals of treatment. By taking a more direct approach, the therapist is guiding the client. The therapist may do this by providing storytelling and well-​thought-​out dialogue that relates to the problem. From the beginning, involving family and having a direct and specific outline for the sessions is important (Bernal et al., 2017; Naeem et al., 2019). Other cultures may stress the cost of taking off work and getting to the session, or they may be new to therapy in general. CBT heavily relies on the use of work in between sessions. This may be a problem for many different cultures, including Western cultures. Having homework that requires less written work and involves family may be beneficial for non-​Western cultures. Having the client read something or listen to audio resources may be a better alternative to written assignments. CBT is also well-​known for its use of mindfulness and breathing techniques. This is something that is well-​liked among other cultures and may be used often in sessions. Making sure the individual understands the phrases and words used will help them to connect better with the therapist. Asking the client questions often to understand better how they connect their thoughts to actions is an effective strategy (Naeem et al., 2019). Evidence-​B ased Components to Group CBT Treatment of Depression There are several highly efficacious interventions for children and adolescents who are struggling with depression. These evidence-​based approaches are included in many manualized interventions and modular approaches to group-​based CBT as well as in iCBT. In the next paragraphs, several of the key components found to be effective with depression will be described. Treatment protocols usually include many of these modules due to their evidence base. With adolescent populations, professionals should challenge themselves to find ways for group members to complete out-​of-​session work utilizing their smartphones, as this is an easily accessible and preferred tool among many. Examples of this will be included throughout this section; however, none of the evidence-​based manualized programs discussed utilizing smartphones as a tool. While researchers are beginning to study the utilization of smartphones in therapeutic settings, the topic is scarce in the literature and should be considered as the field continues to develop and improve consumer satisfaction with these interventions (Kauer et al., 2012; Melbye et al., 2020) Goal Setting Goal-​setting strategies are commonly used in many of the evidence-​based interventions for depression. Often, goal setting helps the client focus on some of the evidence-​based strategies and skill development that is known to reduce symptoms of depression in a manner that requires the child or adolescent to take ownership, personalize, or select pieces that fit in areas of the client’s life they are ready to change. According to a meta-​analysis on goal setting with adolescents who were struggling with depression and anxiety, goal setting was reported to be helpful (Jacob et al., 2022). Challenging Negative Thoughts Challenging negative thoughts is a common module utilized in many of the evidence-​based group CBT interventions designed to reduce depressive symptoms. Example questions often raised in therapeutic settings, including group-​based environments, may include questions such as “What

136  Courtney L. Leone and Hannah Brimkov

is the evidence?”; “What are some alternative perspectives?”; “What are the advantages of taking your perspective?”; and “What are your biases that are contributing to this perspective?” The goal of utilizing this strategy is to assist the child or adolescent in becoming more aware of their thoughts that are contributing to their feelings. Eventually, the therapist guides the group members to work on changing their thoughts to change their moods. Self-​Monitoring Self-​monitoring is a strategy used in many of the evidence-​based programs designed to reduce symptoms associated with depression because this strategy has been found to increase emotional self-​awareness. Children and adolescents may be challenged to self-​monitor their moods throughout a day or across a week when they are out of session. An adolescent with a smartphone could easily use a notes app to create a table or simply keep a running list by day with the information they are tracking. Within the session, the therapist often asks the child or adolescent to complete both qualitative and quantitative work that involves reflecting on their mood. Self-​monitoring may also include behavior. For example, clients may be asked to self-​monitor pleasant activities or social engagement, or even social media use, which is emerging in the literature as a risk factor associated with depression (Haidt & Allen, 2020). Problem-​S olving Problem-​solving has been found to be effective in treating depression both within group settings and in individual therapy (Bell & D’Zurilla, 2009). Having a system or method to solve problems reduces overall stress by increasing effectiveness in school, extra-​curricular, and social settings. According to a meta-​analysis by Bell and D’Zurilla, in addition to teaching the four main problem-​solving steps (defining the problem, brainstorming options/​alternatives, deciding, and implementing and revising), teaching to view a problem from a positive problem-​solving orientation versus only teaching the steps was found to be effective. Maintaining a positive problem-​solving orientation is a metacognitive approach used to assist clients in improving their awareness of their thoughts. Relaxation Training Relaxation training includes teaching strategies that help to reduce stress in the client. Several strategies will be discussed in this section due to the diversity of approaches that work for individual people. One of the first relaxation strategies that likely comes to mind is deep breathing and progressive muscle relaxation. Both strategies are physical and require the client to go through a series of steps that are intended to reduce stressful thoughts and bring the body into a calmer state. Some of these approaches have a high level of structure, which may include a script or an audio guide. Other approaches to teaching these skills even involve biofeedback. Many of the biofeedback programs that are designed for children and adolescents are individual game-​based. As of the writing of this chapter, no group-​based or team-​based biofeedback interventions were identified. However, this is a concept that should be considered for future development. Another relaxation training strategy is meditation. Like deep breathing and progressive muscle relaxation, there are varying levels of structure to meditation, as well as many different types of meditation. Meditation is a common module included in CBT-​based group therapy designed to address symptoms of depression due to the evidence-​base related to stress reduction both physically

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(i.e., reduced blood pressure, improved sleep) and mentally (i.e., improved focus, increased happiness, decreased aggression, improved connection with others). Meditation for some is as simple as sitting or laying in a quiet room and breathing and letting thoughts go enough to reach a more calm, clear-​minded state –​this is usually termed “do nothing meditation.” Mindfulness meditation or mindfulness training is similar; however, there is more intention related to this approach, which is designed to assist clients in being more grounded in the present moment. The goal is to help clients become more aware and accepting of their thoughts as they occur. Often, this skill is necessary for helping children and adolescents begin to gain awareness of their thoughts so that as therapy progresses, they can then start working on changing their thoughts that are negatively impacting them behaviorally and emotionally. There are many more variations of relaxation training, including movement meditation (i.e., walking meditation, forest bathing, gardening, or even tai chi). Other variations include focused meditation, which focuses on one of the five senses, and mantra meditation. Spiritual meditation is another form but is not conducive to most group-​based therapeutic settings. Pleasant Activity Scheduling Pleasant activity scheduling is another common strategy used in group-​based CBT interventions. It is a simple strategy that can be organized in many ways to help clients plan things they enjoy in their day and week to assist them in breaking or stopping unhealthy behaviors associated with withdrawal and to engage in taking action through activities that elevate their mood. Pleasant activity scheduling has been found to be an effective strategy. Moreover, the utilization of CBT with pleasant activity scheduling is all efficacious (Ertezaee et al., 2019). Pleasant Activity Scheduling Weekly Schedule Example Day

Morning

Afternoon

Evening

Example

8:00am Journal about goals

11:30am Walk on the nature trail for 20 minutes

9:00pm Progressive muscle relaxation

Monday Tuesday Wednesday Thursday Friday Saturday

Successive Approximation Successive approximation is when larger tasks are broken down into smaller tasks, which, in theory, makes the large task easier to complete because clients can complete pieces and experience the behavioral momentum associated with productivity. Successive approximation is a strategy that is built into many of the skills taught within many of the evidence-​based strategies that are known to combat depression. For example, sessions or lessons that focus on mood monitoring, problem-​solving, building healthy coping skills, and goal setting all often utilize this approach.

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Exercise Exercise is established in the research as having a positive impact on reducing depressive symptoms. In one study, depressive symptoms were found to decrease by 58% over an eight-​week exercise intervention consisting of moderate aerobic exercise (Olson et al., 2017). Out of all the evidence-​based interventions that were included in this chapter, which are designed for group settings, none included exercise within the session or lesson schedule. This is an area researchers may consider including in group-​based therapy in the future. An example of ways to include this may be setting a group movement goal of three times per week for 20 minutes and then increasing the movement goals as the group progresses through the sessions or simply taking the time to set individual movement goals in which members report back to the group as homework/​out of session assignment. Prevention and Intervention Programs Preventative Programs The POD-​Teams program (Garber et al., 2009), as well as the Penn Resiliency Program (PRP), are two of the more well-​researched group-​based prevention programs that target the prevention of depression. Adolescents included in the POD-​Teams prevention program have been found to have fewer depressive episodes than their peers included in a treatment-​as-​usual group. This program is designed for youth who show risk signs related to depression but who do not meet the criteria for depression. The POD-​Teams has eight sessions, which are 90 minutes each and are available for free online. The PRP is a well-​researched intervention that has been found to be effective with youth at risk for depression across multiple ages, income ranges, and cultures (Cardemil et al., 2002). Researchers have found this intervention to be effective in long-​term follow-​up studies with some evidence of effectiveness beyond two years (Gillham et al., 2006). Typically, PRP consists of 12 sessions that are 90 minutes each or 18 to 14 sessions that are 60 minutes each. Table 8.1 includes an outline of these sessions. The Blues Program is a CBT-​based group intervention designed for older adolescents between the ages of 15 and 18 years of age. It includes six one-​hour group sessions that focus on cognitive restructuring and developing response plans. Research has shown a decrease in symptoms Table 8.1 Session Outline for the Penn Resiliency Program Lesson number

Session topic

Lesson 1 Lesson 2 Lesson 3 Lesson 4 Lesson 5 Lesson 6 Lesson 7 Lesson 8 Lesson 9 Lesson 10 Lessons 11 and 12

Link between thoughts and feelings Thinking styles Challenging beliefs: Alternatives and evidence Evaluating thoughts and putting them in perspective Review of lessons 1 to 4 Assertiveness and negotiation Coping strategies Graded task and social skills training Decision-​m aking and review of lessons 6–​8 Social problem-​s olving Application, review, and celebration

Source: Cardemil et al. (2002).

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associated with depression and improved social functioning even at six-​month follow-​up (Stice et al., 2008; 2010). Intervention Programs The Adolescent Coping with Depression Course (CWD-​A; Clarke et al., 1990) is one type of CBT intervention that has been shown to be effective. The CWD-​A was originally designed for adults who were depressed; however, as strong evidence accumulated, a variation for 13-​to-​19-​year adolescents was developed. Multiple studies have been reported to have significant results in reducing depressive symptoms (Clarke et al., 1999; Kahn & Kehle, 1990; Lewinsohn et al., 1990; Rhode et al., 2005). The CWD-​A program consists of 16 sessions, which are two hours each. However, the research consists of variations in the number and duration of the sessions, similar to other packaged programs in the literature. Table 8.2 contains an outline of the sessions for CWD-​A. ACTION Program (Stark & Kendall, 1996) is a 30-​session intervention with each session scheduled for one hour. It is a manualized program that is designed to target 8 to 13-​year-​old girls. Limited outcomes studies have been published. However, Stark et al. (2012) found a reduction in symptoms associated with depression in more than 80% of adolescent girls who participated in the intervention. Teaching Kids to Cope (Puskar et al., 1997) is a CBT-​based intervention that targets depression and is designed for older adolescents and young adults (ages 15 to 18 and 19 to 24). This intervention is ten sessions long and 45 minutes per session. Outcome research on this intervention has included a decrease in depressive symptoms (Hamdan-​Masour et al., 2009). MATCH-​ADTC is a modular-​based intervention designed for children ages 6 to 15 that is organized within one manual (Chorpita & Weisz, 2009). It is designed to help children and adolescents who are struggling with anxiety, depression, trauma, and disruptive behavior. Included in the manual are 33 strategies. Outcome data have shown greater improvements in the areas targeted up to 24 months post-​intervention in adolescents who received the MATCH-​ADTC intervention compared to a treatment-​as-​usual group (Chorpita et al., 2013). Stressbusters (Asarnow et al., 2002) is a face-​to-​face, CBT-​based interactive computer software intervention program designed for adolescents ages 8 to 12. It includes eight 45-​minute sessions. Table 8.2 Session Outline for the CWD-​A Program Session number

Topic

Session Session Session Session Session Session Session Session Session Session Session Session Session Session Session Session

Depression and social learning Self-​o bservation and change Reducing tension Learning how to change Changing your thinking The power of positive thinking Disputing irrational thinking Relaxation Communication, Part 1 Communication, Part 2 Negotiation and problem-​s olving, Negotiation and problem-​s olving, Negotiation and problem-​s olving, Negotiation and problem-​s olving, Life goals Prevention, planning, and ending

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Part Part Part Part

1 2 3 4

140  Courtney L. Leone and Hannah Brimkov Table 8.3 Evidence-​B ased Prevention and Intervention Groups for Depression Prevention and intervention program name

Authors

Ages

Primary type

POD-​Teams Penn Resiliency Program Blues Program CWDA ACTION Teaching Kids to Cope MATCH Stressbusters

Garber et al. (2009) Cardemil et al. (2002)

Adolescence 9–​1 4 15–​1 8 13–​1 9 8–​1 3 (female) 15–​1 8 and 19–​2 4 6–​1 5 8–​1 2

Prevention Prevention Prevention Intervention Intervention Intervention Intervention Intervention

Clarke et al. (1990) Stark and Kendall (1996) Puskar et al. (1997) Chorpita and Weisz (2009) Asarnow et al. (2002)

Researchers have found a statistically significant decrease in depressive symptoms up to three months follow-​up with specific improvement in the areas of reducing negative automatic thoughts and improved healthy coping. The authors were not particularly clear about the intention or design of this program to be group-​based or not. However, this publication appears to reflect that it has been used in this way. Table 8.3 provides a review of the evidence-​based prevention and intervention programs for depression. Obstacles Related to Group-​B ased Treatment of Depression Not Understanding the Problem and Social Judgment of the Problem Radez et al. (2022) reported that not understanding there is a problem was one of the primary issues cited by adolescents who were struggling with depression and anxiety. They reported they thought how they felt was “normal” or “they’re normal.” Secondarily, if they knew it was not normal, the social judgments they felt would result from sharing that their challenges were too high, which is also directly related to a reluctance to seek outside help. These issues speak to the need for ongoing advocacy to improve mental health education and end mental health stigma. Professionals have opportunities to advocate and share mental health information on a local, regional, state, and national level. No matter how small, professionals are encouraged to take the initiative to share messages about mental health awareness. An Advocate While multiple levels of advocacy are important to combat stigma, what also stood out in the research was that someone supporting an adolescent to get connected to resources is pivotal (Radez et al., 2022). Since adolescents usually do not seek the help they need on their own, parents, caregivers, teachers, and other mentors play a key role in influencing and supporting adolescents in need. Suicide Suicide is one problem commonly associated with depression. Usually, suicide is associated with clients who are experiencing more symptoms associated with depression. For example, sharing fewer pleasant activities or fewer positive thoughts about the future. However, it is true that for some clients, an improvement in symptoms may result in the onset or more intense thoughts of

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suicide. Therefore, a common obstacle discussed by many professionals when treating clients with depression is the extent to which symptoms fluctuate and, as a result, present as more severe or less severe as treatment progresses, resulting in an onset of symptoms associated with suicide. In group-​based therapy for depression, this underscores the importance and need for thorough progress monitoring. Both quantitative and qualitative data need to be collected and analyzed for changes related to the issue of suicide. Since this information is being collected on forms, professionals must ensure they have systems in place to review all progress monitoring data before anyone leaves in case a client has expressed an immediate safety threat (i.e., intent to harm themselves or others, suicidal thoughts or plans, and so on). In addition, anything shared in the group must be addressed either as a part of the group process or after the group regarding suicidal thoughts. Summary The rates of depression are rising, and the need for prevention and intervention services is demanding. For children and adolescents to get the help they desperately need in an evidence-​based and efficacious way, CBT-​based group therapy is both a research-​supported and logical tool. Given children and adolescents are required to attend school, often utilization of the school setting is an effective place to deliver these types of interventions. For the prevention and treatment of depression, several evidence-​based interventions that are more established in the literature were discussed in this chapter. The purpose of this chapter was to provide professionals with a comprehensive approach and essential foundational information to be able to progress in their implementation of group-​based CBT programs that target depression in order to make a difference in a population that is, unfortunately, showing unrelenting rates. References Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA school-​age forms & profiles. Research Center for Children, Youth, & Families. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing. American Psychological Association, APA. (2017, July). What is cognitive behavioral therapy? Clinical practice guideline for the treatment of posttraumatic stress disorder. www.apa.org/​ptsd-​guidel​ine/​patie​nts-​and-​ famil​ies/​cognit​ive-​beh​avio​ral Andersson, G. (2009). Using the internet to provide cognitive behaviour therapy. Behaviour Research and Therapy, 47(3), 175–​180. Andersson, G., & Titov, N. (2014). Advantages and limitation of internet-​based interventions for common mental disorders. World Psychiatry, 13(1), 4–​11. Angold, A., & Costello, E. J. (1987). Mood and feedlings questionnaire (MFQ). Duke University Medical Center. Asarnow, J. R., Scott, C., & Mintz, J. (2002). Cognitive-​behavioral treatment and family interventions for children with depression. A combined cognitive-​behavioral family education intervention for depression in children: A treatment development study. Cognitive Therapy and Research, 26, 221–​229. doi:10.1023/​ A:1014573803928. Beck, J. S., Beck, A. T., & Jolly, J. B. (2005). Beck youth inventories, 2nd edition: Manual. Psychological Corporation. Bernal, G., Jimenez-​Chafey, M. I., & Domenech Rodriguez, M. M. (2017). Cultural adaptation of treatments: A resource for considering culture in evidence-​based practice. Professional Psychology: Research and Practice, 48(2), 91–​99. Bell, A. C., & D'Zurilla, T. J. (2009). Problem-​solving therapy for depression: a meta-​analysis. Clinical Psychology Review, 29(4), 348–​353.

142  Courtney L. Leone and Hannah Brimkov Cardemil, E. V., Reivich, K. J., & Seligman, M. E. (2002). The prevention of depressive symptoms in low-​ income minority middle school students. Prevention & Treatment, 5(1), 8a. Chand, S. P., Kuckel, D. P., & Huecker, M. R. (2022). Cognitive behavior therapy. StatPearls Publishing. Chorpita, B. F., & Weisz, J. R. (2009). Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH-​ADTC). Satellite Beach, FL: PracticeWise LLC. Chorpita, B., Weisz, J., Daleiden, E., Schoenwald, S., Palinkas, L., Miranda, J., Higa-​McMillan, C., Nakamura, B., Austin, A., Borntrager, C., Ward, A., Wells, K., Gibbons, R., & Research Network on Youth Mental Health. (2013). Long-​term outcomes for the child STEPs randomized effectiveness trial: A comparison of modular and standard treatment designs with usual care. Journal of Consulting and Clinical Psychology, 81, 999–​1009. Clarke, G., Lewinsohn, P., & Hops, H. (1990, August). Adolescent coping with depression (The CWD-​A). Center for Health Research. Retrieved August 28, 2008, from www.kpchr.org/​ Clarke, G. N., Rohde, P., Lewinsohn, P. M., Hops, H., & Seeley, J. R. (1999). Cognitive behavioral treatment of adolescent depression: Efficacy of acute group treatment and booster sessions. Journal of the American Academy of Child and Adolescent Psychiatry, 38(3), 272–​279. Daly, M. (2022). Prevalence of depression among adolescents in the US from 2009 to 2019: Analysis of trends by sex, race/​ethnicity, and income. Journal of Adolescent Health, 70(3), 496–​499. Eisen, S. V., Grob, M. C., Klein, A. A., & Lefkowitz, D. S. (2019). BASIS-​32: Behavior and symptom identification scale, 5th edition: Administration and scoring manual. Pearson Assessments. Ertezaee, B., Asghari, K., Oreizi, H., & Ghasemi, N. (2019). The mediating role of pleasant activities in cognitive behavior therapy for depressed adolescents. International Journal of Behavioral Sciences, 13(1), 33–​39. Garber, J., Clarke, G. N., Weersing, V. R., Beardslee, W. R., Brent, D. A., Gladstone, T. R., DeBar, L. L., Lynch, F. L., D’Angelo, E., Hollon, S. D., Shamseddeen, W., & Iyengar, S. (2009). Prevention of depression in at-​risk adolescents: A randomized controlled trial. JAMA, 301(21), 215–​224. Gillham, J. E., Hamilton, J., Freres, D. R., Patton, K., & Gallop, R. (2006). Preventing depression among early adolescents in the primary care setting: A randomized controlled study of the Penn Resiliency Program. Journal of Abnormal Child Psychology, 34(2), 203–​219. doi:10.1007/​s10802-​005-​90147. Grist, R., Croker, A., Denne, M., & Stallard, P. (2019). Technology delivered interventions for depression and anxiety in children and adolescents: A systematic review and meta-​analysis. Clinical Child and Family Psychology Review, 22(2), 147–​171. Haidt, J., & Allen, N. (2020). Scrutinizing the effects of digital technology on mental health. Nature, 578, 226–​227. doi:10.1038/​d41586-​020-​00296-​x Hall, G. C., Ibaraki, A. Y., Huang, E. R., Marti, C. N., & Stice, E. (2016). A meta-​analysis of cultural adaptations of psychological interventions. Behavior Therapy, 47(6), 993–​1014. Hamdan-​Mansour, A., Puskar, K., & Bandak, A. (2009). Effectiveness of cognitive-​behavioral therapy on depressive symptomology, stress and copping strategies among Jordanian university students. Issues in Mental Health Nursing, 30(3), 188–​196. doi:10.1080/​01612840802994577 Hoover, S., & Bostic, J. (2021). Schools as a vital component of the child and adolescent mental health system. Psychiatric Services, 72(1), 37–​48. Idsoe, T., Keles, S., Olseth, A. R., & Ogden, T. (2019). Cognitive behavioral treatment for depressed adolescents: Results from a cluster randomized controlled trial of a group course. BMC Psychiatry, 19(1), 1–​17. Jacob, J., Stankovic, M., Spuerck, I., & Shokraneh, F. (2022). Goal setting with young people for anxiety and depression: What works for whom in therapeutic relationships? A literature review and insight analysis. BMC Psychology, 10(1), 171. Johnson, J. G., Harris, E. S., Spitzer, R. L., & Williams, J. W. (2002). The patient health questionnaire for adolescents: Validation of an instrument for the assessment of mental disorders among adolescent primary care patients. Journal of Adolescent Health, 30(3), 196–​204. Kahn, J. S., & Kehle, T. J. (1990). Comparison of cognitive-​behavioral, relaxation, and self-​modeling interventions for depression. School Psychology Review, 19, 196–​212. Kauer, S. D., Reid, S. C., Crooke, A. H. D., Khor, A., Hearps, S. J. C., Jorm, A. F., Sanci, L., & Patton, G. (2012). Self-​monitoring using mobile phones in the early stages of adolescent depression: Randomized controlled trial. Journal of Medical Internet Research, 14(3), 67. doi:10.2196/​jmir.1858

Using CBGT with Youth Depression 143 Kovacs, M. (2010). Children’s depression inventory, 2nd edition: Technical manual. Multi-​Health Systems. Lewinsohn, P. M., Clarke, G. N., Hops, H., & Andrews, J. (1990). Cognitive-​behavioral group treatment of depression in adolescents. Behavior Therapy, 21, 385–​401. Melbye, S., Kessing, L. V., Bardram, J. E., & Faurholt-​Jepsen, M. (2020). Smartphone-​based self-​monitoring, treatment, and automatically generated data in children, adolescents, and young adults with psychiatric disorders: Systematic review. JMIR Mental Health, 7(10), 1–​7. doi:10.2196/​17453 Merry, S. N., Stasiak, K., Shepherd, M., Frampton, C., Fleming, T., Lucassen, M. F. G. (2012). The effectiveness of SPARX, a computerized self-​ help intervention for adolescents seeking help for depression: Randomised controlled non-​inferiority trial. BMJ, 344, 1–​16. doi.org/​10.1136/​bmj.e2598 Naeem, F. (2019). Cultural adaptations of CBT: A summary and discussion of the special issue on cultural adaptation of CBT. The Cognitive Behaviour Therapist, 12, 1–​20. Naeem, F., Phiri, P., Rathod, S., & Ayub, M. (2019). Cultural adaptation of cognitive–​behavioural therapy. BJPsych Advances, 25(6), 387–​395. doi:10.1192/​bja.2019.15 Oliveira, J., Butini, L., Pauletto, P., Lehmkuhl, K., Stefani, C., Bolan, M., Guerra, E., Dick, B., Canto, G., & Massignan, C. (2022). Mental health effects prevalence in children and adolescents during the COVID-​19 pandemic: A systematic review. Worldview on Evidence-​Based Nursing, 19(2), 130–​137. doi.org/​10.1111/​ wvn.12566 Olson, R., Brush, C., Ehmann, P., & Alderman, B. (2017). A randomized trial of aerobic exercise on cognitive control in major depression. Clinical Neurophysiology, 128, 903–​913. doi:10.1016.clinph.2017.01.023 Puskar, K. R., Lamb, J., & Tusaie-​Mumford, K. (1997). Teaching kids to cope: A preventative mental health nursing strategy for adolescents. Journal of Child Adolescent Psychiatry Nursing, 10(3), 18–​28. doi:10.1111/​j.1744-​6171.1997.tb00410.x Radez, J., Reardon, T., Creswell, C., Orchard, F., & Waite, P. (2022). Adolescents' perceived barriers and facilitators to seeking and accessing professional help for anxiety and depressive disorders: A qualitative interview study. European Child & Adolescent Psychiatry, 31(6), 891–​907. https://​doi.org/​10.1007/​s00​ 787-​020-​01707-​0 Reynolds, C. R., & Kamphaus, R. W. (2015). Behavior assessment system for children (3rd ed.). Bloomington, MN: Pearson Assessments. Reynolds, W. M. (2019). Reynolds Adolescent Depression Scale, 2nd edition: Professional manual. Psychological Assessment Resources. Richards, D., Murphy, T., Viganó, N., Timylak, L., Doherty, G., Sharry, J., & Hayes, C. (2016). Acceptability, satisfaction, and perceived efficacy of “space from depression” an internet-​delivered treatment for depression. ScienceDirect, 5, 12–​22. doi.org/​10.1016/​j.invent.2016.06.007 Rohde, P., Lewinsohn, P. M., Clarke, G. N., Hops, H., & Seeley, J. R. (2005). The Adolescent coping with depression course: A cognitive-​behavioral approach to the treatment of adolescent depression. In E. D. Hibbs & P. S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders (2nd ed.) (pp. 219–​237). American Psychological Association. doi:10.1097/​01.chi.0000121067.29744.41 Sander, J., Herren, J., & Bishop, J. A. (2015). Depression. In R. Flanagan, K. Allen, & E. Levine. (Eds.), Cognitive and behavioral interventions in the schools integrating theory and research into practice (pp. 85–​96). Springer. Sbrilli, M. D., Jones, J. D., Kanine, R. M., Gallop, R., & Young, J. F. (2020). The depression prevention initiative: Trauma as a moderator of prevention outcomes. Journal of Emotional and Behavioral Disorders, 30(4), 247–​259. https://​doi.org/​10.1177/​10634​2662​0945​665 Selph, S., & McDonagh, M. S. (2019). Depression in children and adolescents: Evaluation and treatment. American Family Physician, 100(10), 609–​617. Shaffer, D., Fisher, P., Lucas, C. P., Dulcan, M. K., & Schwab-​Stone, M. E. (2000). NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-​IV): Description, differences from previous version, and reliability of some common diagnoses. Journal of the American Academy of Child & Adolescent Psychiatry, 39(1), 28–​38. Srinivasan, R., Walker, S., & Wakefield, J. (2019). Cognitive behavioural therapy, short-​term psychoanalytical psychotherapy and brief psychosocial intervention are all effective in the treatment of depression in adolescents. Archives of Disease in Childhood-​Education and Practice, 104(1), 56.

144  Courtney L. Leone and Hannah Brimkov Stark, K. D., & Kendall, P. C. (1996). Treating depressed children: Therapist manual for “ACTION.” Ardmore. PA: Workbook Publishing. Stark, K. D., Streusand, W., Arora, P., & Patel, P. (2012). Childhood depression: The ACTION treatment program. In P. C. Kendall (Ed.), Child and adolescent therapy: Cognitive behavioral procedures (pp. 190–​ 233). The Guilford Press. Stice, E., Rohde, P., Gau, J., & Wade, E. (2010). Efficacy trial of a brief cognitive-​behavioral depression prevention program for high-​risk adolescents: Effects at 1-​and 2-​year follow-​up. Journal of Consultation and Clinical Psychology, 78(6), 856–​967. doi:101037/​a0020544 Stice, E., Rohde, P., Seeley, J. R., & Gau, J. M. (2008). Brief cognitive-​behavioral depression prevention program for high-​risk adolescents outperforms two alternative interventions: A randomized efficacy trial. Journal of Consultation and Clinical Psychology, 76(4), 595–​606. doi:10.1037/​a0012645 Thapar, A., Collishaw, S., Pine, D. S., & Thapar, A. K. (2012). Depression in adolescence. The Lancet, 379(9820), 1056–​1067. Topooco, N., Berg, M., Johansson, S., Liljethörn, L., Radvogin, E., Vlaescu, G., & Andersson, G. (2018). Chat-​and internet-​based cognitive–​behavioural therapy in treatment of adolescent depression: Randomized controlled trial. BJPsych Open, 4(4), 199–​207.

Chapter 9

Improving Coping for Angry and Aggressive Youth John E. Lochman, Nicole Powell, Caroline Boxmeyer, Annie Deming, and Laura E. Larsen

Introduction In this chapter, we will provide an overview of anger and aggression in children and adolescents, noting how childhood aggression can be a central risk marker for later serious antisocial behavior. A cognitive-​behavior model describing the development and maintenance of children’s aggressive behavior will be presented, and this contextual social-​cognitive model serves as a foundation for cognitive-​behavioral group interventions for aggressive children. Cognitive-​behavioral group interventions have certain advantages relative to individually delivered intervention, including the opportunity for role-​playing and peer modeling of skills, peer reinforcement of positive behavior, and greater cost-​efficiency. Relevant evidence-​based group interventions will be noted, and a case example from the Coping Power (CP) program will be provided to illustrate key intervention goals. Recent evidence of obstacles to group treatment with aggressive children will be discussed, along with potential methods for addressing these obstacles. Anger and Aggression in Children and Adolescents Aggression can be defined as behavior that may result in harm to a person or an object. Within our youth population, behavioral patterns involving aggression, acting-​out, and other generally disruptive behavior patterns represent the highest referral rates for mental health services. In addition, these behavioral patterns are highly prevalent, occurring in about 3% to 7% of youth (Zahrt & Melzer-​Lange, 2011). Children who are aggressive tend to have increased risk for peer rejection, school failure, delinquency, and substance use (Reijntjes et al., 2011). Aggression is also correlated with other mental health difficulties, including depressive symptoms (Evans et al., 2017; Vitaro et al., 2011). Aggressive behavior is a symptom of and risk factor for the development of Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), and Antisocial Personality Disorder. Given the potential for negative outcomes for the individual and for society at large, aggressive behavior is a necessary and appropriate target for intervention. Cognitive-​B ehavioral Conceptualization of Intervention Aggressive behavior and the development of antisocial behavior can be conceptualized within a cognitive-​behavioral framework. One such framework is the contextual social-​cognitive model, which was significantly influenced by Novaco’s work with aggressive adults and Crick and Dodge’s (1994) social information processing model and Lochman and Wells’ later work with the contextual social-​cognitive model. This model assumes that factors in a child’s social and

DOI: 10.4324/9781351213073-11

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psychological development and family environment relate to childhood aggression and later delinquency and substance use (Lochman & Wells, 2002a). It is widely accepted that poor parenting, including harsh or inconsistent discipline and parental responses, contributes to the development of children’s aggression. Then, children’s aggressive behavior becomes more prevalent, influencing developmental processes that heighten the risk of negative outcomes such as substance abuse and conduct disorder (Dodge et al., 2008). As children become more oppositional, they experience more negative reactions from parents, peers, and teachers, leading to distortions in social information-​processing. As they are experiencing these negative reactions, their bond with their school decreases, their academic progress weakens, and they experience peer rejection, causing these children to be more susceptible to deviant peer group influences. By adolescence, this trajectory can result in an increased risk of substance use, delinquency, and school failure. Therefore, the contextual social-​cognitive model posits that two types of factors contribute to adolescent antisocial behavior: (1) child-​level factors, including poor social cognitive skills and lack of social competence, and (2) parent-​level factors, including inconsistent or harsh discipline and low caregiver involvement with the child. Child-​Level Factors Literature reviews identify several risk factors that are correlated with childhood aggression, including neglect, psychological maltreatment, and exposure to violence in the media (Zahrt & Melzer-​Lange, 2011). Individual-​level variables, likely impacted by these risk factors, contribute to the behavioral choice to be aggressive. The contextual social-​cognitive model focuses on how a child responds to interpersonal conflicts, frustrations, or anger. Two distinct sets of cognitive processes are at work during an interpersonal interaction: (1) the child’s perceptions and attributions of the problem, which affect the child’s level of anger and involve the first three steps of Crick and Dodge’s (1994) model, followed by (2) the child’s plan for a response to the situation, which involve the final three steps of Crick and Dodge’s model. Although anger is a primary emotion and not considered problematic itself, poor coping mechanisms for anger contribute to a choice to behave aggressively (Down et al., 2011). During the first three steps, children encode internal and external cues, interpret these cues, and formulate a goal. Research has shown that aggressive children have particular difficulties during the early stages of information processing because of their problems encoding incoming information and in interpreting other’s intentions correctly. For example, aggressive children exhibit a hostile attribution bias, in that they view other’s intentions as hostile more often than their nonaggressive peers (Yaros et al., 2014). Aggressive children also tend to generate interpersonal goals such as power, dominance, and revenge more than their nonaggressive peers (Holmes & Lochman, 2009; McDonald & Lochman, 2012). The final three steps involve accessing possible responses, choosing a response, and enacting that response. Compared to nonaggressive peers, aggressive children tend to generate fewer solutions and their solutions are of poorer quality. Their solutions often involve aggression and do not often include verbal assertions (Lochman & Dodge, 1994). Aggressive youth also exhibit a belief that aggression is an appropriate and effective method to achieve a goal (Pardini et al., 2003). Parent-​Level Factors Research has shown that children’s aggressive behavior is influenced and maintained by parenting practices. Harsh and/​or inconsistent discipline, poor parental monitoring, vague commands, low parental involvement, and maternal depression have all been found to contribute to children’s

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aggressive behavior (Downy & Coyne, 1990; Patterson et al., 1992; Wang et al., 2016). More recent literature points to the importance of emotion-​related parenting behavior, defined as “a series of parenting behaviors that reflect parental beliefs, goals, and values in regard to their children’s experience, expression, and modulation of emotion” (Eisenberg et al., 1998). In particular, parental psychological control (manipulating children’s emotions to meet parent expectations) and parental emotional dysregulation are associated with childhood aggressive behavior (e.g., Crandall et al., 2015). The relation between parenting practices and aggressive behavior can be thought of as bidirectional in that poor parenting contributes to the onset of aggressive behavior which in turn results in negative reactions from parents and impedes the use of effective parenting practices. Research indicates that child-​level factors and parent-​level factors both contribute to childhood aggression and an outcome of adolescent antisocial behavior. Thus, the contextual social-​cognitive model posits that prevention and intervention should focus on both types of factors in order for treatment to be successful. Assessment and Group Identification An effective assessment battery for determining group inclusion can optimize treatment gains on both the individual and group levels. Such an assessment can provide a comprehensive understanding of an individual’s symptoms and possible diagnoses. In treating childhood aggression, it is also critical to examine the child’s social-​cognitive skills, as these are central to treatment (Lochman et al., 2011; Lochman & Wells, 2002a). Pre-​treatment assessments can also go beyond aggression-​ specific factors to examine personality traits and other characteristics that can make an individual more suited for and likely to succeed in a group therapy setting. Behavioral Assessment Typically, compiling a variety of data will provide the best indication of an individual’s treatment needs and likelihood of success in a group setting (Grunblatt, 2016). Assessment tools can range in their level of structure, from more open screening interviews to semi-​structured play sessions to formal psychological assessment measures. Group observations, in which potential group participants are observed in a small group setting, though less often used (Riva et al., 2000), can provide a wealth of information on a child’s interpersonal skills. As noted in this chapter’s subsequent section on obstacles to group therapy, attention can be paid to children’s level of behavioral inhibition, emotional dysregulation, and heightened social orientation as potential predictors of their constructive engagement with group work. This discussion will focus specifically on formal psychological assessment measures, particularly norm-​referenced tests and rating scales relevant to the assessment of childhood aggression. However, note that by utilizing a wide variety of tools and examining consistencies and discrepancies between responses, a stronger conceptualization of the issues at hand can be formulated to guide treatment decisions (Sattler, 2001). The tests and rating scales available for assessing aggression include a variety of both broad-​ and narrow-​band scales. Broad-​band scales provide a more comprehensive assessment of general competencies and problem areas (Collett et al., 2003). As these scales often provide normative data and cut-​off scores useful for classification and comparison, they are better able to inform clinical decisions. However, these scales generally offer a limited depth of understanding. As they assess numerous areas of functioning, fewer questions are allotted to each specific area. Additionally, they often combine different aspects of externalizing behavior into one subscale, providing an obscured picture of aggressive traits (Collett et al., 2003). Alternatively, narrow-​band scales can specifically

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assess the characteristics of aggressive behavior and other externalizing symptoms (Collett et al., 2003). However, as these scales are typically used for research purposes, they often lack normative data and psychometric information to enhance their clinical value. The broad-​band, norm-​referenced measures that have proven useful in assessing for aggression are measures of behavioral, social, and emotional competency across a range of internalizing and externalizing problems. The Behavior Assessment System for Children, Third Edition (BASC-​3; Reynolds & Kamphaus, 2015), Revised Behavior Problem Checklist (RBPC; Quay & Peterson, 1996), and the Conners, Third Edition (Conners 3; Conners, 2008) provide integrative approaches to assessment across multiple informants. Despite the general, broad-​band nature of these measures, both the RBPC and the Conners 3, focus primarily on externalizing problems. The parent-​completed Personality Inventory for Children, Second Edition (PIC-​2; Lachar & Gruber, 2001) and its self-​report companion, the Personality Inventory for Youth (PIY; Lachar & Gruber, 1995), also include measures of disruptive behavior and delinquency. The Achenbach System of Empirically Based Assessments (ASEBA; Achenbach & Rescorla, 2001), including the parent-​reported Child Behavior Checklist (CBCL), the Teacher Report Form (TRF), and the Youth Self Report (YSR), examine social problems, rule-​breaking behavior, aggression, oppositional defiant behavior, and conduct problems. Some broad-​ band, norm-​referenced measures such as the Reynolds Adolescent Adjustment Screening Inventory (RAASI; Reynolds, 2001) and the Student Behavior Survey (SBS; Lachar et al., 2000) are designed for use as screening measures. While they do assess for aggression and conduct problems, they are best used in conjunction with corroborating measures due to their psychometric limitations. There are also several narrow-​band rating scales that measure specific conceptualizations and components of aggression. The Overt Aggression Scale (OAS; Yudofsky, 2003) was developed for use in inpatient psychiatric settings and is most appropriate for seriously aggressive individuals who typically score beyond the limits of other aggression rating scales. The Children’s Aggression Scale (CAS; Halperin, 2003) examines the frequency and severity of verbal, physical, provoked, and unprovoked aggression across various settings and is more relevant for outpatient youth who demonstrate mild to severe acts of aggression. The Proactive and Reactive Aggression Scale (PRA; Dodge, 2003) focuses on the proactive and reactive motivations behind aggressive acts. The Direct and Indirect Aggression Scale (DIAS; Bjorkqvist, 2003) makes a distinction between indirect forms of aggression and direct confrontational forms of physical and verbal aggression. From these measures, a battery of behavior rating scales can be compiled based on the specific population and treatment goals of the related group intervention. Assessment of Social-​C ognitive Skills While many factors are believed to contribute to the development and maintenance of aggressive behavior, not all factors can be addressed through therapeutic interventions. However, social competence and social-​cognitive skills, two factors believed to mediate the negative outcomes of aggressive behavior (Lochman & Wells, 2002a) can be accessed in treatment. The social-​cognitive model of children’s aggression suggests that aggressive children demonstrate cognitive distortions when interpreting incoming social information and evaluating social problems, and they show deficiencies in formulating appropriate responses to these problems (Lochman et al., 2011; Lochman & Wells, 2002a). Consequently, the assessment of a child’s social-​cognitive skills and functioning is central to understanding the child’s therapeutic needs and their likelihood of benefiting from group intervention. While there are several measures used for assessing social-​cognitive functioning, most have poor validity and are not adequate for assessing social-​cognitive skills (Van Manen et al., 2001). However, the Selman and Byrne test (1974), the Means-​End Problem Solving Inventory (MEPS; Platt & Spivack, 1989), the Taxonomy of Problematic Social Situations for Children (TOPS; Dodge et al., 1985), and the Social Cognitive Skills Test (SCST; Van Manen et al., 2001) do possess

Improving Coping for Angry and Aggressive Youth 149

clinical utility. These measures use social problem situations, presented through pictures or stories, to assess a child’s social cognitive skills and problem-​solving abilities. The Selman and Byrne test and the MEPS ask the child to relay how a protagonist would react in a situation requiring social-​ cognitive problem-​solving abilities. Similarly, the SCST uses visual depictions of social stories to assess the child’s functioning on eight specific social cognitive skills. The TOPS utilizes teacher ratings of a child’s ability to appropriately manage various social situations. Children who demonstrate greater deficits in these social-​cognitive skills are poised to benefit from group interventions targeting these integral skills.

General Assessment of Group Readiness If time permits, pre-​treatment screenings may also focus on assessing more global skills relevant to treatment success, such as how an individual is likely to manage the demands of group therapy. A clinical interview can be used to discuss a child’s history of peer interactions to gauge their likely functioning in a group setting. Semi-​structured interview protocols such as the TAP-​In Selection Checklist (Morganett, 1990; Smead, 1995) can provide direct observation of an individual’s interpersonal behaviors. More formal assessment tools can be used to tap into the personality traits that could impact group success (Baker, 2010). These might include the Personality Assessment Inventory (PAI; Morey, 1999) and the NEO Five-​Factor Inventory (McCrae & Costa, 2004). Examining factors such as openness, extroversion, agreeableness, defensive behavior, avoidance, rebellion, and conflict can be of particular use before beginning group interventions (Johnson et al., 2005). This is not to say that a homogenous group of personalities is ideal. While group similarities can facilitate group cohesion, individual differences can foster the introduction of new ideas and behaviors that push the group toward prosocial treatment goals. Furthermore, group-​specific measures such as the Group Selection Questionnaire (GSQ; Burlingame et al., 2011) can provide insights into whether potential group participants are likely to participate in and benefit from a group therapy setting.

A Model for Assessment-​B ased Inclusion The Coping Power program for children with conduct problems is a group intervention that relies on assessment to determine inclusion in the program (Lochman & Wells, 2002b, 2004). Behavioral assessments were utilized to identify a need for intervention, and social-​cognitive assessments were used to further assess for the appropriateness of inclusion in the Coping Power program. This multiple-​gating approach began with teachers rating each of their student’s severity of verbal aggression, physical aggression, and disruptiveness, as well as their cognitive ability. The 22% most aggressive children were then contacted for inclusion in Gates 2 and 3 of screening. For Gate 2, parents gave consent for the teacher to complete the TRF. For Gate 3, parents completed the CBCL. Children with T-​Scores below a specific cut-​off on these measures were excluded from the program (Lochman & Wells, 2002b, 2004). These assessment-​based decisions allowed for the selection of the most aggressive youth who were in greatest need of treatment to address their aggressive behavior and social-​cognitive deficits. Cognitive-​B ehavioral Group Interventions A number of group treatment programs have been developed to address cognitive-​behavioral deficits associated with anger and aggression in youth. Empirical research has demonstrated positive effects on behavior and social-​cognitive functioning following participation in group interventions

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for children from preschool age to adolescence. Effective group interventions come in a variety of forms; they may be long term or short term, they may target children exclusively or may include components for parents and/​or teachers, and they may be clinic-​based or school-​based. This section will review several evidence-​based group programs for youth, including the Coping Power program. An example of an effective cognitive-​behavioral program for young children is Webster-​ Stratton’s (2004) Dinosaur School. In this program, six-​to eight-​year-​old children with disruptive behavior problems attend small groups that target emotion regulation, social skills, and problem-​ solving. Several studies have established positive effects on externalizing behavior and social skills for children who attend groups (see Green et al., 2019), with stronger effects when parents also attend a concurrently run program (Webster-​Stratton et al., 2004). However, improvements in peer social skills and classroom behavior are apparent for participants of the child group alone, demonstrating that even young children can benefit from a group CBT intervention. Adolescents with conduct problems have also been shown to benefit from participation in cognitive-​behavioral group interventions, as described in McCart’s (2022) review. Five programs incorporating group-​based CBT were identified as “probably efficacious” based on positive results of rigorous intervention outcome studies. Four programs target juvenile-​justice involved adolescents (e.g., Equipping Youth to Help One Another; Leeman et al., 1993), and one is designed for students in community school settings (Social Cognitive Intervention; Singh, 2017). For school-​age children demonstrating angry, aggressive behaviors, or other conduct problems, interventions that have documented beneficial effects include Anger Coping and Coping Power. Anger Coping, an 18-​session cognitive-​behavioral intervention targeting children in the fourth through sixth grades, has been shown to reduce participants’ likelihood of future substance abuse and conduct problems (Lochman et al., 1997). More immediate effects include reduced disruptive behavior, increased on-​task behavior, less parent and teacher-​rated aggression, and improvements in self-​esteem (Lochman et al., 1997). Improvements in self-​esteem and lower rates of substance use have been maintained at a three-​year follow-​up, though other behavioral improvements have not persisted (Lochman, 1992). To improve outcomes and preventative effects, Anger Coping was revised and expanded, resulting in the Coping Power program, a multi-​component intervention for late elementary-​to early middle school-​aged children and their parents. In addition to anger management, the 34-​session Coping Power child component includes units on goal setting, emotional awareness, relaxation training, social skills training, problem-​solving, and handling peer pressure. Participants are also seen individually on a monthly basis to increase leader–​student rapport and to individualize the program as needed. Generalization of treatment effects in the classroom is enhanced through the use of goal sheets which allow teachers to provide daily feedback on students’ progress toward behavioral goals. Coping Power includes a 16-​session parenting component designed to run concurrently with the child sessions. Parents are instructed in skills taught in the child component and are encouraged to promote their children’s use of these skills at home. The parenting component also addresses parent involvement in academics, management of parents’ own stress, behavior management, family communication, and parent–​child relationship building. Support for the Coping Power program has been demonstrated through eight randomized controlled trials showing improvements in Coping Power participants’ disruptive behavior and social functioning, as well as in their risk for substance use and delinquency. Reductions in aggressive behavior are evident at post-​treatment (Lochman & Wells, 2002b), one-​year follow-​ up (Lochman & Wells, 2003), and up to three years later for children seen in the full-​length program (Lochman et al., 2013) and in an adapted version that reduces the treatment length by one-​third (Lochman et al., 2014).

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Effectiveness studies of the Coping Power program have established the intervention’s flexibility, with positive effects documented in both school (e.g., Lochman, Boxmeyer et al., 2009; Mushtaq et al., 2017) and clinic (Muratori, Milone et al., 2019; Helander et al., 2018; Zonnevylle-​Bender et al., 2007) settings; in individual and small group formats (Lochman et al., 2015); in a hybrid version combining a brief set of Coping Power in-​person meetings with online internet components (Lochman et al, 2017); and when cultural adaptations are made (e.g., for use in Pakistan, Italy, Sweden, the Netherlands). The program has also retained effectiveness when modified for younger children (e.g., Muratori, Lochman et al., 2019), early adolescents (Pas et al., 2019), girls involved in the juvenile-​justice system (Goldstein et al., 2018; Leff et al., 2015), aggressive deaf children (Lochman et al., 2001), and children with intellectual disabilities (Schuiringa et al., 2017). Mindful Coping Power, an adaptation that incorporates mindfulness into the child and parent interventions, improved children’s internal, embodied experiences (self-​regulation, anger modulation, breath awareness; Boxmeyer et al., 2021) and stress physiology (Boxmeyer et al., under review) at post-​ intervention, and teacher-​reported child externalizing outcomes at one-​year follow-​up (Boxmeyer et al., under review). Overcoming Potential Obstacles Although there are evident unique strengths for using a group format with angry and aggressive youth (e.g. opportunities for peer reinforcement, role-​playing, group rewards), there are a set of potential obstacles that can interfere with the optimal functioning of the group and which can detract from the effectiveness of the intervention. To rigorously explore these concerns, we randomly assigned 20 schools to have either group or individual formats of Coping Power for 360 aggressive children (Lochman, Dishion et al., 2015). Results indicated both intervention delivery methods led to similar significant reductions in parent-​rated externalizing problems through a one-​year follow-​up period. However, although teacher-​rated externalizing problems also declined significantly for both intervention conditions, the reductions were significantly greater for children receiving Coping Power in an individual format. This main effect was moderated by certain pre-​existing child characteristics and therapist behaviors which can affect children’s outcomes in cognitive-​behavioral group therapy. These issues will be briefly described, and then relevant methods for overcoming these obstacles will be discussed. Child Characteristics Which Can Limit Group Effects Low levels of inhibitory control. Although most children with angry and aggressive behavior display some problems with impulsivity and weak inhibitory control, children with particularly weak inhibitory control present and incur particular problems in group treatment. Such children may have co-​occurring Attention Deficit Hyperactivity Disorder (ADHD) characteristics, and can create serious disruptions in group functioning because their uncontrolled hyperactive behaviors can lead them to impulsively interrupt and intrude on others. In terms of their outcomes, children with fewer problems with inhibitory control responded in similarly positive ways according to teacher ratings to either the group or individual format (Lochman et al., 2015), but children with weak inhibitory control benefited more from being seen in one-​to-​one sessions. Highly impulsive children can be relatively unable to attend to information presented in the group, and thus will be less likely to remember and incorporate new social cognitive skills (Lochman & Wells, 1996). Similar findings were evident for substance use, a long-​term consequence for children with aggressive behavior, in a longer-​term follow-​up of the same sample through 11th grade (Lochman et al., 2021). Youth with the weakest inhibitory control prior to intervention had slower increases in substance use if they were seen individually rather than in groups. However, youth with stronger

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inhibitory control actually had better substance use outcomes if they were randomized to the group format rather than the individual format, indicating the likely positive benefits of peer role-​play of behavioral resistance skills in groups. Weak emotional regulation. As with behavioral inhibition, most aggressive children have some difficulties with weak emotional regulation, but those with more extreme levels of dysregulation can have more difficulty with group rather than individual formats. Children’s poor emotional regulation can result from overactivity of the sympathetic nervous system (SNS; prepares for “fight or flight”) and diminished ability of the parasympathetic nervous system (PNS) to dampen that arousal and bring children back to their initial level of arousal. Extreme difficulties regulating arousal can cause aggressive children to experience intense anger and “hot” angry cognitions which then interfere with their adaptive information processing and lead to reactive aggression (Lochman & Wells, 1996). Children may misperceive that other group members are receiving more favorable treatment from group leaders, they may feel that they are being blamed for some problem in the group, or they may feel victimized by a peer’s efforts to dominate and control others. Children’s emotional reactions to each other in these situations can be highly contagious and can lead to bursts of aversive, conflictual interpersonal behavior between group members In the study comparing the two formats of Coping Power, children with weak emotional regulation, evidenced by low levels of respiratory sinus arrhythmia (a PNS indicator), had greater reductions in teacher-​rated aggression at a one-​year follow-​up if they were seen individually rather than in groups (Glenn et al., 2019). In a related way in a longer-​term four-​year follow-​up, children who had higher skin conductance reactivity (an indicator of poor SNS functioning) were found to have greater reductions in teacher-​reported externalizing behavior problems if these children were seen individually (Lochman et al., 2019). Aggressive children who have hypersensitive stress responses, evident in their autonomic nervous system over-​reactivity, and who are seen individually may be better able to understand and practice the intervention’s methods for emotional regulation in the safe context of their therapeutic relationship with their therapist in comparison to similar children assigned to group intervention. Excessive social orientation and proneness to deviant peer effects. Group members may reinforce each others’ antisocial behavior and antisocial attitudes and create potentially iatrogenic effects (Dishion & Andrews, 1995). Delinquent adolescent dyads have been found to provide high rates of positive reinforcement for their partners’ deviant talk, while nondeviant dyads provide reinforcement for each others’ normative, non-​deviant discussions (Patterson et al., 2000). This pattern of reinforcement of rule-​breaking talk among deviant dyads directly affects these youths’ subsequent substance use and delinquency (Dishion et al., 1997). In a key study that demonstrated how deviancy training could be a primary mechanism accounting for the negative effect of aggregating antisocial youth, Patterson and colleagues (2000) found that deviancy training in dyadic interactions partially mediated the effect of boys’ involvement with deviant peers in fourth grade and their substance use, police arrests and number of intercourse partners in eighth grade. Extending this focus on deviant peers to interventions, Dishion and Andrews (1995) found that deviancy training led young adolescents who were in a group intervention program to have higher rates of tobacco use and more delinquent behaviors at a one-​year follow-​up than did control children. These iatrogenic effects remained even at later three-​year follow-​ups, especially for youth with more moderate levels of antisocial behavior at baseline (Poulin et al., 2001). In contrast, in the case of our study comparing group versus individual formats of intervention, there were no indications that well-​structured groups had overall iatrogenic effects, as children in both conditions had significantly lower parent-​and teacher-​rated externalizing behavior problems over time. However, as noted previously, there was significant variability in outcomes for certain children receiving the group format. Children receiving the group intervention who were less

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prone to social reward (indexed in this study by the A/​A genotype of oxytocin receptor gene SNP rs2268493; Glenn et al., 2018) had better teacher-​rated outcomes than their peers. However, children who were prone to social reward and had a high social orientation had better outcomes when seen individually. Aggressive children with a high need for social bonding may have been more prone to modeling deviant peers and responding to peer reinforcement of their own deviant talk and behavior. Aggressive children who have very strong social orientations, such as children with the G/​G genotype for the oxytocin receptor gene, may also have been more over-​involved with peers in the group condition, and thus less able to deeply incorporate and internalize the social-​ cognitive regulation skills being discussed and practiced. Overcoming obstacles related to child-​level concerns. Assessment and ongoing monitoring of these and related risk factors for aggressive children is clearly important in reducing negative outcomes for some children. Once aware of children’s difficulties with weak inhibitory control, emotional dysregulation, and excessive social orientation, therapists can tailor the structure and behavioral management of the group. Key elements of therapy structuring and behavioral management are important for all group members and especially for those at risk of weaker outcomes. Overcoming obstacles: Using intervention structure. Initial planning issues have to do with the age of the youth in the group and inclusion of co-​therapists. Latrogenic deviancy training effects seem to be more evident in adolescent-​age groups than in preadolescent groups, and thus should receive special attention in groups for adolescents. The inclusion of two group leaders can increase leaders’ ability to scan children’s behavior continually and detect subtle signs of peers’ reinforcement of deviant behaviors. Once the group is formed, it is useful to carefully follow aspects of the intervention that involve monitoring and providing consequences for children’s behavior. Thus, in our Coping Power groups, we place emphasis on having clear group rules, starting in the first session, and on providing points for children’s adherence to these rules and for their positive participation in group sessions. Other program elements which alert children to how their behavior can lead to consistent consequences include the use of weekly goal setting procedures for each group member, having group contingent rewards for the entire group successfully attaining a certain number of points over several months, and working with the parents in the parent group sessions on their ability to provide clearer instructions to the children and to provide consistent consequences for children’s positive and negative behaviors. Ongoing contact by the group leaders with the teachers can be critically important in facilitating teachers’ abilities to monitor children’s social behavior and to provide logical consequences within the school setting. Overcoming obstacles: Group behavioral management strategies. Minor structural changes in the group can be helpful in providing stimulus control to prevent behavioral escalation in the group. Such minor structural changes include changing seating arrangements so that a group leader is between two particularly reactive children. Group leaders’ use of nonverbal cues (e.g., eye contact, physical proximity, animated voice tone) can also be an important means for gaining children’s optimal attention. Effective group leaders also are able to assist children with making smooth transitions from one group activity to another or from the group back to the class or the waiting room by verbally preparing them several minutes prior to the change of activity, and guiding them through the transition. If some group members are demonstrating high levels of positive involvement in the group, they can also be used to serve as a “buddy” for reactive peers, reminding the peer of group rules. Major structural changes can also be implemented in the relatively rare occasions when these minor structural changes and usual program structural elements are insufficient to reduce individual children’s serious problem behaviors in the group. When a central concern is intense rivalry between two children, leading them to frequently initiate conflict with each other, or when two

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children are actively involved in deviancy training with each other, the group can be temporarily split into two subgroups. If there were two group leaders, each leader can then work with a subgroup in a more contained way until group members’ functioning improves and the subgroups can be reintegrated. In cases with a severely and chronically disruptive individual in the group, the individual can be seen individually rather than in the group for a period of time. If this latter child begins to demonstrate a stronger therapeutic alliance after several individual sessions, then he or she may be carefully reintegrated into the group. When a highly unregulated hyperactive child is in the group, it is useful to consult with the parents and to encourage an evaluation for ADHD and for potential medication management. In group sessions, leaders typically have to provide more frequent and more individually tailored monitoring and feedback for the child’s behavior. For example, a group leader can sit next to a highly overactive child and use a simple time-​sampling chart to indicate when the child has had good on-​task behavior in five-​minute blocks during the session. Therapist Characteristics Which Can Limit Group Effects Therapist in-​session clinical skills. Therapists’ own emotional regulation, their use of social reinforcement, and their ability to stimulate child engagement in sessions can all contribute to optimal outcomes from group intervention (Lochman, Dishion et al., 2017). Group therapists’ clinical skills emerged as important predictors of outcomes in the long-​term follow-​up study of the comparison between group versus individual formats (Lochman et al., 2019). The clinical skills construct included ratings for not appearing frustrated, angry, or irritable, having a warm and positive tone of voice with students, acting in a mature and professional way (e.g., appropriate level of self-​disclosure), and not being overly rigid with the implementation of the manualized intervention activities. Leaders with high levels of clinical skills had children who had the most reduced slopes of teacher-​rated externalizing problems over time. Clinical skills were perhaps surprisingly more important in predicting outcomes than were group leaders’ behavioral management and “teaching” styles (Lochman, Dishion et al., 2017). There are at least three ways in which clinical skills, as measured here, can influence children’s outcomes (Lochman, Dishion, et al., 2017). First, group therapists who handle difficult interpersonal provocations from their child clients by exerting inhibitory control over their own expression of their own frustration and by effectively regulating their arousal are modeling key processes which can be instrumental for children learning to improve their own emotional regulation over time (Chapman et al., 2010; Stewart et al., 2007). Second, group leaders who respond more frequently in warm ways to the children in their groups are likely providing more social reinforcement for positive child behaviors within the sessions (Follette et al., 1996) and facilitating sustained generalized reductions in problem behaviors outside of the group sessions. Third, in a related way, group leaders who respond to children with more warmth are likely to develop stronger therapeutic alliances with the children, and the children can become more engaged with the intervention. Children who have become well-​engaged in the Coping Power intervention by the middle sessions of the program have been found to have greater reductions in externalizing behavior by post-​intervention (Lindsey et al., 2019). Children who are more engaged in the intervention may learn social–​emotional skills more deeply. Therapist personality traits. In a separate study, we have found that group therapists who have more conscientiousness and more agreeable personality traits can implement Coping Power with greater quality of implementation and tend to be more likely to sustain their use of the program over time (Lochman, Powell et al., 2009, 2015). More conscientious counselors are organized, thorough, and planful, and these characteristics may facilitate their later persistent use of CP child

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components. Conscientious counselors are likely to be self-​disciplined and to pay close attention to details and the schedules they plan. Consistent with prior discussion of important group therapists’ skills in sessions, therapists with an agreeable personality trait may find it easier to respond in relatively automatic, flexible, self-​regulated ways even during difficult group sessions, to model emotional regulation, and to thus implement group cognitive-​behavioral intervention in qualitatively better ways (Lochman, Powell et al., 2009). Therapist attachment style. In another closely related study, Muratori, Polidori and colleagues (2017) found that therapists who had an anxious, preoccupied attachment style had child clients, who had received Coping Power group intervention in community hospitals, who increased in their aggression over time, in contrast to children who had received Coping Power from therapists who had a secure attachment style. A therapist with an anxious attachment style that involves excessive preoccupation with relationships may tend to intervene anxiously with a difficult child in their group, modeling poor regulation of their own arousal. Overcoming obstacles: Intensive training and supervision. We have learned that in general, intensive training with regular performance feedback to therapists based on review of sessions recordings can significantly enhance the effectiveness of cognitive-​behavioral group interventions like Coping Power (Lochman, Boxmeyer et al., 2009). We anticipate that the behavioral expression of the therapists’ traits and clinical skills capacities noted above can, and should, be addressed and included in intensive training and supervision for group therapists (Lochman, 2022). Some group leaders would likely have to learn to use more deliberate strategies to increase their rates of positive feedback to children and to monitor their own arousal in sessions. In turn, therapists can purposefully use cognitive and physiological regulation strategies themselves during sessions. Thus, the training of group leaders should emphasize not only skill-​training in a traditional sense, but also focus on how group leaders can practice positive reinforcement and emotional regulation themselves while engaged in group work that can be inherently stressful and frustrating at times. Case Example for Cognitive-​B ehavioral Group Intervention Coping Power Child Group Session 10: Practice Using Coping Statements for Anger Coping Mrs. Jones is a licensed clinical social worker who is leading a Coping Power group with five children at the Hope Mental Health Center. She and her co-​leader, Ms. Carr, a marriage and family therapy trainee, greet each of the children as they arrive for session ten. The leaders tell the children how glad they are to see them today and thank them for being on time and remembering to bring their Coping Power binders. Mrs. Jones begins the session by asking each child to report on his or her personal behavior goal for the week. Jeremiah is a ten-​year-​old boy who was referred to the clinic after being suspended from school for fighting. He proudly states that he met his goal of ignoring teasing from peers four out of five days this week. Mrs. Jones congratulates him and awards him four points. Chris is an 11-​year-​old boy whose disruptive behavior has become more pronounced since his father was incarcerated. Chris sheepishly reports that he forgot to have his teacher sign his sheet indicating whether he met his goal of following directions the first time given in class this week. Ms. Carr asks Chris whether he has any ideas about how he can remember to get his goal sheet signed this coming week. One of the other group members, Shaquilla, who is in Chris’ class offers to serve as a buddy and remind him to bring his goal sheet to the teacher at the same time she does each day. Shaquilla is a ten-​year-​old girl who has been diagnosed ADHD. Her parents prefer to manage her ADHD symptoms without medication. Shaquilla excitedly shares that she met her goal of raising

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her hand before speaking in class all five days this week. Ms. Carr praises Shaquilla and awards her five points. Mrs. Jones asks Shaquilla what she did to make such a significant improvement in her goal completion from last week. Shaquilla responds that she put a sticker with a picture of a hand on her desk that served as a helpful reminder. Harper is an 11-​year-​old girl who has exhibited aggressive behavior and depression symptoms since she was sexually molested by a relative in first grade. Harper holds up her goal sheet indicating that she met her goal of using an appropriate voice in class two days this week, thus Mrs. Jones awards her two points. The final group member is Miguel, a ten-​year-​old boy who was referred due to being quick to lash out when things didn’t go his way. Miguel states that he met his goal of not being sent to the principal’s office five days this week; however, an inspection of his goal sheet reveals that he only had it signed one day. Ms. Carr awards him one point and encourages him to remember to have his goal sheet signed so that he can be rewarded for his hard work in the future. Ms. Carr asks the group members to recall one main point discussed during last week’s session. They each give answers indicating that they recall practicing ways to cope with rising levels of anger on their anger thermometers. Shaquilla specifically remembers learning about deep breathing; Miguel about using coping self-​statements; and Jeremiah about using distraction techniques. Mrs. Jones praises them for remembering these positive coping techniques and awards two points to each group member who completed the homework assignment of recording an anger-​arousing event, using their favorite coping technique, and recording the effect on their anger level. She informs the children that they are going to continue to practice using coping self-​statements in group today. In preparation for the group self-​control activity, Mrs. Jones asks each child to take out the list they made last week of their three favorite coping statements. Chris is the first to find his list, which includes: (1) “Grow up, don’t blow up”; (2) “Stay calm, just relax”; and (3) “It’s not worth fighting. Keep your cool and you will find a wise way to handle this.” While the other children are searching for their lists, Ms. Carr places a large, laminated thermometer on the floor. Once she has the group’s attention, Mrs. Jones informs them that they are going to practice using self-​control while being provoked by peers, as they have in the three previous sessions. This time, they are going to practice using coping statements while being teased by their peers and will walk up and down the thermometer to show how angry they feel inside. Prior to beginning the activity, Mrs. Jones reminds the children of the rules they must follow during the activity (e.g., no cursing, no racial comments, no physical contact). They also discuss the reasons why it can be helpful to practice managing your anger. They discussed that anger can alert you to a problem and it is helpful to notice when your anger is on the rise; however, we can typically make the wisest decision about how to address the anger-​provoking situation when we have taken some time to calm ourselves down, get some perspective and brainstorm wise solutions first. Mrs. Jones describes that today’s activity is focusing only on the first step of noticing the anger and using coping statements to calm yourself down, then they will practice the later steps in future sessions. Chris is selected to go first and takes his place on the thermometer while the other group members gather around him. “That’s the ugliest shirt I’ve ever seen,” Miguel shouts, “where’d you get it, the Ugly Shirt Store?” Jeremiah pipes in, “your hair is so red, it looks like it’s on fire. Quick, someone call 911!” Chris walks up to the thermometer as the teasing makes him angry. “Grow up, don’t blow up,” he recites loudly, grow up don’t blow up … It’s not worth fighting, don’t let them bother you … if you keep your cool, they might stop … even if they don’t, staying calm will give you time to find a wise way to handle this and not cause more problems for yourself. Gradually, Chris starts to walk down the thermometer as the use of coping statements helps calm his anger. Eventually, the teasing dies down as the children run out of ideas and see that the teasing

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no longer has the desired effect of making Chris angry. Mrs. Jones gives each group member a turn to practice using self-​statements to cope with teasing from the group. She pauses the activity and gives Shaquilla a strike when she violates a rule by using an “off limits” taunt with Harper. Mrs. Jones models approved ways to tease during the role-​play and resumes the activity. Each group member is given two turns to practice using coping statements, once stating them aloud for the group to hear, and the second time reciting them internally. After each member has had two turns, Ms. Carr leads a discussion of what the children learned from the activity (e.g., “How did you feel when you were teased? What did you say to yourself when you first noticed you were getting angry? Did these thoughts help you cope with your anger? How? What happened to your anger level when you used your coping statements? What happened to the teasing when the group members noticed they weren’t getting a reaction from you?”). The group members noticed that some teases were easier to ignore, while others took a more active effort to cope with and stay calm. They really wanted to yell and fight back at times, but they noticed that when they stayed calm, the teasing decreased. They also noticed they were better able to brainstorm wise actions to address the teasing when they were calmer, i.e., lower on the anger thermometer. With ten minutes remaining, Mrs. Jones begins the session closing activities. She asks each group member to make a positive statement about the member sitting to their right. Miguel compliments Shaquilla on reaching her goal every day this week. Shaquilla apologizes for using an off-​ limits taunt and compliments Harper for using her coping statements and not yelling back at her. Harper says Jeremiah looks nice today. Mrs. Jones encourages Harper to come up with a deeper compliment. Harper then compliments Jeremiah for getting along well with his peers this week. Jeremiah tells Chris that he was brave to go first on the self-​control activity. Finally, Chris tells Miguel that he was good at remembering his coping statements. Mrs. Jones compliments the group on their good work practicing coping statements and self-​control today and informs them that they have each earned their point for following the rules and their point for positive participation. She asks each member to generate a new personal behavior goal for the week while she comes around and tells them their total points and gives them an opportunity to purchase prizes. Harper spends 12 of her 20 points to purchase lip gloss. Miguel spends 25 points to purchase a magic trick set to give to his younger brother for Christmas. Jeremiah, Chris, and Shaquilla decide to save their points so they can buy larger prizes later, respectively: a set of walkie-​talkies, a Nerf basketball hoop, and an iTunes gift card. Mrs. Jones lets the children use the remaining five minutes to play the game of their choosing (Connect Four) and praises them for appropriate turn-​taking while they are playing the game. As they leave, she encourages the children to practice using coping statements in situations that make them angry in school or at home this week. Coping Power Child Group Session 19: Social Problem-​S olving After reviewing the children’s goals sheets, Mrs. Jones asks them what they recall learning about last week. “I know, I know,” Harper shouts excitedly, “we talked about the PICC model.” “That’s right,” says Mrs. Jones, “can anyone tell me what the letters P-​I-​C-​C stand for?” “Problem Identification, Choices, and Consequences,” shouts Jeremiah. “That’s right, now who can remember when we can use the PICC model?” asks Mrs. Jones. “When something makes us angry but we don’t want to get in a fight,” offers Miguel. Ms. Carr praises Miguel for his insightful answer and reminds the group that the first step is to accurately identify the problem. “Let’s play a game,” she says, listen carefully to the following situation and see if you can help figure out what the problem is … Tim has a friend named Bob. He sees Bob walking in front of his house and runs outside and asks him to play. Bob says “no” and keeps on walking … Can someone tell me what the problem is in this situation?

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Shaquilla suggests, “Tim’s feelings are hurt because Bob doesn’t want to be his friend any more.” That’s a good thought Shaquilla, but, that would mean Tim is assuming that Bob doesn’t want to be his friend anymore just because he turned down his offer to play. Can someone else think of a way Tim could describe the problem a little differently? “He could say that his feelings are hurt because Bob won’t play right now and he doesn’t know why,” says Chris. “Good Chris, that’s a more accurate way to describe the problem.” “Now, Shaquilla, what do you think Tim’s goal is?” “He probably wants to find out why Bob said ‘no’ and have his feelings not be hurt.” That’s right, Shaquilla. Now that we have identified the problem very specifically and know what Tim’s goal is, let’s come up with some choices for ways Tim can solve the problem. Let’s make a list of as many solutions as possible. Say the first thing that pops into your head. Don’t worry about whether the solution is “right” or “wrong” or “good” or “bad.” Let’s see how many we can come up with. Chris says, “Tim could go and find someone else to play with.” “Yeah,” says Jeremiah, “or, Tim could tell Bob ‘fine, I didn’t really want to play with you anyway.’ ” “Maybe Tim could ask Bob why he doesn’t want to play,” says Shaquilla. Harper offers, “I think Tim should stop being Bob’s friend.” “You all did a nice job coming up with lots of different choices of ways Tim could solve the problem.” Now, let’s go through and evaluate the likely consequences of each choice. “What do you think would happen if Tim goes and finds someone else to play with?” Miguel says, “Well, Tim might make a new friend and have someone else to play with, but he might never know why Bob said ‘no.’ ” That’s right, Miguel, that is probably a so-​so choice because it might help Tim find someone else to play with, but it wouldn’t help him meet his goal of finding out why Bob said “no” or resolve his hurt feelings. Now, what do you think would happen if Tim tells Bob, “fine, I didn’t really want to play with you anyway”? “I think that might make Bob mad and might make him not want to be Tim’s friend, when maybe he still wanted to be his friend but just couldn’t play right then,” says Chris. “That’s a good insight Chris and you are right, that choice is probably a bad one because it won’t help Tim meet his goal and might make the problem even worse. Now, what do you think would happen if Tim asks Bob why he doesn’t want to play?” Harper offers, “Bob might say that he can’t play because he has to get home for dinner.” “Or Bob might say that he doesn’t want to be Tim’s friend anymore,” says Jeremiah. “Or, Bob might say ‘I don’t know’ and walk away,” says Shaquilla. You are all right, there are a number of different things that Bob might say and it is hard to know which one he will say. Even though we don’t know what Bob will say, this is probably still a good choice because at least Tim will meet his goal of finding out why Bob said “no” and there is at least a possibility it will be something that helps him feel less rejected. Now let’s look at the last choice. What do you think would happen if Tim decides to stop being Bob’s friend and ignores him at school? “That’s not good either,” says Miguel “because then they will stop being friends and maybe that’s not even what Bob wanted.” “Good job Miguel. Now that you have thought about the likely

Improving Coping for Angry and Aggressive Youth 159

consequences of each choice, which one do you think is best?” “I think choice three is best because at least Tim will find out why Bob doesn’t want to play,” says Jeremiah. “Do you all agree that choice three is best?” asks Mrs. Jones. “YEEEESSS!” scream the group members. “Good job, I agree,” says Mrs. Jones. Tim can try that and it should help him understand why Bob said no, and it might help him feel less rejected. If instead, it leads him to feel more rejected, he can problem-​solve further from there. It is helpful to use the PICC model to figure out what the problem is, what your goal is, and which choice is most likely to help you meet your goal. Sometimes we must go through more than one round of problem-​solving. Next time, we will talk about how you can use the PICC model to solve problems in your own life, and how to overcome the challenges that can make this hard to do so. Good job today, guys! Mrs. Jones ends the group with positive feedback, the point transactions, and five minutes of free play time. Summary In this chapter, we have provided a cognitive-​behavioral rationale for group-​based intervention with aggressive children and have illustrated its use within our Coping Power program. Cognitive-​ behavioral group interventions with aggressive children have been delivered in school and clinic settings and have been provided in conjunction with behavioral management training for parents of the children. Multi-​component cognitive-​behavioral group interventions have been found to produce significant reductions in children’s aggressive behavior post-​intervention, and research has indicated that these effects have been maintained at follow-​up points. A major conclusion from the research findings is that cognitive-​behavioral treatment of children’s aggressive behavior can alter their developmental trajectory leading to serious antisocial behavior, and serve to prevent delinquency and substance use in the adolescent years. At the same time, there are obstacles that exist for effective cognitive-​behavioral group intervention with aggressive children, most notably the possibility of deviancy training within groups for these children. Interventions need to be carefully structured and implemented to reduce these obstacles, and certain therapist characteristics can provide protective effects. References Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA School-​Age Forms & Profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families. Baker, E. L. (2010). Selecting Members for Group Therapy: A Continued Validation Study of the Group Selection Questionnaire (unpublished doctoral dissertation). Brigham Young University, Utah. Bjorkqvist, K. (2003). The Direct and Indirect Aggression Scale. Available from Kaj Bjorkqvist, Professor of Developmental Psychology, PB311, FN65101, Vasa, Finland. Boxmeyer, C., Miller, S., Romero, D., Powell, N., Jones, S., Qu, L., Tueller, S., & Lochman, J. (2021). Mindful Coping Power: Comparative effects on children’s reactive aggression and self-​regulation. Brain Sciences, 11, 1119. https://​doi.org/​10.3390/​brain​sci1​1091​119 Boxmeyer, C., Stager, C., Miller, S., Lochman, J., Romero, D., Powell, N., Bui, C., & Qu, L. (under review). Inner work, outer change: Mindful Coping Power effects on children’s autonomic nervous system functioning and long-​term behavioral outcomes. Journal of Clinical Medicine. Burlingame, G. M., Cox, J., Davies, D., Layne, C., & Gleave, R. (2011). The Group Selection Questionnaire: Further refinements in group member selection. Group Dynamics: Theory, Research and Practice, 15(1), 60–​74.

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164  John E. Lochman et al. Yudofsky, S. C. (2003). The Overt Aggression Scale. Available from Stuart C. Yudofsky, MD, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, MS 350, Houston, TX. Zahrt, D. M., & Melzer-​Lange, M. D. (2011). Aggressive behavior in children and adolescents. Pediatrics Review, 32, 325–​332. Zonnevylle-​Bender, M. J. S., Matthys, W., Van De Wiel, N. M. H., & Lochman, J. E. (2007). Preventive effects of treatment of Disruptive Behavior Disorder in middle childhood on substance use and delinquent behavior. Journal of the American Academy of Child & Adolescent Psychiatry, 46(1), 33–​39. https://​doi. org/​10.1097/​01.chi.000​0246​051.53297.57

Chapter 10

Modern Group Eating Disorder Treatment Inclusion from a Cognitive Behavioral Perspective Emily L. Winter, Rachel Baumann, and Erin DeMaio

Introduction Eating disorders are complex psychiatric disorders affecting individuals psychologically, physically, and socially. Characterized by a persistent disturbance of eating or eating-​related behavior (American Psychiatric Association, 2022), eating disorders can compromise overall quality of life, pose significant long-​ and short-​term health complications, and can be fatal. Affecting over five million individuals yearly, on average, 4.4 million cases are reported in girls and women and 1.1 million cases in boys and men in the United States annually (Deloitte Access Economics, 2020). Adolescents and young adults are most at risk, with 1.2 million cases of eating disorders reported for individuals under 20 (Deloitte Access Economics, 2020). Thin idealism and Western cultural norms are linked to dieting behaviors, a significant eating disorder risk factor (Memon et al., 2020). Dieting and diet-​like behaviors associated with eating disorders include binge eating and compensatory behaviors (e.g., restricting, purging, excessive exercise, overvaluation of weight/​shape; Youngstrom et al., 2020). Concerns such as changes in attitude or performance, sudden weight change (e.g., loss, gain, fluctuation) over a short period of time, fatigue and/​or dizziness, rigidity around food, eating, and exercise, frequent trips to the bathroom, and skipping meals should be flagged (American Psychiatric Association, 2022). Eating disorders developed in adolescence often continue into adulthood, necessitating effective intervention (Austin et al., 2020). Group psychotherapy may be a particularly beneficial approach to eating disorder intervention, as it creates a pathway to clinically intervene with primary and secondary symptomology and behaviors in affected individuals. Specifically, the literature highlights the importance of early intervention in increasing the likelihood of complete recovery (Fukutomi et al., 2020). Group therapeutic factors such as peer interpersonal relations and feedback, social learning, emotional expression, and group cohesion (Yalom & Leszcz, 2005) are effective interventions in targeting maintenance factors like interpersonal issues and affect dysregulation (Grenon et al., 2017). Overview Eating disorders emerge from a combination of inheritable temperamental traits and environmental, physiological, and sociological factors. Life-​threatening mental illnesses and eating disorders affect teenagers of all genders, sexualities, ethnicities, shapes, and sizes. Those with bulimia nervosa (BN) and atypical eating disorders (other specified feeding and eating disorders) have double the death rate of peers without eating disorders (Lindvall et al., 2017). Anorexia nervosa (AN) is characterized by a restriction of energy intake relative to bodily requirements, leading to significantly low body weight or delayed growth. The Centers for Disease

DOI: 10.4324/9781351213073-12

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Control (Grave & Calugi, 2020) recommends determining a BMI-​for-​age percentile for children and adolescents as a screening measure. Overvaluation of shape and weight also occurs, as individuals have an intense weight gain fear, which differs from body dissatisfaction (common in the general population). Adolescents with AN develop distortions in the way they see their bodies and often do not see problems with any restricting or binge eating behaviors. To meet the criteria for BN, recurrent binge eating and inappropriate compensatory measures must be present at least once a week for three months on average. A “binge” is an eating episode where an objectively large amount of food is rapidly consumed. The individual also feels guilt, a lack of control, and is painfully full after eating. Several of the following extreme weight control methods must be present: self-​induced vomiting, misuse of laxatives or diuretics, dietary restriction, or excessive exercise (American Psychiatric Association, 2022). Binge-​eating disorder manifests in recurrent binge eating in the absence of the extreme weight control methods employed in BN. Binge eating must occur at least once a week for three months on average. Shame and great distress accompany binging behavior (O’Loghlen et al., 2022). Avoidant/​restrictive food intake disorder (ARFID) is a pattern of eating behaviors that is limited in variety and volume and associated with medical and psychosocial consequences. Consequences must include one or more symptoms: significant weight loss or arrested growth, nutritional deficiencies, reliance on tube feeding or nutrition supplements, or psychosocial impairment. Individuals with ARFID typically avoid or restrict because of sensory sensitivities, a fear of aversive consequences (choking, vomiting), and/​or a lack of interest in eating or in food (American Psychiatric Association, 2022). Atypical AN, which falls under other specified feeding and eating disorders, presents with the same behaviors and cognitive distortions as AN; however, those with this disorder are not considered underweight despite significant weight loss (Flament et al., 2015). Atypical AN is far more common than what is considered typical AN, affecting up to three percent of the population (Hay et al., 2017). Experts suggest that this classification of “other” or “atypical” eating disorders only intensifies the mental health stigma and may prevent individuals from believing that they are, in fact, sick enough to receive help. Providers need to challenge the incorrect belief that an individual needs to appear a certain way for a diagnosis or treatment, as research suggests that individuals with an atypical presentation often struggle with just as many medical and psychological concerns as those with more typical presenting diagnoses (Sawyer et al., 2016). All individuals who struggle with symptoms and eating disorder behaviors require evidence-​based treatment—​no matter their size. Assessment Early intervention impacts recovery and treatment effectiveness while simultaneously mitigating chronic health effects (Fukutomi et al., 2020). Assessment aids clinicians in treatment planning, case conceptualization, and monitoring progress, using data from multiple settings, people, and methods via screeners, interviews, self-​reports, and behavioral assessments. Screening Self-​report screeners are an emerging area of assessment designed to identify the level of help needed across settings (Davidson et al., 2022). The Stanford-​ Washington University Eating Disorder Screen (SWED) 3.0 is a brief online screening tool appropriate for individuals aged 13 and older (Graham et al., 2019) designed to help determine if treatment is needed. The Eating Attitudes Test (EAT-​26; Garner et al., 1982) is a brief and standardized measure that can be used

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for groups or individuals aged 13 and older, making it ideal for schools. These measures do not identify specific diagnoses; however, they encompass questions related to symptoms relevant to AN, BN, binge-​eating disorder, other specified eating disorders, as well as subthreshold eating disorder symptoms. Interview Interviews are frequently used as a clinician builds rapport with a client and their family. Basic therapeutic relationship principles apply, such as relying on verbal and non-​verbal attending skills (i.e., appearing, sounding, and acting attentively), open body language, and open-​ended questions (i.e., questions starting with a what or a how) within a welcoming and non-​judgmental environment (Sommers-​Flanagan et al., 2019). Clinicians may develop personal semi-​structured interviews based on their setting or use a previously developed measure, such as the Eating Disorder Examination (EDE; Fairburn et al., 1993). The EDE is a semi-​structured interview with high evidence of reliability and validity in assessing eating disorders and their symptoms across four domains: (1) Restraint, (2) Eating Concern, (3) Shape Concern, and (4) Weight Concern. Interviews often encompass general topics (e.g., development, school, family, medical) and eating disorder-​specific topics such as laxatives/​diuretics use, fasting, dieting, body image, binging, exercise, and emotional eating experiences. Assessing the following components is suggested: (1) onset, (2) events 12 months before onset, (3) feelings and experiences 6–​12 months after onset, (4) any recent habit changes, (5) the current state of the problem (Dalle & Caludi, 2020), and (6) assessment for comorbidities. Clinicians should be attuned to self-​harm, impulsivity or inattentiveness, mood disorders, anxiety, or substance abuse (Bloomgarden et al., 2007). Medical information such as weight, medical concerns, and immediate risk items (e.g., chest pain, lightheadedness or fainting, dizziness) should be collected and followed up on (Bloomgarden et al., 2007). Questionnaires Questionnaires are often used for intake and progress monitoring. Self-​report measures are brief, quick to administer, easy to track data, and low cost. Yet, as results are based on the client’s self-​ perception, bias may be a concern. Using multi-​informant assessment (e.g., client, parents) is advantageous for this reason. The Eating Disorder Inventory-​3 (Garner, 2004) is a brief 20-​minute standardized evaluation with evidence of consistency and validity for individuals aged 13 to 53. Downsides include the cost and credentials required by the publisher (Brookings et al., 2021). The free Eating Disorder Examination Questionnaire is a 28-​question companion to the previously mentioned EDE (Fairburn et al., 1993) measure for individuals 14 and older, or on the adolescent version for aged 12 and older. Behavioral Measures Self-​monitoring is a behavioral tool in which clients track behavior data naturalistically (e.g., the time of the meal, frequency of eating, type of food consumed, the number of binge episodes). This purpose (1) considers food consumption progress monitoring and (2) increases self-​awareness for real-​time behavior change (Tregarthen et al., 2019). Self-​monitoring may increase personal awareness of triggers and the use of coping skills for symptom management and can be completed on apps such as Recovery Record (Lindgreen et al., 2018).

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Cognitive Behavior Therapy (CBT) Conceptualization Familial and sociocultural factors such as dysfunctional patterns of behavior within the home, criticism, media, and peers are often highlighted as contributing factors to the development and/​or maintenance of eating disorders, and/​or psychological factors such as the physical changes associated with puberty, low-​self-​esteem, negative self-​evaluation, and the presence of comorbid psychiatric conditions like anxiety and personality disorders, developmental disorders, and substance abuse (Marucci et al., 2018), epilepsy (Kolstad et al., 2017), or type 1 diabetes (Zaremba et al., 2019) can be contributors (Himmerich et al., 2021). The underlying cognitive conceptualization of eating disorder pathology is based on the theory that eating disorders are primarily characterized by the overvaluation of weight and body shape, thus maintained by maladaptive cognitive, behavioral, and affective actions and behaviors (Levinson et al., 2018). Common eating disorder cognitions include fear of gaining weight, bodily acceptance and perceived importance of having an ideal weight and shape, and self-​worth related to control in diet and exercise. Compensatory behaviors associated with eating disorders stem from a desire to avoid weight gain (Youngstrom et al., 2020) and often include purging (e.g., vomiting, laxative misuse) and non-​purging behaviors (e.g., fasting, excessive exercise) (Youngstrom et al., 2020). Persistent, rigid core beliefs surrounding body image, diet, and exercise play an essential role in the maintenance of disordered behaviors and cognitive feedback systems. Dysfunctional behaviors can be associated with the core beliefs exhibited by individuals with eating disorders (Legenbauer et al., 2018). Dysfunctional thoughts exacerbate disordered eating actions, such as restrictive eating or purging behaviors. Feedback systems are cause-​and-​effect patterns within the cognitive-​emotional system, leading to recurring cycles of disordered behaviors, physical states, and cognitions. The instability of disordered eating feedback systems depicts the relation between cognition, emotion, behavior, and physiology (Troscianko & Leon, 2020). Further, self-​schemas (i.e., cognitive generalizations that organize sense of self) play a substantial role in the development and maintenance of eating disorders (Williams-​Kerver & Crowther, 2020). Discrepancies between an individual’s physical appearance and what they perceive to be “ideal” can create adverse psychological, emotional, and motivational repercussions for the individual, reflected in their actions/​behaviors surrounding the body and eating (Izydorczyk, 2021). Correlates of Diversity Eating disorders do not discriminate. Historically, research has focused on eating disorders in White female adolescents, with scholars more recently emphasizing the role of eating disorder identification systems and medical guidelines in perpetuating the “female only” eating disorder stereotype. This biased perspective has marginalized males and transgender individuals (Murray et al., 2017), aligning with minority stress theory (i.e., health consequences due to stigma and discrimination; Meyer, 2003). Individuals in the LGBTQIA2S+​community are disproportionately impacted by eating disorders, with transgender individuals diagnosed at higher rates than cisgender individuals (Coelho et al., 2019) and with gay, lesbian, and bisexual teens at higher risk for binge eating, laxative use, and purging as compared to their heterosexual counterparts (Parker & Harriger, 2020). Black individuals are more likely to engage in binge-​purge behaviors compared to White peers (Goode et al., 2020) and yet, Hispanic, Black, and Asian American individuals are less likely to receive eating disorder treatments than their White peers (Hernández et al., 2022; Goel et al., 2022; Goode

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et al., 2020). Taken together, clinicians need to provide affirming therapeutic spaces, advocating for systemic interventions to raise awareness for the intersectionalities of impact. Connection to the broader LGBTQIA2S+​community is a protective factor; thus, clinicians should consider what resources are available locally to their clients. As related to gender, historically, females were an exclusive focus in the literature. Their significance makes complete sense, as eating disorders are twice as common in women than in men (Deloitte Access Economics, 2020). However, a lack of representation has led to a shortage of tailored treatment and a reduction in early intervention (Fukutomi et al., 2020). Research suggests that men with eating disorders are more likely to be hospitalized than women, having the deadliest eating disorder cases (Fukutomi et al., 2020).

Group CBT and Eating Disorders The American Psychiatric (2006) and Psychological (2006) Associations recommend both group and individual CBT-​focused psychotherapy as approved, effective, and evidence-​based eating disorder treatment methods (Grenon et al., 2017). Given the benefits associated with group treatments (e.g., lower cost, decreased dropout rates, treatment acceptance) group-​ based treatment may be highly sought after given the accessibility of services and promising research outcomes (Grenon et al., 2017). There are special considerations when group therapy has an extensive evidence base depicting its effectiveness as an eating disorder intervention. Therapeutic group dynamics create an atmosphere where interpersonal factors underlying disordered eating can be easily addressed via peer feedback, social learning, emotional expression, and group cohesion. Interpersonal problems are often maintained, given that mood intolerance, low self-​esteem, and clinical perfectionism often accompany eating disorders. This can be addressed through group therapy (Grenon et al. 2017). Enhanced cognitive-​behavior therapy (CBT-​E) is an empirically supported transdiagnostic intervention for various types of eating disorders, following a four-​stage process providing individually tailored treatment sessions to their targeted population, often delivered through 20, 50-​minute sessions over 20 weeks (CBTE, n.d). Group adaptations of CBT-​E for eating disorder treatment yield significant reductions in global eating disorder psychopathology and frequency of eating disorder behaviors (Wade et al., 2017). Exploratory research analyses suggest CBT-​E may be particularly effective for individuals with severe comorbid psychopathology within the affected population (Agras, 2019). A sample outline of sessions that uses the CBT-​E framework is explored in Table 10.1. Given the highly specialized nature of the curriculum as well as the fact that comprehensive treatment usually lasts 20+​weeks, guidebooks, such as Cognitive behavior therapy for adolescents with eating disorders (Grave & Calugi, 2020), are suggested to review comprehensive details of what sessions might entail. The typical structure of treatment involves four stages (see Table 10.1) and incorporates principles such as treatment engagement, aims for “starting and ending well,” personal formulation of the eating disorder cause, assessment and progress monitoring of physical and psychological markers of progress, and generalization of skills to personal life. Dialectical behavior therapy (DBT), a variation of CBT, works to increase interpersonal effectiveness, improve emotion regulation, and build distress tolerance through strategies incorporating both cognitive-behavior and mindfulness. DBT’s framework is designed to reduce multiple symptoms simultaneously. DBT may be particularly useful for adolescents, as the underlying maintenance factors of disordered eating, such as emotional dysregulation and substance abuse, can be targeted through DBT’s framework (Vogel et al., 2021).

170  Emily L. Winter, Rachel Baumann, and Erin DeMaio Table 10.1 Sample Treatment Protocol STAGE 1 This intensive stage typically lasts four weeks. A client’s success in this stage is a strong predictor of their likelihood in obtaining recovery. Goals include engagement in treatment, assessment of a client’s needs and mental health, psychoeducation around weight, and eating expectations. Clients begin the endeavor of regaining weight. Topics may include: (1) eating disorder diagnosis, prevalence, and related eating symptoms, (2) eating disorder impact on health, social, and psychological functioning, and (3) details about the CBT-​E process. STAGE 2 This is a rather brief stage in which the therapists and their client review progress, identify any obstacles that are hindering change, make any necessary adaptations, and plan for the next stage. STAGE 3 This stage addresses the remaining factors that are contributing to maintaining the eating disorder, shape and weight concerns, and any extreme dietary restrictions. Generalization to other environments is emphasized, and thus psychoeducation groups may focus on external mechanisms such as perfectionism, self-​e steem, interpersonal relationships, or social media. STAGE 4 The final stage is about “ending treatment well” (Grave, 2012) by paying attention to worries regarding completing treatment, reviewing progress, and anticipating possible setbacks. Psychoeducation groups may further lean into “generalization,” looking to help clients with skills they will need outside of treatment, as well as problem-​s olve real-​life scenarios they have encountered. The group format is especially relied upon to offer collective support and validation as clients face setbacks in the final stages of treatment, as well as celebrate successes. Source: Adapted from Grave (2012) and Grave and Calugi (2020).

Sample Treatment Interventions Cognitive Behavioral Therapy-​E nhanced (CBT-​E ) Cognitive behavioral therapy-​enhanced (CBT-​E) is a group model conceptualization used with all types of eating disorders. CBT-​E posits that the core psychopathology of eating disorders is the over-​evaluation of weight and shape. Adolescents with eating disorders use shape, weight, and control as the primary and usually only method of self-​evaluation (e.g., Am I worthy?; Grave, 2012). CBT-​E challenges distortions by providing other means to self-​evaluate (i.e., relationships with others, effort in school, engagement in extracurricular activities). CBT-​E provides psychoeducation on the over-​evaluation of shape and weight as well as helps challenge the fixed belief that one’s self-​worth is derived from one’s appearance while exploring other life domains they can use to build their self-​worth (Ehrenreich-​May et al., 2017; Grave, 2012; Grave & Calugi, 2020). Group sessions are conducted by two therapists and begin with an overview of the meeting. Sessions follow the content of individual CBT-​E sessions but without individualization. Homework is reviewed, and group members are encouraged to share their successes and challenges with others. The group format provides opportunities for group members to share commonalities, receive mutual support, and actively problem-​solve. The first group session highlights CBT’s underpinnings: in recognizing how our thoughts, emotions, and behaviors are interconnected, we can change how we feel or behave. Psychoeducation and discussion are provided on the topic of how adolescents and people in general evaluate themselves (Grave, 2012; Grave & Calugi, 2020).

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The following are potential group topics: (1) psychoeducation on how people with eating disorders may over-​evaluate based on shape and weight while neglecting healthier life domains, (2) learn about body checking, body fixing, and avoidance behaviors and make a plan to address them, (3) identify external maintaining mechanisms such as perfectionism, low self-​esteem, and interpersonal problems, (4) recognize negative core beliefs and learn how they contribute to their maladaptive behaviors, and (5) challenge and eventually change these negative core beliefs (Grave, 2012; Grave & Calugi, 2020; Legenbauer et al., 2018). CBT-​A R CBT-​AR is an evidence-​based ARFID treatment that examines each client’s behavior from an empathic and non-​judgmental stance. It is imperative to not further shame clients, who have often been ostracized for “picky” eating. First, CBT psychoeducation is provided. Adolescents learn how to separate thoughts, feelings, and behaviors and identify automatic negative thoughts. Discussion includes how automatic negative thoughts about food and eating contribute to maintaining mechanisms (Grave, 2012). Psychoeducation is also provided on the negative consequences of nutrition deficiencies and the need for continued flexibility around eating. The next step includes learning about core beliefs around fear and anxiety and how they are related to the client’s eating patterns (Ehrenreich-​May et al., 2017). Groups discuss how avoidance contributes to increased anxiety over time and how that serves to maintain the mechanisms of the eating disorder. It is helpful to teach and discuss how various cognitive distortions contribute to maintaining the eating disorder. Group members explore how exposure, although uncomfortable and distressing, is the best option to disconfirm their catastrophic beliefs about food (in the case of the fear of aversive consequences). Coping skills are also taught so that clients will learn that even if their unlikely scenario were to occur (e.g., choking), they could cope with it. If there are group members who struggle with eating enough, psychoeducation on strategies for eating enough is included (Thomas & Eddy, 2019). Dialectical Behavior Therapy The third intervention examines the advantages and disadvantages of acting on eating disorder urges and impulses by using dialectical behavioral therapy’s distress tolerance skill, pros/​cons list. The important points to outline to the group are as follows: (1) eating disorder recovery comes after changing behavior and (2) weighing the pros and cons of acting on eating disorder urges and impulses can be a helpful coping strategy (Rathus & Miller, 2015). The therapist may say: Changing our behaviors is imperative to recovery. When you start to change your behavior, uncomfortable feelings and thoughts can begin to change as well. If you struggle with over-​exercise, only after stopping exercise will you learn that it is not scary to discontinue exercise. Sometimes we need to change behavior before thoughts can change. Our thoughts will not change until we change our behavior. The therapist continues: We are going to make a pros and cons list on the board. I would like everyone to participate. What eating disorder behavior should we choose? Sample activity: Pros and cons list for binge-​eating disorder: Group facilitators may draw a DBT pros and cons list that includes: pros of engaging in binge eating behavior, pros of not engaging in binge eating behavior, cons of engaging in binge-​eating disorder behavior, and cons of not engaging in binge-​eating disorder behavior. This activity encourages adolescents to examine the pros and cons of tolerating the distress of a situation (not giving in to eating disorder behavior) and the pros and cons of not tolerating the situation (giving in to eating disorder behavior). The group facilitator can also encourage group members to individually choose an eating disorder urge.

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Individuals then independently brainstorm replacement behaviors for the specific urge (i.e., calling a friend when they feel the urge to binge) and then share and reflect together. Obstacles Although group treatment boasts numerous benefits, groups can be challenging. For instance, symptom sharing increases cohesion between members by establishing a mutual connection via diagnosis or symptom commonalities. The case example below explains that group cohesion fueled by connection beyond mental health diagnosis is essential for health and potential for recovery. Research on adult group treatment outcomes suggests that positive connections develop when group members share challenges related to living with an eating disorder, grounded in the hope and goal for recovery (Waller et al., 2020). In developing a sense of “we-​ness,” the collective group identity inevitably follows, helping members feel less alone in their experiences and connect positively with those who “actually understand,” while cultivating hope and motivation instead of symptom sharing and pro-​eating disorder encouragement (Waller et al., 2020). At the same time, research suggests that clients may feel upset due to seeing people’s bodies or hearing about others’ eating disorder experiences (Waller et al., 2020). Therefore, group facilitators should understand their positive role as leaders (Waller et al., 2020) and help individuals forge connections based on hope and motivation instead of similarities based on diagnoses. Another concern of group treatment involves the attachment of the individual or family members to old habits or patterns of interaction. The first edition of this book (Bloomgarden et al., 2007) emphasized that the practical, direct, assertive communication styles that group participants learn may be jarring for their family members. Nevertheless, it is a natural course of treatment to practice self-​esteem and communication-​strengthening strategies. With current research across levels of care suggesting that familial involvement is imperative to successful recovery (Anderson et al., 2017), tying in family members to learn skills concurrently with the client and learning how to embrace the changes that come with treatment is critical for the success and longevity of recovery. Parents should be involved in support groups, skill-​building sessions, and receive regular updates (within appropriate bounds of confidentiality). Open lines of communication between parents and outside providers who may provide tailored familial-​based support are paramount. At the same time, the client may also resist change. There may be attachment to old habits, even when habits were unhealthy and detrimental to the adolescent. Although the client used unhealthy coping strategies in the past, these behaviors still did something for the client. Thus, it takes time to break down such habits and increase buy-​in (Bloomgarden et al., 2007). Group facilitators must be aware of the stages of change model (Prochaska & DiClemente, 1982) and understand where certain members may be on the journey to behavior change. As long as the client develops an understanding of new methods and connects that material to their life, the client is likely to make better insights and connections, a predictor of behavior change (Bloomgarden et al., 2007). Case Example The following case example presents a group of adolescents receiving group-​based therapy for ARFID. Challenges explored in this example consider the topics of social identification and dropout, both of which frequently are barriers identified in group-​based eating disorder treatment. Specifically, dropout has been shown to be of large concern when treating ARFID, which is the clinical presentation explored in this case study (Zickgraf et al., 2016). Reflecting on the importance of cohesion, group facilitators must foster connection, strengthening bonds from a healthy and treatment-​focused perspective. In this example, Alex, a group member, shares his experience with “rules and assumptions” in an early group session. Given his history of a fear of vomiting, Alex talks about the rules that he feels

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he must follow to avoid the intense and paralyzing fear of throwing up. In this sharing process, Alex may be looking for feedback and, at the same time, has become increasingly dysregulated, thinking about the changes that need to occur to accomplish his treatment goals. He feels hopeless and helpless: “This group is worthless,” he remarks, sharing that he feels that he must follow his rules to avoid the unpleasantness of vomiting otherwise life will be full of misery. He says that the uncertainty of not knowing whether he will throw up is too much to handle. After, Alex gets up and starts to leave the group. The facilitator recognizes the complexity present: (1) talking about a difficult common experience among group members (an opportunity for connection) and (2) the immense feeling of the fear of failure and slight resistance to (or doubt in) treatment that Alex verbalized. “We see you and hear you Alex,” shares the facilitator. “That is a vulnerable and challenging thought to share and I so appreciate that you felt comfortable enough to do so.” Further invitation for connection and feedback is offered: “Does anyone else ever have doubt creep in? If so, how do you remain focused on your goals?” Redirection is offered to the group regarding change-​focused behaviors and the facilitator provides a bid for Alex to re-​engage him in the group process (social identification opportunity). “I invite anyone to offer words of encouragement to Alex right now,” the facilitator proposes. Research suggests that opportunities for positive member-​to-​member feedback lead to the highest level of group cohesion (Kivlighan et al., 2020). Further, perceived similarity (e.g., personal characteristics, symptom profile, interests) across group members is one avenue to foster connection and predict social identification. Social identification is a key force in facilitating positive changes in group therapy (Cruwys et al., 2020). Within eating disorder groups specifically, finding commonality between group members is a critical feature to strengthen the cohesiveness (and thereby the potential for success) of the group as a whole (Waller et al., 2020). However, the potential for peer aggregation (i.e., learning self-​ destructive behaviors from others) is high and needs to be closely monitored by a facilitator. Therein lies the conflict—​a double-​edged sword—​symptom sharing can either further contribute to negative behaviors (i.e., engagement of pro-​eating disorder dialogue) or can facilitate “joining in” of prosocial behaviors. For Alex, feelings of hopelessness and frustration are apparent. If not facilitated appropriately, this scenario could lead to other members sharing their frustration and engaging in increased discussion regarding restrictive eating behaviors. Relying on social identification research, using opportunities like this to communicate similarities different from pure symptomatology may be most appropriate—​redirecting members to share and explore common goals, frustrations/​setbacks, and how those can be overcome. For example, group facilitators may seek to create check-​in activities centered around commonalities, such as hobbies, friends, careers, or future goals. Given dropout rates, it is helpful to include adolescents’ friends, who can serve as excellent motivators to remain actively engaged in treatment (Pisetsky et al., 2016). It is crucial to communicate these benefits when working with adolescents. Facilitators can model and explain identifiers of cohesion, such as noting body language and how this may impact connection feelings (i.e., nodding, diverting eye contact), showcasing validating comments (i.e., “Alex, I am happy you shared that with us”), and identifying themes for mutual understanding. Progress monitoring and data collection should be considered, given that group cohesion is a protective factor against dropout. Prior research has considered that the Group Cohesiveness Scale, a free and brief measure (Treadwell et al., 2001), has been extended for preliminary recommendation in use for clinical therapy groups to measure group cohesion progress (Wongpakaran et al., 2013). Qualitative data can be collected anonymously from group members through free polling systems (i.e., Google Forms, PollEv) to assess questions such as: (1) Do you feel represented in this group’s membership, (2) What is the responsibility of group members to get the mission accomplished,

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or (3) In what ways does the group face challenges or differences of opinion? (Defense Equal Opportunity Management Institute, 2015). Summary Eating disorders are serious, potentially fatal, and complex mental health concerns, often coupled with physical health implications. Experts call for early intervention, citing immediate treatment with an increased likelihood of successful recovery. Groups incorporating cognitive behavioral perspectives (CBT-​E, CBT-​AR, and DBT) may improve symptoms, guiding individuals toward holistic health and recovery. Administered within the group setting, these interventions may benefit adolescents in a practical, low-​cost, and evidence-​based format while simultaneously fostering connection. Acknowledgments Special thanks to Melissa Foley, LPC, NCC, for her support and consultation on clinical resources. References Agras, W. S. (2019). Cognitive behavior therapy for the eating disorders. Psychiatric Clinics of North America, 42(2), 169–​179. https://​doi.org/​10.1016/​j.psc.2019.01.001 American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders. Arlington, VA: American Psychiatric Publishing. American Psychiatric Association. (2006). Practice guideline for the treatment of patients with eating disorders (3rd ed.). American Journal of Psychiatry, 163, 1–​54. American Psychological Association. (2006). Task force on evidence-​based practice. Evidence-​based practice in psychology. American Psychologist, 61, 271–​285. Anderson, L., Reilly, E., Berner, L., Wierenga, C., Jones, M., Brown, T., Kaye, W. & Cusack, A. (2017). Treating eating disorders at higher levels of care: Overview and challenges. Current Psychiatry Reports, 19(8), 1–​9. https://​doi.org/​10.1007/​s11​920-​017-​0796-​4 Austin, A., Flynn, M., Richards, K., Hodsoll, J., Duarte, T. A., Robinson, P., Kelly, J., & Schmidt, U. (2020). Duration of untreated eating disorder and relationship to outcomes: A systematic review of the literature. European Eating Disorders Review, 29(3), 329–​345. https://​doi.org/​10.1002/​erv.2745 Bloomgarden, A., Mennuti, R., Conti, A., & Weller, A. (2007). A relational-​cultural, cognitive-​behavioral, approach to treating female adolescent eating disorders. In R. W. Christner, J. Stewart, & A. Freeman, A. (Eds.), Handbook of cognitive-​behavior group therapy with children and adolescents: Specific settings and presenting problems (pp. 447–​464). Routledge/​Taylor & Francis Group. Brookings, J., Jackson, D., & Garner, D. (2021). A bifactor and item response theory analysis of the Eating Disorder Inventory-​3. Journal of Psychopathology and Behavioral Assessment, 43(1), 191–​204. https://​doi. org/​10.1007/​s10​862-​020-​09827-​2 CBT-​E Enhanced Cognitive Behaviour Therapy. (n.d.). A Description of CBT-​E. CBT-​E. www.cbte.co/​what-​ is-​cbte/​a-​desc​ript​ion-​of-​cbt-​e/​ Coelho, J., Suen, J., Clark, B. A., Marshall, S. K., Geller, J., & Lam, P.-​Y. (2019). Eating disorder diagnoses and symptom presentation in transgender youth: A scoping review. Current Psychiatry Reports, 21(11), 107–​110. https://​doi.org/​10.1007/​s11​920-​019-​1097-​x Cruwys, T., Steffens, N. K., Haslam, S. A., Haslam, C., Hornsey, M. J., McGarty, C., & Skorich, D. P. (2020). Predictors of social identification in group therapy. Psychotherapy Research, 30(3), 348–​361. https://​doi. org/​10.1080/​10503​307.2019.1587​193 Dalle, R., & Calgui, S. (2020). Cognitive behavior therapy for adolescents with eating disorders. The Guilford Press.

Modern Group Eating Disorder Treatment 175 Davidson, K., Barry, M., Mangione, C., Cabana, M., Chelmow, D., Coker, T., Davis, E., Donahue, K., Jaén, C., Kubik, M., Li, L., Ogedegbe, G., Pbert, L., Ruiz, J., Silverstein, M., Stevermer, J., Wong, J., & US Preventive Services Task Force. (2022). Screening for eating disorders in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA, 327(11), 1061–​1067. https://​doi.org/​ 10.1001/​jama.2022.1806 Defense Equal Opportunity Management Institute. (2015). Focus group guide: The climate Assessment process. www.def​ense​cult​ure.mil/​Port​als/​90/​Docume​nts/​A2S /​GDE-​A2S-​Focus_​Group-​20180625.pdf?ver=​ 2020-​02-​10-​132226-​390 Deloitte Access Economics. (2020). The social and economic cost of eating disorders in the United States of America: A report for the strategic training initiative for the prevention of eating disorders and the Academy for Eating Disorders. www.hsph.harv​ard.edu/​stri​ped/​rep​ort-​econo​mic-​costs-​of-​eat​ing-​disord​ers/​ Ehrenreich-​May, J., Kennedy, S. M., Sherman, J. A., Bennett, S. M., & Barlow, D. H. (2017). Unified protocol for transdiagnostic treatment of emotional disorders in adolescents: Workbook. Oxford University Press. Fairburn, C., Wilson, G., & Schleimer, K. (1993). Binge eating: Nature, assessment, and treatment. The Guilford Press. Flament, M. F., Henderson, K., Buchholz, A., Obeid, N., Nguyen, H., Birmingham, M., & Goldfield, G. (2015). Weight status and DSM-​5 diagnoses of eating disorders in adolescents from the community. Journal of the American Academy of Child and Adolescent Psychiatry, 54(5), 403–​411. https://​doi.org/​ 10.1016/​j.jaac.2015.01.020 Fukutomi, A., Austin, A., McClelland, J., Brown, A., Glennon, D., Mountford, V., Grant, N., Allen, K. & Schmidt, U. (2020). First episode rapid early intervention for eating disorders: A two-​year follow-​up. Early Intervention in Psychiatry, 14(1), 137–​141. https://​doi.org/​10.1111/​eip.12881 Garner, D. M. (2004). Eating Disorder Inventory-​3. Psychological Assessment Resources. Garner, D. M., Olmsted, M. P., Bohr, Y., & Garfinkel, P. E. (1982). The Eating Attitudes Test: Psychometric features and clinical correlates. Psychological Medicine, 12(4), 871–​878. https://​doi.org/​10.1017/​S00332​ 9170​0049​163 Goel, N. J., Thomas, B., Boutté, R. L., Kaur, B., & Mazzeo, S. E. (2022). “What will people say?”: Mental health stigmatization as a barrier to eating disorder treatment-​seeking for South Asian American women. Asian American Journal of Psychology. Advance online publication. https://​doi.org/​10.1037/​aap​0000​271 Goode, R. W., Cowell, M. M., Mazzeo, S. E., Cooper-​Lewter, C., Forte, A., Olayia, O. I., & Bulik, C. M. (2020). Binge eating and binge-​eating disorder in Black women: A systematic review. International Journal of Eating Disorders, 53(4), 491–​507. https://​doi.org/​10.1002/​eat.23217 Graham, A. K., Trockel, M., Weisman, H., Fitzsimmons-​Craft, E. E., Balantekin, K. N., Wilfley, D. E., & Taylor, C. B. (2019). A screening tool for detecting eating disorder risk and diagnostic symptoms among college-​age women. Journal of American College Health, 67(4), 357–​366. https://​doi.org/​10.1080/​07448​ 481.2018.1483​936 Grave, D., & Calugi, S. (2020). Cognitive behavior therapy for adolescents with eating disorders. Guilford Publications. Grave, R. D. (2012). Intensive cognitive behavior therapy for eating disorders. Nova Science Publishers. Grenon, R., Schwartze, D., Hammond, N., Ivanova, I., Mcquaid, N., Proulx, G., & Tasca, G. A. (2017). Group psychotherapy for eating disorders: A meta-​analysis. International Journal of Eating Disorders, 50(9), 997–​1013. https://​doi.org/​10.1002/​eat.22744 Hay, P., Mitchison, D., Collado, A. E. L., González-​Chica, D. A., Stocks, N., & Touyz, S. (2017). Burden and health-​related quality of life of eating disorders, including Avoidant/​Restrictive Food Intake Disorder (ARFID), in the Australian population. Journal of Eating Disorders, 5, 21. https://​doi.org/​10.1186/​s40​ 337-​017-​0149-​z Hernández, J. C., Perez, M., & Hoek, H. W. (2022). Update on the epidemiology and treatment of eating disorders among Hispanic/​Latinx Americans in the United States. Current Opinion in Psychiatry, 35(6), 379–​384. https://​doi.org/​10.1097/​YCO.00000​0000​0000​819 Himmerich, H., Kan, C., Au, K., & Treasure, J. (2021). Pharmacological treatment of eating disorders, comorbid mental health problems, malnutrition and physical health consequences. Pharmacology & Therapeutics, 217, 107667. https://​doi.org/​10.1016/​j.pha​rmth​era.2020.107​667

176  Emily L. Winter, Rachel Baumann, and Erin DeMaio Izydorczyk, B. (2021). Body image in eating disorders: Clinical diagnosis and integrative approach to psychological treatment (1st ed.). Routledge. Kivlighan, D. M. III, Ali, R. W., & Garrison, Y. L. (2020). Is there an optimal level of positive and negative feedback in group therapy? A response surface analysis. Psychotherapy, 57(2), 174–​183. https://​doi.org/​ 10.1037/​pst​0000​244 Kolstad, E., Bjork, M., Gilhus, N. E., Alfstad, K., Clench-​Aas, J., & Lossius, M. (2017). Young people with epilepsy have an increased risk of eating disorder and poor quality diet. Epilepsia Open, 3(1), 40–​45. https://​doi.org/​10.1002/​epi4.12089 Legenbauer, T., Radix, A. K., Augustat, N., & Schütt-​Strömel, S. (2018). Power of cognition: How dysfunctional cognitions and schemas influence eating behavior in daily life among individuals with eating disorders. Frontiers in Psychology, 9, 2138. https://​doi.org/​10.3389/​fpsyg.2018.02138 Levinson, C. A., Brosof, L. C., Vanzhula, I., Christian, C., Jones, P., Rodebaugh, T. L., Langer, J. K., White, E. K., Warren, C., Weeks, J. W., Menatti, A., Lim, M. H., & Fernandez, K. C. (2018). Social anxiety and eating disorder comorbidity and underlying vulnerabilities: Using network analysis to conceptualize comorbidity. International Journal of Eating Disorders, 51(7), 693–​709. https://​doi.org/​10.1002/​eat.22890 Lindgreen, P., Lomborg, K., & Clausen, L. (2018). Patient experiences using a self-​monitoring app in eating disorder treatment: Qualitative study. JMIR mHealth and uHealth, 6(6), e10253. https://​doi.org/​ 0.2196/​10253 Lindvall, C., Wisting, L., & Rø, Ø. (2017). Feeding and eating disorders in the DSM-​5 era: A systematic review of prevalence rates in non-​clinical male and female samples. Journal of Eating Disorders, 5, 56. https://​doi.org/​10.1186/​s40​337-​017-​0186-​7 Marucci, S., Ragione, L. D., De Iaco, G., Mococci, T., Vicini, M., Guastamacchia, E., & Triggiani, V. (2018). Anorexia nervosa and comorbid psychopathology. Endocrine, Metabolic & Immune Disorders Drug Targets, 18(4), 316–​324. https://​doi.org/​10.2174/​187153​0318​6661​8021​3111​637 Memon, A. N., Gowda, A. S., Rallabhandi, B., Bidika, E., Fayyaz, H., Salib, M., & Cancarevic, I. (2020). Have our attempts to curb obesity done more harm than good? Cureus, 12(9), e10275. https://​doi.org/​ 10.7759/​cur​eus.10275 Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–​697. https://​doi.org/​ 10.1037/​0033-​2909.129.5.674 Murray, S. B., Nagata, J. M., Griffiths, S., Calzo, J. P., Brown, T. A., Mitchison, D., Blashill, A. & Mond, J. M. (2017). The enigma of male eating disorders: A critical review and synthesis. Clinical Psychology Review, 57, 1–​11. http://​dx.doi.org/​10.1016/​j.cpr.2017.08.001 O’Loghlen, E., Grant, S., & Galligan, R. (2022). Shame and binge eating pathology: A systematic review. Clinical Psychology & Psychotherapy, 29(1), 147–​163. https://​doi.org/​10.1002/​cpp.2615 Parker, L. L., & Harriger, J. A. (2020). Eating disorders and disordered eating behaviors in the LGBT population: A review of the literature. Journal of Eating Disorders, 8(1), 1–​20. https://​doi.org/​10.1186/​s40​ 337-​020-​00327-​y Pisetsky, E., Utzinger, L., & Peterson, C. (2016). Incorporating social support in the treatment of Anorexia Nervosa: Special considerations for older adolescents and young adults. Cognitive and Behavioral Practice, 23(3), 316–​328. https://​doi.org/​10.1016/​j.cbpra.2015.09.002 Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research & Practice, 19(3), 276–​288. http://​dx.doi.org/​10.1037/​h0088​437 Rathus, J., & Miller, A., (2015). DBT skills manual for adolescents. The Guilford Press. Sawyer, S. M., Whitelaw, M., Le Grange, D., Yeo, M., & Hughes, E. K. (2016). Physical and psychological morbidity in adolescents with atypical anorexia nervosa. Pediatrics, 137(4), e20154080. https://​doi.org/​ 10.1542/​peds.2015-​4080 Sommers-​Flanagan, J., Johnson, V., & Rides At The Door, M. (2019). Clinical interviewing. In M. Sellbom & J. Suhr (Eds.), The Cambridge handbook of clinical assessment and diagnosis (pp. 113–​122). Cambridge University Press. https://​doi.org/​10.1017/​978110​8235​433.010 Thomas, J., & Eddy, K. (2019). Cognitive-​behavioral therapy for avoidant/​restrictive food intake disorder: Children, adolescents, and adults. Cambridge University Press.

Modern Group Eating Disorder Treatment 177 Treadwell, T., Lavertue, N., Kumar, V. K., & Veeraraghavan, V. (2001). The Group Cohesion Scale-​ Revised: Reliability and validity. International Journal of Action Methods: Psychodrama, Skill Training, and Role Playing, 54(1), 3–​12. Tregarthen, J., Kim, J. P., Sadeh-​Sharvit, S., Neri, E., Welch, H., & Lock, J. (2019). Comparing a tailored self-​help mobile app with a standard self-​monitoring app for the treatment of eating disorder symptoms: Randomized controlled trial. JMIR Mental Health, 6(11), e14972. https://​doi.org/​10.2196/​14972 Troscianko, E. T., & Leon, M. (2020). Treating eating: A dynamical systems model of eating disorders. Frontiers in Psychology, 11, 1801. https://​doi.org/​10.3389/​fpsyg.2020.01801 Vogel, E. N., Singh, S., & Accurso, E. C. (2021). A systematic review of cognitive behavior therapy and dialectical behavior therapy for adolescent eating disorders. Journal of Eating Disorders, 9(1), 1–​38. https://​ doi.org/​10.1186/​s40​337-​021-​00461-​1 Wade, S., Byrne, S., & Allen, K. (2017). Enhanced cognitive behavioral therapy for eating disorders adapted for a group setting. International Journal of Eating Disorders, 50(8), 863–​872. https://​doi.org/​10.1002/​ eat.22723 Waller, A., Paganini, C., Andrews, K., & Hutton, V. (2020). The experience of adults recovering from an eating disorder in professionally-​led support groups. Qualitative Research Journal, 21(2), 217–​229. https://​ doi.org/​ 10.1108/​QRJ-​07-​2020-​0088 Williams-​Kerver, G. A., & Crowther, J. H. (2020). Emotion differentiation and disordered eating behaviors: The role of appearance schemas. Eating Behaviors, 37, 101369. https://​doi.org/​10.1016/​j.eat​beh.2020.101​369 Wongpakaran, T., Wongpakaran, N., Intachote-​ Sakamoto, R., & Boripuntakul, T. (2013). The Group Cohesiveness Scale (GCS) for psychiatric inpatients. Perspectives in Psychiatric Care, 49(1), 58–​64. https://​doi.org/​10.1111/​j.1744-​6163.2012.00342.x Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy. Basic Books. Youngstrom, E. A., Prinstein, M. J., Mash, E. J., & Barkley, R. A. (2020). Assessment of disorders in childhood and adolescence (5th ed.). The Guilford Press. Zaremba, N., Watson, A., Kan, C., Broadley, M., Partridge, H., Figuereido, C., Hopkins, D., Treasure, J., Ismail, K., Harrison, A., & Stadler, M. (2019). Multidisciplinary healthcare teams’ challenges and strategies in supporting people with type 1 diabetes to recover from disordered eating. Diabetic Medicine, 37(12), 1992–​2000. https://​doi.org/​10.1111/​dme.14207 Zickgraf, H., Franklin, M., & Rozin, P. (2016). Adult picky eaters with symptoms of avoidant restrictive food intake disorder: Comparable distress and comorbidity but different eating behaviors compared to those with disordered eating symptoms. Journal of Eating Disorders, 4, 26. https://​doi.org/​10.1186/​s40​ 337-​016-​0110-​6

Chapter 11

Group CBT for Youth Experiencing Grief Micaela Thordarson

Children experience death, grief, and loss with unfortunate frequency. Approximately one in 14 children will lose a parent or sibling before reaching the age of 18 –​nearly six million young people (JAG Institute, 2023). Grieving a loved one is also a natural and expected process that does not necessarily require intervention from a professional. However, with the general societal taboo against speaking about death and the resulting avoidance of the topic, youth are often left without opportunities to process and understand their reactions properly. Despite numerous available resources, it remains unclear what is necessary for youth to receive in response to the death of a loved one (Revet et al., 2018). Research around major losses is also heavily influenced by a predominantly Western mentality regarding who “counts” as a person for whom a child may experience clinically significant grief. Further, the child’s very experience and expression of grief are markedly impacted by developmental stage and intersectional cultural identities (The Dougy Center, 2023; Revet et al., 2018). Thus, the scientific understanding of grief in youth is limited in a number of ways. Grief is considered a life-​long experience in some ways, as the loss and related emotions often ebb and flow in the context of milestones. Thus, the younger the child, the more frequently and variably a grief reaction may emerge over time (Rider et al., 2021). A child who did not appear to need additional support may become an adolescent in dire need of intervention to address bereavement. A youth’s grief process may be impacted by pre-​existing mental health conditions, family history of mental health conditions, and the manner in which the loved one passed (Boelen et al., 2021). Grief may become “complicated” or be considered “prolonged” if a child ineffectively processes the loss of the relationship and the emotional impact; grief may also become “traumatic” depending on the circumstances of the death (Spuij et al., 2012). Treatment of grief may be indicated if the process becomes pathological or simply if the child may benefit (Revet et al., 2018). The concept of pathological grief processes and the decision of whether to offer intervention remain under discussion in the literature. Overview of Grief Considering death is possibly the only universal human experience, understanding and facilitating healthy processing of grief seems vital. The debate has ensued for years regarding whether there is value in listing a diagnosis related to pathological responses to grief. The DSM-​5 cites Persistent Complex Bereavement Disorder as a condition for further study (American Psychiatric Association, 2013); the ICD-​11 is marked by the addition of prolonged grief disorder (World Health Organization, 2019). Both are characterized by persistent emotional distress, difficulties navigating social relationships and daily functioning, and preoccupation with separation from the deceased. Using a CBT conceptualization, grief is broken down into emotions of intense sadness, loneliness, DOI: 10.4324/9781351213073-13

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and/​or longing. Common associated beliefs include that life cannot be the same without the loved one, the bereaved individual’s identity is transformed, and the youth will be unable to cope with or gain relief from the grief. Behaviors typically involve disruptions in social relationships, typical activities, and general impairments in functioning. And –​youth, in general, vary quite widely in their experience of grief. Due to the permanent nature of death, grief reactions are substantially impacted by developmental stage of the bereaved. It is critical to understand the cognitive and emotional differences of children of all ages to be able to communicate about death and promote healthy responses to grief. Youth under the age of four do not grasp the immutable fact of death and may expect the deceased to return after a time. This age also does not recognize the impact on others and may ask questions about death and the deceased repeatedly without seeming to grasp the answers. They may express their distress more behaviorally, preferring more attention than usual, regressing in certain areas, and displaying generalized emotion dysregulation. Children between the ages of five and eight have cognitive processes that are more concrete, are beginning to explore more of the world independently, and engage in regular magical thinking. At this developmental stage, youth still do not recognize the permanence of death, believe that specific actions may help bring the person back to life, or blame themselves for the death. In addition to disruptions to sleep, energy, and appetite, children at this age may develop fears about whether others will die, separation distress, and nightmares. For youth between 9 and 12, social relationships have more meaning, and abstract concepts are more perceivable. Youth begin to recognize both the long-​lasting nature of death and the life-​long impact. Given the increased social orientation, children may withdraw from their remaining relationships, develop anxiety about whether a loss will happen again and to whom, and seek more information about death and dying. Adolescents fully understand the ramifications of death, are already developing autonomy and identity, and are oriented toward peers. When faced with grief, they may reflect on existential questions or disruptions to the identity they have been forming. Adolescents may engage in substantial risk-​taking behaviors or may attempt to take on caretaking roles in the household. For youth of all ages, giving honest, clear answers is crucial. Avoid euphemisms such as “lost,” “departed,” and “gone.” Maintaining structure and consistency also enhances adaptation and promotes faster recovery. Additionally, given the ways that death can feel outside of any person’s control, it is helpful to provide youth with choices whenever possible to increase their sense of agency. A thorough review of developmental attention to grief can be found at the Dougy Center (www.dougy.org, 2023). Assessment and Progress Monitoring Identifying youth who may benefit from group CBT for grief will depend on the goals of the group leaders. Groups may be designed to include youth within specific developmental levels, with losses within an outlined timeframe, who have lost a designated relationship or by the same means of death, who have been exposed to a large community-​level event, or with multiple mental health concerns. The greatest body of literature supports offering treatment to children with clinically significant grief and without additional primary presenting problems. As other mental health conditions may interfere with the adaptive processing of grief, it is typically indicated to address those issues first to be then able to treat the bereavement. For example, Cohen et al., (2006) determined that youth with post traumatic stress disorder (PTSD) and unresolved loss required trauma-​focused care first to be able to engage in grief-​related interventions. Once the inclusion criteria are identified, a clinical interview is warranted to gather a broad understanding of the daily functioning and general symptomology of the child. The inclusion of caregivers in the clinical interview is strongly recommended. The child’s response to questions

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and discussion during the intake can inform whether the youth is equipped to engage in group treatment. Youth who are unable to discuss any aspect of the deceased without significant emotional dysregulation or youth whose behaviors indicate they may require frequent redirection may not be a good fit for group intervention. A clinical interview is also an opportune time to seek informed consent from both the child and the caregiver regarding the experience of group treatment, expectations for outcomes, and willingness to connect with peers in this matter. Often, adults may prefer a child enter therapy while a child is hesitant or unwilling. Enlisting youth who are not interested in treatment creates a group culture of disengaged participants, which can be unhelpful to all members. In addition to clinical interviews, outcome measures are warranted. The design of a series of questionnaires allows for the identification of youth who are indeed suffering from clinically significant grief, as well as youth who may have more complex clinical presentations. There are a handful of measures to assess symptoms of problematic grief reactions in children; none are cited as necessarily useful for progress monitoring (Revet et al., 2018). Additionally, there are no current measures for youth under the age of eight, given the developmental heterogeneity of symptoms in younger children (Spuij et al., 2017). The Texas Revised Inventory of Grief was designed for adults. It can be used for adolescents and was designed for a general understanding of grief response rather than targeting pathological processes (Melhem et al., 2004). The Inventory of Prolonged Grief has versions for children (ages 8 to 12) and adolescents (ages 13 to 18), and it specifically assesses criteria consistent with the recently established prolonged grief disorder (Spuij et al., 2012). The Grief Cognitions Questionnaire for Children (GCQ-​C; Spuij et al., 2017) is completed by youth ages 8 to 18 and measures negative thought patterns common in youth who have experienced grief. While each boasts solid psychometric properties, none are currently established with adequate sensitivity for monitoring progress. To screen for other disorders, it is recommended to include questionnaires assessing anxiety, depression, and trauma. Broadband measures such as the Child Behavior Checklist (Achenbach & Rescorla, 2001) or the Behavior Assessment System for Children (Merenda, 1996) gather a wealth of clinical information across domains. Alternatively, brief, specific measures can be aligned for targeted assessment. For example, the Revised Children’s Anxiety and Depression Scale (RCADS; Chorpita et al., 2022) can be combined with the Child PTSD Symptom Scale for DSM-​5 (Foa et al., 2018) for adequate screening. The combination of both clinical interview and outcomes measures provides a sufficiently robust understanding of the clinical picture of the youth and whether each may benefit from the treatment offered. Cultural, Ethnic, and Racial Considerations As the United States, and truly the world, recovers in the wake of the COVID-​19 pandemic, there are a number of components that must be considered with respect to grief. As a planet, we were unprepared for the experience of a global event that threatened our way of life. With respect to grief specifically, many families were unable to be present as loved ones died in healthcare facilities (Albuquerque & Santos, 2021), impeding opportunities to say goodbye. Furthermore, large group gatherings were prohibited in some places or for folks who were at high risk for severe illness from COVID-​19 (Fitzgerald et al., 2021), preventing grieving rituals and cultural celebrations. Loss of these events both reduced chances for emotions to be processed and eliminated sources of social support for the bereaved. As a result, some described the experience of losing a loved one during the COVID-​19 pandemic as “hidden” or “erased” (The Dougy Center, 2023). These interruptions to the grief process are likely to yield a higher number of youth who would benefit from intervention in the years to come (Kumar, 2023). Additional complications for youth may include

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the manner in which the loved one passed, and if COVID-​related, whether there is an identifiable source of transmission (The Dougy Center, 2023). Given the numerous stressors that youth experienced during the height of the pandemic, additional mental health conditions and family stressors may contribute to a more complicated grief reaction. Apart from the pernicious effects of COVID-​19, bereavement is an experience that is heavily impacted by an individual’s cultural identity. Gender identity typically shapes “acceptable” forms of grief expression. In Western cultures, social norms for masculine youth create an expectation that young boys will either display an absence of an emotional reaction or anger. Feminine youth, on the other hand, are expected to express sadness with a broader range of expression openly and are expected to be more affected by the loss of relationships (Rodgers & DuBois, 2018). Girls are typically offered more social support, while boys are expected to cope by engaging in activities and “handling” things (Rodgers & DuBois, 2018), creating a major potential vacuum for the adaptive expression and navigation of a grieving process. Youth who are members of religious communities often receive increased social support and community acknowledgment of the death and attend a range of events aimed at honoring and memorializing the life of the loved one (Moore, 2018). This may become complicated when the death occurs as a result of a behavior considered taboo by the specific faith (e.g., suicide, drug overdose, HIV/​AIDS). The faith community may refrain from offering social support, or specific religious ceremonies may be blocked due to the manner of death (Andriessen et al., 2019). Religions often dictate the manner in which grief is expressed, limiting youth from processing the loss in the way they need. Additionally, the developmental stage of the youth (as reviewed above) may contraindicate attendance at funerals, etc., creating a conflict between what may be in the best interest of the youth and the cultural norms of the faith community. Grief processes vary widely by ethnicity and cultural heritage. Unlike mainstream US society, many cultures celebrate death openly (e.g., Mexican traditions), and loved ones who have passed continue to play considerable roles in the family after death. Some groups display grief publicly and effusively (e.g., African American traditions), while others expect mourning to occur exclusively within circumscribed timelines (e.g., Middle Eastern traditions). Youth who are members of marginalized communities may then experience their grief as yet another opportunity to be rejected and judged by society at large. For a detailed review of differing cultural beliefs and practices around death, see Eyetsemitan’s (2021) Death, dying, and bereavement around the world. Grief, as with all emotional experiences, may manifest quite distinctly in each individual and is influenced heavily by both internal and external factors. Group CBT for Grief As with many evidence-​based protocols to address emotional difficulties in youth, the options vary widely for group CBT to treat grief. Group length may range from 45 minutes to two hours for each session and 4 to 12 weeks of treatment (Andriessen et al., 2019; Boelen et al., 2021). The modal number of sessions is eight, and recommendations for length depend heavily on the age of the group. In general, one hour or less is preferable for youth. Ideally, groups are kept to specific developmental levels: ages five to seven, ages eight to ten, middle school, and high school. If that is not possible, expanding in one direction can work (e.g., ages five to ten or middle and high school). Given the wide variety of ways that youth may experience and express their grief process, it is also common to include both verbal and non-​verbal types of interventions. Non-​verbal interventions include the use of art, music, and play to express emotions and thoughts. Younger group members and youth with difficulty articulating experiences for whatever reason are more likely to benefit from other forms of expression (The Dougy Center, 2023; Moore, 2018). Group

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size is recommended to range from four to eight. For larger groups, more diverse composition, youth with co-​occurring mental health conditions, and settings that are addressing a large-​scale loss (e.g., community violence, disaster, classmate suicide), it is strongly recommended that two clinical leaders are present to effectively manage the dysregulation that is more likely to emerge in the treatment context. Many protocols include caregiver components for grief treatments. Caregivers are typically involved in parallel sessions to the youth rather than included directly in the youth intervention. Caregiver sessions are designed to review information specific to supporting a grieving youth rather than assisting in the adults’ adaptive processing of their loss. For more intensive experiences, such as summer camps or day-​long events, some activities include both youth and caregivers. Due to the difference in treatment targets, it is optimal for standard outpatient settings to provide caregivers with a separate space. In some contexts (e.g., school), the required inclusion of caregivers may introduce barriers to services. Thus, clinicians seeking to offer group treatment for grieving youth are recommended to consider ways in which caregivers may be included in treatment, even if physical attendance at sessions is not an option. This chapter will outline an eight-​session group approach for youth coping with the loss of a loved one. To illustrate the ways in which treatment may be delivered across the developmental spectrum, creative adaptations will also be described. This model of treatment can be offered to youth with varying timeframes since loss, focusing on increasing access to adaptive coping with their grief rather than as an acute response to a death. Table 11.1 provides a brief overview of each session, interventions, and possible component caregiver elements. For this protocol, caregivers are invited for parallel sessions in the first week and every even-​numbered week thereafter. Caregiver elements are not reviewed in detail as those interventions are straightforward and do not require adaptation. To maintain fidelity to the CBT model, every session begins with a review of the plan for the session (agenda), solicits input regarding the experience (feedback), and assigns activities to be completed outside of the session (homework). Session One Session one is spent predominantly orienting group members to the treatment process. Group leaders open with limits of confidentiality, guidelines for group behavior, and expectations for what will be covered as a group. Many youth expect therapy to be an intense, overwhelming group processing experience filled with tears and secrets. The immediate and concrete review of what group therapy will (and thus, will not) include often provides relief and increases attendance rates at subsequent groups. When discussing guidelines for group behavior, this is an excellent opportunity to immediately engage members in collaborative dialogue to set the norms for their experience. Group leaders should have a few expectations they will insert if not addressed by the discussion (e.g., expectation of privacy, whether physical contact is appropriate). Left to their own devices, youth often generate reasonable and relevant guidelines and enjoy the empowerment to craft their own group culture. After logistics and regulations are established, the introduction to CBT takes the stage. The remainder of the first session is spent orienting to CBT as a form of treatment, including the use of agendas, the collaborative stance, the importance of feedback, and the function of homework. Group leaders, at this point, can identify elements of CBT that the group has already experienced to demystify integral ingredients further. The CBT model of the interrelationships between thoughts, emotions, physiological sensations, and behaviors is presented next. Regardless of the age of the group, the use of visual materials, either as handouts, drawings, cartoons, or writing on a board, substantially enhances group learning of the model. Once the general CBT conceptual model is

Group CBT for Youth Experiencing Grief 183 Table 11.1 Overview of Group Protocol Session number

Content

1

Introduction to CBT model Education about grief

2

3

4

5

6

7

8

Youth interventions

Orientation to CBT format Review of confidentiality Outline group content and expectations Describe connections between thoughts, emotions, physiological sensations, and behaviors Educate about grief and differences in reactions Introduction to Outline group preferences for group members’ supporting each other losses Briefly introduce each member’s loved one Coach group members on offering support Teach and model compassionate listening Creating grief Each group member creates a “models” CBT model of their grief Share/​p resent as a group, identify similarities and differences Identifying social Identify ways that youth can support determine who are helpful supporters Create ideas for how to request additional support (middle school and above) Memorializing Creation of memorial project for loved one Presentation of loved one to group Making plans for a Outlining how life will look “new” life different than expected in the coming year Identifying and restructuring thought distortions Normalizing the Review the expectation of grief return of grief as an experience that ebbs and Preparing for flows rather than being cured upcoming Create a timeline incorporating milestones past patterns of grief and anticipated future waves Review of major Group shares main concepts learning points learned and progress made Feedback on Group graduation and the group opportunity to say goodbye to Saying goodbye this support system

Caregiver interventions Describe connections between thoughts, emotions, physiological sensations, and behaviors. Review grief as a natural emotional response to death and loss Normalize differences in grief reactions Outline ways the youths’ lives have changed in the context of their loss Review the importance of consistency in the schedule Identify ways to reduce exposure to caregiver stressors

Identify ways in which caregivers can increase support strategies Review options to diversify social support for youth

Identifying milestones where youth may experience a surge in grief Promoting preventive support structures

Review of major concepts Feedback on group Honoring caregiver work with graduation experience

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presented, group leaders then lead the youth in identifying components related to grief that fall under each category. As this is an introductory exercise, attention should be directed toward briefly listing common examples (e.g., sadness, “I miss my daddy,” crying). Once the elements of CBT are introduced, group leaders will review the content of each next session to illustrate the road map of treatment. Feedback is then solicited regarding whether the first session met expectations, things that members found helpful, and things they felt may have been missing. Homework assignments for the first session may range from completion of baseline assessments to writing down a list of dos and don’ts of how each youth likes to feel supported to bringing back a list of suggested group names. This group has often been run using a blank comic book as a treatment journal of sorts. Each segment of comic panels is connected to a specific group session. The case example provided later in this chapter will illustrate the use of this intervention. Younger children may enjoy drawing a picture of their first group experience. High school adolescents may prefer to find memes related to group behaviors or the CBT model to bring back and then post around the group space. The more creative the homework, the more engaged members will be in care. Session Two During the second session, more emotionally evocative content is introduced. The session opens with a review of ways that the group would like to offer support to each other. Youth often experience a range of unhelpful suggestions and responses from their environments when grieving. Establishing the culture explicitly both empowers group members to assert their needs as well as enhancing the social support offered within the group. Next, the group leader introduces a specified structure for the introduction of the loved one that each youth is grieving. Giving clear guidelines such as name, relationship, and a fun fact about the person prevents youth from straying into immediate and overwhelming processing of the loss. For younger groups, it is more helpful to provide a sentence with blanks to fill in, such as, “I am missing my (relationship to loved one), and their name is _​_​_​.” The goal of this component is to scaffold the exposure to thoughts, memories, and emotions related to grief. Once all group members have completed their brief introductions, a second round of group discussion shares elements of each member’s response to the death. Group leaders encourage youth to identify two to three things they miss about the deceased and label emotions they experience as they think about the person. The facilitators promote comforting responses from other members and model active listening as each youth shares. If cognitive distortions are presented during the activity, leaders label the thought as possibly unhelpful and offer restructured statements. Youth may recognize and endorse one of the restructured statements and may not. To illustrate, Youth: Leader: Youth: Leader:

I’m never going to feel happy again. Ouch! I can hear how sad you are feeling. Do you think never ever again, or does it just maybe feel like for now the sad is soooo big? I guess, yeah. I just don’t know how I ever will. That makes sense, I’m glad you’re here to see if we can help you find that out.

Due to the fact that many grieving youths do not necessarily meet the criteria for a diagnosable mental health condition, distorted beliefs can be less difficult to challenge. Youth who do display more pervasive cognitive distortions may warrant additional assessment to determine if there is a mental health condition beyond grief that is impacting their thoughts. If a member becomes dysregulated during this initial share, leaders prompt the group to briefly offer support to that person

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in the established ways before moving on. The goal is for emotions to feel safe to be experienced and expressed while also not derailing the group process or evoking a succession of dysregulated responses in other youth. To close the group, the typical feedback is collected, and then homework is assigned. A favorite assignment for this week is to request that members bring back either a photo or tangible object (e.g., a gift from that person, a baseball glove because they shared that activity, cookies using a recipe they baked together) that reminds them of their loved ones. Alternatively, youth can be prompted to bring in a song that reminds them of their loved one, or that captures the experience of the youth’s grief. Leaders may also choose to assign an art project where members create a visual depiction of their grief. This assignment will serve as a cue for the primary activity in the upcoming session. Session Three Depending on space and materials, this group can be delivered in a wide range of formats. Prior to initiating the main activity, facilitators can lead members in a brief imaginal exercise using the homework to create gentle exposure to the grief before beginning. The main objective for this group is for each member to identify the components of their grief: emotions, body sensations, thoughts, and associated behaviors. One highly engaging method of leading this activity involves using butcher paper to draw each person’s silhouette on a segment of paper; then, youths draw their grief into the person-​shaped outline. Thoughts can be drawn in bubbles around the head or directly into the head; some youths choose to create butterflies or clouds with thoughts. Things like headaches, stomachaches, broken hearts, and heavy bodies can also be graphically depicted in the bodies. Behaviors may be illustrated around the periphery of the silhouette. Images from magazines or stickers can also be used, or simple crayons and markers suffice. If the space is insufficient to allow for this type of activity, a mini version can be created on a handout with a simple gingerbread-​man-​style body shape on a single piece of paper. Ideally, youth have materials that allow for a broader range of expression (e.g., colorful writing tools, stickers). All grief models are then posted around the room, and each member describes the experience of their grief using the CBT framework. After each person has presented, group leaders facilitate a discussion about similarities and differences and normalize that each person has their process. Assignments for this week may then prompt youth to share their models with their caregivers to increase the support they have at home. This assignment also gives adults clear indicators of when the youth may be experiencing their grief more intensely, facilitating further assistance in those times. Session Four At this midpoint, the focus shifts toward external sources of support. With the loss of a major relationship in the child’s life, other connections are often impacted as well. This may be due to those people being similarly impacted by the death, may be due to the youth withdrawing from the social connection as an understandable protection against further pain, and may be related to the subsequent life changes (e.g., moving homes, switching schools, no more reason to visit). Introductory discussion focuses on ways in which people can support us in our lives. Younger children tend to focus on instrumental support and pleasurable experiences, while adolescents may focus on the emotional support and intimate connections relationships offer. Regardless of the developmental stage, the goal is to help members identify a range of ways that people help each other when in need. Typical categories include people who listen, people who can make us laugh/​with whom we have fun, people who help us get our daily needs met, people who assist with school, people

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who give hugs, and people we can talk to about the deceased. Youth who are grieving benefit from understanding that not all social support entails repeated discussions of emotions around grief, death, and loss. Group leaders then have each member create a list of their helpful relationships. Children enjoy art projects with this intervention. For example, using a paper plate as the center sphere and labeling that as the child, construction paper cutouts can then become rays to create a sun or petals to create a flower. Each addition has a person’s name on it, and at the end, children have a visual representation of the extensive network of people who offer comfort and connection. Tweens and teens may instead prefer creating photo albums of their supporters on a mobile device. Facilitators can also prompt adolescents to plan ways to increase connection with their network, such as sending social media messages, calling, or writing “old-​fashioned” letters to be sent by mail. When soliciting feedback, leaders may ask questions such as whether information from this group felt surprising or anxiety-​provoking. Despite being a “wrap-​up” activity, the review of group input is yet another opportunity to catch and restructure distorted beliefs. Activities to do at home should be focused on engaging in a social event with an identified support person. Session Five The fifth week incorporates the most emotionally evocative content thus far, and it can be helpful to give caregivers the alert that youth may be more vulnerable after this session. This week involves the creation of a memorializing experience for the lost loved one. While preferences for methods of honoring the deceased may vary within the group, it can be overwhelming to give too many choices. Options include using photos, music, painting, poetry, and more. To simplify the types of supplies needed and promote the completion of the activity within the session, it is recommended a more straightforward activity is planned. One idea is to bring in (or have members bring in) stones that can be decorated. This way, the extent of decoration is relatively limited, and the memorial is approximately pocket-​sized to allow for easy transportation. Alternatively, leaders may choose to require that a photo of a specific size (e.g., 3 × 5) is brought in, and the group may decorate a simple frame that can be purchased at any craft store. During this activity, facilitators are promoting the active experience of grief emotions and encouraging story-​telling and other forms of emotional exposure. Depending on the group, each member may present their memorial at the close of the activity or youth may simply finish and bring their projects home. The emphasis for connection and processing is placed on the creative activity rather than a formal one-​at-​a-​time presentation afterward. Helpful homework assignments may include coaching youth to place their memorial at a place where they may experience grief more acutely or ways in which the memorial can be carried with them in their daily activities. The presentation of the project facilitates continued, adaptive processing of emotions and prevents maladaptive avoidance. Of note, if there are youth who become overwhelmed by this session, it is helpful to coach caregivers to gradually complete the project over time (e.g., five minutes each day until completion) and then to place the memorial in a specific place the child may access, but without constant exposure. This further scaffolds the exposure to grief cues for those youth who require a more gradual timeline. Session Six The sixth session continues exposure to the loss by focusing on the ramifications of the death. This group may vary widely depending on the recency of each member’s loss. Regardless, given the ways that grief surges in response to various life events and the myriad ways that youth grow over time, the content remains relevant to all members. Leaders walk youth through the creation of a

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future-​oriented timeline, identifying upcoming milestones and meaningful events. Younger children will create a visual map of events coming in their future with less attention to precise timing. Adolescents perceive time better and can thus maintain orientation to specific months. It is recommended that timelines are one year or less in length and that the largest impending life events are noted. Birthdays, school, and social events are important inclusions. Group leaders promote discussion about these events and the ways they will be different in the context of the loss. As youth share, group leaders continue to challenge distortions that may present. By this session, adolescents can catch and shape each other’s maladaptive beliefs. Teens may also simply be cued that their expression appears distorted and prompted to restate independently. In the group setting, this is never an approach that requires the youth to comply or agree with a restructured thought. When approached too forcefully, groups run the risk of reinforcing distorted beliefs or evoking a significant shame experience, alienating specific members. While the main mechanisms of this group include continued exposure to elements of grief and restructuring distorted belief systems, validation of bereavement is also essential. Grief is not necessarily something that can be “fixed” or cured in the way we think of other mental health experiences. Instead, this session balances the painful reality that grief will ebb and flow over time by identifying and correcting habits that may create a pathological grieving process. For homework, it can be helpful to have youth expand on their timelines. This may entail retrospective mapping of each member’s grief process, beginning with the date of death and depicting how grief has varied over time up to today. This may also entail expanding the timeline to larger future events. Homework can be enhanced by including caregivers in the mapping of grief to incorporate family communication and connection experiences. Session Seven Session seven expands further on the concept of the timeline and the ways in which the loss of a loved one will impact the groups’ lives. This session sets the stage for termination of treatment in the sense that youth are explicitly identifying ways in which they can expect their grief to surge over time. Normalizing the return of bereavement facilitates a more adaptive experience of the emotions as they are expected and understood, decreasing the probability that youth will engage in maladaptive and avoidant coping. Adolescents typically focus on the ways that graduation from high school, specific achievements, marriage, and other adult events may be impacted by the loss. Elementary-​age children may tend toward concrete aspects such as missing cuddle time during the night when they wake up from a bad dream or how holiday traditions have changed. As group members review the ways in which their grief may evolve, facilitators begin prompting discussions about adaptive coping strategies. For grief, these often fall into three categories: experiencing the emotions, increasing social support, and continuing to memorialize. It can be tempting to try to teach every possible coping skill in this session, and it is important to remember that these are future-​oriented discussions. Rather than teaching extensively, it is optimal to focus on two to three ideas for coping with grief in times to come. Leaders may teach about the value of setting aside time for experiencing emotions, reflecting on memories, and looking at pictures. Reminding youth of the session where social networks were built can also be helpful, promoting the identification of people to share stories with or ask for help from. Finally, brainstorming ways that people can continue to honor the memory of their loved ones despite their physical absence can also be valuable. Again, selecting a small number of ideas and offering concrete examples is the most useful strategy. The final homework assignment is typically related to preparing for the last meeting. For youth who have lost loved ones, this can be an extremely difficult ending. The group has typically become a microcosm of unwavering and potent social support. Saying goodbye both creates fears

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for how the youth will continue afterward and evokes intense emotions of loss akin to death. It is integral that the final group be planned as a graduation or celebration to increase the expectation of reinforcement and joy rather than loss and sadness. In the time frame to assign homework, group members discuss and plan the way in which they would like to celebrate their time together. Each person is assigned a specific component to contribute to the celebration. This is also an opportune time to hand out final assessments to be returned at the last meeting. Session Eight The final session! This meeting is an opportunity to celebrate growth and learning. A fun way to review the main concepts and strategies covered in group is to create a poster that can then be replicated and shared with all members. If there is available technology to design a poster on a computer, this can be done using simple word processing software with access to the internet to insert images. Alternatively, each group member can draw a poster, and then projects can be exchanged so that each person goes home with a different poster than they created. These posters can then be used as goodbye cards, with members signing each other’s and writing affectionate messages. In essence, the youth create their memorial for their time together and each other. The last session is often a whirlwind of activity, conversation, and emotion. Sticking to the CBT structure of concluding with feedback and homework provides a consistency that prevents dysregulation as the end of the group approaches. Spend time collecting feedback for both the final meeting and the experience as a whole. Group leaders can thank each member for their contribution and conclude with a final homework assignment, such as doing something fun over the weekend. As much as youth feel hesitant about the idea of a grief group, the final session of the experience is often heart-​warming and inspirational for all.

Overcoming Potential Obstacles There are a handful of common challenges that can present in a group for grief with youth. The most frequent is youth who become intensely emotionally dysregulated as the exposures to the emotions, thoughts, and memories are introduced. As with any exposure conducted in CBT, the goal is to evoke emotion to practice regulation, gain mastery, and create state-​dependent learning that specific experiences can be managed. In other words, good CBT seeks to increase emotional activation. It becomes problematic in a group setting when the teaching is derailed, and the group’s focus is instead on a single individual. The optimal way to navigate those situations is to pause the group long enough to offer support in the identified ways and then move on. If there is a deficit in coping ability, the group leader can prompt a skill, “How about you take five deep breaths in the hallway and then come back?” before moving on. This reduces attention given to the behavior, which both allows for the youth to self-​regulate and prevents inadvertent reinforcement for the outburst. If youth are noted to repeatedly become overly emotional in response to group content, this may indicate a need to begin with individual sessions before recommending group so that the child may begin the exposures at lower levels. In addition to emotion dysregulation, there are occasionally youth who come to group with a host of different dysregulated behaviors that seem to demand more attention from leaders. Group members who may have Attention Deficit Hyperactivity Disorder (ADHD), social skills deficits, or maladaptive attention-​seeking behaviors can often seem to take over or dominate groups. These are often behaviors that leave facilitators feeling frustrated and possibly resentful of those members. It is recommended that youth who demonstrate difficulty regulating their behaviors in the group context have an immediate correction to their behaviors, referencing

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the group rules and support guidelines. Additionally, using multiple reinforcement strategies shapes behavior quickly. This can involve specific rewards (e.g., praise, candy, stickers) for on-​task actions, differential reinforcement of others who are complying with expectations, and delivering prizes for the absence of unwanted behaviors. Assigning youth with distracting habits to leadership types of roles can also be helpful; having group members pass out materials, write on the board, or lead discussions are constructive ways to channel energy and adaptive ways of garnering attention. Finally, despite screening procedures, youth may be in group who have other mental health conditions that interfere with both their progress and the group’s experience as a whole. Each practice will need to determine the threshold for impairment from other conditions. If multiple members of the group meet the criteria for other disorders, additional sessions may need to be added to teach and target cognitive restructuring and other coping skills explicitly. In those cases, skills are best added earlier in the protocol before exposures so that the members are appropriately armed with the necessary tools. Broadly speaking, for any of these situations, if a youth is encountering noticeable difficulty across multiple groups, it is important to check in with both the child and caregiver(s) to determine whether continued participation is the most helpful course of action. The management of the treatment with two facilitators will also alleviate a great deal of difficulty as one leader can be focused on teaching, and the other can help redirect those who require additional attention. Case Example One sample of the application of group CBT with youth will follow the case of Tai, a ten-​year-​old, biracial Vietnamese-​Caucasian, cisgender boy. Tai presented for treatment at an outpatient mental health clinic by referral from his pediatrician after the death of his father by sudden cardiac arrest the year before. Tai had recently won an academic award at school and was preparing to graduate from elementary school and start middle school. After the awards ceremony, Tai refused to go to school for two days and then broke down in tears and told his mom he wasn’t sure how he was supposed to keep living his life when he missed his father so much. Prior to the event, the mother reported Tai had seemed not to be heavily distressed by the loss. Tai and his mother promptly agreed to try out a grief group and noted it would be nice to be able to talk with others who had experienced a loss. Tai was administered the Inventory of Prolonged Grief for Children and scored 62. He also completed the RCADS and scored subthreshold on separation anxiety, generalized anxiety, and depression (T =​ 55–​60). He did not reach the clinical cutoff on any subscale or the total anxiety and internalizing scores. Given that he had a significant loved one who died, reported experiencing clinically significant grief, and did not endorse symptoms consistent with another diagnosable mental health condition, he met the criteria for the grief group. The treatment Tai experienced followed the protocol outlined above. He was in a group with other youths ages eight to ten. This group regularly uses a blank, pre-​drawn comic book for the members to draw in throughout treatment; each homework assignment will illustrate the use of this strategy. In the first session, Tai was somewhat withdrawn and appeared hesitant to participate. If called on to solicit a response, he participated. One contribution he had to group norms was that he wanted to make sure no one laughed at each other during the group so that people would not “feel stupid.” After learning of the CBT conceptual model, he asked if this was the reason that grief seemed to be “such a big deal.” When the group leader let him know that the model applied to all emotions and experiences, he seemed to find that confusing. He shared that he did not understand why some things seemed so much harder than others and that he felt like he was supposed to be able to “get over it” faster. Tai avoided using words that explicitly named death (i.e., died, dying, dead). He declined to offer feedback to the group. When the first homework assignment was presented, and the comic book for group was introduced, Tai perked up immediately. He flipped

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through his blank comic book and asked if he was allowed to take it home and draw anything he wanted on it. Tai listened intently to the homework assignment to fill in the first couple of panels with his experiences from group and write down group rules on the panel with the bulletin board. Tai arrived ten minutes early to the second group and excitedly shared his comic drawings. Tai’s panels included images of him looking scared to come to the first group and showed a thought bubble that said, “I don’t think they’re going to like me.” He also drew an image of himself learning the CBT model with a light bulb over his head and a smiling self, standing next to his group rules. Tai immediately withdrew once the lead outlined the guidelines to introduce the grieved loved ones. Tai asked to go last; however, as he listened to other children introduce their losses, he appeared to relax and showed the designated support behaviors to group members. After he introduced his father, he spontaneously said, “Wow. I guess I’m not as alone as I thought.” As agreed upon, each group member walked around the circle of youth in attendance and gave high fives to each other before moving forward with the session. When Tai talked about the things he missed, he teared up and then asked for an extra round of high fives from the group. The assigned homework was to draw one panel representing a favorite or extra-​helpful part of that week’s session, as well as one panel where the grief was drawn as an animal, villain, or stranger. In the third week, Tai arrived late to group and appeared sullen. The group leader gave him instructions to begin the activity of building his grief model. The group completed a worksheet where they described the thoughts, emotions, body feelings, and behaviors associated with their grief. Part of the worksheet is drawing, and part is writing lists of things. Tai expressed frustration that he had missed the homework review and wanted to share it with the group. Rather than stop the group to allow Tai to present, the leader encouraged him to use his homework to help him with his activity. Then, when he finished, and everyone described their models, he could include the homework. This worked well, and Tai was able to complete the activity. He shared the ways that the very large and sad-​looking dragon he drew in his comic book manifested in his grief. Tai also noted that he wasn’t sure that the dragon was a monster and that maybe they could be friends. This led to a productive discussion around the confusion where grief felt so sad and painful but also “nice” in some ways because the youth noted, “It’s almost like [we] can still be with [them].” It was an excellent opportunity to elicit and reinforce adaptive beliefs about grieving. During the fourth session, Tai was initially argumentative with the discussion about sources of social support. Other group members gave examples of friends they once had who then moved away but were still considered friends. For the social network activity, Tai drew his support people in three large comic panels. His first panel was his mother and three grandparents. The drawing displayed them eating a meal around a table. He noted this is his favorite way to hang out with his grandparents because he gets different foods, and they don’t like to play games with him. His second panel illustrated friends, each at their own home playing video games. Tai made a thought bubble that said, “I like how we can play together.” The third panel had many faces without much detail. When he shared, he told the group about the family he has in Vietnam that he doesn’t get to see often and that he fears will not be a part of his life due to his father’s death. Tai became animated when homework assignments included connecting with parts of his social circle. He was pleased he now had a reason that he “had” to play more video games with friends and planned to send letters to his cousins in Vietnam. At the fifth session, Tai excitedly described how he and his mother had video-​conferenced with some family in Vietnam and made spring rolls together. He also drew three panels in his comic book of activities he and his dad had done in the past. The memorial activity used in this session was adapted due to the entire group’s enthusiastic love of comics and superheroes. Each youth created a superhero identity for their loved one, outlining special powers and accomplishments. One page of their comic book was dedicated to the introduction to the superhero, images of them using their abilities, and then one panel where the children drew themselves carrying on the super

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legacy. When Tai returned for the next group, he and his mother made a cape out of an old sports team blanket that he brought to share with the others. When reviewing the timeline for his next year in the sixth meeting, Tai’s mental status shifted. He appeared to be on the verge of tears for most of the group. He stated, “This is why I’m here; I can’t do all these things without my dad.” The group leader led a discussion about how difficult it can be to try to do regular things even when important people are missing. Youths identified coping thoughts to combat their distorted beliefs. Tai noted, “It is going to be hard without my dad, and I can still do things.” For homework, Tai added extra pages to his comic book so that he could draw out the timeline of his grief, beginning with the day he found out his father had died. The seventh session focused almost exclusively on ways group members could cope with upcoming events. Many in the group were graduating fifth grade, and two other youths were going to be moving away. Instead of expanding the timeline, the group leader encouraged everyone to create an action plan for them to use. Instead of working individually, members opted to work together and make a “coping agenda” for their big changes. They were quite pleased to be using CBT strategies! This ended up creating a seamless transition into the discussion about how they would celebrate their time together and say goodbye. For graduation, each youth dressed up in some way to honor their superheroes and one parent volunteered to come in and paint faces. Group members exchanged comic books and described what they read that represented the things they learned in treatment. The children also signed each other’s books and decided to pick a group song so that they could remember each other any time it played. In the feedback, the youths reported feeling like the group had been made just for them and how it never felt like being in a sad place, even though they had been working on many sad feelings. At the conclusion of treatment, Tai and his mother both endorsed T scores less than 40 on all subscales of the RCADS. Tai and his groupmates clearly enjoyed the experience of group therapy and formed a tight connection. This is likely due in part to the fact that many were at a similar social stage and in part to the shared excitement about the comic booklet. Tai did not have siblings, and the opportunity to be around other kids who had also experienced a major death seemed to reduce a great deal of loneliness that he had been experiencing. The group format, however, did not allow for more in-​depth exploration of cultural identities, such as now being the only boy in his home and concerns about whether he would lose touch with international family members. Tai –​and his fellow group members –​resonated strongly with the CBT framework and therapeutic ingredients. Anecdotally, this is consistent between groups of all ages, especially for elementary-​age youth. Tai seemed particularly relieved by the clear and concise structure that CBT offered to help him understand his experiences. While CBT may not be the only effective treatment approach for grieving youth, it most certainly is flexible, digestible, and provides ample room for creative adaptations that bring therapy to life. Summary and Conclusion The field of psychology continues to explore and understand the experience of grief and defining reactions that may be considered problematic. It follows that within a treatment realm, research persists in determining which youth benefit from intervention. Anecdotally, grief specialty centers and clinical experts celebrate the opportunity to support youth and their families as they navigate the resurgent stages of loss for a lifetime. Group CBT for children and adolescents grappling with loss is an effective and often heart-​warming process. Youth build connections with others, understand their emotions and thoughts in new ways, and have opportunities to celebrate their cherished loved ones. CBT is particularly well-​suited for grieving youth as the collaborative process, and explicit structure parallel the precise needs of bereaved children. While interventions can be delivered individually, the social connection and nurturing that exist in a well-​managed group setting are themselves extraordinarily healing. These are the reasons we practice and admire CBT!

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References Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA school-​age forms and profiles. Burlington: University of Vermont. Albuquerque, S., & Santos, A. R. (2021). “In the same Storm, but not on the same Boat”: Children grief during the COVID-​19 pandemic. Frontiers in Psychiatry, 12, 1–​4. doi:10.3389/​fpsyt.2021.638866 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association. https://​doi.org/​10.1176/​appi.books.978089​0425​596 Andriessen, K., Krysinska, K., Hill, N. T., Reifels, L., Robinson, J., Reavley, N., & Pirkis, J. (2019). Effectiveness of interventions for people bereaved through suicide: A systematic review of controlled studies of grief, psychosocial and suicide-​related outcomes. BMC Psychiatry, 19, 1–​15. Boelen, P. A., Lenferink, L. I., & Spuij, M. (2021). CBT for prolonged grief in children and adolescents: A randomized clinical trial. American Journal of Psychiatry, 178(4), 294–​304. Chorpita, B. F., Ebesutani, C., & Spence, S. H. (2022). Revised Children’s Anxiety & Depression Scale: User’s Guide. www.chi​ldfi​rst.ucla.edu Cohen, J. A., Mannarino, A. P., & Staron, V. R. (2006). A pilot study of modified cognitive-​behavioral therapy for childhood traumatic grief (CBT-​CTG). Journal of the American Academy of Child & Adolescent Psychiatry, 45(12), 1465–​1473. The Dougy Center for Grieving Children & Families. (2023, May 8). The Dougy Center. https://​doug​ycen​ ter.org Eyetsemitan, F. E. (2021). Death, dying, and bereavement around the world: Theories, varied views, and customs. Springfield, IL: Charles C. Thomas Publisher. Fitzgerald, D. A., Nunn, K., & Isaacs, D. (2021). What we have learnt about trauma, loss and grief for children in response to COVID-​19. Paediatric Respiratory Reviews, 39, 16–​21. Foa, E. B., Asnaani, A., Zang, Y., Capaldi, S., & Yeh, R. (2018). Psychometrics of the Child PTSD Symptom Scale for DSM-​5 for trauma-​exposed children and adolescents. Journal of Clinical Child & Adolescent Psychology, 47(1), 38–​46. JAG Institute. (2023, May 8). Eluna Network: Childhood Bereavement Estimation Model. https://​eluna​netw​ ork.org Kumar, R. M. (2023). The many faces of grief: A systematic literature review of grief during the COVID-​19 pandemic. Illness, Crisis & Loss, 31(1), 100–​119. Merenda, P. F. (1996). BASC: Behavior Assessment System for Children. Measurement and Evaluation in Counseling and Development, 28(4), 229–​232. Melhem, N. M., Day, N., Shear, M. K., Day, R., Reynolds III, C. F., & Brent, D. (2004). Traumatic grief among adolescents exposed to a peer’s suicide. American Journal of Psychiatry, 161(8), 1411–​1416. Moore, C. (2018). Helping grieving children and adolescents. In E., Bui (ed.) Clinical handbook of bereavement and grief reactions, (pp. 189–​215). Boston, MA: Humana Press. Revet, A., Laifer, L., & Raynaud, J. P. (2018). Grief reactions in children and adolescents. In E., Bui (ed.) Clinical handbook of bereavement and grief reactions, (pp. 63–​83). Boston, MA: Humana Press. Rider, E. A., Ansari, E., Varrin, P. H., & Sparrow, J. (2021). Mental health and wellbeing of children and adolescents during the covid-​19 pandemic. The BMJ, 374, 1–​14. doi:10.1136/​bmj.n1730 Rodgers, R. F., & DuBois, R. H. (2018). Grief reactions: A sociocultural approach. In E., Bui (ed.) Clinical handbook of bereavement and grief reactions, (pp. 1–​18). Boston, MA: Humana Press. Spuij, M., Prinzie, P., Zijderlaan, J., Stikkelbroek, Y., Dillen, L., de Roos, C., & Boelen, P. A. (2012). Psychometric properties of the Dutch inventories of prolonged grief for children and adolescents. Clinical Psychology & Psychotherapy, 19(6), 540–​551. Spuij, M., Prinzie, P., & Boelen, P. A. (2017). Psychometric properties of the grief cognitions questionnaire for children (GCQ-​C). Journal of Rational-​Emotive & Cognitive-​Behavior Therapy, 35, 60–​77. World Health Organization. (2019). International statistical classification of diseases and related health problems (11th ed.). https://​icd.who.int/​

Chapter 12

Building Healthy Media and Device Habits A CBT-​B ased Roadmap Jessica L. Stewart, Ray W. Christner, Christy A. Mulligan, and Emily Fox

In the past decade, media and device use (MDU) has rapidly increased, denoted by a US survey illustrating the increase of smartphone ownership from 30% to 85% between the years 2011 and 2021 (Laricchia, 2022). Increased access to technology has ushered in vast avenues for knowledge and information acquisition and dissemination across platforms like social media, websites, and online forums. These advancements have, therefore, also significantly increased screen time, encompassing devices like smartphones, tablets, computers, and televisions. The global daily screen time average has reached over six hours (Exploding Topics, 2023). Notwithstanding the immense positives of technology in exposing individuals to new concepts, ideas, information, perspectives, and support, there are detrimental consequences of excessive and unhealthy MDU. The omnipresence of technology has amplified screen time for both children and adults, be it gaming, scrolling social media, watching videos, or online browsing. Those who do not balance their use are gravely impacted by excessive and unhealthy MDU, contrasting starkly with those who harness media and devices in healthy ways (Stockings et al., 2016). Constructive MDU can manifest as adolescents leveraging digital platforms and online resources for academics, such as online studying, creating e-​flashcards, sharing resources, or viewing educational content. These practices have become intrinsic to modern education, from elementary levels to advanced degrees and even in professional work settings. Adults, especially those working remotely, often depend on digital tools for tasks like emails, report generation, and video conferencing. However, detrimental MDU is characterized by its content and extended usage, such as prolonged gaming, extensive social media use, or online harassment. Excessive screen engagement, especially when passive and unproductive, can adversely affect one’s physical and mental health. Uncontrolled device use can lead to issues like disrupted sleep patterns, heightened stress, increased risk for anxiety and depression, and social isolation when digital interactions overshadow face-​to-​face socialization and connection. The key to determining “unhealthy” MDU lies in understanding the extent to which such usage negatively impacts an individual’s overall well-​being and functionality, including as it impacts interpersonal relationships. In these ways, intense, unhealthy MDU mirrors addictive behaviors, such as substance abuse or gambling (Kuss et al., 2018). Thus, we believe it could also be addressed effectively through a harm reduction framework. Typically associated with substance abuse treatments, harm reduction strategies focus not on outright cessation but on mitigating the adverse effects of behavior. We believe utilizing a harm reduction approach can offer significant advantages when addressing the negative implications of excessive or unhealthy MDU on individuals’ well-​being and functioning. The goal is to achieve minimal negative impact of one’s unavoidable relationship with technology. A harm reduction or reductionist lens provides insights into the implications of unhealthy use and expands intervention to facilitate a healthy relationship with technology (Tatarsky, 2003). While the benefits of this approach are evident in substance abuse scenarios, there is a gap in understanding the potential DOI: 10.4324/9781351213073-14

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benefits of this approach to interventions against the backdrop of MDU and within group therapy settings. Addressing these concerns within group settings allows participants to find mutual understanding, share personal experiences, and inspire healthier habits within the group. Greer and colleagues (2016) highlighted the benefits of peer involvement in harm reduction approaches, emphasizing its role in enhancing group therapy outcomes and fostering the acquisition and implementation of effective decision-​making skills. Denning (2010) similarly underscored the pivotal role of loved ones’ support in increasing the long-​term success of harm reduction methods for substance abuse. These studies underline the invaluable influence of peers and family within the harm reduction context, suggesting its potential usefulness for modifying unhealthy MDU. Strong familial support and constructive peer relationships can act as a protective factor, potentially reducing an individual’s vulnerability to detrimental MDU habits. Integrating a harm reduction approach in group therapy can be complex due to the diverse backgrounds, experiences, and personalities of its members, which can lead to potential conflicts or misunderstandings if clear guidelines are not established. Group therapy is a space that is unique from group to group, shaped by its participants, but successful when fostering empathy, perspective-​sharing, and mutual respect (Little, 2006). These elements have been established as beneficial within substance use treatment research. So, we believe they would have promise to be universally effective in addressing various harmful or unhealthy behaviors. However, the success of harm reduction methods depends heavily on participants’ desire and voluntary commitment to change (McMahon et al., 2019). In the context of MDU, we believe that altering the reliance on or perceived need to use devices could be instrumental in achieving a greater commitment to moderate use, and thus reducing “dependency” or overreliance on devices like smartphones. Substance abuse research (Avants et al., 2004) offers promising insights into the helpfulness of integrating cognitive-​behavior therapy (CBT) techniques in harm reduction groups. This foundational work in substance abuse paves the way for innovative applications of harm reduction and CBT for addressing excessive and unhealthy MDU. Studies of harm reduction approaches have demonstrated beneficial aspects to intervention, including achievable goals, enhanced empathy, and addressing emotional challenges, among others. In contrast, 12-​step programs, commonly associated with substance abuse, often do not yield sustainable results in comparison to harm reduction approaches (Tartarsky, 2003). When pondering its application to MDU, this approach seems especially relevant, as the idea of abstinence from technology and device use is not a realistic or sustainable option. Given the surge in screen time over the past decade, there is an urgent need for practical, enduring solutions to mitigate potential negative outcomes while finding a realistic, balanced approach to healthy MDU. Viewing interventions from a harm reduction lens makes sense, as it acknowledges and accepts setbacks, ensuring individuals remain optimistic despite nonlinear progress. The core goal is harm minimization—​a strategy potentially transformative in moderating the influence of technology in our lives. As technology evolves, managing one’s relationship with MDU becomes essential, as there is a need to exist with it but without functional implications. Cultivating balanced and healthy MDU habits is crucial to ensuring holistic well-​being for all digital users. Defining Unhealthy MDU Before discussing intervention for unhealthy MDU, it is important to recognize that the potential harm caused by unhealthy MDU is not solely determined by the number of hours spent on screens. While this is often a quick guideline to identify a concern, some individuals log notable time on devices and yet do not experience a negative functional impact from this use. When considering unhealthy MDU, we offer the following key points to consider:

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1 Quality Over Quantity. The impact of MDU largely depends on the content consumed and the activities engaged in while using these devices. Spending several hours on educational, creative, or productive tasks may have different consequences than an equal amount of time spent on “mindless” scrolling or passive consumption. 2 Individual Variability. Individuals have varying thresholds for the amount of screen time they can handle without experiencing negative effects on their mental, physical, and emotional well-​ being. What might be excessive for one person could be manageable for another. 3 Purpose and Balance. The key is to have harmony that aligns with one’s individual needs and goals. Unhealthy MDU often occurs when screen time begins to interfere with essential aspects of life, such as sleep, relationships, work or school performance, and physical health. 4 Context Matters. The context in which screen time occurs is also crucial. For example, screens used for work or education may have different implications than those used for leisure or entertainment. Likewise, the presence of social interaction during screen time can significantly influence its impact (e.g., a group of adolescents sitting in the same room but communicating through social media). Thus, the impact of MDU on well-​being is not solely determined by the number of hours spent but by the quality, purpose, and functional consequences of that usage. Rather than fixating on a specific time limit, we encourage individuals and clinicians working in this area to focus on maintaining a healthy balance between meeting one’s responsibilities and engaging in enjoyable activities while safeguarding their physical, mental, and social health. CBT Conceptualization of MDU Many articles and books are singularly devoted to problematic MDU within a growing field of research and treatment. Theories attempt to differentiate between functional internet, media, gaming, and device use—​that affords the user benefits for productivity, connectivity, simple leisure activity, and other aspects of wellness—​and pathological use, that can be generalized in nature or of a more specific, function-​based problem (e.g., internet gambling or pornography). Theories also attempt to explain unhealthy MDU in terms of neurobiological predispositions (e.g., neural structures and dopamine receptors), behavioral conditioning (e.g., classical conditioning, reinforcement principles), aspects of social psychology (e.g., connectivity and finding a sense of belonging), and cognitive and emotional coping (e.g., depression, escapism, numbing). For example, the I-​PACE (Interaction of Person-​Affect-​Cognition-​Execution) theoretical model, focused on addictive use related to specific internet platforms, emphasizes the interplay between predisposing factors (e.g., neurobiological or psychological traits), moderators (e.g., coping styles and cognitive biases), and mediators (e.g., affective and cognitive responses to situational prompts and internet-​related cognitive biases). In combination with reduced executive function skills, these elements together drive the onset and maintenance of addictive behavior (Brand et al., 2016). As these authors point out, it is important to consider these components separately because some may be more amenable targets for intervention (e.g., moderator and mediator variables), while other aspects may be stable regardless (e.g., genetic predispositions). Kuss and Pontes (2019) offer a good summary of contributing factors increasingly being identified as playing a role in MDU, especially when it may be unhealthy or even pathological (e.g., to the level of being an addiction). An in-​depth review of the expanding literature on factors contributing to the development of unhealthy MDU is beyond the scope of this chapter. However, we believe it is important to consider these same intra-​and interpersonal components when outlining interventions aimed at modifying unhealthy behavior, as well as behavioral conditioning principles and aspects of social functioning. Clinicians must have a basic understanding of these individual factors and how they

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interact with (and potentially reinforce) each other in order to fully appreciate the function of the MDU—​especially when it persists despite the negative functional impacts the person experiences, such as the “consequences” of that behavior, in terms of effective engagement in daily life activities, relationships, physical health, and psychological well-​being. It is important to think about the mechanisms underlying the individual’s drive to engage in the MDU in the first place and determine which can be targeted for intervention to support them in having more control over decision-​making. Physiological and Neurobiological Processes Research has definitively established the concept of neuroplasticity: that brains can structurally and functionally change and are adaptable. Increasing research has also established that, especially for children during critical developmental periods, extensive screen use (and especially gaming) is leading to changes in neural tissue and function (Sigman, 2017). In particular, the development of problematic MDU is increasingly understood as being associated with maladaptive changes to regions associated with addiction—​that is, the frontal lobe (which is primarily responsible for executive function skills) and the limbic system (which is largely responsible for emotion). These structures are thought to be responsible for components of addictive behavior, such as pleasure, reward, craving, emotional management, learning, memory, impaired executive functioning (such as inhibitory control), and decision-​making (Brand et al., 2016). This is increasingly seen as a maladaptive interaction that is bidirectional in that gaming and unhealthy MDU may change brain structures and processes, which then contribute to continued seeking and engaging in stimulating behaviors. Sigman (2017) referred to this collectively as “screen dependency disorders.” Research has established that dopamine is a key neurotransmitter involved in brain systems regulating reinforcement and reward. Structural abnormalities in dopamine-​rich areas of the brain have been observed for those with unhealthy MDU. But there is also evidence for predisposing risk factors that make someone more susceptible to engage in compulsive behavior or addiction. For example, prenatal exposure to higher levels of androgens has been associated with problematic video game addiction (Kornhuber et al., 2013). Also, variation in specific genes coding for the dopamine D2 receptor and dopamine degradation enzyme was associated with excessive internet gaming and “higher reward dependency” (Han et al., 2007). Differences in a cholinergic receptor that plays a role in nicotine addiction were found to be present for those with problematic social media use (Montag et al., 2012). These are just a few examples of the growing research substantiating neurostructural factors involved in unhealthy MDU. Most clinicians will not know their clients’ genetic makeup or what structural abnormalities may be present in critical brain regions. However, it is essential to keep in mind that genetic variation influences brain structure, function, and connectivity, which is increasingly supported in the literature to be associated with internet, social media, and gaming overuse or addiction. So, from predisposing neuroanatomical differences and imbalances in neurotransmitters governing emotion, behavior, and regulation to neuroadaptive changes (changes in the structure and function of the brain because of excessive screen activities), it is clear that neurological dysfunction contributes in part to unhealthy MDU. This must be factored in when understanding and conceptualizing an individual’s situation and, subsequently, any approach to intervention. The good news is that there is increasing evidence that positive changes also occur in functional connectivity in the brain in response to appropriate treatment (Zhang et al., 2016). It is vital to understand a youth’s cognitive and, in particular, executive function skills before intervening to reshape or restructure their belief systems around MDU (Brand et al., 2014) and

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putting in place behavior change goals beyond their capacities to achieve successfully or autonomously. Reduced executive functioning (e.g., inhibition, planning, time management), specifically, detracts from conscious decision-​making even when the will is there to modify behavior. Because of complex interactions between brain chemistry and connections that regulate and motivate behavior, children and adolescents may not be able to choose to stop engaging in a behavior, even when explicitly told to or when negative results will occur (e.g., grounding, removal of privileges). Engagement in MDU results in positive chemical changes that are reinforcing, such as a “high” or lift in mood, the warmth of a connection to peers or social support, a sense of reward or achievement, and the feeling of pleasure. These gains may limit one’s motivation to stop engaging in the behavior. The individual would need to have strong inhibitory capacities, mental flexibility, planning skills, and positive problem-​solving skills to proactively and intentionally structure their efforts to forego the gains of MDU. We believe that executive functioning skills are one of the most critical areas of intrapersonal growth that can be directly targeted as part of any harm reduction approach to intervention (discussed in more detail below). Behavioral Principles of Reinforcement In order to support the cessation or even moderate reduction of problematic behavior, clinicians must also incorporate principles of behavior modification and reinforcement, likely learned in an introductory psychology class, into their conceptualization. Concepts such as reward, positive reinforcement, negative reinforcement, negative punishment, and positive punishment can be confusing (especially the last one!). Yet, each of these is an important contributor to unhealthy MDU. Remember that, essentially, reinforcement is about increasing a behavior, while punishment is about decreasing that behavior. “Positive” refers to adding something to accomplish that increase or decrease, while “negative” refers to the removal of something undesirable. Those who are not familiar with these concepts (like most of the youth attending group therapy and their family members) may assume, for example, that “negative reinforcement” might be the same as punishment. However, it actually refers to the idea that a behavior will be repeated (reinforced) if it removes something undesirable. Those who engage in excessive MDU are often motivated to do so, at least partially, by a desire to reduce a negative emotion (e.g., feelings of isolation or loneliness, the discomfort of anhedonia associated with depression, excessive worry) or increase a positive emotion (e.g., sense of belonging and connection) (Brand et al., 2016). Thus, intervention must include educating group members about and incorporating principles of both positive and negative reinforcement and punishment to help them identify what their excessive or unhealthy MDU brings into their lives (whether it is desired or not) and what they could remove or add into their lives by reducing their unhealthy MDU. Clinicians should also understand schedules of reinforcement, such as intermittent rewards, that may also play a role in unhealthy MDU. You may remember Skinner’s work (1953) that identified the power of an intermittent reinforcement schedule. When behavior is reinforced unpredictably, it will strengthen and be more difficult to extinguish. Being rewarded at unexpected intervals is more powerful than being rewarded consistently and predictably for behavior. As an award-​winning game designer noted, aspects of games must be uncertain (e.g., the outcome, the game’s path, perception, complexity), or it will not hold our interest (Costikyan, 2013). Does the child have a hard time limiting gameplay (e.g., “Just one more round so I can see if I can make it to the end of the level!”), or are they unable to stop scrolling or monitoring posting on social media because they are awaiting the feedback of others as the “reward” (e.g., “I need to see how many likes I can get for this post”)? These are examples of the influence of intermittent reinforcement prolonging one’s MDU.

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Social Factors The idea of posting online to elicit the praise and approval of followers is highly reinforcing. In general, there are social psychology factors that may be contributing to any MDU, such as social thinking (how we perceive the world and ourselves within it), social influence (e.g., issues of stereotypes and biases, why we conform, how to persuade others), and social behavior (e.g., aggression, helping behaviors, attraction and relationships) (Sage Publications, 2019). Social psychologists have long studied—​and proven—​that the feelings and beliefs about the self (self-​esteem) are impacted by the way others treat us and show they value us. The sociometer model posits that self-​esteem is a gauge of perceived social value, whereby self-​esteem is higher to the extent we feel accepted and appreciated (e.g., “liked” on social media) but lower to the extent we feel rejected or not liked by others (Leary & Downs, 1995; Leary & Baumeister, 2000). Additionally, clients may remain excessively engaged with MDU to avoid falling behind a shared social experience among their peers (e.g., friends moving ahead in online gaming, things being shared online about what is happening within a friend group, online auctions/​shopping, news about something happening in the community or larger world that is important to the person), or for fear of missing out, or “FOMO.” Youth typically want to stay connected and be a part of their social group so as not to miss what “everyone else” gets to be a part of, which would otherwise create loneliness, jealousy, a sense of rejection, etc. Maintaining an active presence within online activity is meant to deter these negative feelings (think: negative reinforcement) and provide a sense of connection and belonging (think: positive reinforcement). This sense of belonging is especially important if a client feels isolated, rejected, or neglected in their home, school, or community environments, such as if they identify with a marginalized group. MDU affords us an opportunity to connect for social support to others who share our identities, experiences, struggles, and interests, allowing for the development of meaningful, connected relationships and a sense of belonging that has long been identified as a factor in both physical and mental health and resiliency (Weziak-​Bialowolska et al., 2022). Once this connectedness is established, reducing engagement in one’s online activity or community may be experienced as withdrawal—​chemically and emotionally—​and as a sense of loss. In addition to FOMO and the drive to reduce this negative emotional state, group members may perceive that not being involved in something would change others’ perceptions about them or their place in their social group. Thus, reducing the frequency or duration of MDU would be seen as threatening to the person’s social status or happiness, potentially triggering defensive reactivity and instead solidifying their investment in the activity (to avoid the perceived loss). We often hear from adolescents who may have come to realize their MDU is so unhealthy that they “can’t stop, or else … (this thing) will happen.” Group members may avoid treatment recommendations or interventions meant to lessen MDU so as to avoid perceived social consequences. These social psychology principles typically contribute to a drive to seek the approval of others and to avoid criticism, to stay connected and to avoid rejection and isolation. These are great examples of positive reinforcement: receiving praise leads me to continue to post similar things. This also provides a chemical response, such as a “high” (think the dopamine hit from accomplishment). Collectively, this is an example of the interconnectedness of social, cognitive, behavioral, and neurobiological factors. In addition, social psychology tells us that behavior is a function of the interaction between personality and environment (Sage Publications, 2019). These factors need to be taken into account when conceptualizing a group member’s MDU. For example, certain personality characteristics are associated with using online communication applications or sites excessively, such as extraversion and openness to experience, narcissism, impulsivity and attention deficits, low self-​esteem, social anxiety, and coping style (Brand et al., 2016).

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Cognitive and Emotional (Psychological) Processes A cognitive-​behavioral conceptualization would, of course, include aspects of an individual’s core belief system and ways they interpret events or experiences and how their interpretations contribute to automatic thinking that results in affective (emotional) changes and then behaviors to cope or regulate those emotions. We suggest clinicians consider group members’ beliefs related to empowerment, accomplishments, and competencies, as they may be connected to any special talent or persona supported by their MDU. For example, a client who may struggle in school or to meet expectations in their home environment may feel inadequate in daily life. But if online they are seen as socially desirable (e.g., they are a trusted confidant of others, funny and provide others with entertainment), offer something valued by others, or talented in game play, then MDU provides them a way to feel “special” and more competent. Similarly, those with negative mood states (such as anxiety and depression) would be more likely to engage in excessive MDU as an escape from (or numbing of) those negative mood states. They may believe that engaging in their activities of choice is the only way they can be happy. Again, readers are directed to the summaries by Brand and colleagues (2016) and Kuss and Pontes (2019) for factors contributing to various MDU addictions, including gaming addiction in children, which highlights that escapism (the desire to avoid difficulties in their real lives) as the “strongest motivational factor predicting video game addiction.” Unfortunately, escapism also leads to increased psychiatric distress. The need to achieve and perform are additional factors in gaming addiction, as is the desire for fun, catharsis or autonomy, and boredom. In terms of social networking addiction, “the most popular motives include relationship maintenance, passing time, entertainment, and companionship” (Kuss & Pontes, 2019). As Kuss and Pontes (2019) name, internet use expectancies play a role in motivating behavior because they involve anticipation of how the internet or gaming behavior may help to distract and improve mood, whether by reducing a negative mood state or introducing or enhancing a positive one. When considering how to support a client’s efforts to reduce the frequency of MDU, clinicians need to think about how the individual views the MDU and the meaning they give to it: as a tool, escape, source of pleasure, sense of identity, or other motivation that draws their investment. What function does this behavior serve, whether consciously or unconsciously motivated? As discussed above, harm reduction approaches to therapy are integrated, biopsychosocial approaches rather than sequential models of treatment. Group members will simultaneously be addressing each of these contributing factors (cognitive, emotional, social, behavioral, and physiological responses) to their MDU. They must understand the interrelated aspects of each component in order to commit to making changes. Group members will need to consider their short-​and long-​ term goals individually. Still, the group format allows for the benefits of peer support, accountability, creative problem-​solving, modeling, etc. (outlined in previous chapters) to help facilitate advancement through stages of change and success in modifying behavior. Within the group format, members can see these interactions in the examples of others and work to recognize, in themselves, the relationships between and among each of these factors in order to understand how best to interrupt unhealthy patterns of MDU and limit the harm their current choices cause in their lives going forward, ultimately finding a healthier balance in their MDU. Cultural Considerations Issues related to internet addiction, gaming, and technology overuse are widespread in the United States, with 2%–​5% of gamers facing issues tied to their gaming habits (Pontes et al., 2014). Such problems can disrupt daily life and lead to significant functional impairment (Aarseth et al., 2017;

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Petry et al., 2014). While some researchers debate the prevalence of internet and gaming addiction outside Western societies (Kirmayer & Pedersen, 2014; Snodgrass et al., 2018; Summerfield, 2012), within the DSM-​5’s acknowledgment of Internet Gaming Disorder is noted that it primarily affects young males and is more common in Asia than North America and Europe (APA, 2013). In fact, prevalence rates vary widely, ranging from 1% in Germany (Rumpf et al., 2014) to 18.7% in Taiwan (Lin et al., 2014). Group facilitators must understand the cultural perspectives and beliefs of prospective group members and their families regarding MDU. These views are a part of the context that will shape the definition of “functional impairment” resulting from unhealthy MDU. The perceived severity of excessive MDU can differ based on these individual cultural and ethnic factors, potentially also influenced by generational differences within the families of group members. Readers should be cautious of making broad generalizations about perspectives on MDU based on limited cultural research. However, several insights can guide an understanding of cultural nuances that frame for practitioners the importance of remaining mindful of these factors—​ especially when working with youth from under-​researched cultural backgrounds. For instance, while non-​Western nations, especially in the East, have aggressively addressed internet/​gaming addiction for nearly two decades (Rao, 2019), their perspective contrasts with the Western viewpoint. Western societies often link these issues to the medical model of pathology, while Eastern cultures might perceive them as an idiom of distress, as they are particularly distressing for parents. The high value placed on academic excellence in Eastern cultures intensifies parental control, leading them to view excessive MDU as a sign of losing control over their children, a source of shame (Rao, 2019). Teachers also face criticism if students underperform, possibly due to distractions from MDU. For youth in these cultures, MDU might serve as a respite or escape from heavy academic loads and high expectations (Rao, 2019). In contrast, in Western cultures, excessive MDU is often attributed to individual deficiencies, such as lack of self-​discipline, willpower, or impulse control. When addressing MDU in group settings, it’s crucial to understand both family and individual perspectives on the behavior and the factors driving a youth’s motivation to change. The comparatively lower rates of unhealthy MDU in the United States and Europe, as opposed to Asian countries, can be attributed to cultural differences. First, East Asian societies are rooted in collectivism, emphasizing each member’s role in contributing to family and community welfare. Academic success in children is seen as their contribution, leading to immense pride in high achievers and shame in those who do not meet expectations. Unhealthy MDU magnifies this shame, highlighting parents’ lack of control over their children’s behavior. Second, Asian cultures place significant emphasis on academic excellence. As a result, individuals who struggle academically, whether due to innate challenges, learning differences, or motivation issues, might turn to excessive MDU. This behavior serves as a form of escapism from academic pressures and, at times, as a silent protest against parental expectations and pressures, especially when they feel limited in their capabilities. Our understanding of the interplay between religion and MDU, particularly social media, remains incomplete. Insights into how social media influences and potentially reshapes individuals’ ethical or moral views regarding digital interactions or its role in redefining a sense of religious community for marginalized religious groups are limited. For some, social media offers an alternative way of fostering or preserving community amid extensive societal exclusion. Notably, for religious minorities like Jews and Muslims, social media might act as a refuge, a buffer against the marginalization and societal pressures of anti-​Semitism and Islamophobia (Marizan, 2016). Conversely, the very platforms meant for connection and protection might exacerbate marginalization, creating environments conducive to heightened interreligious tension and division (Alvstad, 2010; Neumaier, 2020). Despite these dynamics, limited research delves into the digital media habits of religious groups and their perspectives on social media in relation to their faith.

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In contemporary, industrialized societies, media plays a role as both the producers and distributors of religious symbols and practices. This mediatization of religion has become a primary source for religious issues, granting social media the power to shape and frame religious narratives (Lim & Sng, 2020). Additionally, social media facilitates the spread of religious information and experiences shared by its users. Increasingly, platforms like Facebook, X, Instagram, and others are stepping in to fulfill roles traditionally held by religious institutions, encompassing societal rituals, moral guidance, and community building (Lim & Sng 2020). The rise of these social networking sites has notably altered the way young people engage in social activities, including their religious practices (Lim & Sng, 2020). Some religious orientations mandate limited technology use on specific days or during certain traditions. Youth breaching these norms due to excessive or undisciplined MDU may face familial conflicts, making their MDU potentially more detrimental than for their peers from less restrictive backgrounds. Clinicians should recognize that device usage can sometimes offer protective benefits for youth, like connecting to their religious communities and enhancing their spirituality, a known resilience booster (Manning et al., 2019). It is essential to assess this within the context of family and community standards to determine its impact. Socioeconomic status (SES) influences access to vital resources like housing, education, and healthcare, including mental health services (Ma, 2023). SES denotes an individual’s standing in society’s economic hierarchy (Lampert & Kroll, 2006) and is usually gauged through a combination of education, income, and occupation (Lampert et al., 2013). Device access and internet quality vary with SES, with higher-​income individuals having better access to sophisticated devices and faster internet (Livingood et al., 2022). A recent study revealed that many middle-​to-​high-​income families exceed the American Academy of Pediatrics (AAP) (2013) recommendation of one to two hours of screen time for children over two years of age through adolescence, often doubling the suggested limit (Mollborn et al., 2022). This deviation from the guidelines by higher-​income youth is interesting given that high-​income parents are typically more educated and aware of such guidelines. Further, their children often engage in after-​school activities, a potential mitigating factor to excessive screen usage. The reasons for this deviation demand further investigation, and it is important to determine the function of the increased use (e.g., using for schoolwork versus passive use). When examining the social and emotional aspects influencing MDU, it is vital to consider that lower SES youth, frequently marginalized due to both SES and race, might view devices and social media as tools to bridge the privilege gap with their higher SES counterparts. They might see MDU as a means to “level the playing field” and equalize disparities evident in school setting, like attire and belongings or access to pricier activities. Even affording them access to conversations and connections through shared interests. This perspective could result in increased MDU. However, social media might intensify feelings of FOMO among lower SES youth, highlighting their disparities when compared to the posts of their peers. Witnessing the affluence of others when one is economically challenged can adversely impact mental health and wellness, making their MDU potentially detrimental. In summary, when navigating and examining unhealthy MDU in youth, it is crucial to acknowledge cultural differences that might underlie or contribute to what makes MDU problematic. Religious considerations might influence perceptions of the individual and their family about “unhealthy” or “excessive” MDU. At the same time, MDU could also be beneficial for connecting to religious communities and reinforcing one’s faith and well-​being. In some cultures, youth might use MDU as an escape from familial expectations, potentially causing conflicts with adults. Economic disparities play a role as well; lower SES youth may have limited access to devices or high-​speed internet, affecting their social (e.g., reduced online community or peer support) and

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emotional (e.g., feeling excluded from experiences shared online by higher SES peers) well-​being. Such disparities might make MDU even more enticing for these youth, enabling them to bridge social gaps in the virtual realm that they face in reality. For cognitive-​behavior group therapy (CBGT) providers, it is essential to consider these cultural factors (among others) when assessing group composition, understanding motivations for MDU behavior, and formulating individualized treatment goals and intervention strategies. Protective Factors In light of the U.S. Surgeon General’s recent advisory on May 23, 2023, addressing the potential risks of youth engagement with social media, this chapter underscores the urgency of understanding and mitigating these risks. Current research, albeit not exhaustive, indicates possible profound effects on the mental well-​being of children and adolescents. Consequently, the Surgeon General has appealed to stakeholders, including technology corporations, policymakers, researchers, and caregivers, to proactively protect youth from potential hazards. The discourse surrounding unhealthy MDU poses some important questions for researchers and practitioners: How can we prevent the detrimental aspects of MDU? What factors render certain youth less vulnerable to the misuse and adverse effects of MDU? One pivotal safeguard is the regulation of access, especially with younger children. An unrestricted gateway to digital media magnifies the potential of unhealthy MDU. In a study by Crittenden (2019), 95% of adolescents either own or have access to a smartphone, with nearly half admitting to near-​constant use. The responsibility, no matter how difficult, is on caregivers to be both observant and informed about the digital use and footprints of their children. While this is not always easy, implementing strategies such as defined and limited screen time, stipulated device-​free periods (e.g., before school, after homework is done, before sleep, or during meals), and designating places for all devices to be stored before bedtime are foundational to nurturing the development of self-​discipline. The U.S. Surgeon General’s Advisory (2023) emphasized the establishment of a Family Media Plan. Such a plan should foster open dialogues about device usage expectations, emphasizing safety measures such as activating privacy settings on social media platforms and establishing boundaries against potentially harmful websites. It is unreasonable to assume that youth possess the intrinsic impulse control and self-​discipline to refrain from device usage beyond allotted times or during unsupervised hours, including the middle of the night—​that is, if devices are permitted in their rooms. Supported by the Social Learning Theory (Bandura, 1971), adults need to model sensible MDU. Children observing parents engrossed in devices after work hours, sidelining essential familial needs and relationships, might undergo disconnection or even emotional distress. On the other hand, witnessing caregivers judiciously navigating social media, delineating clear boundaries between work and leisure, and investing in personal, face-​to-​face interactions increase the likelihood of youth fostering a harmonious or balanced relationship with MDU (U.S. Surgeon General’s Advisory, 2023). Engagement in extracurricular activities also serves as a deterrent from excessive MDU. Extracurricular activities such as sports or the arts often act as a counter to overreliance on devices for stimulation, connection, purpose, and self-​esteem. For children or adolescents who have not found their niche, encouraging them to experiment with a range of activities not only diverts them from screens but also enriches their recreational perspectives, connections, and experiences. As discussed in case conceptualization, enhanced executive function skills—​like self-​awareness, impulse control, and effective time management—​are strong protective barriers against unrestrained use.

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While the above interventions can potentially mitigate unhealthy MDU, we acknowledge the overwhelming societal pressure placed on youth to engage in MDU. An array of studies underscore the negative implications of unrestrained social media use on youth well-​being (Lenhart et al., 2010), including depression (Young & Rogers, 1998), anxiety (Dalbudak et al., 2013), aggression (Lim et al., 2015), and social isolation (Kraut et al., 1998). Therefore, maximizing protective mechanisms against unhealthy MDU is paramount for improved outcomes with youth mental health. Although we focus in this chapter on the use of CBGT for those with excessive and unhealthy MDU, the foundational principles of CBT can be universally applied as a preventive measure, serving as a buffer against potential pitfalls. Those working in schools might find the opportunity to make this part of a health curriculum or offer programming aimed at increasing skills for all children and adolescents to use media and devices in a meaningful and healthy way. The technological landscape is ever-​changing, including advancements in artificial intelligence. With these changes and the rapid evolution of digital media, new challenges will emerge. It remains essential for stakeholders—​parents, clinicians, educators, and others interfacing with youth—​to remain attuned to the shifts in youth’s digital interactions and emerging technological concerns. From this chapter, readers should discern that the strategies for fostering healthy MDU are broadly applicable, focusing more on inherent human behaviors than specific technologies or media. Thus, these interventions maintain their relevance even as the digital realm evolves. Assessment In the preceding sections, we have presented an explanation and conceptualization of unhealthy MDU and the various aspects that need to be taken into account. One crucial factor involves defining what constitutes “unhealthy” MDU, which, as previously discussed, can be complex and encompass multiple elements. One glaring indicator of unhealthy behavior is the displacement of other activities, where device use takes precedence over tasks like homework, physical activity, social interaction, and sleep. Furthermore, excessive MDU can lead to behavioral changes such as heightened irritability, rule breaking (e.g., sneaking device use), anxiety, stress, sadness, and withdrawal. When exploring unhealthy MDU, it is essential to grasp its functional impact. When assessing individuals for potential intervention, such as CBGT, the initial evaluation should be comprehensive. It should delve into factors beyond MDU, including anxiety, executive functioning, depression, and social skills. The primary aim of this initial assessment is to determine suitability for participation in treatment, such as a group intervention, and to gauge the extent of MDU and its influence on daily functioning. Additionally, this initial clinical evaluation can yield a differential diagnosis to investigate any coexisting conditions that may affect progress or necessitate additional, separate interventions. The assessment process does not conclude with group inclusion and the establishment of treatment goals. Throughout CBGT interventions, ongoing assessment is conducted for the purpose of monitoring progress. Progress monitoring often aligns closely with the specific treatment objectives, and for those using CBT, this is a familiar process. In the case of harm reduction intervention for MDU, it frequently looks at patterns that demonstrate a change toward healthier and more functional MDU. In the initial assessment, the clinician will need to carefully consider the nature and function of the MDU when determining whether group composition should be heterogeneous or homogeneous. Issues with availability of group members, setting limitations, and timing may impact clinician’s ability to create the “ideal” group with members whose MDU is based on the same or similar motivations and experiencing similar functional impacts. Likely, though, this is unrealistic

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and groups will be mixed, with overlapping and interdependent motivations for MDU, causing a variety of problematic issues for group members. Essentially, we stress the importance that clinicians use their expertise when conceptualizing each member’s presenting problems and consider how these will interact when contributing to a larger group dynamic. Clinicians must anticipate, to the best of their ability, how to ensure a positive and successful experience for growth for all members. Above all, they must ensure safety. We especially stress how important it is that clinicians assess for, and screen-​out from mixed groups, those youth whose MDU involves pursuing activities online that could be triggering for other group members (e.g., sexual behavior, racially harmful behaviors). It may be more appropriate, for example, for youth who seek online pornography to work in a shared therapeutic space and process. However, there may be instances and circumstances in which a potential member would not be appropriate for inclusion in a group approach to reducing unhealthy MDU, even if the material and/​or nature of their use (e.g., pornographic material) is similar to other members. Some youth may not be appropriate for group-​based CBGT for MDU, and better served in individual interventions. Chapter 1 of this handbook presents a comprehensive discussion on the selection of group members, which will not be reiterated here. Likewise, we will not provide an exhaustive literature review of every available measurement tool. Instead, the aim is to offer a comprehensive overview of clinically relevant ideas, tools, methods, and considerations for evaluating children and adolescents dealing with the emerging issues of unhealthy MDU, with a primary focus on conceptualizing treatment approaches. Clinical Interview At the core of any effective clinical evaluation lies a comprehensive interview and direct behavioral observations. When interviewing young clients, it is often necessary to involve both the child or adolescent and caregivers. However, it is encouraged to dedicate a portion of the interview specifically to a child or adolescent’s perspective. While this can be challenging, clinicians must interview in a manner that does not make the individual feel like they are being judged for MDU, as this has likely been a common theme that led them or their caregivers to seek intervention. Therefore, the interview establishes a relationship and connection with the child or adolescent before delving into problem areas, symptoms, or functional impacts. Before addressing these issues, it is essential to take time to get to know the client. Christner and Mennuti (in press) suggest using open-​ended questions as a starting point for these interviews. For instance: • • • • •

Tell me a bit about yourself. How would you describe yourself? How do you see yourself? How do others describe you? What’s important to know about you?

As youth clients describe themselves, a skilled interviewer will listen for keywords or phrases that may lead to further questioning or clarification. For instance, if a child says, “I’m the troublemaker in my house,” the clinician might follow up with questions like, “You said ‘troublemaker,’ what does that mean for you?” or “Could you give me an example of what happens that makes you a ‘troublemaker’?” Regarding MDU, if an adolescent says, “Everyone says I’m addicted to my phone,” the clinician can delve deeper by asking, “You mentioned they think you’re ‘addicted,’ what does that mean to you?” or “Others use the term ‘addicted’; how do you feel about that? Is that an accurate description? What do they see that makes them use that term?” As with all good

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interviewing, having a set of effective inquiries such as “Tell me more about …,” “Can you give me an example of …,” or “Help me understand what that’s like for you” should be used to encourage the individual to expand on their responses. This also communicates that a clinician cares about understanding the youth’s perspective and including their experiences in the treatment process—​ one they may not yet be fully invested in. We also find that it encourages ownership and deepens motivation for and commitment to the work by asking, “Since you are here and beginning this process, what would you like to be different afterwards?” Beyond establishing a connection and getting to know the individual, a comprehensive clinical interview is essential for gathering information about specific symptoms relevant to a differential diagnosis. Clinicians have numerous options for conducting a general interview, including structured interviews or semi-​structured interviews. While we often rely on our semi-​structured interviews in clinical practice, preexisting interviews such as Diagnostic Interview for Anxiety, Mood, and OCD and Related Neuropsychiatric Disorders: Child and Adolescent Version (DIAMOND-​ KID; Tolin et al., 2023) can be extremely useful. For clinicians using their interviews, it is recommended that topics covered in Table 12.1 be used in addition to MDU questions (discussed below). In addition to general questions during the interview, when working with those who may be experiencing excessive or unhealthy MDU, it is also necessary to ask specific questions to understand the MDU comprehensively. These questions serve the purpose of understanding the extent of the concern while also identifying the functional and motivating aspects of the individual’s MDU. Table 12.1 Common Components of a Clinical Interview • Information about self (e.g., interests, likes, self-​p erception) • Ethnoracial/​C ultural information • Areas of concern (e.g., reason for referral) • Family relations (e.g., household residents, relationships, etc.) • Developmental history (e.g., any delays) • Social history (e.g., friends, relationships, extracurricular activities, what they enjoy doing) • Medical history (e.g., health, illnesses, eating habits, sleep quality, exercise, medications) • Mental health history (e.g., diagnoses, treatment, medications) • Trauma history/​a dverse childhood experiences • Legal and disciplinary history (if relevant, including traffic issues with teens, school suspensions) • Substance use/​a ddiction (e.g., alcohol, recreational and illegal drugs, caffeine, vaping, tobacco) • School/​E ducation history (e.g., grades, work completion, special services, past testing, truancy) • Work history (for adolescents) • Adaptive skills (e.g., self-​c are, community use, reliance on parents) • Clinical symptoms – Anxiety – Mood – Obsessive-​c ompulsive behaviors (including perfectionism) – Attention – Impulse control, including self-​injurious behavior – Anger/​A ggression – Psychosis (e.g., hallucination, delusions) – Autism spectrum – Suicide and homicide screening • Strengths and assets • Readiness to change factors (e.g., precontemplation, contemplation, action planning, action, and maintenance)

206  Jessica L. Stewart et al. Table 12.2 Questions about MDU • How much time do you spend on devices (smartphones, tablets, computers, gaming consoles) each day during the week and on weekends? • Can you describe your typical daily routine regarding device use, including when and where you use them most? • Are there specific apps, games, or websites that you find it difficult to stop using? • Have you ever missed out on sleep, schoolwork, or social activities because of your device use? • How do you feel when you are unable to use your devices for an extended period? Do you get anxious, lonelier, or irritable? • How do you feel (emotionally, mentally, and physically) when you stop (whether voluntarily or after being asked to stop) using your devices? • Do you find yourself using devices to escape from stress, boredom, or negative emotions? • Have your device usage habits ever caused conflicts with your family or friends? • Are there any physical symptoms you’ve noticed as a result of excessive device use, such as eye strain, headaches, or disrupted sleep? • Do you feel that your device use is affecting your ability to concentrate or perform well in school or other activities? • Have you tried to cut down on device use in the past, and if so, how successful were you? • How often do you engage in physical activities or hobbies that do not involve screens? • Are there specific goals or interests you have that you feel are being hindered by your device use? • Are there rules in your household regarding device use, and how do you feel about them? • Can you describe the role that social media plays in your life, and do you ever feel pressured to maintain a certain online presence?

Many of the reasons underlying unhealthy MDU have been discussed elsewhere in this chapter. In Table 12.2, we provide a list of suggested questions for consideration in this context. Rating Scales In addition to conducting interviews, we recommend supplementing the assessment process with the use of standardized objective measures. Various rating scales and behavioral inventories are available for use with children and adolescents, offering comparative data against same-​aged peers. This comparative information can be valuable in examining the extent and severity of behaviors relative to peers, assisting in understanding behavior severity. Moreover, these measures can offer a clearer understanding of symptoms and behaviors, thereby aiding the process of differential diagnosis and treatment planning. Rating scales can be categorized into two main groups: broadband instruments and narrowband instruments. Broadband. Broadband measures are comprehensive assessments encompassing a wide range of symptoms and adaptive skills. These measures are often valuable during the initial clinical assessment and early stages of treatment. Among the most commonly used broadband instruments for children and adolescents are the Behavior Assessment System for Children, Third Edition (BASC-​3™; Reynolds & Kamphaus, 2015) and the Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001). Both of these measures have a well-​established history of use in various settings and provide useful information. Another noteworthy addition in this category is the Christner Behavior and Adaptability Assessment System (C-​BAAS™; Christner, in progress), which stands out due to its built-​in index to assess MDU, along with functional concerns, such as sleep issues. Additionally, within the scope of broadband measures is the need to consider the assessment of executive function skills. Given the connection between executive function skills and unhealthy MDU, a comprehensive evaluation of executive functioning can be essential in case

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conceptualization and treatment planning. While measures like the BASC-​3 offer an index examining executive functioning, we have found that the use of measures specifically tailored to executive functions is more useful. One such example is the Behavior Rating Inventory of Executive Function®, Second Edition (BRIEF®2; Gioia et al., 2015). These specialized measures offer a targeted understanding of executive functioning, which can be relevant not only in MDU assessment but especially intervention. Narrowband. In contrast, narrowband instruments focus more specifically on symptoms, allowing for a deeper exploration of a specific area of concern. These measures are designed to assess specific problem areas and are not only capable of assessing symptoms and impairments but can also track improvements in symptoms, making narrowband measures well-​suited as progress monitoring tools. Several instruments have been adapted from previously validated instruments to provide a broad view of media and device abuse (Király et al., 2015). For example, Young’s Internet Addiction Diagnostic Questionnaire (IADQ) and Internet Addiction Test (IAT) were partially developed based on the original diagnostic criteria for gambling disorder (Young, 1998, 2009). With the increased awareness of unhealthy MDU, additional instruments have been specifically developed for use with this population. It is beyond this chapter to discuss these in great detail. Table 12.3 provides a list of potentially useful measures for review. Table 12.3 Examples of Narrowband Rating Scales for MDU Bergen Social Media Addiction Scale (BSMAS; Andreassen et al., 2012) Internet Gaming Disorder 20 (IGD-​2 0) Pontes et al., 2014) Problematic Internet Use Questionnaire (PIUQ) (Demetrovics et al., 2008) Problematic Online Gaming Questionnaire (POGQ) (Pápay et al., 2013) Social Media Disorder Scale (SMD) (van den Eijnden et al., 2016). Social Media Use Integration Scale (SMUIS) ( Jenkins-​G uarnieri et al., 2013) Social Networking Activity Intensity Scale (SNAIS) (Li et al., 2016) The Adolescent Compulsive Internet Use Scale (ACIUS) (Lopez-​F ernandez et al., 2019) The Internet Addiction Test (IAT) (Young, 2017) The Media and Technology Usage and Attitudes Scale (MTUAS) (Rosen et al., 2013) The Problematic Media Use Measure (PMUM) (Domoff et al., 2019) The Screen Time Questionnaire (Vizcaino, et al., 2019) The Smartphone Addiction Scale (SAS) (Kwon et al., 2013)

Assesses the degree of addiction to social media (originally for Facebook but now expanded). Measures the nine Internet Gaming Disorder criteria suggested in DSM-​5 . Measure problematic or addictive internet use. Measures problematic or addictive online gaming behavior. Assesses the severity of social media disorder based on the nine DSM-​5 criteria for Internet Gaming Disorder, adapting them to a social media context. Evaluates the degree to which social media use is integrated into daily activities and social practices. Measures the intensity and the nature of individuals’ use of social networking sites. Assesses the severity of compulsive internet use with adolescents. Assesses excessive device use, including prolonged internet or app usage on smartphones and other devices. Measures the frequency and duration of media and technology use across different devices. Assesses problematic media use across various devices and screens, including smartphones, tablets, and computers. Assesses daily screen time across different devices and activities. Assesses smartphone addiction and its severity through device usage patterns and behaviors.

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Modular-​B ased Group Intervention When developing group interventions for unhealthy MDU, we propose using a semi-​structured yet adaptable method as the most ideal approach. This is best accomplished by following a modular approach to CBGT, in which there are core units of intervention that introduce and reinforce the development of critical skills necessary for behavior modification. While there is a core set of modules, the work within each module can be tailored to the individual group members’ needs based on the assessment, case conceptualization, and personal goals. This tailored approach might be reflected, for example, in the use of varying techniques within each module or even dedicating more time to a specific skill before moving on, so as to meet the needs of a particular group of children. This chapter offers guidelines rooted in essential harm-​reduction principles, informed by research and our clinical experience with unhealthy MDU. Some group members will require unique or specialized interventions, perhaps outside the group setting, to address issues such as severe emotional problems, developmental social disorders, and sexually addictive behaviors. These go beyond the sequence of modules described below, and clinicians should assess the need for additional or supplemental services during the initial evaluation process and determine whether group intervention is indicated in these circumstances. We recommend clinicians interested in implementing group work with unhealthy MDU follow a harm reduction-​based approach, incorporating the core components outlined below, and progressing in a structured, sequential manner. Here, we offer a description of each recommended module with sample activities provided in Table 12.4. Table 12.4 Sample Activities for MDU Treatment Modules 1. Paving the Way for Successful Goal Setting • Introduce the concept of setting and prioritizing goals as a way to make positive changes. Have all group members brainstorm a list of possible goals they could work on, then write on a whiteboard and discuss the feasibility of each. Have each member pick two goals they feel they would benefit from (or they can come up with one on their own). Help individuals take each of their goals and make them SMART (specific, measurable, achievable, relevant, and time-​b ound). For between-​s ession work, have them break each SMART goal into smaller, manageable steps and create a “plan of action.” • Introduce individuals to the importance of visualizing success and using self-​a ffirmations to boost self-​b elief. Use a visualization activity and ask group members to close their eyes and imagine themselves achieving their goals with MDU. Have them picture what they feel, see, and hear. Play video on “positive thinking” (we like using www.yout​u be.com/​w atch?v=​k O1kg​ l0p-​H w&t=​4 s). Have group members create their positive thoughts or affirmations related to their goals. 2. Developing Insight/​Psychoeducation • Show a short video about the fight or flight response (we like using https://​youtu.be/​r pol​ pKTW​r p4?si=​k o3yM​3 i_​Q​O 5zg​b xc). Ask members to list two or three situations that cause them to feel strong negative emotions, including where and how these are felt in the body. And then list two or three situations that cause positive emotions, including bodily sensations. • Teach the T-​F -​B connection using an example relevant to the group members. For example, with middle school members, share about a client who receives a grade of 62 back on their math test: what did the client think, feel, and do in response to that “trigger”? Then, model for the group how the person’s thoughts and feelings would be different if the context changed (e.g., the client had been receiving 45s on previous tests) to exemplify how perspective and resulting emotional responses can change based on our interpretation of the trigger. • Give each member a blank “thought record,” read a scripted scenario of a child (similar age) experiencing a difficult moment, and ask them to list the resulting T-​F -​B .

Building Healthy Media and Device Habits 209 Table 12.4 (Continued) 3. Empowering Self-​Awareness for Competent Coping • Mindful awareness and observing one’s experiences (thoughts, feelings, and bodily sensations). • Introduce members to mindful meditation to learn to attend to their senses and perceptions (including emotion) without necessarily working to change them. • Use muscle tension/​r elaxation activities that help members recognize the difference between physical states (e.g., progressive muscle relaxation, how difficult it is to hold a tight fist while deep breathing) • Differentiating emotions: • Share or create, as a group, examples of anger as a masking emotion for something else, usually more vulnerable feelings (e.g., hurt, embarrassment, guilt). • Use scenarios that exemplify the difference between emotions, such as anxiety versus discomfort, anger/​irritation versus boredom and restlessness, happiness and contentment versus simply the absence of loneliness. • Learning to gauge emotions on a range and not as “all or nothing states.” • Have members build a “feeling thermometer” of any negative emotion (e.g., anger, anxiety, sadness) relevant to them as well as a positive emotion (e.g., safe, happy, loved), with some experience that produces that emotion at all points from 0 to 10 (similar to creating a SUDS scale for anxiety treatment). 4. Changing the Narrative: Flipping Your Inner Script • A free association activity that requires members to complete a series of sentence starters that all begin with “My use of (media/​d evice) …,” such as: (brings me, makes me feel, makes others feel, makes others think, means I can, means I don’t), etc. Then have members fill in a second group of sentences based on the starter, “If I didn’t (media/​d evice use) …,” such as “I would feel,” “I would spend my time,” “I could,” “my family would,” “in school I could,” “my friends would,” etc. • Introduce the common cognitive distortions (included in Chapter 1 of this text) often referred to as “Thinking Traps,” “Junk Thoughts,” or “Perceptual Prisons,” and discuss as a group, and then ask members to create an example of each distorted thought specifically related to MDU (e.g., generate a few Traps within small groups, assign one or two Traps to each group member). Send a copy home for between-​s ession work for members to identify within another column of their thought records (Thinking Trap). 5. Going from Chaos to Control: Building Your Brain’s Command Center • To foster mental flexibility (which promotes more effective problem-​s olving, discussed more below), have the group engage in collaborative brainstorming activities. • For example, members could identify as many uses as possible for a brick. Or generate a list of food options for a picnic, which will also ask members to begin thinking of the possible “consequences” to solutions (e.g., why ice cream may not be the best choice if the picnic is far away, there are no ice packs, and so on). • Having members work in groups supports flexibility because members will likely have differing perspectives on a given prompt. Another activity could require members to have to explain or defend the rationale of the perspective (once given) of another in their group. • Self-​m onitoring is an important skill that precedes self-​r egulation and can be improved through structured practice. • First, members discuss and make a list of what they would like to manage better in their lives and start with something fairly trivial, such as decreasing the amount of time they say “like” before other words (e.g., “like, I already told you,” or “like, I know”). • In the case of MDU, we might have group members identify what area of MDU is most problematic for them (e.g., do they watch TikTok or YouTube for hours prior to bedtime, do they neglect to nourish their bodies by skipping lunch and dinner because they are so engrossed in gaming). This can begin as an in-​g roup assignment to determine what type of MDU is most problematic for the individual and transition to homework to monitor how much time the MDU that they identified occurs. The group members will keep track throughout the week, recording the start time and end time they engage in the MDU they identified as most problematic. (Continued)

210  Jessica L. Stewart et al. Table 12.4 (Continued) • However, this can also be used to self-​m onitor other MDU activities that the individual did not identify. For example, a group member may have identified online gaming as the most problematic, but after tracking the use of all MDU, they realize they actually spend more time on social media. • This activity will highlight a truth that one cannot achieve through estimation and which produces dissonance between beliefs and behavior that is necessary to promote lasting behavior change. 6. Solving Problems for Success • Have group members brainstorm in-​p erson social interactions to try when changing MDU. Have them list the anticipated pros (e.g., getting to know someone better, including mannerisms, real-​t ime back-​a nd-​forth reciprocal interaction, chemical changes that occur during bonding) and potential cons (e.g., anxiety about looking “stupid” or not making a good impression, worries it will be “boring” or not a good time). They then use cognitive skills to balance their “Thinking Traps” about the replacement activity by creating more positive, empowering self-​t alk before implementing their choice: “Even if I don’t love it, it could still be something I enjoy (like a 6 if it’s not a 10)” or “I’m trying something different which maybe I didn’t even know I could like.” • Have group members list “barriers” or “roadblocks” to changing MDU. List them each on a whiteboard. Have the group pick several that most agree could be problematic. Using a metaphor of a GPS rerouting someone who is trying to get to a certain place when there is construction and detours, have the group come up with options to “reroute” around the MDU roadblocks. Once a list of options is created, have members rank them in a hierarchy of options they believe would help them best. 7. Final Module: Maintenance Assurance • Have group members each write down their “long-​t erm” goal for MDU in moderation. Have them write it in specific terms and write them on a 3 × 5 card. Underneath the goal, have them write the strategies that will be the most useful for them. On the back, have them list the barriers they might face and, next to it, what they will do to “reroute” from barriers. As an alternative, this can be done on a computer and printed. We encourage them to make a couple of copies and place one in the phone case or on their gaming system or computer as a reminder.

Paving the Way with Successful Goal Setting While less of a discrete module, per se, goal setting is a common and important element of CBT that offers numerous benefits in treatment. We suggest that clinicians using CBGT meet with each group member individually to discuss goals and then also discuss goals as part of the early group process. In doing this, group members will have clarity and focus regarding their hopes for progress and have a clear understanding of the objectives of each session. Within the first group meetings, it is important to have each member share their personal goals with the group. This increases accountability and offers a way for group members to support, encourage, and problem-​solve for each other. Goal setting is a collaborative process between the individual and therapist and, at times, the group as a whole. Each session should have a “mini-​goal” for members, to foster accountability, participation, and progress toward the larger goals. This might include monitoring each member’s involvement in group activities, the number of members completing between session work, and sharing specific milestones reached. For instance, one group member may have a goal between sessions to decrease device time by 30 minutes a day. During the check-​in part of the meeting, they share (and show a screenshot of their average weekly use since the last session) that they actually achieved a

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53-​minute reduction. All members can celebrate this accomplishment with the individual. In contrast, another group member, whose goal was to stop video game play after 60 minutes on school nights with only one reminder, reported to the group that they were only successful on four out of seven nights. This is not a time for discouragement but an opportunity to focus on the nights they were successful to determine “what you did well” (reinforcing successful application of newly acquired skills), and to use the group process to problem-​solve the barriers that prevented their success on other nights. Finally, goal setting as an intervention should be twofold—​decrease unhealthy behavior (or functional impairment) and enhance well-​being. Thus, when outlining goals some may resemble “I’ll put my phone on charge each night by 9:00PM” or “I’ll decrease my gaming time by one hour a day.” However, group members might not find this language particularly exciting or motivating by itself (as it focuses on reducing something they have enjoyed). Thus, pairing this with a personal goal that adds something rewarding to their lives is also helpful. We encourage group members to think about what they would like to do differently with their time if they made positive changes to MDU—​what opportunities and space this change may create for additions to their lives. Examples have included, “With the extra time, I will take a karate class,” “I will learn to play Dungeons and Dragons and join a group,” and “I will take one night a week and do something in person with a friend.” Developing Self-​U nderstanding Through Psychoeducation Before more specific behavioral and cognitive skills can be addressed, group members must first understand interacting variables that contribute to the problem behavior. This module is predominantly psychoeducational or informative, acquainting group members with components presented earlier in the case conceptualization section. Psychoeducation includes various topics—​from brain function and neurochemical processes that impact mood and motivation to key aspects of CBT, such as the thought–​feeling–​behavior (T-​F-​B) relationship.1 This foundational knowledge allows group members to begin understanding the function their MDU plays and its impact on fostering risk and well-​being. Gaining self-​awareness through evidence, logic, and facts is vital for group members to connect with ideas, create goals, and commit to any interventions that will follow. By supporting members in more consciously recognizing their beliefs and behaviors, clinicians will be able to leverage the concept of cognitive dissonance that underlies enduring behavior change and relapse prevention. In this module, we propose interventions introducing fundamental brain-​based functions, such as attention, motivation, and reward mechanisms (including dopamine’s significance in mood and behavior reinforcement), the innate “Fight or Flight” response, interpretations of events and bodily sensations (where emotions come from), the mind–​body connection, and the importance of social connectedness for well-​being. We have found that educating children and adolescents on these underlying factors aids them in understanding the “why” of later interventions and increases compliance and follow-​through. While adapting interventions to the group’s developmental level and makeup can be challenging, we encourage clinicians to explore interventions from various programs that meet the goals of this module and consider samples provided in Table 12.4. Building Self-​A wareness for Competent Coping Once group members understand where feelings come from and how our behavior results from our emotions—​as a way to reduce unpleasant experiences or increase pleasant ones—​it is important

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for them to work to improve their emotional regulation skills. This relates to perceiving their emotions accurately (labeling and gauging the degree of the emotion), regulating and coping with them in healthy ways, and even communicating their feelings to others for social support. We need to validate that painful emotions can be experienced not only as an emotion but also as unpleasant physical sensations and mental upset (e.g., worries, resentful or angry thoughts, insecure thoughts, self-​doubt, and confusion) that naturally one would want to remove. But we need to exemplify ways that positive emotions are felt physically, too, and how they may change our thinking (e.g., feeling relief when we avoid a stressful situation may lead us to believe we “can’t handle that situation” and the only way “out” is to escape). When group members better understand the interaction of these experiences and build healthier ways to manage them effectively, they will be better able to tolerate their negative perceptions and reduce their reliance on MDU as a means of coping (e.g., to avoid discomfort or achieve reward). Similarly, when members can understand what contributes to positive emotional, physical, and mental experiences, they can develop a wider range of behavioral choices besides MDU to feel positive states. Some important interventions for this module, which may span two or more sessions, are included in Table 12.4. Changing the Narrative: Flipping Your Inner Script In this module (which could span two or more sessions), members work on more directly addressing their thought process: the “T” they have been learning to attend to and capture through repeated use of the thought record for practice. The goal of this module is to teach members how to recognize and then restructure unhealthy, untrue, and exaggerated interpretations of events or perceptions (including physical sensations as “too hard to feel”) so that negative emotions are less extreme and thus better managed via a variety of coping tools developed in the prior module. Further, this work is meant to change members’ beliefs about themselves and their competencies, interpersonal matters and stressors, and even their MDU so that the meaning they place on it is more balanced based on facts, not assumptions or fears. For example, suppose someone is telling themselves that they can only relate to peers comfortably in the virtual world (e.g., discords). In that case, they may never attempt to do so otherwise (e.g., in school), and the importance of their MDU is exaggerated. Thus, reducing their reliance on MDU as a means of connection will be very difficult, and the suggestion of such a choice would feel threatening. They must be taught to hear the absoluteness of language in their thoughts (e.g., “only relate this way,” “will be rejected if I …”) and appreciate that this all-​or-​none thinking leaves out possibilities that could reduce their social anxiety at the root of it: they could build greater comfort interacting in more ways than through MDU (even if that may remain a preferred method). Similarly, if a client believes “I’m only happy when I play video games with my friends,” they may be resistant to the idea that any other activity may also bring happiness, even if not to the same level of intensity that gaming provides. Extreme beliefs not only maintain unhealthy behavior (MDU), but they also maintain a skewed perspective of one’s competencies that results in resistance to or anxiety about change itself—​ because reducing behavior that provides desired benefits may feel like a loss that one “can’t handle.” The emphasis needs to be on helping members think about their MDU and what contributes to it—​the reasons they engage to the degree that they do, because of what it brings them—​but also how it negatively impacts other aspects of their functioning that, therefore, makes it unhealthy for them in the bigger picture. What makes for a “negative impact” includes the unwanted consequences it may introduce into their lives and also what it does not allow for, such as how it interferes with other goals they have or aspects of functioning they also desire: building closer

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connections, doing better in school, being in trouble less often at home, sleeping more, and even feeling “healthier” or “more real” (as we have heard members report). Helping members recognize alternative ways of thinking that carry truth and validity will help to lessen the hold those distorted beliefs have over them—​emotionally and in terms of choices they would be willing and able to make. These interventions are designed to recognize “hot words” within thoughts that make them irrational, exaggerated, or untrue and to restructure these cognitive distortions to “flip the script.” Moving from Chaos to Control: Building Your Brain’s Command Center As discussed in the case conceptualization section, executive functioning plays a role in one’s ability to regulate their MDU. Youth who are well aware of the downsides of their MDU and the degree to which it is unhealthy may not simply be able to make more disciplined decisions “in the moment” if they struggle with, for example, inhibition. They may not be able to think of consequences before they act when faced with the temptation of a really positive experience (e.g., they click on the long-​awaited video, announced with a “ding,” when they are just starting to write their English essay due in three hours), even when they can consciously name the ways their phone may be a distraction to their schoolwork when speaking intellectually with their parents. Clients who struggle with time management and planning may cause tension in the family or receive consequences in extracurricular activities (e.g., playing time) when they can’t get out the door on time with all necessary materials (e.g., “I know, mom! I only have time for one battle before we have to leave for practice, I will be ready.”). We believe that executive functioning is a critical contributing factor to one’s MDU and needs to be an additional focus of any intervention to adjust this behavior. Solving Problems for Success Once members understand the skills involved in decision-​making and have outlined their own goals for finding balance in their MDU and other aspects of life, they need to learn a more conscious and deliberate process for making decisions. Considering problems as solvable through a step-​ wise process, with the aim of choosing behaviors in line with their goals while minimizing consequences, further supports the development of inhibition, flexibility, planning skills, self-​regulation, and overall competency. The problem-​solving process is well established as an effective skill in decision-​making that promotes accountability because it taps into members’ desire to have their needs met while encouraging awareness of and responsibility for also addressing the consequences of their choices. This module teaches members to define a problem related to MDU clearly and to brainstorm multiple solutions that explicitly consider the positive and negative outcomes of each. Knowing what we “get” and accepting what we may be sacrificing by the choices we make will allow members to internalize more deliberate decision-​making surrounding their MDU. For example, it may be challenging for group members to adjust social media use and networking if they worry they need to abandon it completely, which may also not be in their best interest. Visual pictures on Instagram or Snapchat are reinforcing as this may be a primary source of social connection. When social connectivity is a goal of MDU, problem-​solving will focus on helping members learn how to balance their online presence with in-​person activities that provide connection and belonging. For those who seek entertainment through MDU, videos such as on TikTok and YouTube are especially seductive because they provide an endless supply of personally relevant entertainment for the viewer. As a concept, this form of media can be highly enjoyable and can also be educational (e.g., many people now acquire knowledge about mental health conditions and coping strategies from these resources). The algorithms that tailor available content to individuals based on their viewing patterns (making it highly reinforcing and addictive) can make it more

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challenging to have the self-​discipline necessary to moderate the use of these platforms. Problem-​ solving process will help members gain awareness of the ways that time spent in unproductive, purely entertaining activity reduces time and energy channeled to other areas of life functioning (e.g., school, work, physical activity, sleep, in-​person socializing). Problem-​solving process starts with members defining the problem in clear, behavioral terms (e.g., “I can’t get up for school on time because I am too tired from staying up so late watching episode after episode of my show”). Then, members will create a visual (e.g., on the board, using a large paper easel) that outlines all the possible solutions to address this problem. For example, in order to get up on time for school, the focus could be on strategies that support the member in how to wake up earlier but could also look at how to reduce MDU before bed so that they go to bed sooner (which makes getting up on time more likely). The group then lists the pros and cons of each solution. In this example, if solutions address only strategies for waking on time, they will still have “really tired all day” in the con category. Only solutions that include adjusting MDU before bed in some way will be able to include “getting to bed earlier, being less tired, and having more energy” under the pro column. Once the list of solutions and resulting outcomes (pros and cons) is made, members discuss which choice they will make—​based on thoughtful consideration of which “pros” weigh more for them, according to their individual goals and needs, and which “cons” are tolerable when considered alongside the benefits they would receive. An important part of this process is when members learn to consider ways to address the cons related to the pros they desire, which promotes more of an understanding of balance (not either/​or decision-​making). This includes accepting and tolerating the cons (further strengthening self-​regulation skills already introduced) and proactively finding ways to mitigate their impact (e.g., seeking support from family members and making other changes to offset the unwanted aspects of the solution they choose), which reinforces general problem-​solving skills—​and ultimately a sense of competency. Lastly, in the problem-​solving process, members must implement the chosen solution and evaluate its effectiveness, making adjustments as necessary. Teaching, modeling, and practicing the problem-​solving process within the group setting provides greater flexibility when generating solutions because more voices from varying perspectives collaboratively contribute to generating solutions and anticipating potential pros and cons. In addition to the guided whole-​group activity that introduces and runs through the problem-​solving process using several group members’ examples, members should then generate between-​session experiments to put this process into action. While still in group, they name a problem related to their MDU that they would like to address, generate solutions and accompanying pros and cons lists, and then rate their anticipated satisfaction (0–​10). For homework, they implement the solution/​activity and track what happened: were they accurate in terms of the assumed benefits or consequences, did they feel how they assumed they would during and after they implemented the solution, and were there unanticipated consequences to now address, etc.? Recording all of this information allows them to unpack their potential negative perceptions with fact-​based information. Sustaining Healthy Digital Habits The final treatment module is designed to reinforce members’ (1) acquired knowledge of factors contributing to their MDU, the T-​F-​B interaction, and skills to regulate these experiences more proactively, and (2) their competent application of skills for healthier coping and distress tolerance, intentional goal setting and decision-​making, self-​monitoring and awareness, planning, and problem-​solving. This happens through interactive review and assessment, which can be achieved in a number of creative ways, depending on the makeup of the group (e.g., age or developmental

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stage of members, resources). For example, facilitators may assign members (individually or with a partner) a portion of the educational components of the module lessons to teach back to the group as a whole (which we know is a study strategy that reinforces retention and deeper comprehension). Facilitators could also compile a “webinar” of footage from earlier instructive lessons and group discussions that members can watch for review (and possibly then take home for reference later). We recommend that facilitators also include a formal, individual assessment of knowledge, too, as being “tested” on the language, terms, concepts, and principles behind the skills reinforces comprehension of the “why” for the practical skills they will need to apply post-​group. This can be achieved through pen/​paper methods (e.g., quizzes of varying formats or a written essay). Still, we also like using digital platforms that youth are familiar with in school and enjoy, such as Gimkit and other fun competition-​style games. Assessing members’ ability to apply practical skills competently can also be achieved in a number of creative ways. One option is to have group members pair off and create “skits” (as exemplified above) that demonstrate both the way characters may behave before learning these skills (complete with dialogue written to show a character’s thinking traps, lack of self-​awareness, and poor planning or problem-​solving) and then demonstrate the way they “do-​over” handling a situation with newly acquired skills (e.g., identifying one’s thoughts, feelings, and behavior, reframing thoughts, and then working through the steps of assessing and planning time to achieve the stated goal more directly). This activity is called Take Two. The audience (the other group members) is charged with identifying the terms or concepts, unhealthy patterns and missing skills, and strategies and tools the characters could employ to resolve the situation in healthy ways. The actors then perform the skit again, applying the skills the group members identified to help the situation. The emphasis is on acknowledging and coping with difficult experiences (cognitive, behavioral, emotional, or physical), promoting more effective problem-​solving and decision-​making that is in line with a character’s goals, and creating a more desirable situation and outcome. When members act out the concepts and skills, they gain both review and reinforcement, while the audience practices actively retrieving learned material and identifying ineffective and effective skills “in action” for equal reinforcement. These skits create lived experiences—​of both ineffective (“harmful”) and effective (“success”) coping—​that are now reference points in their memories to draw from in similar situations in the future. Ultimately, the goal of this final module is to support relapse prevention and a healthier, balanced relationship with MDU going forward. Facilitators can get a sense of which members absorbed information for the successful application of skills post-​group and which members may benefit from continued treatment through personally guided individual therapy to acquire or apply important skills for modifying MDU. It is also important in this final module that members reflect on the “portfolio” they created throughout the group intervention that they will take with them after the close of group. This self-​ reflection reinforces awareness of their own MDU: factors that contribute to it, ways in which their use initially was problematic, how they can plan their use now in healthier ways, and especially how their situations will improve if they consciously choose a more balanced relationship with MDU. This includes explicitly knowing healthier strategies for coping with negative emotions and increasing options for bringing positive emotions into their life that do not involve MDU. It also includes the increased capacity for tolerance of physical, emotional, and cognitive discomfort/​distress that will inevitably be a part of life, which they can often address directly through conscious decision-​making. Their portfolio will also include weeks of homework practice in each of the modules, so they have a lasting and tangible resource to support challenging moments in the future. A final point when reviewing their portfolios will be to consider and record what additional resources they may need “in the real world” and brainstorm personal obstacles or barriers to their

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continued commitment to a balanced relationship with MDU. Members will consider the questions: “What may get in the way of adhering to the goal I have made for myself? What will get in the way of my using the more effective skills I have been developing?” This activity can be done individually and then shared with the group so that members may benefit one final time from the collective wisdom of multiple perspectives when brainstorming to identify both the obstacles they may not be able to anticipate on their own and the strategies to address those challenges using skills learned in the group process. We know as interventionists that if we prepare people with problem-​solving skills to address issues they will face, we increase adherence to progress and prevent relapse. Summary Once again, there has been a substantial rise in MDU over the past decade, with screen time averages reaching over six hours daily globally, which is primarily driven by advancements such as smartphones, social media outlets, and digital platforms. While technology offers a myriad of educational and social benefits for people of all ages, excessive MDU can have detrimental effects on physical and mental health, mimicking addictive behaviors like substance abuse. In an increasingly technology-​dependent world, defining what constitutes unhealthy MDU for today’s youth is complex. It involves not just the time spent on screens but also the quality and purpose of use, the balance with life responsibilities, and the overall functional implications for well-​being. This chapter encourages clinicians to consider adopting an established treatment approach for substance abuse, known as harm reduction, to address excessive and unhealthy MDU. We present a model for the application of this approach within a group format, given the benefits of CBGT for delivering therapeutic services to children and adolescents. In order for treatment to be effective, we can’t stress enough the importance of a thorough assessment that contributes to a comprehensive conceptualization of the presenting problem, which is crucial to informing the best interventions to influence change. Problematic MDU is understood through various and emerging theories, highlighting the interplay of neurobiological predispositions, behavioral conditioning, social psychology, and cognitive-​emotional coping, with some components being more targetable for intervention than others to mitigate its negative impacts on daily life and well-​being. Increasing research is establishing the link between MDU and structural and functional changes in the brain, impacting regions related to addiction, emotion, and executive function. These biological factors, combined with behavior principles, social psychology factors (e.g., approval-​seeking and FOMO), difficulties with emotional regulation (e.g., anxiety, depression, loneliness, and intolerance for discomfort), and executive functioning deficits (e.g., poor inhibition and self-​monitoring), collectively influence the degree to which MDU may be unhealthy. Cultural and protective factors also influence what makes a youth’s MDU problematic or not and should not be overlooked. Understanding the relationships between these contributing variables—​and that their influences are likely bidirectional—​is crucial for interventions to be effective. Unhealthy MDU displaces essential activities and can lead to various behavioral changes, necessitating a comprehensive initial assessment that delves into aspects of functional impairment. Clinicians can utilize group-​based harm reduction approaches to help clients understand and modify these patterns toward healthier MDU habits. When developing groups for MDU, clinicians should strategically consider group composition, ensuring positive group dynamics and member safety. Additionally, the use of progress monitoring is vital during interventions so that adjustments can be made to keep the focus on the acquisition and application of knowledge and skills that will facilitate lasting change.

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We believe that adopting a modular, harm-​reduction-​based CBGT approach to intervention will provide both structure and adaptability and allow clinicians to tailor specific interventions to the individual’s needs and goals as well as the group process simultaneously. The progressive modules offered in this chapter are provided as a starting point to address skills we believe are important for the regulation of MDU, such as goal setting, psychoeducation regarding the interconnected variables contributing to MDU, emotional awareness and regulation, cognitive restructuring to ensure a healthier narrative about one’s relationship with MDU, problem-​solving, and executive functioning skills. Clinicians can use this treatment outline as a guide to continue developing a more detailed approach specific to the needs of the particular group of children and adolescents they are treating. Note 1 The T-​F-​B record is a critical tool used across modules throughout GCBT to encourage consistent self-​ awareness and build self-​efficacy to cope with discomfort and improve intentional decision-​making. When this process is internalized, members are able to independently regulate emotions and behaviors more intentionally, to ultimately react to situations in more reasonable ways and make choices that are in line with their goals.

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Chapter 13

Running Multi-​Family Skills Training Groups in DBT for Adolescents Jill H. Rathus

Introduction This chapter will discuss multi-​family dialectical behavior therapy (DBT) skills groups with adolescents and their caregivers. In the 1990s, Miller and Rathus (Miller et al., 1997; Rathus & Miller, 2002) began adapting DBT for emotionally dysregulated, often suicidal and self-​injurious adolescents. At the time, we were working with an adolescent population at Montefiore Medical Center/​ Einstein College of Medicine in the Bronx, NY, an inner-​city hospital setting serving mostly lower socioeconomic status (SES) families from racial and ethnic minority backgrounds, and many immigrants. The teens presented with complex mental health struggles, including suicidal behaviors and mood disorders, and DBT (Linehan, 1993) seemed most effective for treating these struggles. Today, following the losses and school closures during the Covid-​19 pandemic, increases in social media consumption, and ready access to knowledge of frightening issues such as climate change and gun violence, adolescents are facing a mental health crisis about which our surgeon general has issued an urgent advisory (Murthy, 2021). This situation is compounded by the fact that few adolescents receive needed care, and those who do access care experience high attrition rates (Abel et al., 2022). Standard DBT assumes that clients with pervasive emotion dysregulation lack capabilities to regulate emotions, resulting in problems with impulsivity, relationships, self-​management, and identity (Linehan, 1993, 2015). To address these deficits, DBT teaches skills in emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness through skills training groups, a key modality of the treatment. In our early application of the treatment, we observed additional areas of dysregulation particularly pertinent in adolescents: teen-​family conflict and extreme thinking and actions. Thus, we developed an additional family-​focused skills module, Walking the Middle Path, and adapted the DBT model of group skills training to include caregivers in order to address these issues. Our Walking the Middle Path module includes skills on Dialectics (thinking and acting in balanced, non-​extreme ways, while considering the truth in opposing perspectives), Dialectical Dilemmas (recurring extreme behavior patterns that polarize parents and teens, and their “middle path” syntheses), Thinking Mistakes, Validation, and Behavior Change (positive reinforcement and shaping, negative reinforcement, extinction or selective ignoring, and effective use of consequences). We also developed a handful of new skills specific to teens and families, including the THINK skill for perspective taking (Interpersonal Effectiveness module) and Parent-​Teen Shared Pleasant Activities for improving mood through activity scheduling and improved family cohesion (Emotion Regulation module) (Rathus & Miller, 2015). Our adaptation also added a family therapy mode and an optional parenting mode (Miller et al., 2007). This chapter will describe our multi-​ family skills group modality in DBT with adolescents.

DOI: 10.4324/9781351213073-15

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Note that our model espouses comprehensive DBT, in which group skills training is one of several treatment components, comprised of skills training, individual therapy, phone coaching, therapist consultation team, and for DBT with Adolescents, as-​needed family sessions and optional parenting sessions. However, some settings, including inpatient, residential, forensic, schools, and certain outpatient programs, offer DBT skills training only, with or without caregivers. Regardless, the skills curriculum is essentially identical, the only difference being that the Walking the Middle Path module may be omitted in settings without parents (e.g., Mazza, Mazza, et al. 2015), or taught to parents separately (see, e.g., Berk et al., 2022). Overview of the Presenting Problem Marsha Linehan originally developed DBT for adults with suicidal or self-​harming behavior who met criteria for borderline personality disorder (BPD; Linehan, 1993). However, as the efficacy of this treatment for broader populations has been repeatedly demonstrated, DBT has expanded to address multi-​diagnostic, multi-​problem clients (Ritschel et al., 2013); a prototypical adolescent receiving DBT might thus meet criteria for mood, anxiety, attention deficit, eating, behavioral, or substance use disorders while also frequently exhibiting three or more features of BPD. Though DBT was developed for adults, self-​injury, suicidal behavior, emotion dysregulation, and high-​risk behaviors typically begin in adolescence (e.g., Cipriano et al., 2017; Miller et al., 2007), and thus we saw the need to bring this treatment to adolescents and make developmentally appropriate adaptations (Miller et al., 1997). DBT therapists determine the focus of individual therapy sessions by the following hierarchy of treatment targets: reducing life-​threatening behaviors, reducing therapy-​interfering behaviors, reducing quality of life-​interfering behaviors, and increasing behavioral skills. Client and therapist monitor behaviors and emotions occurring throughout the week on the DBT diary card and then address the highest priority targets. The therapist and client target these behaviors using a behavioral or chain analysis (a behavioral assessment strategy identifying the controlling variables of the target behavior) and a solution analysis (generating solutions for key links on the behavior chain, rehearsing new behaviors in session, and getting commitment to apply the solutions outside of session). Often, these solutions are comprised of skills from the DBT skills training group, a modality that occurs in tandem with weekly individual therapy sessions (Linehan, 2015; Rathus & Miller, 2015). In DBT, the four problem-​solving methods therapists use for solution generation are skills training, exposure, contingency management, and cognitive modification. Skills trainers teach the behavioral skills in a group format, and individual therapists then help the teen apply the skills to specific problems in individual therapy sessions. Since parents of teen clients often struggle with their own emotion dysregulation, communication, or parenting challenges, we include them in skills training group. Parent participation not only exposes them to the skills their adolescent is learning, but also helps them regulate emotions and behaviors in the service of improved parent–​teen relationships and a more skillful family context –​the teen’s primary environment. Multiple research trials have demonstrated that comprehensive DBT for Adolescents (with group skills training, individual therapy, phone coaching, and therapist consultation team) works to reduce depression, hopelessness, suicidal ideation, self-​harm, hospitalization rates, treatment drop-​out, emotion dysregulation, and BPD features (Goldstein et al., 2015; Kothgassner et al., 2021; McCauley et al., 2018; Mehlum et al., 2019; Rathus & Miller, 2002). In addition, DeLaquis et al. (2022) conducted a meta-​analysis of DBT skills-​groups-​only outcome studies (i.e., non-​ comprehensive) and found that DBT skills training groups alone can be an effective transdiagnostic treatment for conditions including depression, anxiety, emotion regulation, eating disorders,

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and general symptom reduction. Importantly, utilization of the DBT skills has been found to be a mediator of outcomes (Boritz et al., 2019). Regarding our addition of the Walking the Middle Path module, Rathus, Miller, et al. (2015) found that the module was feasible to deliver, and highly acceptable to both adolescents and their caregivers. Assessment: Group Identification and Progress Monitoring A standard assessment battery to determine eligibility for DBT and its multi-​family skills group includes measures of suicidality, emotion dysregulation, mood, or overall symptoms (e.g., BSI). In addition, the Life Problems Inventory (LPI; Rathus et al., 2015; Wagner et al., 2015) is a reliable and valid measure developed with an inner-​city, racially and ethnically diverse population that assesses the main problem areas targeted with the DBT Skills, and thus contains the subscales: Confusion About Self, Emotion Dysregulation, Impulsivity, and Interpersonal Difficulties. In general, inclusion criteria for DBT multi-​family skills groups are struggling with three out of five problem areas, including the four listed above and the fifth being Teen-​Family Conflict/​ Extremes in Thinking and Acting. These problem areas often occur along with suicidal and self-​ injurious behaviors. In addition, the DBT diary card tracks progress and outcomes, which is filled out daily by clients and contains global ratings of clients’ main target behaviors and urges. These ratings include either yes/​no or 0–​5 on suicidal ideation, suicidal behaviors, non-​suicidal self-​injury (NSSI) urges, NSSI actions, substance use urges and actions, taking medications as prescribed, levels of emotions, and use of DBT skills taught in group. Therapists may also customize columns of the diary card to track a specific teen’s target behaviors, such as school refusal, binge eating, risky sexual behaviors, or risky or impulsive social media engagement. In addition to the LPI and the DBT diary card, clinicians might use a variety of standard measures to track suicidal ideation, depression, or general symptoms. Objective indicators such as suicide attempts, hospitalizations, number of sessions attended, and attrition rates can be used for program evaluation. Parents can fill out assessment measures as well (including a parent diary card; see Berk et al., 2022), to indicate their own struggles with mood or emotion regulation, parenting stress, or perceptions of family conflict. These can also be extremely useful indicators for monitoring adolescents’ progress in DBT. See Berk et al. (2022) for suggested parent measures and Miller et al. (2007) for discussion of adolescent assessment measures. CBT Conceptualization of the Problem DBT combines Western CBT principles with Eastern notions of acceptance and mindfulness. It balances these opposing treatment approaches with an overarching theory of dialectics, or the notion that two things that seem like opposites can both be true at the same time. Linehan viewed this synthesis of opposing positions as a crucial change strategy for a population for which emotional, cognitive, and behavioral extremes were commonplace. The central dialectic in the treatment is the balance of acceptance and change: acceptance of clients as they are while working to help them change, and using validation and problem-​solving to help them do so. In addition, Linehan (1993) conceptualized clients’ self-​harming and other maladaptive behaviors as stemming from capability deficits in emotion regulation, interpersonal effectiveness, mindfulness and self-​management, and tolerating distress. The DBT skills themselves balance acceptance (i.e., mindfulness and distress tolerance skills) and change (i.e., emotion regulation and interpersonal effectiveness). The Walking the Middle Path module, added by Rathus and Miller (Miller,

224  Jill H. Rathus Table 13.1 Characteristics of Dysregulation and Corresponding DBT Skills Modules Some characteristics of dysregulation Emotion dysregulation Emotional vulnerability; emotional reactivity; emotional lability; angry outbursts; steady negative emotional states such as depression, anger, shame, anxiety, and guilt; deficits in positive emotions, difficulty in modulating emotions, mood-​d ependent behaviors.

DBT skills modules Emotion Regulation

Interpersonal dysregulation Unstable relationships, interpersonal conflicts, chronic family disturbance, Interpersonal social isolation, and difficulties getting needs met in relationships, Effectiveness keeping self-​respect in relationships, loneliness. Behavioral dysregulation Impulsive behaviors such as cutting classes, blurting out in class, spending money, risky sexual behavior, risky on-​line behaviors, bingeing and/​ or purging, drug and alcohol abuse, aggressive behaviors, suicidal and non-​s uicidal self-​injurious behavior. Escaping or avoiding emotional experiences.

Distress Tolerance

Cognitive dysregulation and Family conflict Non-​d ialectical thinking and acting (i.e., extremes, polarized or black-​o r-​ Walking the Middle white), poor perspective taking and conflict resolution, invalidation of Path self and other, absence of flexibility, difficulty effectively influencing own and other’s behaviors (i.e., obtaining desired changes). Self dysregulation Lacking awareness of emotions, thoughts, action urges; poor attentional control; unable to reduce one’s suffering while also having difficulty accessing pleasure; identity confusion, sense of emptiness, and dissociation.

Core Mindfulness

Reprinted from Alec L. Miller, Jill H. Rathus, and Marsha M. Linehan, Dialectical Behavior Therapy with Suicidal Adolescents, p. 36, Table 2.1 © Guilford Press, 2007, with permission.

Rathus, & Linehan, 2007; Rathus & Miller, 2015) to address family polarization and extremes in thinking and behavior, is a dialectically based skills module that includes skills of thinking and acting dialectically, validation, and behavior change strategies. Table 13.1 describes DBT’s specific problem areas and the skills modules that address them. Functions of the DBT Multi-​Family Skills Training Mode Further conceptualization in DBT involves the functions of the various treatment modes. Individual therapy in DBT functions to increase the client’s motivation and assesses which factors may be maintaining problem behaviors and impeding progress. The phone coaching mode functions to increase skills generalization and helps with relationship repair. The therapist consultation team functions to increase therapist motivation and ensure treatment adherence. Family and parent therapy sessions structure the environment to be more reinforcing of the adolescent’s progress and increase skills generalization to the environment. Finally, the function of skills training is to enhance participant capabilities through skills acquisition, skills strengthening, and skills generalization. In addition to assignment and review of weekly homework to apply the skills to real-​life situations, inclusion of parents in skills training also facilitates generalization, as new skills are practiced with caregivers, and can help structure

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the caregiving environment to be more reinforcing of skills application. As DBT emphasizes that these functions are met rather than these particular modalities, treatment can be adapted for various settings and situations. For example, enhancing capabilities of the adolescent might occur through a teen-​only group, in an acute inpatient or residential setting, or through teaching DBT skills in the schools (Mazza, Mazza, et al., 2015). Enhancing the teen and caregivers’ capabilities might be accomplished through single-​family skills sessions if a multi-​family group is not available, or through separate or parallel programs for parents. Biosocial Theory DBT conceptualizes chronic emotion dysregulation through Marsha Linehan’s biosocial theory (Linehan, 1993), which holds that emotion dysregulation and its associated problems stem from a transaction over time between a biologically based dysfunction of the emotion regulation system and a pervasively invalidating environment. The dysfunction of the emotion regulation system leads to emotional vulnerability, which consists of an acute emotional sensitivity, intense emotional reactivity, and a slow return to emotional baseline. According to Linehan (1993), the invalidating environment is an environment that pervasively invalidates emotional expression by dismissing emotional experiences as wrong, inaccurate, dramatic, or manipulative (“You’re over-​reacting; go sit by yourself until you can pull yourself together”). This approach may work well enough for a person without emotional vulnerability. But for emotionally sensitive individuals who lack the ability to modulate their emotions, invalidation leads to not trusting their own emotion labels or experiences, learning to look to others for how to react rather than attending to internal cues, and in the face of hearing “just try harder; this is no big deal!” learning to over-​simplify the ease of problem-​solving and self-​regulation. According to the biosocial theory, if emotional vulnerability transacts over time with a pervasively invalidating environment, chronic emotion dysregulation will develop. The transactional nature of the relationship means that the emotional vulnerability and invalidating environment, even if starting off at low levels, will co-​create or exacerbate each other over time. In addition to ignoring or punishing emotion displays, the invalidating environment may intermittently reinforce escalations of emotional communication. As one’s emotional intensity increases, perhaps with threats, suicidal communication, or stronger expressions of distress, someone in their environment might suddenly respond with full attention, give in, or offer extra warmth. Because punishment or ignoring of emotional expression alternates with intermittent reinforcement of its escalation, efforts to suppress emotions alternate with extreme communications of emotions. Efforts to suppress emotions can include not accurately communicating private experiences, saying that “everything is fine” when highly distressed, escaping pain through maladaptive behaviors, or experiencing numbness. This masking alternates with escalated emotional communication that can include emotional outbursts, suicidal communication, and impulsive behaviors. For adolescents, there may be many sources of invalidation. The caregiving environment may be a primary source, in which parents often mean well but may not know how to parent an emotionally powerful teenager. In trying to help, loving parents might communicate that the teen should “just shake it off” or “just calm down” or “take a look at all you have –​you have no reason to be upset.” Invalidating parenting can manifest in a variety of ways, including being abusive or neglectful, feeling overwhelmed or stressed, conveying impossibly high standards that a child consistently fails to meet, or even being loving and caring but a mismatch for a highly emotional child. In addition to the caregiving environment, other environments might be invalidating to teens. Peers, romantic partners, other family members, teachers, coaches, bosses, social media sites, and the broader community or culture can all send messages that a person’s emotions, behaviors, or key

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characteristics are not valid. In addition, school policies and procedures, political environments, and even structural factors such as systemic racism or policies toward immigrants can be invalidating, sending messages such as “you’re not trying hard enough,” “you’re not behaving properly,” “you don’t belong,” or “you’re not welcome here.” Extreme forms of invalidation can include being bullied or harassed (“nobody likes you; you should go kill yourself”), being blamed for a trauma, or race-​based or sexual/​gender minority-​based experiences of discrimination, inequality, exclusion, or denying reality (cf., Harned, 2022). Validation and Accurate Expression Invalidation can lead to emotional flooding in the recipient. (Note: for a less sensitive and reactive individual who possesses emotion modulation skills, a message such as “brush it off; you’ll be fine!” might be helpful in calming them down. Thus, parents and others might puzzle at why such reassurances work for others but not for this particular youth.) For an emotionally sensitive person, this flooding dysregulates cognitive processing, which reduces accurate emotional expression. The person might shut down, storm off, or escalate emotional communication (e.g., yelling or sobbing). As such, inaccurate emotional expression pulls for further invalidating responses (Fruzzetti et al., 2021). Conversely, validating responses encourage accurate expression, and accurate expression is easier to validate (Fruzzetti et al. 2021). Validation conveys that another person’s experience makes sense, legitimizing the other’s emotions, even if a person does not feel the same way. Communicating “I understand,” “your reaction makes sense,” or “we accept you” soothes the emotional recipient, helps their powerful feelings make sense to them, slows their racing thoughts, and assuages their reactions. Validation thus facilitates clear expression, understanding of experiences, willingness to share, and regulated delivery; it then becomes easier for the other to validate the speaker more. As people receive more validation, their emotions become more regulated and they can convey primary emotions (e.g., worry, hurt, or sadness) rather than only secondary emotions (e.g., anger), relay accurate descriptions of events and goals, and access the ability to reason and problem solve. The vicious cycle of invalidation increasing dysregulation transforms into a virtuous cycle, in which validation encourages emotional expression. Thus, in DBT-​A, based on the biosocial theory and the importance of validation, we teach skills to help adolescents learn to reduce emotional vulnerability, change or reduce unwanted emotions, increase validation of others and self-​validation, re-​direct attention to non-​mood-​related cues, and re-​direct behavior to effective, rather than emotion-​driven, actions. Indeed, changes in adolescent emotion regulation mediated self-​harm outcomes in the largest adolescent DBT randomized controlled trial (RCT) to date (Asarnow et al., 2021). In addition, we teach parents to regulate their own emotions and increase validation, interrupting patterns in the adolescent’s primary environment. As parents also learn mindfulness, interpersonal effectiveness, distress tolerance, and middle path skills, their patience, understanding, and family communication improve; emotion dysregulation, coercive interaction cycles, and conflict decrease. Outcome research supports this phenomenon, demonstrating that DBT-​A improves parents’ skills use (Asarnow et al., 2021), which likely helps them support their adolescents struggling with painful emotions.

Cultural, Ethnic, and Racial Considerations As mental health struggles have skyrocketed for adolescents in recent years (Murthy, 2021), the problem is compounded by the fact that 60%–​80% of youth in need of mental health services do not receive them (Abel et al., 2022). Concerns are even greater for minority youth, for whom

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even fewer receive mental health services and fewer still complete treatment, while suicide rates are increasing in these groups (Planey et al., 2019; Rodgers et al., 2022). Researchers have identified key factors contributing to these disparities, including discrimination; poverty; insurance coverage; barriers with childcare and transportation; level of acculturation; fear, stigma, and mistrust regarding mental health care; and few practitioners of color (Lu et al., 2021). DBT for Adolescents offers some promising data with regard to treatment with diverse populations from marginalized backgrounds, as several studies report positive outcomes applying DBT within diverse samples. For example, we started adapting DBT treatment for adolescents and caregivers with a primarily Hispanic and Black population in the Bronx, New York, while working in Montefiore Medical Center’s Adolescent Depression and Suicide Program in the 1990s. Our effectiveness and feasibility trial, the first trial evaluating DBT with adolescents, was a quasi-​ experimental design comparing suicidal and depressed inner-​city youth who received DBT to those receiving treatment as usual (Rathus & Miller, 2002). Examples of additional trials with particularly diverse samples include a large open trial applying DBT in a county mental health clinic (Berk et al., 2020), a large quasi-​experimental study from inpatient admissions (Tebbet-​ Mock et al., 2019), and two of the three DBT adolescent RCTs (McCauley et al., 2018; Goldstein et al., 2015). DBT for adults has also been studied in a variety of diverse samples. According to Harned et al. (2022), ethno-​racial minority groups are represented in DBT trials at rates similar to the US population, and sexual minorities are over-​represented in DBT trials. Regarding central treatment outcomes in DBT, such as self-​harm, hospitalizations, psychiatric symptoms, and drop-​out rates, there were no differences on outcomes with racial/​ethnic minority and sexual minority adults in five important RCTs that included diverse samples (Chang et al., in press). While more DBT trials with diverse youth are needed, these data offer hope for marginalized teen populations. Additional research could focus on youth-​caregiver acculturation mismatches, reaching families with language barriers, and dissemination and access to minority families who may not be accessing care for their high-​risk teens. Description of DBT Skills Group with Emotionally Dysregulated Adolescents and Caregivers Based on a skills-​deficit model of clients with chronic emotion dysregulation, effective treatment needs to increase accurate observation and labeling of emotions, thoughts, and behaviors; effective communication of internal experiences; self-​validation; and effective regulation of emotions. In addition, clients need to learn to tolerate distress, solve difficult problems in living, create and sustain healthy relationships, and use behavioral strategies toward the management of one’s own behaviors. We achieve these goals through the DBT skills training group. Further, because adolescents are still living in their often-​invalidating environments, we need to increase validation, effective modeling of emotion regulation, effective communication, and effective parenting from their environments. We achieve these aims through including caregivers in a multi-​family skills training group model. The DBT multi-​family skills training group (Rathus & Miller, 2015) includes five modules plus an orientation module (Table 13.2 outlines skills taught in each module). Leaders teach the Orientation module at the beginning of each module/​entry point for new families in an open group format (or at the beginning of the group for a closed group format). It consists of describing the DBT problem areas and corresponding skills modules, teaching the Biosocial Theory, introducing group guidelines, and reviewing the DBT assumptions (e.g., people are doing the best that they can and need to do better; people need to use skills in all areas of their life).

228  Jill H. Rathus Table 13.2 Overview of DBT Skills by Module Core mindfulness skills: “Wise Mind” (States of Mind) “What Skills” (Observe, Describe, Participate) “How Skills” (Don’t Judge, Stay Focused, Do What Works) Distress tolerance skills: Crisis Survival Skills: Distract with Wise Mind ACCEPTS (Activities, Contributing, Comparisons, Emotions, Pushing away, Thoughts, Sensations) Self-​S oothe with six senses (vision, hearing, touch, smell, taste, movement) IMPROVE the moment (Imagery, Meaning, Prayer, Relaxing, One thing in the moment, Vacation, Encouragement) Pros and Cons TIPP skills (Temperature, Intense exercise, Paced breathing, Progressive relaxation) Reality Acceptance skills Half-​S mile Radical Acceptance Turning the Mind Willingness Walking the middle path skills: Dialectics Dialectical Thinking and Acting Dialectical Dilemmas Validation Validation of Others Validation of Self Behavior Change Positive reinforcement Negative reinforcement Shaping Extinction Punishment Emotion regulation skills: Understanding Emotions: Model of Emotions Observing and Describing Emotions What Emotions Do for You Reducing Emotional Vulnerability: ABC PLEASE: Accumulate positives long and short term; Parent-​Teen Shared Pleasant Activities Adolescent Wise Mind Values and Priorities Build mastery; Cope Ahead PLEASE (treat PhysicaL illness, balance Eating, avoid mood-​A ltering drugs; balance Sleep, get Exercise): Changing Unwanted Emotions: Check the Facts Problem-​S olving Opposite action (to the current emotion) Reduce emotional suffering The Wave Skill: Mindfulness of current emotion Interpersonal effectiveness skills: Goals and priorities

Running Multi-Family Skills Training Groups in DBT for Adolescents 229 Table 13.2 (Continued) Maintaining relationships and reducing conflict –​ GIVE (be Gentle, act Interested, Validate, use an Easy manner) Getting what you want or saying no: DEAR MAN (Describe, Express, Assert, Reinforce, be Mindful, Appear confident, Negotiate) Keeping your self-​respect: FAST (be Fair, no Apologies, Stick to your values, be Truthful) Wise Mind self-​s tatements to combat worry thoughts Factors to Consider in Asking or Saying No Optional: Reducing conflict and negative emotion: THINK (Think from the other’s perspective, Have empathy, other Interpretations, Notice efforts of the other, be Kind) Adapted from Alec L. Miller, Jill H. Rathus, & Marsha M. Linehan, Dialectical Behavior Therapy with Suicidal Adolescents, p. 74, Table 4.2 © Guilford Press, 2007, with permission.

The Mindfulness and Distress Tolerance are considered the acceptance-​focused modules in DBT. The Mindfulness module repeats and precedes each of the following skills modules in a one –​two-​week teaching format. Mindfulness skills aim to increase awareness and focus, improve concentration and attentional control, increase the ability to notice emotions and urges before acting on them, enhance the ability to observe experiences and thus slow impulsive reactions, increase skillful behavior and decision-​making, and increase joy by increasing engagement with/​participation in the present moment without judgment. The Distress Tolerance module helps participants get through crises, pain, or problems without making the situation worse (e.g., through distracting or self-​soothing). It is important to teach families that distress tolerance is not a lifestyle, but simply a set of strategies to use in moments of intense distress to be able to ride out impulse urges (such as self-​harm or skipping school) without acting on them. The module also offers skills to help decrease intense emotions rapidly to think clearly and make effective decisions. Finally, the Reality Acceptance skills within the module helps members reduce suffering and deeply accept painful situations that cannot be changed. The Emotion Regulation and Interpersonal Effectiveness skills are considered the change-​ focused modules in DBT. Emotion Regulation skills help understand emotions and their functions, recognize and label emotions, increase positive emotions in the short-​and long-​term, reduce vulnerability to painful emotions and emotion dysregulation in the short-​and long-​term, and reduce unwanted emotions once they occur. The Interpersonal Effectiveness module helps participants improve communication in relationships, increase assertiveness, balance building and keeping good relationships with maintaining self-​respect, consider the other’s perspective, and consider the whole context when deciding how to approach an interpersonal situation. The Walking the Middle Path module is a dialectical module, balancing acceptance and change skills. The module aims to improve parent–​teen relationships, decrease family conflict, help members see truth on both sides of an argument (“I can be right and you can be right”) and develop solutions based on both sides, increase balanced (less extreme) thinking, increase validation, and increase effective behavior change strategies. DBT for Adolescents (Miller et al., 2007) adapts the skills training group format proposed by Linehan (1993) to a multi-​family format in which caregivers are invited to learn skills alongside their adolescents. In this group, we typically include two co-​leaders, and four to six families, consisting of the adolescent client and one or two caregivers accompanying each. In comprehensive DBT (see Miller et al., 2007), teens also receive individual DBT therapy with a therapist on the same treatment team. In group-​only models (see DeLaquis et al., 2022, for review),

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which may be appropriate for clients with less severe and high-​risk problems, DBT skills group or multi-​family group might be the only treatment mode, or might complement a CBT-​focused individual therapy. Groups typically last 90 minutes to two hours, and run weekly for six months. Group sessions are structured as follows: welcome and announcements, mindfulness practice, review of last week’s skill practice (i.e., homework), a short break, the teaching of new skills, assignment of homework, and some type of wind-​down exercise such as a closing observation or a commitment to engaging in a new behavior. Importantly, all members, teens and parents alike, participate in all aspects of group, from skill rehearsal to homework review. Skills group teaching generally follows a teach-​ see-​do model; leaders offer didactics on a skill, often demonstrate it, and include ample opportunities for practicing the new skill. The goal is to get the skill into clients’ repertoires during group, with coaching and feedback to enhance implementation. DBT prioritizes behaviors to address in session with target hierarchies. As described above, the hierarchy for individual therapy is to decrease life threatening behaviors, decrease therapy interfering behaviors, decrease quality-​of-​life interfering behaviors, and increase behavioral skills. In skills training groups, however, the hierarchy is as follows: decrease behaviors likely to destroy therapy; increase skills acquisition, strengthening, and generalization; and decrease therapy-​ interfering behaviors. The idea is that unless members are engaging in behaviors that will destroy therapy for themselves or others (such as self-​harming in group), skills trainers persist in teaching and rehearsing skills continuously as the top priority, giving less (or outside of group) attention to any therapy-​interfering behaviors such as disengagement. Sample of Treatment Interventions Each of the five skills modules includes many skills (see Table 13.2). This section highlights three skills that are central to DBT and critically important for both adolescents and parents. The description of the skills includes discussion of how we teach them in multi-​family skills groups. Mindfulness Skills DBT positions mindfulness as foremost among all of the DBT skills, and mindfulness skills have their own module. Skills trainers teach this shorter module at the beginning of each new skills module, and also conduct a mindfulness practice at the start of each weekly group session. As they involve practices to increase awareness and focus attention, Linehan considered them the core DBT skills; they are necessary to practice all other DBT skills. While mindfulness has now become prevalent in popular culture, Linehan (1993) was the first to include this Eastern practice based on eastern philosophy/​Zen teachings within a Western psychology approach, in DBT. Practicing mindfulness in DBT includes first noticing and identifying one’s states of mind. In Emotion Mind, people’s urges, actions, and thoughts are driven purely by emotions. In Reasonable Mind, urges, actions, and thoughts are driven by logic and facts, devoid of emotions. Wise Mind is a synthesis of Emotion and Reasonable Mind, where one combines emotional and logical information in a more intuitive and beneficial manner to increase self-​awareness, make decisions, and guide behavior. Wise Mind can be reached through DBT’s What and How skills, that is, what steps we take to access wise mind and how we take them. The What skills include Observing, Describing, and Participating. Observing involves just noticing experience without trying to change it. The skill of observing sensations, emotions,

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urges, thoughts, or other internal or external experiences, is central to the practice of the other What and How skills and all of the DBT skills. We must be able to notice our experience as well as environmental attributes to respond thoughtfully rather than reacting impulsively. Describing involves putting words on our experience, and Participating is being fully present with our experience in the moment. The How skills indicate how we observe, describe, and participate; we perform these skills Non-​Judgmentally, One-​Mindfully (staying focused and not multi-​tasking), and Doing What Works, focusing on what will be effective in reaching our goals. Mindfulness skills are practiced in a variety of ways in skills training, including noticing one’s breath, putting words to body sensations or other emotional experiences, observing urges, noticing sounds or sights. Rathus and Miller (2015) list 30 mindfulness practices for teens, and there are so many more available in the public domain. Helpful strategies in teaching and practicing mindfulness in group include (1) routinely providing the rationale: to develop greater awareness inside and outside of ourselves, and to cultivate greater attentional control; (2) referring to being able to insert a pause between awareness and action to notice feelings, thoughts, urges, and body sensations; (3) linking it to clients’ general therapy goals, such as being able to identify one’s wants, needs, and emotions, notice emotions and urges when they are at a 10 or 20, before they reach 80 or 90 at which point people act on their impulses, and staying present and focused in important conversations; and (4) to at times telling stories illustrating its helpfulness (e.g., a time when a group-​leader was not mindful and a consequence of being less effective or impulsive, and how the leader used the What and How skills to get into Wise Mind). Model of Emotions Leaders teach the model of emotions in the beginning of the Emotion Regulation module. It is a schematic with linked boxes (some with bi-​directional arrows) presented on a handout that breaks down an emotion into its component parts. The boxes represent the components of an emotion, including: • • • • • • • • •

The prompting event for the emotion Vulnerability factors preceding the prompting event that make the emotional reaction stronger Thoughts/​interpretations about the event Internal body reactions Emotion-​related urges to act Facial expressions, body language, words, and actions The emotion name(s) Aftereffects of the emotional experience The next prompting event

The leader tells or elicits an emotional story (e.g., the train breaks down on the way to see your favorite band in concert), and uses it to fill in all of the boxes, with the group members’ contributions (asking questions such as “what thoughts would you be having? What would your urges have been? What might you be feeling in your body? What might you have been saying or doing?”). In doing so and filling out the entire schematic collaboratively on a white board, the model teaches group members the many components of an emotion, which increases their awareness of emotions and abilities to observe and describe their many parts, and identify these within themselves. This increased emotional awareness helps them learn that (1) emotions are complex and cannot be simply stopped by will, (2) many emotion components/​pathways are bidirectional (e.g.,

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extreme thoughts can intensify urges, body sensations, and actions, and conversely, observing and describing urges without acting, reducing body sensations with skills such as paced breathing or relaxation, and choosing effective actions, can reduce extreme thoughts), (3) one can experience impulse urges but not act on them as urges and actions are two separate entities, and (4) each component offers an opportunity to apply various DBT skills to break the emotion cycle, regulate the emotions experienced, and positively impact the outcome of the prompting event and strong emotions. Validation Validation of others, or conveying that someone’s feelings, thoughts, or actions make sense, even when we may not agree, is crucial for helping them feel heard and understood (e.g., a parent can validate a teen’s desire to stay home from school because of feeling tired and overwhelmed, without allowing the teen to stay home). As explained above in the section on the Biosocial Theory, validation also helps another person stay in emotional conversations, express themselves more fully and accurately, and feel connected, thus strengthening the relationship. Additionally, validation helps with dialectical thinking and action (another Walking the Middle Path skill), in searching for and acknowledging the grain of truth in another’s perspective. Moreover, it is the best tool we have for helping to regulate others’ emotions. Conversely, invalidation increases another’s emotional intensity, and decreases effective emotional expression and often leads to them shutting down or storming off and feeling alone and misunderstood. Thus, validation is essential for improving family interactions, and we teach and practice it within the Walking the Middle Path module. We first teach the rationale for validation: to demonstrate we are listening, we understand, and we can even disagree without having a big conflict. And, we highlight its role in helping regulate the emotions of the recipient. We then teach what to validate, which includes feelings, thoughts, and behaviors, and point out that validation does not indicate agreement. We then teach how to validate, typically starting with modeling through role plays. We first role play a conversation (e.g., a teen wants to quit soccer and the parent does not want them to) using invalidation and demonstrate how the conversation escalates in intensity and nothing is resolved. We then ask the group to comment on what they observed. Next, we re-​play the conversation, this time including ample validation, but not necessarily agreement, and demonstrate how validation keeps both parties emotionally regulated and continuing the discussion in a productive manner. We ask the group again for their observations, after they have witnessed the impact of validation. They now are more invested in learning to validate, after seeing the power of the skill in action. We then teach the steps of validation, breaking it down into: • • • •

actively listening, reflecting the person’s feeling back without judgment, searching for how the person’s feelings make sense given their perspective or the situation, responding in a way that shows you are taking the other person seriously, both with words and non-​verbal reactions.

And then, behavioral rehearsal of the validation skill is essential. We do go-​arounds or break into small groups for practice, giving group members prompts or scenarios that they each must reply to using validation. Leaders provide feedback and coaching until near mastery of validation is reached. Adolescents, not just parents, also practice validation of others, since it is a critical skill for maintaining healthy relationships with family members, friends, teachers, bosses, coaches, and others.

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Finally, we teach and practice self-​validation (e.g., it makes sense that I am feeling so anxious about starting a new school; of course I feel stressed with my increasing work demands while trying to be present as a parent). We offer the rationale that validating oneself helps us understand and accept our own emotional reactions, thereby lowering self-​directed negative judgments (e.g., “I’m over-​reacting”; “I SHOULD just be able to handle all of this”) and helping to regulate our own emotions. Overcoming Potential Obstacles to Group Treatment for Emotionally Dysregulated Youth Probably the biggest obstacle is that rather than bringing themselves to treatment, kids are often brought in by parents or referred by schools, inpatient units, or other sources. Thus, they do not often agree to enter therapy or even that there is a problem, and when they do think there is a problem, they often think it is their parents, their school, their peers, and so on. Thus, as with all youth treatments, we face the task of increasing and maintaining their commitment to engaging in the treatment. DBT does this with a pre-​treatment phase that emphasizes orientation to the complex nature of DBT and all of its requirements (multi-​family skills group, individual therapy with diary cards for self-​monitoring and a treatment target hierarchy that determines what gets addressed in sessions, phone coaching, as-​needed family sessions, as-​needed parenting sessions and a therapist consultation team; Rathus & DeRosa, in press). In addition, therapists employ a set of DBT commitment strategies, such as playing devil’s advocate about entering treatment, and considering the pros and cons of starting DBT versus keeping things as they are. Therapists apply commitment strategies both in pre-​treatment and throughout the therapy when asking clients to do something (such as apply a skillful behavior to a difficult situation) or try something new. Additionally, DBT targets therapy-​interfering behavior, as its highest priority after life-​threatening behavior, which includes behaviors such as not attending group, coming late, or not participating in group. Therapists address these behaviors through behavioral chain analysis in individual therapy that assesses all of the relevant antecedents and consequences of such a behavior, to understand what might be eliciting and maintaining it. The therapist then generates solutions with the client and obtains commitment to implementing them. Notably, the therapists also address parents in pre-​treatment, use commitment strategies to enlist parents’ commitment, and address therapy-​ interfering-​behavior of parents, whom kids often rely on to get to treatment (Rathus & DeRosa, in press). Another obstacle is kids not wanting to learn skills in a group setting, often due to social anxiety, or with their parents, often due to family conflict. For adolescents who raise these objections, we address them through exposure via being in the group, setting a group culture of respectful and supportive behavior across and within families, and addressing family conflict via the skills themselves and intermittent family sessions to apply them to challenging interactions. Finally, therapists face the challenge of assembling a group of emotionally dysregulated teens and caregivers, who are at times also dysregulated, in a room together, and the distractions or emotions that might ensue and interfere with learning. Whether delivered via in-​person formats or Telehealth, a group skills training format that became common during the pandemic and has lasted in some settings (often due to issues of distance, transportation, or resources), group leaders first set the stage with orientation to a set of clear group guidelines and expectations that minimize distractions or disrespectful behavior and enhance effective participation. In addition, it is standard to employ two group leaders, and while one is leading/​teaching, the co-​leader monitors group members’ engagement and behavior and in overt or covert ways, working to get both back on track. Moreover, group leaders employ tactics to make group engaging, such as humorous role plays between co-​leaders, sharing (semi-​) personal stories of skills use, small group work in families or

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dyads applying skills, behavioral rehearsal of new skills in session, and use of multi-​media such as music or video clips to practice or see models of related concepts. Case Example T was a 16-​year-​old Hispanic female with parents who immigrated from Central America. Her mother worked three jobs to support their family, and her father was on disability from a work-​ related accident. She was the oldest of three siblings. Her father brought T into treatment following discharge from an inpatient unit for a suicide attempt by overdosing with Tylenol and experiencing a major depressive episode. T’s life-​threatening target behaviors included the suicide attempt, suicidal ideation, and self-​ injury approximately twice weekly using a razor, pencil, or scissor to scratch or cut her arms and legs. Her therapy-​interfering behaviors included urges to drop out of group when she was frustrated with her father and did not want to attend with him. She also at times did not complete her diary card. T’s quality-​of life-​interfering behaviors included recurrent major depressive episodes with low mood, low energy, trouble concentrating, identity confusion, emptiness, low self-​esteem, irritability, insomnia and an erratic sleep schedule in part due to staying up and engaging with social media. She also experienced daily social and general anxiety. She had experienced “friend drama,” including her best friend rejecting her, saying she was “a lot to handle,” and turning others in their friend group against her. She used marijuana and alcohol to calm herself when experiencing anxiety, engaged in impulsive on-​line behaviors such as meeting strangers and posting highly personal information that she later regretted sharing, and had a high-​conflict relationship with her father, whom she said was “old school” and traditional, and didn’t understand American culture, including her wanting to date and spend time with friends on the weekends. When discovering substance use or risky social media behaviors, he would ground her or take away her phone for days, which made her feel further socially isolated. In considering T.’s problems with regard to the five problem areas discussed above, she experienced (1) confusion about self and trouble staying focused, (2) emotion dysregulation (with frequent experiences of sad mood, anxiety, irritability and anger), (3) impulsivity (with a suicide attempt, self-​harm, substance use and risky on-​line behaviors), (4) interpersonal difficulties (with peer conflict and regular arguments with her father), and (5) teen-​family conflict and extreme thinking (stand-​offs and polarization with her father, beliefs that she was worthless and that life would never get better). T’s strengths included being a straight-​A student and well-​liked by teachers, baby-​sitting for her siblings and cousins and relating wonderfully with children, helping around the home with chores and cooking, and being highly artistic. She was open, self-​reflective, and willing to engage in DBT. All modalities of DBT contributed to T’s treatment, though this example will primarily highlight the group skills training intervention following brief descriptions of the other modalities. In individual therapy, the therapist conducted behavioral chain analyses of T’s target behaviors to understand their controlling variables (e.g., self-​injury functioned primarily to reduce emotional pain), and collaboratively generated solutions based on this thorough assessment. Solutions included exposure to emotions of anxiety and sadness (without escaping them through use of substances or self-​harm), cognitive modification of extreme thoughts like “if I don’t have my best friend, I am worthless,” contingency management (e.g., if diary card was not complete, discussion of topics would not begin until T completed it in session), and skills from all of the modules, as described in the following paragraphs. Phone coaching helped T apply the skills in moments of emotional dysregulation outside of session before engaging in a target behavior such as self-​injury. Monthly family sessions helped T and her father apply skills to regulate their emotions while discussing

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heated topics, improve their communication and validation skills, and begin to consider the truth in each other’s positions, whereas in the past they had been polarized and stuck. T and her father participated in multi-​family skills group together. In the group orientation, they each acknowledged that the other was doing the best that they could given their circumstances and capacities, while each clearly having room to do better. Through mindfulness, T learned to recognize how “emotion mind” was driving many of her impulsive and risky behaviors, and became better able to notice emotions rising within her, so that she could observe and describe them, and then act with consideration of her goals. As she accessed wise mind, she became better able to generate other skills she could use to manage her moods and urges. Likewise, her father learned to pause before responding to T., so that he could listen and validate rather than responding with frustration or impatience. With the distress tolerance skills, T was able to learn strategies such as distracting and self-​ soothing when she was anxious or sad and wanted to self-​injure or use substances to ease emotions. She used the TIPP skills (Tip body chemistry through cold Temperature on the face, Intense exercise, Paced breathing, or Progressive muscle relaxation) to reduce arousal when her emotions were so high she couldn’t think clearly or remember other skills, and she considered the pros and cons of using cutting, substances, or risky on-​line behaviors to feel better versus more skillful approaches. Radical Acceptance helped her with the loss of her friend group and the fact that she often resented her mother for working so much. She began prioritizing spending time with and helping her mother during her brief time off. Her father came to understand that when T was putting in her headphones or grabbing ice to put on her face, she was using skills to manage emotions, and was able to support rather than block her efforts, seeing them as skillful rather than avoidant or disrespectful. He also used the Distress Tolerance skills to help manage his physical pain and his own frustration and sadness regarding being on disability. With the Middle Path skills, T and her father became better able to take a dialectical problem-​ solving approach (considering truth in each other’s positions) to topics on which they were polarized, such as her wanting more freedom. T and her father each validated the other and generated Middle Path solutions to disagreement that took both sides into account, such as his supporting her spending a portion of weekend time with new friends while she also allocated time for the family. T realized she engaged in Thinking Mistakes such as labeling herself negatively and mindreading in social situations. Her father also positively reinforced T for what she was doing at home (rather than routinely punishing her or telling her she wasn’t doing enough), which increased her motivation to contribute even more. She in turn positively reinforced her father for his caring, his involvement in her daily life, and his attending group and family sessions with her. From the Emotion Regulation module, T. began to understand the various components of her emotions, and was able to apply various skills such as Opposite Action to emotion urges to reduce painful emotions and engage in less mood-​dependent behavior. She also started Accumulating Positives by increasing Short-​Term Pleasant Activities to balance Taking Steps Toward her Long-​ Term Goals of completing school and becoming a doctor. Though often overwhelmed by her schoolwork and childcare responsibilities, she began Building Mastery with scheduled, manageable daily tasks, and would Cope Ahead for stressful periods at school and for family sessions. She and her father began employing the PLEASE skills to take better care of their health through prioritizing sleep hygiene, healthy diet, and regular exercise, and both reaped the benefit on their moods. In learning to schedule Parent-​Teen Shared Pleasant Activities, they began working out together, going for bike rides, and cooking together. From the Interpersonal Effectiveness module, T learned that she could enhance other friendships and manage how peers treated her with her skills for being assertive (DEAR MAN), for reducing conflict and maintaining relationships (GIVE skills), and practicing self-​respect (FAST skills). She also found the THINK skill, for perspective taking and generating benign interpretations, helpful

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in seeing that her father often restricted her based on his own upbringing and on fear, rather than because of simply being mean or stubborn. After several weeks, T. and her father began setting aside time to teach T.’s mother the skills and review worksheets with her during the week, which was their “middle path” solution to the fact that she could not attend and they believed she would strongly benefit from learning the skills. T’s father also began to connect with the other parents in group, deriving support from other parents with similar concerns. By the middle of the six-​month treatment period, T.’s suicidal ideation and self-​injurious behaviors went down from 4s and 5s on the diary card to 1s, once she gained hope that treatment would help her and help her relationship with her father, and learned other coping strategies to reduce her distress. Although urges to self-​injure remained moderately elevated at 2s and 3s, they declined to near zero by the end of the six-​month treatment, as T. incorporated continuous skill use into her repertoire. Similarly, her substance use declined from several times per week to zero or one time on most weeks. T.’s depression remitted and her emotional vulnerability decreased, as she was engaging in pleasurable activities, building mastery as she worked toward her goals, establishing a better sleep schedule, and reducing reliance on marijuana and alcohol. Her peer relationships improved, which led to a decrease in her social anxiety. As her misery declined, her impulsive social media behaviors declined as well. Her family relationships improved, as her father decreased his tendency to rely more on punishing consequences and positively reinforced her effective behaviors. He also spoke gently, listened actively, and validated her emotions, which led to her confiding in him more. T.’s father reported not only that he had seen significant improvement in his daughter’s mood and behaviors, but also that he had developed his own toolbox of strategies to use to improve his own emotions and relationships. Finally, both reported that T.’s mother was benefitting from learning the skills during the weekly time they’d carved out for sharing them with her, and that the family as a whole was more regulated, connected, and cohesive. Summary A hallmark of DBT for Adolescents is its unique multi-​family skills group format for increasing capabilities in both teens and their caregivers. This group teaches Mindfulness, Emotion Regulation, Interpersonal Effectiveness, Distress Tolerance, and Walking the Middle Path skills to families in the spirit of increasing adolescents’ emotion regulation and related capacities while structuring the family environment to promote skillful means and increase validation. Research trials support the use of DBT skills groups as part of comprehensive DBT for more severe and high-​risk populations, and as a possible sole treatment modality for less severe and complex presentations. Readers who would like more exposure to the multi-​family skills group model and specific skills content can read DBT Skills with Adolescents (Rathus & Miller, 2015), or view the on-​line self-​paced skills training video course from Psychwire (Miller et al., 2021), that teaches the skills and provides demonstrations of running multi-​family group. As teen mental health struggles remain an urgent public health matter, DBT skills groups offer an efficient and effective way for adolescents and their caregivers to receive much-​needed help. References Abel, M.R., Bianco, A., Gilbert, R., & Schleider, J.L. (2022). When is psychotherapy brief? Considering sociodemographic factors, problem complexity, and problem type in U.S. adolescents. Journal of Child and Adolescent Psychology, 51, 740–​749. Asarnow, J.R., Berk, M.S., Bedics, J., Adrian, M., Gallop, R., Cohen, J., Korslund, K., Hughs, J., Avina, C., Linehan, M.L., McCauley, E. (2021). DBT for suicidal self-​harming youth: Emotion regulation,

Running Multi-Family Skills Training Groups in DBT for Adolescents 237 mechanisms, and mediators. Journal of the American Academy of Child and Adolescent Psychiatry, 60(9), 1105–​1115. Berk, M.S., Starace, N.K., Black, V.P., & Avina, C. (2020) Implementation of dialectical behavior therapy with suicidal and self-​harming adolescents in a community clinic. Archives of Suicide Research, 24(1), 64–​81. Berk, M.S., Rathus, J.H., Kessler, M., Clark, S., Chick, C., Shen, H., et al. (2022) Pilot test of a dbt-​based intervention for parents of youth with recent self-​harm. Cognitive and Behavioral Practice, 29(2), 348–​366. Boritz, T., Zeifman, R.J., & McMain, S.F. (2019). Mechanisms of change in DBT. In M. Swales (Ed.). The Oxford Handbook of Dialectical Behavior Therapy (pp. 515–​532). Oxford, UK: Oxford University Press. Chang, C., Halvorson, M., Lehavot, K., Simpson, T., & Harned, M. (2023). Sexual identity and race/​ethnicity as predictors of treatment outcome and retention in dialectical behavior therapy. Journal of Consulting and Clinical Psychology, 91(10), 614–​621. https://​doi.org/​10.1037/​ccp​0000​826 Cipriano, A., Cella, S., & Cotrufo, P. (2017). Non-​suicidal self-​injury: A systematic review. Frontiers in Psychology, 8, 1946. doi.org/​10.3389/​fpsyg.2017.01946. DeLaquis, C., Joyce, K., Zalewski, M., Katz, L., Sulymka, J., Agostinho, T., & Roos, L.E. (2022). Dialectical behavior therapy skills training groups for common mental health disorders: A systematic review and meta-​ analysis. Journal of Affective Disorders, 300, 305–​313. doi:10.31234/​osf.io/​rpu9h Fruzzetti, A.E., Payne, L.G., & Hoffman, P. (2021). DBT with families. In L. Dimeff, S. Rizvi, & K. Koerner (Eds.). DBT in Clinical Practice, 2nd Edition. New York: Guilford Press. Goldstein, T.R., Fersch-​Podrat, R.K., Rivera, M., Axerlson, D.A., Merranko, J., Yu, H., Brent, D.A., & Birmaher, B. (2015). DBT for adolescents with bipolar disorder: Results from a pilot randomized trial. Journal of Child and Adolescent Psychopharmacology, 25(2), 140–​149. Harned, M. (2022). Treating Trauma in Dialectical Behavior Therapy: The DBT Prolonged Exposure Protocol (DBT PE). New York: Guilford Press. Harned, M., Coyle, T.N., & Garcia, N.M. (2022). The inclusion of ethnoracial, sexual and gender minority groups in randomized controlled trials of DBT: A systematic review. Clinical Psychology: Science and Practice, 29(2), 83–​93. Kothgassner, O., Goreis, A., Robinson, K., Huscsava, M., Schmahl, C., & Plene, P.L. (2021) Efficacy of DBT for adolescent self-​harm and suicidal ideation: A systematic review and meta-​analysis. Psychological Medicine, 51(7), 1057–​1067. Linehan, M.M. (1993). Cognitive Behavioral Therapy for Borderline Personality Disorder. New York: Guilford Press. Linehan, M.L. (2015). DBT Skills Training Manual. New York: Guilford Press. Lu, W., Todhunter-​Reid, A., Mitsdarffur, M.L., Munoz-​Laboy, M., Yoon, A.S., & Xu, L. (2021). Barriers and facilitators for mental health service use among racial /​ethnic minority adolescents: A systematic review of literature. Front Public Health, 9, 641605. doi.org/​10.3389/​fpubh.2021.641605 Mazza, J., Mazza, E.D., Miller, A.L., Rathus, J.H., & Murphy, H. (2015). DBT Skills in Schools: Skills Training for Emotional Problem Solving with Adolescents (STEPS-​A). New York: Guilford Press. McCauley, E., Berk, M.S., Asarnow, J.R., Korslund, K., Adrian, M., Avina, C., et al. (2018). Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: A randomized clinical trial. JAMA Psychiatry, 75(8), 777–​785. Mehlum, L., Ramleth, R.K., Tormoen, A.J., & Haga, E. (2019). Long-​term effectiveness of DBT versus enhanced usual care for adolescents with self-​harming and suicidal behavior. Journal of Child Psychology and Psychiatry, 60(10), 1112–​1122. doi:10.1111/​jcpp.13077 Miller, A.L., Rathus, J.H., & Linehan, M.M. (2007). DBT with Suicidal Adolescents. New York: Guilford Press. Miller, A.L., Rathus, J.H., & Linehan, M.M. (2021). DBT Skills Training Groups with Adolescents and Caregivers. On-​line video course, Psychwire. Miller, A.L., Rathus, J.H., Linehan, M.M., Wetzler, S., & Leigh, E. (1997) Dialectical behavior therapy adapted for suicidal adolescents. Journal of Practical Psychiatry and Behavioral Health, 3(2), 78–​86. https://​doi.org/​10.1097/​00131​746-​199703​000-​00002 Murthy, V.H. (2021). Protecting Youth’s Mental Health: The U.S. Surgeon General’s Advisory. U.S., Department of Health and Human Services/​Office of the Surgeon General. Planey, A.M., Smith, S.M., Moore, S., & Walker, T.D. (2019) Barriers and facilitators to mental health help-​seeking among African American youth and their families: A systematic review. Children and Youth Services Review, 101, 190–​200.

238  Jill H. Rathus Rathus, J.H., & DeRosa, R. (in press). DBT enhances treatment motivation, engagement, and adherence in multi-​problem, high-​risk adolescents. In V. Fornari , I. Dancyger, & P. Silver (Eds.). Pediatric Nonadherence –​A Solutions Based Approach. New York: Springer. Rathus, J.H., & Miller, A.L. (2002). Dialectical behavior therapy adapted for suicidal adolescents. Suicide and Life-​Threatening Behavior, 32(2), 146–​157. https://​doi.org/​10.1521/​suli.32.2.146.24399 Rathus, J.H., & Miller, A.L. (2015). DBT Skills Manual for Adolescents. New York: Guilford Press. Rathus, J.H., Miller, A.L., Campbell, B., & Smith, H. (2015). Treatment acceptability study of walking the middle path, a new DBT skills module for adolescents and their families. American Journal of Psychotherapy, 69(2), 163–​178. Rathus, J.H., Wagner, D., & Miller, A.L. (2015). Psychometric evaluation of the life problems inventory, a measure of borderline personality features in adolescents. Journal of Psychology & Psychotherapy, 5, 1–​9. Ritschel, L., Miller, A.L., & Taylor, V. (2013). DBT with multi-​diagnostic youth. In J. Ehrenreich-​May & B. Chu (Eds.). Transdiagnostic Mechanisms and Treatment for Youth Psychopathology (pp. 203–​232). New York: Guilford Press. Rodgers, C.R., Flores, M.F., Bassey, O., Augenblick, J.M., & Lê Cook, B. (2022). Racial/​ethnic disparity trends in children’s mental health care access and expenditures from 2010–​2017: Disparities remain despite sweeping policy reform. Journal of the American Academy of Child and Adolescent Psychiatry, 61(7), 915–​925. Tebbet-​Mock, A., Saito, E., McGee, M., Woloszyn, P., & Venuti, M. (2019). Efficacy of DBT versus treatment as usual for acute-​care inpatient adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 59(1), 149–​156. Wagner, D., Rathus, J.H., & Miller, A.L. (2015). Reliability and validity of the life problems inventory: A self-​report measure of borderline personality features, in a college student sample. Journal of Psychology & Psychotherapy, 5, 1–​7.

Chapter 14

CBT Groups with LGBTQ Youth Johanna de Leyer-​Tiarks

Introduction Sexual orientation and gender-​diverse children and adolescents (i.e., LGBTQ1 youth) are vulnerable to myriad mental health problems. This chapter will describe the ways in which prejudice and discrimination impact LGBTQ youths’ experiences and utilize a cognitive-​behavioral Minority Stress Model to explain the processes by which minority stress contributes to the formation of maladaptive coping mechanisms and negative psychosocial outcomes. Contextualizing LGBTQ youths’ mental health within a minority stress framework reveals the need to incorporate treatment strategies that affirm children and adolescents’ diverse gender identities and sexual orientations, as well as challenge distorted cognitions and alter maladaptive behaviors that have arisen subsequent to minority stress. The chapter will conclude with an in-​depth discussion of affirmative cognitive-​behavior group therapy (CBGT), including sample treatment protocols, intervention techniques, and progress monitoring strategies. Overview LGBTQ children and adolescents may experience difficulties directly or tangentially related to their sexual orientation or gender identity. Research has shown us that LGBTQ youth exhibit high rates of anxiety and depressive symptoms, negative attitudes toward education, and a diminished sense of social belonging (GLSEN, 2022; Trevor Project, 2022). LGBQ adolescents are significantly more likely than their heterosexual counterparts to have engaged in risky sexual behaviors and abused drugs or alcohol (Centers for Disease Control and Prevention [CDC], 2019), and they are at greater risk for actual psychiatric diagnosis or meeting the criteria for mental illness (Mustanski et al., 2010). Of note, 47% of LGBTQ youth aged 13–​18 seriously considered suicide and LGBQ youth were four times more likely than their heterosexual peers to have attempted suicide within 12 months of reporting (CDC, 2019). The factors that contribute to these poor outcomes among LGBTQ youth are referred to as minority stress. The Minority Stress Model (Meyer, 2003) holds that the following four factors drive the high rates of negative psychosocial outcomes experienced by LGBTQ individuals: previously experienced 1 Author note on terminology: Throughout this chapter, the term LGBTQ youth will be used to describe children and adolescents of all diverse and minoritized sexual orientations and gender identities, not merely lesbian, gay, bisexual, transgender, and queer/​questioning youth. Similarly, the term LGBQ will be used when referring to children and adolescents of diverse sexual orientations who are cisgender and transgender will be used to describe individuals from all minoritized genders. While LGBTQ is commonly used to refer to this population, it is essential to recognize that the LGBTQ acronym does not represent many identities within this community. For resources on learning more about the LGBTQ population, including definitions of various sexual orientations, gender identity labels, and acronyms, please visit the National LGBTQIA+​Health Education Center www.lgb​tqia​heal​thed​ucat​ion.org/​. DOI: 10.4324/9781351213073-16

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instances of prejudice, expectations of experiencing future prejudice, concealment of minority status, and internalizing homophobia. Meyer’s theory explains that the cause of distress among LGBTQ individuals does not lie within the LGBTQ person, but instead, it lies within prejudicial societal beliefs (i.e., heterosexism and cisgenderism) that oppress them. Research supports this explanation (i.e., Mongelli et al., 2019), as recent data reported in GLSEN’s 2021 National School Climate Survey and The Trevor Project’s National Survey on Youth Mental Health (2022) shows that LGBTQ children and adolescents continue to experience discrimination in the forms of harassment and assault, anti-​ LGBTQ remarks, and discriminatory policies (i.e., being prevented from using the pronouns, facilities, and clothing aligned with their gender; being prevented from forming Gay-​Straight Alliances; being disciplined for holding hands, etc.). Indeed, according to survey outcomes, 75% of LGBTQ children and adolescents report having ever experienced discrimination and more than 50% have experienced discrimination within a year of reporting (Trevor Project, 2021). When examining the experiences of LGBTQ children and adolescents, it is important to note that individuals within this group come from a diversity of backgrounds and identities. For example, even within the LGBTQ community, transgender youth are more likely than their cisgender peers to experience discrimination and victimization, with transgender boys reporting more negative experiences in schools than transgender girls and nonbinary students. Similarly, adolescents who identified as pansexual (regardless of gender identity) report more victimization and lower educational aspirations than their peers of other minoritized sexual orientations. Cisgender LGBQ boys report higher levels of sexual orientation-​based hostility than cisgender girls; however, cisgender girls report more gender-​based hostility (GLSEN, 2022). In line with the Minority Stress Model, LGBTQ children and adolescents do indeed expect to experience future prejudice on the basis of their gender identity and sexual orientation. In fact, in a national survey on LGBTQ youths’ experiences in schools, approximately 40% of respondents indicated that they avoided school bathrooms, locker rooms, and physical education classes, and 78.8% of respondents reported that they had avoided school functions or extracurricular activities due to feeling unsafe or uncomfortable (GLSEN, 2022). Additionally, according to survey outcomes, over 30% of students reported missing “at least one entire day of school in the past month because they felt unsafe or uncomfortable,” and 16.2% reported having changed schools due to safety and comfort concerns (GLSEN, 2022). LGBTQ youth conceal their identities (i.e., stay in the closet) for many reasons. They may choose to hide or delay their coming out due to worry about rejection by their families or for fear of retaliation from peers, coaches, or teachers, such as in the form of bullying or the affordance of fewer social, academic, or extracurricular opportunities. Some LGBTQ youth may stay in the closet due to personal feelings of shame surrounding their sexual orientation or gender identity. Internalized homophobia is the term used to describe LGBTQ individuals’ negative judgments, dispositions, and emotions toward other members of the LGBTQ community and themselves. Internalized homophobia occurs when LGBTQ people internalize negative social messaging about minoritized sexual orientations and genders and consciously or unconsciously use that negative messaging as the basis for their thoughts and feelings about themselves and other LGBTQ people. When LGBTQ children and adolescents grow up hearing these messages, they will invariably internalize the message, which results in the development of shameful and negative feelings about themselves (Goldbach & Gibbs, 2017). Personal feelings of shame, the same feelings that could cause an LGBTQ child or adolescent to stay in the closet, are a result of internalized homophobia. CBT Conceptualization Feelings of confusion, inauthenticity, isolation, hopelessness, and despair are common among LGBTQ youth who have internalized stigmatizing messages about their identities. A child may develop a sense of confusion when their internal perceptions of their sexual or gender identity are met with negative social messaging. A teen who has delayed disclosure of their LGBTQ identity due to dissonant internal

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and external beliefs may maintain a sense of self that feels inauthentic and can cause them to feel disconnected from themselves and others. Despite the increasing visibility of individuals of diverse genders and sexualities, many LGBTQ youth feel that they are different and alone. They may experience a sense of isolation stemming from non-​conformity to societal expectations of gender and sexuality. This isolation, when experienced alongside confusion and shame, leads to feelings of hopelessness and despair about the future for many LGBTQ children and adolescents. They may worry that they will never be able to live as their true self or may feel that their future opportunities are limited due to their sexuality and/​or gender identity and expect to be rejected on the basis of their identity. LGBTQ youth may believe that they will never be able to find someone who will date, love, or marry them, that they will never find a job or be able to have a family, and that they will experience rejection and discrimination throughout their lifetimes. As a result of their hopelessness and despair, young LGBTQ individuals can feel as if they can never be proud or feel good about their identity. The Minority Stress Model for understanding LGBTQ youths’ mental health outcomes aligns well with cognitive-​behavioral theory. When taking a cognitive-​behavioral perspective, cognitions are distorted by minority stress via the internalization of negative societal messages about the LGBTQ community. This internalized homophobia generates feelings of shame, confusion, isolation, hopelessness, and despair. When experienced over time, these feelings result in psychological distress and facilitate a series of self-​destructive behaviors, which are made in an effort to cope with the emotional fallout of traumatic experiences and internalized homophobia. Group Identification and Progress Monitoring Members of the group should identify as members of the LGBTQ community or have an awareness that they are not cisgender and/​or straight. They do not need to be “out” to others, but they must be “out” to themselves or have begun to acknowledge their sexuality and/​or gender identity. They can vary in their degree of self-​acceptance of their identity. Because therapeutic group work with LGBTQ youth can include discussion of topics related to physical development and sexual intercourse, group members must be of a similar age and developmental level. It would be advantageous to have at least two group members who (1) identify with one or more minoritized sexuality/​gender labels, (2) are secure in their identity (have accepted it and integrated it into their understanding of themselves), and (3) are motivated and possess the interpersonal skills to develop connections to serve as models. The experiences of LGBTQ youth vary widely across sexualities, genders, and other held intersecting identities. Therefore, when constructing the group, practitioners must also consider the ways in which demographic makeup may impact group dynamics and each member’s personal therapeutic experiences. In order to facilitate interpersonal connection and reduce the possibility of inadvertently reinforcing perceptions of isolation, it is important to be mindful of group composition in terms of factors including, among others, race, ethnicity, religion, economic status, and, of course, gender and sexuality. For instance, will a teen who is a Hispanic transgender boy be the only transgender person in the group? Will he be the only boy? Will he be the only person of color?2 If the answer is “yes” to any of these considerations, how might that impact his ability to obtain support and connect with others in the group via shared experiences? For some individuals, this type of representation is essential to their success within the group. However, it is entirely possible that the aforementioned trans teen would be comfortable in a group of peers who are all white cisgender girls of diverse sexualities. While either scenario may be the case, it is important to discuss the demographic context of the group with prospective members in a developmentally appropriate way so that they can make an informed decision about their participation. 2 The illustrative examples provided throughout this chapter were adapted from Nealy, E. C. (2017). Transgender children and youth: Cultivating pride and joy with families in transition. W. W. Norton & Company.

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It is ideal to conduct a private screening interview with each prospective member when identifying individuals for inclusion in a CBT group for LGBTQ youth. Private interviews facilitate the acquisition of accurate and relevant information because they allow LGBTQ youth an opportunity to self-​disclose in a safe and supportive space. Interviews (see Appendix) should consist of a combination of open-​and closed-​ended questions. They may be supplemented with inventories or rating scales to provide further information relevant to group composition and/​or to gather baseline data for progress monitoring purposes. In order to reduce the risk of outing, practitioners should avoid gathering sensitive data through electronic forms to be filled out on personal devices, which may be surveilled (i.e., recovering browsing history, IP tracking) by family members or peers. The Sexual Minority Adolescent Stress Inventory (SMASI; Schrager et al., 2018) is a valid and reliable tool for measuring minority stress among sexual minority youth aged 14 to 17. It provides scores for 10 domains, including social marginalization, family rejection, internalized homonegativity, identity management, homonegative climate, intersectionality, negative disclosure experiences, religion, negative expectancies, and homonegative communication. The SMASI is a useful tool for collecting detailed information on individuals’ sources, experiences, and internalization of sexuality-​related stigma, which can be used as part of the screening process and as a progress monitoring tool. Additional tools such as the State-​Trait Anxiety Inventory for Children (STAI-​CH; Spielberger et al., 1970), the Screen for Child Anxiety Related Disorders (SCARED; Birmaher et al., 1999), and the Severity Measure for Depression—​Child Age 11–​17 (adapted from PHQ-​9 modified for Adolescents [PHQ-​A]; Johnson et al., 2002) may be useful for collecting data on the internalizing problems associated with minority stress. Cultural, Ethnic, and Racial Considerations When Working with LGBTQ Youth The effects of minority stress are compounded for LGBTQ youth who hold one or more minoritized identities in addition to their status as LGBTQ. In fact, in a national survey, half of LGBTQ youth of color reported experiencing discrimination based on their race/​ethnicity within one year of reporting (Trevor Project, 2021). Rates of discrimination experiences were highest among Black youth (67%) and Asian/​Pacific Islander youth (60%; Trevor Project, 2021). Within the schools, more than 50% of LGBTQ students of color experience victimization based on their race/​ ethnicity in school, with Native American LGBTQ youth experiencing the most hostile school climate, greatest rates of victimization based on sexual orientation/​gender identity, and lowest levels of school belonging than LGBTQ youth of any other racial/​ethnic group (GLSEN, 2022). When working with LGBTQ youth who hold additional minoritized identities, it is important to consider the ways in which multiple sources of minority stress may impact the child or adolescent’s life. LGBTQ youth of color may have a difficult time distinguishing between sources of minority stress. A Chinese-​born pansexual adolescent who recently immigrated to the United States with her family may experience discrimination based on her gender, based on her race and ethnicity, and based on her sexual orientation. Furthermore, children of immigrant families (i.e., first-​generation youth or second-​generation youth) may experience familial rejection and personal confusion due to a misperception that their sexual orientation and/​or gender identity are the result of acculturation to US norms and rejection of their cultural heritage, rather than an innate part of their identity. For youth of color and youth from minoritized ethnic or cultural backgrounds, family relationships can serve as a protective factor against systemic injustices such as racism, xenophobia, religious discrimination, etc. (Luh et al., 2023). For LGBTQ youth who hold additional marginalized backgrounds and come from families who do not accept their LGBTQ identity, they may be unable to benefit from the protection offered by the family against discrimination. However, practitioners should be aware that when family members from minoritized backgrounds are accepting, they can offer unique support through connecting their own discrimination experiences with the

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discrimination their LGBTQ family member is experiencing on the basis of their gender and/​or sexual orientation. When working with LGBTQ youth, practitioners must develop a holistic understanding of the child’s familial relationships when determining sources of support and minority stress. Group CBT with LGBTQ Youth Therapeutic work with this population should affirm and explore sexual orientation, gender identity, and gender-​and sexuality-​related experiences. For instance, sessions may center on navigating macro-​level or systemic issues that individuals within this population face (i.e., discrimination, underrepresentation, and rejection) or on common or shared experiences among members of the group due to their status as LGBTQ. In order to frame accurate perspectives and contextualize their experiences, LGBTQ youth need to learn the facts about diverse sexualities and genders, LGBTQ history, and the lived experiences of other members of their community. Such psychoeducation can be facilitated through reading, listening, and speaking with people of diverse genders and sexualities who model happy and successful lives. Cognitive behavioral interventions should be conducted in a safe and supportive space in which group members do not feel as though they have to justify or prove their LGBTQ identity. Group therapy is indicated for LGBTQ youth because it provides the opportunity for LGBTQ children and adolescents to build community with each other via exploring shared experiences and witnessing each other’s emotions. Within-​community support enhances psychological well-​being, and this support serves as a protective factor for LGBTQ youth (Robinson & Schmitz, 2021). Thus, therapeutic, safe spaces are most powerful and empowering for LGBTQ children and adolescents when created within the context of a group composed of members within their community who are “like them.” Affirmative cognitive-​behavior therapy (CBT) (Pachankis et al., 2015) is a derivative of traditional CBT that integrates techniques that validate the experiences of LGBTQ individuals in order to address the difficulties they face due to minority stress. Practices unique to affirmative CBT include explicit discussion of systemic injustices and acknowledgment of the ways in which social stigmatization of minoritized sexualities and genders can impact, or have impacted, members of the group. The goals of affirmative CBT are to reduce feelings of identity-​related shame by externalizing clients’ homophobia and to facilitate clients’ holistic understanding of the ways in which stress impacts their well-​being. Similarly, Austin and Craig (2015) developed a four-​component model for CBT interventions with transgender individuals, which can be easily applied when working in groups with LGBTQ youth. It emphasizes (1) creating a safe and affirming space that allows for the disclosure of identity and experiences, (2) facilitating the externalization of homophobia by helping youth to see the connections between their experiences and minority stress, (3) enabling youth to challenge negative internalized messaging and recognize their resiliency, and (4) encouraging behaviors that empower the individual and their community, such as advocacy and community building. The AFFIRM program (Craig & Austin, 2016) is currently the only evidence-​based affirmative CBT treatment protocol for LGBTQ youth. AFFIRM is a manualized program consisting of eight weekly sessions, and it has been demonstrated to reduce participants’ symptoms of depression, improve coping and feelings of hope, and increase adaptive appraisals of threat, challenge, and resources (Craig & Austin, 2016; Craig et al., 2021). Table 14.1 outlines the AFFIRM curriculum. Sample of Treatment Interventions CBT interventions that are responsive to the needs of LGBTQ youth are designed to facilitate group members’ acquisition of cognitive strategies that allow them to understand the external nature of stigma against members of the LGBTQ community, question or challenge discriminatory

244  Johanna de Leyer-Tiarks Table 14.1 AFFIRM Curriculum Modules Session

Activities

1. Introduction to CBT and understanding minority stress

• • • • • •

2. U  nderstanding the impact of anti-​ LGBTQ attitudes and behaviors on stress • • 3. U  nderstanding how thoughts affect feelings

4. U  sing thoughts to change feelings

• • • • • • • • • •

• • • • 6. P lanning to overcome • counterproductive • thoughts and • negative feelings • 7. U nderstanding the • impact of minority • stress and anti-​ LGBTQ attitudes/​ • behaviors on social • relationships 8. D eveloping safe, • supportive, and • identity-​a ffirming social networks • 5. E  xploring how activities affect feelings

I ntroductions D iscussing the theory and purpose of CBT approaches E xploring stress and minority stress U nderstanding the causes of stress in our lives C heck-​in and review E xamining homophobia, heterosexism, and transphobia at the individual, institutional, and cultural level I dentifying how these experiences impact thoughts, feelings, and behaviors F ostering strategies for both coping with and combating anti-​ LGBTQ discrimination at all levels C heck-​in and review D istinguishing between thoughts and feelings E xploring how thoughts influence feelings and behaviors I dentifying counterproductive thinking patterns Recognizing negative self-​t alk and feelings of hopelessness L earning thought stopping C heck-​in and review I ncreasing positive thinking and feelings of hope C hanging negative thoughts to positive thoughts C hallenging negative thinking and internalized homophobia/​n egative feelings through the ABCD method C heck-​in and review E xamining the impact of various activities on feelings I dentifying supportive and identity-​a ffirming activities T he impact of LGBTQ-​a ffirming activities on feelings C heck-​in and review D istinguishing between clear and unclear goals I dentifying short, mid, and long-​t erm goals F ostering hope for the future C heck-​in and review A nti-​LGBTQ discrimination can lead to feelings of discomfort around others Responding to discrimination or harassment in social situations L earning to be assertive C heck-​in and review M aintaining a healthy social network: Attending to thoughts, expectations, feelings, and behaviors within relationships I dentifying a plan for building a supportive network

Source: Craig & Austin (2016, p. 139).

beliefs, and identify specific sources of minority stress which impact their well-​being. Clinical interventions should provide a safe space where group members can work through the emotions that arise due to stigma, both when internalized and when appropriately conceptualized as part of the external social environment, as well as emotions resulting from experiences of discrimination. Additionally, responsive CBT interventions encourage the development of behavioral coping strategies that allow LGBTQ youth to navigate experiences of discrimination and stigma and resulting emotions safely and adaptively and have been demonstrated to improve mental health across populations (i.e., goal setting, seeking interpersonal support from safe and supportive people, using positive affirmations).

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The ABCDE Method The ABCDE method (Stein & Book, 2011) is an effective method for encouraging young people to examine their reactions in order to understand the connection between their environment, thoughts, and feelings. It is rooted in Albert Ellis’s (1955) Rational Emotive Behavior Therapy, which posits that our experiences are consequences of beliefs that have been activated following some event within our environment (Activating event > Belief > Consequence). The ABCDE method challenges individuals to debate, dispute, and discard their beliefs and reflect on the effects of the exercise on their understanding of the event, their behavior, and their feelings (Activating event > Belief > Consequence > Debate > Effects). For LGBTQ youth, the ABCDE method is a particularly useful intervention for addressing feelings of shame, hopelessness, and despair that have arisen due to minority stress. When used for this purpose, the ABCDE method can help LGBTQ youth identify the internalized homophobia that underlies their feelings, appropriately locate the stigma as external to themselves, and challenge the negative messaging. In a group setting, the ABCDE method is best implemented as an independent, structured writing activity, which is then encouraged to be shared with the group (see Figure 14.1). When applying this intervention in LGBTQ youth groups, it is particularly pertinent to point out the (Activating event→Belief→Consequence→Debate and Dispute→Effects) Think of a situation that made you feel poorly about being LGBTQ • Describe the unpleasant emotions you were feeling and any behaviors that accompanied them. We call these Consequences, write them down in the C column. • This situation that made you feel poorly is called the Activating Event. Describe the situation (Where were you? Who were you with? What happened?) and write it down in the A column. • The key aspect of the ABCDE approach is to capture your Bs. B stands for Beliefs—​you can think of your Bs as your internal self-​t alk that was triggered by the situation. Your Bs can be almost imperceptible during upsetting situations and are easily overlooked even when remembering the event. See if you can pin down what went on in your mind right after the activating event and write that down in the B column. • Your next task is to actively Debate and Dispute the maladaptive, self-​d efeating beliefs that give rise to your Cs. Debate and dispute each B you identified by pointing out the reasons the B could be wrong and writing down convincing arguments that challenge the B’s truthfulness. Write your answers in the D column. • Your last task is to reflect on the Effects of challenging your beliefs by describing how it felt and what you thought about while you were filling in column D. Consider the following questions: How did debating and disputing your beliefs make you feel? Was it hard to think of reasons why any of your Bs could be wrong? How did you come up with arguments? Do you feel like your arguments are convincing? Now, think again of the situation that made you feel poorly about being LGBTQ and describe how you might feel and react if something similar were to happen in the future. Write this down in column E. A B C D E Figure 14.1 ABCDE Worksheet. Source: Adapted from Stein & Book’s (2011) ABCDE Method.

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ways in which participants’ negative internalized beliefs may mirror societal messaging that stigmatizes LGBTQ individuals and the LGBTQ community. While ABCDE work is shared, practitioners should normalize and affirm participants’ experiences by drawing connections across any reported events, beliefs, or feelings that are common across participants’ ABCDE work or that have come up in group discussions previously. Practitioners should also use this opportunity to support community building by challenging the group to share their perspectives on how they have debated or would debate each other’s negative beliefs if they were to hold those beliefs themselves. Self-​C ompassion Break The Self-​Compassion Break (SCB; Germer & Kneff, 2019) is a mindfulness-​based mind–​body health intervention that can be used to help LGBTQ youth recognize the personal effects of minority stress. The intervention directs participants to recall a difficult situation and identify how the negative emotions manifest in their bodies. It encourages self-​compassion as a way to combat stress through the use of positive self-​affirmations during meditation. SCB can be used as an intervention within the therapeutic setting, and the meditation portion can be taught or provided via recording for future use as a coping skill. By drawing on the science of the mind–​body connection, SCB provides the opportunity for participants to mindfully experience the effect that their emotions and cognitions can have on their physical well-​being (see Figure 14.2). When implemented in concert with psychoeducation The Self-​C ompassion Break is taught as a reflective exercise. Individual components of the Self-​C ompassion Break can be applied either singly or in combination in daily life in response to stress. The following meditation script can be read verbatim or modified to fit the needs of the group: Think of a situation in your life that is difficult, that is causing you stress. Call the situation to mind, and see if you can actually feel the stress and emotional discomfort in your body. Now, say to yourself: “This is a moment of suffering.” That’s mindfulness. Other options include: • “This hurts.” • “Ouch.” • “This is stress.” “Suffering is a part of life.” That’s common humanity. Other options include: • “I’m not alone, Others are just like me.” • “This is how it feels when a person struggles in this way.” • “We all struggle in our lives.” “May I be kind to myself.” That’s self-​k indness Other options might be: • “May I give myself what I need.” • “May I accept myself as I am.” • “May I learn to accept myself as I am.” • “May I forgive myself.” • “May I be strong.” • “May I be patient.” • “May I live in love.” If you’re having difficulty finding the right words, imagine that a dear friend or loved one is having the same problem as you. What would you say to this person, heart-​t o-​h eart? If your friend were to hold just a few of your words in their mind, what would you like them to be? What message would you like to deliver? Now, can you offer the same message to yourself? Figure 14.2 Self-​C ompassion Break Script. Source: Germer and Kneff (2019).

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about minority stress and long-​term health outcomes among LGBTQ individuals, SCB can be a powerful tool for facilitating LGBTQ youths’ comprehension of the seriousness of minority stress on their health and well-​being. Similarly, SCB empowers LGBTQ youth by directing them to mindfully experience the results of relaxation efforts as they are happening. While this intervention can be a powerful one, it may not be appropriate for youth who are experiencing dysphoria surrounding their physical appearance. Practitioners should use caution when implementing this intervention in groups with transgender, non-​binary, or other gender-​expansive individuals. LGBTQ Community Stories For LGBTQ youth, hearing stories about the lives of other LGBTQ people offers a way for the youth to feel connected to their community and their history. Life narratives by LGBTQ people and stories about notable figures or events important to LGBTQ history provide information from which LGBTQ youth can contextualize their own experiences. Based on LGBTQ youth’s unique risk and support factors (Luh et al., 2023), strategies like LGBTQ community stories can be used within the therapeutic setting as a way to address feelings of isolation and hopelessness. Building off of Scheff’s (1990) concept of attunement and the literature on recovery narratives (Ng et al., 2022), LGBTQ community stories can facilitate “empathetic intersubjectivity” (Scheff, 1990, p. 7) or a sense of mental and emotional mutual understanding, as a powerful antidote to the isolation and hopelessness experienced by LGBTQ youth resulting from minority stress. Figure 14.3 includes detailed instructions for implementing LGBTQ community stories. Overcoming Obstacles There are two reasons that challenges may arise when conducting group treatment with LGBTQ. The first are challenges arising from identity disclosure. LGBTQ youth who have not disclosed their identity to anyone else or for those who are out to only a select few may avoid group treatment for fear of being “outed.” It is important to clearly communicate to group members that confidentiality can never be guaranteed, but it is expected that each group member abide by a “what is said in here, stays in here” rule. During group sessions, practitioners can reinforce this message by calling on the rule each time a group member discloses a fear of being outed. This ongoing reinforcement of maintaining confidentiality might look like this, “I hear that you are scared that your father will find out you are planning to go to the Gay Prom event. It’s common for people to worry about their family finding out that they are LGBTQ; that is why it is so important that whatever we say in this room stays in this room.” Additionally, in order to protect group members from the possibility of being outed by simply attending the group, practitioners should exercise extreme caution when advertising the group and when describing the nature of the group with parents/​guardians in conversation or via permission forms. Secondarily, LGBTQ youth may be resistant to group treatment because they feel as though they do not belong in the group (i.e., an “I’m not one of them” ideology). In these cases, it is important to consider the role of internalized homophobia on the youth’s reticence. Many LGBTQ youth who do not identify with their LGBTQ peers or the LGBTQ community at large have developed distorted perceptions of LGBTQ people due to the internalization of negative societal messaging about their community. Children and adolescents who are resistant to group membership on the basis of such internalized homophobia should be encouraged to participate. While less frequently occurring, there are cases where LGBTQ youth should be affirmed in their dis-​identification with the group. For example, an adolescent who transitioned from male to female at a young age and has been living as her true gender for many years may not identify

248  Johanna de Leyer-Tiarks

Selecting Stories: Practitioners should select non-​f iction (i.e., real-​life) stories that represent the experiences of LGBTQ individuals with whom group members can identify. That is, the characteristics of the story’s subject (i.e., narrator if autobiographical, main character if biographical) and the content of story narrative (i.e., themes) should be relatable to members of the group. In cases where the group varies widely in terms of members’ demographics and/​o r experiences, practitioners should select a variety of stories that represent a diversity of experiences and LGBTQ individuals. In order to facilitate therapeutic benefits, stories should portray narratives of LGBTQ individuals who are resilient and living well despite the adversities they face. Keep in mind: • Stories should be non-​f iction, they should contain the narratives of real LGBTQ individuals • Stories should be relatable in terms of the subject’s characteristics and/​o r the themes discussed • Stories should portray the experiences of resilient LGBTQ individuals Implementing LGBTQ Community Stories: LGBTQ Community Stories can be delivered in a variety of formats. Stories can be told aloud in the form of a live reading, an audio recording, or a video recording, or they can be provided for group members to read independently within the group setting. Depending on the needs of the group, practitioners may wish to vary delivery formats from session to session in order to improve accessibility and facilitate members’ motivation and attention. While follow-​u p discussion is not necessary for implementing LGBTQ Community Stories, for certain groups, a post-​s tory discussion that explores relevant therapeutic themes may be advantageous. In general, LGBTQ Community Stories should be administered at a rate of one story per group session. Dosage can vary to fit the needs of the group, and should be informed by trends in progress monitoring data. Keep in mind: • Stories can and should be delivered in a variety of formats (spoken, recorded, independent reading) to fit the groups’ needs • Follow-​u p discussion is not necessary but may be included if deemed therapeutically advantageous • Give one story per session • Use progress monitoring data to determine when it is time to withdraw the intervention Story Resources: We Are The Youth: http://​w earet​h eyo​u th.org/​a bout/​ Short autobiographical stories by LGBTQ youth. Format: Written (with photos) Allyship is a Verb: www.ally​s hip​i sav​e rb.com/​ Hour-​long episodes featuring interviews with LGBTQ individuals from a variety of backgrounds. Format: Podcast Born This Way Blog: https://​b or​n gay​b orn​t his​w ay.blogs​p ot.com/​ Short autobiographical stories written by LGBTQ adults about their childhood memories. Format: Written (with photos) It Gets Better Project: https://​i tget​s bet​t er.org/​ Short, uplifting autobiographical stories by LGBTQ individuals from a variety of backgrounds. Format: Video, written (with photos) Figure 14.3 A Guide to Implementing LGBTQ Community Stories.

herself as a transgender girl; she may simply view herself as a girl. In this case, it would be damaging to insist that she participate in a group designed for LGBTQ youth because she does not frame her identity in this way. Practitioners can determine how internalized homophobia may be impacting an LGBTQ youth’s reticence by gathering data using tools such as the SMASI and discussing the youth’s experiences and perceptions in an individual interview prior to inclusion in group treatment.

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Summary By acknowledging and understanding processes by which minority stress distorts and reinforces maladaptive thought patterns and behaviors, practitioners can better support LGBTQ youth. Affirmative CBGT is an ideal choice for treating psychological difficulties experienced among LGBTQ youth because it addresses internalized homophobia directly through legitimizing LGBTQ youths’ experiences of prejudice and discrimination and challenging distorted cognitions that underlie feelings of shame, hopelessness, and despair. Affirmative CBGT builds on research findings that demonstrate the protective power of community relationships and empowers LGBTQ youth by providing them with the coping skills necessary to persist in the face of adversity. Case Example Affirmative CBGT was used to support LGBTQ youth in a diverse, working-​class, suburban neighborhood. The treatment was offered in a child-​focused private practice in response to concerning trends in local data on LGBTQ youth mental health and recent conversations with LGBTQ clients corroborating the trends. Because there was existing support for LGBTQ youth in the neighborhood, the group was specialized for LGBTQ adolescents who were struggling with internalizing problems such as depression and anxiety. Prospective group members were identified via referral from neighborhood entities, including schools, mental health organizations, doctors’ offices, and community centers whom the facilitator contacted to notify of this new service. The facilitator also advertised the group on their private practice webpage; however, they were careful to avoid explicitly stating that the group was for LGBTQ youth only. The webpage advertisement read: I am currently accepting clients to participate in a new group for adolescents who are struggling with negative feelings about themselves, their identity or orientation, or the identities of others like them. If you or your child are interested in joining this group, please contact my office. Screening consisted of 30-​minute private, individual meetings with prospective group members from which the facilitator collected demographic information, including sexual identity, orientation, gender identity, and expression (SOGIE) data. If an adolescent did not indicate that they were a member of the LGBTQ community, they and their parent/​guardian were immediately notified that they were not eligible for the group, and they were connected to appropriate resources. For LGBTQ prospective group members, the facilitator continued the meeting by conducting a semi-​structured interview to build rapport and gather information on the adolescent’s sources of minority stress, gender-​and sexuality-​related experiences, and mental health. Following this, during the last part of the screening meeting, the prospective group member filled out the SMASI, the SCARED, and the PHQ-​A. In order to be included in the group, the LGBTQ youth must have endorsed experiencing minority stress on the SMASI and have indicated clinically significant or at-​risk levels of internalizing problems on either or both of the SCARED and PHQ-​A report forms. Out of ten youth screened, six were included in the group. Following the Minority Stress Model for conceptualizing LGBTQ individuals’ mental health difficulties, the facilitator opted to run the group using a CBGT approach. Each 1.5-​hour group session involved (1) a brief check-​in, (2) psychoeducation on minority stress, (3) implementation of a CBT-​aligned evidence-​based intervention, and (4) completion of progress monitoring forms. The following illustrates a sample session in Jordan’s CBT group for LGBTQ youth: Check-​in prompt:

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• “Before we start, let’s do a quick pulse check. Take a few moments to reflect on your week, then come up with two words that describe your week to share with the group. Once everyone has finished telling us their two words, anyone who would like to share more about their week will have the opportunity to do so.” Psychoeducation on minority stress: • Topic: Expecting Prejudice • Sample lesson: • Operationally defined: “People expect prejudice when they believe that they will experience things like discomfort, harassment, rejection, or limited opportunities because they are different.” • Link back to the Minority Stress Model of mental health and make explicit that LGBTQ people are more likely than non-​LGBTQ people to expect prejudice. • If relevant, explain how expectations of prejudice may be compounded for people who hold multiple minority identities (i.e., Black transgender girls). • Explain the ways in which expecting prejudice can impact a person’s behaviors (i.e., avoidance, acting out or acting differently, social withdrawal, aggressiveness, etc.). • Give concrete examples that are relevant to the group members’ LGBTQ identities. • “A transgender person may avoid joining a sports team because they believe they will not get any playing time because they are transgender.” • “Gay boys might put on a macho-​man act when around other boys when they believe they will be rejected for their sexual orientation.” • “A bisexual girl might not want to bring her girlfriend home to meet her parents because she believes it will confuse her parents, who know that she has dated boys in the past.” • Close out by re-​stating that according to the Minority Stress Model, expectations of prejudice are one of the reasons LGBTQ people can develop feelings of depression and anxiety, then ask the group to consider the ways that the former may cause the latter. • Leave time for questions Intervention: Self-​Compassion Break (see Figure 14.2) Progress monitoring: • PHQ-​A • SCARED Group sessions were held weekly for ten weeks. Throughout the treatment, all of the group members experienced clinically meaningful reductions in internalizing symptoms as reported on their progress monitoring measures (PHQ-​A and SCARED). Throughout the sessions, and in line with research on the protective impact of within-​community bonds among LGBTQ youth, the facilitator encouraged group members to build community by exchanging contact information and seeking out social opportunities with each other and others like them outside of the group. References Austin, A., & Craig, S. L. (2015). Transgender affirmative cognitive behavioral therapy: Clinical considerations and applications. Professional Psychology: Research and Practice, 46(1), 21–​29. https://​doi.org/​ 10.1037/​a0038​642

CBT Groups with LGBTQ Youth 251 Birmaher, B., Brent, D. A., Chiappetta, L., Bridge, J., Monga, S., & Baugher, M. (1999). Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): A replication study. Journal of the American Academy of Child and Adolescent Psychiatry, 38(10), 1230–​1236. Centers for Disease Control and Prevention. (2019). Youth Risk Behavior Survey. Available at: www.cdc. gov/​YRBSS Craig, S. L., & Austin, A. (2016). The AFFIRM open pilot feasibility study: A brief affirmative cognitive behavioral coping skills group intervention for sexual and gender minority youth. Children and Youth Services Review, 64, 136–​144. Craig, S. L., Leung, V. W. Y., Pascoe, R., Pang, N., Iacono, G., Austin, A., & Dillon, F. (2021). AFFIRM Online: Utilising an affirmative cognitive-​behavioural digital intervention to improve mental health, access, and engagement among LGBTQA+​youth and young adults. International Journal of Environmental Research and Public Health, 18(4), 1541. https://​doi.org/​10.3390/​ije​rph1​8041​541 Ellis, A. (1955). New approaches to psychotherapy techniques. Journal of Clinical Psychology, 11, 207–​260. https://​doi.org/​10.1002/​1097-​4679(195​507)11:33.0.CO;2-​1 Germer, C. & Neff, K. D. (2019). Mindful Self-​Compassion (MSC). In I. Itvzan (Ed.) The handbook of mindfulness-​based programs: Every established intervention, from medicine to education. (pp. 357–​367). Routledge. GLSEN. (2022). The 2021 National School Climate Survey: The experiences of LGBTQ+​youth in our nation’s schools. GLSEN. Goldbach, J. T., & Gibbs, J. J. (2017). A developmentally informed adaptation of minority stress for sexual minority adolescents. Journal of Adolescence, 55, 36–​50. https://​doi.org/​10.1016/​j.adol​esce​nce.2016.12.007 Johnson, J. G., Harris, E. S., Spitzer, R. L., & Williams, J. B. (2002). The patient health questionnaire for adolescents: Validation of an instrument for the assessment of mental disorders among adolescent primary care patients. Journal of Adolescent Health, 30(3), 196–​204 Luh, H., deLeyer-​Tiarks, J. M., Wojcik, H., & Mandracchia, F. (2023). Preparing LGBTQ youth for the high school to college transition: A multidimensional approach. Journal of LGBT Youth. https://​doi.org/​10.1080/​ 19361​653.2023.2264​830 Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–​697. Mongelli, F., Perrone, D., Balducci, J., Sacchetti, A., Ferrari, S., Mattei, G., & Galeazzi, G. M. (2019). Minority stress and mental health among LGBT populations: An update on the evidence. Minerva Psichiatrica, 60(1), 27–​50. https://​doi.org/​10.23736/​s0391-​1772.18.01995-​7 Mustanski, B. S., Garofalo, R. Emerson, E. M. (2010). Mental health disorders, psychological distress, and suicidality in a diverse sample of lesbian, gay, bisexual, and transgender youths. American Journal of Public Health, 100(12), 2426–​2432. https://​doi.org/​10.2105/​AJPH.2009.178​319 Ng, F., Newby, C., Robinson, C., Llewellyn-​Beardsley, J., Yeo, C., Roe, J., Rennick-​Egglestone, S., Smith, R., Booth, S., Bailey, S., Castelein, S., Callard, F., Arbour, S., & Slade, M. (2022). How do recorded mental health recovery narratives create connection and improve hopefulness?. Journal of Mental Health, 31(2), 273–​280. https://​doi.org/​10.1080/​09638​237.2021.2022​627 Pachankis, J. E., Hatzenbuehler, M. L., Rendina, H. J., Safren, S. A., & Parsons, J. T. (2015). LGB-​affirmative cognitive-​behavioral therapy for young adult gay and bisexual men: A randomized controlled trial of a transdiagnostic minority stress approach. Journal of Consulting and Clinical Psychology, 83(5), 875–​889. https://​doi.org/​10.1037/​ccp​0000​037 Robinson, B. A., & Schmitz, R. M. (2021). Beyond resilience: Resistance in the lives of LGBTQ youth. Sociology Compass, 15(12), e12947. https://​doi.org/​10.1111/​soc4.12947 Scheff, T. J. (1990). Microsociology: Discourse, emotion, and social structure. University of Chicago Press. Spielberger, C.D. Edwards, C.D., Montuori, J., & Lushene, R. (1970). The state trait anxiety inventory for children. Mind Garden. Stein, S. J. & Book, H. E. (2011). The EQ edge: Emotional intelligence and your success. Jossey-​Bass. The Trevor Project. (2021). 2021 National Survey on LGBTQ Youth Mental Health. The Trevor Project. The Trevor Project. (2022). 2022 National Survey on LGBTQ Youth Mental Health. The Trevor Project.

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Appendix Verbiage for Gathering Data on Sexual Orientation and Gender Identity/​E xpression The following sample interview verbiage is formulated to facilitate disclosure by normalizing the LGBTQ experience. It should be modified to fit the interviewee’s developmental level, identity, and communication style. Ascertaining Sexual Orientation “How would you describe your sexual orientation?” “People describe their sexuality in different ways such as gay, lesbian, queer, straight, pansexual, asexual, or bi. Do any of these words describe you? Or would you use some other words to describe your sexual orientation or attractions?” “I’d like to know more about how you identify. What terms do you use to describe your sexual orientation or romantic attractions?” “I’d like to gather some information about your sexual orientation. Can you tell me about the types of people you are typically attracted to? Do you use any labels to describe your sexuality?” “Have you ever felt differently about your sexual orientation or had any questions about if that sexual orientation fit you?” Ascertaining Gender Identity “How would you describe your gender identity?” “Some of the people I work with feel like they are more of a boy on the inside, while others feel like they are more of a girl on the inside, or something else entirely. What has this been like for you?” “Have you ever felt like your gender does not match the way that people describe you?” “People have different ways they experience their gender. For many people, their gender matches the sex they were assigned at birth. For other people, their own sense of themselves may not line up with how they were assigned at birth. You might think I know, but I ask everyone: What sex were you assigned at birth?” Followed by: “Have you ever felt differently or had any questions about whether that gender identity fit for you?” “People describe their gender identities in different ways—​girl, boy, nonbinary, transgender girl, transgender boy… Do any of these words describe your gender? Or would you use another word to describe your gender?” Asking about relationships “Are you involved with anyone?” “Is there someone special in your life? Can you tell me about them?” “Are you dating anyone? If you are, what are they like?” “When people date, their relationship can be only or mostly romantic, only or mostly sexual, or some combination of both. What does the term “dating” mean to you?” “Thinking about all of the different types of relationships, like friendships, romantic or sexual partners, or casual dating, what types of relationships do you have the most?” “What has this been like for you?”

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Asking about identity concealment “Some of the people I work with feel like they can live authentically as an LGBTQ person sometimes, but not at other times.” “Are there any places or situations that make you feel uncomfortable because of your sexual orientation or gender identity?” If yes: “What about those places makes you feel this way?” “Are there any people in your life that you feel you need to hide your sexuality or gender identity from?” If yes: “Who are they and why do they make you feel this way?”

Chapter 15

Building Team Cohesion and Optimal Performance Jason von Stietz

Each day, countless individuals and groups of people make it their goal to achieve excellence in sport performance. Sport performance is influenced by numerous factors, many of which require psychological intervention and often relate to one’s overall life functioning (Moore & Bonagura, 2019). In the field of applied sport psychology, most approaches to helping athletes with psychological issues and concerns have drawn from cognitive-​behavior therapy (CBT; Andersen, 2009). The purpose of this chapter is to give a broad introductory overview of how to use cognitive-​ behavior approaches to enhance the performance of adolescent and early adult athletic teams. Gen Z Athletes The current generation of high school and collegiate athletes are members of Generation Z (Gen Z). Gould, Nalepa, and Mignano (2020) argue that, as a cohort, Gen Z was shaped by world events and a social context involving global socioeconomic turmoil, international terrorism, and natural disasters. Furthermore, Gen Z is the most educated and technologically savvy generation to date, as it is the first cohort to be born into a completely digital environment. What does this mean for Gen Z athletes and those who support their growth? In a qualitative study, Gould et al. (2020) interviewed highly qualified and experienced coaches and sport science providers on their perceptions of Gen Z athletes. Findings suggest Gen Z athletes are perceived as educated, able to access information using technology quickly, are visual learners, and are curious and open to learning. For example, coaches commented on the ability of Gen Z athletes to watch video analyses of athletic performance and utilize the information. In addition to their strengths, Gen Z athletes were perceived by coaches as having four main issues, making it challenging to work with them (Gould et al., 2020). First, they were perceived as having short attention spans, making it difficult for them to focus longer than a few minutes. Second, they were perceived as lacking independence from their parents and often denied responsibilities related to practices such as scheduling or arranging workouts with training partners. Third, coaches viewed Gen Z athletes as more entitled and ungrateful for the opportunities given to them in sport. Fourth, coaches viewed them as preoccupied with social media and phone usage, which coaches saw as a distraction from athletic development. Coaches also discussed challenges related to working with the support network of Gen Z athletes (Gould et al., 2020). One challenge identified by coaches involved what coaches viewed as the over-​involvement of parents. Coaches reported perceiving parents as setting goals for Gen Z athletes and then living vicariously through them. This is supported by findings suggesting that adolescent athletes perceived their parents as very interested in sport, sport participation is considered important in their family, their parents train in a sport weekly, and their parents have a strong desire for them to compete in sport (Strandbu, Bakken, & Stefansen, 2020). A second challenge DOI: 10.4324/9781351213073-17

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identified involved the number of adults in the support network of elite Gen Z athletes. Coaches reported that the numerous sources of adult input and differing opinions appeared unhelpful and confusing to the athletes (Gould et al., 2020). Four suggestions for those working with Gen Z athletes from coaches were listed by Gould et al. (2020). The first suggestion by coaches was to adapt to the generational changes seen in athletes and help them build upon their strengths. Coaches advised avoiding falling into the trap of viewing athletes through a stereotypical lens and comparing current athletes to prior generations. The second suggestion was for coaches to cultivate strong trusting relationships in order to help Gen Z athletes develop motivation and communication skills. The third suggestion was for coaches to manage the support network of adults working with Gen Z athletes to prevent confusion. The fourth suggestion was that coaches not only help athletes with their sport-​related development but also their personal development by teaching life skills that are transferable outside of sport.

The Athlete Minority Stress Model Lee, Lombera, and Larsen (2019) observed that athletes from historically marginalized communities experience stressors and challenges not experienced by those from the majority communities. They posited that athletes from marginalized groups faced chronic stressors, specifically due to their devalued societal position, which impact not only their sport performance but also their psychological and physical health. Lee et al. (2019) introduced a minority stress model based on the work of Meyer (2003). According to the minority stress model proposed by Meyer (2003), minority stress negatively impacts health through processes referred to as distal and proximal stressors. A distal stressor is one that is an objective occurrence and unrelated to one’s own perceived identity. For example, someone can be called a homophobic slur whether or not someone identifies as gay. Proximal stressors, on the other hand, are more subjective. Meyer (2003) identified three proximal stressors, including concealing a stigmatized identity, expectations of rejection and discrimination, and internalizing stigma. Throughout one’s life, the accumulation of chronic stress from these processes leads to diminished physical and mental health. Although Meyer (2003) primarily applied this model to the lesbian, gay, and bisexual (LGB) community, Lee et al. (2019) applied the minority stress model to athletes with marginalized identities. An example they gave of a distal stressor was a Muslim American athlete being told to “go back to where you came from.” In a situation such as this, the athlete’s nationality, self-​perception, or views of the United States are irrelevant to the act of prejudice they experienced. Furthermore, Lee et al. (2019) gave examples of proximal stressors experienced by marginalized athletes. Marginalized athletes, such as non-​heterosexual women, might conceal their identities by making efforts to present as feminine so that their sexual orientation is not questioned. Athletes who are transgender might fear using locker rooms due to anticipation of rejection and discrimination. Athletes from marginalized identities might also fall prey to internalized stigma. For example, an athlete who identifies as gay might view his sexual orientation as a sin due to the internalization of religion-​based societal homophobia. Lee et al. (2019) argue that minority stress leads to a variety of negative consequences for athletes. For instance, sport performance is often impacted if an athlete is managing distress related to the possible use of homophobic slurs by fans. Psychological consequences such as mood disorders are possible. Behavioral consequences such as maladaptive coping involving substance use and disordered eating are possible. Minority stress is even related to stress-​related chronic disease and the frequency of emergency room visits.

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Addressing Minority Stress with Cultural Awareness In order to address minority stress, Lee et al. (2019) argue that one must first become aware of discrimination in sport and how one might contribute to systems of oppression. Sport psychology professionals and therapists alike are often encouraged to strive for cultural competence, which can be defined as the ability to understand the cultures of others and the awareness of one’s own cultural assumptions (Quartiroli, Vosloo, Fisher, & Schinke, 2020). Lee et al. (2019) argue that to gain cultural competence, one must first recognize one’s own intersection of identities, recognize one’s own experience with marginalization as well as one’s societal privilege, and scrutinize the impact of power and privilege on one’s work. A recent survey of sport psychology professionals found that they typically receive formal training in cultural competence, but most find it to be only moderately helpful (Quartiroli et al., 2020). Another recent survey found that sport psychology professionals were largely unaware of how their own cultural identities impact their work despite their endorsement of the importance of cultural competency (Lee et al., 2020). Lee et al. (2019) contend that, in addition to cultural competency, sport psychology professionals should endeavor to practice with cultural humility, which is the continual practice of learning through self-​reflection while establishing partnerships with individuals and communities that are mutually beneficial. Cultural humility is an ongoing and lifelong process. Lee et al. (2019) propose that there are two coping strategies athletes can use to deal with minority stress experienced on a personal level: emotion-​focused and problem-​focused. Emotion-​ focused coping is often useful when a stressor is related to a situation out of one’s control, such as situations involving systemic oppression. Lee et al. (2019) emphasize the importance of helping athletes deal with minority stress by listening empathically and validating their emotions related to their unique situations. Additionally, minority stress can be addressed by helping athletes to get connected to communities with which they identify to expand their support system. For example, an athlete who identifies with a marginalized cultural group and sexual orientation may feel isolated and could benefit by finding a community with people of similar identities. Problem-​focused coping can also be an effective option for dealing with minority stress (Lee et al., 2019). For example, discussing the pros and cons of reporting an act of discrimination while helping the athlete to feel empowered to make the final decision can be an important problem-​ focused coping strategy. Lee et al. (2019) also suggest applying traditional sport psychology interventions, such as mental imagery, to minority stress. They gave the example of an athlete preparing to compete in a hostile environment by incorporating the athlete hearing a slur into the imagery script the athlete uses in preparation for a competition. In addition to the personal coping strategies of emotion-​focused and problem-​focused coping, Lee et al. (2019) advocated for the use of societal-​level coping strategies. They argue that sport psychology professionals are in a unique position to advocate for inclusive policies for coaches, support staff, and administrators. Sport psychology professionals can use their relationships with key members of institutions to provide training on using inclusive language and developing institutional policies for correcting occurrences of non-​inclusive language and behavior. Assessment In many ways, assessment in sport psychology is similar to assessment in other areas of psychology. Gardner (2019) posits that assessment helps to answer specific questions and guide decision-​ making related to diagnosis, case conceptualization, and choice of intervention. The assessment process involves an interview, behavioral observation, and psychological testing. Practitioners have the choice of providing unstructured, structured, and semi-​structured interviews. Whereas

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unstructured interviews have the benefit of providing a comfortable space for clients to express themselves, structured interviews are more likely to provide the needed information for effective case conceptualization. Gardner (2019) primarily argues in favor of semi-​structured interviews, which allow data collection to occur during a fluid conversation. Two semi-​structured interviews that comprehensively address sport and nonsport-​related issues are the Sport-​Clinical Intake Protocol (SCIP, Taylor & Schneider, 1992) and the Multi-​level Classification System for Sport Psychology (MCS-​SP, Gardner & Moore, 2004). Behavioral observation can provide valuable information during a psychological assessment. Gardner (2019) proposes that observing athletes during practice and or competition can give insight into the specific psychological challenges they face within the context of their sport. During behavioral observation, practitioners might observe athletes responding to adversity and success and interacting with teammates, opponents, referees, and or coaches. Gardner (2019) suggests integrating observed behavioral information into the comprehensive assessment with great care. He urges practitioners to wait until all data is collected before interpreting behavior, as early interpretations could color and bias interpretations of incoming data. Psychological testing, also referred to as psychometric evaluation, can provide vital information during an assessment. Gardner (2019) argues that practitioners should base their decision regarding whether or not to use psychological tests on the value the instruments in question bring to the work with the clientele, the validity and reliability of the instruments, and practical considerations such as time and availability. Data collected from psychological testing should be integrated with information obtained from the interview and behavioral observation and should not be the sole source of information. For example, Gardner (2019) recommends practitioners use the MCS-​SP semi-​ structured interview (Gardner & Moore, 2004) in combination with the Performance Classification Questionnaire (PCQ). This ten-​item self-​report measure helps to determine if subclinical psychological issues are impeding performance (Wolanin, 2005). The PCQ can be used with individuals or with groups as a screening tool (Gardner, 2019). Group Cohesion Group cohesion is an emergent state critically important to a team’s success (Kim, Panza, & Evans, 2021). It can be defined as “a dynamic process that is reflected in the tendency for a group to stick together and remain united in the pursuit of instrumental objectives and/​or for the satisfaction of member affective needs” (Carron, Brawley, & Widmeyer, 1998, p. 213). The two key components of a team or group’s cohesiveness are task and social cohesion. Task cohesion describes the degree to which a group is united in its orientation toward the performance of a task. Social cohesion, on the other hand, describes the degree to which the members of a group feel socially connected to each other (Carron et al., 1998). Both task and social cohesion are linked to team performance. Moreover, Kim et al. (2021) list several benefits associated with group cohesion, such as higher motivation, improved social skills, higher satisfaction with sport involvement, and improved capacity for coping with stress. Team-​b uilding Team-​building is a common sport psychology intervention aimed at helping teams perform better by providing them with strategies and information that facilitate problem-​solving (Lacarenza, Marlow, Tannenbaum, & Salas, 2018). Kim et al. (2021) argue that the main purpose of team-​ building is to enhance team members’ perceptions of cohesion in order to facilitate members’ efforts toward team goals as well as value their social connection to the team. Lacarenza et al.

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(2018) contended that four commonly utilized approaches to team-​building can be utilized independently or in combination with each other. One approach is termed role clarification, in which role ambiguity, confusion, and conflict are uncovered. Then, clear roles are established, and communication between coaches and team members is increased to ensure understanding and performance of roles. A second approach is termed interpersonal relationship management, which aims to help team members resolve conflicts, build trust, and, in general, strengthen social bonds. A third approach, problem-​solving, involves facing interesting and unique challenges that require team members to collaborate to identify effective decision-​making processes and solve task-​related problems. Finally, goal setting involves team members collaborating to set goals that are ambitious and specific that can aid in their performance. One alternative approach to team-​building has been referred to as personal disclosure mutual sharing (PDMS), in which team interaction and communication are fostered by encouraging team members to share personal stories and private information with teammates (Piasecki, Loughead, Paradis, & Munroe-​Chandler, 2021). The PDMS approach often involves team members discussing their personal values and the meaning that they attribute to their experience in their sport (Kim et al., 2021). Piasecki et al. (2021) developed an eight-​week PDMS program centered around group mindfulness meditation. An intercollegiate soccer team met each week to learn and practice mindfulness meditation. Each session began with a “check-​in” in which players discussed their experiences and challenges related to learning meditation as well as stressors related to sport and life. Findings suggested that the team that participated in the intervention program had significantly higher social cohesion than their counterparts in a control group. Another approach to team-​building involves improvisational theater, often referred to as improv. Improv is an unscripted collaborative performance (Felsman, Gunawardena, & Seifert, 2020) that requires performers to give up their individual agendas in favor of the emerging team agenda (Ingall, 2018). Reid-​Wisdom and Perera-​Delcourt (2022) examined the perceived mental health benefits of experienced improvisers. Their qualitative study found that improvisers reported themes related to increased capacity for collaboration, more helpful thinking patterns, improved personal relationships, and increased tolerance of uncertainty. They attributed some of these benefits to the similarity between one of the guiding principles of improv, referred to as “yes, and” in which improvisers fully accept the material presented by each other in order to facilitate collaboration, and the psychotherapeutic concept of unconditional positive regard. The mental health benefits of improv are further supported by experiments finding that 20 minutes of improv activities increased measures of divergent thinking, uncertainty tolerance, and positive affect compared to other social interactions (Felsman et al., 2020). Sport Performance Competitive sport is psychologically demanding of its participants. Gardner and Moore (2007) summarized the numerous factors related to sport performance as the following: instrumental competencies, environmental stimuli and performance demands, dispositional characteristics, and behavioral self-​regulation. They described instrumental competencies as an individual’s cognitive and sensorimotor/​physical skills and abilities. Environmental stimuli and performance demands were described as the challenges related to the competitive, situational, interpersonal, institutional, and work-​related conditions that the individual must face. They summed up dispositional characteristics as cognitive-​affective schemas related to how the individual perceives, interprets, responds to, and copes with performance demands. Lastly, they described behavioral self-​regulation as the foundation of goal-​directed behavior in any domain involving the interconnected processes related to cognition, affect, physiology, and behavior. Competitive sport is likely to place heavy demands on athletes and strain their capacities in each of these areas.

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When an athlete is functioning well in each of these four areas, Gardner and Moore (2007) argue that the athlete is in a state conducive to optimal performance. A state optimal for performance can be described as a flow state (Csikszentmihalyi, 1975) in which performance on a task is often characterized as automatic and effortless. Similarly, many athletes and lay persons are familiar with the term “the zone,” which is the lay term for “the zone of optimal functioning,” referring to an individual’s level of arousal most conducive for peak performance (Hanin, 1980). In other words, there exists an ideal combination of cognitive, affective, and physiological conditions that allow athletes to perform their sport-​related skills in a way that feels effortless and automatic to them (Gardner & Moore, 2007). In spite of the existence of an optimal state for sport performance, it is not necessary, nor is it always possible, to achieve such a state. Ken Ravizza, a pioneer in the field of sport psychology, noted that early in his career, he often focused his efforts on helping athletes spend more time in the zone of optimal functioning, only to realize that this led them to overly focus on their internal state rather than fully engaging in competition (K. Ravizza, personal communication, 2017). Ravizza further noted that in the later stages of his career, he focused his efforts on helping athletes to optimally deal with the moment-​to-​moment demands of their sport. In his sport psychology manual for baseball and softball players, he and his co-​author instructed athletes to focus on playing one pitch at a time and give their full effort that they are capable of giving in that moment, regardless of whether or not their physical abilities are diminished due to fatigue or injury (Ravizza & Hanson, 1995; Ravizza & Hanson, 2016). This is congruent with the concept of acceptance of internal and external distress as a critical component of optimal performance (Gardner & Moore, 2007). Possible CBT Approaches The term CBT is an umbrella term that is used to describe a variety of cognitive-​behavioral approaches to psychotherapy and or methods of assisting in behavioral change. Turner et al. (2020) highlighted how four practitioners, each using a different cognitive-​behavioral approach, would treat a hypothetical athlete in individual psychotherapy. The four approaches highlighted by the authors were rational emotive behavior therapy (REBT), cognitive therapy (CT), schema therapy (ST), and acceptance and commitment therapy (ACT). Although each of these approaches falls under the umbrella of CBT, they are nevertheless distinct in their chief aims and interventions. The chief aim of REBT, summarized by the authors, is to address the unhealthy negative emotion of shame by addressing core beliefs about the self. They noted that this is done by collaboratively disputing irrational beliefs with the client. Furthermore, they suggested not challenging a client’s interpretation of events but rather challenging them to take responsibility for their emotional reactivity. For example, a soccer player who underperformed in previous games and was “benched” by the coach might perceive herself as letting down her coach and teammates. They suggested helping the client dispute their beliefs about letting people down that cause them such distress. A possible question would be, “What are you telling yourself about letting people down that makes you feel this way?” The next approach discussed by Turner et al. (2020) was CT, which is similar to REBT but a distinct form of CBT. The authors described the chief aim of CT as addressing unhelpful emotions and behaviors by addressing thoughts and inferences about self, others (e.g., coaches), and expectations about the future. They noted that CT involves a complex conceptualization that is developed collaboratively with the client throughout treatment. In CT, unhelpful emotions and behaviors are conceptualized as the result of an individual’s core beliefs, assumptions, and negative automatic thoughts. The main strategy of a CT intervention is to consistently dispute negative automatic thoughts that hamper clients in their functioning. The authors suggested helping clients to dispute their unhelpful thoughts by asking questions such as “How does believing your negative

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automatic thought impact you?” and “What is the worst thing that could happen, and how would you cope with it?” Although there is a lack of research on the use of ST with athletes, Turner et al. (2020) argue that it is well suited for use in a sport-​related context. The chief aim of ST, summed up by the authors, is to identify and reduce maladaptive schemas and develop adaptive alternatives. During ST, maladaptive schemas are identified, and their origin is explored in order to help clients understand that schema-​related thoughts are derived from past experience and not necessarily from the current situation. One possible ST intervention, suggested by the authors, is imagery rescripting in which the client is asked to remember, in vivid detail, the first time in their childhood that they felt strong, uncomfortable emotions similar to the way they feel in their current struggles. They suggested that the therapist help the client reimagine these experiences in a way in which their childhood needs were met by those around them. The goal is not to pretend that the past experiences did not happen but to help the client reach a new emotional understanding and weaken the maladaptive schema. ACT, in contrast to other forms of CBT, does not address unhelpful thoughts by disputing them. Turner et al. (2020) noted that the chief aim of ACT is to assist clients to have a more helpful relationship with their internal experiences, reduce experiential avoidance, and increase psychological flexibility. The authors noted that case formulation involves establishing a client’s unique struggles related to ACT’s six core processes (i.e., acceptance, cognitive delusion, being present, self as context, values, and committed action). They noted that interventions early in treatment would focus on the ineffectiveness of attempting to control internal experiences. One creative-​hopelessness exercise that highlights this point is the metaphor of the “Chinese finger trap.” The more one struggles to free their fingers from the trap, the more stuck in the trap they become. This illustrates the point that it is futile to try to control internal experiences and encourages clients to practice acceptance. A variety of CBT approaches can be useful in working with athletes to bring about positive behavioral change. Turner et al. (2020) argue that a variety of cognitive-​behavioral approaches can help a single case, and practitioners should not limit themselves to REBT, CT, ST, or ACT but seek formal training in one or more of the many forms of CBT. Further evidence that multiple CBT approaches could be helpful for athletes was found by Röthlin and Birrer (2020), who developed two separate sport psychology programs for two groups of athletes. Each of the two programs consisted of a series of workshops based on a distinct CBT approach: mindfulness-​based approaches (MAI) and psychological skills training (PST). Athletes from both groups gave a mixture of both positive and negative feedback. Athletes from both groups appreciated the learning tools they were provided during the program via text message and audio files. Both groups of athletes appreciated the relationship with the practitioner, being able to engage with relevant topics, help solve problems, and utilize resources. PST in Sport Psychology PST consists of mental training techniques deriving from CBT that aim to assist athletes in managing and regulating their internal experiences (e.g., thoughts, feelings, and physical sensations) with the goal of optimizing athletic performance (Röthlin & Birrer, 2020). Sport psychology practitioners so commonly utilize five psychological skills in their work with athletes that they are referred to as “the canon” of psychological skills. These psychological skills are relaxation, self-​ talk, goal setting, imagery, and concentration (Andersen, 2009). In fact, athletes are often already familiar with the cannon, as coaches often use them to aid in learning sport-​related skills and weightlifting techniques. For example, coaches regularly help athletes in goal setting, encourage athletes to use vivid imagery related to properly executing sport-​related techniques, and use cue words to motivate themselves when fatigued (Arthur et al., 2019).

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Relaxation An athlete’s ability to relax while under pressure is crucial to athletic success. Elevated arousal levels leading to muscle tension are at odds with the skilled motor control needed for optimal athletic performance. Therefore, utilizing a relaxation technique to activate one’s parasympathetic nervous system and or dampening one’s sympathetic nervous system is a valuable psychological skill (Andersen, 2009). Relaxation training with athletes typically includes progressive muscle relaxation and breathing relaxation (Röthlin & Birrer, 2020) or any variety of relaxation strategies. Relaxation can serve the purpose of shifting attention away from doubt and anxiety, decreasing muscle tension that interferes with masterful body mechanics, and staving off mental and physical fatigue (Andersen, 2009). Self-​Talk The term self-​ talk is often used broadly to describe various approaches to addressing unhelpful cognitions that often lead to anxiety (Andersen, 2009). In general, athletes are asked to gain awareness of their internal monologue by tracking their thoughts during practices and games as a first step in producing an internal monologue more conducive to sport performance (Zhou, 2022). Athletes can use intentional self-​talk to re-​interpret distressing situations, sometimes referred to in athletic environments as cognitive/​mental conditioning (Andersen, 2009), which is otherwise known as cognitive restructuring. Athletes can use self-​ talk that is encouraging and goal-​directed, such as, “I know I can win,” to shift attention away from worry-​based self-​talk, such as, “What if my opponent cheats?” (Boudreault, Trottier, & Provencher, 2019). Imagery Imagery is a foundational psychological skill that commonly involves other psychological skills (e.g., relaxation and concentration) during its use (Andersen, 2009). Athletes are often encouraged to use mental imagery during practice and games. For example, basketball players are coached to relax, focus on the present moment, and then visualize themselves successfully using proper technique before drills in practice as well as during games (Zhou, 2022). Imagery can include a variety of modalities, such as visual, auditory, and tactile, and can include multiple dimensions, such as duration and vividness. Imagery can have an internal perspective in which the image is viewed from the first-​person perspective or an external perspective in which the image is viewed from an outside third-​person perspective (Andersen, 2009). One widely applied and studied approach to utilizing mental imagery is the PETTLEP model (Holmes & Collins, 2001), which offers guidelines to practitioners to aid in utilizing imagery in interventions. The model suggests that imagery approximates the movement preparation and execution involved in athletic performance as closely as possible by incorporating seven elements: physical, environment, task, timing, learning, emotion, and perspective. A systematic review of the model found that athletes experienced greater improvements in performance when all of their senses were included in the imagery exercises (Morone et al., 2022). In addition, imagery is likely best utilized when in combination with physical practice. A recent study found that youth tennis players improved their serve the most when combining PETTLEP imagery training with serve-​related training compared to players who received only PETTLEP training or serve-​related training (Cherappurath et al., 2020).

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Goal Setting Knowing what types of goals to set and track is a psychological skill that is crucial to athletic success. It is likely most common for athletes and performers of all kinds to set outcome goals, such as winning a championship or garnering praise from high-​status individuals. However, process goals related to tasks and skills (e.g., setting a goal to warm up for practice with deliberate intention) are more beneficial to athletic success. Athletes benefit from learning to distinguish between and set outcome goals, process goals, and performance goals focusing on the outcomes of specific tasks (e.g., setting a new personal record in a weightlifting exercise). A recent meta-​analysis of 27 journal articles examining the effects of goal setting on athletic performance found that process goals had the largest effects compared to performance and outcome goals. Findings indicated that process goals led to improvements in performance, self-​efficacy, intrinsic interest, and satisfaction (Williamson et al., 2022). Concentration Concentration is a skill that, according to Andersen (2009), involves the culmination of the other canon of psychological skills. He noted that relaxation involves concentrating on resting some muscle groups while activating others. Self-​talk includes cue words that can help athletes to best focus their efforts during training and or competition. Using imagery to mentally rehearse a golf swing before physically executing requires concentration. Short-​, medium-​, and long-​term process goals help athletes stay concentrated on and engaged in vital sport-​related tasks. As Andersen (2009) argued, concentration works interdependently with the other psychological skills making up the canon. A Case Study The following case study is an account of my work with an elite amateur soccer team. My experience with this case demonstrates the realistic victories, challenges, and limitations of working with athletic teams. Introduction to the Team The team was a member of the Women’s Premier Soccer League (WPSL), which is an elite amateur female soccer league in the United States and Canada. I learned about them by watching a local public access show that highlighted local high schools, community colleges, and amateur sport. The team was featured in a television segment due to their success in their previous and initial season, which resulted in six of their players being recruited to play for professional leagues overseas. After viewing the segment, I emailed the head coach, who was interested in sport psychology services for the team. Assessment After exchanging emails and briefly speaking on the phone, I met with the head coach at a local coffee shop. I asked him about his experience working with the team and what he considered to be their strengths and weaknesses/​areas of growth. He informed me that the team was a “great group” of skilled athletes who, overall, were a pleasure to coach. He noted that their one area of needed growth was their ability to work together as a team. He informed me that WPSL games took place

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in the summer. Therefore, the team consisted of college athletes returning home for the summer, players from various universities and community colleges, and players who recently graduated from local high schools. The players had little time to build camaraderie before being thrust into competition together. A few days after meeting with the head coach, I attended one of the team’s home games and sat in the stadium without introducing myself to anyone. I observed the lack of teamwork mentioned by the head coach. I noticed players visibly frustrated when they weren’t passed the ball. I noticed players arguing with each other on the field and the sidelines. I could hear players yelling in frustration at each other from across the field. I was most surprised to notice fans, who were presumably relatives of players, loudly voice their frustrations and heckle the team from the sidelines. Due to limitations in time and resources, questionnaires were not used further to assess the attitudes or mental skills of the players. Team Demographics The team was part of a soccer club that had several other teams competing in different age categories of competition. About 30 to 40 players attended each meeting. The meetings were often attended by an unknown number of players from the youth categories who were training with the team to enhance their athletic development and assist the team. Data was collected from 16 team members who attended the final team session. Their ages ranged from 18 to 28. They had played competitive soccer for 6 to 24 years. Eleven of the players had previously competed in the National Collegiate Athletic Association (NCAA) Division I or Division II level of competition. The remaining five had previous experience competing in the National Intercollegiate Association (NAIA) or the National Junior College Athletic Association (NJCAA). Eight out of the 16 players reported that this was their first experience working with a sport psychology practitioner. Details about the Program I met with the team once a week for a total of four team sessions. Each team session was 20 to 45 minutes. Each team session was scheduled immediately prior to their team practice and took place at their training facility. The sessions consisted of a combination of group activities (i.e., initiative games and improvisational comedy exercises) and PST, often emphasizing distress tolerance. The format of each session was very flexible. I briefly discussed helpful psychological skills before the start of the group activity. Then, I paused the group activity throughout the activity to continually debrief and discuss relevant psychological skills. The PST integrated into the group activities was adapted from HeadsUp Baseball (Ravizza & Hanson, 1995) and HeadsUp Baseball2.0 (Ravizza & Hanson, 2016), which are widely utilized PST books in the softball and baseball communities. One of the key concepts utilized was the metaphor of the internal traffic signal. The players were taught to view their athletic performance as similar to driving a car through an intersection with a traffic light. When the light is green, drivers continue without making any adjustments. When a light is yellow, a driver must assess the situation and decide whether to continue without making an adjustment, safely accelerate, or slow to a stop. When the light is red, the driver must stop to avoid a traffic accident. Similarly, when a player is performing optimally, they are like a driver with a green light and should continue performing without making adjustments. When a player is performing, and they notice self-​doubt, anxiety, unhelpful thoughts, or anything that could impede their performance, they should view the situation as a yellow light. Players were taught to notice yellow lights and utilize psychological skills in hopes of either returning to a green light or avoiding a red light in their athletic performance.

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Players were prompted to remember their best performances and their worst performances. Players discussed their thoughts, feelings, and behaviors during their best performances and were taught to associate those experiences with a metaphorical green light. Players discussed what situations resulted in unhelpful thoughts, feelings, and behaviors, and they were taught to associate those internal and external experiences with a metaphorical yellow light. Discussions of metaphorical red lights were limited, as the emphasis was on increasing awareness of yellow lights and utilizing psychological skills. Players were advised to limit efforts to distinguish yellow lights from red lights and instead focus their efforts on utilizing their preferred psychological skills. The following vignette is representative of the team discussion about the traffic signal metaphor: Practitioner: You can think of athletic performance like driving a car. When you’re driving, and the light is green, you keep going. That’s like when you’re performing, and you’re in the zone or a flow state. Everything is easy and effortless. You don’t need to think about anything. Just keep competing. Now, when you’re driving a car, and the light turns yellow, what do you do? Team: (Unintelligible shouting) Player 1: SPEED UP! Team: (Laughing) Practitioner: Exactly! When the light turns yellow, often, people speed up. What happens next? What can go wrong if you speed up at a yellow light? Player 1: (Uses hand gestures to demonstrate two cars crashing into each other) BOOM! Team: (Laughing) Practitioner: Exactly! When you speed up at a yellow light, maybe it works out, or maybe you get into an accident. It would help if you took a moment to assess the situation. Then, you can take the best course of action. When you’re an athlete, and something goes wrong, and you start to struggle, that’s like being at that yellow light. Frequently, when athletes feel uncomfortable, they rush or try really hard. Sometimes rushing or trying to force something works out, but it usually just leads to sloppy technique and poor performance. So, when you’re at that yellow light, and you’re starting to doubt yourself, and the game is speeding up on you, and your mind is starting to race, pause, take a breath, and get back into a green light. The traffic signal metaphor helped players gain awareness of when to utilize psychological skills. One of the key psychological skills adapted from Ravizza and Hanson (1995, 2016) and taught to the team was the utilization of breath to aid performance. The team discussed how to use breath to regulate their arousal levels. They could focus on their inhale to raise their arousal level or focus on their exhale to lower their arousal level. They discussed opportune times to take a slow, controlled breath, such as whenever the ball would go out of bounds or during any break in the action. The team discussed using breath to redirect their attention from unhelpful thoughts to the task at hand. The team was taught to focus on “playing one play at a time,” an idea adapted from Ravizza and Hanson (1995, 2016). To illustrate this point, players were asked to imagine dribbling two soccer balls at once. The team discussed how ruminating about a previous play instead of focusing on the current play is like trying to dribble two balls at the same time. The players were also taught to develop helpful pregame routines. They were prompted to think about their best and worst performances and remember how they spent their time prior to those competitions. They were taught the phrase, “It begins before it begins,” which is adapted from (Ravizza & Hanson, 1995, 2016). This helped them to determine when they should begin mentally preparing for the competition. For some, it was when they laced their soccer cleats, while for others, it was when they arrived in the stadium parking lot. Emphasis was placed on each individual,

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reducing unhelpful behaviors, such as arguing with others via text message and increasing helpful behaviors, such as listening to music. An emphasis was also placed on each individual respecting other players’ routines, as some players perform better after socializing, and others perform better after spending time alone. Group Activities The group activity during the first team session was an initiative game called group juggle. The players were instructed to stand in a circle facing the center. During the first round of the activity, players were instructed to catch a bean bag thrown to them. Then, tell a story about their name (e.g., why their parents chose their name or what their name means to them). After sharing their story, the players would throw the bean bag to someone who had not yet received it. This round of the activity helped them learn each other’s names, which was still necessary as they were a newly formed team. It also facilitated the sharing of meaningful personal information, helping the players to bond. After each player had received the bean bag, I asked them to briefly throw each other the bean bag again in the same order. I used a timer to measure how long it took them to pass the bean bag from the first person to the last. In the next round of the activity, I challenged them to beat their previous time. I made each following round increasingly challenging by adding more bean bags. In between each round, we would briefly discuss what problems arose and how to solve them. One of the problems was throwing the bean bag to someone unprepared to receive it. The players adopted the strategy of calling out the next person’s name and waiting to make eye contact before throwing it to them. The most salient problem throughout the activity was that some players were frequently boisterous and off-​task, leading them to drop the bean bags and or distract others. Throughout the activity, I discussed the connection between disruptive behavior seen in the moment to possible disruptive behavior in practice and competition, which is related to poor performance and negative outcomes. I discussed the importance of having fun while remaining on task. The disruptive behavior was reduced throughout the activity but was not eliminated. The group activity in the second team session was an initiative game called Nutstacker. First, I instructed players to find a partner by seeking a teammate with the same shoe size. This served as a fun method of randomizing the pairings. Next, I informed the players that they would be tasked with stacking hex nuts vertically using one chopstick held with only one hand. They were not allowed to use their other hand to stabilize the stack of hex nuts, guide their other hand, or help the process in any way. Benches near the soccer field were used as flat surfaces to make the stacks. Each round of the activity incorporated a different challenge and included a time limit of 1 to 2 minutes. One of the challenges involved each player stacking one hex nut before handing the chopstick to their partner to stack the next hex nut. In this challenge, each pair raced against the other pairs to create the highest stack within the time limit. Another challenge involved each player competing against their partner by taking turns stacking hex nuts while their partner distracted them with “trash talk.” Another challenge involved dividing the team into two large groups competing in a relay race. Each group was lined up about ten feet away from their pile of hex nuts. At the start of the race, one person from each group ran to their pile while holding a chopstick and stacked one hex nut. Then they ran back to their group and handed off the chopstick to the next person in line. After each round of Nutstacker, the players discussed the mental and emotional challenges. Players discussed the difficulty of dealing with distractions and their personal strategies for refocusing on their tasks. Players discussed whether they were motivated or discouraged by working with or against their partner in various rounds. Players also began to open up about their

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frustrations related to dealing with negative comments from teammates. Players discussed how personal insults were not helpful, and they suggested to each other that they make efforts to cheer for and verbally encourage each other in practice and games. The group activity in the next team meeting was an initiative game called Pipeline. In this game, the team was given four plastic pipes and a marble. Their task was to move the marble from one pipe to another without dropping it. Each player was required to pass a marble through a pipe at least once. Once the marble hit the ground, the round was over, and they needed to restart. The marble moved very quickly, and players were boisterous and frustrated. In order to be heard, I loudly shouted guidance such as “Communicate!” and “Is that helping?” and “What can you do instead?” In between rounds, players reminded each other to focus their efforts on encouraging each other and problem-​solving rather than blaming each other. The team played improvisational comedy games in the final team session. One of the games played was Ancient Proverb, in which the team collectively created a soccer-​related proverb. Each player took a turn contributing one word until the team decided the proverb was complete. The team played multiple rounds in an effort to make the proverbs increasingly coherent. The players discussed challenges related to needing to change the word they planned on contributing as the proverb developed before their turn. They related this to needing to adapt on the field based on the decisions of their teammates. They discussed how improvisational comedy demonstrated the importance of focusing on the present moment and responding to the situation as it unfolds rather than attempting to force a preconceived strategy. They discussed how the rule “yes, and” applied to improvisational comedy, soccer, and life in general. Evaluation At the end of the last team session, players were invited to volunteer to fill out a brief questionnaire about their experience. Players were asked to rate the helpfulness of the team sessions in improving their skills in focus, communication, and teamwork. Players were asked to rate each of the skills using a 4-​point Likert scale (1=​ Not helpful, 2=​ Somewhat helpful, 3=​ Helpful, 4=​ Very helpful). Players were asked to write a brief description of something helpful they learned and how they plan to apply it in the future. They were also asked to suggest a topic for a future team session. Sixteen players volunteered to fill out the questionnaire. The players’ ratings of the skills were encouraging (Focus=​2.9, Communication=​3.2, Teamwork=​3.6). Furthermore, the written responses mirrored the quantitative ratings. For example, many players commented that they planned to continue focusing on the present moment and or communicating in practice and games. In contrast, some of the suggestions for future topics were alarming. I was surprised by the finding that five players suggested a future team session on how to handle negativity and conflict from a coach. Previously, my interactions with the head coach led me to believe that the coaching staff was generally supportive. A few days after our final team session, I attended their final game of the season and stood near the sideline with support staff. I was alarmed to see an assistant coach was frequently hostile toward players, other coaches, and the referees. Near the end of the game, this assistant coach was ejected for arguing with a referee. After the game, several players approached me to discuss the distress they experienced playing under this assistant coach and asked me to talk to the head coach on their behalf. The following week, I met with the head coach to debrief. I discussed the positive findings from the evaluation and, most importantly, the issue of the hostile assistant coach. The head coach was very receptive, as he was previously aware of the issue. The coach expressed discomfort with firing the assistant coach due to their friendship. However, he decided he could no longer tolerate the assistant coach’s hostile behavior. I helped the head coach manage

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any remaining ambivalence and collaborated with him to decide how to inform the assistant coach he was to be let go from the team. Conclusion In my work with athletic teams, time and resources are often sparse. Although it is a challenge, spending adequate time with coaches, players, and support staff is an invaluable part of developing strong relationships and assessing issues related to performance and life functioning. One possible strategy is to ask at least one player about their goal of the day related to practice as players are waiting to begin the team session. It is also important to demonstrate the same psychological skills being taught to athletes by maintaining present-​moment focus while interacting with them and practicing communication skills by being willing to have difficult conversations (e.g., about the hostile assistant coach). The role of the practitioner is to provide and demonstrate skills that help the athlete on and off the field. References Andersen, M. B. (2009). The “canon” of psychological skills training for enhancing performance. In K. F. Hays (Ed.), Performance psychology in action: A casebook for working with athletes, performing artists, business leaders, and professionals in high-​risk occupations. (pp. 11–​34). Washington, D.C.: American Psychological Association. https://​doi.org/​10.1037/​11876-​001 Arthur, R. A., Callow, N., Roberts, R., & Glendinning, F. (2019). Coaches coaching psychological skills-​why not? A framework and questionnaire development. Journal of Sport & Exercise Psychology, 41(1), 10–​23. https://​doi.org/​10.1123/​jsep.2017-​0198 Boudreault, V., Trottier, C., & Provencher, M. D. (2019). A case study of junior elite tennis players’ and their parent’s self-​talk. The Qualitative Report, 24(7), 1658–​1680. https://​ doi.org/​10.46743/​2160-​3715/​ 2019.4016 Carron, A. V., Brawley, L. R., & Widmeyer, W. N. (1998). The measurement of cohesiveness in sport groups. In J. L. Duda (Ed.), Advances in sport and exercise psychology measurement (pp. 213–​226). Morgantown, WV: Fitness Information Technology. Cherappurath, N., Elayaraja, M., Kabeer, D. A., Anjum, A., Vogazianos, P., & Antoniades, A. (2020). PETTLEP imagery and tennis service performance: an applied investigation. Journal of Imagery Research in Sport & Physical Activity, 15(1), 1–​9.https://​doi.org/​10.1515/​jir​spa-​2019-​0013 Csikszentmihalyi, M. (1975). Beyond boredom and anxiety. San Francisco: Jossey-​Bass. Felsman, P., Gunawardena, S., & Seifert, C. M. (2020). Improv experience promotes divergent thinking, uncertainty tolerance, and affective well-​being. Thinking Skills and Creativity, 35. https://​doi.org/​10.1016/​ j.tsc.2020.100​632 Gardner, F. L. (2019). Psychological assessment in sport psychology. In M. H. Anshel, T. A. Petrie, & J. A. Steinfeldt (Eds.), APA handbook of sport and exercise psychology, volume 1: Sport psychology., Vol. 1. (pp. 59–​76). Washington, D.C.: American Psychological Association. https://​doi.org/​10.1037/​0000​ 123-​004 Gardner, F. L., & Moore, Z. E. (2004). The multi-​level classification system for sport psychology (MCS-​SP). The Sport Psychologist, 18(1), 89–​109. Gardner, F. L., & Moore, Z. E. (2007). The psychology of enhancing human performance: The mindfulness-​ acceptance-​commitment (MAC) approach. New York: Springer. Gould, D., Nalepa, J., & Mignano, M. (2020). Coaching generation Z athletes. Journal of Applied Sport Psychology, 32(1), 104–​120. https://​doi.org/​10.1080/​10413​200.2019.1581​856 Hanin, Y. L. (1980). A study of anxiety in sports. In W. F. Straub (Ed.), Sport Psychology: An analysis of athlete behaviour (pp. 236–​249). Ithaca, NY: Movement.

268  Jason von Stietz Holmes, P. S., & Collins, D. J. (2001). The PETTLEP approach to motor imagery: A functionalequivalence model for sport psychologists. Journal of Applied Sport Psychology, 13(1), 60–​83. Ingalls, J. S. (2018). Improvisational theater games: Performatory team-​ building activities. JOPERD: The Journal of Physical Education, Recreation & Dance, 89(1), 40–​45. https://​doi.org/​10.1080/​ 07303​084.2017.1390​507 Kim, J., Panza, M., & Evans, M. B. (2021). Group dynamics in sport. In Z. Zenko & L. Jones (Eds.), Essentials of exercise and sport psychology: An open access textbook. (pp. 613–​642). Society for Transparency, Openness, and Replication in Kinesiology. https://​ doi.org/​10.51224/​B1026 Lacerenza, C. N., Marlow, S. L., Tannenbaum, S. I., & Salas, E. (2018). Team development interventions: Evidence-​ based approaches for improving teamwork. AmericanPsychologist, 73(4), 517–​531. https://​doi.org/​10.1037/​amp​0000​295 Lee, S.-​M., Lombera, J. M., & Larsen, L. K. (2019). Helping athletes cope with minority stress in sport. Journal of Sport Psychology in Action, 10(3), 174–​190. https://​doi.org/​10.1080/​21520​704.2019.1642​271 Lee, S., Quartiroli, A., Baumann, D., S. Harris, B., C. Watson, J., J. Schinke, R. (2020). Cultural competence in applied sport psychology: A survey of students and professionals. International Journal of Sport Psychology, 51(4), 320–​341. doi:10.7352/​IJSP.2020.51.320 Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–​697. https://​doi.org/​ 10.1037/​0033-​2909.129.5.674 Moore, Z. E., & Bonagura, K. (2019). Evidence-​based sport psychology counseling. In M. H. Anshel, T. A. Petrie, & J. A. Steinfeldt (Eds.), APA handbook of sport and exercise psychology, volume 1: Sport psychology., Vol. 1. (pp. 675–​696). Washington, D.C.: American Psychological Association. https://​doi. org/​10.1037/​0000​123-​034 Morone, G., Ghanbari Ghooshchy, S., Pulcini, C., Spangu, E., Zoccolotti, P., Martelli, M., … & Iosa, M. (2022). Motor imagery and sport performance: A systematic review on the PETTLEP model. Applied Sciences, 12(19), 9753. Piasecki, P. A., Loughead, T. M., Paradis, K. F., & Munroe-​Chandler, K. J. (2021). Using a personal-​disclosure mutual-​sharing approach to deliver a team-​based mindfulness meditation program to enhance cohesion. Sport Psychologist, 35(1), 22–​29. https://​ doi.org/​10.1123/​tsp.2019-​0116 Quartiroli, A., Vosloo, J., Fisher, L., & Schinke, R. (2020). Culturally competent sport psychology: A survey of sport psychology professionals’ perception of cultural competence. The Sport Psychologist, 34(3), 242–​ 253. https://​doi.org/​10.1123/​tsp.2019-​0075 Ravizza, K., & Hanson, T. (1995). Heads-​up baseball: Playing the game one pitch at a time. New York, NY: McGraw-​Hill Education. Ravizza, K., & Hanson, T. (2016). Heads-​up baseball2.0: 5 skills for competing one pitch at a time. Tampa, FL: Hanson House. Reid-​Wisdom, Z., & Perera-​Delcourt, R. (2022). Perceived effects of improv on psychological wellbeing: A qualitative study. Journal of Creativity in Mental Health, 17(2), 246–​263. https://​doi.org/​10.1080/​15401​ 383.2020.1856​016 Röthlin, P., & Birrer, D. (2020). Mental training in group settings: Intervention protocols of a mindfulness and acceptance-​based and a psychological skills training program. Journal of Sport Psychology in Action, 11(2), 103–​114. https://​doi.org/​10.1080/​21520​704.2018.1557​771 Strandbu, Å., Bakken, A., & Stefansen, K. (2020). The continued importance of family sport culture for sport participation during the teenage years. Sport, Education & Society, 25(8), 931–​945. https://​doi.org/​ 10.1080/​13573​322.2019.1676​221 Taylor, J., & Schneider, B. A. (1992). The Sport-​Clinical Intake Protocol: A comprehensive interviewing instrument for applied sport psychology. Professional Psychology: Research and Practice, 23(4), 318–​325. https://​doi.org/​10.1037/​0735-​7028.23.4.318 Turner, M. J., Aspin, G., Didymus, F. F., Mack, R., Olusoga, P., Wood, A. G., & Bennett, R. (2020). One case, four approaches: The application of psychotherapeutic approaches in sport psychology. The Sport Psychologist, 34(1), 71–​83. https://​doi.org/​10.1123/​tsp.2019-​0079

Building Team Cohesion and Optimal Performance 269 Williamson, O., Swann, C., Bennett, K. J., Bird, M. D., Goddard, S. G., Schweickle, M. J., & Jackman, P. C. (2022). The performance and psychological effects of goal setting in sport: A systematic review and meta-​analysis. International Review of Sport and Exercise Psychology, 1–​ 29. DOI: 10.1080/​ 1750984X.2022.2116723 Wolanin, A. T. (2005). Mindfulness-​acceptance commitment (MAC) based performance enhancement for Division I collegiate athletes: A preliminary investigation. Dissertation Abstracts International: Section B, 65, 3735–​3794. Zhou, M.-​Y. (2022). Sport psychology in coaching: Improving the personality traits and thinking skills of basketball players. Thinking Skills & Creativity, 46, N.PAG. https://​doi.org/​10.1016/​j.tsc.2022.101​115

Chapter 16

Providing Positive Psychology Interventions in Group Counseling Shannon M. Suldo, Sarah A. Fefer, and Kai Zhuang Shum

Overview of Subjective Well-​B eing Optimal mental health entails both the absence of psychopathology and the presence of positive factors such as subjective well-​being (Suldo & Doll, 2021). Youth with the best academic, social, and physical health outcomes have both low psychopathology and elevated subjective well-​being (DiLeo et al., 2022; Smith et al., 2020; Suldo & Shaffer, 2008). Historically, psychological research and practice have focused on identifying and treating emotional and behavioral problems –​the psychopathology factor in a dual-​factor model of mental health. Research from positive psychology –​the science of happiness –​sheds light on how to promote well-​being, which is the less studied of the two continua (wellness, illness) in a dual-​factor model. In this chapter, we describe assessment strategies to identify youth with low subjective well-​being and promising interventions that can be provided in a small group modality to identified youth. Assessment: Group Identification and Progress Monitoring In positive psychology, wellness is defined by “feeling good” about life (i.e., hedonic tradition) and/​or striving for excellence and functioning well in life (i.e., eudaimonic tradition; Keyes, 2009). Assessment of wellness differs based upon the model used to conceptualize it. The subjective emotional well-​being framework includes three related but separate constructs: life satisfaction, positive affect, and negative affect (Diener et al., 2009). Global life satisfaction refers to a cognitive appraisal of one’s quality of life. Positive and negative affect involves the frequency of one’s emotional experiences over time. An individual with high subjective well-​being has high life satisfaction and experiences more frequent positive affect (e.g., joy, elation) than negative affect (e.g., sadness, anger; Diener et al., 2009). Since this model of authentic happiness was introduced with subjective well-​being as the primary outcome, more complex models of flourishing emotional states have been advanced. These models differ in their inclusion of positive internal and environmental/​relational assets as aspects of well-​being, pathways to achieving well-​being, or constructs that reflect the presence of well-​being, as well as varying terminology. Case in point, Seligman’s (2011) updated theory of well-​being purports that flourishing is predicted by Positive emotions, Engagement, Relationships, Meaning, and Accomplishment (PERMA). The first element –​ positive emotions –​includes pleasant feelings such as pride, cheer, joy, enthusiasm, and is akin to the positive affective dimension of subjective well-​being. Kern and colleagues (2016) advanced the EPOCH model to measure characteristics in adolescents that may influence the PERMA domains later in life, specifically: Engagement, Perseverance, Optimism, Connectedness, and Happiness. Furlong and colleagues’ (2014) concept of covitality advances 12 positive-​psychological “building blocks” that span relational assets (e.g., peer support, school support) and internal social–​emotional

DOI: 10.4324/9781351213073-18

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competencies (e.g., gratitude, optimism) that comprise students’ level of underlying covitality which, in turn, is highly predictive of subjective well-​being. If using one of these frameworks to define wellness, assessment may involve (a) the 8-​item Flourishing Scale (Diener et al., 2010) (b) the 20-​item EPOCH Measure of Adolescent Well-​Being (Kern et al., 2016) or (c) the Social Emotional Health Survey-​Primary (SEHS-​P; Furlong et al., 2013) or secondary version (SEHS-​S; Furlong et al., 2014). In this chapter, we focus on subjective well-​being as the primary outcome addressed most often in group positive psychology interventions (PPIs). Given the subjective nature of the construct, assessment often involves self-​reports of life satisfaction appraisals and frequency of affective experiences. Measures of life satisfaction ask respondents to rate satisfaction with their life as a whole (i.e., global life satisfaction) or satisfaction with domain-​specific areas of life that are considered central to overall appraisals of happiness (e.g., school, family, friends). The 7-​item Students’ Life Satisfaction Scale (SLSS; Huebner, 1991) and the 40-​item Multidimensional Students’ Life Satisfaction Scale (MSLSS; Huebner, 1994) are among the most commonly used outcome measures of life satisfaction for youth (grades 3–​12). The 6-​item Brief Multidimensional Students’ Life Satisfaction Scale (BMSLSS; Seligson et al., 2003) contains one item for each scale assessed in the SLSS (global life satisfaction) and the MSLSS (five domains of life) and is often used for screening purposes. Measures of affect can inquire about one’s mood in the moment (e.g., “How do you feel right now?”) or how often –​from not at all to frequently –​one has felt various positive emotions (e.g., cheerful, proud) and negative emotions (e.g., scared, mad) during an identified period of time such as the past day or few weeks. An example of the latter type that is appropriate for use with youth is the 27-​item Positive and Negative Affect Schedule for Children (PANAS-​C; Laurent et al., 1999). The PANAS-​C assesses the frequency of positive and negative emotional experiences over the past few weeks. Ebesutani and colleagues (2012) used item response theory to advance a shortened version of the PANAS-​C that retains five items assessing positive affect and five items assessing negative affect. The resulting PANAS-​C-​ 10 has both youth and parent report options. Of note, all measures mentioned above of subjective well-​being are available for free in the public domain. In our work in elementary and middle schools, we commonly use the BMSLSS to identify students for group intervention, and the SLSS alongside the PANAS-​C-​10 and sometimes the MSLSS to assess change in subjective well-​being from pre-​to post-​participation in intervention. Life satisfaction scores are often emphasized in screening procedures because it is the most stable dimension of subjective well-​being. For group identification in our current work in middle schools, all students with permission to take part in universal screening complete the six items of the BMSLSS through paper-​and-​pencil or web-​based administration. For each item (e.g., I would describe my satisfaction with my friendships as), students select the best option from the seven-​point response scale: (1) terrible, (2) unhappy, (3) mostly dissatisfied, (4) mixed, (5) mostly satisfied, (6) pleased, and (7) delighted. Scores across the six items are averaged. Of note, national norms are not currently available to aid interpretation of scores on most measures of life satisfaction, including the BMSLSS. Instead, the clinician1 determines a clinically meaningful cut score, in other words, a position/​number on the response metric that reflects a point perceived to differentiate a student with low or at-​risk well-​being from a student with satisfactory or sufficiently high well-​being. Then, students with average BMSLSS scores below the cut score are considered for intervention. To illustrate, cut scores from BMSLSS screening data reported in prior group implementations of the Well-​Being Promotion Program (WBPP) range from ≤ 4.0 (Wingate et al., 2018; a conservative identification of students dissatisfied with life) to ≤6.0 (Roth et al., 2017; a liberal identification of students with room for growth in life satisfaction). In our recent work (2020–​2024) in middle schools across two states, our use of a cut score of < 5.0 (capturing students whose average scores

272  Shannon M. Suldo, Sarah A. Fefer, and Kai Zhuang Shum

are less than the response options that indicate at least mildly positive life satisfaction) has identified approximately one-​quarter to one-​third of students as well-​suited for a selective group intervention intended to increase subjective well-​being. Using a multi-​tiered system of support (MTSS) model to organize school-​based programs and practices, this small group intervention may be best conceptualized as a Tier 2 (selective prevention) support given the focus on early intervention for students with emerging similar needs, specifically relatively low life satisfaction (Hoover et al., 2019). In contrast, Tier 1 supports (universal or primary prevention) are provided to all students to promote well-​being and competencies, whereas Tier 3 supports (indicated; treatment) are provided to individual students with identified severe mental health needs. CBT Conceptualization of Well-​B eing In the traditional treatment of mental illness, a cognitive-​behavior therapy (CBT) approach to case conceptualization involves considering the biological, behavioral, cognitive, social, environmental, and societal factors that have contributed to the onset and maintenance of psychopathology (Kuyken et al., 2009). Just as virtually all forms of mental illness are understood to have a biopsychosocial etiology, the determinants of wellness (happiness) entail genetic predispositions, circumstantial variables, and relational components, as well as individual differences in intentional ways of thinking, behaving, and striving (Sheldon & Lyubomirsky, 2021). Similar to the traditional CBT approach, positive psychology recognizes the role of genetics on overall well-​ being and that individuals inherit a predisposition for their momentary and chronic happiness to be within a certain set range of subjective well-​being scores (Nes & Roysamb, 2017). Positive psychology theories also propose that individual differences in subjective well-​being result in part from volitional activities (Sheldon & Lyubomirsky, 2021) and that virtually all people have room for growth in well-​being. Individuals can increase happiness by performing purposeful actions that alter their cognitive, social, and behavioral functioning in ways that evoke Positive emotions, increase Engagement, strengthen Relationships, cultivate a sense of Meaning and purpose, and/​ or lead to Accomplishment and achievements (PERMA; Seligman, 2011). Mental health promotion from a positive psychology lens emphasizes the best in life by upregulating positive affective states to foster emotional flourishing (Morrish et al., 2018). In contrast, many CBT treatments and school-​based social–​emotional learning (SEL) programs focus on downregulating negative emotional states to reduce psychopathology. Haworth et al.’s (2015) study of genetic and environmental determinants of subjective well-​being and depression among 4,700 teenage twins concluded that there are significant predictors of well-​being beyond the absence of mental illness; these researchers assert that “different interventions will be needed for treating mental illness and promoting mental health…interventions will need to target different biological pathways” (p. 7). Theories that inform plausible mechanisms of change pertain to functions of positive emotions and positive attentional focus (Smirnova & Parks, 2017). Positive emotions mitigate the effects of negative emotions but, perhaps more importantly, upregulate positive outcomes that promote psychological wellness (Fredrickson, 2001). Positive emotions create an upward spiral marked by increased cognitive capacity and behavioral flexibility that, over time, allows one to build personal, social, psychological, and physical resources. Extensive empirical support for this “broaden-​and-​ build” theory shows that positive emotions open up our minds, broaden the scope of our attentional field, and create new opportunities for positive experiences (Fredrickson, 2001). For example, when we receive an act of kindness from others and feel gratitude (positive emotion), we become more aware of the social supports we have in our lives (broaden attention) and are more open to forming new relationships and helping others (build enduring personal resources). With a more open mind and flexibility, we also create more opportunities to interact with others and are more

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likely to be reinforced with positive feedback and social connection. This, in turn, helps us feel more fulfillment in life and generates more positive emotions such as pride and love, illustrating an upward spiral fueled by positivity. Positive emotions foster personal knowledge and social connections, whereas negative emotions lead to impulsive, rigid, and narrow thoughts and behavioral responses. Stiglbauer et al. (2013) found feeling connected and confident at school promoted greater positive affect, which fostered more positive school experiences for high school youth. These reciprocal relations showed how positive affect can lead to “an upward spiral of positive school experiences and happiness over time” (Stiglbauer et al., 2013, p. 239). Other longitudinal studies with adolescents find positive reciprocal relations between life satisfaction with academic engagement (Datu & King, 2018) and achievement (e.g., course grades; Ng et al., 2015) and positive effects of PPI targets (e.g., hope) on later positive affect and grades (Ciarrochi et al., 2007). The broaden-​and-​build theory applies to all people; those with co-​morbid psychopathology may further benefit from the shift of attentional focus to more positive events (via cognitive construal that comes from gratitude or optimism interventions) rather than negative events (Xu et al., 2015). Less focus on negative events limits harmful cognitive patterns (e.g., rumination, catastrophizing) common to depression and anxiety. PPIs aim to systematically amplify the positive resources of clients without dismissing the negative symptoms (Rashid & Howes, 2016). Through building on clients’ identified cognitive, social, and behavioral strengths, PPIs help clients grow, find fulfillment, and enhance their well-​being, which may help reduce psychopathology symptoms. Instead of focusing on cognitive distortions, positive psychology helps clients initiate and maintain ways of thinking that can enhance well-​ being, such as focusing on gratitude, hope, and optimism. These positive thoughts often bring forth positive feelings and actions, reflecting the reciprocal interactions between thoughts, feelings, and behaviors in the CBT model. One behavioral factor being considered in a positive psychology conceptualization includes helping clients identify and utilize signature character strengths to improve life functioning. Utilizing character strengths and other PPIs also helps clients improve social relationships. For example, being kind to others or expressing gratitude to important individuals in clients’ lives contributes to stronger relationships and connections with others. This example also fits with the CBT reciprocal interaction model. Overall, considering positive psychology theories within the CBT approach puts a positive twist on the CBT model. The interactions between cognition, emotions, and behaviors continue to be reciprocal but in a positive direction toward enhancing well-​being. Group Interventions Using Positive Psychology Interventions The advancement of the science of positive psychology in the late 1990s ushered in a plethora of research on the effectiveness of interventions posited to lead to enduring gains in well-​being. These interventions have alternately been referred to in the literature as PPIs, positive activities, well-​ being interventions, or simply an activity grounded in positive psychology theory and research on the determinants of happiness. Our definition of a PPI is consistent with Schueller and colleagues’ (2014) focus on intervention goals and pathways. With respect to goals, PPIs intentionally aim for increases in positive emotional and psychological outcomes, indicators aligned with eudemonic and/​or hedonic conceptualizations of well-​being. With respect to pathways, PPIs “operate via mechanisms that are known to promote positive emotions, behaviors, and/​or thoughts rather than fixing deficits or addressing maladaptive patterns” (Schueller et al., 2014, p. 92). These pathways to wellness (vs. illness) reflect the theory and research on processes that support well-​being, as evident in positive activities that build relationships and evoke positive emotions through targeting gratitude, kindness, hope, optimism, savoring, mindfulness, forgiveness, grit, courage, and

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use of signature character strengths, among others. These PPIs range from singular activities (e.g., maintaining a gratitude journal and performing acts of kindness) to programs that include multiple practices grounded in positive psychology. Some such programs (alternatively referred to as multitarget or multicomponent) created for clinical use combine PPIs with traditional treatments for mental illness –​such as cognitive-​behavioral interventions for depression –​with the goal of both upregulating positive emotions and downregulating negative emotions for a client with emotional distress. In the past 20 years, studies of PPIs have evolved from identifying which activities are effective in increasing well-​being to understanding how growth can occur and be sustained. Case in point, Donaldson and colleagues (2021) encourage practitioners to apply the growing empirical understanding of PPIs to arrange learning opportunities that maximize the potential benefit of a given positive activity. This intentional design of enacting a PPI involves providing opportunities to: learn about the topic (e.g., gratitude), practice a relevant skill or exercise (e.g., identify a list of things for which one is grateful), reflect and reinforce the experience (e.g., consider how completing a gratitude journal entry affects one’s mood and behavior), relate to keep accountable to complete the exercise and amplify the effects (e.g., discuss items from the gratitude journal with a friend, family member, or counselor), and plan for continued use (e.g., set specific goals to incorporate journaling in one’s daily life; Donaldson et al., 2021). This approach to designing an effective PPI is aligned with the behavioral skills training aspect of CBT or any skills-​based approach to group counseling. Modern understanding of conditions under which PPIs are most effective also underscores the importance of personal motivation, effort, culture, and person–​activity fit (see the Positive Activity Model; Lyubomirsky & Layous, 2013). PPIs have been applied in various settings with a wide range of populations. A meta-​analysis conducted by Carr and colleagues in 2021 examined 336 published papers (reporting 347 studies) on the effectiveness of PPIs across 41 countries in North America (48%), Europe (24%), Asia (18%), Australasia (9%), and Africa (1%). Approximately 20% of these studies had samples of primarily children and adolescents. The PPIs had an average duration of ten sessions over six weeks and were offered in multiple formats (group therapy, individual therapy, self-​administered). An analysis of change from pre-​ to post-​intervention indicated statistically significant small to medium effects on all outcomes, including positive indicators of well-​being (g =​0.39) and quality of life (g =​0.46) as well as indicators of internalizing forms of psychopathology such as anxiety (g =​ −0.62) and depression (g =​ −0.39). Moderator analyses revealed strong effects of PPIs on well-​being and depression when the intervention was delivered through group therapy (g =​0.59 and −0.53) as compared to self-​administered PPIs. In the treatment of adults, positive psychotherapy (PPT; Rashid & Seligman, 2018) is perhaps the most well-​researched application of PPIs to clinical services. It was originally developed to help individuals demonstrating moderate to severe symptoms of depression, with sessions completed through individual or group therapy. Grounded in Seligman’s (2002, 2011) PERMA model and character strengths (Peterson & Seligman, 2004), PPT acknowledges the client’s strengths and inherent capacity for growth, as well as values a therapeutic relationship built upon empathy for the client’s traumatic events and exploration of the client’s positive characteristics and experiences (Rashid & Seligman, 2018). Numerous studies have associated PPT with increases in positive outcomes, such as life satisfaction and happiness, as well as reductions in negative outcomes, particularly depressive symptoms (Hoppen & Morina, 2021). Case in point, in a randomized controlled trial (RCT), Furchtlehner et al. (2020) compared group-​based PPT with group-​based CBT in a sample of 92 adults (M age =​41 years) with depressive disorders. At post-​treatment and six-​month follow-​up, PPT was shown to reduce negative symptoms of internalizing distress, with effect sizes for PPT larger than those for CBT on all measures of depressive symptoms.

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Sample Group Positive Psychology Interventions A growing number of evidence-​based practices and programs have been advanced to develop students’ skills in increasing positive emotions (for a review, see Suldo et al., 2021). In this section, we highlight three programs that include multiple positive activities, may be considered multitarget (address multiple targets such as gratitude, kindness, and optimism), and have been implemented and evaluated in a group modality with youth. Well-​B eing Promotion Program The Well-​ Being Promotion Program (WBPP; Suldo, 2016) is a multicomponent PPI that addresses multiple targets underlying subjective well-​being (positive past, present, and future emotional experiences) through activities delivered across social contexts (i.e., includes a caregiver information component in addition to the student-​focused group work) to build relationships as well as encourage students’ continued use of the positive activities outside of the group sessions. The program was designed for middle school students but has been adapted for use with children in elementary and high schools (Suldo, 2016). Two small-​scale RCTs have yielded promising effects of the WBPP in increasing adolescents’ subjective well-​being (increases in life satisfaction and positive affect) and trends toward decreasing internalizing and externalizing symptoms (Roth et al., 2017; Suldo et al., 2014). We are in the midst of a five-​year multi-​site RCT to evaluate the WBPP with respect to a larger set of mental health and academic outcomes (for details about the study design, see Registry ID #4600.1 in https://​sree​reg.icpsr.umich.edu/​ sree​reg/​). This small group manualized program contains ten weekly core sessions and two to four monthly follow-​up sessions, as outlined in Table 16.1. Each session lasts about 45 minutes and seeks to help youth develop skills to evoke positive emotions about the past, present, and future. Table 16.1 Focus of Group Sessions in the Well-​B eing Promotion Program (WBPP) Session

Target

Strategies/​Positive Activities (PA)

Parents

Psychoeducation

Introduction to Positive Psychology and the WBPP

Positive Emotions about the Past 1 Positive Introduction Me at My Best (PA 1) 2 Gratitude Gratitude Journals (PA 2) 3 Gratitude Gratitude Visit (PA 3) Positive Emotions about the Present 4 Kindness Acts of Kindness (PA 4) 5 Character Strengths Introduction to Strengths (VIA classification system) 6 Character Strengths Survey Assessment of Signature Character Strengths (PA 5) 7 Strengths; Savoring Use Signature Strengths in New Ways (PA 6); Savoring Methods (PA 7) Positive Emotions about the Future 8 Optimistic Thinking Optimistic Explanatory Style (PA 8) 9 Hope Best Possible Self in the Future (PA 9) 10 All Termination; Review of Strategies and Plan for Future Use (practice) Boosters All Review; Spotlight on Gratitude, Strengths, or Optimism (practice)

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The program also emphasizes the building of positive relationships and the cultivation of motivation to generalize the positive activities students learned in group. The targets of WBPP include gratitude, acts of kindness, character strengths, optimistic thinking, and hope. The caregiver component of the WBPP includes one manualized caregiver information session and weekly handouts. At the caregiver information meeting, caregivers are introduced to positive psychology and the intervention goals, learn the benefits of high subjective well-​being, and receive a schedule of student activities. The weekly caregiver handouts provide (a) an overview of the lesson covered in the youth session, (b) a description of the homework assigned, and (c) suggestions for caregivers to apply intervention strategies in their own lives and/​or as a family unit. Regular communication with caregivers is intended to further the knowledge and skills youth learn each week in their small group sessions. Each session follows a similar agenda, with students sharing their experiences with their at-​ home practice assigned during the previous session, followed by an introduction to a new positive activity, an opportunity to practice in session and share with peers, and a new assignment or “take home challenge.” A sample script within Session 2 of the WBPP, which introduces gratitude as a positive activity focused on the past, includes: You feel gratitude (thanks, appreciation, grateful) when you recognize that you received an intentional act of kindness from another person. More specifically, you feel gratitude after gaining a benefit that you view as valuable, that was provided intentionally and altruistically (not for ulterior motives) and occurred at some cost to the person who provided the benefit. (Suldo, 2016, p. 176) The manual then prompts counselors to lead youth through self-​rating of current gratitude level, followed by a discussion on the link between gratitude and well-​being. Next, the group leader introduces a first exercise targeting gratitude –​ maintaining a gratitude journal in which one lists five things for which they are grateful. After giving students time to decorate and personalize a journal dedicated to this purpose, the group leader gives students clear instructions (with examples) on how to create a gratitude entry and asks students to write the first entry in their new journal independently. The sample script says: I want you to take 5 minutes, think about your day, and write down five things in your life that you are grateful for, including both small and large things, events, people, talents, or anything else you think of. Some examples may include generosity of my friends, my teacher giving me extra help, family dinner, your favorite band/​singer, and so on [Provide examples relevant to your students that you are aware of]. (Suldo, 2016, p. 177) Then, the group leader prompts students to share one or two items with the group. The session wraps up with students being assigned the take-​home challenge of completing a gratitude journal entry each day for the following week. Students are encouraged to discuss the gratitude journal with people at home and deliver the caregiver handout. In the book Promoting Student Happiness: Positive Psychology Interventions in Schools (Suldo, 2016), readers can find a detailed appendix with reproducible forms, including session protocols that outline planned activities for use by group leaders (with sample scripts for use to convey didactic information or provide directions for activity completion, as illustrated above), student handouts, fidelity checklists, and one-​page caregiver handouts for each session. The group leaders can be school or community mental health providers, including counselors, psychologists, social workers, and other youth support personnel. Cultural adaptations of the WBPP are described

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in a subsequent section of this chapter on cultural, ethnic, and racial considerations in positive psychology. MindUp MindUp (The Hawn Foundation, 2011) is a SEL program rooted in positive psychology, neuroscience, and mindful awareness. A team of experts with support from The Goldie Hawn Foundation built the program in 2011 to increase social–​emotional competencies among youth ages 3 to 14. There are separate manuals by developmental levels (pre-​K-​grade 2, grades 3–​5, grades 6–​8). The intervention covers how the brain works, how to build awareness, mindful listening/​eating/​movement, perspective taking, optimism, savoring, gratitude, acts of kindness, and how to take mindful actions in the world. Teachers are the intended interventionists of this program when implemented classwide, but mental health providers can also deliver it to small groups (Hiltz, 2016; Kempf, 2020). Children and adolescents who received MindUp showed improved stress management, academic performance, peer relationships, self-​regulation, as well as optimism, and happiness (Crooks et al., 2020; Hai et al., 2021). More details about the MindUp program, including how to access the curriculum and training, are available online (see https://​min​dup.org/​). The program is also available in Spanish. Strengths-​B ased Resilience The Strengths-​Based Resilience (SBR; Rashid et al., 2015) program is a small group intervention based on character strengths, resiliency, mindfulness, and PPT (Rashid & Seligman, 2018). The SBR program aims to help adolescents and young adults identify, build, and apply signature character strengths in real life to overcome life adversity. There are a total of 14 modules that guide youth to use strengths-​based strategies to cope with daily stress/​challenges, as well as skills to evoke positive experiences and strengthen relationships. The SBR includes three phases: (1) creating a story of resilience and learning about flexible thinking (growth mindset and recognizing/​ dealing with cognitive distortions), (2) being introduced to character strengths and putting character strengths into action, and (3) building positive relationships (identifying strengths in others) and seeking purpose and meaning. The program also includes lessons on problem-​solving, gratitude, empathy, perspective-​taking, altruism, and savoring. The SBR has been delivered in school and clinical settings and with diverse populations (Gillham et al., 2019). Compared to high school students who did not receive the SBR, students in the intervention group showed significant reductions in stress and problem behaviors, as well as significant improvements in well-​being and resilience. The SBR can be delivered by a variety of professionals, including secondary school teachers, administrators, and school/​community mental health clinicians. The manual includes a cultural and learning fit section that offers suggestions for interventionists to adapt the lessons for culturally and linguistically diverse (CLD) youth (Rashid et al., 2015; 2024). The interventionist training also emphasizes cultural considerations. Next, we discuss more fully a range of cultural, ethnic, and racial considerations in applications of positive psychology theory and research to practice. Cultural, Ethnic, and Racial Considerations in Positive Psychology The 2020 U.S. Census Bureau report showed that the United States population is more diverse than ever. Although the White population remains the largest group, this population has dropped from 64% to 58% since 2010. The second largest group is Hispanic/​Latinx (19%), followed by African American (12%). The rest of the population is comprised of a diverse group, including American

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Indian and Alaska Native, Asian, Pacific Islander, and multiracial individuals. The Department of Homeland Security (DHS, 2022) reported that approximately 221,000 individuals obtained lawful permanent resident status, with the top five countries of origin being Mexico, India, China, El Salvador, and the Dominican Republic in the first half of 2022. There was also a 408 percent increase in refugees’ admittance from 2021. The refugees mainly came from the Democratic Republic of Congo, Syria, Burma, Ukraine, and Sudan. In addition to race and country of origin, the U.S. population is also becoming increasingly diverse in ethnicity, language, religion, sexual orientation, and socioeconomic background. In the aforementioned meta-​analysis of PPIs (Carr et al. 2021), 82% of the papers reviewed reported on studies conducted in Western, educated, industrialized, rich, and democratic (i.e., WEIRD) countries. Most of the studies (70%) included participants without clinically significant physical or mental health problems. Individuals with low socioeconomic status comprised about half of the population studied, and ethnic minority participants represented about 30% of the total sample reviewed. There is a need for further research on the effectiveness of PPIs when used with CLD youth. The current reality is that we must consider cultural adaptations of interventions if we want to serve all youth effectively. Thoughtful adaptions related to culture and language serve to increase the chances that CLD children, who are exposed to more major life stressors compared to their peers in mainstream culture (Desai et al., 2021), can relate to and benefit from small group PPIs. As the field of mental health care tries to figure out how to serve CLD children and adolescents best, some studies found that culturally adapted programs are more accepted by this group, which in turn increased participation and generalization of skills (Rathod et al., 2018). When youth perceive the program as relevant to their lived experiences, they become more invested in the content and are better able to apply the skills outside of the group to improve life functioning. The factors discussed in the subsequent paragraphs have been recommended as key considerations when adapting social–​emotional interventions for multicultural youth (Castro-​Olivo et al., 2021; DeBoer et al., 2022; Gillham et al., 2019). This list is not exhaustive and is only meant to serve as a beginning guide for best practices in cultural considerations in small group PPI. We also share our experiences with adapting the WBPP to be more culturally inclusive. Language The language of the program should match the language used by the youth in a small group. If that is not possible, adapt the materials to align with best practices for English Language Learners (ELL), such as providing more visuals, repeating keywords, and checking for comprehension frequently. The National Education Association and the American Federation of Teachers sponsor Colorín Colorado (www.colo​rinc​olor​ado.org/​), a website that provides valuable resources for educators and mental health practitioners to adapt lessons for ELLs. Practitioners should also incorporate relatable (e.g., local expressions) and easy-​to-​understand language that uses developmentally appropriate terms. For example, in the WBPP, visual aids, scaffolding, as well as short, succinct explanations are used to help youth understand complicated concepts such as character strengths and optimistic thinking. Ethnicity/​C ultural Background Ensure that the CLD youth in a small group can relate to the program’s values. This can be done by spending sufficient time getting to know each child’s background in and out of the group. WBPP group leaders are encouraged to start each session with an icebreaker activity to learn about each member’s values, beliefs, and norms. They also establish group norms with student input at the first session to ensure that all students feel safe and welcomed in the group. The WBPP co-​leading

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model allows an adult to check in with one of the children during group if they notice that a child needs more time to communicate their thoughts. Completion of a value card sort activity can be helpful to guide youth to communicate in the group what is important to them in life. Practitioners can adapt the free online value card sort template shared by Miller et al. (2011) to best fit the needs of CLD youth they are working within small groups. Risk and Protective Factors Seek to understand real-​life challenges faced by CLD youth, such as financial constraints that prevent them from being aware of, joining, and engaging in small group PPIs. Identifying protective factors in CLD children’s lives can help practitioners mitigate some of the risk factors, such as utilizing community resources (e.g., transportation) to help children attend small groups after school. In the WBPP, children learn that although some factors that influence well-​being are outside of our control (i.e., genetic influences and life circumstances), there are positive activities that youth can practice to increase their life satisfaction when they desire to experience greater positive affect. Group leaders emphasize and validate students’ experiences that cause negative emotions or may suppress well-​being and lead students through a series of positive activities to have in their toolbox to use to evoke positive feelings when it is right for them. The WBPP group leaders are encouraged to increase the positive activities’ cultural relevance by addressing identified risk factors in groups (e.g., making sure students have free supplies, offering alternative ways to complete writing assignments, identifying social resources beyond a parent who may assist in homework completion, and providing caregiver handouts in the language spoken at home). Group leaders should also strive to promote trust and belongingness for students and families, as this is one of the strongest protective factors for CLD youth (Fisher et al., 2020). Holding groups consistently, checking in with children when they miss a session, and making oneself available outside of the group session time are examples of ways of showing the care that can lead to strong relationship building. Involving Local Communities Collaborate with local community members to increase the cultural relevance of a program. Family and student voices are crucial in creating a program that resonates with the local youth and reflects their lived experiences. A community advisory board that is representative of the local population can be utilized to gather feedback from the community about the intervention content and approach. Gillham et al. (2019) shared that involving the community also helped increase local interest in their program, which led to increased future engagement. When possible, train community members to lead the program delivery to increase the likelihood that youth feel safe and comfortable to participate in the group. Local leaders are also well-​positioned to understand the unique challenges of the youth in their community and provide relevant metaphors and examples. Within our ongoing RCT study of the WBPP, school mental health providers employed by the district, such as school counselors, school social workers, and school psychologists, are trained to deliver the small group intervention to the students in one of the schools they serve. Ensuring the Cultural Competency of Group Leaders Strive to incorporate cultural humility in the delivery of any small group curriculum, starting by completing relevant trainings and through ongoing self-​reflection and supervision. To deliver a culturally inclusive program, it is essential that group leaders recognize that culture matters and work to increase their own cultural awareness and appreciate the worldview of CLD youth. In our ongoing RCT of the WBPP, group leaders engage in learning about cultural humility through initial

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professional development and ongoing coaching support. They receive specific feedback on how to be more culturally inclusive when delivering small groups; examples include asking appropriate questions to understand CLD youth and their daily lives further, coming up with relevant metaphors or examples, setting norms, and maintaining expectations to create a safe space for all youth, reflecting on how their values and beliefs differ from youth in their groups, and seeking feedback from children in the group to improve the cultural relevance of the WBPP. Overall, there is much left to be learned and examined in the realm of adapting PPIs for culturally diverse youth. The strategies and considerations listed in this section serve as a starting point for practitioners to begin adapting PPIs for youth who are traditionally marginalized in our society. Overcoming Potential Obstacles to Group Treatment for Low Subjective Well-​B eing Group-​based service delivery is well suited to a positive psychology approach with children and adolescents due to the focus on teaching new skills, practicing positive activities in context, strengthening relationships, and harnessing motivation to engage with the activities. However, positive psychology groups come with obstacles, some similar and some different than more traditional approaches to mental health treatment. Logistics and Planning As with all group treatment approaches, logistics drive both the planning and implementation of positive psychology groups. Coordinating schedules across multiple youth, families, and group leaders can be challenging, as can coordinating different funding sources, educational or therapeutic goals, skill levels, and student needs. Positive psychology can serve the needs of many different types of clients across a variety of potential strengths and presenting concerns due to its focus specifically on improving happiness or increasing well-​being. Positive psychology approaches are typically used in a proactive or preventive way, which may be viewed as less medicalized or stigmatized compared to other approaches focused on specific diagnoses or mental health symptoms, and, therefore, may be more accessible or acceptable to some youth and families. However, this can also create challenges related to insurance and billing depending on the specific practice setting in which a clinician works. For these reasons and others, the size of the group is a key consideration. Accommodating a relatively large group size may be more of a possibility when using a positive psychology approach to group therapy, as there is no assumption of significant internalizing or externalizing psychopathology among a population of children or adolescents with room for growth in life satisfaction. Moreover, middle school students participating in our current RCT have expressed a preference for larger group sizes. Both group leaders and students report high acceptability of groups of approximately ten middle school students, especially when there are two leaders available to facilitate the content and manage the group. Positive psychology is also appropriate for classwide approaches to social–​emotional support (see Suldo, 2016), and some clinicians and schools we have partnered with have chosen to incorporate positive activities into classroom instruction or to frame the WBPP as a positive psychology “course” or “class.” A larger group size brings about challenges that are similar to those that arise in a classroom environment (e.g., engagement, behavior management, peer relations) and can be difficult if students demonstrate challenging behavior, while a smaller group size can come along with greater expectations for each student to share and contribute to the session. Some students may feel uncomfortable sharing in a group, and others may feel less pressure if there are others present to share “talk time” during the group meetings.

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Potential obstacles related to group composition can be overcome with careful consideration of group dynamics and peer relations when forming positive psychology groups. Ideally, clinicians will be able to get input about the strengths, needs, and preferences of each group member from caregivers, teachers, and the youth themselves. This could be accomplished through an informal intake survey or by holding a meeting with key team members when planning groups. In schools, where students in the group are more likely to know each other before sessions, it is often important to consider previous relationships or history of peer dynamics (both positive and negative) in decisions about group composition. In our work in middle schools, after the school mental health team has a list of students to support and is ready to plan when and where to serve them, we aim to gather a team of counselors, teachers, and administrators together to balance scheduling needs (i.e., minimize missed class time) with considerations of student behavioral, social, and academic needs and history. Grouping students based on developmental stage or academic abilities should also be considered. However, many clinicians are skillful in differentiating activities to meet the learning needs of each youth in the group. They can look to positive peer models in the group to demonstrate or support skills for others. Time is another primary logistical consideration and potential challenge; larger groups often require more time to run effectively since the goal is to have students practice activities and share their experiences during group time. We have had success with using 45-​minute elective and flex or study hall periods for our WBPP groups in middle schools, as well as rotating weekly sessions across class periods to ensure that students do not miss the same class each week. Maximizing Engagement Although logistics seem to be where many challenges arise in the planning stage, effectively engaging students in the content and activities throughout a multi-​session group intervention is a primary obstacle to effective implementation. Engagement is a key target for intervention success because engagement is a prerequisite for learning (Wang & Hofkens, 2020). Student engagement. In the WBPP, potential group leaders are taught specific strategies to maximize student engagement during sessions, between sessions (e.g., with homework), and in relationships with peers and leaders. During initial professional development, clinicians acquire a toolbox for maximizing engagement, beginning with leader-​focused and group management strategies that they have the most control over, through strategies focused on supporting individual student engagement that they have less direct control over (Barry et al., 2023). First, leaders are encouraged to allocate time to prepare before sessions in order to set an agenda and establish routines and structure for their group, and to ensure that students have multiple and varied opportunities to respond (e.g., choral responding, think-​pair-​share, thumbs-​up, prompting all group members to share one example). Practitioners are also reminded of the importance of their behavior as group leaders in demonstrating warmth, care, and cultural humility. This is further operationalized by ensuring that positive interactions outweigh any negative or corrective interactions (e.g., a 5:1 ratio of positive to negative statements) and valuing the unique perspectives and life experiences of each group member. Beyond leader behavior, group-​level considerations for maximizing engagement relate to setting clear and collaborative norms or expectations as a group, finding opportunities to seek student input and provide choices to promote autonomy, and arranging the physical environment to encourage meaningful interaction among group members to decrease challenging behavior. The norms or expectations should be established at the beginning and reviewed often to ensure that the group is productive and comfortable for all students. Revisiting the “why” behind this intervention approach is also important to maximize youth buy-​in; strategies to harness motivation include

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encouraging them to find the activities that fit best in their lives, encouraging them to talk to others in their environment (e.g., parents, friends) about the program between sessions, and identifying changes in mood and other salient outcomes as they engage in the session activities. Although the hope is that all members of the group are fully engaged with intervention content with these less intensive leader and group-​level strategies, there may be students in the group who need more individualized support due to behavioral, academic, or social–​emotional needs. As a first step, leaders are encouraged to check in with the student individually to enhance the relationship between the student and group leader, gain insight into the student’s experience, and learn from the student about the support they may need to be successful. With the additional insight gained, hypotheses about why the student is not engaged can begin to form (i.e., hypothesized function of the behavior), and the strategies used can be more individualized to meet student needs. Some students may need more praise or acknowledgment for their presence and engagement in the group, and others may benefit from having increased choices or decreased task demands in order to maximize their engagement. Individual supports, such as a token board for active participation or a choice between attending the group as scheduled or as a 1:1 make-​up session, can be incorporated into the context of group therapy to maximize engagement for all. Family engagement. Potential obstacles pertinent to caregiver engagement can occur throughout the preparation and implementation stages of a group-​based PPI. Practitioners should plan carefully for how to maximize caregiver engagement when requesting permission for the youth to participate, during initial information sharing about the intervention, and in weekly communication to keep caregivers informed of the activities their child is learning. Minimizing demands and ensuring that there are reasonable and clear expectations for families will increase the likelihood that caregivers will be involved in the intervention alongside their child. Seeking and using caregiver communication preferences for ongoing communication throughout the intervention is one easy way to decrease the demands on caregivers. Additionally, prioritizing informational materials that help to ensure that caregivers understand the “why” behind the positive psychology approach is essential to encourage caregiver permission for participation and family engagement in intervention activities. Case Example: Providing the WBPP with Groups of Middle School Students Upon returning to school after prolonged school closures due to COVID-​19, a team of counselors at a small middle school serving 527 students in grades 5-​8 found themselves inundated with new counseling requests from students and families. The team desired to get upstream and increase their proactive mental health support. Identification of Students Appropriate for the Group With the support of their principal, the school mental health team decided to conduct a school-​wide screening of student life satisfaction using the BMSLSS in the early Fall. Their goal was to identify the students in their school with the lowest life satisfaction scores (bottom quartile) to provide them with school-​based access to the WBPP through a partnership with their local university. Ninety-​six percent of the school (504 students) completed the screening, and 116 (23%) met the eligibility criteria of an average score below 5.0 (less than “mostly satisfied”) on the BMSLSS. Upon review of the 116 who met screening criteria, 102 were determined to be a good fit for a Tier 2 PPI and were invited to participate (the other 14 were excluded due to chronic absences, move from the school, or known behavioral or cognitive problems that would pose challenges to group services).

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Parent consent and student assent to take part in the WBPP were obtained for 49 students (48% of those invited), and those students were randomly divided into two groups to ensure the feasibility of implementation –​one group of 25 students across grade levels would receive the intervention immediately, and the other 24 would receive the intervention after the first group completed the 10-​week program. Group Composition The uneven distribution of students with permission to participate across the four grade levels (nine in 5th grade through four in 8th grade) precluded running one group per grade level as was initially planned, so the counseling team decided to combine the five 7th-​grade students with the four 8th-grade students to create a mixed-​grade group of nine students (ages 12–​14). This created a scheduling challenge as these grades did not share an elective block, and the counselors were committed to minimizing missed instructional time from core classes. As a compromise, they scheduled the group to occur at a 45-​minute period in the school day that spanned the second half of the 8th-​grade elective block and the first half of the 7th-​grade elective block. Table 16.2 presents demographic details and subjective well-​being scores for each of the nine students in the group. During the group composition planning meeting, there was a concern about a recent relational bullying incident between two students in the group (Students I and F), but the counselors decided to forge ahead with the grouping (i.e., serving all students in grades 7 and 8 together) and hope that the girls could potentially form a relationship in the group (which they did by the end of the ten weeks!). Most students within the same grade knew each other prior to the group, but none of the students were familiar with any of the students in the other grade. Students E and F identified one another as best friends, whereas most said they didn’t have friends in the group and that they were just classmates. Student H was brand new to the school and didn’t know any of the other group members. Counselors identified him as struggling with forming peer relationships, and he came to the school with an Individualized Education Program (IEP) based on a previous diagnosis of Autism Spectrum Disorder. Students A, B, and G also had IEPs. Student I was experiencing homelessness with her family of six and was attending this middle school for a 5th year due to chronic attendance challenges and missed instruction. Student B was frequently getting into trouble in school and had recently been suspended. She had significant hearing loss and only occasionally wore her hearing aids, and also had significant challenges with peer relationships. There was some initial nervousness among the adults involved in planning about the “hodgepodge” of student needs and challenges among students in this group. Their BMSLSS screening scores indicating that they were less than mostly satisfied (