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ethics_paper_reference_list.docx
So there is not confusion about what an empirical article is, I wanted to touch base with you about the difference between an empirical journal article vs. a theoretical journal article vs. a literature review
Empirical articles (the ones you need to use for your ref list and paper) are intended to address a specific research question and test a specific hypothesis via data collection and analysis.
Theoretical articles are based on theoretical contexts, models, frameworks, etc. These articles usually do not include empirical/research data (although they might use secondary data to support certain conclusions) but, instead, attempt to make connections between concepts and ideas to define or advance a theoretical position.
Literature reviews are similar to theoretical papers in that they do not use original data collected by the author(s) of the article. Instead, lit reviews summarize, synthesize, discuss, and criticize existing research and hopefully, show gaps in the research.
As indicated above, for your Ethics Paper Reference List, Rough Draft, and Final Paper, you will need at least 10 empirical, peer-reviewed journal articles. You are welcome to use additional references/sources, including theoretical articles, lit reviews, and books, once you have the 10 required empirical articles. The more references the better (well, most of the time. :D) It will be evident from your writing and citing of sources what sources were used to build your paper. Just a word of caution: Make sure to build your paper around empirical research, not theoretical contexts or frameworks.
One of the "quickest" ways to determine whether or not an article is empirical is to read the abstract. If the abstract mentions a study that was done with participants and briefly summarizes the results, it is very likely an empirical article.
An empirical article usually has these sections:
1. Introduction/Literature review
2. Method
3. Results
4. Discussion
5. References
I wish I had an easy system you could follow to find empirical articles. You might want to try adding the words "research" or "study" to your search terms. I typed in the words "research and ethics and group counseling" and got several promising hits. I attached one of the articles that came up. You will notice this article reports on an actual study that was conducted. It has the following sections: Introduction/Background, Method, Results, and Discussion.
This next article is an example of a theoretical article. In brief, this article looks at various group interventions that counselors can use in school-based settings when working with children exposed to domestic violence. It has a lot of good information. However, it is not an empirical article. It does not report on a specific research study. The authors used secondary data to make treatment recommendations, but no original research was conducted. Thus, while this is a very interesting article, it would NOT count as one of the 10 empirical sources you need to use for this paper. You could use the article in addition to the 10 empirical ones, but, again, itwouldn’t count as an empirical article.
Finally, the last article is a literature review. In brief, this article reviews the literature on the growing number of interventions that use religion and spirituality in group counseling. The authors also offer some practical suggestions for counselors. As with the theoretical article above, this would NOT count as one of the 10 empirical sources you need to use for this paper as this is not an empirical research paper. Like the theoretical article, you could use the article in addition to the 10 empirical ones, but, again, it wouldn’t count as an empirical article.
Hope this information helps. Please remember, find you will need to find 10 empirical articles for the ref list assignment and paper.
Spirituality and Religion in Group Counseling: A Literature Review With Practice Guidelines
Marilyn A. Cornish and Nathaniel G. Wade Iowa State University
There has been increased discussion of the need to attend to clients’ spirituality and religion as a part of the counseling process, but much of the literature to date has focused on individual counseling. How do the research and resulting practice implications apply to group counseling? This article provides a rationale for attending to spirituality and religion in counseling, explores the opportunities and barriers in attending to spirituality and religion in group counseling, and reviews the literature on the growing number of group interventions with a spiritual or religious focus. The article ends with specific guidelines for when and how to incorporate spirituality and religion into group counseling.
Keywords: spirituality, religion, group counseling, group therapy
Spirituality and religion have been increasingly viewed as im- portant components of people’s lives that can be successfully attended to in mental health treatment. The increasing interest and changing perceptions have stimulated a growth in research on spirituality and religion in counseling. However, much of this literature has focused on individual counseling. Although knowl- edge continues to grow about the use of spirituality and religion in individual counseling, very little is known about how to best attend to spirituality and religion in group counseling.1 A growing num- ber of group interventions include a spiritual or religious focus, but there is little general guidance for how to best approach the topic of spirituality and religion in group counseling. Group counseling is an effective means of treatment and can provide a viable, cost-effective alternative to individual counseling. In addition, the structure of group counseling can actually provide additional ben- efits not easily achieved in individual counseling (Corey, 2008; Yalom, 2005). Thus, it is important to consider the ways in which spirituality and religion can be most effectively attended to in group counseling.
Defining Spirituality and Religion
Defining spirituality and religion, as well as differentiating between the two concepts, is a difficult task. Although the con-
cepts of spirituality and religion are distinct in some regards, they also share characteristics that make it difficult to separate the two (Zinnbauer, Pargament, & Scott, 1999). Spirituality can be defined as “the feelings, thoughts, experiences, and behaviors that arise from a search for the sacred” (Hill et al., 2000, p. 66). Here, sacred refers to “a divine being, divine object, Ultimate Reality, or Ulti- mate Truth as perceived by the individual” (Hill et al., 2000, p. 66). Spirituality may or may not occur within the context of religion.
To paraphrase Hill et al. (2000), religion can be defined as “the feelings, thoughts, experiences, and behaviors that arise from a search for the sacred” (p. 66) that may also include a search for nonsacred goals (e.g., identity, belongingness, or wellness) within the context of the sacred search. The sacred search process re- ceives validation and support from an identifiable group of people. As such, religion is often viewed as occurring within a formally structured religious institution, whereas spirituality is often per- ceived to be based on personal experiences and meaning making (Hill et al., 2000).
Rationale for Attending to Spirituality and Religion in Counseling
Spirituality and religion have not historically been attended to in counseling research and practice, but this trend is changing. Sev- eral factors provide a rationale for this increased attention. First, there is a high prevalence of religious belief in the United States; 92 percent of Americans report a belief in God or a universal spirit and 56 percent report that religion is very important in their lives (Pew Forum, 2008). Therefore, many clients in the United States are likely to have significant religious or spiritual commitments that are an integral part of their lives. These clients may view problems and potential solutions through a spiritual or religious
1 The term group counseling, used throughout this article, is intended to be broad. In the use of this term we include most forms of psychothera- peutic treatments provided in a small group setting. This includes group psychotherapy, general group-oriented counseling, and psychoeducational group interventions.
This article was published Online First September 6, 2010. MARILYN A. CORNISH received her MS in psychology from Iowa State University. She is a doctoral student in counseling psychology at Iowa State University. Her research interests include religion and spirituality, group counseling, forgiveness, and stigma related to counseling. NATHANIEL G. WADE received his PhD in 2003 from Virginia Commonwealth University. He is an Associate Professor of Psychology at Iowa State Univer- sity in the Counseling Psychology program. His research interests are in forgiveness, psychotherapy process and outcome, religion and spirituality in therapy, and stigma related to psychological help seeking. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Mari- lyn A. Cornish, Department of Psychology, Iowa State University, Lago- marcino W112, Ames, IA 50011. E-mail: [email protected]
Professional Psychology: Research and Practice © 2010 American Psychological Association 2010, Vol. 41, No. 5, 398 – 404 0735-7028/10/$12.00 DOI: 10.1037/a0020179
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lens, regardless of whether they came to counseling for problems related to their spirituality or religion (Pargament, 2007). Second, a sizable minority of clients report experiencing distress stemming directly from spiritual or religious concerns (Johnson & Hayes, 2003), and others report that their presenting concerns impact their spiritual or religious functioning (Hathaway, Scott, & Garver, 2004).
Third, many clients have a desire to discuss spirituality or religion in counseling. Over half (55%) of the individual counsel- ing clients surveyed in one study reported such a preference (Rose, Westefeld, & Ansley, 2001). Although this preference has yet to be empirically examined among group counseling clients, anecdotal evidence provides support for clients’ willingness and desire to discuss spirituality in group counseling (e.g., Lindgren & Coursey, 1995; Phillips, Lakin, & Pargament, 2002). Fourth, group inter- ventions that incorporate spiritual or religious elements have been found to be effective (e.g., Richards, Berrett, Hardman, & Eggett, 2006; Rye & Pargament, 2002; Rye et al., 2005). These factors provide support for attending to spirituality and religion in treat- ment.
Opportunities and Barriers in Attending to Spirituality and Religion in Group Counseling
Opportunities
There are several opportunities or potentially beneficial effects of attending to spirituality and religion in group counseling. First, such discussions can deepen the conversation in an area many people may be uncomfortable talking about outside their own faith tradition. This may help clients expand their zone of tolerance for sharing their worldview or beliefs (Pargament, 2007) and help them to connect with the other group members at a deeper and more satisfying level. These bonds can occur as some members find that others share their beliefs, whereas others are accepted for who they are despite differences. Through these deepened bonds, more effective group work can occur.
Another benefit is providing clients with the space to talk about spiritual or religious concerns they might perceive as being taboo in their social support systems. Many people hide their questions, doubts and differences from their religious or spiritual communi- ties (Altemeyer, 1988). This can then lead to feelings of isolation, fear, and uncertainty. For example, a client in a group co-led by Nathaniel G. Wade shared her feelings of self-loathing and isola- tion that were related to her sexual urges and behaviors. She stated that her religious group taught sexual prohibitions for single peo- ple, such as refraining from any sexual contact, masturbation, and sexual fantasies. As the therapists incorporated a discussion of her religious and spiritual beliefs into this topic, the client was able to identify and articulate her own beliefs that differed in some ways from those of her religion. This enabled her to make decisions that were ultimately satisfying for her, to free herself from pretending to endorse a standard she did not believe in, and to alleviate the guilt that was complicating her anxiety and depression.
Finally, discussing spirituality and religion in group counseling can help to identify and highlight the ways that spirituality or religion is a source of strength and resilience for some clients. By addressing spirituality and religion, therapists might help clients to access the beneficial elements afforded by their spiritual or reli-
gious beliefs, practices, or communities. Furthermore, they might help clients to apply these strengths to their presenting concerns in a way that facilitates healing and growth.
Barriers
There are several factors that may be considered barriers to attending to spirituality and religion in group counseling. First, research has demonstrated the dearth of training clinicians receive regarding spirituality and religion (Brawer, Handal, Fabricatore, Roberts, & Wajda-Johnson, 2002; Young, Cashwell, Wiggins- Frame, & Belaire, 2002). The general lack of training in this area likely leaves many practitioners hesitant to approach the topic in counseling. Second, the average psychologist is less religious than his or her clients (Delaney, Miller, & Bisonó, 2007; Hill et al., 2000). If spirituality and/or religion are not important to a clini- cian’s worldview, he or she may be less likely to attend to clients’ spirituality or religion.
Third, some clinicians may view spiritual or religious discus- sions as inappropriate for counseling. Some of these clinicians may have concerns about attending to spirituality or religion in a civic setting (Richards & Potts, 1995) and others may hold a belief that “religious or spiritual issues are outside the scope of psychology” (Shafranske & Malony, 1990, p. 75). A fourth potential barrier is a fear of imposing one’s own values on clients (Mack, 1994). Of course, clinicians should not use treatment as a way of promoting their own spiritual or religious views (Richards & Bergin, 2005), but discussions of spirituality and religion and even the use of spiritual or religious interventions with willing clients does not equate with imposing one’s own values. Clinicians are able to navigate many topics, about which they may have very strong opinions, without imposing their own values on clients. This should also be possible with discussions of spirituality and reli- gion.
The structure of group counseling might provide additional barriers to attending to spirituality and religion. For example, in groups there are multiple people with potentially very different spiritual and religious beliefs and worldviews. If a group discusses a spiritual or religious topic, members with opposing viewpoints may come at odds with one another. For example, many faith traditions have sects that teach a separation from those with different beliefs. Clients who adhere to such teachings might be more willing to connect with other group members and learn from them if they do not know their religious or spiritual beliefs. However, once this information emerges, these clients might with- draw from those with differing spiritual or religious views. This might also work in the opposite direction, in which a secular client withdraws from group members viewed as adhering to supersti- tious or irrational beliefs. However, groups often discuss topics about which members have differing views, and clinicians are able to effectively navigate the resulting group dynamics (Corey, 2008). In addition, Pargament (2007) notes that group counseling can be a particularly suitable context for facilitating spiritual and religious tolerance. Group members can learn to respect the beliefs of others without sacrificing their own beliefs.
In addition, group facilitators may worry the group could be derailed from its main work by discussions of spirituality and religion. The topic of religion and spirituality has the potential for plunging members into unproductive and intellectualized discus-
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sions of “hot topics,” such as creation versus evolution or prayer in schools. These topics can generate interest and energy but are often distracting and ultimately unhelpful. Avoiding intellectualization, containing group members, and redirecting them to share from their own experiences can be especially difficult in these situations and might present a considerable challenge.
Finally, group practitioners may worry that discussions of spir- ituality and religion will leave some members feeling left out. This is a possibility, but an effective group leader will be aware of changing dynamics and use that as a source of discussion (Corey, 2008; Yalom, 2005). If some members do not view themselves as spiritual, the leader can facilitate a discussion on the various ways in which the group members view the world. Personal definitions of spirituality can be discussed and challenged. Through this, some members may realize they have a personal spirituality but had not previously defined it as such, or they may find support and acceptance from others for their lack of spiritual beliefs that they may not have experienced before.
Group Interventions With a Spiritual or Religious Focus
Despite the general lack of literature on attending to spirituality and religion in group counseling, a growing number of group counseling interventions have been developed that explicitly in- corporate spirituality or religion as a treatment component. Most of these interventions were developed for very specific purposes, but practitioners could tailor elements of the interventions for their own groups. Many of these groups are psychoeducational; others are more psychotherapeutic in nature. Descriptions of these groups, as well as evidence of their effectiveness, are included below. In addition, twelve-step group programs are briefly dis- cussed.
Psychoeducational Groups
Several psychoeducational group interventions have been devel- oped that include a spiritual or religious focus. For example, Rye and colleagues have conducted two randomized clinical trials to examine the role of religion in facilitating forgiveness of romantic partners by female college students (Rye & Pargament, 2002) and ex-spouses by divorced men and women (Rye et al., 2005). In both studies, the intervention tailored to Christians loosely followed Worthington’s (1998) REACH model of forgiveness. Leaders ac- tively encouraged participants to utilize their religious resources to help them forgive, and prayer and scripture readings were utilized in session. The religious treatment was compared to a secular treatment (which had all the same components except that religion and spirituality were not explicitly addressed) and a control group. In both studies, participants in the active intervention groups improved significantly more on a variety of forgiveness and men- tal health measures than did those in the control group. There were no outcome differences between the religious and secular inter- ventions. Interestingly, participants in the secular and religious interventions were equally likely to report that they drew upon religious or spiritual resources to promote forgiveness, which may explain the lack of outcome differences between the religious and secular interventions (Rye & Pargament, 2002; Rye et al., 2005).
Some individuals, then, might benefit from spirituality and religion in the process of forgiveness.
A psychoeducational group with a religious focus has also been created for Mormon students struggling with perfectionism, the effects of which were tested in a pilot study (Richards, Owen, & Stein, 1993). A religious emphasis was incorporated in several ways. First, the relationship between religious beliefs and perfec- tionism was explored (e.g., many devout Mormons literally and rigidly interpret scriptural passages that call them to be perfect). Second, religious bibliotherapy was used, in which clients read material by Mormon leaders with themes of forgiveness, grace, and acceptance of oneself despite imperfections. Third, religious imagery was used in relaxation exercises. From pre- to post- treatment, perfectionism and depression significantly decreased and self-esteem and existential well-being (i.e., satisfaction with the direction of one’s life) significantly increased. Religious well- being (i.e., perceived strength of relationship with God) did not change as a result of this intervention.
A group counseling intervention designed to enhance awareness of the sacred was examined as a treatment for social anxiety (McCorkle, Bohn, Hughes, & Kim, 2005). Each session in this intervention had a different focus, including the meaning of sa- credness, sacred gifts given and received, and sacred sharing of suffering. Group members rated their anxiety and perceptions of sacredness before and after each session. In all but the final session (which was devoted to termination and celebration), perceptions of sacredness increased from pre- to post-session. In addition, anxiety ratings decreased during nine of ten sessions, with a falling trend line over the course of the intervention. Participants indicated that focusing on external, sacred elements took the focus off their internal reactions to anxiety-provoking stimuli.
A spiritual coping group was created for adults living with HIV/AIDS (Tarakeshwar, Pearce, & Sikkema, 2005). Different topics were covered in each session, including HIV and relation- ships, control versus active surrender, and the effects of spirituality on mental and physical health. Much of the intervention focused on coping methods; members shared their own experiences with coping, and facilitators provided information about healthier cop- ing and the benefits of using spiritual coping strategies. From pre- to post-intervention, members reported an increase in self-rated religiosity and in positive spiritual coping (e.g., looking to a higher power for strength), as well as a decrease in negative spiritual coping (e.g., feeling angry at a higher power, feeling punished by a higher power) and depression. Post intervention evaluations indicated that members found focusing on spirituality often helped them “let go” and find “peace” (p. 187) in the face of uncontrol- lable events.
Several psychoeducational groups have been developed for in- dividuals with severe mental illness. Lindgren and Coursey (1995) developed a group with a focus on how spiritual themes can provide a sense of self-worth and support for those with severe mental illness. Group members explored spiritual versus societal values, the spiritual meanings they had given to their illnesses, self-forgiveness, and the impact their spiritual experiences had on their feelings and symptoms. After receiving the intervention, members showed an increase in perceived spiritual support. In addition, greater reductions in depression from pre- to post- intervention were correlated with more frequent thoughts about God (r � .42).
400 CORNISH AND WADE
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Another group intervention for individuals with severe mental illness was designed to provide members with new information about spirituality (Phillips et al., 2002). Topics covered in this group included spiritual resources, spiritual strivings, spiritual struggles, forgiveness of others, and hope. Ways in which their mental illness affected their spirituality were often discussed, along with suggestions to deal with or overcome the barriers associated with their illnesses. No formal evaluations were made of this group.
Psychotherapeutic Groups
Several psychotherapeutic groups have been developed that included a spiritual or religious component. A controlled clinical trial was conducted to examine the effectiveness of a spiritual group intervention for women receiving inpatient treatment for eating disorders (Richards et al., 2006). The intervention included the use of a book with non-denominational spiritual readings and educational materials from a Judeo-Christian perspective about topics such as spiritual identity, grace, forgiveness, repentance, faith, prayer, and meditation. Group members were encouraged to discuss their experiences related to spirituality during group ses- sions. This intervention was compared to a cognitive group and an emotional support group. These interventions were in addition to an already rigorous inpatient treatment program for individuals with eating disorders. Those in the spiritual group improved sig- nificantly more on measures of religious well-being, symptom distress, and relationship distress than did those in the other two groups. Those in the spiritual group also improved significantly more on measures of eating attitudes, existential well-being, and social role conflict than did those in the cognitive group, but did not differ from those in the emotional support group on these measures (Richards et al., 2006).
A spiritually-focused psychotherapeutic group was also created for people diagnosed with cancer (Cole & Pargament, 1999; Cole, 2005). The goals of this intervention were to enhance overall adjustment, enhance spiritual support, and identify and resolve spiritual struggles and strain. The intervention focused on four existential concerns: control, identity, relationships, and meaning. Participants self-selected into a control group or spiritually- focused group therapy (SFT). After treatment, participants in the SFT group remained stable on measures of pain severity and depression, and participants in the control group increased on both measures. Positive religious coping was associated with less de- pression, anxiety, and pain severity and with greater physical well-being.
Kehoe (1998) described a psychotherapeutic group designed for individuals with severe mental illness. The primary goals of this group were to provide a therapeutic context for clients to examine their religious beliefs and traditions and to facilitate exploration of various questions, problems, and feelings clients had about their religious beliefs or absence of such beliefs. The group used a spiritual lens to examine many of the problems typically faced by individuals with severe mental illness. For example, when discuss- ing anger, the group explored whether they were allowed to be angry at God, whether God was angry at them, and whether their illness was a sign that God has abandoned them. No outcome data on this group were reported.
Twelve-Step Groups
Twelve-step self-help recovery groups, such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), have a strong spiritual component. In fact, several of the steps specifically in- clude the word God (Twelve Steps, 1953). Despite the specific use of the word God, 12-step programs are not based on any particular religious tradition and members are encouraged to conceptualize God or another higher power in any way they choose, as long as it represents a power higher than their own willpower to overcome addiction (Twelve Steps, 1953).
Twelve-step programs, designed as self-help groups, are con- ducted without a professional, but are worth mentioning here because of their well-known use in addiction recovery. Practitio- ners wishing to encourage participation in twelve-step programs as an adjunct to treatment can engage in twelve-step facilitation (TSF; Nowinski & Baker, 1992). TSF is a structured, time-limited treatment designed to encourage active involvement in twelve-step programs as a means of overcoming addiction. Practitioners choos- ing to use TSF should be prepared to discuss spirituality with their clients, as the program calls for several explicit discussions on the topic. Although designed for individual treatment, it has been suggested that TSF can be tailored for use in group treatment as well (Nowinski & Baker, 1992).
The interventions outlined above were created for very specific purposes, but it is possible for group practitioners to incorporate elements of these interventions in their more general group work. In addition, clinicians could benefit from additional guidance on attending to spirituality and religion in group counseling. Thus, the following section outlines some initial guidelines for attending to spirituality and religion in group counseling. Although meant to help clinicians, these guidelines can also be seen as hypotheses to be tested in future research.
Guidelines for Attending to Spirituality and Religion in Group Counseling
Homogenous Groups
Homogenous groups refer to counseling groups that limit mem- bership based on member demographics or presenting concern (Gladding, 2003). For practitioners working with homogenous groups, there is a small but growing literature that includes guide- lines or suggestions for attending to spirituality and religion in group work with specific populations. These populations include Native Americans (Dufrene & Coleman, 1992), HIV-infected gay and bisexual men (Norsworthy & Horne, 1994), African Ameri- cans (Williams, Frame, & Green, 1999), Latina women (Rodri- guez, 2001), Orthodox Jewish victims of domestic violence (Swei- fach & Heft-LaPorte, 2007), and college students experiencing spiritual struggles (Gear, Krumrei & Pargament, 2009). Readers are encouraged to reference these sources for information on ways to attend to spirituality and religion in group work with these populations.
The use of ritual or ceremony could be a particularly powerful spiritual tool when working with counseling groups composed of a specific cultural group. Practitioners leading such groups could survey members to identify common spiritual rituals or ceremonies that could be incorporated in the group process. Being able to
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engage in a shared practice could serve to strengthen the bond among members of such groups.
Offering additional guidelines for homogenous groups is diffi- cult because the most effective therapeutic approach may greatly depend on the specific population included in the group. However, many of the more general guidelines offered below can also be used in homogenous groups. In addition, practitioners are encour- aged to seek information about spiritual and religious elements that may be unique to the population served by their homogenous groups.
Heterogeneous Groups
Heterogeneous groups are counseling groups that do not limit the membership based on particular demographics or presenting concerns. In fact, therapists leading such groups may seek to make the group as diverse as possible to reflect the social world in which clients live (Yalom, 2005). Addressing spirituality and religion in a heterogeneous group without a specifically spiritual or religious focus is a clinical skill that has received little attention in the literature. Still, there are some guidelines that might help to direct clinicians. These guidelines are based on adaptations from research findings on spirituality and religion in individual counseling, the general group counseling literature, and our own clinical experi- ence with counseling groups.
First, clients may be unsure whether it is acceptable to talk about spirituality or religion in group counseling. Counselors can set the norm that spirituality and religion are appropriate topics by asking clients general questions about their spiritual and religious func- tioning during the assessment process (Brabender, Fallon, & Smo- lar, 2004; Leach, Aten, Wade, & Hernandez, 2009) or in group sessions. These questions can be more generally about worldview and values or more specifically about spirituality or religion (for a list of sample questions, see Table 1). By asking clients such questions, it makes explicit that they can approach spirituality and religion in group counseling if they want to. Clinicians can also include a section in their informed consent documents or treatment information forms on the possible discussion of spirituality and religion (for examples, see Leach et al., 2009). When this is done, the clinician should define the appropriate scope of such discus- sions, highlighting the importance of respect for others’ beliefs and including an explicit sanction against proselytizing. Providing this information in writing prior to the start of treatment not only informs clients about the therapist’s openness to these discussions, but begins to lay the boundaries for what is and is not appropriate in group.
During group sessions, if and when a client brings up spirituality or religion, clinicians should approach rather than avoid the topic. The clinician should encourage the client to discuss the issue further and can include other members by (a) asking them to provide feedback to the client, (b) encouraging them to share ways they can relate to the group member’s experience, or (c) asking them to share their experiences with spirituality or religion. Dis- cussions of spirituality and religion can, and should, be treated as any other personally important and clinically-relevant issue. When the discussion of spirituality or religion does occur, it could be appropriate to ask all the members to share about their past or current spiritual or religious experiences. Alternatively, group leaders could facilitate a more structured group exercise focused
on spirituality or religion. For example, group leaders could have members pair off to interview each other about their spiritual or religious experiences and beliefs and then report what they learned back to the larger group. Group members will likely be more comfortable discussing spirituality and religion when they know more about their fellow members’ spiritual and religious back- grounds and have developed some trust with each other related to these topics.
Clinicians can also invite feedback and reactions to the discus- sion of spiritual and religious topics. To encourage open and honest discussions, group leaders can make it explicit that any reactions are appropriate to share, but that members should be respectful of one another, even when they disagree (Kehoe, 1998). Connections can be made to other topics group members have been able to respectfully disagree on. When inviting reactions to the discussion of spirituality and religion, clinicians should be prepared for some level of group conflict. When handled appro- priately, this conflict may serve to deepen group members’ aware- ness of and respect for alternative worldviews and to increase understanding of their own beliefs, values, and practices. Conflict appropriately expressed and worked through will also deepen the group members’ experiences with each other and help to form a foundation that can be used to support the group members through other difficult times.
Finally, group leaders should be prepared to address spirituality and religion in the most therapeutic way. There are several things that therapists might do to prepare themselves. For example,
Table 1 Sample Questions To Facilitate Discussions of Spirituality and Religion in Group Counseling
General questions regarding worldview, values, or beliefs “What are some of the most important beliefs that you hold?” “What in your life has shaped your beliefs the most?” “What are the things that you value most in the world/your life?” “How has your view of the world been affected by [presenting
symptom or problem]?” “What values or beliefs might help you as you learn to deal with
[presenting problem]?” “What are one or two beliefs or values that are central to you as a
person?” “How similar do you think your beliefs and values are to the rest of
the group?” Specific questions regarding spirituality and religion
“What are your experiences with spirituality/religion?” “To what degree would you say that you are a spiritual/religious
person?” “How similar are your current spiritual/religious beliefs with those of
your childhood?” “How have your spiritual/religious beliefs been affected by
[presenting problems]?” “To what degree does your spirituality/religion relate to the problems
you are experiencing?” “How comfortable are you talking about spirituality/religion in this
group?” “What would make you feel more at ease to discuss
spirituality/religion with the group?” [To the group]: “Spiritual/religious topics have been implied in much
of what you all have said today. What are the obstacles to talking about these concerns more directly in here?” or “Are these topics that you would like to be able to talk about more explicitly in the group?”
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therapists are encouraged to understand their own backgrounds, biases, perspectives, and beliefs. Conducting a spiritual self- assessment that includes a statement of spiritual or religious be- liefs, a spiritual genogram (i.e., spiritual beliefs and experiences of people throughout one’s family tree), and an honest listing of one’s biases is a great way to begin understanding one’s spiritual or religious perspective. This exploration will also prepare clinicians to respond to questions about their own beliefs posed by group members.
Therapists might also seek additional education to prepare them- selves to attend to spirituality and religion in group counseling. There are now many excellent books on spiritual and religious integration (e.g., Miller, 2003; Plante, 2009; Richards & Bergin, 2005), and a growing number of symposia, continuing education programs, and workshops address religion and spirituality in coun- seling. What is likely not available is specific integration of spir- ituality and religion into group work. Here consultation and su- pervision might be necessary. Also, training in religious or spiritual traditions, theology, and practice might be worthwhile for those working with particular populations. Many local universities have courses that survey world religions, providing useful back- ground information for most of the major religions of the world.
Structured Versus Unstructured Groups
Another way in which counseling groups differ is in the degree to which they are structured. Psychoeducational groups that teach a specific scripted curriculum are at one end of this continuum with psychotherapy groups whose leaders simply facilitate group process at the other. Although we do not believe the usefulness of the guidelines detailed above are seriously affected by the degree of structure in a group, the way in which those guidelines are applied very well may be. For example, the suggestion to approach religious or spiritual topics might take a more explicit form in structured groups. A clinician leading a structured psychoeduca- tional group might include a short presentation about the role spirituality can play in the topic under consideration (e.g., spiritual meditation practices to cope with anxiety). In contrast, in an unstructured group, the therapist might follow up with clients who bring up spiritual issues or may direct the group’s attention to the ways a specific topic relates to spirituality. For example, in a discussion of grief and loss, a leader might ask, “In what ways do your spiritual beliefs impact the way that you experience the death of loved ones?”
Another guideline that might differ based on the level of structure in a group is the suggestion to elicit feedback about and process discussions of spirituality and religion in group. The classic practice of processing group interactions is a mainstay of less structured process groups (Yalom, 2005), making this suggestion easier to in- corporate in unstructured, process-oriented groups. However, receiv- ing feedback on how members accept and respond to spiritual or religious discussion can also be applied in structured groups. In such groups, therapists can set aside a particular time to elicit feedback from members. They might set this up as a “go-around” asking each member to respond to a specific question. Alterna- tively, therapists might have clients complete a homework assign- ment that encourages them to apply spirituality or religion to a particular problem or concern and write about their successes or struggles with this. Although most of the guidelines are applicable
to either structured or unstructured groups, the way in which they are applied needs to be carefully considered and might very well differ based on the group, the counselor, or the specific situation.
Conclusion
Despite the growing amount of literature on spirituality and religion in counseling, there is still a lack of guidance for attending to clients’ spirituality and religion in the group counseling context. Group practitioners are encouraged to utilize the above sugges- tions, but additional research is still needed in order to identify appropriate and effective methods of assisting clients in exploring their spirituality and religion in group counseling.
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Accepted May 5, 2010 �
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Empirical article.pdf
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Research articleComparison of group counseling with individual counseling in the comprehension of informed consent: a randomized controlled trial Rajiv Sarkar1, Thuppal V Sowmyanarayanan1, Prasanna Samuel2, Azara S Singh1, Anuradha Bose3, Jayaprakash Muliyil3 and Gagandeep Kang*1
Abstract Background: Studies on different methods to supplement the traditional informed consent process have generated conflicting results. This study was designed to evaluate whether participants who received group counseling prior to administration of informed consent understood the key components of the study and the consent better than those who received individual counseling, based on the hypothesis that group counseling would foster discussion among potential participants and enhance their understanding of the informed consent.
Methods: Parents of children participating in a trial of nutritional supplementation were randomized to receive either group counseling or individual counseling prior to administration of the informed consent. To assess the participant's comprehension, a structured questionnaire was administered approximately 48-72 hours afterwards by interviewers who were blinded to the allocation group of the respondents.
Results: A total of 128 parents were recruited and follow up was established with 118 (90.2%) for the study. All respondents were aware of their child's participation in a research study and the details of sample collection. However, their understanding of study purpose, randomization and withdrawal was poor. There was no difference in comprehension of key elements of the informed consent between the intervention and control arm.
Conclusions: The results suggest that the group counseling might not influence the overall comprehension of the informed consent process. Further research is required to devise better ways of improving participants' understanding of randomization in clinical trials.
Trial Registration: Clinical Trial Registry - India (CTRI): CTRI/2009/091/000612
Background The doctrine of informed consent is a cornerstone of eth- ical medicine, both in clinical and in research settings. However, research has shown that often participants do not understand all of the information required to make an educated choice [1-3]. Studies have shown that the participants' ability to recall facts differ with different methods of providing information [4-6], although reten- tion of information is usually poor in most settings. There are profound difficulties concerning the understanding of risks, which is crucial information that patients need to
comprehend to make appropriate decisions and act in what they believe to be their best interests [7]. The com- prehension of informed consent is also often influenced by the socioeconomic background and the environment of the study participants [8].
Studies, particularly from developing countries, are often carried out in settings with individuals from differ- ent cultural backgrounds and education levels, thereby posing challenges in administering the informed consent [9]. The moral importance of appropriate and complete communication of information cannot be overempha- sised in this context.
There are published quantitative studies on compre- hension of informed consent by research participants in developing countries [10-15]. However, to the best of our
* Correspondence: [email protected] 1 Department of Gastrointestinal Sciences, Christian Medical College, Vellore - 632 004, Tamil Nadu, India Full list of author information is available at the end of the article
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knowledge, there are no studies on the efficacy of group counseling for administration of informed consent. Group counseling, followed by individual discussion of informed consent, might have advantages over individual counseling alone in allowing individuals in close-knit communities to use their support and decision making systems prior to enrolling in a trial. In a community- based survey involving low-income women, the partici- pants preferred a 'group consent' process [16].
This study was conducted to assess whether partici- pants subjected to group counseling recall the informed consent better than those subjected to individual coun- seling. Group counseling can be helpful in large-scale community-based studies, like vaccine trials, in terms of logistics and ease of administration of the informed con- sent process and of communicating with communities about the study during its conduct and after its comple- tion.
Methods Study area and population This study was undertaken as part of a clinical trial on the effectiveness of nutritional supplementation on malnutri- tion in under-5 children in the Kaniyambadi block of Vel- lore district. The Community Health and Development (CHAD) of Christian Medical College, Vellore provides primary and secondary health care to all residents in the study area. In the year 2005, this area had 102,629 perma- nent residents, with a male/female ratio of 1:1.02. The adult literacy rate was 83.2% for males and 59.2% for females; 41.2% of the residents belonged to the low socio- economic status (SES), 38.0% to the middle and 20.8% belonged to the high SES category (CHAD, unpublished data).
A survey was conducted in 16 rural pre-schools (balwa- dis), run by CHAD in the study area, to identify children with malnutrition. Children attending these balwadis come from families with similar educational background and SES status (CHAD, unpublished data). The parents of these children were then approached to allow their child to participate in a study wherein they were individually randomized to receive either a nutritional supplementa- tion and health education or health education alone for a period of three months. Blood samples were collected at baseline and towards the end of the study for the estima- tion of serum albumin, plasma zinc, plasma vitamin B-12, hemoglobin and red cell indices. Monthly anthropomet- ric measurements were also obtained. Out of a total of 141 malnourished children identified from the balwadis, 128 (90.8%) children were enrolled following written informed consent given by their parents [17].
Collection of data To assess the efficacy of group informed consent, parents of the malnourished children were randomized to receive
either group counseling or individual counseling prior to individual administration of the informed consent. The unit of randomization was a balwadi, i.e. parents of all children from a particular balwadi were assigned to a par- ticular arm. Randomization was carried out by an inde- pendent statistician, who was not involved with administration of the informed consent or collection of data. The allocation sequence was provided in an opaque, sealed envelope and was opened on the day of recruit- ment for the specific balwadi. Prior to opening the enve- lope, the name of the balwadi was printed on its cover.
The informed consent was administered by two study nurses, well versed with the study protocol. Each nurse was assigned equal number of balwadis in the group and individual informed consent category. A check list was provided to ensure that the person administering the informed consent cover all relevant points in the docu- ment. The group informed consent was administered in the form of focus group discussions. Each group com- prised a minimum of 4 and a maximum of 9 participants. Following the group counseling, participants were given approximately 10-15 minutes for discussion. The nurse acted as a facilitator in the discussions and clarified any questions or doubts raised by the group. Following this, soon after the discussion written informed consent was taken from the participating family representative. For the balwadis not receiving group counseling, parents were approached individually, and after discussion, writ- ten informed consent was taken from the participating family representative.
Approximately 48-72 hours following administration of the informed consent, each participating family represen- tative was approached by a field worker, not involved with the informed consent process, and interviewed with the help of a structured questionnaire. The questions were primarily focused on assessing the respondent's recall of key elements of the informed consent, which were under- standing the fact that his/her child was participating in a research study, recognizing the nature and purpose of the study, the risks and benefits of participation, random allocation to either intervention or control arm, the vol- untary nature of participation and the freedom to with- draw at any point. Socio-demographic data were also collected at baseline. The interviewers (field workers) were blinded to the allocation group of the respondents. Verbal consent was obtained from all participants prior to administration of the questionnaire. Both the study on informed consent and the study on nutritional supple- mentation were independently evaluated and approved by the CMC Institutional Review Board.
Sample size was calculated considering knowledge of the study intervention as the primary outcome variable. Accounting for a 10% loss to follow-up the sample size was calculated to be 120. With an alpha error of 5%, this
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would have a power of 80% to detect a difference of 25% in the primary outcome variable between the interven- tion (group counseling) and the control (individual coun- seling) arms. We did not adjust for clustering as we expected a very low design effect, given the homogeneity in the socio-demographic and educational profile of our potential participants.
Statistical Analysis Data were entered in Epi-Info 2002 (CDC, Atlanta, GA, USA), and analyzed using STATA version 9.0 (StataCorp, College Station, TX, USA) software. Descriptive statistics were calculated for all study variables. The intracluster correlation coefficient (ICC) calculated for the present study was found to be 0.02. Consequently, the design effect was calculated as 1.1 (1.0-1.2), with a median (range) cluster size of 7 (3-12). This was considered to be low [18], hence, standard methods of analysis were used. Comparison between the intervention and control arm was done using the χ2 test or the Fisher's exact test for categorical variables and using the two-tailed indepen- dent t-test or Mann-Whitney U test for continuous vari- ables.
Results Of a total of 128 participants enrolled in the study, we could contact a total of 118 (92.2%) participating family representatives. The mean (SD) age of respondents was 29.3 (7.3) years. There was no significant difference between the intervention and control arm in terms of age of the respondents (t-test, P = 0.36). A large proportion of the respondents (104, 88.1%) were Hindus. Most were married females (113, 95.8%). Twenty-one (17.8%) of the respondents did not have any formal education and 101 (85.6%) did not finish high school (year 10). Almost half of the families (51, 44%) belonged to the low socio-eco- nomic status. The socio-demographic characteristics of the respondents are represented in Table 1. Overall, the intervention and control groups were comparable in terms of baseline socio-demographic characteristics.
All respondents knew that their child was participating in a research study. However, when asked what the main purpose of the study was, 113 (95.8%) of the respondents stated that it was to test how many children were under- weight. Only one respondent could state the real purpose of the study, i.e. to test the efficacy of nutritional supple- mentation on underweight children. When asked about the study intervention, 111 (94.1%) respondents correctly identified either one of the two interventions i.e. special food supplementation or health education. There was no difference between the intervention and control arm in this respect (Fisher's exact test; P = 0.13). Only three respondents correctly identified both.
Everyone was aware of the fact that blood samples and monthly anthropometric measurements would be obtained from their child as a part of the study protocol. Most of the respondents (112, 94.9%), however, failed to comprehend the random nature of allocation of interven- tion with 99 (88.4%) stating that it was the balwadi teacher who would decide what intervention their child would receive. The proportion of such respondents were comparable across the intervention and control groups (Fisher's exact test, P = 0.15).
More than half of the respondents (73, 61.9%) did not perceive any risk to their child by participation in this study, although a larger proportion of respondents in the intervention group perceived some risk to their child [24 (48%) vs. 21 (30.9%)]; this difference was near significant (χ2 test, P = 0.06). Almost all respondents (116, 98.3%) said that their child would benefit from this study, and all stated that the study would benefit other children in future. The most important anticipated benefit to their child was availability of free treatment or at a subsidized rate at the CHAD hospital (n = 107, 90.7%). This remained constant across both intervention and control group (Fisher's exact test, P = 1.00).
Sixteen (32%) respondents in the intervention arm and 19 (27.9%) respondents in the control arm (χ2 test, P = 0.63) consulted either spouse (25, 22.1%) or parents (5, 4.4%) or both (5, 4.4%) before enrolling their children into the study.
When asked whether they felt compelled to join the study, 115 (97.5%) answered in the negative. However, only 54 (45.8%) know that they were free to leave the study at any point. Many respondents (95, 80.5%) felt that not participating in the study could adversely affect their or their children's regular medical care. These did not dif- fer significantly between the intervention and control groups (χ2 test, P = 0.12 and P = 0.73 respectively). Table 2 summarizes the result of the comparison of the respon- dents' understanding of the key elements of the informed consent between the intervention and control arm.
Discussion A true and meaningful informed consent is one of the cornerstones of ethical research. However, administering the informed consent in a manner in which it is easily comprehensible to the research participants is a major challenge for researchers in developing countries. Studies in different settings have found that participants' under- standing of informed consent is poor [19-22]. Increasing pressure on researchers to recruit participants within a limited time-frame due to budgetary and other financial constraints has led to instances of unethical research practice, including improper administration of informed consent [23].
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In order to improve the participants' understanding of the information provided, researchers have tried different methods to supplement the traditional informed consent process [5,6,11,24,25]. However, these interventions have shown conflicting results. A systematic review of trials on interventions to enhance participants' understanding of informed consent failed to find any evidence of positive association and concluded that further research was needed [4].
We undertook a randomized controlled trial to assess whether group counseling prior to administration of informed consent resulted in better comprehension of the informed consent than individual counseling. We felt that this would not only ease the burden of recruitment on researchers, but discussion among the probable par- ticipants could also help enhance their comprehension and help make a better decision, thereby improving the overall quality of the informed consent process. In this study, however, there was no difference in comprehen- sion of key elements of the informed consent between the intervention and control group.
This apparent lack of difference between the interven- tion and control group could be due to many factors including the fact that a large proportion of our study population comprised mainly of people from the low SES and with lower literacy levels. Previous studies have shown that illiteracy and SES adversely affect a partici- pant's comprehension of the informed consent [26-28], although, in a multicentric trial of a lipid lowering agent, researchers noted that the comprehension of the study participants did not differ by education or SES provided
the consent form is explained in a simple language [29]. Using a simplified version of the written consent docu- ment with pictorial representation and the use of consent educators or professional nurses with prior research experience have also been shown to improve the partici- pants' comprehension [30-32]. Devoting more time for explanations, use of the local language and obtaining con- sent at home have also been suggested as potential means to improve the informed consent process [33].
A major methodological limitation of this study was that it was not conducted across different studies. It has been shown that parents of children with acute life- threatening conditions find it more difficult to compre- hend information than parents of children with less acute conditions [34]. Also, researchers have found that inabil- ity to concentrate at the time of signing the consent form could also adversely affect comprehension of the study procedures and outcomes [35]. Under such circum- stances, the group consent process might be more effec- tive as the participants are more likely to share information amongst them. A second limitation of this study was that all recruitments in a particular balwadi (for the study on nutritional supplementation) were done on the same day. The effect of intervention may have been diluted to some extent as the control group could possibly have discussed the research study. Further, although the study nurses were provided with a checklist to cover all the relevant points at the time of administra- tion of informed consent, the researchers did not exercise any control over the discussions during the counseling session, either group or individual. As a result, we cannot
Table 1: Baseline socio-demographic characteristics of the respondent families
Variable Intervention (n = 50)
Control (n = 68)
P-value
Mean (SD) age of respondent 1 27.58 (6.76) 28.82 (7.61) 0.36
Mean (SD) age of study child 1 3.49 (0.96) 3.64 (0.84) 0.37
Respondent gender: Female 2 50 (100%) 65 (95.6%) 0.26
Child gender: Female3 27 (54%) 31 (45.6%) 0.37
Hindu religion 2 46 (92%) 58 (85.3%) 0.39
Mean (SD) years of education (respondent) 4 6.22 (3.05) 5.35 (3.63) 0.22
Mean (SD) years of education (head of the household) 1 6.56 (3.98) 6.74 (3.32) 0.80
Nuclear family 3 27 (54%) 34 (50%) 0.67
Housewives(only for female respondents) 2 37 (74%) 39 (60%) 0.12
Low SES 2 24 (48%) 27 (39.7%) 0.37
Mean (SD) number of family members 1 5.12 (1.53) 5.62 (2.18) 0.17
1. Comparison using t-test 2. Comparison using Fisher's exact test 3. Comparison using χ2 test 4. Comparison using Mann-Whitney U test
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know precisely what was discussed in the counseling ses- sions. This fact potentially limits our ability to evaluate comprehension solely on the basis of group vs individual informed consent process. In addition, studies conducted across a more diverse population group and in a more controlled environment might provide better results.
This study highlights limited comprehension about issues related to randomization and voluntariness among trial participants. Although the respondents knew that they were in a research study, the understanding of ran- domization and treatment allocation was poor. Previous research has also shown that in pediatric clinical trials, parents are less likely to understand the concepts of ran- domisation and this is more likely in people from the low socio-economic status [36]. Further research is required to devise better ways of improving participants' under- standing of randomization in clinical trials.
Conclusions There was no difference in comprehension of the key ele- ments of informed consent between participants who received group counseling and participants who received individual counseling to allow their children to partici- pate in a trial of nutritional supplementation for mal- nourished children.
Competing interests The authors declare that they have no competing interests.
Authors' contributions All authors were involved in designing the study protocol and interpretation of the data. RS & PS analyzed the data. RS and GK wrote the manuscript. All authors read and approved the final version of the manuscript. RS and GK are guarantors of the paper.
Acknowledgements We would like to thank Sisters Margaret and Charlotte for administering the informed consent, and Ms. Sarala and Ms. Gomathy for their help with the data collection. Also, we thank the participants for their support. This study was part of a long-term training program in bioethics funded by National Institutes of Health, USA through the project "Centrally Coordinated Bioethics Education for India", conducted by the Indian Council of Medical Research (ICMR). RS was supported by the Global Infectious Disease Research Training Grant (No. D43TW007392).
Author Details 1Department of Gastrointestinal Sciences, Christian Medical College, Vellore - 632 004, Tamil Nadu, India, 2Department of Biostatistics, Christian Medical College, Vellore - 632 004, Tamil Nadu, India and 3Community Health Department, Christian Medical College, Vellore - 632 004, Tamil Nadu, India
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Received: 3 October 2009 Accepted: 14 May 2010 Published: 14 May 2010 This article is available from: http://www.biomedcentral.com/1472-6939/11/8© 2010 Sarkar et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.BMC Medical Ethics 2010, 11:8
Table 2: Comparison of responses between the intervention and control group
Participants' knowledge and belief about study components Intervention (n = 50)
Control (n = 68)
P-value
Study involving underweight children 48 (96%) 65 (95.6%) 1.00
Knowledge of either of the two study interventions 45 (90%) 66 (97.1%) 0.13
Randomization 3 (6%) 3 (4.4%) 0.70
Collection of blood samples 50 (100%) 68 (100%) -
Anthropometric measurements 50 (100%) 68 (100%) -
Benefit their own child 50 (100%) 66 (97.1%) 0.51
Benefit other children 50 (100%) 68 (100%) -
Free treatment as a perceived benefit 45 (90%) 62 (91.2%) 1.00
Consulted others before deciding about participation 16 (32%) 19 (27.9%) 0.63
Joined the study voluntarily 49 (98%) 66 (97.1%) 1.00
No difference in child's medical care if not joining the study 9 (18%) 14 (20.6%) 0.82
Could leave study at any time without adverse consequences 1 27 (45%) 27 (39.7%) 0.12
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ORIGINAL ARTICLE
School-Based Group Interventions for Children Exposed to Domestic Violence
E. Heather Thompson & Shannon Trice-Black
Published online: 6 March 2012 # Springer Science+Business Media, LLC 2012
Abstract Children exposed to the trauma of domestic vio- lence tend to experience difficulties with internalized and externalized behavior problems, social skills deficits, and academic functioning. Mental health practitioners in the school setting, including school counselors, school psycholo- gists, and school social workers, can address developmental concerns that impede development through group counseling interventions that include both structured activities and play therapy. The school environment offers an ideal setting in which to work with child survivors of trauma, as all students have accessibility to school mental health resources. This article outlines the primary objectives and corresponding pro- cedures for a developmentally- appropriate group interven- tions for elementary-aged children who have been exposed to the trauma of domestic violence.
Keywords Domestic violence . Children . Counseling
Nearly four million children in the United States struggle with a diagnosable mental disorder that significantly hinders various areas of functioning which impacts their ability to be successful at school (U.S. Department of Health and Human Services 1999). Less than 20% of those children will get the mental health services they need (U.S. Department of Health and Human Services 2000). Many of the urgent mental health needs of children are first recognized and addressed
in the school setting (Farmer et al. 2003; Salmon and Kirby 2008). Recent research indicates the importance of provid- ing mental health services for children within their schools in order to help them succeed academically and socially (Baker et al. 2006; Farmer et al. 2003).
School mental health professionals often provide preven- tive and responsive interventions to student needs (American School Counselor Association [ASCA] 2005; National Association of School Psychologists 2010). In fact, the ASCA (2005) recommends that school counselors spend at least 80% of their time in direct contact with students. Based on this, schools counselors often are faced with the wide- reaching problem of domestic violence which affects ap- proximately 15 million children each year (McDonald et al. 2006). Children who reside in homes marked by domestic violence are exposed to various forms of aggression which may include repeated physical assaults, mental humiliation and degradation, threats and assaults with guns and knives, threats of suicide and homicide, and destruction of property (McClosky et al. 1995). Investigation of the negative effects of children’s exposure to domestic violence reveals a link between witnessing violence in the home and a wide array of adjustment problems. Child-witnesses of domestic violence often experience chaotic, distressing events, of which they have very little control or comprehension. Expressions of hostility between intimate partners are often followed by what appear to be loving exchanges, which may inhibit children’s abilities to trust, develop a sense of personal control, or develop a sense of safety and security in the world (Campbell and Lewandowski 1997; Tyndall-Lind 1999). Emotional problems related to children’s exposure to domes- tic violence include depression, anxiety (Litrownik et al. 2003), somatic complaints, sleep disturbances, separation anxiety, and withdrawal (Margolin and Gordis 2000; Pepler et al. 2000). Child-witnesses of domestic violence also may
E. H. Thompson Counseling Department, Western Carolina University, Candler, NC 28715-8945, USA
S. Trice-Black (*) Counselor Education Department, College of William and Mary, Williamsburg, VA 23187-8795, USA e-mail: [email protected]
J Fam Viol (2012) 27:233–241 DOI 10.1007/s10896-012-9416-6
have feelings of self-blame for the abuse of a household member (Sullivan et al. 2004). Witnessing domestic violence is also associated with increased risks for suicidal behaviors, phobias, and decreased self-esteem (Fantuzzo and Mohr 1999). Furthermore, research has shown that children ex- posed to domestic violence may externalize their emotional problems behaviorally exhibiting problems in hyperactivity, reduced impulse control, temper tantrums, aggression, bul- lying, and cruelty to animals (Fantuzzo and Mohr 1999; Pepler et al. 2000).
Additionally, children who reside in families character- ized by violence often exhibit decreased levels of social competence, which is evidenced by diminished interper- sonal sensitivity, empathy, and appropriate interpersonal problem-solving skills (Margolin and Gordis 2000; Fantuzzo & Mohr, 1999). Childhood exposure to domestic violence is related to the attitudes that children develop regarding the use of violence as an appropriate strategy for stress reduction and an acceptable approach to conflict resolution (Hay-Yahia and Dawud-Noursi 1998; Mihalic and Elliot 1997). Poor conflict resolution skills or the avoidance of conflict all-together can hinder the develop- ment of significant interpersonal skills. Any feelings of grief, anxiety, helplessness, and isolation in conjunction with maladaptive externalizing behaviors such as bullying, aggression, disobedience, and difficulty concentrating may further exacerbate a lack of social competence.
Furthermore, children exposed to domestic violence have a greater risk of developing Posttraumatic Stress Dis- order (PTSD), which may further exaggerate developmental problems related to exposure to domestic violence. Physio- logical responses to repeated exposure to domestic violence elevate the stress feedback system in the brain and heighten the child’s perception of danger (Mohr & Fantuzzo, 1999). This heightened awareness may be evidenced by trauma symptoms such as hypervigilance, exaggerated startle re- sponse, anxiety, poor regulation of affect, and depression which may worsen externalizing behavioral problems, decrease academic functioning, and hinder social skill development.
The ramifications of exposure to domestic violence often follow children into adolescence and adulthood. For exam- ple, it frequently leads to problematic behaviors in adoles- cence such as substance abuse, aggressive and antisocial behavior, interpersonal problems in school, and decreased academic functioning (Fisher 1999; Maker et al. 1998). In early adulthood, Evans and Sullivan (1995) found that un- dergraduate college students who witnessed abuse experi- enced higher levels of depression, trauma-related symptoms, and lower self-esteem than non-witnesses. As adults, the ramifications of childhood exposure to violence include increased risk for violent behavior, criminal activity, and poor parenting practices (Margolin and Gordis 2000).
Research on domestic violence interventions with chil- dren indicates the benefit of treatment early on (Suderman et al. 2000; Sullivan et al. 2004). Child-witnesses who partic- ipate in group counseling interventions experience a reduc- tion in internalizing and externalizing behavior problems, an increase in self-esteem (Kot et al. 2005), diminished feelings of self-blame, and increased safety knowledge (Suderman et al. 2000; Sullivan et al. 2004). Elementary school interven- tions for children exposed to domestic violence, such as small group counseling, can provide support, assist with emotional and problem-solving skills, and help prevent problems later in life.
The majority of families in the general population who are affected by domestic violence do not receive clinical services (Huth-Bocks et al. 2001). The current economic struggles have impacted many domestic violence shelters, and the services they provide. As a result, many children exposed to violence may not receive therapeutic services. In order to reach the vast number of children exposed to domestic violence, supportive services may be provided in the school setting. School mental health professionals, such as counselors, psychologists, and social workers can provide services to child-witnesses of domestic violence in order to help them succeed socially, personally, and academically. The school environment offers an ideal setting in which to work with children exposed to domestic violence, as all students have access to school mental health resources. Domestic violence counseling in the school setting reduce limitations of accessibility, transportation, and scheduling that are often an obstacle when children are in need of services (Huth-Bocks et al. 2001).
Although school mental health professionals often cannot change the home and community environments in which child-witnesses live, they can create a safe environment for the development of affirmative and encouraging relation- ships, emotional and academic support, and healthy models of interaction styles. Clinicians within the school can play an integral part in bolstering resilience and healthy coping skills in children exposed to domestic violence in order to promote academic and social successes (Dean et al. 2008; McAdams et al. 2009; Silva et al. 2003).
Group counseling is one of the most efficient ways in which school mental health professionals can promote the growth and development of children exposed to domestic violence. This form of treatment enhances relatedness be- tween and among children within a supportive social system that permits mutual aid which empowers children to be sources of assistance to each other as well as recipients of support (Emshoff and Jacobus 2001). Research indicates that group counseling is an effective approach to addressing developmental issues related to exposure to domestic violence (Huth-Bocks et al. 2001; Kot et al. 2005; Sullivan et al. 2004). Through group counseling, children can contribute to the
234 J Fam Viol (2012) 27:233–241
development of one another as the adverse effects of exposure to domestic violence are explored (Huth-Bocks et al. 2001; Kot et al. 2005; Sullivan et al. 2004). The group setting, as opposed to one-on-one counseling, is often less threatening to child-witnesses, which may reduce anxiety while stimulating activity and spontaneity among the group members (Landreth and Sweeney 1999). A group environment helps bridge the gap in trust for child-witnesses by forming a safe and nurtur- ing environment in which group members can learn to reach out and connect (Nisivoccia and Lynn 1999). The group also provides a forum for children to develop new patterns of interactions that enhance social skills and the development of empathy for others (Landreth and Sweeney 1999).
The purpose of this article is to illuminate the ways in which school mental health professionals can facilitate group interventions that address the social, emotional, be- havioral, and cognitive development of elementary-age children who have been exposed to domestic violence. The group intervention outlined in this article includes evidence- based interventions and techniques that promote the well- being of children exposed to the trauma of domestic vio- lence (Suderman et al. 2000; Sullivan et al. 2004). This particular model emerged from a qualitative study detailing the interactions of children engaged in counseling groups for child-witnesses of domestic violence (Thompson 2011). The child-witnesses who participated in this domestic vio- lence group, which included many of the structured and non-structured interventions discussed in this article, devel- oped protective factors such as the ability to trust, share, offer support to others, take perspective, solve problems, assert themselves, voice attitudes against violence, and cor- rectly attribute of blame.
School-Based Group Interventions
Selection of Group Members
Classroom guidance lessons provide an appropriate venue for school mental health professionals to present safety planning and prevention of abuse for all students. One way to present this material, in an elementary setting, is to begin a classroom lesson with a therapeutic story such as, Mommy and Daddy are Fighting, which is written from the perspective of a child who witnesses a fight between her parents (Paris 1986). The school mental health professional can help the students process the story through discussion and drawing pictures of the story and of their own experiences.
Children who reveal exposure to violence in their homes can have an opportunity to meet with a school mental health professional for a more formal intake to determine the appropriateness of the counseling group for the child.
Child-witnesses of domestic violence may also be referred for a formal intake with the school mental health profes- sional through self-referral, teacher referral, and parent re- ferral. The following questions can assist in the discussion of domestic violence: “Who do you call family?”, “Who lives with you?”, “Have you ever seen grown-ups fight?”, and “What happens when they fight?” (Thompson, in press).
Informed Consent and Confidentiality
Prior to starting the group, a full explanation of the group in order to obtain parental permission is important for pre- group screening and informed consent (American Counsel- ing Association [ACA] 2005; ASCA 2010). Consent forms can be sent home to the parents/caregivers of children ex- posed to violence who do not currently reside with an active perpetrator. It may not be safe for children who reside with an active perpetrator to participate in a domestic violence group. These child-witnesses may be safer working with school mental health professionals individually or partici- pating in other counseling groups such as self-esteem or friendship groups. As part of informed consent, school mental health professionals are required to explain the parameters of student confidentiality to student participants as well as their parents/caregivers (ASCA 2010). School mental health professionals can explain confidentiality to students in child-friendly language such as, “What is said in here stays in here.” Exceptions to confidentiality should also be explained to group members. As with all types of counseling, confidentiality for group members cannot be guaranteed. Efforts that can help maintain confidentiality include continual discussions, explanations, and references to confidentiality throughout the group sessions.
According to the Code of Ethics of the ACA (2005) and the ACSA’s Ethical Standards for School Counselors (2010), school counselors are expected to protect student confidentiality unless information is deemed to be of clear and imminent danger to the student or to others, or it is legally required to break confidentiality. Notes or documen- tation regarding the counseling group can be considered part of a student’s record, and therefore, accessible by parents, as outlined in the federal law of Family Educational Rights and Privacy Act (FERPA 1974). School mental health profes- sionals should be familiar with their state’s mandated report- ing laws for child maltreatment. Some children who are exposed to severe violence at their home are at significant risk and should be reported to child protection agencies (Edleson 1999).
Parental Participation
Support services for non-violent parents and caregivers can be provided while their children participate in group
J Fam Viol (2012) 27:233–241 235
counseling. Domestic violence interventions for non-violent parents or caregivers can provide validation and support, as well as education about domestic violence, conflict resolu- tion, normative child development, empowering parenting practices, and safety planning. While concurrent caregiver and family sessions are recommended best practices, it is not always feasible, due to reasons such as a lack of personal readiness on the part of the parent/caregiver for counseling, inability to participate because of work schedules, and/or possible transportation issues. Children should not be de- nied services because of limited parental/caregiver involve- ment. In such cases, school mental health providers can schedule brief weekly phone conferences to communicate support, validate parent/caregiver experiences, and discuss group objectives, activities, and ways to cement their child’s learning at home.
Group Interventions
The foundation of this group intervention is based on evidence-based practices in the field of domestic violence, the facilitation of numerous domestic violence groups in school settings, and a thorough understanding of the litera- ture on domestic violence. Within the group setting, school mental health professionals can offer both structured inter- ventions and non-structured play therapy, in order to provide children with a safe environment in which to explore their personal feelings and experiences and learn safety skills. The following are descriptions of group play therapy and structured group interventions for use when working with children exposed to domestic violence.
Structured Interventions
Structured interventions aimed at the amelioration of the developmental consequences of exposure to violence in the home can benefit children exposed to domestic violence (Sullivan et al. 2004). Structured interventions refer to a variety of techniques such as problem-solving role-plays and the identification of feelings and safety measures through games, puppets, stories, videos, and art projects. With structured group interventions, group members can work together to discuss common problems and to create social, emotional, and behavioral skills to promote resiliency. Role-plays, games, and discussion can be used to address issues related to labeling feelings, self-esteem, coping skills, safety planning, attitudes about violence, and dealing with loss (Jaffe et al. 1986).
Bibliotherapy
Bibliotherapy, through the use of stories and videos, has been shown to be an effective tool in helping children
exposed to family violence and in teaching children nonvi- olent means of conflict resolution (Butterworth and Fulmer 1991). There are several therapeutic stories and videos for children who have been exposed to domestic violence. A video used by the first author, in the domestic violence groups she facilitates is Tulip Doesn’t Feel Safe, which is a 12-minute video designed to help children develop safety plans, label and express feelings, and explore alternative responses to domestic violence (Prin 1993). Examples of books for children’s domestic violence groups include: A Terrible Thing Happened, (Holmes 2002), Mommy and Dad- dy are Fighting (Paris 1986), and Something is Wrong at My House, (Davis 1984).
School mental health professionals can assist members in meeting the group objectives by processing the content and messages presented in videos and books. Group facilitators can ask questions about the characters, explore possible feelings expressed or experienced by characters, and en- courage children to draw pictures of personal experiences related to those of the characters. Simple, yet effective exploration of feelings with children can be facilitated with the choice of four feelings: sad, mad, glad, or scared. Facil- itators may also use these opportunities to help reinforce safety plans for group members.
Play Therapy
Through play therapy, school mental health professionals can enter the world of elementary school students by using children’s play and toys as a common language (Landreth et al. 2009). The Piagetian perspective of development empha- sizes the power of play as a natural form of communication for children to express their thoughts, feelings, and experi- ences (Sweeney and Homeyer 1999). Based on Piagetian tenets of cognitive development, play is the most develop- mentally appropriate means of communication for young children (Kot et al. 1998; Landreth 2002). Children’s responses to traumatic experiences such as exposure to domestic violence are influenced by their developmental stage (Bokszczanin 2007; Gumpel 2008; Lieberman and Knorr 2007; Solberg et al. 2007). Unlike adults, young chil- dren are significantly limited in their ability to use abstract cognitive verbalization as their primary means of communi- cation. Play, however, bridges the developmental gap between concrete and abstract thought. Through the vehicle of sym- bolic representation in play, children may be able to commu- nicate feelings associated with traumatic life experiences, such as domestic violence (Sweeney and Homeyer 1999).
In play therapy, children gain emotional distance from the anxiety-provoking past experiences by using toys to explore and discharge hidden fears and emotional tensions related to intense traumatic experiences (Doyle and Stoop 1999; Robinson 1999). By projecting intense feelings and
236 J Fam Viol (2012) 27:233–241
emotions towards toys, and experiencing control and mas- tery over situations in fantasy, children experience empow- erment rather than helplessness (Robinson 1999; Webb 1999). As the feelings of mastery become incorporated in the child’s sense of self, the child’s self-concept and self- efficacy are enhanced (Kot and Tyndall-Lind 2005; Schaefer and Carey 1994). During play therapy in the group session, members may be permitted to shape the direction of the group through play and interactions. Play therapy can also assist with reduction in self-blame by providing a safe venue in which to overcome feelings of shame and guilt (Namka 1995; Carmichael and Lane 1997).
Through the provision of a wide variety of toys, children may experience and demonstrate responsibility and decision-making in the safety of the group setting. Utiliza- tion of crayons, play dough, and blocks, which can be mastered and manipulated easily, can help facilitate the development of a positive self-image (Landreth 2002). Real-life toys such as dolls, animals, puppets, cars and trucks, and a phone may allow group members to express lived-experiences. Aggression-release toys such as an alli- gator puppet, a boxing glove, and soldiers provide avenues for children to express hostility and anger. Power and con- trol toys such as handcuffs and a rope allow for the expres- sion of power. Nurturing toys, which may include a medical kit, kitchen set, baby bottle, and baby doll, can also be provided. As the group facilitator, the school clinician can rely on limit setting and the reflection of feelings to help children learn to identify and express their emotions in a socially appropriate manner (Landreth 2002; Webb 1999). Limits can be set in the form of choices, thereby honoring the child’s natural ability to make positive behavioral choices.
Group Objectives
Through both play therapy and structured interventions, school mental health professionals can focus on primary objectives related to areas of concern commonly experienced by young children exposed to domestic violence. The over- arching goals of the group should be to improve children’s emotional, behavioral, social, and academic development. The primary objectives could include: (a) conflict resolution and problem solving (Margolin and Gordis 2000; Mohr and Fantuzzo 2000); (b) identification and expression of feelings (Schewe 2008); (c) reduction in self-blame (Schewe 2008; Fosco et al. 2007); (d) safety planning, which includes the development of protective coping strategies and the identifi- cation and utilization of supportive adults (Schewe 2008; Peled and Edleson 1998); (e) increased knowledge, aware- ness, and attitudinal changes about the use of violence (Schewe 2008; Wilson et al. 1989); and (f) enhanced self- concept (Schewe 2008; Holt et al. 2008).
Objective 1: Conflict resolution and problem-solving
The ability to resolve conflict through the assertive expression of needs and feelings is an important attri- bute to the overall healthy development of children. Poor conflict resolution skills or the avoidance of con- flict hinders the development of significant interpersonal skills that are necessary for success in school. Children can grow in areas of social competence, which enhances conflict resolution skills, by: (a) using words to solve conflicts, (b) acknowledging and appropriately respond- ing to the feelings of others, (c) verbalizing needs, (d) verbalizing feelings, and (d) sharing and taking turns (Stevahn et al. 2000). These skills can be enhanced through games, role plays, and interventions occurring in the here-and-now (Stevahn et al. 2000).
Additionally, visual tools, such as that of a stoplight, can enhance the teaching and learning of conflict resolution. The use of a stoplight is a structured intervention influenced by the work of the Exchange Club Family Center in Memphis, Tennessee (The Exchange Club Family Center 2004). The stoplight can be used to demonstrate appropriate choices when confronted with intense emotion. By applying the stoplight to problem-solving scenarios, children can learn the importance of stopping their actions (red light), thinking of a good choice (yellow light), and selecting the good choice (green light). As the group facilitator, the school mental health professional may tailor specific problem sce- narios to pertinent issues in her or his group.
Objective 2: Identification and expression of feelings
Through art and play, children can learn about and explore difficult feelings related to personal trauma (St. Thomas and Johnson 2007). Group facilitators may assist children in their exploration and discovery of their feelings by asking questions such as: “How did you feel when that happened?”, “Can you show me an (angry, sad, scared, happy, etc.) face?”, “Show me where the (anger, sadness, fear, happi- ness, etc.) goes in your body.”, “How do you get those feelings out?”, “How do you feel now that you talked about…?”, “What is one thing you can do to feel better when…happens?”, “Draw me a picture of a time you felt….”, and “What made you feel…?” Through the reflec- tion of group members’ feelings in structured exercises, as well as that of play therapy, children can learn more about their own feelings and develop empathy for the feelings of others. Reflecting feelings through play therapy can help children use words to share their internal experiences (Land- reth et al. 2009). Structured interventions, such as teaching coping mechanisms to deal with intense emotional experi- ences, can contribute to the reduction in externalizing behaviors exhibited in the classroom.
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Objective 3: Reduction in self-blame
Children who witness domestic violence often struggle with feelings of self-blame, guilt, and desires to intervene in fights at home which may stem from child-witnesses’ beliefs that they are responsible for preventing or ending fights that occur in the home (Fosco et al. 2007). Correct attribution of blame can be enhanced by asking questions about culpability related to a child’s drawings and stories of domestic violence. The group facilitator might ask: “Who caused the fight to happen?”, “Are children to blame for fights?”, and “Who is to blame when adults choose to hit another person?” Self-blame should be assessed and cor- rected continuously throughout the group process.
Objective 4: Safety planning
Children who are exposed to domestic violence often report feelings of personal responsibility to intervene in violent conflicts (Burgess et al. 2006; Gumpel 2008; Laumakis et al. 1998). Compelled by a sense of obligation, children may go to courageous lengths to protect loved ones from abusive adults, which jeopardizes the physical safety of children. Children can be provided with the knowledge to engage in the creation of a safety plan, modified for their own personal and unique circumstances (Cohen and Mannarino 2008). Research indicates that elementary- and middle school- aged children, who have been exposed to trauma, can de- velop a sense of empowerment and control through the creation of individual safety plans (Brown et al. 2006). Safety knowledge can be enhanced through structured inter- ventions in which group members are encouraged to do the following: (a) identify people in their lives who can provide support in dealing with problematic situations related to domestic violence, (b) list both safe and unsafe places to go when fighting occurs in the home, and (c) distinguish when it is appropriate and how to call 911. Safety planning questions might include: “Can you remember a fight that happened at your house?”, “What did you do when…?”, “What would you do now to be safe?”, “Who can you talk to about fights?”, and “How would you start to talk to them?” The use of puppets and drawing may also help children demonstrate safety skills.
Group members should be taught when and how to call 911. Group members can practice choosing when to dial 911 using a structured technique such as, “Stop, Think and Go,” in which school mental health professionals create different scenarios based on the experiences of group members (Exchange Club Family Center 2004). For example, the school mental health professional might provide a concrete example such as, “Your mom’s boyfriend is yelling at her because she spends too much money at the store. You feel scared. STOP! THINK of a good choice. Do you (a) call
911, (b) stand there and watch, or (c) go outside and play or go to a neighbor’s house until the fight ends? GO with the best choice.”
Facilitators may want to give each group member a sticker labeled with his or her address and encourage them to place the stickers in easily accessible areas, such as the refrigerator, in order to provide a 911 operator the necessary information. Group members should complete a visual safety plan after practicing calling 911. A sample safety plan might include the following: (a) When I get scared, I can think about ___________, (b) When there is a fight at my house, I can go to ___________, (c) In case of an emergency, I can call _____________, and (d) my address is ______________. Group members should be encouraged to identify a neighbor or family member whose house they may go to in an emergency. Each child’s safety plan should be personalized because chil- dren who live in rural areas may not live close to others and not all children have access to a phone.
Safety plans are important tools for use in enhancing a child’s ability to cope with aggressive disruptions in the home. Other coping mechanisms that empower young chil- dren who are exposed to domestic violence include the identification of adults who can provide guidance, reassur- ance, and a model of appropriate interpersonal responding. School mental health professionals can help children iden- tify realistic and accessible support people, a means in which to contact that person, and examples of times when they have talked to this person about difficulties. Group facilitators can role-play conversations with children and the support people they have identified. Puppets may be helpful in getting children to role-play the initiation of potential conversations with their identified support person. Creating safety plans, practicing coping skills, and identify- ing support people may empower children by helping them feel better prepared to cope. Children who feel more empowered to cope with aggressive family disruptions may in turn feel decreased powerless and fearfulness mak- ing them better able to focus and succeed in other areas of their life including school.
Objective 5: Knowledge, awareness, and attitudes about domestic violence
The group setting provides a social microcosm in which children can learn to deal with conflict. Group facilitators can set limits, which communicates to group members that certain behaviors such as hitting, kicking, and pushing are not appropriate ways to express oneself (Landreth et al. 2009). First, facilitators can verbalize the limit (“People are not for hitting”) and then redirect the child to an appropriate outlet for her or his aggression, such as a pillow or punching bag. The facilitator should then use empowering language to
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acknowledge the child when the behavior changes (“You chose to hit the bag instead of your friend. That is a safe choice.”). The manner in which the limits are set communi- cates the boundary without embarrassing or shaming the child for her or his behavior. Acknowledging the child’s choice to change her or his behavior communicates to the child that she or he has the power to make good choices. The group setting provides an opportunity for the facilitator to actively take advantage of opportunities to facilitate constructive problem- solving conversations between and among group members who are in conflict. In addition to these structured interven- tions, group facilitators can allow non-structured time in each group session, in order to permit the natural emergence of conflicts and the proceeding facilitation of conflict resolution in the here-and-now.
Objective 6: Self-concept
Child-witnesses often reside in home environments charac- terized by negative messages resulting in the internalization of negative ideas as part of the child’s self-concept. Enhanc- ing a child’s self-concept can serve as a protective factor that improves children’s abilities to cope with domestic violence (Tyndall-Lind 1999). Group facilitators should make a con- certed effort to do this by giving praise and calling attention to prosocial behaviors exhibited by group members. These behaviors may include sharing, taking turns, waiting pa- tiently, supporting another group member, offering a com- pliment or advice to another group member, asserting personal needs, verbalizing feelings, appropriately express- ing feelings, and exercising self-care or self-soothing behav- iors. Group facilitators should offer acknowledgement and encouragement for good choices and appropriate social interactions. For example, the group facilitator might say, “You chose to share the markers and that was kind of you,” or “You really want to play with that, and you are waiting patiently for your turn.” These are examples of empowering statements that can be internalized by children and re- enacted later, which may further facilitate the enhancement of self-concept.
Discussion
The need for therapeutic interventions that address develop- mental problems and adjustment concerns related to domes- tic violence is evident. Although limited in nature, findings from research on the effectiveness of domestic violence group interventions with children indicate that children ben- efit from early interventions (Suderman et al. 2000; Sullivan et al. 2004; Wagar and Rodway 1995). School counseling groups facilitated by school-based counselors, social work- ers, and psychologists can provide structured interventions and play therapy for young children exposed to domestic
violence. Schools provide an ideal setting for an interven- tion, as all children have access to school mental health professionals; whereas many children may not have access to supportive services outside of the school environment.
While a wealth of research indicates that domestic vio- lence can significantly impact the overall functioning of young children, many school mental health professionals may not feel prepared to address issues regarding children exposed to domestic violence because information on spe- cific interventions is not easily accessible. This manuscript provides school mental health professionals with informa- tion on the effects of domestic violence on children and specific, detailed interventions that can help identify and assist elementary-aged child-witnesses in a counseling group setting. Providing young child-witnesses with a sup- portive environment in which to explore and share experi- ences, identify and express feelings, enhance social skills, create personalized safety plans, develop coping skills, and internalize experiences of success, mastery, and acceptance, will help promote the personal, social, and academic success of children exposed to domestic violence.
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