{"id":1032,"date":"2016-04-26T10:11:15","date_gmt":"2016-04-26T14:11:15","guid":{"rendered":"https:\/\/starr-commonwealth-new.local\/?p=1032"},"modified":"2019-05-21T14:30:05","modified_gmt":"2019-05-21T18:30:05","slug":"adapting-sitcap-art","status":"publish","type":"post","link":"https:\/\/starr.org\/2016\/adapting-sitcap-art\/","title":{"rendered":"Adapting SITCAP-ART"},"content":{"rendered":"

Adapting SITCAP-ART: The Story of One Program\u2019s Journey in Group Implementation for Transformative Results<\/strong><\/p>\n

This paper explores the adaptation of SITCAP-ART to fit needs and aptitudes of at risk adjudicated youth in a particular intensive after care program.\u00a0 After describing the program, population served, and problems with prior groups, it explores the process this therapist went through to awaken to SITCAP, and how the curriculum was designed to fit our clients and program.\u00a0 It specifies how we \u2018sold\u2019 the group to others, our results, outcomes, and continued challenges. \u00a0It is intended to be \u2018user friendly\u2019\u00a0 in the hopes that other practitioners will learn from our experience and borrow any or all ideas for their own programs and mental health treatment services.<\/p>\n

Background<\/strong><\/p>\n

Our program, named Reentry Services, provides intensive after care (IAC) treatment in the form of groups, individual therapy, and case management\/CPST to at-risk adjudicated youth returning to the community after a residential placement for their juvenile offenses.\u00a0 The youth are court ordered to attend as part of their parole or probation terms and receive our services over a range of 4-8 months.\u00a0 The majority of youth are African American from poor neighborhoods in urban Cincinnati.\u00a0 They come with generational, developmental and\/or complex trauma histories characterized by abuse or neglect in childhood; school behavior, truancy and academic problems; separation\/abandonment from incarcerated or murdered family members, particularly fathers; poverty or financial instability; and high exposure to community violence, drugs, guns and death.\u00a0 \u00a0They are most frequently diagnosed with PTSD or other Trauma indicators, ADHD, Conduct Disorder (D\/O), Substance Abuse D\/Os (marijuana being the highest prevalence of use), and often Borderline Intelligence (from low IQ scores.)\u00a0 Other common but less frequent diagnoses are: Reactive Attachment \u00a0D\/O, various Mood D\/Os, and Learning D\/Os.\u00a0 Occasionally but rarely do we have Bipolar D\/O or any form of psychosis.<\/p>\n

The youth also experience long separations from families and their communities after multiple placements that often accumulate to years, based on their repeated adjudications and probation violations.\u00a0 \u00a0In residential placement, they are subject to group programming developed by juvenile justice (JJ) academic organizations, with very structured curriculums that are cognitive behaviorally based to correct criminal thinking, stop substance abuse, and manage anger.\u00a0 Occasionally mental health treatment is provided, and trauma specific therapy is rare.<\/p>\n

In our phased, step down IAC program, youth typically attend 3 groups a week the first month, then step down to two for another two months, then remain with just individual therapy and case management for their last \u2018phase\u2019.\u00a0 Since the program\u2019s inception in 2009, the three groups have varied in definition and content, with titles such as \u2018Community Life\u2019, \u2018Relationship Group\u2019, and \u2018Substance Abuse\u2019 groups.\u00a0\u00a0 They were designed to use CBT and motivational interviewing interventions that built on the treatment concepts they learned at their placements, assisting them to internalize the skills as they transition to the community.\u00a0 As one of the therapists who developed the curriculums and facilitated the groups throughout the program\u2019s first three years, we tried an array of formats, ranging from very structured to more open, client led groups.\u00a0 We learned that groups work best \u2018in the middle\u2019 of the spectrum, with enough structure to provide direction and focus, but loose enough to allow the client to engage in what we call \u2018real talk\u2019, honestly sharing about their thoughts, feelings, and behaviors since their return.\u00a0 We also had some success using creative, right-brain, fun activities to keep groups interesting and dynamic, while keeping a fast pace for fidgety and easily distracted youth.<\/p>\n

The Problem<\/strong><\/p>\n

When the youth arrive at our program, they are burnt out on groups.\u00a0 They are tired of just talking and doing worksheets, with lots of rules to keep behavior in check.\u00a0 Positively, they are equipped with CBT skills that they learned in placement, yet they have not been able to practice or use them in real life.\u00a0 Then typically they get exposed to real life traumatic situations anew and\/or triggered upon return to old environments and, alas, they are unable to use their new found CBT skills. \u00a0In other words, their prefrontal cortex is not able to work with the trauma affected, unhealed parts of the brain. \u00a0So essentially, the thinking based skills go right out the window, leaving probation officers and treatment providers baffled.\u00a0 This restarts the punitive cycle, as triggered youth with no trauma healing go AWOL, commit new offenses, smoke marijuana, struggle in school, and \u2018act out\u2019 emotionally and physically.\u00a0 The courts give citations and violations, or send them to new placements.\u00a0 Meanwhile, we scramble to add more services, particularly high dosage of substance abuse services.\u00a0 We find ourselves saying things like, \u2018you had all these great goals and seemed so motivated to change, what went wrong?\u2019\u00a0 Or, \u2018Why aren\u2019t you using the skills you learned in placement?\u2019\u00a0 In other words, \u2018what\u2019s wrong with you?\u2019<\/p>\n

Awakening to SITCAP<\/strong><\/p>\n

I remember learning briefly about CBT trauma therapy in grad school, and felt immediately after starting work at our agency, that we were missing out on addressing trauma more directly.\u00a0 Often I would debate with our service providers with long histories in juvenile justice, about the discomfort I had with not addressing feelings thoroughly enough, as this also is an important component of CBT I observed was consistently short changed.\u00a0 I also read about how the JJ residential programming and our IAC model was based on the adult criminal system, which was created for anti-social adults,\u00a0\u00a0 emphasizing correcting anti-social beliefs and attitudes.\u00a0 It was missing developmental understanding, compassion for what the youth had experienced, and was not sufficiently strength based.<\/p>\n

It was about two years ago that I was able to attend the initial SITCAP trainings.\u00a0 I remember thinking that finally, here is a model that has the right \u2018lens\u2019 for seeing and understanding our youth.\u00a0 There are interventions that fit them, focusing on healing the brain and body, and addressing more than the logical, thinking part of the mind.\u00a0\u00a0 The whole person is addressed – mind, body, and spirit.\u00a0\u00a0 And the fun activities we tried to fit in awkwardly to our groups are an essential part of the healing and done with intention, leading to the CBT part of reframing the story for hope, and moving from victim to survivor.\u00a0 We decided we would replace our \u2018relationship group\u2019 with a SITCAP\/trauma healing group (as well as train our therapists and CM\u2019s to incorporate SITCAP interventions in their practice, but this is not a subject of this paper.)<\/p>\n

Big \u2018Aha\u2019<\/strong><\/p>\n

So while the overall model of SITCAP, the themes, the treatment process, and the approaches all made sense for our population, I concluded that the SITCAP-ART curriculum would not work as-is for our group.\u00a0 First, the language often centered on specific traumatic events, and our youth could not identify these events, indeed they don\u2019t think of traumatic experiences as particular events, necessarily.\u00a0 This is because there are so many of them, they don\u2019t remember them, or they don\u2019t want to be directly asked about them.\u00a0 Second, I felt the language and pictures were too young for our youth who, though may be behind in developmental maturity, talk with more mature language, and are very sensitive about being talked to like they are young.\u00a0 Third, I felt the activities did not adequately reflect the black, urban culture, and that this would be key to connecting with them in a trauma group.<\/p>\n

Thankfully, I had two \u2018aha\u2019 moments at this point.\u00a0 First, our agency trainer and expert in SITCAP consulted with me, and assured me that the materials were just a starting point, and that I should find a way to adapt the materials to our youth.\u00a0 This was liberating, I just didn\u2019t know how!\u00a0 The second, \u2018aha\u2019 came when I took TLC\u2019s online course called \u2018Breathe, Rock, Draw\u2019, by Barbara Dorrington, MBSW, MEd, CTC-S. I was fascinated by how she organized and structured activities for her classroom into three areas: breathing exercises, rhythm routines, and drawing\/writing.\u00a0 It included positive affirmations, warm ups, and encouraged creativity in identifying the activities that could be used in the three areas.\u00a0 I started to think about how the exercises energized or calmed, both types being needed by our youth, covering the range that was needed to address hypo and hyper arousal.\u00a0 Thus began a kind of creative brainstorming over several weeks, laying out ideas and talking to others, until finally it hit!\u00a0\u00a0 We could redesign our groups to incorporate both active and calming activities, while also addressing the model themes and providing narrative reframing.<\/p>\n

Group Redesign<\/strong><\/p>\n

We would structure our groups around these three categories:\u00a0 Mellow, Move, and Make (MMM).\u00a0 We would end on a positive or \u2018Up\u2019 note each group as is important for the model.\u00a0 Each group would have a SITCAP theme e.g. anger, hurt, victim\/survivor.\u00a0 This way, we would be following the overall progression of the model which is so important to address the trauma themes and get to the narrative reframing, but also allow us to actively engage in emotional management, thereby reducing traumatic stress symptoms. We would have psychoeducation pieces to assist facilitators in being deliberate and aware in the healing work.\u00a0 We would invite speakers occasionally, to bring the themes and activities to life.\u00a0 \u00a0We kept our group norms, but we added one to allow members to find ways to self regulate and encouraged this via the norm:\u00a0 \u2018Find & use what you need to stay and be part of group: mandalas, doodling, stress balls, stretching\u2019. \u00a0See the attachments titled \u2018Self Group Design: Mellow Move Make\u2019 and \u2018Self\/MMM Group Introduction\u2019 for more thorough descriptions.<\/p>\n

We use a matrix approach by adding various activities in each of the three categories and for each theme.\u00a0 This allows flexibility for the facilitators to alter activities to fit the group, and keeps the groups from getting repetitive (as some clients end up repeating groups over time).\u00a0 The activities are designed to be more culturally relevant, referencing current events, contemporary African American urban culture, and common themes that reflect attitudes and beliefs we have learned over time from our youth.\u00a0 See the attached group example titled \u2018Self\/MMM Group Example – Anger\/Love.\u2019<\/p>\n

We also kept our Community Life CBT and AOD groups, although eventually we \u2018wrapped\u2019 SITCAP around them, and continue to evolve them this way.<\/p>\n

The Sell<\/strong><\/p>\n

When we began using SITCAP in our agency, there were just a few of us practicing with one SITCAP experienced and certified trainer to assist as we gained practice using the tools and model in our own service areas.\u00a0 Not surprisingly, we met some resistance and skepticism in the agency, as happens with new or different approaches. I particularly felt this in Juvenile Justice.\u00a0 So it was important that I \u2018sold\u2019 the new group to my management in a way that assured we would be covering the critical treatment concepts, while improving the way we were doing so.<\/p>\n

Our proposal was based on the need to solve the problem of client burnout, by creating groups that provide a new experience from what they have known. \u00a0We proposed the SITCAP approach could make groups transformational and challenging, which was everybody\u2019s goal.\u00a0 Importantly, \u00a0we were not introducing new or contrary treatment concepts, we were simply reframing \u00a0treatment concepts that we have always used, bringing them to life with SITCAP, and bringing in a couple of new concepts for trauma education and healing.\u00a0 We would be improving our ability to provide a safe environment that is more resilient to negative peer influences.\u00a0 By tackling exposure to traumatic events we proposed it would make it easier for the youth to make connections to their offending behaviors.\u00a0\u00a0\u00a0 We also could finally bring in health & wellness psychoeducation for certain topic areas that had been a stretch to add in the past, like sex education and sleep hygiene, which began our foray into the mind-body work.<\/p>\n

We vetted the group with our agency\u2019s trauma practitioners.\u00a0 We did this by having the practitioners experience being the group members, with us facilitating.\u00a0 This was extremely helpful, for we got some great tips, plus it helped validate our curriculum.<\/p>\n

Our director asked for how we could sell this to the courts, and we used this:\u00a0 We teach our youth important skills while they are in their placements for their crimes.\u00a0 Many accept responsibility for what they have done and want to change.\u00a0 However, when they return to their stressful environments, they get triggered and\/or emotionally dysregulated again.\u00a0 This shuts down the thinking part of the brain, so they can\u2019t use the skills.\u00a0 We need to heal and regulate emotionally, calming down the brain, so that the CBT skills can be used and internalized.<\/p>\n

We also used brief surveys the youth filled out for the end of the old groups and the beginning of the new, that confirmed positive trends needed to continue forward with implementation.<\/p>\n

We were now ready for \u2018prime time\u2019, and started the groups in October, 2014.<\/p>\n

Our Results<\/strong><\/p>\n

A year and a half under our belts, here are our key learnings from conducting our adapted SITCAP-ART group:<\/p>\n