Utilizing Trauma-Focused Cognitive Behavioral Therapy as a Framework for Addressing Cultural Trauma in African American Children and Adolescents: A Proposal

Mar 26, 2019 | Articles, Volumes

Ricardo Phipps, Stephen Thorne

This article proposes a model for an intervention designed to mitigate cultural trauma in African American children and adolescents using trauma-focused cognitive behavioral therapy (TF-CBT), an evidence-based practice for treating post-traumatic stress in children and adolescents. There is a paucity of approaches to treat cultural trauma in African American youth and the negative effects cultural trauma can have on academic performance and social interactions. This proposed intervention includes a mentoring program focused on the use of TF-CBT to help African American children and adolescents and their families in constructing positive self-images that support resilience and empowerment.

Keywords: cultural trauma, trauma-focused cognitive behavioral therapy, African American, children, empowerment

The complexity of traumatic experiences and their influence on psychological well-being expand far beyond the current diagnostic nomenclature and symptom descriptions available in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013; Burstow, 2005). Researchers and practitioners acknowledge that post-traumatic stress disorder (PTSD) has been observed in individuals not directly affected by narrowly defined traumatic experiences, creating the occasion for the study of such phenomena as vicarious traumatization or secondary traumatization, particularly when associated with mental health providers and caretakers who show PTSD symptoms because of their exposure to the stories of clients (Pearlman & Saakvitne, 1995). Beyond this concept of vicarious traumatization, researchers and practitioners also note the experience of intrafamilial PTSD symptoms driven by the display of symptoms in one or more family members. When this phenomenon involves the effects of trauma extending to other generations in the same family beyond the generation of the person experiencing primary trauma, mental health professionals have labeled this transgenerational trauma or intergenerational trauma (Danieli, 1985).

Transgenerational transmission of trauma was first documented in the literature in reference to Holocaust survivor families, with an emphasis on the psychological states of the second generation of survivor families (Danieli, 1985). The children of individuals who survived concentration camps displayed muted emotions and other symptoms of grief, loss, and depression. Researchers are currently focusing on better understanding transgenerational trauma in families affected by a variety of traumatic contexts, including child sexual abuse (Frazier, West-Olatunji, St. Juste, & Goodman, 2009), natural disasters such as Hurricane Katrina (Goodman & West-Olatunji, 2008), and immigration trauma (Phipps & Degges-White, 2014). In addition to the study of transgenerational transmission of trauma within family systems, there also is a growing scholarly interest in the effects of collective traumatic experience upon groups of people and how the traumatic experience affects subsequent generations. The term historical trauma has been used to describe the traumatization of Native American peoples at the hands of European colonizers, resulting in mass genocide and geographic displacement (BraveHeart & DeBruyn, 1998; Whitbeck, Adams, Hoyt, & Chen, 2004). Distinctly, but similarly, the construct of cultural trauma has been identified in reference to the enslavement of peoples of African descent in the United States and the subsequent oppression through “Jim Crow” practices that occurred post-emancipation (Eyerman, 2004). Cultural trauma is linked to the psychosocial outcomes that have resulted from the cultural wounds left by the experience of chattel slavery, which refers to the usually permanent holding of another human being as personal property with no rights (Eyerman, 2004; Stamm, Stamm, Hudnall, & Higson-Smith, 2004). DeGruy (2005) has referred to this phenomenon as post-traumatic slave syndrome. Vontress, Woodland, and Epp (2007) have described the psychological after-effects of enslavement and subsequent oppression and discrimination of African Americans as cultural dysthymia, suggesting that African Americans often experience a low-grade depression, or dysthymia, as a result of systemic oppression, which can affect academic, occupational, and social functioning, but do not meet other criteria for more severe depression diagnoses. Smith (2004) coined the term racial battle fatigue to depict the psychological and physiological stressors and subsequent behavioral responses some African Americans experience in reaction to repeated, cumulative racial discrimination.

Historical and cultural trauma has been recognized to be a part of the experiences of various marginalized, indigenous groups throughout the world who have undergone mass atrocities at the hands of colonizers, such as Japanese American survivors of internment camps (Nagata & Cheng, 2003), Palestinian youth (Giacaman, Abu-Rmeileh, Husseini, Saab, & Boyce, 2007), victims of the Rwandan genocide (Schaal & Elbert, 2006), and Mexican and Mexican American immigrants (Phipps & Degges-White, 2014). In the immediate and long-term aftermath of traumatic experiences, individuals have exhibited similar internalized and externalized behaviors that are characteristic of post-traumatic stress disorder and that are seen as responses to the collectively experienced trauma. Although some of the aforementioned groups underwent traumatic experiences that spanned a period of a few months or years and occurred within the last century, the history of the enslavement of African peoples in the Americas and their subsequent oppression and discrimination originated centuries ago and has endured since the first Africans were brought to the Americas. Given such prolonged exposure, the symptoms of historical and cultural trauma are highly pronounced in those African Americans who lack the protective factors needed to counter the disempowering effects of enslavement and oppression (Vontress et al., 2007).

A Brief Overview of Cultural Trauma

DeGruy (2005) and Reid, Mims, and Higginbottom (2004) proposed that African Americans have sustained traumatic psychological and emotional injury because of enslavement, exacerbated by social and institutional inequality, racism, and oppression. The effects are thought to be linked even to physical health disparities, which place African Americans at higher risk for certain medical conditions (Sotero, 2006). Wilkins, Whiting, Watson, Russon, and Moncrief (2013) and DeGruy (2005) asserted that the restrictions of slavery prompted enslaved African American parents to stress to their children the necessity of not confronting Whites, resulting in frustration with life in an oppressive system in which individuals were not permitted to question injustice. In the generations since the emancipation of slaves and the enactment of Civil Rights legislation passed to eliminate racial discrimination and unequal treatment, African Americans in large numbers continue to experience political disenfranchisement (Barnes, 2016), economic struggle (Croll, 2018), social marginalization (Benner & Wang, 2014), workplace discrimination (Hagelskamp & Hughes, 2014), housing segregation (Roscigno, Karafin, & Tester, 2009), and academic disparities (Morris & Perry, 2016). Sztompka (2000) characterized the aforementioned historical phenomena as limited collective agency, which refers to a sociocultural tendency of a group to be inhibited in positively transforming its own oppressed condition both because of external barriers and because of internalized hopelessness. Internalized responses to this limited collective agency influence self-esteem, relationships, occupational functioning, and overall psychological well-being. Linked to this are higher rates of depression and anxiety than seen in other ethnic groups, higher rates of exposure to individual and community violence, and higher rates of psychosis and other psychiatric challenges (Vontress et al., 2007).

Just as all individuals who are exposed to traumatic experience do not display symptoms of PTSD, not all African Americans display overt symptoms of cultural trauma or display them to the same degree. Rasmussen, Rosenfeld, Reeves, and Keller (2007) argued that the subjective interpretation by individuals of traumatic experience largely dictates whether their response will be pathological or whether adaptation and resiliency mechanisms will enable them to self-stabilize. Varying degrees of perceptions of limited agency, because of a plethora of factors, such as socioeconomics, educational achievement levels, family attachment and protective dynamics, and even skin tone dynamics, lead to a wide range of responses to the residual social milieu left behind by enslavement, “Jim Crow” practices, and current-day racially motivated injustice.

In a now dated publication, Pouissant and Atkinson (1972) linked exhibited feelings of rage and passivity among some African Americans to intrapsychic functioning learned during slavery as a survival mechanism. They further explained that this dynamic of rage and passivity was adopted in response to witnessing the brutality faced by enslaved peers who did challenge slave owners. Tatum (2002) postulated that this reaction to historical oppression has morphed into a number of responses to social injustice today, namely assimilation, crime, delinquency, or protest. This cultural trauma affecting African Americans has particularly and directly impacted the well-being of African American children and adolescents.

Assimilation, along with internalized racism, is no more evident than in the original and duplicate “doll studies” first launched by Clark and Clark in 1939. African American children showed preference for White dolls over Black dolls when asked to identify which were beautiful and good. Subsequent critique of the research methodology used by the Clarks and replicated and expanded studies have highlighted inattention to such details as how the skin tone of Black dolls shown to participants or developmental stage would influence their racial self-identification (Jordan & Hernandez-Reif, 2009). However, the study still demonstrates that one of the effects of cultural trauma is a preference for majority culture and characteristics over one’s own.

In terms of crime and delinquency, a long-standing trend of disproportionate numbers of African American men in the U.S. criminal justice system is paralleled by disproportionate numbers of African American males receiving disciplinary measures in schools (Monroe, 2006; Noguera, 2003). It can be argued that these statistical trends are connected to stereotyping and targeting of African American males as offenders. Alternatively, Conger et al. (2002) asserted that higher levels of externalizing symptoms and problematic behaviors in African American children and adolescents are correlated with systemic oppression and economic distress. These attitudes and behaviors, though not prevalent in the experience of all African Americans, indicate a pervasive stress that does not seem to mitigate over time and across generations. This pervasive stress has had a significant effect on the academic performance and school behavior of African American students. Thompson and Massat (2005) found in a sample of African American sixth graders attending inner-city Chicago public schools that academic achievement was significantly related to post-traumatic stress, family violence, and witnessing violence.

Cholewa and West-Olatunji (2008) have framed the academic performance divide that separates out some African American children as cultural discontinuity, highlighting a preference for Eurocentric ways of communicating, relating, and behaving in American schools. Cholewa and West-Olatunji asserted that those whose cultural background does not align with this preferred European style often find themselves marginalized in school environments, which can affect their access to academic instruction. Morris and Perry (2016) furthered this discussion by highlighting the existence of higher suspension rates of African American students and identifying the negative impact that this disparity has on African American students’ academic performance. Using data from the National Longitudinal Study of Adolescent Health, Benner and Wang (2014) concluded that segregation of students into schools in certain areas based on race and socioeconomics resulted in lower academic performance. Although researchers have not explicitly investigated the impact of cultural trauma as a complex construct on the academic performance of African American youth, the aforementioned studies indicate considerable support for the influence of various components of cultural trauma on academic performance, such as the pressure to change one’s communication style to fit a preferred Eurocentric model or the experience of being confined to a school environment with limited resources. Just as the external factors of cultural trauma and the related stressors caused by cultural trauma have perpetuated achievement divides between African American students and other groups, we propose that intentional, external interventions are needed to mitigate the effects of cultural trauma.

Interventions in Response to Cultural and Historical Trauma

Culturally sensitive curricula and character-building programs have been designed to stimulate learning and positive self-image in students of color (Vontress et al., 2007). Jarjoura (2013) adamantly maintained that such programs must be relational and address exposure to various types of traumatic experience. Jaycox (2004) created the Cognitive Behavioral Intervention for Trauma in Schools (CBITS) program as a model for working in inner-city school settings with children and adolescents of ethnically diverse backgrounds who exhibited symptoms of post-traumatic stress. The overall objective of CBITS is to reduce behavioral problems and optimize social and academic performance in students with trauma histories. Successful utilization of CBITS with Native American school children has been documented by Morsette et al. (2009). Honoring Children, Mending the Circle (HC-MC) is a structured program designed to address traumatic symptomatology in Native American children through a blending of evidence-based, trauma-focused cognitive behavioral therapy and culturally appropriate indigenous practices (BigFoot & Schmidt, 2010). BigFoot and Schmidt (2010) sought to provide an intervention in HC-MC that addressed both the high rates of exposure to traumatic events as well as the pervasive cultural, historical, and intergenerational trauma experienced by Native American children and youth, commonly referred to by BraveHeart and DeBruyn (1998) and Whitbeck et al. (2004) as historical trauma.

With the specific needs of African American children in mind, the Celebrating the Strengths of Black Youth (CSBY) program was developed as a strengths-based, small-group approach to building positive racial identity and nurturing self-esteem among African American children. CSBY focuses on teaching students skills to handle the typical challenges that Black students face related to race (Okeke-Adeyanju et al., 2014). President Barack Obama (2014) initiated My Brother’s Keeper as a mentorship program for boys of color to provide a space for accountability, guidance, and support, recognizing the need for culturally relevant approaches to help boys of color transcend barriers created by external stressors and internalized racism. Educators in various parts of the United States have designed schools and curricula around these same mentorship ideals, such as Urban Preparatory High School in Chicago (King, 2011) or Gesu School in Philadelphia (Thorne, 2015). At the core of their mission is a recognition of the need to diminish the “cultural gap” that exists between those who educate children, and the children and their families themselves. Part of bridging this cultural gap involves acknowledgment and understanding of past and present traumatic experience endured by African American people across generations. It is not only educators who need support in developing heightened awareness of these historical and current phenomena; children and their families sometimes need assistance in understanding the historical context for the current divide that often disadvantages African American children.

As models are continuously developed to address historical and cultural trauma, there is growing awareness of the need for culturally sensitive programs that target African American children and youth affected by cultural trauma and are rooted in evidence-based practice. With this in mind, we propose an approach to diminishing the effects of historical and cultural trauma in African American children and adolescents that utilizes the principles of trauma-focused cognitive behavioral therapy (TF-CBT) and key aspects of African American racial identity development and Afrocentric values and strengths.

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

Cohen, Mannarino, and Deblinger (2006) developed Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) as a relatively short-term, integrated approach aimed at the reduction of negative affective responses, distorted cognitions, and maladaptive behaviors that can arise from trauma exposure. TF-CBT utilizes gradual exposure to reminders of the traumatic experience and supports participants in constructing trauma narratives that focus on strengths and empowerment. Clinicians utilizing TF-CBT work to engage parents so that their support of their children is maximized. TF-CBT has proven successful with children and adolescents between the ages of 3 and 18.

The core components of TF-CBT include Psychoeducation and Parenting Skills, Relaxation, Affect Regulation, Cognitive Restructuring, Trauma Narrative, In Vivo Exposure, Conjoint Parent–Child Sessions, and Enhancing Safety Planning. The acronym P-R-A-C-T-I-C-E provides a shorthand reminder of these core components (Cohen et al., 2006). The Psychoeducation and Parenting Skills component focuses upon discussion and education about child abuse in general and the typical emotional and behavioral reactions to physical, emotional, and sexual abuse. This component helps both clients and parents understand that their reactions to trauma experience are typical and that there are evidence-based, effective responses to these behaviors.

Clinicians teach relaxation techniques as a precursor to exposure interventions. Techniques, such as focused breathing, progressive muscle relaxation, and visual imagery, help child and adolescent clients cope with overwhelming, negative emotions that can accompany trauma exposure so that they do not abandon the exposure therapy part of healing because it is distressing. The Cognitive Restructuring component involves clinicians helping their clients and parents better understand how thoughts, feelings, and behaviors are interrelated and how to identify and restructure distorted ways of thinking (Cohen et al., 2006).

The construction of a trauma narrative involves gradual exposure exercises, inviting clients to communicate about the traumatic experience and eventually create a verbal, written, symbolic, or artistic account of the traumatic experience. This provides an opportunity for the clinician to further identify any distorted cognitions related to self-blaming or guilt held by clients and to help with restructuring them into more realistic and empowering ways of thinking (Cohen et al., 2006).

Through in vivo exposure, clinicians introduce gradual reminders of the trauma in environments that are in the everyday experience of the clients or that are significant to the traumatic experience. The relaxation techniques learned earlier in therapy are then utilized to facilitate reduction of distress when clients are reintroduced to settings that trigger traumatic memories. Clinicians facilitate enhanced communication through conjoint parent–child sessions, particularly assisting parents in offering needed support in the home when traumatic memories are triggered. Lastly, clinicians focus upon offering education and skills building related to maintaining personal safety, boundaries, and healthy interpersonal relationships so that clients feel empowered to advocate for themselves more effectively when future stressors arise in life (Cohen et al., 2006).

Although a great deal of research has been conducted studying the use of TF-CBT with child and adolescent survivors of sexual abuse (Cohen, Deblinger, Mannarino, & Steer, 2004), TF-CBT also has been shown to be effective with clients who have been exposed to community violence (Voisin & Berringer, 2015), traumatic grief and loss (Cohen & Mannarino, 2004), and even natural disasters (Jaycox et al., 2010). TF-CBT has been designated as evidence-based because of the number of random control treatment studies supporting its effectiveness. de Arellano et al. (2014) documented 10 random control treatment studies that support the effectiveness of TF-CBT in various trauma exposure contexts, seven of which compared TF-CBT participants with active control groups and three compared TF-CBT participants with wait-list control groups. Five of these studies assessed the effectiveness of TF-CBT with child survivors of sexual abuse (de Arellano et al., 2014). O’Callaghan, McMullen, Shannon, Rafferty, and Black (2013) conducted a study of Congolese girls affected by war and sexual exploitation, using a single-blind, parallel design, randomized control study, and found significant reduction in symptoms in participants treated with TF-CBT. The intervention was administered to participants in a group format in this study of Congolese war survivors.

Jensen et al. (2014) conducted a randomized control study using TF-CBT in which 156 youth in a community mental health clinic, ranging in age from 10 to 18, presented with a variety of trauma histories; the results showed significantly fewer PTSD symptoms, less depression, and greater improvements in functional impairment for those treated with TF-CBT. A field trial of children in New Orleans exposed to the trauma of Hurricane Katrina who received TF-CBT treatment both in schools and in mental health clinics showed significant reduction of PTSD symptoms (Jaycox et al., 2010). Cohen, Mannarino, and Iyengar (2011) documented similar effectiveness of TF-CBT with children exposed to intimate partner violence.

Researchers are continuously expanding the trauma contexts for which TF-CBT is utilized and studied, indicating its robustness and solidifying its evidence-based quality (Cohen et al., 2011). Given the highly adaptable nature of TF-CBT in treating children and adolescents affected by traumatic experiences, we propose an approach to addressing cultural trauma in African American children and adolescents that uses TF-CBT as its basis.

TF-CBT as a Frame for Cultural and Historical Trauma Treatment

Using the major components of TF-CBT denoted in the P-R-A-C-T-I-C-E acronym, we have drafted the following intervention to address cultural trauma in African American children and youth. This intervention is tailored to early adolescents, namely middle school students (ages 12–14), and should be adjusted when used with younger or older participants. The program is a group intervention that can be utilized in an after-school setting at a school, a church, or community center. Ideally, the program spans 16 weeks, which would roughly correspond to a school semester if conducted in the school setting. Warfield (2013) advocated for the modification of TF-CBT by practitioners to fit the cultural context of clients while maintaining the integrity of the model. To foster sensitivity to the more collectivist outlook seen in African American communities, the proposed program is community-based, involving a group approach to treatment, as opposed to a more individualistic, Eurocentric approach to treatment, which might only involve the child and clinician, with sporadic parental involvement.

Psychoeducation and Parenting Skills. From the beginning, the program is family focused. Thorne (2015) maintained that parental engagement is a critical component in the building of community networks that will support the academic and social success of African American children. Given that participants will have different experiences of family and differing family structures, participants are invited to identify a support team of at least three significant persons who will constitute “family” for the purposes of the program—a strategy utilized by Boys’ Latin Charter School in Philadelphia (Thorne, 2015). This team of three is expected to attend some family sessions and will be supported in initiating regular conversations outside the program setting about the program goals.

The introductory session of the program draws participants and their team of three together for an informational presentation on cultural and historical trauma, discussing the history of the enslavement of people of African descent in the United States, the subsequent era of segregation, the ongoing Civil Rights movement, and how these historical experiences have affected the African American family today. Ongoing psychoeducation about historical trauma may take the form of group visits to museums that highlight African American history, such as the Smithsonian Museum of African American History, the Museum of Civil and Human Rights in Atlanta, or any local museum of African American history, followed by group processing of the experience.

Relaxation. Soto, Dawson-Andoh, and BeLue (2011) cited a connection between the experience of racialized stress and discrimination in African Americans with physiological reactions to stress, such as anxiety. Cultural trauma involves a pervasive, ongoing perception of racialized stress and discrimination that can be associated with restlessness, sleep disorders, muscle tension, and other symptoms. TF-CBT stresses the importance of self-soothing and coping mechanisms that stimulate relaxation in tense situations. Muscle relaxation, deep breathing exercises, and guided imagery are promoted by TF-CBT–oriented clinicians. The proposed program places similar emphasis on the teaching of these relaxation strategies.

Spirituality, prayer, and meditation are other mechanisms that are commonly used by African Americans to manage stress and cope with and challenge discrimination (Hayward & Krause, 2015). Spirituality is a very personal expression, meaning participants will likely demonstrate a large amount of variety in their attitudes toward spirituality. Without promoting any specific spiritual tradition, participants will be invited to explore their spiritual beliefs and practices and connect them to how they cope with racism and discrimination.

Affect Regulation. The TF-CBT model also highlights the significance of the development of emotional intelligence (Cohen et al., 2006), including the proper identification of emotions and the conscious choosing of appropriate and healthy emotions. In the case of cultural trauma, as participants learn more about the history of racial power dynamics in the United States, negative emotions may increasingly arise. As a strengths-based program, emotions, such as anger, frustration, and outrage, are honored and recognized but are seen as transitions to constructive approaches to eliminating unequal power dynamics.

According to Chaplin (2015), gender differences exist in how humans express emotions, best explained through a combination of biological, psychosocial developmental, and social constructionist factors. For example, adolescent girls are thought to experience symptoms of depression significantly more often than adolescent boys (Hankin & Abramson, 2001). Along racial lines, there are differences according to gender in how African Americans typically respond to the systemic oppression and discrimination associated with cultural trauma (Vontress et al., 2007). African American boys may suppress anger and dissatisfaction with school incidents, particularly those involving microaggressive behaviors targeting them or more blatant forms of discrimination (Thomas & Stevenson, 2009). Likewise, suppressed anger may be redirected into other expressions, such as hypermasculinity, which may be interpreted by instructors and school administrators as unfounded defiance.

Role play is effective in helping participants reflect upon how they express emotions and how emotional expression influences the identities that they are striving to form (Brown, 2003). Schonert-Reichl and Lawlor (2010) documented the effectiveness of a mindfulness education program in helping fourth to seventh graders develop emotional competence and in fostering positive emotions. Both mindfulness exercises and role play can be used to help participants broaden their emotional vocabulary, experiment with various methods of controlling emotional expression, and practice new ways of communicating emotions honestly and productively. Anderson and Stevenson (2019) highlighted reactions that parents of children and adolescents of color may have when they find out their sons or daughters have been exposed to discriminatory racial encounters, one of which is described as “preparation for bias.” This includes pointed conversations about how to handle potentially dangerous encounters such as racial profiling, with opportunities to allow young people to rehearse how they will respond to situations that may generate panic in the moment. Role play in this proposed program affords the opportunity for candid preparation of participants for life incidents that may be fueled by racial discrimination.

Cognitive Restructuring. Black identity development models, such as the Cross model, underscore that the beginning of racial identity development in people of color is often characterized by positive beliefs about the dominant group and negative beliefs about their own cultural group (Cross, Parham, & Helms, 1991). In the case of African American middle school students, such negative self-beliefs may present in such subtle manners that program participants are not aware and may even deny.

One approach to engaging participants in cognitive restructuring of distorted cognitions about race, self-image, and privilege and power dynamics involves teaching young people about microaggressions directed toward African Americans. Role play is beneficial in creating a space for participants to reflect upon microaggressive behaviors and to correct the stereotypes upon which they are based. Córdova and Cervantes (2010) documented the experience of within-group discrimination among Latino youth based on English proficiency, documentation status, and generational status. In both African American and Latino American communities, within-group skin tone stratification, often referred to as colorism, perpetuates internalized racism, creating a preference for skin tones seen as lighter and more European (Hunter, 2016; Maxwell, Brevard, Abrams, & Belgrave, 2015). Reflection upon within-group microaggressions and internalized racism is utilized to foster participants filtering out negative self-images that they have incorporated based on the manner in which oppressive systems have depicted African Americans as well as individuals from other racial/ethnic groups.

Trauma Narrative. As an important component of the TF-CBT model, trauma narration creates the space for deconstruction and reconstruction of the young person’s understanding of the traumatic experience (Cohen et al., 2006). The clinician monitors for cognitive distortions that might suggest the young person is still blaming self or viewing self through a lens of weakness. Trauma narration is designed to help individuals further claim their own strengths and resources.

In the context of cultural trauma of African Americans, African American children and adolescents often have mistaken views and understandings of the history of African peoples and the history of African Americans (O’Donovan, 2009). They may not be aware of how their own personal families’ histories intersect with key moments and movements in African American history, which suggests a lack of knowledge about family strengths, empowerment, and triumphs over oppressive systems.

A critical part of addressing cultural trauma is the deconstruction and reconstruction of family history. Given the dynamics of slavery, African Americans are often not able to trace their ancestry in the same way that European Americans are able to. Students engaged in cultural trauma programs will benefit from doing oral history interviews with elders in their families and communities to better understand the evolution of their families, the perspectives of the elders on family resilience and strength, and the hopes and dreams that elders have for the current generation of youth. Although there can be obstacles to tracing ancestry beyond the previous century, students can be challenged to explore possible family history scenarios based on the social contexts of African Americans living in the same geographic regions as their known ancestors.

Although the validity of DNA ancestry kits, such as Ancestry.com or 23andme, has been questioned regarding their ability to provide accurate profiles of the ethnic origins of their consumers (Duster, 2014), these tools may still point users in the direction of developing a better understanding of their family histories. In an effort to help students bridge their family histories beyond the Americas, ancestry kits may be used to give students information about African ancestry so that they may research particular countries and tie their history into how they understand their own familial contexts.

This portion of the program is necessarily collaborative in that students will have to reach out to family members for information. It is advised that students complete this with direct involvement with their support team of three significant persons. Upon completion of the project, ideally students will present their information in a spirit of pride to the whole program group with the help of their support team.

n Vivo Exposure. The TF-CBT model encourages the use of in vivo exposure of participants as reminders of the traumatic experience in order to desensitize them to anxiety-provoking reactions (Cohen et al., 2006). In vivo exposure helps to minimize avoidance of stimuli that can trigger memories of the traumatic experience. In lieu of avoidance, participants are supported in using the coping mechanisms they have learned to manage their anxiety.

One aspect of cultural trauma that can greatly influence academic performance and social relationships is low self-efficacy. Low self-efficacy can lead to avoidance of academic challenges as well as unfamiliar social interactions (Uwah, McMahon, & Furlow, 2008). Mathews, Dempsey, and Overstreet (2009), in a study of African American children ages 10–13, found an inverse relationship between exposure to community violence and the academic performance and attendance of students. According to these researchers, the experience of community violence trauma is often associated with a lack of engagement in school activity and an overall sense of powerlessness. Interventions that foster an increase in self-efficacy can enhance students’ willingness to engage in new experiences—academic, occupational, or interpersonal. In reference to cultural trauma of African American children and adolescents, deliberate exposure to opportunities to execute projects and work that can both benefit others as well as enable students to demonstrate leadership and learn new skills can build self-efficacy and result in other positive benefits.

Scales, Blyth, Berkas, and Kielsmeier (2000) concluded from a study of racially and socioeconomically diverse middle school students that service learning (experiential educational moments that revolve around action and reflection) is positively correlated with concern for others’ social welfare, frequency of talking with parents about school, and increased belief in the efficacy of helping behaviors. Stott and Jackson (2005) highlighted growth in self-awareness and self-efficacy as additional benefits for middle school students. Song, Furco, Lopez, and Maruyama (2017) concluded from research with college students from underrepresented groups, not limited to racially diverse groups, that service learning can have a positive impact on their educational outcomes. Thus, service learning opportunities are proposed to expose participants to challenges that may be apparent in their communities and to foster a sense of power in terms of being a part of positive change and community growth.

Service learning opportunities that involve collaboration between students and parents may take the form of neighborhood clean-up days in underprivileged communities, collecting or preparing food to be distributed to homeless populations, or visits to nursing homes to share personal items that have been collected for residents. Reflection time after the project offers students the space to discuss apprehensions they had, the internal processes they used to overcome those apprehensions, and the new self-images they own since the experience.

Conjoint Sessions. The responses children and adolescents receive from their parents and guardians are powerful influences in how young people attribute meaning to trauma, including cultural trauma. Frankish and Bradbury (2012) conducted a qualitative study with Black South African families about how the decision of older family members to refrain from discussing the horrors of apartheid violence with their children and grandchildren born after the end of apartheid in 1994 has often resulted in the development of inaccurate narratives about the past. The proposed program capitalizes upon the power of parental figures, family, and other significant influences to help shape a balanced picture of the past and present and a healthy image of self. The conjoint sessions are woven through the TF-CBT model, with particular emphasis on conjoint sessions after the participant has completed the trauma narrative (Cohen et al., 2006). In this proposed program outlined to address cultural trauma, conjoint sessions are also woven throughout the process. The “family” is invited to actively participate in the Psychoeducation and Parenting Skills stage, in the Trauma Narrative stage, and in the In Vivo Exposure stage. Ideally this high level of parental involvement will stimulate conversation about the themes of the program when students are at home or in other family settings. In summary, “the family” has a critical role to play in ensuring that the narrative from which participants learn to operate is an accurate one.

Enhancing Safety. In the TF-CBT model, the Enhancing Safety component is designed to help participants develop safety plans so that they feel more empowered to advocate for and protect themselves if they find themselves in positions of danger or vulnerability. This could include helping participants generate a list of trustworthy persons to whom they can reach out if uncomfortable situations arise or helping participants assemble emergency contact numbers. Rather than encouraging hypervigilance, the Enhancing Safety component sends the message to participants that they have the power and skills to protect their well-being (Cohen et al., 2006).

Anderson and Stevenson (2019) highlighted the efforts that parents of color may engage in after discovering that their children have experienced a discriminatory racial encounter, such as unfair treatment in school because of race, or after a highly publicized racially motivated assault, such as the fatal shooting of Trayvon Martin. Parents may use affirmational messages to assuage thoughts in their children that victims of discrimination are to blame. In this sense, teaching safety and protective factors is both about the protection of young people from physical attack or violation and about their protection from assault on their identity. In the context of cultural trauma, safety from the effects of cultural traumatization can be promoted through relationships with positive role models who will continue to support growth in self-esteem among student participants. Role models also can serve as accountability partners beyond the parental or family system so that students have other positive and supportive voices as they individuate from their caretakers. Enhancing safety involves teaching participants through case examples and role playing how to recognize systemic oppression and discrimination and how to solicit the support of family, church, and community to confront discrimination and oppression through appropriate administrative, community, and political channels. Helping students identify a cause about which they feel passionate and teaching them about self-advocacy through a letter-writing campaign is a practical strategy that can be used to facilitate this skill.

Conclusion

In conclusion, the potential utilization of TF-CBT as an intervention to address cultural trauma in African American youth requires a large amount of creativity and adaptation to the needs and resources of each participant group. We identify the following recommended priorities for those seeking to use the TF-CBT framework in this context.

First, the format of this program to address cultural trauma in African American middle school students ideally should take place in environments that are not reminiscent of traditional classroom spaces. We propose a program that is informative and inspiring, but not framed as an extension of usual school time. Although logistics might dictate the use of school spaces, it is suggested that efforts be made to decorate program spaces with youth-friendly and culturally relevant art and symbols, perhaps selected or created by participants when possible. If students experience traditional classrooms as a place of disempowerment, efforts are encouraged to promote a sense of ownership and positive investment in the program space by participants.

Second, program leaders—who might be school administrators, teachers, school or professional counselors, social workers, clergy, or community activists—are charged with building relationships with participants and their families to help them engage in their own within-family dialogues about the existence of cultural trauma, and also about the resources within families and communities to challenge and upset the existing power dynamic that has held African American people in a position of social disadvantage for centuries. Initial recruitment for the program as well as ongoing engagement will require program leaders to do regular check-ins to make sure participants, especially parents and guardians, understand the vision of the program and see that they are integral parts of its success. It is recommended that persons in the community who are seen as charismatic and engaging be invited to use these strengths to elicit and maintain participation.

Third, it is important that young people participating in the program feel respected and heard. In the face of conversations and discussions about very difficult and painful subject matter, such as past or present family traumas or racial violence, differing viewpoints may emerge along the lines of age and generational perspectives. Without sacrificing the effect of the wisdom and experience adults bring to the conversation, an environment that is open to the perspectives of youth participants is crucial. Program leaders should have some experience and training in active listening and facilitating difficult dialogue.

Lastly, this adaptation of TF-CBT to address cultural trauma is a time-limited program. Realistically, youth participants will need reminders and reinforcement of the lessons they learn about their family history, their cultural identities, and themselves. As they continue to develop psychosocially, new stages of growth will bring about new challenges that may cause participants to further question the manner in which the program prompted them to make sense of the world in which they live. In role model and mentorship relationships that participants are encouraged to develop, it is recommended that ongoing and long-term efforts be made to help participants continuously reflect upon and reintegrate their sense of empowerment so that it fits their reality as they progress into high school, college, and beyond. The manner in which a middle school student understands cultural trauma might be very different from the manner in which a college student conceptualizes cultural trauma.

Without denying or minimizing what has taken place and continues to persist (i.e., the historical oppression and current discrimination of African Americans on the basis of racial background), this approach to addressing cultural trauma emphasizes the adoption of an empowered sense of self and a heightened sense of collective agency that allows for creative self-transformation even in a society that continues to exhibit systemic injustice.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.

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Ricardo Phipps, NCC, is Assistant Director of Student Counseling Services at Marymount University. Stephen Thorne is a chaplain and adjunct professor at Neumann University. Correspondence can be addressed to Ricardo Phipps, 2807 N. Glebe Rd., Arlington, VA 22207, rphipps@marymount.edu.