By Deb Klemann, MS, LCPC
The NNCTC is pleased to announce the publication of Cognitive Behavioral Intervention for Trauma in Schools for American Indian Youth (CBITS–AI), our adaptation of Cognitive Behavioral Intervention for Trauma in Schools (CBITS), an in-school group counseling intervention for middle school students. First developed in 2003 by Lisa Jaycox, with a 2nd Edition coauthored by Jaycox, Audra Langley, and Sharon Hoover arriving in 2018, CBITS helps young people develop skills that promote healing from traumatic stress. CBITS is designed to be delivered in schools, helping to eliminate numerous practical and cultural barriers that might stand in the way of caregivers’ ability to ensure that their kids regularly get to therapy appointments.
The NNCTC has been providing training and consultation in CBITS implementation for more than fifteen years, with the understanding that the manualized course of treatment could be further modified by community members to best meet their needs. We have supported numerous clinicians and counselors who have facilitated CBITS group sessions in schools serving tribal communities. These providers working in tribal communities have consistently found, over the years, that CBITS is effective in reducing symptoms of traumatic stress and increasing positive coping strategies.
At the same time, the providers we partner with have shared their belief that portions of the CBITS manual could benefit from alterations that would make it a better cultural fit for American Indian students. Until now, each individual clinician has been responsible for making their own changes to the manual to make it more culturally responsive. Sometimes, this process goes smoothly. But it isn’t always a workable solution. Some CBITS facilitators may have too much on their plate already, or in cases when they aren’t from the local tribe, they may not have the cultural knowledge or permission to carry out a thorough cultural adaptation.
In an attempt to address these obstacles, and with the permission of the CBITS developers, the NNCTC formed a workgroup to guide a cultural adaptation that could be used across tribal communities, including some generalized structural changes, delivery nuances specific to tribal beliefs and customs, and numerous culturally responsive constructs. Based on consistent partner feedback, we also prioritized the promotion of traditional healing methods and students’ connections to their tribe, community, culture, and language as resilience-building factors.
The workgroup guiding the cultural adaptation consisted of NNCTC staff members with clinical experience serving tribal populations, as well as individuals with experience facilitating CBITS in schools serving tribal youth. The group included both tribal and non-tribal participants. Our shared goal was to re-work the intervention so that indigenous methodologies, tribal cultural knowledge, tribal beliefs, and traditional cultural practices serve as its foundations, while retaining the existing core components of CBITS.
Some specific examples of changes we made:
1. To promote an indigenous perspective privileging community interconnectedness, we encourage the counselor/facilitator to self-disclose about themselves more than traditional clinical models would encourage. We recommend that the facilitator identify themselves to the students in relation to the tribe, community, and school, and then lead a discussion with the students about how to maintain confidentiality.
2. The manual uses the American bison as a metaphor for resilience. Of enormous cultural significance to Plains tribes, the bison, like North American tribes, are native to this land. Despite colonizers’ attempts to eliminate the bison population, bison are resilient. They have survived, and their numbers are growing. A herd of bison, confronted with a storm on the Plains, will choose to head directly into the storm, because that is the quickest way through it. The manual uses this image of strength and resilience to encourage students to face difficulties, share their traumatic stories, and overcome anxiety.
3. Psychoeducation (education about mental health issues) is a core component of CBITS. To help students understand common reactions to stress and trauma, CBITS teaches that thoughts, feelings, and behaviors are all connected. To convey this concept in a culturally relevant way, the CBITS-AI manual uses the medicine wheel, a common Native American symbol in teachings and practices related to wellness, health, and balance. Students learn how trauma reactions can impact the interconnectedness and balance of the four directions: mind, body, emotions, and spirit.
These are just a few examples of changes we made in the hope of making CBITS a better cultural fit for tribal youth. We recognize that there are limits to pan-tribal cultural adaptation and that further adaptation to meet the needs of individual tribes and communities may still be needed. We are happy to provide training and technical assistance in the implementation of CBITS-AI and to support community-level adaptations. The complete manual is available for download at no cost through the RAND institute, our partners in bringing this project to fruition. If you would like to request training and/or technical assistance in implementing CBITS–AI, please submit a TTA request, and we will contact you to discuss the details.
Deb Klemann is the NNCTC’s Clinical Consultant. She is an experienced clinical counselor and the lead author of two classroom-based social and emotional learning curricula focused on mitigating the effects of trauma and rooted in the principles of Cognitive Behavioral Therapy, one for adolescents and one for younger children.