a critical review of trauma interventions and religion among youth exposed to community violence

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A Critical Review of Trauma Interventions and ReligionAmong Youth Exposed to Community ViolenceJill Witmer Sinha a & Lisa B. Rosenberg ba Rutgers University, School of Social Work , New Brunswick , NJb Riverton School District , Riverton , NJPublished online: 23 Oct 2012.

To cite this article: Jill Witmer Sinha & Lisa B. Rosenberg (2013) A Critical Review of Trauma Interventions andReligion Among Youth Exposed to Community Violence, Journal of Social Service Research, 39:4, 436-454, DOI:10.1080/01488376.2012.730907

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Journal of Social Service Research, 39:436–454, 2013Copyright c© Taylor & Francis Group, LLCISSN: 0148-8376 print / 1540-7314 onlineDOI: 10.1080/01488376.2012.730907

A Critical Review of Trauma Interventions and ReligionAmong Youth Exposed to Community Violence

Jill Witmer SinhaLisa B. Rosenberg

ABSTRACT. Thirteen studies were reviewed to explore the promise of school- and community-basedsolutions in reducing the impact of exposure to violence and chronic traumatic events among urbanminority youth aged 11 to 19 years old. Because the variables of spirituality and religion are oftenoverlooked in empirical research, studies that measured or included these concepts were prioritized.Out of a total of 35 studies, 13 were included in this review. The 13 studies included 5 interventionstudies, 5 cross-sectional studies, and 3 nonexperimental studies that met our criteria. Six of thestudies included spirituality or religion as a variable. The review confirmed significant associationsbetween rates of exposure to chronic community violence and presence of posttraumatic stress disorder(PTSD) symptoms within this population. Five intervention studies confirmed the effectiveness ofcognitive-behavioral therapy or group therapy in reducing trauma symptoms expressed through PTSDsymptoms and depressive symptoms. Two cross-sectional studies identified spiritual or religious factorsas buffering or moderating the impact of chronic community violence, and 1 revealed higher rates ofspirituality/creativity among adolescents with more exposure to traumatic events. Recommendationsfor future research are outlined.

KEYWORDS. Spirituality/religion, youth/adolescents, chronic community violence, complex chronictrauma

Various studies hint at the high levels of trau-matic stress among urban, minority youth andthe importance of addressing chronic traumasymptoms to promote youth’s academic, emo-tional, and social development. Youth who havefrequently experienced anxiety, loss, and/or lackof trust or safety are also characterized by:school-related problems (chronic truancy, aca-demic failure or poor performance, suspensionsor other disciplinary actions, or dropout); family-related problems (alcohol and/or drug abuse,homelessness, violence, or child neglect); and

Jill Witmer Sinha, M.Div., Ph.D., is an Assistant Professor at Rutgers University, School of Social Work,New Brunswick, NJ.

Lisa B. Rosenberg, M.Ed., MSW, is a School Social Worker at Riverton School District, Riverton, NJ.Address correspondence to: Jill Witmer Sinha, M.Div., Ph.D., Rutgers University, School of Social Work,

536 George Street, New Brunswick, NJ 08901-1167 (E-mail: [email protected]).

individual problems (alienation, attachment dif-ficulty, alcohol and/or drug abuse, depression,aggression, and anxiety). These types of socialand emotional issues impede the ability of manyyoung people to form healthy relationships, meetgoals, or dream and plan for the future.

In urban areas with concentrated poverty,overlapping and exacerbating conditions includehigh rates of incarceration, lack of employmentor low-wage employment, and long-term im-pacts of racial discrimination. In many suchcommunities, the likelihood of experiencing

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Trauma Interventions and Religion 437

one, multiple, or chronic traumatic events is veryhigh—as high as 65% in one sample of urbanyouth aged 20 to 23 years old (Breslau, Wilcox,Storr, Lucia, & Anthony, 2004) and ranging from40% to 60% in studies among similar popula-tions (Farrell & Bruce, 1997; Finkelhor, Turner,Ormrod, Hamby, & Kracke, 2009; Pearce, Jones,Schwab-Stone, & Ruchkin, 2003).

In the not too distant past, the use of the wordtrauma, in practice, often referred to either seri-ous and sudden physical injury or the psychoso-cial aftermath of experiencing and surviving oneseverely catastrophic event. However, traumatheory has more recently expanded to include theresponse to chronic and multiple events, ratherthan only to “one-time” catastrophic events. To-day, the terms “complex,” “chronic,” and “com-pounded” are used in the study of posttrau-matic stress disorder (PTSD) among refugees,veterans, and communities that have enduredlong-term violence, constant stress, and lack ofsafety due to war, violence, and discrimination.Horowitz, Weine, and Jekel (1995) proposed theconcept of compounded community trauma todescribe primary and indirect exposure to var-ious types of violence that are prolonged andrepeated.

Complex traumatic stress results from one orco-occurring events including: abuse, neglect,interpersonal violence (assault or rape), commu-nity violence (gang violence, shootings, or bombthreats), or loss/grief from the murder/deathof a relative or close friend (Cook, Blaustein,Spinazzola, & van der Kolk, 2003). In com-parison, chronic trauma refers to experiencingmultiple traumatic events or ongoing trauma,such as continued exposure to violence, neglect,or abuse. The impact of traumatic events on in-dividual adolescents varies. However, researchlinks long-term impacts of chronic traumaticstress to: impaired attachment; social and emo-tional competency; self-assurance/confidence(Cook et al., 2005; Hazen, Connelly, Roesch,Hough, & Landsverk, 2009); inability to viewthe world as a safe place and handle normalstress; difficulty relating to/empathizing withothers; difficulty regulating or describingemotions; self-destructive behavior; aggression;sleep disturbances; disturbed body image; and

shame/guilt (Cook et al., 2005; Kiser, 2007;Schwab-Stone et al.,1995).

A handful of studies have shown modest andsignificant results in reducing PTSD and depres-sive symptoms among urban youth exposed toviolence or other traumatic events. These stud-ies did not incorporate spiritual or religious be-liefs, despite evidence that the use of religious orspiritual beliefs and practices can play a benefi-cial role in coping with traumatic stress resultingfrom adverse life events. Research on religiousbeliefs and engagement among youth providesevidence for the protective role religion can playin reducing the likelihood for engaging in delin-quent and risky behaviors (Pearce et al., 2003;Sinha, Cnaan, & Gelles, 2007). A notable ex-ample is the study by Johnson, Joon Jang, DeLi, and Larson (2000), who found among a na-tionally representative sample of African Amer-icans who lived in high-risk neighborhoods, thatparticipation in a religious community was asso-ciated with fewer incidences of involvement inserious crime. They controlled for neighborhoodpoverty, lack of order or control, and increasedexposure to violence and subsequent acts of vio-lence among youth (see also Brooks-Gunn, Dun-can, & Aber, 1997; Levanthal & Brooks-Gunn,2000). Furthermore, Johnson et al. and Tittle andWelch (1983) observed that the more disorderedthe neighborhood, the larger the impact of the re-ligious involvement was on delinquent behavior.Thus, this review also included nonexperimen-tal studies with religious values or spirituality intheir intervention or assessment.

Several scholars proffer explanations for re-ligion and spirituality as mechanisms that pro-mote resilience and positive coping with griefand loss. Viewed as belief systems, religion andspirituality are frameworks within or throughwhich individuals interpret life experience. Wal-ters and Bennett (2000) suggested that individ-uals (religious or not) have beliefs about whyevents occur, what they mean, and what can bedone in response. These beliefs are called intoconsciousness when people need to make senseof complex events, cope with adversity, or mo-tivate themselves to change. As suggested byWalters and Bennett, religious and spiritual be-liefs can provide a sense of purpose in life and a

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438 J. Witmer Sinha and L. B. Rosenberg

relationship with transcendent, inner peace. Fur-thermore, religious beliefs are often accompa-nied by religious practices, such as membershipin a religious congregation or other supportivecommunity (Walters & Bennett).

In coping with adverse events, religious orspiritual belief systems are described as work-ing in the following ways. Religion or spiritualbeliefs are used to reinterpret and literally trans-form, or “make new meaning” of, a negativeor stressful experience (Park, 2005). An exam-ple of making new meaning was described byVictor Frankl (1959) in Man’s Search for Mean-ing. Frankl describes the “will to meaning” asan elemental driving force in human personality,which allows humans to find meaning even inapparently meaningless situations. He describesan elderly patient who came seeking relief fromdepression after his wife died. In conversation,the man and Frankl created a meaningful inter-pretation of the man’s suffering: Because shedied first, the man’s current suffering alleviatedher need to suffer had he died first. Accordingto Park, coping with adverse events requires in-dividuals to “make meaning” of, or reinterpret,loss or grief. Furthermore, Park suggests thatthis “meaning-making” model is more salientwhen the event or experience that caused thetrauma cannot be repaired or undone. Left “un-interpreted,” the meaninglessness of the loss orgrief has no purpose, and recovery is thwarted.

For this article, the concepts of spiritualityand religion are considered to be unique, as wellas overlapping: Spirituality refers to beliefs andbehaviors practiced or used by an individual; re-ligion refers to additional or overlapping beliefsand behaviors that are practiced or used in col-laboration with, and in the presence of, a faithcommunity or congregation, including family,small groups, and organized religious groups.An individual may hold spiritual beliefs andcarry out spiritual practices and also be engagedin a congregation or organized faith community,in which case the two concepts overlap.

To corroborate a statistically significant as-sociation between rate of exposure to chroniccommunity violence and traumatic symptomsamong urban minority youth, and to explore theeffectiveness of community-based interventions,this article reviews the outcomes of community-

based and school-based interventions to reducePTSD, depression, and other behaviors amongyouth aged 9 to 18 years old. The article alsoreviews research on the prevalence of chronic,complex trauma among urban, minority youthin communities with high rates of exposure toviolence. Given the use of religious and spiri-tual frameworks in reinterpreting loss and grief,studies that included religion or spirituality asa variable were included and the use of spiri-tual or religious components in interventions isdiscussed. This literature is explored in greaterdepth in the next section.

Religious and Spiritual Beliefs andIntervention for Traumatic Stress

Why include the role of spiritual and religiousbeliefs and practices in research on traumaticstress? Several pertinent reasons suggest thatspirituality and religion are too meaningfulto ignore when discussing community-basedtrauma interventions among urban, minorityyouth. First, many U.S. inner-city and urbanregions are those with high rates of violenceand poverty, and they contain high proportionsof African American and Latino youth. Second,minority cultures, especially African Americanand Latino communities, value or utilize spiri-tuality and religious affiliation and practices in away that is distinctive from mainstream culture.

Surveys of African American and Latinoadults and adolescents have documented a morefrequent use of spiritual beliefs and practices andparticipation in organized religious communitiescompared with their White counterparts (Bryant-Davis, 2005; Cnaan, Gelles, & Sinha, 2004;Sinha et al., 2007). Additionally, research andpractice affirm that minority cultures value spiri-tuality as a primary resource, more frequently as-cribe to a spiritual worldview, and view religiouscommunities as a hub of social services provi-sion (Christian & Barbarin, 2001; Jones, 2007;Taylor, Chatters, & Levin, 2004). Notably, Jonesidentifies spirituality, along with formal and in-formal kinship systems, as one of three majorconcepts that compose Afrocentric principles.

Another reason for including the role of spir-ituality and/or religiosity in the study of youth,and minority youth in particular, is that these

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concepts have been associated with positive im-pacts on mental health outcomes, through in-direct, moderating, or “buffering” effects (Cal-houn, Cann, Tedeschi, & McMillian, 2000;Jones, 2007; Perkins & Jones, 2004). Direct ef-fects of religious beliefs and practice have alsobeen observed and are hypothesized to be relatedto attendance at a congregation, positive peer in-fluence, engagement in prosocial activities, andmoral development (Regnerus, Smith, & Smith,2004; Smith, 2003). Though negative religiouscoping has been linked with negative impact onmental health functioning, published empiricalevidence more frequently supports a positive im-pact for most youth (for further reviews of reli-gious coping, see Ano & Vasconcelles, 2005;Mahoney, Pendleton, & Ihrke, 2006).1

Finally, as noted, literature on coping hasestablished the role of spirituality and reli-gious beliefs as a supportive mechanism in pro-cessing traumatic experiences. Among AfricanAmerican and Latino cultures, spirituality hasbeen frequently recognized as a primary copingstrategy for dealing with adverse events (Brown& Gourdine, 2001; Bryant-Davis, 2005; Jones,2007; Pearce et al., 2003; Shorkey, Garcia, &Windsor, 2010).

This article reviews the outcomes ofcommunity-based and school-based interven-tions as well as research on chronic, complextrauma among urban, minority youth in commu-nities with high rates of violence. A secondarypurpose of the review was to locate studies de-scribing interventions that utilized a spiritual orreligious component, and about half of the stud-ies reviewed here incorporated some measure ofspirituality or religiousness among adolescents.

METHODS

The aim of this review was to examineliterature that assessed the effectiveness ofschool-based and community-based programsand interventions that included spirituality orreligion/religious beliefs and were intendedto reduce PTSD, depression, and related be-haviors among youth exposed to high rates ofcommunity violence and other traumatic events.

The initial search for this systematic reviewincluded several databases via the RutgersUniversity libraries system, including SocialWork abstracts, Social Sciences full text,Academic Search Complete, and the EducationResource Information Center. Key search termswere “school-based interventions, trauma,adolescents, maltreatment, community-based,urban youth, youth, spirituality, and spiritual.”Research designs included in this systematicreview were experimental or quasi-experimentalin nature, or included descriptive statistics on theprevalence of trauma-related symptoms amongthe population of interest. The studies relied onlarge sample sizes to corroborate whether thereis a statistically significant relationship betweenexposure to violent trauma and level of traumasymptoms, depression, and related behaviors.

The search yielded 35 articles, 13 of whichwere included in this review (see Table 1).Twenty-two of the articles were excluded forthe following reasons: The studies did not de-scribe empirical data; the studies did not includeyouth older than the age of 9 or younger than theage of 18; the sample did not include youth inan urban locale who were especially at risk forexposure to chronic trauma or exposure to vio-lence within their locale; the intervention siteswere not school- or community-based; the stud-ies occurred prior to 1997 or did not occur in theUnited States.

DESCRIPTION OF STUDIES ANDFINDINGS

This section describes the 13 articles includedin this review. The summary is organized by re-search design, sample size, and whether the pro-gram included an assessment of spiritual or reli-gious variables or utilized a spiritual componentin an intervention. Outcome variables measuredincluded symptoms and level of PTSD, anxiety,and depression in relation to exposure to and ex-perience of violence, through various self-reportsurvey measures. Three broad designs of studieswere found: experimental or quasi-experimentalintervention studies (Table 1; 5 articles); non-experimental studies that utilized descriptiveor cross-sectional survey methods to assess

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TAB

LE1.

Sys

tem

atic

Rev

iew

Tabl

eW

ithIn

terv

entio

nS

tudi

es

Inte

rven

tion

Stu

dies

Set

ting

and

Sam

ple

Stu

dyD

esig

nP

rimar

yO

utco

me

Var

iabl

e(s)

Spi

ritua

l/Rel

igio

usFa

ctor

Sca

les

Use

d

Sal

loum

,Ave

ry,&

McC

lain

(200

1):“

Pro

ject

Last

”C

omm

unity

;N=

45;A

ges

=11

–19

year

sE

xplo

rato

ry,1

0-w

eek

grou

pth

erap

yw

ithpr

etes

t/pos

ttest

;no

cont

rol(

PT

SD

sym

ptom

leve

l)

PT

SD

sym

ptom

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lN

oC

hild

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ttrau

mat

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tres

sR

eact

ion

Inde

x

Ste

inet

al.(

2003

):“C

BIT

S”

Sch

ool;

N=

126;

Age

s=

10–1

2ye

ars

Effe

ctiv

enes

sst

udy;

10-s

essi

ongr

oup

CB

Tw

ithpr

etes

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ttest

;ran

dom

and

cont

rol

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SD

sym

ptom

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sion

,beh

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ral

(cla

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DS

ympt

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cale

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ldD

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her–

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iatr

icS

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heck

list

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aoka

etal

.(20

03):

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IP”

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ool;

N=

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Age

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enta

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ion

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pC

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ando

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ntro

l

Exp

osur

eto

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ence

;P

TS

D,a

nxie

ty,a

ndde

pres

sion

No

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Eve

nts

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le;C

hild

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Sym

ptom

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n’s

Dep

ress

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ntor

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(200

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with

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l

Exp

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eto

viol

ence

,PT

SD

sym

ptom

s,co

gniti

ve,

affe

ctiv

e,an

dbe

havi

oral

depr

essi

vesy

mpt

oms

No

Mod

ified

Life

Exp

erie

nces

Sur

vey;

Chi

ldP

TS

DS

ympt

omS

cale

;C

hild

ren’

sD

epre

ssio

nIn

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Str

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Diffi

culti

esQ

uest

ionn

aire

Kof

fman

etal

.(20

09):

“JIP

P”

Com

mun

ity&

Sch

ool;

N=

387;

Age

s=

12–1

8ye

ars

Pre

vent

ion/

Inte

rven

tion,

18-w

eek

prog

ram

with

pret

est/p

ostte

st;n

oco

ntro

l

Psy

chos

ocia

l–em

otio

nal

(dep

ress

ion)

,beh

avio

ral

(dis

cipl

ine

refe

rral

s,su

spen

sion

rate

s),a

ndac

adem

ic(t

ests

core

s)

No

Bec

kD

epre

ssio

nIn

vent

ory

440

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prevalence of exposure to community violenceand related symptoms (Table 2; 5 articles); andnonexperimental case studies that examined aspiritual/religious component in the interventionor evaluation (Table 3; 3 articles). These 13 stud-ies are described here, by design category, inchronological order.

Intervention Studies

Salloum, Avery, and McClain (2001) describean intervention using Project Last, an interven-tion developed with the Children’s Bureau ofNew Orleans in 1997 to 1998. During the 1-yearperiod, six 10-week community-based, grief andtrauma therapy groups were conducted at fourpublic schools in New Orleans among adoles-cents who had lost a loved one to violence. Thegroups were conducted by trained social work-ers in middle schools and high schools (N =45). Using the Child Posttraumatic Stress Reac-tion Index, students’ posttest scores decreasedon average by 10 points, and this difference wassignificant. The youth were 100% African Amer-ican, average age was 14 years old, and 60%were female. Although no comparison groupswere available, the study concluded that grouptherapy significantly reduced PTSD symptomsamong the adolescents.

Stein et al. (2003) conducted a random-ized trial of the Cognitive-Behavioral Interven-tion for Trauma in Schools (CBITS) mentalhealth program among recently immigrated stu-dents in two middle schools during 10 ses-sions, during a 1-year period. Sixty-one studentswere in an intervention group and 65 studentswere waitlisted to provide a comparison group.The CBITS intervention incorporated standardcognitive-behavioral therapy (CBT) skills in agroup format with 5 to 8 students, conductedby trained school mental health clinicians, toaddress PTSD, anxiety, and depression symp-toms related to exposure to community vio-lence. Three months after the intervention, treat-ment groups scored significantly lower on PTSDsymptoms, depression, and psychosocial dys-function compared with the waitlisted students.The measures used are listed in Table 1. Af-ter the waitlisted groups received the interven-tion, the differences between the groups were no

longer significantly different for PTSD symp-toms, depression, or psychosocial functioning.The researchers commented on their decision toinclude students who had comorbid disorders,unless the student’s behavior was deemed dis-ruptive to the group treatment. This decision isbelieved to increase the findings’ generalizabil-ity in the field and was encouraged as an ex-ample of evaluation that is relevant and applica-ble in community-based settings. When schoolsparticipate in providing mental health care, par-ticularly among poor and minority youth, it ad-dresses a population whose mental health careneeds are least likely to be met through otherhealth care providers and also addresses a pop-ulation who are at highest risk for exposure toviolence (Stein et al., 2003).

Kataoka et al. (2003) adapted the CBITSmodel for an inner-city school-based mentalhealth clinic and multicultural school-basedpopulation and called it the Mental Health forImmigrants Program (MHIP). During a 1-yearperiod, the study compared 152 students whocompleted the intervention with group CBT inSpanish, conducted by bilingual trained schoolsocial workers. Forty-seven students werewaitlisted and provided a comparison group.Postintervention, the treated students’ PTSDand depressive symptoms were significantlyimproved compared with the waitlisted students.Measures are listed in Table 1. The study notedthat although the bulk of mental health servicesare provided to youth through the public schoolsetting, little is known about the effectivenessof care in this setting. Other future researchcould examine how age affects youth’s level ofparticipation and completion in school-basedprograms, especially among youth who par-ticipate in other activities after school, such assports. Finally, the researchers noted that theycould not distinguish the potential influences ofvarious components of the intervention, suchas parent versus student groups and teachereducation (Kataoka et al., 2003).

Jaycox, Langley et al. (2009) also adaptedthe CBITS model to the Support for StudentsExposed to Trauma (SSET) program, whichwas assessed with 39 intervention and 37 wait-listed middle school students in 10-week ses-sions. During a 2-year period, four groups were

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TAB

LE2.

Sys

tem

atic

Rev

iew

Tabl

eW

ithD

escr

iptiv

e/C

orre

latio

nS

tudi

es

Des

crip

tive/

Cor

rela

tion

Stu

dies

Set

ting

and

Sam

ple

Stu

dyD

esig

nP

rimar

yO

utco

me

Var

iabl

e(s)

Spi

ritua

l/Rel

igio

usFa

ctor

Sca

les

Use

d

Farr

ell&

Bru

ce(1

997)

Sch

ool;

N=

436;

Age

s=

10–1

4ye

ars

Long

itudi

nalc

ohor

tsur

vey

with

thre

eda

taco

llect

ion

poin

tsE

xpos

ure

tovi

olen

ce,

emot

iona

ldis

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s,fr

eque

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ofvi

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tbeh

avio

r

No

“Thi

ngs

Ihav

ese

enan

dhe

ard”

;D

epre

ssio

n&

Anx

iety

subs

cale

inE

mot

iona

lDis

tres

sS

cale

–Wei

nber

ger

Adj

ustm

ent

Inve

ntor

y;B

ehav

iora

lFre

quen

cyS

cale

sP

earc

eet

al.(

2003

)S

choo

l;N

=1,

703;

Age

s=

11–1

9ye

ars

Fol

low

-up

coho

rtsu

rvey

Exp

osur

eto

and

vict

imiz

atio

ndu

eto

viol

ence

;con

duct

prob

lem

s,pa

rent

invo

lvem

ent,

relig

ious

ness

Yes

Soc

iala

ndH

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Vic

timiz

atio

nan

dW

itnes

sV

iole

nce

Sca

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sele

cted

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son

the

Mul

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onal

Mea

sure

ofR

elig

ious

ness

/Spi

ritua

lity

Jone

s(2

007)

Com

mun

ity; N

=71

;Age

s=

9–11

year

sC

ross

-sec

tiona

l,co

nven

ienc

esa

mpl

eE

xpos

ure

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olen

ce,c

ompl

exP

TS

D,k

insh

ipsu

ppor

t,sp

iritu

ality

,Afr

ocen

tric

supp

ort(

adde

dfo

rmal

kins

hip,

info

rmal

kins

hip,

and

spiri

tual

ity)

Yes

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ldre

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Rep

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TAB

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stud

ies

Trau

ma

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sure

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Yes

Issu

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ith

inC

BT

Mod

ifyin

ga

relig

ious

and

spiri

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ssm

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2005

)

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conducted by trained teachers and school coun-selors during school hours. The study indicatedsignificant reduction in depression, and for chil-dren in the high-symptom group, reduction inboth PTSD and depression. Measures are listedin Table 1. The study reported good fidelityfor implementing the adapted model by school-based practitioners, the satisfaction of parentsand youth with the program, and the promiseof school-based interventions for reducing trau-matic stress (Jaycox, Langley et al., 2009).

Koffman et al. (2009) described a community-based program for delinquent youth or youth atrisk for truancy and their parents. The programoccurred during 18 weekends in a high school.The Juvenile Intervention and Prevention Pro-gram (JIPP) is a collaboration of Los AngelesPolice Department officers, teachers, and so-cial workers and includes physical training, acomputer-based social and emotional develop-ment curriculum, facilitated group discussion foryouth, and mandatory weekly parent participa-tion in a parent training component. In its 12thseason, the JIPP reports that twice as many youthin the program presented in a “normal” range onthe Beck Depression Inventory compared withbaseline; high school disciplinary referral andsuspension rates have decreased by 90%, andthe number of days youth are suspended has de-creased by 50% for the school.

These five studies confirm that school- andcommunity-based, group-based CBT and otherinterventions (JIPP and Project Last) were effec-tive in reducing depression and trauma symp-toms in these settings. The interventions wereprimarily implemented by trained social workersand teachers, and this modality was effective, al-though some concerns about the additional costand burden imposed on staff due to conduct-ing groups and data collection were noted (seealso Langley, Nadeem, Kataoka, Stein, & Jay-cox, 2010). These studies looked at community-based interventions for youth who are at riskfor exposure to violence, but these studies didnot incorporate the use of religious or spiri-tual concepts in meaning making or process-ing loss and grief, which are part of recoveryfrom trauma, nor did these studies report reli-gious participation or spiritual practices as con-trol or background variables. These studies were

included because the literature on school-basedand community-based interventions is so scarce;these five studies represent the most recent, andonly, quasi-experimental and experimental stud-ies available to date.

Nonexperimental Descriptive orCorrelation Studies

The next set of studies establishes the ratesat which youth are witnessing and experienc-ing community-based violence among severalpopulations of school-aged youth and corrob-orates the association between community vi-olence and PTSD and depression symptoms.Three of these studies included variables to as-sess whether spirituality and/or religious prac-tice “buffered” the negative impact of experi-encing violence and trauma.

Farrell and Bruce (1997) examined the preva-lence of exposure to community violence in re-lationship to distress and depression among 436youth in a public school system on three oc-casions during a 1-year period. The study con-firmed high rates of exposure to community vio-lence, especially for boys who were more likelyto have experienced assault and threats than weregirls. Forty percent of the sample reported wit-nessing someone get shot. Boys reported lowerlevels of emotional distress than did girls, andexposure to violence was related to a higher fre-quency of violent behavior by girls at the end of1 year.

Pearce et al. (2003) assessed the relationshipbetween witnessing or being victimized by com-munity violence and conduct behaviors during a1-year time frame, among 1,703 youth in an ur-ban public school system. Religious beliefs andpractices were measured with select items fromthe Multidimensional Measure of Religious-ness/Spirituality (Fetzer Institute, 1999). Youthwho reported higher rates of witnessing violenceand being victims of violence also reported moreconduct problems. Like Jones (2007), Pearceet al. found that private religious practice hada unique effect on decreasing conduct problemsand that dimensions of religiousness (spiritualbeliefs and private practices) moderated nega-tive effects of exposure to violence, when parentinvolvement did not.

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Jones (2007) examined the relationship be-tween chronic community violence and com-plex PTSD (C-PTSD) and whether formal kin-ship, spirituality, and other supports typical ofAfrican American cultural values moderated (re-duced) the relationship with C-PTSD, among 71youth. Jones’s findings indicate that for youthin settings with high chronic community vio-lence, high formal kinship and high spiritualitysignificantly moderated the impact of violenceon C-PTSD.

Jenkins, Wang, and Turner (2009) used a con-venience sample of 401 African American ado-lescents from chronically violent settings andcollected data to examine the prevalence and im-pact of violent and nonviolent traumatic eventson PTSD, depression, and internalizing and ex-ternalizing behaviors at two time periods. Thestudy confirmed high rates of exposure to vio-lent and nonviolent traumatic events, with 69%of youth reporting being a victim of an as-sault; 93% had witnessed violence, includinga third who saw someone shot with a gun.The cross-sectional data indicated gender dif-ferences, where loss of a close other predicteda slightly higher, statistically significant rate ofPTSD for girls and internalizing behaviors andexternalizing behaviors for boys.

Kisiel, Fehrenbach, Small, and Lyons (2009)published the results of a large survey of youthin Illinois state protective custody from 2005to 2007. They used the Child and Adoles-cent Needs and Strengths (CANS) tool, includ-ing incidences of community or school vio-lence. The analysis found that youth who experi-enced chronic and multiple exposures to traumaalso tested slightly and significantly higher forstrengths in creative interests and spiritual andreligious interests.

The studies by Jones (2007), Pearce et al.(2003), and Kisiel et al. (2009) support find-ings by Calhoun et al. (2000) and Perkins andJones (2004), which proposed unique and ad-ditive benefits of including spirituality or reli-gious attributes in processing the experiences oftrauma. Spiritual and religious concepts wereobserved as aiding coping, finding meaning inthe experience of and in recovery from trauma,and processing trauma for youth. Spirituality,private religious practices and beliefs, along with

such supports as parental involvement and for-mal kinship, are observed to nurture resilienceand buffer the negative impacts of traumatizationamong youth.

Nonexperimental Case Studies With aSpiritual/Religious Component

Barry, Sutherland, and Harris (2006) con-ducted pretest and posttest surveys with 51 and91 African American youth, respectively, whowere recruited to be part of a 12-month pro-gram to reduce access to alcohol and otherdrugs and support academic achievement, posi-tive self-concept, and positive interactions withpeers and parents. The Faith-Based Preven-tion Model was implemented through three ru-ral African American congregations in Florida.Congregation members volunteered to be trainedas mentors. Mentor teams completed an 8-weektraining, which included knowledge of alcoholand tobacco use, use of community agencies,program planning, implementation, evaluation,and reporting procedures. Weekly activities foryouth occurred primarily in church buildings andincluded group instruction on drug-related in-formation and life skills; social and competitiveevents; and award ceremonies to acknowledgeexcellence and school achievement, mentoring,and parenting skills. Posttest self-report surveysindicated improvement in self-worth, academicachievement, and interactions with peers andparents, and decreased reports of access to al-cohol and other drugs. Religious and spiritualbeliefs or practices that may have been part ofthe program are not explicitly discussed. Thesurveys did not assess prevalence or presenceof PTSD or depressive symptoms, which maybe correlated with chronic complex trauma eventhough the program was coordinated in responseto community violence, among other risks.

Washington, Johnson, Jones, and Langs(2006) assessed a culturally centered mentor-ing program that emphasized spirituality as aprotective factor among 12 African Americanboys selected from a sample of 110 boys whohad been separated from their parents. The cur-riculum had been developed prior to the studyand included themes in cultural identity, self-exploration, value clarification, and nonviolent

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conflict resolution. Results indicated a slight in-crease in spiritual orientation base and improvedbehavior at school and home.

Walker, Reese, Hughes, and Troskie (2010)discussed the relevance of spiritual and religiousissues within the context of trauma-focused CBTwith youth. The authors presented three cases inwhich specific traumatic interpersonal incidentswere addressed and discussed how religious be-liefs aided in fostering hope and meaning duringthe recovery process. The study draws attentionto the use of prayer by clients, individually andwith parents, as supporting the youths’ sense ofsafety. The authors clarified that prayer was not asubstitute for safety planning and implementingappropriate precaution for the environment.

The design limits of these three nonexperi-mental studies make it challenging for scholarsand practitioners to draw conclusions from thefindings. Namely, the samples were convenienceor purposive samples, and the assessment tech-niques include self-reports, focus groups, obser-vation, and interviews. Such assessments offervaluable insights and suggest the benefits of in-cluding religious and spiritual components ingroup therapy and programming among youth,but they cannot address which or whether suchfactors are systematically related to the observedchanges in youth. At the very least, the studiesconfirm that there was not an observed negativeimpact from including religious and spiritual dis-cussion, prayer, and supportive community onyouth outcomes.

One additional study is worth noting here be-cause it adds to the examination of how reli-gious and spiritual elements may complementCBT in a school-based setting. Kataoka et al(2006) adapted the CBITS intervention for useby practitioners in a Catholic school in which80% of the students’ families qualified for thefree or reduced lunch program and were primar-ily from a Latino background. The therapeuticcontent was implemented by “culturally sensi-tive staff” and used “religious rationales” and“religious imagery during relaxation exercises”as a way of counteracting maladaptive thoughts(p. 95). Kataoka et al. (2006) described the col-laborative process involved in implementing theprogram, but to date, further results on the im-pact of the study have not been published.

DISCUSSION

How can further evaluation contribute to de-scribing and assessing the potential of includ-ing spiritual or religious components in inter-ventions with and for youth in reducing PTSDand coping with loss and grief in community-based settings? The most striking observationproffered by this review, is that, to date, sofew community-based and/or school-based pro-grams or interventions have assessed (baseline)trauma symptoms, and just a handful of rigor-ous studies have been carried out to evaluatethe effectiveness of school-based or community-based interventions in reducing trauma symp-toms among youth who live in communitieswith high rates of exposure to violence. Pub-lished literature on evaluation of such programsis scarce (Salloum et al., 2001). As noted byJaycox, Stein, and Amaya-Jackson (2009), thereare few interventions that have been designed foryouth who have experienced or witnessed trau-matic or violent events and that are also feasiblewithin school-based settings. Interventions thatuse teachers, social workers, and other trainedclinicians are just beginning to be evaluatedwith experimental and quasi-experimental stud-ies (see also Jaycox, Morse, Tanielian, & Stein,2006; Jaycox, Stein, Amaya-Jackson, & Morse,2007), despite the widespread prevalence of ex-posure to violence and other traumatic eventsamong youth in urban areas.

A second broad observation concerns theUnited States as a setting for research. U.S.society, in general, takes pride in its fundamentaland constitutional commitment to the separationof church and state. As a society, this high valueplaced on religious independence typicallyimpedes the inclusion of religious or spiritualelements in therapies or interventions that occurin public settings, or in private settings that usepublic funding (Lupu & Tuttle, 2005; Rogers& Dionne, 2008). This reluctance to openlydiscuss the inclusion of religion and spiritualityin a therapeutic sense, in secular settings, mayinhibit programming or interventions that utilizeor allow expressions of religious and spiritualbelief. The relative absence of discussion aboutthe role of religious and spiritual beliefs in pro-cessing traumatic events fuels a lack of rigorous

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evaluation. A recent review of literature onspiritually based interventions indicated that al-though social workers may incorporate their per-sonal spirituality in their therapeutic work, theyare not complying with any set of ethical guide-lines and that social work students and workershave not received instruction on religion or spiri-tuality in their professional training or education(Sheridan, 2009). Until service providers arecomfortable talking about issues of religious di-versity, tolerance, and how to respect the separa-tion of church and state, programs that utilize re-ligious and spiritual beliefs, and the assessmentof these programs, will likely continue to bescarce.

The studies presented here suggest thatyouth’s private religious practice and religiousbeliefs, along with parental involvement, canmoderate the level of PTSD symptoms. Thesestudies suggest the importance of continuingthis line of research and discourse. This maybe particularly true for communities that arelikely to continue to witness or experience trau-matic events and community violence, given thehypothesized role of belief systems in makingmeaning of, or “reinterpreting,” adverse events.Research on the use of spiritual or religious con-cepts in therapy may aid clinicians who sensethat allowing discussion of religious and spir-itual beliefs will support the recovery processthrough meaning making, providing hope, asense of safety, and an enhanced ability to copewith loss and grief.

Studies that assess the role of religiosity andspirituality in coping with trauma and grief areneeded to examine the theoretical and empiricalbasis for understanding how spiritual develop-ment changes as youth mature and to identifywhich aspects support positive behaviors andcoping. There is growing consensus on how toassess spiritual and religious beliefs and practicewith youth, although few studies use compre-hensive measures of religious and spiritual be-liefs and practices among youth (Cotton, Larkin,Hoopes, Cromer, & Rosenthal, 2005; Harriset al., 2008; Pearce et al., 2003). Assessmenttechniques within practice settings are varied(see Hodge, 2005), but few scales that capturethe multidimensional nature of spirituality andreligion have been developed and tested to the

point of having known reliability and validityamong youth populations. Notable exceptionsinclude: the Brief Multidimensional Measure ofReligiousness/Spirituality, which is useful be-cause it is not long (32 items), is composed ofsubscales that can be used independently, hasitems that measure both practice and beliefs, andhas known psychometrics for youth aged 14 to17 years old (see Harris et al.; also Fetzer Insti-tute, 1999; Pearce et al.; Sinha, 2006). Anotherrecent study validated the Adolescent ReligiousCoping Scale for measuring the coping aspectof religious and spiritual beliefs and practices(Bjork, Braese, Tadie, & Gililland, 2009).

Important factors in conceptualizing and mea-suring multidimensional aspects of adolescentspirituality and religiousness include: atten-dance at organized faith community events, at-tendance patterns of their parents and/or family,and level of spiritual development, which is re-lated to cognitive development and emotionalmaturity. Young people vary in their ability toquestion their experience of spiritual or existen-tial issues, and they differ in confidence to drawconclusions that are distinct from their familyand friends. Measuring an adolescent’s individ-ual and family’s religious and spiritual beliefsand practices are one among the many com-peting and complementary factors that impactyouth development (Cooley-Strickland et al.,2009).

Addressing Limits in Future Research

Assessing the presence and severity of traumasymptoms among youth exposed to chroniccomplex trauma is a relatively new layer ofassessment in the field of youth development.This section offers recommendations to guidefuture research on conducting evaluations andstrengthening effective research and practice inaddressing trauma symptoms among youth. Thefollowing areas are addressed: design issues, theneed for subjective assessment, the need for earlyassessment, and the importance of setting andcultural relevance of intervention models. Thesection concludes with a discussion on the ben-efits and limits of participatory action models inevaluation.

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Design Issues

As with many types of intervention studies,the plausible and ethical way of getting con-trol groups is to waitlist. This impairs randomsampling, random assignment, and the ability togeneralize the results. Studies with large samplesizes that assessed spirituality and religious fac-tors suggested them as factors that promote orsupport decreased traumatic stress and depres-sion, but these studies did not assess spiritualityor religion as independent variables, nor werethey intervention studies. In this review, stud-ies that assessed religious and spiritual beliefsor behaviors as integral to the intervention werenot experimental nor did they include long-termoutcome data. These limitations make it difficultto estimate the length of time that will maximizeintervention impact. However, a recommenda-tion for longitudinal studies is warranted: Lon-gitudinal studies enhance a practitioner’s abilityto plan, fund, and implement interventions andstrategies to support well-being and diffuse thepotential longer-term effects of trauma (Cooley-Strickland et al., 2009). Funders who are in-terested in eliciting robust research in this areashould support multiyear evaluations.

Assessing Subjective Accounts

In this review, 5 of the 13 studies includedsome qualitative assessment. Qualitative mea-sures provide insights into people’s feelings, ex-periences, and views on the relevance of inter-ventions. However, such studies were not thenorm, and future research that develops andtakes advantage of qualitative interviewing willstrengthen future findings. Qualitative measuresare well suited to record the views of youth,which are likely to be different from those of pro-fessionals and policymakers and may yield piv-otal insights. Qualitative studies should exploreyouth and community participants’ perspectiveon how to effectively intervene and prevent com-munity violence, how best to cope with traumaticstress, and whether the inclusion of religious orspiritual beliefs or practices in interventions willprovide insights for effective programming incommunity-based settings.

Early Assessment of Trauma

Many providers routinely include demo-graphic information. However, standard earlyassessment in community-based settings doesnot commonly include an assessment of traumasymptoms, including history of exposure to vi-olence, or presence of religious and spiritualbeliefs. High schools, youth clubs, or commu-nity organizations that routinely work with youthwho are likely to have been exposed to ongoingor chronic traumatic events could routinely in-clude items to assess symptoms associated withexposure to violent and traumatic events. Suchdata would corroborate the prevalence and sever-ity of traumatic symptoms among urban mi-nority youth and would document the need forstress-reducing interventions. A number of toolsthat could serve this purpose have been devel-oped and are available for little or no cost (seeStrand, Pasquale, & Sarmiento, 2006; The Na-tional Child Traumatic Stress Network, n.d.).

Setting and Cultural Relevance

Mental health treatment is less accessible andavailable in inner cities (Cooley & Lambert,2006). Thus, treatment and prevention services,as well as evaluations of these services in high-risk urban areas, need to be implemented in waysand settings that are relevant and accessible. Thisis particularly important given that youth whoreside in high-violence neighborhoods and whohave been exposed to family- or community-based trauma are unlikely to seek out clini-cal mental health resources (Jaycox, Langleyet al., 2009; Kataoka et al., 2003; Koffman et al.,2009). For these reasons, services that are not“place-based” and customized to the particularpopulation and context are unlikely to be usedfrequently, or to be successful (Koffman et al.;Reese, Vera, Thompson, & Reyes, 2001).

Another argument that suggests the need forcommunity-based interventions and evaluationis that a common setting can normalize, ratherthan stigmatize, the use of prevention and in-tervention programs. For example, the school-based JIPP (Koffman et al., 2009) required par-ents to attend a weekly parenting session in theschool setting along with their teens. Through

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this experience, parents are affirmed in the re-alization that parenting a teen is a tough job,and they gain personal and communal skillsaround effective relationship building. Further-more, parents tell other families and neighborsabout the program, which lessens the stigma of-ten attached to the use of mental health or devel-opment programs. As more youth go through theprogram and graduate from high school, gradua-tion becomes an attainable goal and the commu-nity adopts graduation as a realistic expectation(S. Koffman, personal communication, January31, 2011). Thus, through using a school-basedsetting and mandatory parent participation, theexperience of being in an intervention is nor-malized, more community members are willingto participate, and it raises an expectation thatgraduation is attainable.

Solutions, such as the JIPP, involve multiplesystems—families, schools, school board, andjuvenile justice—and engage students, teachers,parole officers, and social workers. Similarly, wesuggest that evaluation strategies that engage lo-cal actors from multiple systems will producebetter knowledge with which to confront com-plex, systemic issues such as exposure to chroniccommunity violence in its varied forms, such asdomestic violence, street violence, and traumadue to loss of loved ones.

Benefits and Limits of a ParticipatoryAction Model for Evaluation

What types of evaluation strategies engagelocal actors from multiple systems? Participa-tory, or action, research is a framework that in-volves varied stakeholders in research design,development of research questions, data collec-tion, analysis, interpretation, and dissemination.There can be varying amounts of participation atthese various stages. For example, teachers andsocial workers were used in conducting inter-ventions and in data collection in several studiesreviewed here. Stein et al. (2003) used trainedmental health clinicians from the school districtto administer the intervention in the school set-ting. Other predata and postdata were collectedfrom students, teachers, and parents to assessstudents’ symptoms of PTSD, depression, psy-chosocial dysfunction, and classroom behavior.

The study authors noted that the study was fea-sible because of its strong collaboration withschool staff and mental health clinicians who ranthe intervention and collected data. Staff wereconsulted on how to implement the intervention,and teachers and administrators benefited fromlearning new ways to think about how violenceaffects children’s social and cognitive develop-ment.

As this example shows, community-basedresearch that is participatory offers specializedbenefits: It can increase the feasibility ofinterventions, and it can maximize “buy-in”from community partners (Griffith et al., 2008).However, one caution in the use of localpractitioners in evaluation and data collectionactivities is that these activities represent extrawork for these staff. Interventions carried out inschools, for example, may require staff to fill outsurveys, conduct observations, or perform otherdata collection activities in addition to theirregular workload. However, rather than beingburdensome, conducting research may becomea routine part of more professions—much likequality assurance. The move toward evidence-based practice in social work and health carerequires that providers are knowledgeableabout and use best practices. Thus, employerswho devise incentives for staff participation inevaluation will be more likely to be compliantwith evidence-based practice standards and mayalso improve employee morale.

Implications

The intersection of three research and practiceareas has been highlighted in this review: 1) CBTintervention programs that can be implementedin community- and school-based settings; 2) theunique role of spirituality and religious beliefsand practices in processes of meaning making,providing hope, a sense of safety, and copingwith loss and grief related to trauma; and 3) spe-cialized benefits of engaging community mem-bers in collaborative efforts in addressing traumasymptoms and carrying out evaluations. This in-tersection suggests a promising venue for re-search and action, which will provide locally rel-evant knowledge and support advocacy effortsaround violence prevention and interventions

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for traumatic stress. Salloum et al. (2001) sug-gest that there is little question that CBT isan effective method for working with adoles-cents given the rates of violent and frequentloss, as well as the nature of complicated griefand chronic trauma. Researchers are obligatedto continue conducting systematic research withthis population on this debilitating issue.

Because trauma is a multidimensional con-cept, a continuing challenge is to develop con-sensus around what outcomes or indicators areuseful for measuring or predicting subsequentmental and emotional health (social–emotionaldevelopment) and productivity long term. Liter-ature in the recent past, which reviewed the roleof youth spirituality, has primarily confirmedspirituality and religion as a protective factoron various health, substance use, education, andother risk behaviors (see Joon Jang & Johnson,2010; Regnerus, 2003; Regnerus & Elder, 2003;Rew & Wong, 2006; Sinha et al., 2007; Smith,2003). This review suggests utilizing a spiritualor religious framework to support the process-ing of grief and loss and meaning making, and asa coping strategy among minority urban youthwho are at a higher risk for exposure to vio-lence. Research has not identified how spiritualor religious beliefs and practices aid resilience,but two pathways were described here, includ-ing religious participation as a type of socialgroup activity that promotes physical, mental,and social health (Ellison, 1991), and spiritualand religious beliefs as a mechanism for inter-preting meaning and purpose in life especiallyin the face of adverse events (Pargament, Smith,Koenig, & Perez, 1998; Park, 2005; Walters &Bennett, 2000).

It is notable that therapists do not have to bepersonally committed to or entirely well-versedwith religion or spirituality to allow youth to re-fer to religious beliefs or spiritual meanings asthey interpret and reinterpret their experiences.Experienced therapists are adept at discerningwhen clients are making positive progress to-ward reintegration versus when a client’s be-lief system is damaging or impeding progress.Practitioners may incorporate religious and spir-itual beliefs or practices in interventions throughcommon CBT tools. As described by Kataokaet al. (2006), social workers within a Catholic

setting utilized religious rationales to substitutefor maladaptive thoughts and used religious im-agery during relaxation exercise. Similarly, in astudy comparing effectiveness of cognitive ther-apy that used religious imagery, even when thetherapist was nonreligious, the cognitive therapywith religious elements was slightly more effec-tive at follow-up among religious adults (Propst,Ostrom, Watkins, Dean, & Mashburn, 1992).Fuller discussions of therapeutic work that allowreligious and spiritual assessment and inclusionof religious frameworks and potential pitfalls areavailable (Canda, 2010; Hodge, 2011; Lukoff,Lu, & Turner, 1998; Walker et al., 2010).

Youth, their families, and their communitiesmay be well served by additional spaces andrelationships in which it is safe to talk aboutgrief, loss, and traumatic events. The survey byJenkins et al. (2009) among 403 sixth to eighthgraders from chronically violent neighborhoodsin Chicago draws attention to PTSD and depres-sion symptoms, which were significantly relatednot only to violent trauma, but also to nonviolent,accidental trauma, such as a family member hurtor killed in an accident. This finding indicatesthe need for programs that enable the expres-sion of grief and loss of all kinds, for girls andfor boys. Thirty years ago, it might have beenaccurate to assume that many individuals’ pri-mary setting or outlet for the expression of andcoping with trauma, including grief and loss,was a local faith community. Today, however,despite high rates of belief in God among thegeneral population (ranging from 86% to 92%in national polls by the Barna Group [2009] andGallup [2011]), declining rates of membershipand attendance in many religious denominationssuggest that is not accurate to assume that youthand families have adequate resources or settingswithin which to express and process loss, suchas those that a local congregation may provide(Newport, 2011; Pew Forum on Religion andPublic Life, 2008). One alternative is the devel-opment of school- and community-based mentalhealth support services.

Further research needs to concentrate onrobust, longitudinal, qualitative and quantita-tive assessments to determine the effectivenessof various interventions, such as the use ofCBT, and needs to assess whether and how the

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inclusion of spiritual or religious elements ishelpful to youth, especially within AfricanAmerican and Latino cultures. School- andcommunity-based settings that utilize youth de-velopment models and trauma-informed therapy,and that explore the use of religion in meaningmaking and reinforcing positive coping, are idealvenues for participatory research. Community-engaged models can support the creation ofspaces where loss and grief can be expressed and“normalized” within the community. Pathwaystoward healing can be made more accessible toa wider range of youth and families throughearly assessment, community-placed interven-tions, and the engagement of parents, teachers,social workers, and youth development profes-sionals.

NOTE

1. For fuller reviews of the literature on the use ofspirituality and clinical practice with adolescents, seeCanda (2010); and for religion and/or spirituality ongeneral adolescent health, in general, see Rew & Wong(2006) and Cotton, Zebracki, Rosenthal, Tsevat, andDrotar (2006).

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a critical review of trauma interventions and religion among youth exposed to community violence

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