Expressive group counseling as a model for increasing self-awareness to reduce trauma symptoms experienced by children in Palestine

The purpose of this study was to test the effectiveness of a time-limited group counseling program based on expressive activities in improving levels of self awareness and reducing PTSD symptoms for children experiencing symptoms of trauma in the West Bank of Palestine. The sample consisted of 30 children who have all experienced significant losses and trauma from Nablus, Palestine ranging from 912 years of age. Participants were randomly assigned to either a treatment or control group (15 in each condition). Results demonstrated that using expressive techniques in a counseling group over a 16 week period improved the level of self-awareness and reduced symptoms of PTSD significantly when compared to a no treatment control group. These findings support the implementation of time limited counseling groups using expressive techniques with children in situations of high intensity and multiple exposure trauma.


INTRODUCTION
Children in Palestine are exposed to multiple level stressors that are traumatic in nature.Death and detention of parents (primarily fathers), extreme poverty, and moving through armed checkpoints, outbreaks of military violence, etc. are common experiences within the population of school -aged children in the West Bank.Despite that fact there are few treatment programs of any kind to address generalized trauma for the school aged population.As resources are limited both professionally and monetarily it is imperative to investigate methods to address symptoms resulting from trauma within a wide population.
Trauma as defined in the DSM-5 for both children and adults is based on an external event, either witnessed or experienced that involves actual or threat of death or serious injury to self or others and evokes fear, helplessness, and horror.These events may include being physically assaulted, threatened with arms, and or witnessing violent acts perpetrated on others.The experiences lead to a fear of death, loss of physical well-being, self-integrity, and safety.The individual response may or may not include immediate fear, helplessness, or shock but generally elicits a psychophysiological state of arousal.Trauma symptoms as defined under the diagnosis of Post-Traumatic Stress Disorder may present as multifaceted and individually specific especially in the case of children, which may challenge mental health professionals in making accurate diagnosis.
The fifth edition of the diagnostic and statistical manual describes the symptoms of trauma in three categories: 1. Re-experiencing the trauma through dreams, flashbacks and unwanted thoughts.2. Avoidance and numbing of objects and emotions related to the trauma 3. Hyper arousal which is the physiological reactivity related to traumatic triggers (Johanson, 2009, P4).
Research demonstrates that children develop traumatic symptoms in a variety of situations including being victims of kidnapping, rape, school shootings, car accidents, child abuse, or being a friend or relative of someone who has committed suicide or has been killed.Despite childhood resilience, the rates of PTSD are equal or higher to that of adults experiencing similar trauma (Olive, 2007).This effect increases dependent on the age of the child.Approximately 39% of preschoolers develop PTSD after a trauma, whereas only 33% of middle school students and 27% of high school students develop the disorder after a similar event (Olive, 2007).
Traumatized children are likely to present several symptomatic responses such as: dissociation, generalized anxiety, difficulties eating and sleeping.Psychological symptoms may include phobias, social withdrawal, depression, and separation anxiety.Behavioral symptoms such as aggression are also common (Barkley and Mash, 2003).
Self-awareness is a higher order cognitive function that differentiates between self and non-self, critical in early development.It is the basis of later ability to accurately appraise the self and to accurately represent one's own traits, abilities and attitudes and to eventually understand the behavior of other human beings during interpersonal communications.
The ability to self-reflect has been found to be impaired in many psychological disorders including PTSD and exhibits a wide range of behavioral manifestations including impaired insight into your own actions, lack of empathy, or impaired social understanding.Thus, it is not surprising that deficits in self awareness have been associated with compromised psychosocial and clinical outcomes in trauma subjects (Keshavan et al., 2012).Individuals with low levels of self-awareness may lack the internal self-monitoring and that would otherwise assist them in them in managing their feelings, thoughts, needs, goals, and behaviors.People with low self-awareness may complain of emptiness, confusion about who they really are, suggestibility, contradictory thoughts and feelings, and an inability to set goals for the future (Briere and Rickareds, 2007) Counseling has long used expressive therapies and techniques in addition to traditional "talk therapy" to deepen the counseling process as well as expedite process, diagnosis, treatment and prevention (Liebmann, 2008).
Self-expression is a powerful technique to improve selfawareness among traumatized children.Expressive activities allow the participants to give form to the experience of life, providing an opportunity for self expression and connection with others, for shaping and refining personal experiences, for distancing and witnessing oneself and others, and for responding to that which touches and moves us.Expressive therapy is a bridge between an individual's inner and outer worlds (Suggs, 2007).
Expressive activities have the power to help traumatized children transcend the mundane to connect with parts of themselves that traditional talk therapy may not so readily offer.The expressive therapy provides a medium through which the individual may draw on inner feelings and the unconscious to produce a tangible product, whether a sculpture, a story, a painting, or a dance.Engagement in expressive activities allows clients to explore their deepest and often hidden feelings, to use symbols to represent their inner feelings and conflicts, and to physically express their internal issues.This process opens opportunities for self-exploration and selfexpression that traditional talk therapy does not offer.It is the process, not the processing; of art making that promotes client growth, which may be a novel idea for contemporary professionals, including counselors, clinicians and social workers (Davis and White, 2011).
In investigating the effects of expressive activities in reducing the level of trauma exposure and improving the level of self-awareness, several studies have been conducted.Pizaro (2006) used art and writing therapy to reduce symptoms of PTSD using a sample including forty five undergraduate students who had varying traumas.The results demonstrated a significant decrease in social dysfunction as well as improving mental and physical health after using expressive therapy techniques.With the goal of reducing depression and anxiety as well as improving self-awareness, Natasha (2007) used a group expressive therapy intervention among a sample of sexually abused girls aged (8-11) years in the City of Johannesburg.The research used a four group design to test the efficacy of the intervention.The results emphasized that the experimental groups improved significantly compared to the control groups in the areas of anxiety, depression, trauma symptoms and self awareness.
In the examination of trauma focused expressive therapy in reducing PTSD symptoms among traumatized children.Patricia (2007) compared two treatment conditions: The first treatment focused on expressive therapy and the second one considered as control group.Results showed significant differences in PTSD symptoms between the two groups in favor of the experimental group.
In assessing the role of expressive therapy in reducing PTSD symptoms, Erickson (2008) examined the effectiveness of expressive therapy in decreasing symptoms of trauma and psychological distress among abused women.Results indicated empirical evidence that the group expressive treatment was effective in reducing psychological trauma and distress in this population.
Improving the level of self-awareness to reduce PTSD symptoms, Kunzle (2008) used narratives written by survivors of childhood abuse in Alberta Province.Results showed a significant increase in positive emotional words, self awareness and reducing of PTSD symptoms among those who received the therapeutic intervention.
In assessing the efficacy of expressive tools to improve self-awareness and reduce PTSD symptoms, Bresba (2009) used narrative therapy with a sample of refugees' children in Montreal.The findings of this study showed improvement in the self-awareness and relationships with families of participants.
In an attempt to assess war trauma, refugee status and other factors related to self-awareness, Begovac (2004) studied a sample of children from Bosnia, Herzegovina and Croatia who suffered from war trauma.Results of this study showed that (60.32%) of the examinees had low level of self awareness, and (13.68%) of the participants in this study had psychological problems related to trauma.Results emphasized that war trauma, refugee status are related to poorer self awareness.In examining trauma exposure as a predictor of selfawareness, affect deregulation, and relational disturbance, Briere and Rickards (2007) studied 620 children who suffered from emotional and physical abuse in the State of Florida.Results of this study indicated that trauma exposure was associated negatively with selfawareness, affect deregulation and relational disturbance.
In order to evaluate behavior, self-awareness, and the emotional profile of traumatized children with a surgically corrected congenital heart disease in the state of New York, Francois et al. (2007) created a matched factor study.Results indicated that traumatized children report significantly lower self awareness, more school problems, and a higher percentage of repetition of a school year.
In estimating the effect of trauma on self-awareness, Kruk (2011) examined the relationship between symptoms of psychological trauma and levels of emotional awareness among homeless children who live in shelters in the City of New York.The results indicated full support for the relationship between self-awareness and management of trauma symptoms.
In identifying the relationship between trauma and self awareness, Pfeifer (2011) studied perceived selfawareness and its relationship with psychological trauma among college students.Results showed that trauma was a significant predictor of low self-awareness.In addition self awareness was effective predictors of trauma management.It follows that expressive therapy techniques which are based on improving level of self-awareness would be effective in reducing PTSD symptoms among traumatized children.
The children of Palestine are faced each day with traumatic events but there are little to no programs of group counseling using expressive activities for children.This study was undertaken to develop a counseling program based on expressive activities and test its efficacy in improving the level of self awareness and reducing symptoms of PTSD among a sample of traumatized children in the city of Nablus, West Bank, Palestine.
Specifically, this study tried to answer the following hypotheses: 1. Will treatment exposure create a significant difference on self-awareness and symptoms of Post-Traumatic Stress Disorder regardless of client factors such as gender 2. Will treatment effects remain significant after a 30 day period after the termination of treatment METHODOLOGY Subjects 120 children from a local community center were administered a PTSD scale created by the investigator.Over 70 children tested were found to have clinically significant PTSD scores.A sample randomly selected 30 children from those who received highest scores and then separated them into two groups one receiving the treatment and other not.The program lasted approximately 16 weeks after which the performance of the two groups was again measured.A third assessment was performed for the treatment group only after three weeks of finishing the counseling program.80% of the children selected had experiences occupation related trauma and had experienced the loss of their fathers.20% had experienced either domestic violence, child abuse, or community based violence.

Arabic language PTSD scale for children
As no standardized validated scales were available in Arabic, a PTSD scale was constructed based on the practical and theoretical literature in this filed (Johnson, 2009;Scott and Stradling, 2006).It included all symptoms of PTSD among traumatized children.

Validity of the scale
In order to test the validity of this scale, the following methods were used: First: Content Validity: A committee of experts in counseling psychology totaling (10) reviewed the items of the scale for content validity and comprehensiveness.The criteria of inclusion was 80% of agreement.5 items of the scale were dropped.
Second: Construct Validity: In order to test construct validity, the correlation between each item and the total score of PTSD scale among a sample of 50 traumatized children independent in the sample of the study (Validity Sample) was calculated.All correlations between total score of PTSD scale and its items were significant.
The final form of the PTSD scale contained 47 items representing six dimensions; including re-experiencing trauma, avoidance and numbing, hyper-arousal, physical symptoms, traumatic play and psychological symptoms.

Reliability of the scale
In order to test reliability of the scale, Chronbach's Alpha formula among a sample of 50 traumatized children independent to the sample of the study was used to assess internal consistency for the PTSD.The reliability of the scale was 0.95, which is appropriate for the purpose of this study.

Scale scoring
The scale contains a five point rating scale (always, mostly, sometimes, rarely and never) ranging between 5-1.The total score of PTSD scale ranges between 47 -235, the score 235 indicating high level of PTSD.On the other hand, the score 47 indicating low level of PTSD

Arabic language self awareness scale for children
The self-awareness scale was constructed based on the practical and theoretical literature in this filed (Ashley and Reiter-Palmon, 2012).It included relevant components of self-awareness among traumatized children.

Validity of the Scale
In order to test validity of this scale, the following methods were used: First: Content Validity: A committee of experts in counseling psychology totaling 10 reviewed the items of the scale for content validity and comprehensiveness.A criteria of 80% percentage agreement was used for each item.Accordingly 6 items were dropped.

Second: Construct Validity:
In order to test construct validity, the correlation between each item and the total score self awareness scale among a sample of 50 traumatized children independent to the sample of the study was calculated.All correlations between total score of self awareness scale and its items were significant.The final form of the self-awareness scale contained 45 items representing four dimensions: awareness of emotions, awareness of personal strengths and weakness, awareness of body and awareness of thoughts.

Reliability of the scale
In order to test reliability of the scale, Chronbach's Alpha formula among a sample of 50 traumatized children independent to the sample of the study was used to assess internal consistency for self-awareness.The reliability of the scale was 0.93, which is appropriate for the purpose of this study.

Scale scoring
The scale uses a five point rating scale (very much sure, much sure, moderate sure, little unsure and totally and unsure) ranging between 5-1 scores.The total score of self awareness scale ranging between 45-225 the score 225 indicating high level of self awareness, on the other hand the score 45 indicating low level of self awareness.

Group expressive counseling program
The group expressive counseling program was developed based on the theoretical and practical literature in the field of expressive activities such as: play, dolls, dance, movement, drama, sand, visual art, free drawing, poetry and music (Abla, 2002;Coholic, 2010;Liebmann, 2008;Rubin, 2010;Sherwood, 2004;Silver, 2007).The expressive counseling program included 16 sessions, two sessions per week; every session lasted for 90 min.The program aimed at improving level of self awareness and reducing PTSD symptoms among a sample of traumatized children.Each session of the program included objectives, therapeutic exercises, and homework utilizing a variety of expressive methods including music, drama, poetry, art, sculpture, personal time lines, etc.A committee of experts in counseling psychology totaling 10 reviewed the counseling program and made some modifications, which took into consideration.The program curriculum is found in attachment 1.

Data collection
All participants (control and experimental groups) were given both the PTSD Symptom Screening Tool and the Self Awareness Screening Tool at the initiation and termination of the treatment group.The scales were administered by two research assistants in Arabic verbally with the children.For the experimental group a third assessment was given three weeks after the termination of treatment to insure that changes were stable.

Treatment effects
MANCOVA tests were used to test the significance of differences on post test scores between the control and experimental groups.Gender as a determining factor was also tested to insure that treatment effects were not mediated by sex of participants.

Post Test Scores of PTSD Symptomology for Control and Experimental Groups
Results of Tables 1 and 2 show significant differences between experimental and control group on total score of PTSD scale and its dimensions in favor of experimental group, whereas there were no significant differences due to gender and covariate pre test.
Results of Tables 3 and 4 show significant differences between experimental and control group on total score of self awareness scale in favor of experimental group, whereas there were no significant differences due to gender, pre test and interaction between group and gender.

Results related to the second hypothesis of the study
There are no significant differences ( = 0.05) in self awareness and symptoms of post traumatic stress disorders between post and follow up tests for those who received a group counseling program Experimental group.
To answer this question; Means, standard deviations, and paired samples T-test were used for experimental group on post test and follow up test for PTSD and self awareness scales as shown in the results of Table 5; there were no significant differences between post test and follow up test in symptom of PTSD between post and follow up tests.
Results of Table 6 show no significant differences in self awareness between post and follow up tests.

DISCUSSION
This study was designed to test the effectiveness of a group counseling program based on expressive activities on improving levels of self awareness and reducing PTSD symptoms among a sample of traumatized children in Nablus, West Bank Palestine.
The results of this study demonstrated the effectiveness of treatment in improving the level of self awareness and reducing PTSD symptoms among participants.
Analysis of post-test scores showed significant differences between experimental group and control groups in PTSD symptoms (reduction of) and level of self-awareness (increase) in favor of experimental group.The results reflect the effectiveness of expressive techniques and exercises which were used as an intervention in improving level of self awareness and reducing PTSD symptoms.
The study did not show significant differences between males and females in PTSD symptoms and self awareness, which is an indication that techniques and exercises which were used in this program supported all participants of this program.
Regarding self awareness, the results of this study showed significant differences between experimental and control group in favor of the experimental group.The expressive counseling program appears to have allowed participants to develop self-awareness through expressive techniques and exercises.Self-awareness is considered to be a relevant factor in recovery from PTSD.The results of this study are consistent with previous research (Natasha, 2007;Patricia, 2007;Kunzle, 2008) which found expressive treatment techniques useful in reducing symptomlogy of PTSD and increasing selfawareness.
In an attempt to investigate the maintenance of the therapeutic change over time a three week follow up test in PTSD symptoms and level of self-awareness was completed to program participants which found that treatment effect levels did not significantly change over time.
These results indicate the initial effectiveness of the expressive counseling program in reducing PTSD symptoms and increasing the level of self awareness.Although the period of time was short, group performance on the post test was very high, and might explain why there were no significant differences between post-test and follow up test.
The results of the investigation need to be accepted within context.The sample was a very homogenous group all from a specific local and 80% of which had lost their fathers.The internal social support of same age peers with a similar history and living in close proximity may have enhanced the effectiveness of the therapeutic interventions.The use of non-standardized measures adds a dimension of insecurity which must be analyzed over time in a variety of populations using the same measures.Lastly clearly the time for follow-up needs to be increased to three to six months to have more confidence in the strength and stability of the proposed therapeutic change.

RECOMMENDATIONS
Using expressive techniques in a group counseling setting for traumatized children in Palestine opens opportunities for time and cost effective treatment delivered to a wide spread vulnerable population.Such treatments could make a significant impact on the lives of children at critical junctures in development and enhance natural recuperation given the dearth of services available currently.The following recommendations are posed to further investigate the use of this potentially powerful tool in lives of vulnerable children.
1. Further expound on the expressive method used to identify critical change elements in the proposed treatment curriculum.2. Expand treatment population by geographic area, age and trauma type to identify demographic parameters of the proposed treatment.
3. Training a continuum of professionals such as school counsellors, teachers, social workers, etc. in expressive technique so that availability of these needed methodologies are increased across the territories.

Table 2 .
Post test scores of self-awareness experimental and control group.

Table 5 .
Means, standard deviations and paired samples T-Test for PTSD scale on post and follow up tests.

Table 6 .
Means, standard deviations, and paired samples T-test for self awareness scale on post and follow up tests.