Treatment Plan Problem: Posttraumatic Stress Disorder
Secondary Problem: Domestic Violence Survivors – Female
Adapted from The Group Therapy Treatment Planner, with DSM-5 Updates Second Edition
By Kim Paleg and Arthur E. Jongsma, Jr.
Counselor: Nora Gomez
Population and demographics of group:
This posttraumatic stress disorder (PTSD) group consists of five adult women with various ethnicities, ages 20-30, who have undergone domestic violence and have subsequently developed posttraumatic stress disorder. Most of the women have experienced a series of events that incurred a risk of bodily harm and/or a threat to life. Many also report experiencing nightmares, flashbacks, and/or intrusive thoughts about the trauma. Additionally, some have also reported emotional numbing. Reports of intentional infliction or physical and psychological pain are consistent. Several members have also verbalized feelings of low self-esteem as well as lacking communication and problem-solving skills.
Definitions of Posttraumatic Stress Disorder
Members with PTSD have experienced a series of events that incurred a risk of bodily harm and/or a threat to life. Some may report having felt, and continuing to feel fear, helplessness, and/or horror about the experience and of future potential traumas. Reports of emotional numbing and experiencing nightmares, flashbacks, and/or intrusive thoughts about the trauma are common. Members may demonstrate symptoms of physiological arousal including hypervigilance, insomnia, difficulty concentrating, startle response, anxiety, and/or irritability. They may also express a loss of interest in work or leisure activities. Members can also describe a tendency to avoid places and activities that evoke memories of the traumatic event. Some may express feelings of alienation resulting in social isolation or emotional distance from others. They may also report problems with intimate and/or causal relationships. Members may verbalize guilt over surviving or being somehow responsible for the trauma. Additionally, members do not abuse alcohol or other substances.
Definitions of Secondary Issue: Domestic Violence Survivors – Female
Members who have survived domestic violence may report intentional affliction of physical and/or psychological pain or injury by her partner. They may fear continuing physical injury or emotional abuse resulting from their partner’s assaultive attacks, threats, intimidation, or berating. Also, a pattern of increasing frequency and severity of abusive episodes may be revealed. Additionally, there may also be reports of periods of calm, loving (“honeymoon”) behavior by the abusive partner between abusive episodes. Members may lack communication and problem-solving skills, feel helpless and hopeless about their own and their children’s safety, verbalize feelings of low self-esteem, and/or minimize, rationalize, or justify the abusive partner’s violence.
Goals:
Members will increase feelings of control and safety in all areas of life; reduce behaviors aimed at avoiding situations reminiscent of the trauma; develop and maintain a sense of meaning in life; and increase the ability to sustain meaningful relationships. Members will also increase feelings of autonomy and self-esteem and develop behavioral repertoire for derailing cycle of violence.
Pre-session:
Prior to the first session, members will complete the PTSD Checklist for DSM-5 (PCL-5). This is a 20-item self-report assessment which can be used to screen members for PTSD (American Psychological Association, 2018). It has been found useful as an instrument to monitor changes in symptoms (American Psychological Association, 2018).
| SHORT-TERM OBJECTIVES | THERAPEUTIC INTERVENTIONS |
| Session One: | |
| Verbalize both acceptance of the rules of the group and understanding of the potential impact of being in the group. | Describe the ground rules for the group (e.g., confidentiality, no substance use, preferably no missed sessions, the ability to take an interactive time-out if overwhelming feelings arise in the session) and ask for the members’ commitment to those ground rules. Ensure that the members understand that participating in the group may elicit a temporary increase in PTSD symptoms. |
| Introduce self and describe the symptoms that precipitated joining the group as well as the trauma that triggered those symptoms. | Ask the members to introduce themselves, describing their symptoms and in a general way the trauma that triggered those symptoms. Elicit from the members their personal stories of domestic violence, including the triggers, frequency, and severity of violence incidents, whether the police and the court have been involved in treatment to prevent continued abuse. |
| Verbalize an understanding of the typical symptoms of posttraumatic stress disorder. | Explain the typical range of symptoms of PTSD Frame the members’ problems in terms of their trauma. |
| Session Two: | |
| Verbalize the erroneous beliefs that have resulted from the trauma experience. | Describe to the group the most common cognitive distortions that can result from trauma exposure (e.g., an inability to tolerate mistakes in oneself or others; a denial of any personal problems resulting from the trauma; all-or- nothing, or black-and-white, thinking; the need to continue survival tactics to avoid further disaster). Help the members identify how their cognitive distortions have led to erroneous personal beliefs about themselves and the world. Facilitate the members in starting to challenge their distorted, erroneous beliefs, recognizing that challenging beliefs involves challenging defenses. |
| Accurately evaluate the current level of own physical, mental, emotional, and spiritual safety. | Explain to the group the difference between physical, mental, emotional, and spiritual safety (e.g., that one’s body is not in danger, that one is able to choose beliefs or patterns of thinking that are helpful, that one is able to use one’s emotions as the basis for taking appropriate action, that one can trust one’s beliefs in a Higher Power and use those beliefs in healthy ways). Facilitate a group discussion differentiating between the members’ actual and imagined levels of safety in different settings. |
| Acknowledge strengths demonstrated during the trauma. | Help the members identify positive traits that they demonstrated—either in thought or behavior—during their traumatic experiences or thereafter (e.g., determination, will to survive, courage, intelligence, resourcefulness, faith, physical strength, emotional strength, creativity, resilience, intuition, optimism, righteousness, personal responsibility). Encourage the members to keep a healing journal, beginning with a description of their positive traits, and writing about their trauma in metaphorical terms, including themselves as the hero or heroine, and using symbols of their choice (e.g., to stand for the trauma, ideas of safety, mastery of the problem). |
| Session Three: | |
| Implement coping strategies to reduce trigger impact with at least 75 percent success. | Teach the group strategies for dealing with triggers (e.g., distraction, ignoring it, staying in the present); have the members visualize success with specific strategies that they will use with specific triggers. Instruct the members to practice the trigger coping strategies during the week and report to the group on their success in subsequent meetings. |
| Practice strategies aimed at reducing numbing and avoidance. | Explain to the group the types of avoidance and numbing behavior that are characteristic of PTSD (e.g., avoiding thoughts, feelings, activities, people, or places associated with or reminiscent of the trauma; forgetting important aspects of the trauma; substance use; suppression of emotions; isolating from others) and their function as protection against distress; help the members identify their own patterns. Teach the group strategies to reduce avoidance and numbing behaviors (e.g., accurately evaluating the threat in any situation, using coping strategies to face triggers, increasing stress management activities); encourage the members to practice the strategies between sessions. |
| Practice dual awareness exercises with at least 75 percent success. | Describe to the group the concept of dual awareness (e.g., the awareness during a flashback that although it feels like the trauma is recurring, it actually is not). Lead the group through dual awareness exercises (e.g., remembering a mildly distressing event, becoming aware of the physical and emotional reactions to the memory, then returning awareness to the present and its sensory components, then taking awareness back to the distressing event while maintaining awareness of present surroundings, and finally back again to the present). Elicit a commitment from the members to practice the dual awareness exercises at home until they are able to maintain awareness of their present surroundings while remembering a mildly unpleasant event with 100 percent success; encourage the members to use a slightly more disturbing memory and practice the exercises until they have at least 75 percent success. |
| Session Four: | |
| Identify and replace distorted self-critical cognitions. | Help the members identify the distorted, negative, and self- critical cognitions that trigger feelings of low self-esteem. Assist the members in developing realistic, self-affirming cognitions to replace negative self-talk; encourage them to practice reviewing these positive thoughts during the week. Review the members’ experiences in replacing negative cognitions, reinforcing successes and redirecting unsuccessful attempts. |
| Articulate the difference between passive (including passive-aggressive), aggressive, and assertive behaviors. | Clarify for the group the distinction between passive, passive-aggressive, aggressive, and assertive behavior. Teach the group active listening skills and the use of assertive feeling statements (e.g., “I feel____when you____because I____. I would like____.”); role play situations where the members make assertive requests of their dyad partners. |
| Develop a healing ritual and agree to implement it at least once. | Describe to the group the importance of ritual in healing and help the members orchestrate a healing ritual (e.g., selecting something symbolic to represent that trauma or things lost in the trauma, and deciding how to bid farewell to those things; writing a letter describing the trauma and the life beyond the trauma and reading it aloud; holding a memorial for someone that died in the trauma) for themselves. Encourage the members to complete their healing ritual once; process the experience in a later group session and explore the value of repeating the ritual more regularly (e.g., on the anniversary of the trauma). |
References
American Psychological Association. (2018, September 26). PTSD assessment instruments.
https://www.apa.org/ptsd-guideline/assessment
Paleg, K. & Jongsma Jr., A.E. (2015). The Group Therapy Treatment Planner, with DSM-5
Updates Second Edition. John Wiley & Sons, Inc.
Discerning Trauma 