lk de Ca Saves you hours of painstaking paperwork, whue praiicing optimum latitude in developing customized treatment plans for working in group settings Patterned after the bestselling The Complete Adult Psychotherapy Treatment Planner, this invaluable sourcebook brings a proven treatment planning system to the group therapy treatment arena. It contains all the necessary elements for developing focused, formal treatment plans fre group therapy that satisfy all of the demands of HMOs, managea se companies, third-party payers, and state and federal review agencies Organized around 28 main presenting problems ranging from domestic violence, to chronic pain, to codependence, to parenting problems, this book features: Bajed » ews6uor * Over 1,000 well-crafted, clear statements that describe the probly ang he long-term goals and short-term objectives of treatment, as wei! sa clinically tested treatment options + Asample treatment plan that can be emulated in writing plans that meet all requirements of third-party payers and accrediting agencies, including the JCAHO and the NCQA ‘* A quick-reference format that allows you to easily locate treatment plan components by behavioral problem or DSM-IV diagnosis ig The Complete Adult Psychotherapy able resource features: | + Treatment plan components for 28 ly based problems that surface in group therapy settings * A step-by-step guide to writing treatment plans * Large workbook-style pages affording plenty of space to record your ‘own customized definitions, goals, objectives, and interventions KIM PALEG, PhD, is a psychologist in private practice in Berkeley, California. She is the author of The Ten Things Every Parent Needs to Know and Kids Today, Parents Tomorrow; coauthor of When Anger Hi Kids and Couple Skills; and coeditor of Focal Group Psycho! ARTHUR E. JONGSMA, Jr., PhD, is the founder and Director of Psycholo: Consultants, a group private practice in Grand Rapids, Michigan. He coauthor of the bestselling The Complete Adult Psychotherapy Treatment Planner, Second Edition; The Child and Adolescent Psychotherapy Treatment Planner; and TheraScribe® 3.5 for Windows®: The Computerized Assistant to Psychotherapy Treatment Planning. A a a a a etn * 1000s of prewritten treatment goals, objectives, and interventions * Handy workbook format with your own treatment space to record in options UANNWTd LNAWAVIUL AdVHIHLOHDASH dNOUD IHL * Over 200,000 Practice Planners sold http://www.wiley.com/practiceplanners $48.95 ‘sav 047125409-y ASN i Kim Paleg and Arthur E. Jongsma, Jr. @Fewe Leiz el fi .e ePlanners’: Gus 3 Arthur E, Jongsma, J OO Rete la Luca @WILEYPractice Planners” mentai heath professionals a full array of practice management .wols. These easy-to-use resources include: The Ad Pychoterpy ‘5 PROGRESS NOTES PLANNER \ i ‘ a Oe gc ace Ra a ae etter cy pStiepy erences : ao eon Coircemmnmnnrersy :Hosur , Agate 2008. The Group Therapy Treatment PlannerPRACTICE PLANNERS™ SERIES Treatment Planners The Child & Adolescent Psychotherapy Treatment Planner The Chemical Dependence Treatment Planner The Continuum of Care Treatment Planner The Couples Psychotherapy Treatment Planner ‘The Employee Assistance Treatment Planner ‘The Pastoral Counseling Treatment Planner The Older Adult Psychotherapy Treatment Planner The Complete Adult Psychotherapy Treatment Planner, 2¢ The Behavioral Medicine Treatment Planner The Mental Retardation and Developmentally Disabled Treatment The Severely and Persistently Mentally Il Treatment Planner ‘The Group Therapy Treatment Planner The Child Peychotherapy Treatment Planner, 2e The Adolescent Psychotherapy Treatment Planner 2e The Gay and Lesbian Psychotherapy Treatment Planner ‘The Neuropsychological Treatment Planner Homework Planners Brief Therapy Homework Planner Brief Child Therapy Homework Planner Brief Adolescent Therapy Homework Planner Documentation Sourcebooks The Clinicat Documentation Sourcebook The Forensic Documentation Sourcebook The Psychotherapy Documentation Primer went Documentation Sourcebook entation Sourcebook lineal Documentation Sourcebook linieal Documentation Sourcebook, 26 ‘The Continuum of Care Clinical Documen on Sourcebook The Group Therapy Treatment Planner Kim Paleg Arthur E. Jongsma, Jr. ® JOHN WILEY & SONS, 1 New York * Chichester # Weinheim ic isbane + Singapore * TorontoI dedicate this book to Jim Voetberg, my group therapy partner when. we were both just learning to listen, support, confront, teach, and affirm, Arthur E. Jongsma, Jr ‘To the clients in groups everywhere who have shared the wealth of their experience and made this book possible. Kim Paleg ‘Theo i printed on aid ee pape Copytight © 2000 by Kim Palg a Arthur € Jongema Je All ghts reserved "eSons Ine yin Canada, content of Append 8 are reprinted with permis al Disorders. Fourth Edition. Cope “lho Wiley & Sons, In, Tied Avenue, New York NY 80-801, fax (212 8506005 E-Nask PERSIREQ G WILEY.COM, sb Joagema, Ankur 1983 planers so.t604a cP siesvis2—der, Printed in dhe Unied States oF Americ, 198165452 CONTENTS Adult Children of Alcoholics Agoraphobia/Panic Anger Control Problems Anxiety Assertiveness Deficit Bulimia Caregiver Burnout Chemical Dependence Child Molester—Adolescent Chronic Pain Codependence Depression Domestic Violence Offenders Domestic Violence Survivors Grief/Loss Unresolved HIV/AIDS. Incest Offenders—Adult Incest Survivors—Adult Infertility Parenting Problems Phobias—Specific/Social Rape Survivors Separation and Divorce Shyness Single Parents ‘Toxic Parent Survivors vii 10 20 34 44 53 64 73 79 89 100 qu 118 128 137 148 156 167 178 186 195 206 219 227 236 248 257CONTENTS, Type A Stress Vocational Stress Appendix A: Bibliotherapy Suggestions Appendix B: Index of DSM-IV Codes Associated with Presenting Problems About the Disk 269 282 291 297 303 PREFACE ‘The Group Therapy Treatment Planner was conceived as a way to facil tate the treatment of specific therapeutic problems in the group setting. Ata time when managed care organizations are becoming the norm in health care and mental health benefits are being severely restricted, there is enormous pressure to treat problems in as cost-effective a way as possible. Focal group therapy is an effective, cost-reducing alternative to individual therapy. Focal groups, in contrast to more traditional transference-based mod. cls of group therapy, are characterized by their homogencit degree of structure, their goal orientation, and their high educational function. Most are time-limited; though in this Planner the specific length of each group is left up to the individual clinician to determine. ‘Also left up to the individual clinician are the issues of group size and the specific screening procedures she or he will use in determining eligibility for the group, apart from meeting the behavioral definitions listed for each specific problem. Because most problems encountered in life are problems of relation- ships with others, from the family to the workplace to social activities, dealing with specific problems in the group format allows clients to work on their issues in the mode that often feels most familiar and comfort- able to them. In a group setting, client problems ean be acted out directly, as opposed to symbolically, and thus addressed more effectively. Fur- thermore, group members can share their resources and their insights and develop new self-pereeptions along the way as they see themselves interacting in different ways. The Group Therapy Treatment Planner outlines many treatment is- sues, the specific goals for treating them, and a range of eclectic inter- ventions for reaching those goals, It is important to remember, ho that this treatment planner cannot substitute for either good clinical training and judgment or experience with groups. Both criteria must be ‘met in order for the material in this book to be most effectively used. On a personal note, I am grateful to Art Jongsma for his guidancePREFACE and feedback; to his right-hand woman Jen Byrne for her uncomplain- ing approach to the difficulties incurred by my inability to bring my technological skills up to scratch; to my editor at John Wiley & Sons, Kelly Franklin, for her encouragement and support; and to the scores of colleagues who are doing terrific work with groups and from whose ex- perience I drew in writing this book. Last but not least, I would like to thank my husband, who patiently guided me through my introduction to Windows and the electronic age of e-mail, and my children, who put up with late pickups, hastily thrown-together meals on writing days, and Saturday disappearances when writing days did not suffice. Kin Pates, Px.D, INTRODUCTION Formalized treatment planning has become an essential component of mental health service delivery in the 1990s. To meet the standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and to help clients qualify for third-party reimbursement, ‘mental health professionals must develop treatment plans that are spe- cific regarding problem definitions and interventions, and measurable in terms of setting milestones that can be used to chart progress. In con- dueting group therapy, treatment plans are no less important; group leaders as well as group members must be very clear about what they are attempting to attain in the group and how to determine whether those goals and objectives are in fact achieved, The purpose in writing this book, therefore, is to clarify, simplify, improve, and accelerate the group therapy treatment planning process. ‘TREATMENT PLAN UTILITY Detailed, measurable, written treatment plans can benefit not only the clients, but also the therapist, the treatment team, the treatment agency, the insurance community, and even the entire mental health profession. The clients are served by a written plan because it clearly delineates the issues that are the focus of their treatment group. It is very easy for both the therapist and the group members to get stuck in the sharing of personal stories and lose sight of what they are hoping to attain, The treatment plan is a guide that structures the focus of the therapeutic contract. Because groups are made up of different mixes of people, each with their own particular version of the general issues, the treatment plan must be viewed as a dynamic document that will be up- dated to reflect major changes in emphasis as they occur. While recog- nizing that the plan may evolve throughout treatment, it nevertheless remains important to settle on specific treatment goals at the outset. Behaviorally based, measurable objectives clearly focus the treatment2 THE GROUP THERAPY TREATMENT PLANNER endeavor and provide a means of measuring treatment outcome, Clear objectives also allow the clients to channel their efforts into specific changes leading to the long-term goal of problem resolution, ‘Therapists are aided by treatment plans because they are forced to think analytically and critically about which interventions are best suited for a particular sot of group therapy participants. In multi- provider settings, treatment plans not only help to clarify objectives but also serve the important function of delineating which clinician is, responsible for which intervention. By providing a common language, ‘The Group Therapy Treatment Planner can facilitate consistent and clear communication between members of the treatment team and with the clients. Clinicians also benefit from clear documentation of treatment be- cause it provides a measure of added protection from possible client lit- igation. Malpractice suits are increasing in frequency, and insurance premiums are soaring. The first line of defense against allegations is a complete clinical record detailing the treatment process. A written, for- mal treatment plan that has been reviewed and signed by each client and is accompanied by complete progress notes is a powerful defense against false claims. Finally, the psychotherapy profession as a whole stands to benefit from the use of more precise, measurable objectives to evaluate success in mental health treatment. With the advent of detailed treatment plans, outcome data, particularly concerning the efficacy of group ther- apy compared with individual therapy, can be more easily collected for interventions that are effective in achieving specific goals. HOW TO DEVELOP A TREATMENT PLAN ‘The process of developing a treatment plan involves logical steps that build on one another. The foundation of any effective treatment plan is the data gathered in a thorough biopsychosocial assessment. As the clients present themselves for inclusion in a group, the therapist must lis- ten sensitively to discern where their struggles lie—in terms of family-of- origin issues, current stressors, emotional status concerns, social network. pressures, physical health problems, coping skills, interpersonal conflicts, and so on, Assessment data may be gathered from such diverse sources as social histories, physical exams, clinical interviews, psychological tests, and genograms. The integration of this data by the therapist or the ciplinary treatment team is critical for understanding the dividual issues and their dynamics as a member of a theraj ‘oup. Once the assessment is complete, use the following six steps to de- velop a treatment plan, INTRODUCTION 3 Step One: Problem Selection This Group Therapy Treatment Planner offers treatment plan compo- nents for 28 problems most effectively dealt with in the group setting For the most part, clients presenting themselves for participation in a specific group are clear about the problems they experience that make them appropriate candidates for that group. Sometimes a client may present with problems that could be adequately addressed in more than ‘one group; at these times the therapist needs to determine whether the presenting problem is in fact the primary issue or whether another more pressing issue needs to be addressed more immediately. An effec: tive group treatment plan ean be applied only to a somewhat homoge. neous population with a specifie problem in common. Step Two: Problem Definition Tolead a focal group, a therapist must decide on a specific problem focus and include as group members only those clients meeting specific be- havioral criteria. Because each client presents for group treatment, ‘que nuanees regarding how a particular prablem manifests itself in his or her life, it's essential for the therapist to use clinical judgment in screening out clients whose problems don't sufficiently overlap those of the other group members. Symptoms of clients included in the group should be associated with diagnostic criteria and codes such as those found in the Diagnostic and Statistical Manual (DSM) or the Interna- tional Classification of Diseases. The Group Therapy Treatment Planner, following the pattern established by DSM-IV, offers an array of behav iorally specific problem definition statements, Each of the 28 presenting Problems has several behavioral symptoms from which to choose. These rewritten definitions may also be used as models in erafting additional definitions. Step Three: Goal Development ‘The next step in treatment plan development isto set broad goals for the resolution of the target problem. These statements need not be crafted in measurable terms, but instead should focus on the long-term global out- comes of treatment. In writing long-term goals, it is important to re- member the chosen time span of the specific therapy group being treated and to write goals that realistically reflect the allotted time. Although. the Planner suggests several possible goal statements for each problem, it is not necessary to have more than one statement for a particular treatment plan,44 THE GROUP THERAPY TREATMENT PLANNER Step Four: Objective Construction In contrast to long-term goals, objectives must be stated in behavior- ally measurable language. It must be clear when group members have achieved the established objectives. Review agencies (eg., JCAHO), HMOs, and managed care organizations insist that treatment results bbe measurable, The objectives presented in The Group Therapy Treat- ‘ment Planner are designed to meet this demand for accountability. Nu- merous alternatives are presented to allow construction of a variety of treatment plan possibilities for the same presenting problem. The ther- apist must exercise professional judgment about which objectives are most appropriate for a particular group of clients Bach objective should be developed as a step toward attaining the broad treatment goal(s). In essence, objectives can be thought of as a se- ries of steps that, when completed, will result in the achievement of the Tong-term goal. Given that even @ fairly homogeneous group contains many different permutations of the same problem, there will nevessar~ ily be more objectives than might be necessary for individual clients in order to facilitate every geoup member achieving the desired go objectives may be added to the plan as the group progresses. Achieving all the necessary objectives should signify resolution of group members’ problems and attainment of the written long-term goalts) Step Five: Intervention Creation Tnterventions are actions by the therapist designed to help group mem- bers achieve the objectives. There should be at least one intervention for every objective, If members do not accomplish the objective after the i tial intervention, new interventions should be added to the plan. Interventions should be selected on the basis of group members’ needs and the therapist's full treatment repertoire. This Group Therapy ‘Treatment Planner contains interventions from a broad range of thera- peutic approaches, including cognitive, behavioral, dynamic, pharmaco- logical, family systems, experiential/expressive, and solution-focused brief therapy. Other interventions may be written by the therapist to re- flect his or her own training and experience. ‘Some suggested interventions listed in the Planner refer to spe- cific books that can be assigned to group members for adjunctive bib- liotherapy. Appendix A contains a full bibliographic reference list of these materials and others. The books are arranged under each prob- lem for which they are appropriate as assigned reading for group members, INTRODUCTION 5 Step Six: agnosis Determination ‘The determination of an appropriate diagnosis for a particular group member is based on an evaluation of that member's complete clinical presentation in the group. The therapist must compare the behavioral, cognitive, emotional, and interpersonal symptoms presented by that client in the group to the criteria for diagnosis of a mental illness as de- scribed in DSM-IV. Careful assessment of behavioral indicators facili- tates more accurate diagnosis. HOW TO USE THIS PLANNER Learning the skills of effective treatment plan writing can be a tedious and difficult process for many therapists. The Group Therapy Treatment Planner was developed as a tool to aid therapists in quickly writing treat- ment plans that are clear, specific, and customized to the particular needs of a group therapy population. Treatment plans should be developed by’ moving in turn through each of the following steps; Choose the presenting problem (Step One) that you plan to use as the focus of a therapy group. Locate the corresponding page number for that problem in The Group Therapy Treatment Planner’s table of con- tents. Determine the optimal number of participants required for conducting this group. Select two or three (or more) of the listed behavioral definitions (Step ‘Two) and record them in the appropriate section on the treatment plan form. Select at least one long-term goal (Step Three) and record it in the Goals section of the treatment plan form. Review the listed objectives for this problem and select the ones clini- ly indicated for the population represented in the group (Step Four). Because groups consist of many different permutations of the same problem, it will probably be necessary to have several objec- tives to ensure achievement of goals for all snembers. Determine the length of the group necessary to achieve the chosen objectives. Choose relevant interventions (Step Five). The numbers of the interven- tions most salient to each objective are listed in parentheses fall ing the objective statement. Feel free to choose other interventions from the list or to add new interventions as needed in the space pro- vided. DSML-IV diagnoses that are commonly associated with the problem are listed at the end of each chapter. These diagnoses are suggestions(6 THE GROUP THERAPY TREATMENT PLANNER for clinical consideration. For a particular group member, select a di- agnosis listed or assign a more appropriate choice from the DSM-IV (Step Six). Note: To accommodate those practitioners who tend to plan treat- ment in terms of diagnostic labels rather than presenting problems, Ap- pendix B lists all of the DSM-IV diagnoses that are included in the Planner, cross-referenced to the problems related to each diagnosis, Following these steps will facilitate the development of complete treat- ment plans, ready for immediate implementation and presentation to the group. The final plan should resemble an expanded (particularly with respect to objectives and interventions) version of the sample plan presented on the following pages. ELECTRONIC TREATMENT PLANNING As paperwork mounts, more and more therapists are turning to com- puterized record keeping. The presenting problems, goals, objectives, in- terventions, and diagnoses in The Group Therapy Treatment Planner are available in electronic form as an add-on upgrade module to the popular software TheraScribe 3.0 for Windows: The Computerized As- sistant to Treatment Planning and TheraScribe 3.5 for Windows. For more information on TheraScribe or The Group Therapy add-on mod- ules, call John Wiley & Sons at 1-800-879-4539, or mail the information request coupon at the back of this book. A WORD OF CAUTION Whether using the print Planner or the electronic version (TheraScribe), it is eritical to remember that effective treatment planning requires that each plan be tailored to the needs of the specific population of clients in that group. Treatment plans should not be mass-produced, even when running the same kind of group again. The strengths and weaknesses of each particular group of clients, with their unique stressors and interac- tional patterns, must be considered in developing a treatment strategy. The clinically derived statements in this Planner can be combined in many way’ to develop detailed treatment plans. In addition, readers are encouraged to add their own definitions, goals, objectives, and interven- tions to the existing samples. INTRODUCTION 7 -——_—____ SAMPLE TREATMENT PLAN PROBLEM: ANGER CONTROL Definitions: Overreaction of hostility to insignificant irritants Consistent pattern of challenging or disrespectful treat. ‘ment of authority figures. Use of verbally abusive language. Goals: Decrease overall intensity and frequency of angry feel- ings in provocative situations, Learn effective coping behaviors to stop escalation and resolve conflicts. Express anger in a controlled, respectful manner with reasonable judgment regarding time and place. Objectives Interventions 1. Verbalize an understanding 1. Teach that anger is a two-step of the two-step model of anger. process, requiring both (1) ex: perience of pain (physical or emotional) and packaging. (2) use of trigger thoughts (at tributions that blame others for the painful experience) to discharge arousal. Facilitate group discussion about anger’ self perpetuating cycle of anger: anger-trigger thoughts-more anger. Encour- age members to share their ‘own experiences with this eyde. 2. Implement the combined use 1. Lead group members through of deep muscle relaxation, safe entire combined relaxation place visualization, and slow program: progressive muscle abdominal breathing, relaxation (without tension), followed by safe place visus ization, and finally deep ab- dominal breathing using cue words, 2. Assign members to practice the entire sequence daily during ‘the week and report on their Drogress the folowing week, eee | (Continued){8 THE GROUP THERAPY TREATMENT PLANNER INTRODUCTION 9 pe 3. Identify own common trigger 1. Give group members a list scenes using relaxation and thoughts for anger. doseribing major trigger positive self-statements to ve- thoughts, including three types duce anger arousal. of shoulds: entitlement (“1 want it so much, I should be able to Group Member Diagnosis: 312.94 Intermittent Explosive Dis- have it" fairness (“It’s fair, 80 order 2, Blicit from group members personal examples of the of each type of and the rest es each category of thoughts and copies for each group member. Assign group members to identify two midrange anger scenes (5 or 6 on scale of 10) Lead members through sev eral imagery coping skills rehearsals of midrange anger 5. Use imagery to practice coping 1. Assign group members to skills in high-anger sits identify two high-range anger scenes (9 or 10 on scale of 10) 2, Lead group members through several coping skills rehearsals (Continued)ADULT CHILDREN OF ALCOHOLICS BEHAVIORAL DEFINITIONS 1. Ahistory of being rai ings, or talk openly about self, we of other people. tbmissive to the wishes, wants, and needs of others; too abandonment and desper sy want to hear rather than the truth. other people wh: sness and a belief that being treated T. Persistent feelings of worthl normal and expected. Strong feelings of panic and helplessness when faced with being alone as a close relationship ends. Chooses partners and friends who are chemically dependent or have other serious problems. 10, Distrusts authority figures—trusts only peers. 11, Takes on the parental role ina relationship, 12, Chronic feelings of alienation from others ADULT CHILDREN OF ALCOHOLICS. 11 LONG-TERM GOALS Decrease dependence on relationships while beginning to meet own needs, build confidence, and practice assertiveness, 2. Demonstrate healthy communication that is honest, open, and self- disclosing. 3. Recognize adult child of an alcohol effects on relationships. Reduce the frequency of behaviors exclusively designed to please others, Demonstrate the ability to recognize, accept, and meet the needs of self, Replace negative, self-defeating thinking with self-enhancing mes. sages to self. Choose partners and friends who are responsible, respectful, and reliable. Overcome fears of abandonment, loss, and neglect as the source of these feelings (i., being raised in an alcoholic home) becomes clear, Reduce feelings of alienation and improve feelings of self-worth, traits and their detrimental SHORT-TERM THERAPEUTIC OBJECTIVES INTERVENTIONS. 1. Ask each group member to describe life problems that Joining the life. 2, 3) jonal material of ACOA traits if necessary to supplement members’ knowledge, and teach an ac- 4 A : 5 5 8 8 teracti2 19. nL, 12, 13, M4 ‘THE GROUP THERAPY TREATMENT PLANNER List childhood family expe- riences that shape behavior, thoughts, and emotions into an ACOA pattern. (5) Verbalize feelings surround- ing childhood family experi- ences of conflict. (6, 7, 8) Identify own role within family of origin. (9, 10) Describe how the role played in childhood family influences current relation- ships. (4, 1D) Verbalize an understanding of the rules of “don't talk, don't trust, don't feel” that were learned in family of origin and cite examples of hovr they were implemented in own experience. (12, 13) List the negative impact on interpersonal relationships of the rules “don't talk, don't trust, don't feel."(4, 11, 13) Identify own alcohol prob- lem and follow through with a referral for treat- ment. (14) Verbalize the difference be- tween emotional needs and personal desires. (15) Identify own emotional needs and personal desires. a8) Practice the expression of own emotional needs and personal desires within the group first and then in daily life circumstances. 7, 18, 19) Ask someone outside the group for help in meeting curate understanding of this pattern of behavior. As- sign reading of It Will Never Happen to Me (Black) or Codependent No More Beattie), Elicit from group members examples of their own be havior that corresponds to the typical ACOA character istics. ‘Teach group members how the lack of consistency, pre- dictability, and safety, the secrecy and fear, combine to result in ACOA traits, soliciting from members examples of experiences that shaped their per- sonality. Describe the family- sculpting exercise. Have each member sculpt 2 typical scene of turmoil in his or her family, using other group members as role players. The active member positions each per. son, explains who he or she represents in the fat and direets the verbal and physical interaction, After each sculpting exer- cise, process the group ‘members’ feelings arising from directing, role-playing, or witnessing the experi- ‘Teach group members the four potential roles adopted by children of alcoholics as described in It Will Never Happen to Me (Black): the 16, a, 18, 19, 20. ADULT CHILDREN OF ALCOHOLICS 13, own emotional needs and personal desires. (18, 19) Identify fears of not being in control of situations, (20,21) 10, Verbalize the link between, growing up in an alcoholic family and the need to con- trol. (22) Identify own attempts at controlling others’ behav- i. iors. (23) Describe what can reason- ably be expected to be con- trolled and what situatio cannot be controlled. (23, 24) Verbalize an understanding of the concept of a higher power and how a spiritual faith in this higher power ‘can reduce the need to be in control. (25) Verbalize an understanding of the concept of compas- sionate detachment versus rejection. (26, 27) Report on the in vivo prac- tice of compassionate de- tachment toward others’ needs in order to reduce caretaking behavior. 1, 13, (28, 29, 30) Verbalize an understanding of where own responsibility 44 for satisfying others’ emo- tional needs begins and ends. (31, 32) Identify own feelings, and express them openly and i assertively in group. (83, 34, 35, 36, 37) responsible one, the ad- juster, the placater, and the acting-out child. Facilitate group discussion of the four roles adopted by children of alcoholics and help members identify their own role within their family of origin. Encourage group sharing of how own role within family of origin affects current in terpersonal relationships. ‘Teach group members about the unspoken rule in alco- hholic families that the alco- holism remain a secret that requires children to rely only on themselves (don’t trust), and about the denial of feelings that re- sults from such a situation (don’t feel). See It Will Never Happen to Me (Black). Facilitate group discussion about the don’t talk, don’t trust, don't feel rules that were learned in the family of origin, highlighting the negative impact of these rrules on all interpersonal relationships. Evaluate each member's current alcohol and sub- stance use and make an ap- propriate referral where necessary. Clarify the differences be- tween emotional needs (e.g., to be loved, to be accepted) and personal desires (e.g., to go to the movies, to get a14_THE GROUP THERAPY TREATMENT PLANNER 24 25. 26. 27 30, Identify fears of expressing anger, including the fear of being abandoned. (38, 39) Communicate feelings openly and honestly with significant others outside the group. (40, 41) Demonstrate congruity be- tween thoughts/feelings and verbal and nonverbal com- munication. (42, 43) Identify and implement self- Report a reduction in feel- ings of shame, worthless: ness, fear, and alienation, 46, 47, 48) Verbalize an understanding of the elements of trust. (49) 16. 18. 19, 20. 21. 22, 23 24. new job, to eat Thai food for dinner), Assist group members in identifying their emotional needs and personal desires. Use role playing and model ing to teach assertiveness, and then have group mem- bers practice assertive re- quests in small groups. Assign group members to express emotional needs and personal the week, for help or support. Process the group members’ ‘success in attempting to as- sertively express their needs and desires. Explore members’ feelings about the situations in which they do not have control, Encourage group sharing of members’ fears of giving up attempts to be in control. Facilitate group discussion about the link between chaos and unpredictal of growing up in an aleo- holic home and the current need to be in control. Encourage group explo- ration of ways in which members attempt to control others’ behavior, Elicit examples from group members of situations over which they have control ver- over which, ADULT CHILDREN OF ALCOHOLICS. 15 25. 26. 27. 28. 29, 30. Encourage group discussion of the concept of a higher power that runs the uni- verse and how acceptance of this concept helps with let- ting go of control and turn- ing concerns over to the higher power. Encourage members to share their own. ideas (or alternative) of this concept, ‘Teach group members the relationship between letting 40 of control and the coi cept of compassionate de. tachment (Le., caring for another person but main- Have group members dis- cuss the distinction between detachment and rejection and relate it to their own lives. In small groups, have mem- bers develop strategies for handling situations at home taining boundaries of r sponsibility). Assign group members to try using at least one of hment strategies ing the week, Review members’ experi- ences in applying detach- ment strategies during the week, reinforcing successes and further strategizing for faitures,16 THE GROUP THERAPY TREATMENT PLANNER 31 32, 33 34. 85, 36. 37, ‘Teach group members the differences between en- meshed relationships and those with healthy bound- Have group members sculpt ‘examples of enmeshed rela- tionships and those with healthy boundaries. Assist group members in identifying own feelings (Ge, using “P’ statements: “Teel when you because " “Twould like as they pertain to material raised in the group. ‘Teach active listening skills ige by paraphras- ing) as an alternative to solution-finding responses; confront any inappropriate ownership of responsibility. Reinforce the appropriate expression of feelings in the group. Facilitate group discussion of the idea that the honest, open expression of feelings is a healthy alternative to controlling, ACOA behavior. ‘Teach group members how expressing feelings and needs honestly and openly is most critical when situa- tions stir up feelings of shame, worthlessness, fear, and alienat ADULT CHILDREN OF ALCOHOLICS 17 38. 39, 40. 41 42, 43. 44. Elicit group members’ fears of expressing anger, includ- ing their fear of being aban- doned by those they love if they express anger toward them, Encourage group members to write out their angry feelings before expressing them in“T” statements. Facilitate the development of feeling statements for each group member about people they care about. As. sign members to use at least one of their feeling statements during the week. Review members’ success using feeling statements with significant others, Elicit group members’ ex- amples of own behavior that was congruent with their feelings and thoughts, as well as examples of incon- gruent behavior. Demonstrate and encourage group members to provide ‘empathic confrontation of incongruity in any mem- bers’ behavior. Facilitate group brain- storming of self-nurturing behavior (e.g, taking a walk, listening to music, taking a bath), and assign members to practice at least one self-nurturing behavior each day.18 THE GROUP THERAPY TREATMENT PLANNER 45. 46 47. 48, 49. Assist group members in identifying negative, ds torted cognitions that fuel and maintain ACOA behav- ‘Teach group members thought: stopping tech- niques (eg., mentally shout- ing “Stop,” snapping a rubber band around the ind encourage them ‘Teach group members how to challenge the né distorted cognitions using Socratie questioning. Facilitate the development of reality-based, self affirming cognitions to replace the distorted cognitions, and demonstrate the link between positive, realistic thoughts and calm feelings of self-esteem, Encourage group discussion of the characteristics that are necessary for building trust between two people honesty, self-disclosure, acceptance, etc) Assign pairs of group mem- bers to go on a “trust wall,” where one member leads another “blind” member (eyes closed or blindfolded) on awalk around the room. Each sighted leader helps the “blind” person explore the surroundings using touch, sound, and smell Process the blind members! ee) ADULT CHILDREN OF ALCOHOLICS. 19 difficulty in letting go of control and trusting the partner, DIAGNOSTIC SUGGESTIONS Axis i Asis I: 311 300.00 309.81 300.4 301.82 301.6 301.9 Depressive Disorder NOS Anxiety Disorder NOS Posttraumatic Stress Disorder Dysthymic Disorder Avoidant Personality Disorder Dependent Personality Disorder Personality Disorder NOSAGORAPHOBIA/PANIC BEHAVIORAL DEFINITIONS, Unexpected, sudden, and repeated panic symptoms (shallow breath s, heart racing or pounding, dizziness, depersonalization trembling, chest tightness, fear of dying or losing control, nausea). Fear of having another panic attack in situat perceived to be difficult Avoidance of those situations where panic attacks have previt occurred or where they may occur. Dependence on the company of a support person, including spouse or partner, on ventures outside the home, 1s where escape is pression in the face of a decreasing range of possible activ. ities. Prevalence of negative, anxiety-producing self-tal 'y to environmental stimuli (temperature, light, sounds, Sensitivity to other people and their feelings. ‘Tendency to please others over own needs and desires. Very rich and vivid imagination. High degree of emotional re ‘Tendency toward perfectionism, AGORAPHOBIA 21 LONG-TERM GOALS Reduce incidence of panic attacks. Reduce fear so that he/she can independently and freely leave home and comfortably be in public environments. Reduce panic symptoms and the fear that they will recur without the ability to cope with and control them, 4, Replace anxiety-provoking cognitions with reality-based, self affirming cognitions, 5, Inérease feelings of self-esteem while reducing feelings of inade- quacy, insecurity, and shame. 6. Reduce experience of general social anxiety. SHORT-TERM ‘OBJECTIVES THERAPEUTIC INTERVENTIONS 1. Get to know another person Have members introduce in a social context. (1) each other in dyads (paired with a stranger) and then introduce their partner to the group. Explain and discuss the Verbalize an under- standing and acceptance of the ground rules of the group. (2, 3) 2 Agree to do homework con- sistently. (2, 3) ty of doi asking permi the room to cal feeling anxious (and return- ing if at all possible), shai ing weekly progress w discussing spec ‘Verbalize an understanding of the development of agora: phobia and relate it to own experience. (5) symptoms, and avoiding Identify a safe person (or unnecessary anxiety- place) on which dependence provoking situations u exists. (6)22. THE GROUP THERAPY TREATMENT PLANNER AGORAPHOBIA. 23 1. Verbalize an understanding appropriate skills have been 18, Verbalize an accurate un- personality traits of the of how depression often learned, derstanding of the nature of agoraphabie person (e.,, stems from the shrinking 3. Teach group members that panic attacks. (23) sensitivity to environmental from daily opportunities for fears must be addressed on 19, Report suecess at accepting, stimuli sensitivity to other activity. (7) a daily basis in order for re- observing, and floating with people's feelings and needs, 8. Identify within self the covery to proceed and that i the feelings of panic when “people pleaser,” creative characteristic personality relaxation, exercise, desen- i they occur rather than ‘and intelligent, rich and traits of the agoraphobic sitization, and cognitive fighting them. (24, 25) vivid imagination, high person. (8) restructuring must be 20. Articulate the distinction ‘emotional reactivity, preva- 9. Give support to and accept practiced consistently to between first and second lence of negative thinking, achieve this. tendency toward perfection- support from other group fear. (26) : de id by members. (9) 4. Elicit from group members 21, Use enping statements taf ism, tendency t avoid by 10. Verbalize an understanding thei history of panic at- cilitate an attitude ofealm erie aa of the long-term, predispos- tacks, including cireumstan. acceptance toward panic at ‘ Problem), ing factors that lead to ago- tial triggers, severity, tacks and to float with the 9. Foster group cohesiveness raphobia and relate them t syinptom pattern, chronic- waves of panic. (27) by distributing, ater per- vin experience. (10, 11) ity, and attempts at coping oh eerie en mission has ben privately 11, Identify own love ofcumu- resolution te Meni eary stages of Sees lative stress and its rela- eure members. Ask each member tionship to a vulnerability covers ener 23, Temporarily withdraw from to call one other (different) to panic attacks. (12, 13) 2 cmplication ina pean a situation when anxiety of member each week to talk 12. Describe frst panic attack jee eee eee Tevel 4 is reached and re- for at least afew minutes to and its triggering event or Se errata turn to it when anxiety is get further acquainted or to situation. (14) Cahners reduced. (30, 31, 32) share a success achieved 13. Tdentify those elements that tack occurred, but of the , 24, Report success in using di- during the week. maintain own agoraphobia possibility of another panic version techniques to re- 10. ‘Teach group members the (13) attack in any remotely simi- i duce panic. (33, 34) predisposing causes of ago- 14. Practice abdominal breath- lar situation. ‘ 25. Report success using ab- ‘raphobia that occur in ing and progressive relax- eee, ee dominal breathing. childhood, which ean in- ation to reduce stress level of the dependence on a safe (28,17, 35) clude parents who commu: (26,17, 19) person and/or safe place 26, Report success using coping nicate an overly cautious 15, Implement visualization of that resulted from (or con- statements along with re- view of the world, are over! a peaceful scene to reduce tributed to) their agorapho- laxation skills to reduce critica, set excessively high stress. (18, 19) ia. panic. (16, 36) eer ae 16. Exercise aerobically at 7. Explore with group mem: i 27. Keep a journal of panic at- ee least four times per week bers the hopelessness and tack symptoms, environ- age ee for atleast 20 to 30 min helplessness they experi- mental cireumstance, Lepiehay easier utes. (20, 21) ence as a result oftheir severity rating, and coping eo euaerancnerae 17. Verbalice an understanding avoidance, strategies used. (87, 38) eee of the panic eycle. (22) 8. Assist group members in 28, Make appropriate decision be unlearned, regardless of identifying within them- ; regarding the need for med: predisposition selves the characteristic24_ THE GROUP THERAPY TREATMENT PLANNER AGORAPHOBIA. 25 ication to reduce panic 11. Have group members share passive, aggressive, and as- 17. Lead members through pro. symptoms. (39) those predisposing factors sertive, and then demon. gressive relaxation protocol 29. Verbalize an understanding that pertain to their own strate assertive expression where each muscle group is of the concepts of sensitiza- experiences. i of feelings in group and first tightened and then re- tion and desensitization 12, Facilitate group discussion ' with significant others. laxed, Stress the need for (40) of the way stress accumu- (68, 59) daily practice. 30. Complete successful desen- lates when it is not dealt | 40. Increase the implementa. 18. Guide members through a sitization protocol using imn- with and how it can lead to i tion of self-nurturing behav- visualization of a peaceful agery. (41, 42, 43, 44) psychophysiological ill iors. (60,61,62), scene, eliciting as many de- 31. Confront own resistance to nesses, including panic at- | 41, Decrease consumption of tails ofthe scene as possi- eaten eee e tacks. Encourage members caffeine and refined sugar ble. Encourage members to fear inducing situation or ta identify their cumalative and focus on good nutrition. tolerating anxiety in those ee | 63) after relaxation protocol soe as) 18, Assign group members to 42. Verbalize a commitment to _-29..‘Review members’ suecess 32, Verbalize an understanding lees ee ee relapse-prevention pro: using progressive relaxation of difference between avoid- soo ie ee gram. (64) and visualization during cent stressors that could be cee ance and temporary retreat, (ds) ee ee Bs to group members Lo bia. ee the anxiety-reducing effects 92. Compete suave 44 Big am gp ner eee | the stories of their first -—-7TT elicit a commitment from 34, Reward self for small sue panic attack and the situa- Se ‘each member to incorporate cesses that demonstrate tions that triggered them. - ae exercise into their dally rou- any progress al all, (48) 15, Describe the factors that tine at least four times a 35. Identify negative, anxiety- contribute to the mainte ne ‘week for at least 20 to 30 provoking cognitions. (49) nance of agoraphobia (es. minutes, Recommend read- 36. Develop reality-based, self phobic avoidance; self ing Exercising Your Way to affirming cognitions to chal- that fosters anxiety Better Mental Health lenge and replace the ity to assertively express i (Leith. nogative, anxiety provoking feelings, needs, and wants; 21, Have members report back cognitions. (50, 51, 52) inadequate self-nurturing to the group on their 87. Identify the mistaken be- skills; a high-stress progress in meeting their liefs that fuel the anxiety- lifestyle; and a lack of exercise commitment. provoking cognitions, and ‘meaning or purpose in life). 22, Teach the concept of the counter with positive aff Encourage group members panie cycle, where a physi mations. (53, 54, 55) to identify those factors tal or emotional trigger 38. Express feelings, including eee leads to body symptoms of anger, openly and honest! 16. Teach deep-breathing tech- panic (heart palpitations, in group and then with sig- nique, instructing group shortness of breath, sweat- nificant others, (6,57) suember to inale slowly ing diziness, trembling, ; aaa and deeply, pause, and ex- tightness in the chest, ete. re hale slowly and completely. ‘The negative thoughts that tween behaviors that are immediately follow the be.26 THE GROUP THERAPY TREATMENT PLANNER 23. 24. 25, 26. ginning of body symptoms lead to intensified body symptoms, which in turn lead to more negative, cata strophic thoughts and re- sult finally in a full-blown, panic attack. Elicit group ‘members’ experiences that conform to the panic cycle, Present accurate informa- tion (eg., that panic attacks are simply the fight-or- flight response occurring out of context; that they are not dangerous and will nat result in heart attack, faint- ing, dizziness, or going crazy) that counters the myths regarding the nature of panic attacks. Introduce the concept of accepting and observing rather than fighting the panic attack. Discuss float- ing with the “wave” of panic, and explain that the physio: logical eoncomitants of the fight-or-ight response are time-limited and will end of their own accord. Assign group members to practice observing the pat- tern of their panic attacks and to try floating with the panic rather than fighting it. Have members report back to the group on their Describe to the graup the distinction between the first fear (ie, the actual physio- logical reactions underlying panic) and second fear (ie., | 27. 28, 29, 30. the one elicited by the nega- tive, frightening self- statements made in response to first fear) Provide group members with a list of coping state- ments (e.g.,“I can be anx- ious and still deal with this situation”; “This is just anxiety, it won't kill me"; “I've survived this before and I'll survive it now") to encourage acceptance and igness to float with the panic rather than fight- ing it, Help group members de- velop a personal anxiety scale from 0 (calm and re- axed) to 10 (terror, major panic attack), using 4 (marked anxiety) as the point between tolerable anxiety and out-of-control panic. Have members iden- tify specific personal physio- logical signs that indicate a potential panic attack Ask group members to use personal anxiety scale to identify early stages of panic (4 or below), when in- tervention is still possible. Explain to group members the concept of being sensi- tized to a situation by stay- ing in it while experiencing increased anxiety. Describe how a phobia to that situa- tion could be developed o1 already in existence, rein- forced. if28 THE GROUP THERAPY TREATMENT PLANNER. 31 32, 33. 34. 36. ‘Teach group members the strategy of withdrawing temporarily from situations where anxiety level of 4 is reached, and then returning after anxiety is reduced, ‘Ask group members to use the withdrawal strategy during the week, and then have them report back ta the group on their success. Assign the practice of di: version strategie to someone; engaging in physical activity; di something that requires in- tense concentration; prac- ticing thought-stopping techni a panic at reaches levels higher than 4. Review members’ use of di- version strategies, reinfore- ing successes and redirecting failures. Assign group members to use abdominal breathing and relaxation during the ‘week to abort panic attacks in which anxiety levels are at 4 or below, Have mem- bers report back to the Assign group members to choose three or four coping statements and practice them with abdominal breathing and relaxa first in group and then in vivo during the week, Have group members keep a log of their panic attacks 38. 39, 40. 41 42, AGORAPHOBIA 29 during the week, noting when and where the attack occurred, what t might have preci ttack, the maximum inten- sity of the attack based on their personal anxiety scale, and the coping strategies they used to abort or limit the attack. Have members share with the group insights gained from the log. Help group members evalu- ate their need for medi ion in handling severe attacks, and make appropri- ate referrals to a both imagery and experiences, Help group members con- struct an appropriate de- sensitization hierarchy for a phobic situation, from least to most anxiety-provoking stimuli, Encourage mem- bers to include reality-based details of each step of the hierarchy. Lead group members through the steps of sys- eating the scene ui longer has the cay ise anxiety levels above Lon the personal yy scale before progress- ing to the next scene in hierarchy.30. THE GROUP THERAPY TREATMENT PLANNER 43 44 45. 46. 2 41. 48, 49. 50, Assign group members to continue working on desen- sitization protocol every day for 20 minutes. Ask mem- bers to develop hierarchies for three other phobic situa- tions. Review members’ success in working on desensitization hierarchies. Facilitate group discussion of possible resistance to the discomfort and hard work of in vivo desensitization, em- phasizing the difference between avoidance and temporary retreat. Teach that sometimes anxiety gets worse before it gets better. ign group members to 19 desensitiza- their safe person. Stress the exposure-retreat- recover-return cycle that ation in vivo, Help group members de- velop a reward system for reinforcing small steps toward recovery. Clarify distinction between thoughts and group members i the distorted, negat thoughts that trigger fear and anxiety. Ip members develop (using the Socratic 51 52 AGORAPHOBIA 31 tions to challenge and re- place anxiety-provoking cognitions. Assign group members to vo challenging their nega- provoking turing, reinforcing success and redirecting failure, Explore with group m bers the underlying Challenge members’ beliefs using the Socr: of questioning, and help them develop affirmations to counter the mistaken beliefs Assign group members to use their affirmations dur- ing the week to challenge mistaken beliefs, and report, Explore with group mem: bers their fears about ex- pressing anger, including fears of losing control or of Help members write out their angry feelings before communicating them to an- other person,32. THE GROUP THERAPY TREATMENT PLANNER 58, 59. 60. 61, 62 63. Clarify the distinction be- tween passive, aggressive, and assertive behaviors. ‘Then role-play situations where members make as: sertive requests of their dyad partners. Encourage honest, assertive expression of feelings within the group and then with significant others. Introduce the concept of the inner child who carries the pain of childhood trauma Help members develop a of self-nurturing behav iors to heal feelings of ne- glect or abuse, and assign group their success in self- nurturing. Explore with group mem- bers their use of caffeine and refined sugar and the influence of these chemicals on anxiety and depression via hypoglycemia. Discuss the importance of decreas- ing the use of both, as well as focusing on good nutri- tion and vitamin/mineral balance to increase stress resistance. cit commitment from group members to a relapse- prevention program con- sisting of daily relaxation, cal exercise, good and cognitive restructuring. Include AGORAPHOBIA. 33 twice-weekly sessions of agery and in vivo desensiti- zation around specific fears, DIAGNOSTIC SUGGESTIONS Axis I Asis It 300.21 300.22 300.01 301.6 Panic Disorder With Agoraphobia ‘Agoraphobia Without History of Panic Disorder Panic Disorder Without Agoraphobia Dependent Personality DisorderANGER CONTROL PROBLEMS BEHAVIORAL DEFINITIONS Body language of tense muscl looks, or refusal to 6. Use of verbally abusive language. 7. Recos lence against either persons or property. 9. No current abuse of drugs or alcohol. LONG-TERM GOALS 1. Decrease overall intensity and frequency of angry feelings in provocative situ au ANGER CONTROL PROBLEMS 35, 2. Learn effective coping behaviors to stop escalation and resolve con- Alicts 3. Express anger in a controlled, respectful manner with reasonable judgment regarding time and place, SHORT-TERM THERAPEUTIC ‘OBJECTIVES INTERVENTIONS 1. State reason for participat- 1, Ask members to introduce ing in group. (1) themselves to the rest of the 2. Verbalize an understanding group and explain why they of goals and ground rules of are seeking help, the group therapy experi 2. Clarify goals of the group ence. (2) therapy experience and ground rules, emphasizing 3. Keep a log of circumstances aaa importance of homework. surrounding the experience of anger. (3, 4) 3. Assign group members to anger log to facilitate self-observation, Entries in- lude date, time, the situa- On, anger-triggering an understanding 6) an awareness of the futility of ven an anger-control tool sameness 6, Verttize the stinaion be. rest Denavir) 7. Articulate a commitment to share with the group in ed. 4. Review members’ anger logs and have members coping with pain rather sights than blaming with anger. dues a0) 8. Demonstrate mastery of progressive muscle relax- ‘Teach that anger is a two- step process, requiring both experience of pain (phys- ical or emotional) an26 THE GROUP THERAPY TREATMENT PLANNER 10, uL 12, 13, 4 18. 19, ation and relaxation with: out tension. (11, 12, 13, 14) Demonstrate mastery of vi- sualization of a safe place. (15,17, 18) Demonstrate quick reflexive use of safe place visualiza- tion in group and in vivo stressful situations. (16) Demonstrate use of cue word coupled with deep, ab- dominal breathing. (19, 20) Implement the combined use of deep-musele rel ation, safe place visi tion, and slow abdominal breathing. (21, 22) Verbalize an understanding of Blis's ABC model of ex plaining how thoughts lead to emotion, (23, 24) Verbalize an increased awareness of trigger thoughts that generate anger. (25) Identify own common trig- ger thoughts for anger. (26) List coping self-talk state- ments for use in response to trigger thoughts. Demonstrate use in i agery of the coping skills of relaxation and positive self: talk in low-anger situations. (28, 29, 30) ‘Monitor effects of relaxation and coping self-talk in anger log. (31, 32) Use imagery to practice coping skills in medium- anger situations. (33, 34, 35, 36, 97, 38) 10. u. use of trigger thoughts (at- tributions that blame others for the painful expe- rience) to discharge arousal, Facilitate group discussion about anger’s self perpetuating cycle of anger: anger-trigger thoughts-more anger. En~ courage members to share their own experiences with this cycle, Elicit group members’ be liefs about the value of venting anger; then correct misperceptions by teaching that ventilation increases rather than dissipates anger. Clarify the distinction be- tween anger as an emotion and aggression as a behav- ior. Emphasize that they can occur independently. Elicit examples from group members of the indepen- dent occurrence of anger and aggressive behavior. Encourage group discussion ‘about the choice between developing coping strategies to deal with the painful ex- perience versus blaming others for the pain, empha- sizing the advantages of the former alternative. ‘Teach progressive muscle relaxation, tensing and then axing each musele group in the body. ‘Teach muscle relaxation of each muscle group without, 20. 21, 22, 23, 26. 2 Use imagery to practice cop: ing skills in high-anger sit- uations. (30, 40, 41) Yerbalize an understanding of active and passive Re- sponse Choice Rehearsal (ROR). (42, 43) Demonstrate memorization of six ROR responses. (44) Verbalize own need state- ments, negotiating state- ments, and self-care solutions assertively, not ag- gressively. (45, 51) Verbalize an understanding of the ways in which RCR responses can be used. (46,47) Demonstrate flexible use of the six ROR responses in role-play situations. (48, 49, 50, 51) Report success on leaving ‘anger-arousing situations if withdrawal statement is ig- nored. (52) Demonstrate flexible use in vivo of the six RCR re- sponses in low-, medium, and high-anger situations, (53, 54, 5 13, 14, 16. 18, 19 ANGER CONTROL PROBLEMS 37 using intentional muscle tension, Assign members to practice progressive muscle relax- ation daily, with and with- out using intentional muscle tension. Have members report back to the group on their suc- cess in using progressive muscle relaxation. Lead group members in a detailed visualization of a personal “safe place” where they feel relaxed and safe. Have members practice vi- sualizing their safe place quickly, then returning to the group. Tell them to stay one minute in each place, cycling back and forth to achieve reflexive use of this technique in stressful situ- ations. ‘Assign members to practice safe place visualization daily after progressive muscle re- laxation, as well as in any situation that has potential to provoke or disturb. Review members’ success in avoiding provocation using safe place visualization. ‘Teach group members deep, abdominal breathing, help- ing members push out their bellies with each breath. Have group members select acue word (e.g, relax, ‘peace, blue) to use with deep abdominal breathing to cue relaxation. Instruct mem-38 THE GROUP THERAPY TREATMENT PLANNER 21. 22, 23. 24, 26. bers to say cue word on each exhalation, Lead group members through entire combined re- laxation program: progres- sive muscle relaxation (without tension) by safe place visual and finally deep abdominal breathing using cue words, Assign members to practice the entire sequence daily during the week, and report on their progress the follow- ing week. (emotion). Encourage sharing of per- sonal examples that fit the ABC model. Give group members a list describing major trigger thoughts, including three types of shoulds: (CT want it so mucl be able to have (ts fair so it shor pen"); and change sist enough, she should do it my way"); and three types of lamers: assumed intent (He's doing that deliber- from group members personal examples of the 27. 28. 29, 20, 31 ANGER CONTROL PROBLEMS 39 use of each type of trigger thought and the resulting anger. Facilitate development of a list of coping self-talk state- ments for each category of trigger thought and a list of general coping statements (Tan sta each group member, ‘Ask group members to se- lect responses from each list, that seem most useful to them. fe group discussion ing statements that work the best, Help members who have prob- lems generating effective coping statements, Lead group members through several rehearsals anger stene (3 or 4 on a scale of 10) and use trigger thoughts to arouse anger; (3) erase scene, using relax- ls and coping self- statements to become relaxed again, “Assign group members to in- clude coping efforts in anger log, and note if emotional arousal or aggressive behav ior decreases as a result,40 THE GROUP THERAPY TREATMENT PLANNER 92, 33. 34, 36. 37, 38, 39. A Review members’ progress in using positive self-talk and relaxation as indicated in anger logs, noting changes in frequency, inten- sity or duration of anger. Assign group members to identify two midrange anger scenes (5 or 6 on scale of 10). * Lead members through sev eral imagery coping skills rehearsals of midrange- anger scenes, Have members share the rest of the group thei experiences with coping. Focus on particular trigger words and thoughts that members report difficulty coping with, and facilitate development of appropriate responses, Lead group members through several coping- skills rehearsals of ‘medium-anger (7 or 8 on scale of 10) scenes. Have members stay in the scene and practice relaxation and coping self-talk statements. Encourage members to share their successes with the rest of the group in cop: ing with high- to midrange. anger scenes, group identify two high-anger scenes (9 or 10 on scale of 10). 40. 41 42. 48. ANGERCONTROL PROBLEMS 41 Lead group members through several eaping- skills rehearsals using high- positive self-statements to reduce anger arousal, Celebrate with members their successes in coping with high-anger scenes. ‘Teach three active (when client is feeling anger) Re- sponse Choice Rehearsal (RCR) opening statements (MeKay and Rogers) ‘Ask for what you n in order to take ‘care of myself”), ‘Teach three passive (when other person is fe RR opening state- icKay and Rogers) (1) Get information (“What do you need in this situa- jothers you is ithdraw “I want to stop and cool off for42 THE GROUP THERAPY TREATMENT PLANNER 44. 46. 40. 48. 49, 50. Emphasize the need for ‘memorization of statements for the benefits of de- escalation to accrue. Assign group members to memorize RCR opening statements. Help group members de- velop appropriate, assertive need/want statements, ne- ting statements, self-care solutions. Empha- size positive voice control (no sarcasm or anger Teach group members to start with one RCR sta ment and switeh if anger continues or sistance. Si tinue until success is achieved Teach members to swits stuck, from active to pass responses or from passi active Have triads of group mem- bers role-play and high-anger scenes (with one person the provocateur, one praeticing the RCR Facilitate group discussion about role-play experiences. Coach group members in developing appropriate ne- gotiation and compromise statements to use in role plays. Confront members’ state- ments that focus on revenge rather than on negotiating or self-care. ANGER CONTROL PROBLEMS. 43 52. Encourage groiip members to leave a situation if their withdrawal statement is ig. nored. 58, Assign members to practice in vivo RR with a low-risk person with whom they've had conflict. Have them plan ahead their need/want state. ment, a fallback position, and a self-care solution, 54, Have members report back to the rest of the group their success with in vivo RCR situations Assign members to practice and report back to the group. DIAGNOSTIC SUGGESTIONS Axis Axis TI: 312.81 312.82 296.xx 312.34 301.83 30L7 Conduct Disorder/Childhood Onset Type Conduct Disorder/Adolescent Onset Type Bipolar I Disorder Intermittent Explosive Disorder Borderline Personality DisorderANXIETY BEHAVIORAL DEFINITIONS 1. Excessive daily anxiety and worry, without factual or logical basis, veral life circumstances. 3. Symptoms of autonomic hyperactivity, such as ness of breath, dizziness, dry mouth, trouble swal diarrhea. 4. Symptoms of hype ep, and general state of irritabi Prevalence of negative, anziety-provoking self-talk. A high degree of sensitivity to other people and their feelings. ‘Excessive tendency to please others over own needs and desires. ‘Tendency to perfectionism. LONG-TERM GOALS 1, Reduce overall level, frequency, and intensity of the anxiety sothat, increasing ANXIETY. 45, 3. Replace anxiety-provoking cognitions with reality-based, self- affirming cognitions. 4. Increase feelings of self-esteem while reducing feelings of inade- quacy and insecurity regarding acceptance from others. SHORT-TERM THERAPEUTIC OBJECTIVES INTERVENTIONS 1. Bach member describe own 1. Ask each member to de- anxiety symptoms that led scribe his/her symptoms of to parti i anxiety and the incident that precipitated joining the anxiety group. 2. Have members describe their personal histories of group. 2. Describe 3 an understanding anxiety; including the nega- of the long-term, predispos- tive impact on their social ing causes of anxiety and and vocational functioning. relate them toown experi 3, Teach group members the ence. (3, 4) long-term, predisposing 4, Identify own level of cumu- causes of anxiety (ex, Be- netic predisposition; growing up in family where parents fostered overcautiousness, perfectionism, emotional security, and dependence, or where parents suppressed assertiveness). 4, Have group members share the long-term, predisposing causes of anxiety that per- nt visualization of oe peaceful scene to reduce stress, (10) lative stress and its rela- tionship to anxiety. (5, 5. Identify the emotional, cog- 6. Practice abdominal breath ing and progressive muscle4 10. 13, M4, 16, 16. THE GROUP THERAPY TREATMENT PLANNER Report on the degree of suc- cess in reducing anxiety when using abdominal breathing, progressive mus- cle relaxat ization techniques. (11 Exercise aerobically at least four times per week for at least 20 to 30 minutes. (22, 13, 14)" Identity own negative, (7, 18, 19) Identify the mistaken be. liefs that fuel anxiety- provoking cognitions, (20) Report success in using pos- itive affirmati distorted, negative beliefs, (21,22) Report increased ak identify and describe sup- pressed feelings, (23, 24, 25) assertively in group and then with significant others, (26, 27, 28, 28) Verbalize the difference be- tween behaviors that are 40, nL. 12, te group discussion f the way stress accumu psychophysiological ill: nesses. Encourage members Assign group members to Bill out a Holmes and Rake stress chart to identify re- cent stressors that could be Encourage members to identify the elements that fain their own anxiety ‘Teach group members ab- dominal breathing and pro- gressive muscle relaxation, techniques. Lead group members through detailed visu and encourage this imagery f gressive muscle relaxation, Assign members to practice abdominal breathing, pro- gressive muscle relaxation, and safe place visual daily and report back to group on their experience, Describe to group members the physiological and psy- 18, 19. 20. BT 22, 23, Demonstrate assertive communication, including ‘the expression of emo: tional needs and personal desires and the ability to say no, (29) Demonstrate problem- solving skills, (30) Demonstrate use of as: sertive techniques to avoid manipulation. (31, 32, 33) Increase implement daily self-nurt Decrease consumption of caffeine and refined sugar focus on good nutri- 7) Make appropriate decision regarding the need for medi cation to reduce anxiety. (38) Verbalize a commitment to a relapse-prevention pro- gram. (39) 13, 14, 15. 16 ANXIETY 47 ical impact of exercise (eg. rapid metabolism of excess adrenaline and thy- roxin in the bloodstream; enhanced oxygenation of blood and brain, leading to improved concentration; production of endorphins; being; reduced depression). Help group members formu: late exercise programs building toward a goal of 20 to 30 minutes at least four days per week. Recommend Exercising Your Way to Bet ter Mental Health (Leith). Review members’ exper ences with their exercise Programs, rewarding s cesses and supportively con. fronting resistance, between ings. Help group members identify the negative, anxiety-provoking thoughts that maintain their anxiety ‘Teach group members the zajor types of cognitive tortioas: overestimating (It it was so awful this tim next time it could catastrophizing CIE don't follow through, I'll never be able to face my friends again’), overgeneralizing (“I always make bad judgments about potential employees") filtering (responding to a single criticism in spite of a basically positive review) (*T os