The main goal of group therapy for veterans with PTSD is to jointly overcome behavioral problems associated with avoiding, aggressive, self-harm, or antisocial behavior. The first objective of this goal is to establish a trusting relationship between the counselor and veterans who suffer from PTSD. An essential point in goal setting is to identify the main obstacles that refrain patients from confidential communication with a counselor and other group members.
Although most veterans are men, there may also be women among patients. It must be taken into account since men often behave following the generally accepted norms of masculinity. According to Corey et al. (2014) “all-male groups provide men with the support they need to become aware of the restrictive rules and roles they may have lived by and provide them with the strength to question the mandate of the masculine role” ( p. 390). The female presence in groups can prevent men from opening up to the counselor and other participants, instinctively playing a “real man”.
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Although PTSD results in military service and battles, the counselor will focus on the positive aspects of being a veteran during group meetings. Richard E. Adams postulates that a veteran’s positive self-image or “high veteran centrality” can be a significant help to former military personnel (2019, p. 308). The counselor will show the group that military service for the benefit of the country and fellow citizens is a reason for pride and high self-esteem. Placing a positive emphasis on the military role, allows these veterans to get rid of the guilt associated with their condition and find the internal resources to overcome the behavioral problems that they are currently struggling with.
In addition, the counselor will assist group members with assessing and normalizing feelings and reactions associated with trauma by building resilience. Group therapy will increase their awareness and help them identify the unhealthy ways in which they currently cope with these traumatic experiences. In turn, they will share experiences and adopt healthier coping mechanisms in dealing with stress. Sharing the experience of PTSD will enable them to resist self-incrimination and also receive feedback from other group members. Lastly, group therapy will also provide them with information on resources that are available within the military community and outside the military community such as the Disabled American Veterans Organization (DAV) and the Wounded Warrior Project.
Screening, Selection, and Orientation
The group practice has its drawbacks, and it is preferable to conduct a preliminary selection of patients who have given written consent to work in a group. The screening process is important for both the participants and the counselor. It allows participants to make an informed choice in deciding whether to not to join. This group is conducted voluntarily, and each member has the right to leave the group at any time. The counselor will disclose the intended nature of the group and the potential participants will be allowed to discuss their expectations and any issues and/or concerns.
- According to Corey et al. (2014), “The goal of screening is to prevent potential harm to clients, not to make the leader’s job easier by setting up a group of homogeneous members. For some types of groups, screening is based on whether potential members have a specific problem area that is in alignment with the general objectives of the group” (p. 146). Due to this essential statement, the group leader has to evaluate veterans with PTSD within different criteria. To identify the target group members, the group leader will ask the individual if he or she has ever served in any of the branches of military service (US Army, Navy, Marines, etc). Secondly, the group leader will conduct a brief survey that includes the following questions:
- Do you have repeated, disturbing memories, thoughts, or images of a stressful experience from the past? (a) never (b) sometimes (c) very often
- Do you avoid activities or situations because they remind you of a stressful experience from the past? (a) never (b) sometimes (c) very often
- Do you feel irritable or have angry outbursts? (a) never (b) sometimes (c) very often
Thirdly, the group leader will administer a technique as described in a study by Richard E. Adams. He suggests evaluating PTSD factors under the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the PTSD (American Psychiatric Association) checklist (Wortmann et al., 2016, p. 1393). To establish the PTSD factor, veterans must pass the test and meet criteria A - E and G for DSM-5. The criteria list includes exposure to trauma (A), obsessive symptoms (B), avoidance (C), negative mood changes (D), excessive agitation (E), and distress syndrome (G) (p. 1396). Veterans must have most of their symptoms described to partake in this group therapy. Seating is limited therefore only the first eight individuals to complete the task listed above will be allowed to participate in this group therapy.
Orientation and Preparation of Members
The first session will focus on getting the veterans orientated into the group. The veterans will engage in an introductory icebreaker activity to build member-to-member and member-to-leader rapport. The facilitator will discuss the group rules with all members such as respect for each other, everyone having the freedom to speak or not speak and only one person talking at a time. She will stress the importance of maintaining confidentiality and how breaching confidentially is grounds for being terminated from the group. The facilitator will allow members to add to the list of ground rules, but not take away from them. The group rules will be on display during each session. Furthermore, the facilitator and members will also discuss roles and expectations. Lastly, she will allow the members to state any concerns and ask questions.
Practical Considerations in Setting
Location
Meetings will be held at the VFW Post 6018 at 116 Chance Street Fayetteville, North Carolina 28301. The building is centrally located near Fort Bragg and the surrounding Veterans Affairs Medical Centers making it a useful resource for this area and the target population. The Fayetteville Area System of Transit has a route that runs right by the location which allows easy access to public transportation for members. The building has several rooms that are the appropriate size to accommodate the group therapy sessions. During group therapy, it is vital to set group members in an equal position. The counselor will arrange the seats so that each member can easily see the other’s member’s faces, placing the group in a circle on comfortable chairs. The room will have a Do Not Disturb sign placed on the door when in session. On the far right corner of the room will be a refreshment table with bottled water and coffee for members to enjoy at their leisure.
Meeting times and Frequency of Meetings
The group will meet for 12 sessions every week. Studies indicate “the relationship between encounters and PTSD symptoms leveled out between 8 and 14 encounters” (Hoyt & Stewart, 2018, p. 685). The group will meet every Thursday during lunch hour from noon to 1 pm. The sessions will last 60 minutes each and they will be closed. No new members will be allowed to enter the group as it navigates from week to week to maintain cohesion and progression of training and skill development.
Discussion of the Group Format and Procedure
After the initial session, each session that follows will begin with an icebreaker, followed by a mindfulness-based, stress-reduction group therapy focused on teaching patients to attend to the present moment in a nonjudgmental, accepting manner, adopting kindness and curiosity (O’Malley, 2015). Although the counselor will have an agenda of specific themes to discuss she will allow the group members to set the tone for the topic of discussion if she feels it coincides with what the group needs. However, Levi et al. (2017) suggest that group sessions should include (a) group-building activities, which were designed to establish a sense of togetherness and group cohesion, (b) differentiation of group members, which focuses on the personal, unique, and different characteristics of each group member, (c) intimacy, which aimed to establish intimacy and mutuality between group members and encourage intrapsychic and interpersonal insights, and (d) termination stage, which facilitated separation from the group. As described by Levi et al. (2017) closure is important therapeutically because our experience indicates that war Veterans with PTSD commonly show a behavioral–emotional pattern of “non-ending” and “non-closure” in many life situations (p. 1251).
During each session, the counselor will focus on providing support, and teaching coping skills, all while paying great attention to the emotional inclusion of all group members. She will also assist them with ways to explore and express their feelings. Having the members do this, will allow him or her to empathic support to other members, helping to eliminate hopelessness and despair, and also allow getting rid of the illusion of uniqueness and intolerance of his or her suffering. The counselor will stimulate the group members to an active conversation, giving examples from other people with PTSD.
Group Outcome Evaluation
The overall expected outcome of attending group therapy is to provide veterans suffering from PTSD with a safe environment in which they can discuss their thoughts and feelings about traumatic events that they have endured. Equally important, it offers them the opportunity to see the meaning of the traumatic event and lay the foundation for cognitive processing. To re-evaluate the success of group therapy, the counselor will reuse the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and the PTSD (American Psychiatric Association) checklist (Wortmann, et al., 2016, p. 1393). The group facilitator will provide the veteran with the opportunity to meet one-on-one, in person or via telephone, to conduct a group follow-up session. Lastly, to test the longevity of the treatment, participants will be asked to redo the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and the PTSD (American Psychiatric Association) checklist one year from the completion of the session. The group facilitator will also encourage members to suggest group structural and mechanical changes.
Recommendations for Future Work and Social Work Implications
There are several recommendations that the author noted that would better assist fellow veterans suffering from PTSD. First, social workers should show more commitment to reducing the gap between those leaving the military and those entering the civilian world. They can do so through continual education. Although many schools have adopted programs that focus on working with service members, veterans, and their families these programs need to be more specifically directed at knowledge of treatments for PTDS. In addition, social workers working with this population need to remain culturally aware that the military has its own culture. Many of the veterans have had exposure to the seen and unseen sides of the war, yet to them it is a cultural norm. Furthermore, all social workers, not just those who work for the Department of Defense (DoD) or the Office of Veterans Affairs (VA) need to have working knowledge of basic information so that they too can work with a military-connected family and/or individual.
Moreover, a continued discussion about the role of social work in inter-professional health care is necessary to build a stronger sense of social workers' potential role and to improve ways to better meet the needs of clients in all populations. Social workers can help educate military service members, veterans, and their families about specific conditions, available services, and helpful programs directed specifically for them. Lastly, future work will be useful in assessing risk prediction models for PTSD in current service members to intervene sooner and start preventative treatment efforts to reduce their chances of becoming at risk of developing the disorder later in life.
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