Adult Treatment Planner

Objectives and Interventions

• Describe the history and nature of PTSD symptoms.
  • Establish rapport with the client toward building a therapeutic alliance.
  • Assess the client's frequency, intensity, duration, and history of PTSD symptoms and their impact on functioning (or assign "How the Trauma Affects Me" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma; see also The Anxiety Disorders Interview Schedule for the DSM-IV by DiNardo, Brown, and Barlow).
• Complete psychological tests designed to assess and or track the nature and severity of PTSD symptoms.
  • Administer or refer the client for administration of psychological testing to assess for the presence of strength of PTSD symptoms (e.g., Minnesota Multiphasic Personality Inventory-2 [MMPI-2], Impact of Events Scale, PTSD Symptom Scale, or Mississippi Scale for Combat Related PTSD).
• Describe the traumatic event in as much detail as possible.
  • Gently and sensitively explore the client's recollection of the facts of the traumatic incident and his/her emotional reactions at the time (or assign "Share the Painful Memory" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma).
• Verbalize the symptoms of depression, including any suicidal ideation.
  • Assess the client's depth of depression and suicide potential and treat appropriately, taking the necessary safety precautions as indicated (see Depression and Suicidal Ideation chapters in this Planner).
• Provide honest and complete information for a chemical dependence biopsychosocial history.
  • Assess the client for the presence of chemical dependence associated with the trauma.
  • Use the biopsychosocial history to help the client understand the familial, emotional, and social factors that contributed to the development of chemical dependence.
  • Refer the client for treatment for chemical dependence (see Chemical Dependence chapter in this Planner).
• Cooperate with an evaluation by a physician for psychotropic medication.
  • Assess the client's need for medication (e.g., selective serotonin reuptake inhibitors) and arrange for prescription if appropriate.
  • Monitor and evaluate the client's psychotropic medication prescription compliance and the effectiveness of the medication on his/her level of functioning.
• Verbalize an accurate understanding PTSD and how it develops.
  • Discuss how PTSD results from exposure to trauma, resulting in intrusive recollections, unwarranted fears, anxiety, and a vulnerability to other negative emotions such as shame, anger, and guilt.
  • Assign the client to read psychoeducational chapters of books or treatment manuals on PTSD that explain its features and development (e.g., Coping with Trauma by Allen).
• Verbalize an understanding of the rationale for treatment of PTSD.
  • Discuss how coping skills, cognitive restructuring, and exposure help build confidence, desensitize and overcome fears, and see one's self, others, and the world in a less fearful and/or depressing way.
  • Assign the client to read about stress inoculation, cognitive restructuring, and/or exposure-based therapy in chapters of books or treatment manuals on PTSD (e.g., Reclaiming Your Life After Rape by Rothbaum and Foa; I Can't Get Over It by Matsakis).
• Learn and implement calming and coping strategies to manage challenging situations related to trauma.
  • Teach the client strategies from stress inoculation training such as relaxation, breathing control, covert modeling (i.e., imagining the successful use of the strategies) and/or role-playing (i.e., with therapist or trusted other) for managing fears until a sense of mastery is evident (see A Clinical Handbook for Treating PTSD by Meichenbaum).
  • Explore the client's schema and self-talk that mediate trauma-related fears; challenge negative biases and assist him/her in generating appraisals that correct for the biases and build confidence.
• Identify, challenge, and replace biased, fearful self-talk with reality-based, positive self-talk.
  • Explore the client's schema and self-talk that mediate trauma-related fears; challenge negative biases and assist him/her in generating appraisals that correct for the biases and build confidence.
  • Assign the client a homework exercise in which he/she identifies fearful self-talk and creates reality-based alternatives; review and reinforce success, providing corrective feedback for failure (see "Negative Thoughts Trigger Negative Feelings" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma; Reclaiming Your Life After Rape by Rothbaum and Foa).
• Participate in imaginal and in vivo exposure to trauma-related memories until talking or thinking about the trauma does not cause marked distress.
  • Direct and assist the client in constructing a fear and avoidance hierarchy of feared and avoided trauma-related stimuli.
  • Assign the client a homework exercise in which he/she does an exposure exercise and records responses (see "Gradually Reducing Your Phobic Fear" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma; Posttraumatic Stress Disorder by Resick and Calhoun); review and reinforce progress, problem-solve obstacles.
  • Have the client undergo imaginal exposure to the trauma by having him/her describe a traumatic experience at an increasing but client-chosen level of detail; repeat until associated anxiety reduces and stabilizes. Record the session; have the client listen to it between sessions (see Posttraumatic Stress Disorder by Resick and Calhoun); review and reinforce progress, problem-solve obstacles.
• Learn and implement thought stopping to manage intrusive unwanted thoughts.
  • Teach the client thought-stopping in which he/she internally voices the word "Stop" and/or imagines something representing the concept of stopping (e.g., a stop sign or light) immediately upon noticing unwanted trauma or otherwise negative unwanted thoughts (or assign "Making Use of the Thought-Stopping Technique" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma).
• Learn and implement guided self-dialogue to manage thoughts, feelings, and urges brought on by encounters with trauma-related stimuli.
  • Teach the client guided self-dialogue procedure in which he/she learns to recognize maladaptive self-talk, challenge its biases, cope with engendered feelings, overcome avoidance, and reinforce his/her accomplishments (see Posttraumatic Stress Disorder by Resick and Calhoun); review and reinforce progress, problem-solve obstacles.
• Implement relapse prevention strategies for managing possible future trauma-related symptoms.
  • Discuss with the client the distinction between a lapse and relapse, associating a lapse with an initial and reversible return of symptoms, fear, or urges to avoid and relapse with the decision to return to fearful and avoidant patterns.
  • Identify and rehearse with the client the management of future situations or circumstances in which lapses could occur.
  • Instruct the client to routinely use strategies learned in therapy (e.g., using cognitive restructuring, social skills, and exposure) while building social interactions and relationships.
  • Develop a "coping card" or other reminder on which coping strategies and other important information (e.g., "Pace your breathing," "Focus on the task at hand," "You can manage it," and "It will go away") are recorded for the client's later use.
• Cooperate with eye movement desensitization and reprocessing (EMDR) technique to reduce emotional reaction to the traumatic event.
  • Utilize EMDR technique to reduce the client's emotional reactivity to the traumatic event.
• Acknowledge the need to implement anger control techniques; learn and implement anger management techniques.
  • Assess the client for instances of poor anger management that have led to threats or actual violence that caused damage to property and/or injury to people.
  • Teach the client anger management techniques (see Anger Management chapter in this Planner).
• Implement a regular exercise regimen as a stress release technique.
  • Develop and encourage a routine of physical exercise for the client.
  • Recommend that the client read and implement programs from Exercising Your Way to Better Mental Health (Leith).
• Sleep without being disturbed by dreams of the trauma.
  • Monitor the client's sleep pattern and encourage use of relaxation, positive imagery, and sleep hygiene as aids to sleep (see Sleep Disturbance chapter in this Planner).
• Participate in conjoint and/or family therapy sessions.
  • Conduct family and conjoint sessions to facilitate healing of hurt caused by the client's symptoms of PTSD.
• Participate in group therapy sessions focused on PTSD.
  • Refer the client to or conduct group therapy sessions where the focus is on sharing traumatic events and their effects with other PTSD survivors.
• Verbalize an understanding of the negative impact PTSD has had on vocational functioning.
  • Explore the client's vocational history and treat his/her vocational issues as appropriate (see Vocational Stress chapter in this Planner).
• Verbalize hopeful and positive statements regarding the future.
  • Reinforce the client's positive, reality-based cognitive messages that enhance self-confidence and increase adaptive action.