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Accepting the Loss of a Lover
As a highly debilitating disease that occurs after an individual has experienced a shocking, scary, and at times dangerous event, Post-Traumatic Stress Disorder (PSTD) is a major issue in clinical therapy. Occurrences such as terrorism, flooding, earthquakes, and war can trigger PSTD. In addition to the aforementioned, natural occurrences such as the death of a loved one may cause this disease. In light of this, social workers, now more than ever before have a duty of assisting individuals who suffer from PSTD to recover from this ailment so that they may have an improved quality of life. In order to ensure full recovery, a social worker must assist the patient through the engagement and interaction, assessment, intervention, termination, and evaluation steps. The social worker’s efforts notwithstanding, the patient on his/ her part has the duty of being cooperative in the treatment process. This paper will show a therapeutic treatment process of Betty, a 70-year-old widow who is suffering from PSTD.
Identification of Problem
Betty is a 70-year-old widow who is having a hard time to adjust to her new status after losing her husband one year ago. She is a mother of three grown up children and a grandmother to three children. Two of her children her children live close to her premises, just a distance of 30 minutes, the other child, however, lives out-of-state. Before, her husband’s death, he was the breadwinner and she used to survive on his income and social security. In particular, the lack of a stable source of income is worrying to her. Due to the lack of income, she needs to move out of her current house to a retirement home or a single family home. Unfortunately, she is very confused and cannot make any decisions on her own. Although she visits her children, grandchildren, and friends, she is mostly lonely and spends her days playing solitaire. As a result, she has lost purpose in living. She feels her life has crumbled, and this is not how she intended to spend her old age. Betty needs to have a peer group with which she will share her loss, otherwise, she may end up experiencing severe effects of PTSD such as suicide.
Betty’s feeling of emptiness and frustration with life is brought by PTSD. The loss of her husband left her with a big void, which has made her feel desperate. In addition, the lack of individuals to share her experience, or of a communal group of individuals who have gone through a similar situation makes her lonely. In fact, she is unaware of individuals who may empathize with her situation.
Targeting the Problem
When targeting a problem, only one problem can be aimed at a time. Betty has an available social circle of close relatives with whom she can share her problems. In particular, she has her children who live close to her home, as well as her grandchildren who may give her company. In addition, although some of her friends do not talk to her as often as they used to when her husband was alive, she has indicated that there is still a number of them who visit. The main cause of her problem is that she has excluded herself from her social circle. By her admission, she has indicated that she spends a lot of time at home playing solitaire and she has difficulty getting out of bed. These words indicate that she does not have enough time to socialize with people who would assist her to overcome the trauma caused by the loss of her husband. This problem appears to have accumulated over time and is exaggerated by factors such as the lack of enough finance to pay for her needs. In addition, her exclusion from her social circle has resulted in her not been able to to have individuals to assist her in making various decisions.
Having identified the lack of social networks as one of the factors that are enhancing and emboldening Betty’s PTSD, a social worker should seek ways of working with her. In the treatment of PTSD, therapy is effective only when the social worker works with the client instead of working for the client. MacEachron and Gustavsson (2012) note that peer groups are effective in improving an individual’s self-efficacy by enabling him/ her to cope and manage a stressful environment. PTSD has the overall effect of affecting an individual’s mood. In particular, this change in her attitude such as spending a lot of time alone is due to PTSD. In addition, it also explains her negative thoughts towards the world, such as the loss of interest in the world in general.
The use of support groups will enable Betty to cope with the problem of PTSD. These groups will provide her with an opportunity to express her feelings. Moreover, it will expose her to individuals who are undergoing a similar situation; but are still coping with these challenges. Effectively, this will give her hope and trust in her ability to overcome the pain occasioned by the loss of her husband. Ready et al. (2013), posits that loneliness and deficiencies in social skills are one of the main causes of PTSD. With this in mind, it is essential to target PTSD by using rehabilitation techniques to ensure that the patient feels much better after the therapy.
Potential Treatment Method
Having chosen the problem target, the next step was to identify the treatment methods available for Betty. The treatment method should enable her to be able to socialize more with her peers, and in turn, to recover from PTSD. Since the targeting of the disease stage identified the lack of having a peer group as the leading cause in her development of PTSD, the treatment method will mainly rely on the use of psychotherapy and not medication.
Cognitive behavioral therapy has been identified as one of the most effective methods in the treatment of PTSD. Group therapy, which is often used by civilians, the military, and veterans has been found to be effective in the treatment of this disease (Schnurr, 2007). A self-help peer group acts as a supportive, educational, and change-oriented mutually benefiting system for all members. The peer groups are formed based on empathy, respect, shared responsibility, and shared experiences such as emotional and psychological pain (McEachron & Gustavsson, 2012). Brown and Lucksteed 9-38, opined that the overlapping dimension of a peer support group was not only due to shared experiences but also due to the empowering and healing process. As defined by McEachron and Gustavsson (2012), the overarching cause of PTSD is based on the psychological and emotional pain suffered by the victim. Therefore, this model aims at treating Betty from the emotional and psychological pain caused by the loss of her husband. When Betty is able to accept the loss of her husband, she will be able to overcome PTSD and focus more on the ordinary life challenges that she is facing, such as possible eviction from her home.
The purpose of this therapy is to enable Betty to cope with her loss so that she can undertake a more pragmatic approach to living. To achieve this goal, she will need a peer group of preferably elderly women who have experienced a similar loss as her. This situation will enable her to realize that there are people who are empathizing with her situation and understand the pain caused by the loss of a loved one. These peer groups will enable Betty to have a positive attitude towards life. It will also modify her perception that most people are not concerned about her welfare as they used to be when her husband was alive. Better still, she will have friends who will be able to feel the void left by the death of her husband.
The underlying principle in peer support groups is that individuals in these groups normally have a shared experience, which enables them to have trust, empathy, and respect for each other. In addition, they enable members to learn on how to cope with the situation that they are facing. Better still, individuals learn through the contextual wisdom from group member stories of recovery and adaptive coping (Solomon, 2004). From this perspective, a peer group of elderly widows and widowers may positively influence Betty on how to adopt in her new status. In addition, they will also influence her on ways of coping with her changing status. For instance, she will have to cope with the new reality that she cannot continue to stay in her old house since she cannot afford the required amounts of rent. To support the aforementioned, Rivers and Southwick note that a reduction in social support is related to an increase in PTSD.
Another important role of peer groups is the improvement of self-efficacy. Simply, self-efficacy is the belief that an individual has the ability to influence change through his/her own actions on the situation that he/she is facing (Benight & Bandura, 2004). Self-efficacy requires individuals to be pro-active enough to cope with the various challenges that they are facing. Consequently, individuals with self-efficacy see challenges as opportunities for them to focus their strengths and overcome various setbacks. On the contrary, those with low self-efficacy retreat and shy away from challenges. In fact, they see these challenges as their own personal failure. Accordingly, self-efficacy is essential in overcoming PTSD. One of the main importance of peer groups in influencing self-efficacy is that these groups show their members how to cope with various challenges and encourage them to engage in various beneficial activities by influencing them on their ability to overcome all challenges (Benight & Bandura, 2004).
An analysis of Betty shows that she is lacking this trait. Specifically, while self-efficacy is based on an optimistic belief that an individual can perform tasks and succeed in them when faced with various adversity, Betty is confused on how to find a sustainable source of income. To begin with, she admits that she used to survive on her husband’s income and pension. Worse still, she does not disclose any strategy that she is implementing on how she will continue to pay her bills since she can no longer access these form of financing. While it is impractical to expect her to have the energy to engage in intense economic activities, she should at least have some simple strategies on how she is planning to have a sustainable source of income.
From a social cognitive perspective, peer groups will also have the beneficial impact of enabling Betty to be more proactive. Benight and Bandura (2004) note that in order for an individual to be resilient when faced with an adversity he/she requires his/her own personal enablement more than environmental factors. Through peer groups, individuals are able to learn various coping skills, which enable them to master ways of overcoming trauma. Specifically, self-efficacy by itself requires an individual to be pro-active enough and to have the belief in his/ her ability to overcome various problems that they may be facing. Betty’s behavior at the moment is more reactionary than proactive. When she is faced with a potential of eviction, she decides to relocate to a cheaper house. Although her children live only 30 minutes from her current locality, she had not made enough efforts to constantly visit them so that she is not bored, instead, she used to spend most of the time sleeping and playing solitaire. Finally, although she had shown that she acknowledged the need for friends, especially those who used to visit her before the demise of her husband, she had not shown any interest in joining a peer group that would enable her to have more friends.
The Chosen Treatment Method
Having assessed Betty’s health and identified various treatment methods, both Betty and I formed a treatment plan. Jointly, we decide to use peer groups for treatment of PTSD. Importantly, this decision was supported by the fact that there were already eight peer groups in Betty’s town, which she could easily join. In group treatment, there are three main categories; psychodynamic and interpersonal groups, supportive groups, and cognitive behavioral therapy.
Psychodynamic groups focus on understanding how the trauma affects the patient’s sense of self, interpersonal functioning, and experience. Interpersonal group treatment aims at identifying the relationship difficulties on its group members, depending on the type and pattern of traumatic events. Finally, CBT focuses on cognitive therapy in which common posttraumatic cognitions are reviewed such as trust, control, and safety, and the accuracy of these cognitions are challenged. Importantly, CBT groups usually have few members, as a result group members are able to have clear specific skills that they are learning so that they may manage their PTSD. These skills normally include training and trauma-focused techniques such as cognitive restructuring and exposure. Importantly, these skills enable the patient to manage anger, stress or both depending on the individual’s underlying problem.
Since the main effect of PTSD that is affecting Betty is fear, CBT groups that train members on how to overcome stress will enable her to recover from her PTSD. In particular, Betty is stressed by the fear that she may be homeless. The goal of this therapy will be to enable her to overcome this stress. In addition, it will make her more social, proactive, and increase her self-efficacy so that she can engage in activities that will improve her welfare. Generally, CBT groups usually have 12 to 16 sessions in which members discuss their underlying stressors. The participants respond and give feedback, emotional support, and assistance on ways of overcoming these issues. As a social worker, I also believe that the socialization brought by groups will enable Betty to overcome her loneliness.
Assessment
I have developed an assessment tool (Figure 1) which I will use to assess the health status of Betty. This assessment tool consists of ten closed-ended and four open-ended questions. The set of questions, Am I Able to Do All Things? has been created to evaluate if Betty has developed self-efficacy to deal with her PTSD. These questions will focus on evaluating the stressful factors on Betty’s life. In addition, they will be used to assess how she is recovering from PTSD. Quantitative closed-ended questions are used to assess her stress levels. A scorecard has been created where the response to each question has a weight of between 1 and 4.
 
Name…………………….
Date………………………
Am I Able to Do All Things?
Part 1
Instructions: Fill in the below list of general instructions. Give an honest opinion and view of yourself over currently. Use the choices A, B, C, and D that have been given to answer the questions.

True Somehow True False Extremely False
A B C D

 

Questions Score
1.      I feel that my elderly age is enjoyable.  
2.      I look forward to getting out of bed every day.  
3.      I enjoy hanging out with friends and family.  
4.      I at times feel like I am a failure.  
5.      I feel that my family has abandoned me.  
6.      I fear that I may not be able to afford for my necessities.  
7.      I can make my own independent decisions without fear.  
8.      I feel that I am the best grandmother in the world for my family.  
9.      I am proud of the person that I have become.  
10.  My family values me in the same manner that they did when I was with my husband.  

Part 2
Instructions: Fill in the below list of general instructions. Give an honest opinion and view of yourself over currently.

1.      Name two activities that you love to do when you are bored.  
2.      Name two things that your friends can learn from you.  
3.      Name three lessons in life that you are proud to have taught your children  
4.      Identify three things that you want to learn from your friends  

 
The open-ended questions were structured to evaluate her self-efficacy. In addition, they were designed in a manner that they could instill confidence in her on her ability to succeed in various endeavors. One of the main objectives of CBT is to instill confidence in an individual, which enables the person to be proactive and to engage in various economic and social activities.
The CBT will be done in a structured group. The group will be composed of 8 members, five of whom will be Betty’s friends and live within the same locality. The other three will still be residence from the same locality, but individuals that she is not familiar with. In order to ensure gender equity, the assessment will have four men and four women. It is important to note that the need for using individuals from the same region is to ensure that they can easily meet on their bi-weekly group meetings. The use of individuals whom Betty is not familiar with is to enable her to build a bigger network of friends. On the other hand, the use of individuals with whom Betty is familiar will enable her to easily integrate with the member of the group.
The scoring consists of placing a value for each question. The highest score is very true, which has a value of 4, somehow true has a value of 3, false has a value of 2, and extremely false has a value of 1. Since there are ten questions, the highest possible score in part 1 is 40, the lowest possible score is 10. In part two, each question will have 10 points for appropriate responses. Inappropriate responses will have a score of 1. Purposefully, this assessment is simple to ensure that the research outcomes are accurate and easy to interpret by even a lowly trained assessor. The results of this test will be used to test if indeed Betty is recovering from her PTSD when she interacts with her group member. Assessments will be done every time that these individuals meet. The assessment will be done before the group meetings and after the group meeting.
A score of 40 to 31 in part 1 accompanied by appropriate responses in part two will indicate that Betty is stress-free and can recover from PTSD. A score of 30 to 20 will indicate that she has minimal stress, a score of between 16 and 10 will indicate that she has high-stress levels, while a score of 10 or less will indicate that she has extremely high-stress levels. Since it is common for an individual to have “bad days” occasionally, a score of 17 to 19 will indicate that an individual is experiencing ordinary stress.
In part B, a score of less than 20 will indicate that the patient is still suffering from stress and low-self efficacy. Scores that are between 30 and 21 will indicate that the patient is recovering from stress, However, there is still some underlying stress problem. In case the score findings in part 1 contradict those in part 2, score in the latter will be used to form a conclusion on the patient’s stress status.
System for Assessment
The assessment will be given bi-weekly. There will be a pre-assessment before Betty starts her group meetings. The purpose of the pre-assessment is to have a baseline for comparison. The post assessment tests, which will be done before the start of every meeting will indicate the impacts of the meetings on her ability to manage stress. The assessment was done in a private room, where she will indicate her honest opinion on how she feels about herself in the assessment chart. Once she had filled the questionnaire, she will join her fellow group members for their group meeting. Noteworthy, there will always be a social worker in these meetings to ensure that the meeting remains focused on its main objectives.
Tracking Method
The bi-weekly results of the assessment were used to track Betty’s results in a graph. The stress indicator scores were plotted on the y-axis of the graph. The x-axis of the graph showed the period when these scores were evaluated. Her baseline score indicated that she had extremely high-stress levels at the start of the therapy. However, after 8 weeks, she had fully recovered and was on her way to being declared free of PTSD. The figure below indicates Betty’s stress levels during the 7-week therapy.
 
 
 
 
 
Figure 2
From the chart, it is clear that she became very stressed after her first two sessions. Generally, the acclimatization process that she was going through occasioned the increase in stress. After adapting to her new environment and with the group members, her stress levels decreased quickly since she was able to express herself and she found people who were ready to empathize with her.
Termination
From the start of the session, I had told Betty and her family that the therapy would end after she had been able to attain a score of 36 in four consecutive sessions. While the score of 36 by itself was an indication that she was not stressed. However, it could also be due to a single event of one-time excitement, which has been occasioned by abnormal conditions. From week 6 she had been able to attain this score. Accordingly, our therapy session came to an end in the second session of week 7. Nonetheless, during the closing meeting of our last therapy session, I informed her of the need of having a close circle of friends with whom she would be able to openly share her opinions and to express her emotions. I encouraged her to continue communicating with individuals that she was able to learn in the group therapy. In addition, I told her children to closely monitor her and provide her with financial assistance so that she would not be stressed due to the lack of a place to live.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
References
Baldwin SA, Murray DM, Shadish W. (2005). Empirically supported treatments or type I errors? Problems with the analysis of data from group-administered treatments. Journal of Consultative Clinical Psychology. 73(5), 924–935.
Benight, C. C., & Bandura, A. (2004). Social cognitive theory of posttraumatic recovery: The role of perceived self-efficacy. Behavioral Research and Therapy, 42, 1129-1148.
MacEachron, A., & Gustavsson, N. (2012). Peer support, self-efficacy, and combat-related trauma symptoms among returning OIF/OEF veterans. Advances in Social Work, 13(3), 586-602.
Ready DJ, Thomas KR, Worley V, Backscheider AG , Harvey.LA, Baltzell D, & Rothbaum BO. (2008). A field test of group based exposure therapy with 102 veterans with war-related posttraumatic stress disorder. Journal of Trauma Stress, 21(2).150–57.
Schnurr P. (2007). The rocks and hard places in psychotherapy outcome research. Journal of Trauma Stress. 20(5), 779–792.
Solomon, P. (2004). Peer support/peer provided services underlying processes, benefits, and critical ingredients. Psychiatric Rehabilitation Journal, 27(4), 392-401.