Final Semi System

Client Descriptions:
Name: Hayley McDonald

Gender: Female

Diagnosis: Trauma and Stressor-Related Disorder - Post Traumatic Stress Disorder

Age: 15

Client Description:
Client is a 15-year-old Caucasian female with Post Traumatic Stress Disorder. On March
15, 2017, a physician referred the client to our facility. Referral is based from a recent
suicidal attempt that stems from family dysfunction and trauma. Client tends to
experience frequent occurrences of stress, anxiety, and depression. Client engages in
substance abuse to cope with daily stressors and has a history of attempted suicide.
Client is currently enrolled at Crestwood High School. If patient does not increase grade
scores, it is likely she will not be able to graduate.

Family or Patient Reports:

At the age of 10 the client’s birth parents separated, resulting in family dysfunction. Soon
after the patient's mother remarried. Stepfather sexually abused client beginning at the
age of 12. The initial assault was kept quiet for over a year, until the incident repeated
itself. Patient later told her birth mother, response resulted in anger and disbelief. Client
has a close bond with birth father and younger brother; they often participate in outdoor
activities. Client is no longer in communication with mother. Upon discharge, client
hopes to increase self worth and decrease anxiety/depression level. Client explained
that attending college and becoming more focused within the classroom is something
valued. Outside of her close father/brother bond, patient would like to increase social
interactions within school setting.

Interests:
 Hiking
 Walking dog
 Frisbee
 Alcohol

Patient Outcomes:
Upon request, client will state (verbally or in writing) a single definition of stress, as
facilitated by recreational therapist through group process.

Name: Meggan Wilson

Gender: Female

Diagnosis: Trauma and Stressor-Related Disorder - Post Traumatic Stress Disorder

Age: 14
Client Description:
Patient is a 14-year-old Hispanic female who was admitted to our facility on March 5,
2017 for Post Traumatic Stress Disorder by her grandmother. Client experiences weekly
anxiety attacks and recurrent nightmares based on emotional distress. Beginning at the
age of 10 the patient's birth mother began abusing alcohol heavily. Client is often the
target of physical/verbal abuse when her mother reaches a state of intoxication. This
ongoing abuse has resulted in limited social interaction and increased stress levels.
Client tends to avoid any situation that could potentially trigger flashbacks to previous
traumatic events.

Family or Patient Reports:

Patient is an only child who is often left alone. If the client's mother is not intoxicated she
is working a full time job. The client's father also works full time, usually exceeding 50
hours per week. If patients mother lashes out her father often avoids the situation,
ultimately resulting in a complete absence. Client has a close bond with her
grandmother. When the patient becomes victim of abuse she often reaches out to her
grandmother. The close bond between the client and her grandmother frustrates her
birth mother and results in increased abuse. Recently, the patient has been avoiding
school and staying at her grandmother's. This was reported to stem from her fear of a
public anxiety attack.

Interests:
 Reading
 Drawing
 Writing
 Singing

Patient Outcomes:
Through group process, client will identify three sources of positive stress, as judged by
the recreational therapist.
Name: Becca Sowards

Gender: Female

Diagnosis: Trauma and Stressor-Related Disorder - Post Traumatic Stress Disorder

Age: 16

Client Descriptions:
Client is a 16-year-old Caucasian female who was recently diagnosed with Post
Traumatic Stress Disorder. She was referred to our facility February 27, 2017 for suicidal
ideation and attempt. Client was found by her sister with several cuts on her wrists,
arms, and legs. Client sleeps an average of 16 hours a day, and never engages in
physical activity. Recently, client has been skipping school to abuse alcohol and
marijuana. This behavior is a result of a traumatic incident that happened two years prior
to admission. At the age of 14 client found her father after a suicidal attempt. She often
reflects back to the experience, and uses substances to cope with her feelings of stress
and anxiety.

Family or Patient Reports:

Client is the oldest of three siblings. Since the traumatic event the patient has slowly
stopped attending family activities, and presents feelings of resentment. The client often
feels like she has fallen victim to family stress because she is the oldest. Her parents
claim that the patient is hopeless about the future, emotionally numb, and avoids
anything that could potentially trigger the flashbacks to the traumatic event. Patient
stated that she hopes to decrease her thoughts of hopelessness and develop coping
skills to deal with suicidal thoughts.

Interests:
 Hanging out with friends
 Going to the mall
 Marijuanna
 Alcohol
 Poetry

Patient Outcomes:
Upon request, client will verbally state one source of daily stress and three coping
techniques.

Name: Cami Westervelt

Gender: Female

Diagnosis: General Anxiety Disorder (GAD)

Age: 14

Client Description:
Client is a 13-year-old white female who was admitted to the program on November 3,
2016 for Generalized Anxiety Disorder. Beginning in 3 grade, Cami’s teachers have
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reported her often appearing worried and anxious, as well as having severe panic
attacks or crying fits in the middle of class. Cami has a history of missing several days of
school, complaining of stomach pain and headaches. Client has been on guanfacine for
about a year, but still struggles with major panic attacks. Cami was admitted by her
parents after missing a full consecutive week of school due to panic attacks.

Family or Patient Reports:

Cami is the oldest of 6 kids. She has a strong relationship with both of her parents, but is
particularly close to her mom. Her parents have reported Cami having her most severe
panic attacks when she cannot get something exactly right, or when she does not get
straight A’s in her classes. She spends most of her time secluded in her room studying
and doing homework. Cami’s parents also reported a lack of social interaction, including
not spending any time with friends, and little time with other family members. Cami
usually attends church with her family (when her parents can convince her to go), but
her family reports of her being fidgety and uneasy throughout the meeting.

Interests:
· Drawing
· Crafts
· Hiking
· Taking walks

Patient Outcomes:
Through group process, client will identify three sources negative stress and six sources
of positive stress.
Name: Hannah Fenton

Gender: Female

Diagnosis: General Anxiety Disorder (GAD)

Age: 15

Client Description:
Client is a 15-year-old white female who was admitted on February 17, 2017 for
Generalized Anxiety Disorder. In 7 grade, Hannah’s parents reported an increase in
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Hannah’s agitation level, stress level, and seclusion. She often avoids attending any
type of social event, including birthday parties or spending time with friends. Hannah’s
teachers have reported that she will often sit by herself, and doesn’t talk to very many
other students. When asked to give a presentation in class, Hannah ran from the room
and hid in the girl’s restroom until the class period was over.

Family or Patient Reports:

In the spring of 2016, Hannah’s parents separated. Hannah has a strong relationship
with her mother, whom she currently lives with, but shows resentment and hostility to her
father. She spends every other weekend with her father, but often fights with her mother
about going, and shows little to no interest with doing activities with him while she is
there. Hannah has a 10-year-old sister, and is very close with her.

Interests:
 Computer Games
 Reading
 Card games
 Watching TV

Patient Outcomes:
Client will verbally state a single definition of stress and three coping methods to deal
with personal stress, as judged by the recreational therapist through group process.
Name: Chloe Hudgins

Gender: Female

Diagnosis: General Anxiety Disorder (GAD)

Age: 16

Client Description:
Client is a 16-year-old African-American female who was admitted on January 9 , 2017
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for Generalized Anxiety Disorder. In her freshman year of high school, Chloe
unexpectedly ran out of the dress rehearsal for her school play. She reported feeling
overwhelmed, and having racing thoughts that were spiraling downward. Following this
incident, Chloe stayed home from school for 3 consecutive days, telling her parents she
was sick. Client struggles with handling stress, and finding balance in her life. Chloe
played the flute in the band, played forward on the girl’s
soccer team, and was involved with student government at her school before being
admitted.

Family or Patient Reports:

Chloe’s parents report that her symptoms of anxiety came on rather suddenly. She was
extremely social in school, and active in many clubs and activities until the previously
mentioned dress rehearsal of the school play. After this incident, Chloe has shown signs
of decreased self-confidence, problems coping with stress, and increased agitation.
Chloe is the second oldest of four children. She has a strong relationship with both of her
parents, but is closest to her dad. Chloe is also very close to her grandmother who lives
with them.

Interests:
· Soccer
· Playing Flute
· Running

Patient Outcomes:
Through group process, client will identify positive stress, negative stress, and daily
stress as facilitated by the recreational therapist.
PROGRAM: Stress Management

Purpose: To define stress, identify personal stressors, and to develop techniques to

manage stress.

Program Objectives

TPO 1. To demonstrate knowledge of the concept of stress

EO 1. To define a working definition of stress
EO 2. To identify personal stressors.
TPO 2. To demonstrate the ability to perform stress management techniques-- breathing
and progressive relaxation
EO 1. To demonstrate deep breathing capabilities as a stress management
technique.
EO 2. To demonstrate progressive muscle relaxation as a stress management
technique

Implementation Description

Population
The Stress Management Program is designed for a group of five to ten individuals with
Post Traumatic Stress Disorder (PTSD) and/or other anxiety related disorders. It can be
used with adolescents or young adults. It is desirable to group participants by similar
ages, so that discussions can be more relevant. Clients must be able to communicate
and contribute verbally to discussions in a relevant manner within a group setting. Based
on individual needs, this program can be modified to meet certain physical limitations.

Program Length and Duration

This program is designed with six sessions, each lasting 50 minutes. These sessions are
scheduled once a week for a period of six weeks. Time between sessions can be
modified if necessary, although completion of all six sessions is essential to achieve
program objectives.

Program Context
This program can be utilized within clinical, school, or community based settings. It can
be implemented within any agency serving the described population.

Staff
One professional staff member is needed for every four clients; at least one staff per
group must be licensed as a TRS/MTRS who is nationally certified as a CTRS. The staff
member must have a knowledge of the emotional conditions and diagnosis of each
client, the ability to lead group discussions, and the ability to utilize behavioral-
management techniques.

Facility
This intervention requires an open area that has at least two chairs. This may be
facilitated in the gym or in a classroom setting. Set up the two chairs 6 feet apart, facing
each other.

Equipment
Session 2
  2 chairs
 Large stack of newspapers
 7 large textbooks
 1 roll of masking tape
 A tape measure
 Stopwatch

Additional Information

A Note on the Discussions

Much of the learning in this program is based on discussion. Leaders must, therefore, be
capable of guiding discussions according to the needs and experiences of the group
members. Stimulating discussions may require that the leaders contribute information
and personal experiences; however, they should not dominate the session. Instead, they
should build as much as possible on the responses of clients.

Evaluation of the Performance Measures

Evaluation of client performance should be conducted on an ongoing basis. Participants
will be meeting most of the criteria stated in the performance measures during
discussions. It is therefore necessary that leaders record progress made during or
directly after conducting a session. Notes made during the session should be taken as
unobtrusively as possible. Before each session, it is advisable for leaders to review the
performance measures relevant to the content being covered.

A Note on Instructions
Instructions on the Content and Process Sheets are presented in a narrative style. This
is to facilitate understanding of how the material may be presented. Leaders are to note
this style, but should not memorize or read the instructions while conducting group
sessions. Instead, an attempt should be made to reproduce the relaxed, conversational
tone when giving instructions to the group.

Program: Stress Management

Terminal Program Objective: 1. To demonstrate knowledge of the concept of stress

Enabling Objective Performance Measure

1. To define a 1. Upon request, client will state (verbally or in writing) a single

working definition of definition of stress, as facilitated by recreational therapist
stress. through group process.
1. Through group process, client will develop skills to identify
positive stress, negative stress, and daily stress as facilitated by
the recreational therapist.
2. To identify
personal stressors.
Program: Stress Management
Terminal Program Objective: 2. To demonstrate the ability to perform stress
management techniques- breathing and progressive relaxation

Enabling Objective Performance Measure

1. To demonstrate deep 1. Upon request, client will demonstrate box

breathing capabilities as a stress
management technique.
2. To demonstrate progressive
muscle relaxation as a stress
management technique.
breathing as a stress management technique.
1. In group process, client will demonstrate the
ability to use progressive relaxation—systematically
tensing and relaxing as a stress management
technique.

Content and Process Description

TPO No.: 1
EO No.: 1 To define a working definition of stress

Content Process

Opening the group:
 Begin the group by reviewing the
group rules and reviewing the
content of the previous session.
Stress defined:
(Definitions that were discussed in the 1st
session)
 Any aspect of the environment that
requires the individual to make an
adaptive change in behavior may be
considered stress.
 A state of mental or emotional strain
or tension resulting from adverse or
very demanding circumstances.
 Pressure, tension, or strain placed
on a material object.
Review the content to the left (group rules
and content of previous session) to open
group.
The leader should welcome questions
from the group.
“Last session, we went over several
different definitions of stress. To open
group today, let's go around in a circle and
each say our names, and three words that
you would use to define stress”
“Who would like to start?”
 Content and Process Description
TPO No.:
EO No.: 2. Through group process, client will develop skills to identify positive stress,
negative stress, and daily stress as facilitated by the recreational therapist.
Content
Before the intervention begins,
set up 2 chairs facing each
other, 6 feet apart. Be sure to
leave enough room for the
clients to be able to form a circle
around the chairs.
Introduce the “Building Bridges”
challenge activity.
Equipment: Two chairs, large
stack of newspaper, six
textbooks, one roll of masking
tape, tape measure, stopwatch.
Process
Ask the students to form a circle around the two
chairs that have previously been set up.
“Today we will be building a bridge. You will be given
1 roll of tape and this stack of newspapers, and the
bridge you build must extend from one chair to the
other.
The goal of this is to be able to work together to build
the strongest bridge you can. Here are the rules:
 Each person must take a turn contributing to
building the bridge.
 You may discuss and talk with your peers, but
only one person is allowed to be in the circle
and work on the bridge at a time.
 Each person will only have 30 seconds to
work on the bridge before it is the next
person’s turn.
 You may only use the newspapers and tape
given to you.
 The bridge itself cannot touch the ground
(only the chairs can make contact with the
ground).
 The chairs must remain 6 feet apart from
each other.
 You have 15 minutes to build the bridge
collectively as a group.”
“As you do this, consider what is important for a
bridge to have, and what will make it the strongest.
Are there any questions?”
Answer any questions if necessary. Place the
newspapers and tape in the middle of the circle, set
the timer for 15 minutes, and tell the clients to begin.
When the 15 minutes is up, announce that the
 students must stop, and that it is time to test the
bridge.

Hand out a textbook to each student, and instruct

them to each take turns placing their books on the
bridge until the bridge breaks.

Ask the clients to sit in a circle on the floor, next to

the broken bridge.
Begin a discussion using the following questions:
Identifying personal stressors,
and sources of stress
(processing).
The bridge represents us, or our
resilience to stress.
The textbooks represent
personal stressors.
Be sure that while processing,
everyone has an equal
opportunity to participate and
speak.
 Describe to me what we just did.
 What went well?
 What was frustrating?
 Why was it important for the bridge to be
strong?
 What would have happened if we had
dropped all the books on the bridge at once?
 What are the books in our lives?
 How are we like the bridge?
 How do you react to stress?
o Is that healthy or unhealthy?
 How do you treat people under pressure?
o Is there anything that needs to
change?
 Can stress ever be a good thing?
o If so in what situations can stress be
positive?
o What is the difference between
positive and negative stress?
 What can you do to be better prepared for
stressful situations?
 What can you do to lighten your load and get
rid of some of the negative stress in your life?

“I want to thank all of you for coming and participating

in group today, and thank you each for the things you
have shared. As you go about your day, I want to
invite all of you to remember and reflect the things we
have talked about today.”

“Before you leave, let’s all clean up the tape and

newspapers and throw them away/recycle them.
Thanks, again.”

Closing:
 Sequence Sheet

TPO EO Description Session Time

NO. (min.)

Preparation Before Group: 2 5

 Set up two chairs six feet apart. Allow space for
participants to form a circle around the chairs.
 Place required equipment between the chairs.
(Newspaper, six textbooks, one roll of masking
tape, tape measure, stopwatch)

1 1 Introductions: 2 10
 Therapist will begin group by reviewing group
rules and content from previous sessions.
 Therapist will ask group members to go around
in a circle and say their names along with one
word that defines stress for them.

1 2 “Building Bridges” Challenge: 2 20

 Group members will be asked to form a circle
around existing chairs and equipment.
 Therapist will introduce the “Building Bridges”
challenge activity.
 The goal of the activity is to work together to
build the strongest bridge that extends from one
chair to the other.
 Each group member will be given one roll of tape
and one stack of newspapers.
 Each person must take a turn contributing to
building the bridge.
 Each member may discuss and talk
with teammates, but only one person is allowed
in the circle to work on the bridge at a time.
 Each person will only have 30 seconds to work
on the bridge before it is the next person’s turn to
work on it.
 The group will have 15 minutes to build the
bridge collectively.
 Once 15 minutes is up therapist will handout a
textbook to each student and instruct them to
place their books on the bridge until the bridge
breaks.
o Note: review process criteria for the
complete set of rules and guidelines.

1 2 Closing: 2 15
 The therapist will ask clients to sit in a circle on
the floor.
  Therapist will lead the group discussion.
o Note: see discussion questions in
process criteria.
 Following the group discussion, facilitator will
thank the group members for coming to group
and encourage them to reflect on the purpose of
the session.

Time 50
Total:

Performance Sheet
Program: Stress Management Staff:
Date:

Program Performance: Personal Performance:

Client Name:
TPO. 1 EO. 1 TPO. EO. 2 Personal Objective Staff Initials
1 Date

1.

2.

3.

4.

5.
6.

7.

8.

9.

10.

Measurement Scale
5 - Objective Exceeded
4 - Objective Met
3 - Objective Somewhat Met
2 - Objective Not Met
1 - No Participation