Running head: CRISIS/TRAUMA CASE STUDY

Crisis/Trauma Case Study

Westley Wu

Mount Saint Marys University

April 2017
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The client, Mark is a 21-year old Caucasian male. It has been 5

months since the client has returned from war in the Middle East. He

experiencing realistic dreams of when he was deployed. The client is having

flashbacks and cold sweats whenever he encounters anything that reminds

him of being at war. The client recounts a 4th of July barbeque where he

cowered in fear at the sound of fireworks. Because of his extreme anxiety,

the client began to avoid social events and isolate himself. The also client

complains that he has difficulty sleeping at night and has turned to alcohol

and drugs to cope with his symptoms. The client has 3-year old daughter and

states that his marriage is in turmoil due to constant fights. The client

reports growing up in a military family and that being in military is something

that he was expected to do. The presenting problem is the social anxiety,

flashbacks, dreams, and isolation that has brought the client to see the

therapist.

The therapist has dual diagnosed the client with Post Traumatic Stress

Disorder(PTSD) and Alcohol and Substance Use Disorder. The dual diagnosis

model is where the client is rooted in deeper psychological issues such as

PTSD and addiction and will need treatment of both issues. Based on the

DSM-V, PTSD is a trauma and stress disorder. It is a psychological disorder

generated by either witnessing or experiencing a traumatic event. This

occurs when an acute stress response persists over a month. It is caused by

recurrent physical and mental distress. The symptoms are classified into 4

main clusters. The first is where the client is reliving the event through
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intrusive memories, nightmares, or flashbacks. The second involves avoiding

situations which the individual with PTSD associates with the traumatic

event. The third is associated with excessive physiological arousal which can

include heart palpitations, muscle tension, and anxiety or irritability and

major problems sleeping or concentrating. The fourth is having pervasive

negative changes in emotions and beliefs such as excessive feelings guilt,

fear, or shame or no longer finding enjoyment from what the client had once

found to be gratifying. Clients may also feel periods of numbing, flat affect,

and dissociation. That may lead to situations of feeling unreal or surreal. (ie:

feelings that time has slow down or sped up or even blacking out) This leads

to an impairment of the ability for an individual to function and the

impairment itself can lead to further dysfunction. When any disorder is left

untreated, clients may feel desperate and turn to substance or alcohol

abuse. Unfortunately, there are too many instances of co-occuring disorders

such as PTSD and substance abuse. It can be difficult to recover from one

disorder without dealing with other diagnosis. In the United States, 2 in 10

veterans suffer from complex PTSD. More than 1 in 5 veterans who have

PTSD also struggle with substance abuse. And 1 in3 veterans seeking

treatment for substance abuse also have PTSD. (US Department of Veteran

Affairs)

From the psychophysiological perspective, the triune brain model

divides the brain into 3 parts. The reptilian brain, also known as the brain

stem, is the innermost part of the brain. It maintains basic bodily functions
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and is responsible for survival instincts. The mammalian brain, also

instinctive, is known as the midbrain or the limbic system. It regulates

emotions, conveys sensory relays, and is responsible for fear and pleasure.

The neo-mammalian brain or the neo cortex is the outermost part of the

brain. It controls cognitive processing such as planning, control, logic,

imagination, decision-making, learning, memory, and inhibitions. Usually, the

brain gives instruction in a top down structure, from the outer most brain,

the neomammalian, to the mammalian brain and finally to the reptilian brain.

However, when faced with a trauma, the order reverses and the reptilian

brain takes over. It activates the sympathetic nervous system and initiates

the fight, flight, or freeze response. Because the front cortex is conscious, it

takes more time to process. But in a life-threatening situation, because the

reptilian brain is unconscious, it processes faster so an individual can quickly

react in a life or death situation.

The body then releases adrenaline and starts pumping blood and oxygen to

your muscles, sending your body in a state of readiness to do something

physically taxing. The stressful situation also causes changes in specific brain

regions. The chemical activity causes the brain to create memories and

temporary imprints in the brain circuitry and neuro-pathways. Every time an

individual recalls the trauma, the imprints on those pathways can be

reactivated. This brings back the stressors from the initial event and forces

an individual to relieve that life-threatening situation. But in a normal

situation, this effect does not last as the brain excretes cortisol which inhibits
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memory retrieval of previously stored information and memories. The cortisol

also places the brain back into its normal top-down structure. The imprints

on the pathways usually fade away and over time recalling the trauma will

not cause the same stress reaction. But in case of PTSD, the brain does not

shift into recovery mode and the imprints on the neuro-pathways stay. The

reptilian brain remains ready to deal with a threat. Memories of a trauma and

the associated stress response do not disappear. The lingering chemical and

biological imbalance keeping the brain in a fear state and trauma is relived

through memories. The amygdala, which is responsible for sensing danger, is

overstimulated and keeps the memories active and processes the past

trauma event as if it were occurring in present time. The hippocampus, which

is responsible for filing away memory, is underactive and fails to process and

consolidate the trauma in long-term memory bank. Those are the

neurological effects that create PTSD. The brain keeps secreting cortisol to

combat the remembered trauma. Long-term exposure to cortisol damages

and shrinks the hippocampus and impairs learning ability. The effects are

that the traumatic memories remain vivid and fresh through flashbacks and

nightmares.

Trauma memories have different characteristics than normal

memories. They are generally not well-organized and sequential, but are

fragmented. Individuals have little control over the retrieval of these

memories, which means the trauma memory comes back involuntarily. A

person with PTSD can be affected by a number of triggers such as color,

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smell, sound, and sensation. They are conditionally accessible which means

they are usually triggered by reminders in the environment. When triggered,

an individual with PTSD recalls the emotional and physiological sensation

from the initial trauma.

There is now considered to be a dissociative sub-type characterizes by

amnesia, avoidance, and numbing. Indicators of this subtype are heightened

verbal and analytical activity. And reduced limbic or emotional activity in

response to traumatic stimuli. People diagnosed with dissociative sub-type of

PTSD often experience depersonalization and emotional detachment.

My client meets the 4 different Criteria for PTSD. In Criteria A, my

clients stressor is direct exposure, and repeated and extreme indirect

exposure. In Criteria B, my client has intrusive symptoms which include

involuntary and intrusive memories, traumatic memories, dissociative

reactions, intense and prolonged distress after exposure to traumatic events.

In Criteria E, my client alterations in arousal and reactivity, which include

irritable and aggressive behavior and sleep disturbances. In Criteria F, the

duration of my client has exceeded one month. My clients main symptoms

are psychological, this includes nightmares, flashbacks, and intrusive

thoughts. This has lead to behavioral problems such avoidance where my

client tried to attempt to block or suppress memories, or situations and

environments that may trigger the past trauma. He has also become

hypervigilant and is always on guard, and becomes hyperaroused and gets

activated by the most minute trigger. The therapist believes that this
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behavior has lead to his insomnia or other sleep problems which follows

irritability and angry outbursts. Some of my clients risk factors and ethical

issues include substance abuse, domestic violence, prison, suicidal ideation,

and homicidal ideation. For instance, if he got into a heated discussion with

his wife and completely lost control, he might main or kill her because he is

trained to kill. He would probably end up in jail if that had happened. And his

child would be left without her parents.

The relay of emotions and somatic experience is stored in the clients

memory in the present moment, not in the past. It is as if the trauma is

happening in the Now. Trauma is a corruption of memory and the bodys

processes. The body keeps coming back to patterns of self-defense. Although

the trauma did happen to them, he is not necessarily defined by his trauma.

The answer is for the client to be able to come out of where he has been

frozen psychologically. The client can still be able to recall and process

images and feelings in a gentle way.

Substance Abuse is the compulsive and excessive substance use or

initially pleasurable behavior that interferes with ordinary life, work, health,

and relationships. Addiction can be defined as a physiological need for a drug

that reveals itself through unpleasant withdrawal symptoms if the use stops

or reduces, and/or a psychological need to use a drug, or complete an

activity to relieve negative emotions. The client meets criteria for alcohol use

disorder (AUD). Binge drinking is defined as drinking 5 or more alcoholic

drinks on the same occasion on at least one day in the past 30 days.
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(Substance Abuse Mental Health Services Administration or SAMHSA) Based

on the DSM-V, the client exhibits Criteria A- Impaired Control, which is using

more than the intended amount, wanting to reduce but being unable to do

so, and spending excessive time procuring or using the substance. (DSM-V)

The client also exhibits Criteria B, social impairment which includes

neglecting responsibilities, such as child care and his marriage and he is also

getting into heated arguments about his use.

Treatment of PTSD and AUD can be complicated, as people with PTSD

and AUD are reluctant to engage in their thoughts, emotions, and

conversations of their symptoms. Research had shown exposure therapy,

which slowly exposes individuals that cue or recall the trauma, can be very

effective. Group therapy is also very effective for PTSD. It can provide PTSD

survivors a place they can share their trauma in a supportive environment.

The therapist will also refer the client to see a psychiatrist for anti-

depressants, anti-anxiety, and sleep aids. This will help alleviate some of the

symptoms while utilizing coping strategies.

When therapists offer the support and treatment they are asked for,

they actually can destabilize the client more. A traumatized persons brain is

protecting them, but that can get in the away of doing really work in therapy.

Therapist does not expect a logical, linear story. Working to satiate the needs

of client will garner more results. Because relationships need attachment,

dependency, and intimacy that can be triggering. The therapist does not

want to propel the process any faster and stronger than what the client can
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handle. The client can stop it and get back in a comfortable space. It is

important to realize the clients threshold. The therapist can anticipate what

that threshold may look, but often times, the therapist will not know their

clients threshold until the therapist hits a wall or the client falls apart. It is

trial and error. Therapist will allow the clients arousal to rise, but be

observant enough to see where the client feels overwhelmed and be able to

back off and give the client space.

PTSD is treatable, however it is not a quick fix. Oftentimes in trauma,

clients are without sufficient resources. It is so logical that being aware of

ones feelings and resources is part re-processing. Reprogramming the brain

and body to resume normal function takes time. My client can eventually

learn to live with and manage their PTSD symptoms. The purpose of the

intervention is to promote post traumatic growth(PTG), which is that occurs

when a client has positive or beneficial growth as result of adversity or

challenges in order to rise to higher level of functioning.

The interventions used by the therapist will be prolonged exposure

and mindfulness cognitive behavioral therapy. Both of these modalities are

evidence-based and have been proven to be effective when tackling PTSD.

Prolonged exposure is a specific type of CBT. Prolonged exposure will teach

the client to incrementally approach the trauma-related memories,

situations, and emotions that my client may have been avoiding. By

confronting the trauma, my client can gradually decrease his PTSD

symptoms. Clients with PTSD frequently try to avoid anything that reminds
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them of the trauma. Although avoidance can allow my client to feel my safe

in the moment, but it is not sustainable. Avoidance of triggers may actually

keep my client from recovering from PTSD. The intervention PE will serve my

client by challenging him to face his fears. By having a conversation about

the details of the trauma in safe environment will allow my client to decrease

his PTSD symptoms and regain normal functioning.

The therapist will begin treatment with client by giving the client an

overview of the techniques. Therapist will try acquire as much data as

possible on the client and establish rapport with him. There are two types of

PE, in vivo and imaginal exposure. Over the course of therapy, the client will

work with the therapist in practicing in vivo exposure. IV involves repeatedly

engaging in situations, behaviors, or activities that are avoided due to

trauma, but are not inherently dangerous. After time progresses, IV exposure

decreases unrestrained fear, and other emotions that had previously caused

distress. It also encourages the identification that the avoided situations are

not threatening, and that the client can cope effectively without feeling

debilitated. The client will prudently confront these situations that the client

may find triggering. IV exposure is good for changing behaviors. For

example, the client may avoid driving because he is afraid of that bomb

might explode. The therapist will ask the client to just sit in his car in the

driveway. Next, the therapist will ask him to drive around his neighborhood

and to notice his surroundings. After that, the client might drive around his

city. Last, the client will resume normal driving function and be able to
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maintain it because he is aware that he is in the present and is safe from a

war zone. After a few sessions, the therapist will begin imaginal exposure

and will ask the client to talk about details of his trauma. By talking about

the trauma, this can help the client release emotions such as anger, fear,

sadness, and guilt. IE is constructed of a series of repeated guided revisiting

of the traumatic experience in clients memory. The client will describe the

event out loud in detail. The clients story or narrative will be recorded. For

homework, the client will listen to the recording in between sessions to

accentuate therapeutic growth. Revisiting promotes the processing of the

trauma memory. By activating the thoughts and emotions associated with

the trauma in a safe context, the client can make peace with the event. It

can also help alleviate any distress associated with the trauma memory. For

instance, the client may feel survivors guilt that he is alive while his friends

had been shot or killed in action. As homework, the client will listen to

recordings of his imaginal exposure between sessions. By addressing the

details of the trauma in therapy, he will find that he will have fewer

unwanted memories. The point of IE is for the client to recount the incidents

of trauma with a charge attached to it. (SAMHSA)

Mindfulness Cognitive Behavioral Therapy (CBT) is a type of meditation

that helps the client remain in their present experience. Practicing

mindfulness as simplistic as noticing the taste of a chocolate on the clients

tongue. Activities like brushing teeth or flossing can be a beginners way of

staying present. Mindfulness involves deliberate observation of feelings and

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sensations of these daily experiences. Studies have shown that mindfulness

help to diminish symptoms of PTSD, such as avoidance and hyperarousal.

The goal of mindfulness is for the client to be paying attention to and being

aware of the present moment. The client will able to do that by accepting his

experience by his feeling and thoughts without judging them. Breathing

techniques can also help manage the clients anxiety, PTSD, and alcoholism.

Whenever my client feels triggered or has a craving, he can practice

mindfulness techniques such as focusing on his breath. Concentrating on the

inhalation and exhalation will allow his mind to slow down and help him focus

on the present moment. Mindfulness involves allowing your thoughts and

feelings to pass without attachment or adversely pushing them aside. The

client becomes merely a witness of his experience rather than a victim.

When practicing mindfulness, it is normal to have distracting thoughts, as it

part of the the process of just noticing and allowing.

Mindfulness can magnify my clients ability to cope with difficult

emotions, such as the depression and anxiety that is associated with PTSD.

Mindfulness practice can help my client be present with his emotions and

thoughts without judgment or labeling them as positive or negative, and

without acting on them by reacting or avoiding them. Mindfulness is a

continuous process. Although mindfulness can be difficult to master in the

beginning, the with the right mindfulness techniques, my client can learn

how to take a step back from his thoughts and take control of his life. No

longer will he be at whims of his flashbacks, emotions, or thoughts, but he

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will be able to take responsibility for his actions and impulses. Mindfulness

practice can also help my client expand and develop more compassion

toward himself and others by becoming less critical of himself and others.

This will help the client be empathetic towards others in his periphery. It is

also a good precursor to PE. As PE has plenty of retelling and writing down of

the past trauma, mindfulness will give the client confidence and skills so that

he may be able to handle his feelings. As he acquires new strategies of

coping, he will be able to process his emotions in a healthy way.

There are some diversity issues concerning the client and the

therapist. The client is a veteran and military man. He grew up in a military

family and continued his familys legacy by joining the military himself. The

therapist has never been in the military nor does he have any affiliation with

people who served for United State Armed Forces or any military veterans.

Knowing this, the client might be suspicious and doubt the competency of

the therapist to help the client him because it might me difficult to build

rapport and/or relate. The client is also Caucasian and the therapist is Asian,

so there might be a racial and power dynamic that might be challenging for

both the client and the therapist.

There are plenty ethical issues concerning the client and therapist. The

client had been deployed in a war zone where he had to kill, maim, and

murder people. There will be probably be some transference on the

therapists part. Also, the therapist might also have vicarious trauma as the
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client recounts in detail the horror and atrocities of war. As for treatment, is

the therapist disease-focused or patient-focused? Because the therapist

must decide if he going to use a more holistic modality to include the client

as a whole or just tackle the symptoms and issues suffered by the client.

Citations
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Bishop, S. R., Lau, M. A., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J.,

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Psychology: Science and Practice, 11, 230-241.

Block-Lerner, J., Salters-Pedneault, K., Tull, M. T., Orsillo, S. M., & Roemer, L.

(2005). Assessing mindfulness and experiential acceptance: Attempts to

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treatment for generalized anxiety disorder: Integrating

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Follette, V. M., & Vijay, A. (2009). Mindfulness for trauma and posttraumatic

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Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in

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