Running head: PTSD: ONE MANS JOURNEY

Post Traumatic Stress Disorder (PTSD): One Mans Journey G. Yvonne Christie University of the Rockies

PTSD: ONE MANS JOURNEY Abstract

This paper is a case study on a client who has been diagnosed with Post Traumatic Stress Disorder (PTSD) from the Vietnam War. A narrative case description is included, which supports the clinical diagnosis and as well as an empirical treatment plan. The treatment plan has included the necessary identifying information with appropriate changes to shield the clients real identity. The client was referred from the Veterans Administrative (VA) hospital in La Jolla, California. As part of the treatment plan the presenting problems will be identified and correlated to the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition text revision (DSM-IV-TR) multiaxial diagnosis. This case study is based upon a holistic foundation, which includes the interconnectedness of: the presenting problems, long-term goals, objectives, methods or interventions, treatment length, and measurement of potential outcomes. This paper concludes with a self-critique by the therapist regarding every aspect of the presented case study. Key Words: PTSD, Treatment Plan for Vietnam Vets, Holistic Foundation. Post-Traumatic Stress.

PTSD: ONE MANS JOURNEY Post Traumatic Stress Disorder (PTSD): One Mans Journey Descriptive Narrative

Dick is a retired military man, in his late fifties, suffering from clinical DSM-IV-TR chronic military-related posttraumatic stress disorder (PTSD). He stated that he had served in Vietnam, Panama, Grenada, the Gulf War, and several other armed conflicts. Dick explained that being in the military for twenty years he has been exposed to a wide variety of cultures and environments. He described tours as taking place across the globe and that he had fought in jungles, deserts, and urban settings. He emphasized the most painful wounds that he had sustained could not be seen by the naked eye. He served from late 1970 until mid-1972 in Vietnam and was assigned to rescue missions via river patrol boats and Special Operations. The client was a civilian for a few years, and then re-entered the armed forces and completed his twenty-year career serving in Special Operations, or as he termed it Special Ops. According to Dick, although it has been over thirty years since the Vietnam War, the majority of his problems stem from that time with varying levels of intensity. Dick reports that he did not experience any of his current PTSD symptoms during his active duty time. He recalls that a few years after his 1995 retirement, he started to experience outbursts of anger, heightened startle response, survivors guilt, extreme difficultly in relationships, especially male-female ones, and frequent, overpowering flashbacks. Dick stated there have been brief spans of time when he was unaware of any prominent symptoms, yet reports that he could not feel regular emotions and mostly just suffered through these times in silence (Hyer, Summers, Braswell & Boyd, 1995). Dick says he has just made a major geographic relocation this past year and feels very good about the move, but this has triggered some intense flashbacks and other symptoms. Dick decided to seek treatment in the hopes of laying some of his ghosts to rest once and for all. He feels he is in a good stable position emotionally and mentally, as well as very motivated to take a more aggressive treatment approach.

PTSD: ONE MANS JOURNEY PTSD Background

In 2000, the American Psychiatric Association revised the PTSD diagnostic criteria in the fourth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association (APA), 2000). In 1980 the APA formally codified PTSD in the DSM-III and it was for the first time officially recognized as a formal diagnosis. Prior to 1980 it was documented under many names. Critical Incident Stress (CIS) is the latest term for the lingering effects of war that has been charted in the United States as early as the American Civil War. This disorder was first known as Combat Stress Reaction, then Battle Fatigue (WW I), Shell Shock (WW II), Acute Stress Disorder (Korea), Traumatic Stress and recently, Posttraumatic Stress Disorder (Kates, 2000). American heroes returned home after the Vietnam War to be greeted by an angry and apathetic country. The effects of PTSD gradually went away for a select group of fortunate veterans after they were reunited with family and friends. Some were not so lucky and the effects of PTSD began to do serious damage to those unable to receive any support or help (Haley, 1985). The Vietnam War reached into almost every aspect of American life. The family, community and the whole nation were impacted by the ordeal these soldiers went through on their tour of duty in Vietnam. The continued stress of combat causes an adaptive split. This happens, according to Horowitz, to any person exposed to extreme stress (1976). For many years the readjustment problems experienced by Vietnam soldiers increased, as did the media coverage and the mental health communitys awareness (Cooney, 1991). Treatment Plan Identifying Information The client will be referred to as Dick, since his true identity has been withheld in accordance with the International Committee of Medical Journal Editors. Dick is 57 years old, single but in a

PTSD: ONE MANS JOURNEY

committed relationship. He resides in southern California and currently lives alone, with plans to cohabitat with his girlfriend in the near future. He is retired from the military after twenty years of service and has also retired this past year from his civilian job. He is in overall good health with recurring kidney stones and general age maladies, but is physically fit. He has no criminal history or addictions to alcohol or other substances. Dick spends the majority of his time alone and does not openly share his PTSD situation with others. His girlfriend is fully aware of his issues with the PTSD flashbacks and bad memories and has shown tremendous support and encouragement. His biological family is spread out, but Dick is in fairly regular contact with them. Overall he reports having good relations with his mother and three sisters. Relevant Information/Referral The clinician providing this treatment will be an outside consultant, Yvonne Christie, M.S.. The client was referred by the Veteran's Administration San Diego Healthcare System, 3350 La Jolla Village Drive San Diego, CA 92161; (858) 552-8585. The client identification to refer to on all test and charts is 1977XLch. The client payments are to be paid in cash by the client with reimbursement from the Department of Veteran's Services. DSM-IV-TR Diagnosis The following criteria are from: American Psychiatric Association. 309.81 Posttraumatic Stress Disorder. In: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. (File revised 15 August 2004). The symptoms italicized are the ones experienced by the client, Dick. Diagnostic criteria for 309.81 Posttraumatic Stress Disorder A. The person has been exposed to a traumatic event in which both of the following were present: (1) The person experienced witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of others.

PTSD: ONE MANS JOURNEY

(2) The person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior. B. The traumatic event is persistently reexperienced in one (or more) of the following ways: (1) Recurrent and distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. (2) Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content. (3) Acting or feeling if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur. (4) Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event (5) Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following: (1) Efforts to avoid thoughts, feelings, or conversations associated with the trauma (2) Efforts to avoid activities, places, or people that arouse recollections of the trauma (3) Inability to recall an important aspect of the trauma (4) Markedly diminished interest or participation in significant activities (5) Feeling of detachment or estrangement from others (6) Restricted range of affect. (e.g., unable to have loving feelings)

PTSD: ONE MANS JOURNEY

(7) Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: (1) Difficulty falling or staying asleep (2) Irritability or outbursts of anger (3) Difficulty concentrating (4) Hyper vigilance (5) Exaggerated startle response E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month. F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: Acute: If duration of symptoms is less than three months. Chronic: If duration of symptoms is three months or more. Specify if: With Delayed Onset: If onset of symptoms is at least 6 months after the stressor. Multiaxial Diagnosis Axis I: Post Traumatic Stress Disorder 309.81 Axis II: none Axis III: Good health, prior incidences of kidney stones, and infrequent occurrence of joint stiffness and shoulder muscle soreness. Axis IV: Semi-isolation, lack of group support from fellow PTSD veterans. Good personal

PTSD: ONE MANS JOURNEY support in a healthy male-female relationship, supportive nuclear family. Axis V: Global Assessment of Functioning Scale Score: 80. Positive home environment and

hopeful outlook, limited friends and social activities, moderate psychological disturbances due to uncontrollable PTSD flashbacks resulting in inability to function normally. Presenting Problems Dick is currently concerned with the unexpected onslaught of flashbacks that last from a few hours to a few days. During these times he isolates, shutting himself off from his girlfriend and everything else. This has caused some problems between him and his girlfriend. He behaves in a very clandestine fashion; his behavior is secretive and deceptive. He is a chronic liar about everything for no apparent reason. He has life-long bouts of suddenly becoming distant, withdrawn, non-communicative and flat emotionally (Marshall, Schell & Miles, 2010). He runs from any type of confrontation or emotional outburst and then disappears for great lengths of time. He becomes very agitated and angry then almost comatose and sits and stares blankly for hours on end. During these times, he does not shower or change his clothes for days on end. He describes feeling in a zombie-like trance. He feels worthless, weak, and powerless against the vivid memories that he describes as being burned into his soul forever. Goals (long term) 1. Decrease the client's frequency and intensity of flashbacks. 2. Increase the client's social network. 3. Build a happy healthy whole life with his girlfriend.

Objectives

PTSD: ONE MANS JOURNEY Goal #1 Decrease the client's frequency and intensity of flashbacks. a. Keep a daily written journal on thoughts, feelings, and everyday activities. b. Start training three times a week for upcoming bicycle marathon in three months. c. Attend weekly counseling session.

d. Learn and practice Eye Movement Desensitization and Reprocessing (EMDR) four times a week for two weeks, increasing two session each week for three months (Lipke, & Botkin, 1992). e. Attend weekly biofeedback sessions for six months (Tarler-Benlolo, 1978). Goal #2 Increase the client's social network. a. Participate in a veteran's group weekly. b. Make friends with neighbors by going for daily walks of at least thirty minutes a day. c. Dine out at a public facility once a week and greet someone each time. d. Initiate social functions with girlfriend and friends a minimum of once monthly. e. Join a bowling team that meets every week. Goal #3 Build a happy healthy whole life with his girlfriend. a. Initiate plans to move and be an active participant. b. Daily say or do something nice or complimentary. c. Be as honest as possible, even about the inability to be honest. Practice telling the truth one hour a day, for one week, then two hours a day for one week and continue until the 24-hour goal is reached. (Being silent or not communicating does not count). Keep a schedule of times and dates and work to break each day's record. d. Invite family members of new friends to meet your girlfriend. e. Practice being happy and being in love in a new way every week. f. Learn to want to do the dishes.

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Methods or Interventions The client and therapist have agreed on the benefits of using a holistic approach and treating Dick as a whole person, rather than a man diagnosed with PTSD. Studies done on the effects of trauma have shown that the whole person needs to be explored in depth to understand the totality of trauma memories (Hyer, et al., 1995). The therapist (Yvonne) and the client (Dick) have established a respectful relationship, where both actively contribute to the ongoing treatment plan and willingness to explore whatever options feel like they may work. Both have agreed that the treatment should remain dynamic and what works stays and what does not, goes. Three-month time frames have been set for evaluation of each section of the plan with options for extensions, add-ons, extinction, replacement or time-out periods in that one area. The client has a time-out option on all segments of the treatment plan and may use a seven-day time out without reason. After seven days he has agreed to continue or talk it out and process what was not working for him and together they will decide where to go from there. Due to the nature of this particular treatment and the intensity of it, a safety valve of time-outs will be employed. The greatest intervention at the onset is Dicks enthusiasm and determination along with his open willingness to try a variety of new things. In this sense Solution-Focused Therapy is actively implemented. Dick feels strongly that what he has been doing does not work, even to the point that it is now the problem (Butcher, Mineka & Hooley, 2010). Dick wants to continue building a happy, healthy, whole relationship with his girlfriend. He wants to move in together to a new home that they can share equally. He has expressed strong motivation to improve his interpersonal skills and to be able to feel emotions of any kind. He is ready to try to experience a full life and actually make future plans. He wants to work on being able to open himself up more in a personal manner. He wants to stop lying all the time and being abrupt and sullen.

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He wants the vivid memories to at least fade to some degree. He wants to leave Vietnam and to be present in his own life. Estimated Length of Treatment Each facet of Dicks treatment plan will be evaluated on an ongoing basis. The maximum time frame for each facet is three months. At three months a joint decision will be made to keep it, change it, add to it and so forth. Some facets have built-in acceleration potential. Dick will be the ultimate architect for his journey to wholeness and self-actualization. The overall estimate of length of time is not determinable at this time. Outcome Measures Self-report, Dick will be the person who will be affected the most. His treatment is all about him, he decides what needs to be measured or he may decide not to measure. The glass just is, it is neither half-full nor half-empty. Clinician Signatures Yvonne Christie, M.S. Choose the Red Door Inc. Harmony, Baja California Norte, Mexico Therapist Self-Critique This therapist is very aware of her limitations in the area of treating Vietnam War veterans, as her career began with them in 1984. This therapist readily admits to having boundaries that can be breeched as well as counter-transference issues. The sheer magnitude of horrific experiences these men have endured is humbling to this therapist. This therapist has felt the frustrating impotence at the lack of therapeutic progression for this population, because as Horowitz (1979) has painfully concluded, "for some [victims of catastrophic stress] the damage appears irreversible; the horror was too great, and

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treatment can become only a reliving, but not a dispelling of the nightmares" (p. 121). This therapist is cognizant of the slim-to-no possibility of complete recovery, yet is encouraged by Dicks braveness and need to keep trying. Yvonne is committed to learn as much as possible and to gain more skills and learn new tools or even create new tools if necessary. This therapist has learned from past mistakes and recognizes the glaring inadequacies in her self and the mental health community in the ability to offer an effective solution. This therapist will ask for help when and if a situation presents itself that she is ill equipped to handle. Her optimum goal is always to do what is best for Dick. This means if necessary she is prepared to bring in a co-counselor or even do a referral. Yvonne is also aware that this is not short-term therapy, this is a life long journey and she knows how to safe guard her self against being consumed. Working with clients such as this creates a symbiotic relationship, which is mandated for effective therapy, yet keeps the therapist right on the edge of the line between therapeutic and harmful. This therapist has learned how to take a deep breath and take a step back, or ten if necessary.

PTSD: ONE MANS JOURNEY References

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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders DSMIV-TR (Fourth ed.). Washington D.C.: American Psychiatric Association. Butcher, J. N., Mineka, S., & Hooley, J. M. (2010). Abnormal Psychology (14th ed.). Boston, MA: Pearson Education, Inc. Cooney, J. A. (1991). Review of "Trauma and the Vietnam War generation: Report of the findings from the National Vietnam Veterans Readjustment Study". Psychotherapy: Theory, Research, Practice, Training, 28(1), 191-192. doi:10.1037/h0092240. Haley, S. A. (1985). Some of my best friends are dead: Treatment of the post-traumatic stress disorder patient and his family. Family Systems Medicine, 3(1), 17-26. doi:10.1037/h0089646. Horowitz, M. J. (1976). Stress response syndromes. New York, NY: Jason Aronson. Hyer, L., Summers, M. N., Braswell, L., & Boyd, S. (1995). Posttraumatic stress disorder: Silent problem among older combat veterans. Psychotherapy: Theory, Research, Practice, Training, 32(2), 348-364. doi:10.1037/0033-3204.32.2.348. Kates, A. R. (2000). Cop shock: Surviving posttraumatic stress disorder. Tucson, AZ: Holbrook Street Press. Lipke, H. J., & Botkin, A. L. (1992). Case studies of eye movement desensitization and reprocessing (EMDR) with chronic post-traumatic stress disorder. Psychotherapy: Theory, Research, Practice, Training, 29(4), 591-595. doi:10.1037/0033-3204.29.4.591. Marshall, G. N., Schell, T. L., & Miles, J. V. (2010). All PTSD symptoms are highly associated with general distress: Ramifications for the dysphoria symptom cluster. Journal of Abnormal Psychology, 119(1), 126-135. doi:10.1037/a0018477.

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Tarler-Benlolo, L. (1978). The role of relaxation in biofeedback training: A critical review of the literature. Psychological Bulletin, 85(4), 727-755. doi:10.1037/0033-2909.85.4.727