The case study is that of Carla, a 38-year-old married Caucasian female. She has been married to her husband Jack for 14 years. Carla sought marital therapy mental health services due to marital discord and poor communication. She has three children between the ages of 6 and 12 years at the time she sought mental health services. She is a very active individual participating in various service and women's ministries in her church and an active member of PTA. She has a meaningful spiritual life whereby she professes the Christian faith.
During her first sessions at the marital therapy, she spoke of her day to day activities and the corresponding relationships in a respectful manner. However, she lacks animation or sense of connectivity or vitality. On the contrary, she spoke of her children depicting an emotional bond between her and her children. Carla seemed committed, likable and reliable and reported no hobbies during the sessions. She is not passionate about the activities and relationships of her life; i.e., she fails to mention any details about her relationship with her husband. Also when asked about her close friends, i.e., confidants she only responded with a shrug of her shoulders. This shows that though she is actively involved in the community, she lacks close friendship bonds with members of the community. She, however, is among the most liked individuals in her community, and this can be attested to the fact that she participated actively in school and church activities. She has been experiencing marital challenges which have led to the possibility of residential separation with her husband. Neither Carla nor Jack can draw a connection between the emergence of Carla's symptoms and any recent events in their marital life.
This report seeks to identify the impacts of the trauma on Carla and also identify the principles of crisis intervention that can be used with the client in an initial encounter. This report will also identify and evaluate the symptom presentation and apply the DSM-5 diagnoses on Carla's case. Lastly, the report will apply the Complex Trauma (DESNOS) criteria to help the client overcome the mental health issues.
Impacts of Trauma
Carla's early life is described during the therapy sessions as one being affected emotionally. First, her father was not presented emotionally during her childhood years. On the other hand, her mother was an alcoholic who once attempted to overdose on sleep medication when Carla was just 12 years old. She was emotionally affected by the incident given that she was the one that found her mother unconscious. She discovered a suicide note which a mother had wrote before she then called the police for emergency medical assistance. Carla shows no signs of emotional trauma as she has already; she has found industrious ways to manage the emotional trauma she experienced while growing up. She turns to play solitaire on her smartphone. Her husband jack described her and added that he doesn't know her anymore.
Carla during her sessions with the therapists admitted some active suicidal ideation. She fantasized about possible methods she could use to commit suicide. However, Carla denies having acquired the means to commit suicide. She also does not endorse suicidal intent. Looking at her files, Carla has no prior history of suicidal attempt. She recalls he mothers suicidal attempts and the impacts it had on the family.
Carla is also a victim of sexual assault trauma. She was sexually assaulted while in college during her junior years. Her assaulter was a 20 year old in the bathroom during a university athletic event. Though she saw a therapist after the incident, Carla did not seem to have overcome the sexual assault trauma. This is because when asked about the instance she gave a light reply and said that she would not have talked about it since it happened a long time ago. Carla felt that sharing her sexual assault experiences will fall short of her expectations as the therapists will not fully understand their experiences. She, therefore, decides not to discuss her experiences.
Hyperarousal and Sleep Disturbances
During the therapy sessions, the therapists discerned complaints by Carla of disrupted and non-restful sleep. Carla states during the sessions that she has started to have nightmares which have occurred a couple of times each weak. She experiences a physiological state of panic and awakens from these nightmares in a sweat.
Carla experiences trigger her sexual assault during her junior year in college. She states during her sessions that she often feels sick during her daughter's ball game. According to her description, the games make her feel edgy and tense. Though she gets tense before and during the games, this can be as a result of her assault during her game in the women's bathroom. She was attending a game and attending her daughter's game brings back those memories. She spends more time watching the crowd than actually watching the softball game according to her husband, Jack. This is because she is probably worried that someone in the crowd could have intentions of assaulting her daughter or team members.
Application of Crisis Intervention Principles to Carla's Situation
The effects of trauma on Carla can be seen in both problems directly related to trauma as well as problems that appear to be unrelated. According to studies, victims of sexual violence experiences trauma longer in their life, with impacts related to the incident and other unrelated impacts. According to Saakvitne et al. (2000), trauma symptoms arising from past violence and the absence of a safe environment creates obstacles to services, treatment, and recovery from survivors. Survivors tend to develop strategies for self-protection, combined with the posttraumatic stress symptoms of hyperarousal or avoidance impact on the client's response to trauma-informed care (TIC). Unacknowledged or poorly treated trauma and related symptoms interfere with seeking help for health, mental health, hamper agreement in treatment and make relapse more likely (Brown, 2000). Most common practices and procedures in service settings retrigger trauma reactions and are experienced as emotionally unsafe and disempowering for trauma patients (Harris & Fallot, 2001). As a result trauma counseling services should subscribe to principles of trauma-informed treatment and ensure that the service provider understands the pervasive long-term impact of trauma. This ensures that a validating environment is created by implementing the crisis intervention principles of trauma-informed treatment.
Crisis in trauma-informed care is defined as a state of emotional turmoil or acute emotional reaction to a powerful stimulus or demand. There are three characteristics of crisis, i.e., the usual coping mechanisms fail, the normal balance between thinking and emotions is disturbed and evidence of impairment in an individual. Crisis intervention helps trauma patients during a period of extreme distress.
For Carla's case, the following crisis intervention principles should be implemented to create a validating environment for trauma-informed care:
This principle argues that people respond best to simple procedures. Simple things have the best chance of having a positive effect. For the case of Carla, the crisis intervention should utilize the use of simple solutions. The therapists should ensure that the trauma-informed care models implement to provide a simple solution to her trauma.
The trauma-informed care offered to Carla should remain short. This means that the therapy sessions should be brief from minutes up to one hour. This will help avoid boredom well at the same time utilizing the period to facilitate normal recovery progress. In the case the sessions are prolonged, Carla is likely to lose interest and may fail to attend the sessions.
The therapists should be creative while offering trauma-informed care. Specific instructions on trauma care do not exist for every circumstance or case. Therefore, the therapists should innovate new ideas to deal with Carla's case as this is a unique case given that she is experiencing impacts of trauma which occurred during her early years of life. The therapists should treat this case as special and therefore should resist implementing rigid instructions or care model.
The therapist should keep the trauma care practical. For example, the therapist's should resist from impractical suggestions as they can lead to Carla feeling more frustrated and out of control as opposed to helping her through the care. Some of the impractical suggestions for Carla, in this case, could be; she explains why she loves her husband, whom she loves more between her children, husband or parents, etc.
Trauma-Informed care support services should be given in a safe zone. This means that the care to Carla during the therapy sessions should be close to her normal area of function.
The immediacy principle provides that trauma care services should be delivered right away. Carla is facing an emotional crisis as a result of her trauma experiences. Her marital relationship, as well as the relationship with community members, is at risk as a result of the crisis. This demands rapid interaction as delays can undermine the effectiveness of the support services.
Lastly, Carla's case support services should be led by expectations of a reasonable positive outcome. The therapists should formulate expected outcomes, i.e., goals which he/she should work towards achieving. Failure, to set goals will lead to failure of the trauma-informed care.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is a taxonomic and diagnostic tool developed by the American Psychiatric Association (APA) that serves as the principal authority for psychiatric diagnoses (American Psychiatric Association, 2013). The DSM-5 classifications determine the treatment recommendations as well as payment by health care providers.
A DSM-5 differential diagnosis for Carla is discussed in the table below:
ICD-9-CM/ ICD-10-CM Disorder/ explanation
308.3(F43.0) Acute stress disorder (ASD)
Based upon the information provided by Carla meets the diagnostic criteria A 4 (Carla experienced repeated exposure to aversive details of the sexual assault which occurred when she was in college. The exposures occurred every time she accompanied her daughter to her game. This is evident from the fact that she kept staring at the audiences rather than the softball game as reported by her husband); B (Presence of symptoms form categories of avoidance, negative mood, intrusion beginning and worsening after the traumatic events occurred). B2 (recurrent, involuntary and intrusive distressing memories of trauma through nightmares Carla reports to experience), B4 (Carla experiences prolonged psychological distress in response to external cues that symbolize an aspect of traumatic even. She experiences these distress symptoms during her daughter's ball games. She reported that she feels sick to her stomach and gets nervous) B5 (Carla experiences persistent inability to experience positive emotions. Carla does not seem to enjoy a relationship with members of the community as well as with her husband. She failed to develop a relationship with her therapist resulting in the therapists being frustrated at how elusive the sense of connection with Carla seemed), B10 (Carla experiences sleep disturbances); C (duration of the disturbance. Carla feels very insecure, she displayed psychomotor agitation in session whereby she shakes her leg whenever the conversation moved towards tones of deeper affect)
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