PTSD

Case Study Form
[Name]
[Institution Affiliation]
[Date]

Phone +1 212-238-7000
Fax: +1 212-238-7321
Location: 725 5th Ave, New York, NY 10022

Jude Scott
Solidarity Therapeutic Clinic
Personal Details
Name Emily Lindy Jefferson
Age 47 years old
Gender Female
Marital Status Married
Address 516 5th Ave, New York, NY 10022
Telephone (Work) +1 212-238-2340, (Home): +1 212-238-2143, (Cell): +1 212-238-9357
Referred by Gouverneur Health Facility on 5th November, 2016
Other members in the clients Family
James Jefferson: This is the client’s husband. They got married at 19 years old and have four children together. James is 53 years old and has a successful contracting firm that in New York
Emma: This is the client’s firstborn child. She is 27 years old and is a lawyer with a successful firm in New York.
Freddie: This is the client’s only son and the second child in the family. He is 24 years old and has recently acquired an internship with a reputable architectural firm after finishing his college degree.
Natalie, the third child is 20 years old and is still in college.
The last born is Jamie who is 16 years old and still attending high school.
The estimated Annual Household Income is approximately $150000
SOCIAL HISTORY OUTLINE FOR EMILY
Reasons for referral
The client was referred to this institution by Dr. Festus McLaren of the psychiatric department at Gouverneur Health Facility New York. According to the report sent by the information department of the former clinic, the client has symptoms of post-traumatic stress disorder.

The report contains an extensive description of the client. According to the report, she started attending the clinic one year and three months before the date of referral. Initially, the client reported mild infections such as fever and flu accompanied with severe headaches. These infections were previously treated independently. However, the frequency of the infections prompted the physician to investigate any underlying cause of the obvious law immunity. Approximately five months since the first reporting day, the client admitted to experiencing persistent loss of sleep. The physical also noted that when probed, the client exhibited signs of avoidance and anger. Although the challenge were initially anticipated to be mild and temporary, the problem has persisted over time to a level that the health facility management unanimously agreed that the client would benefit more in a specialized institution. The client records her personal profiles as follow; she is a married woman of 47 years and of white descent. She has three daughters and one son. Among the children, one is an adult; two are young adults while one is a teen. The client lost one leg in combat and therefore operates on a wheelchair throughout her waking hours. On the reporting date, the client was neatly dressed with evidence of good care at home. Apart from the information on the report by the previous service provider, the client can express themselves occasionally with remarkable precision. The husband, who accompanies her to therapy is also willing to respond to questions when need be. In the recent past, the client’s mental status has deteriorated with aggravated her behavior. There is increased the loss of sleep and aggravated flashbacks. During these periods, the client expresses fright and attempts to escape which often leads to toppling over from the wheelchair and other accidents. Also, the client expresses disorientation and therefore frequently speaks about the meaningless of life. Although not out rightly shown, the client shows signs of developing suicidal tendencies. The sharp aggravation of the behavioral characteristics thus prompted the family and former medical service providers to refer the client to the agency.
Definition of the casework
The client enrolled in the military at the age of 18 and served for 21 years. For the last five years, the client worked in combat in various bases across Asia. The final year was in Iraq where she, unfortunately, lost a leg in an attack and therefore retired henceforth. In the early retirements, the client expressed mild distress that was considered normal with regard to the devastating events of her last mission. Indeed, with time, her condition normalized with the client going around her normal daily activity without many challenges. Approximately two years ago, the signs of distress started re-emerging. This coincided with the inability to attend the important event at the daughter’s junior high school event. Since then, the client began expressing mild illnesses anytime there was a major event approaching. These diseases consequently ensured that she would not attend public events such as parties. The expression of illnesses such as flu during these periods initially masked the tendency to avoid public association. After ten months with numerous recurrences, the family prompted the client to seek medical attention at which the client first visited Gouverneur health facility. After the speculation that psychosocial challenges were causing the unusual reactions, the client received psychiatric assistance at the health care center. About three months ago, the client was left alone. Upon returning, the husband James found her locked inside her room. She claimed that there was an enemy attacking and it was useless to fight back and therefore urged the husband to take cover. As the husband was still thinking about the proper course of action, the client recovered and opened the door. Even more disturbing to the family is that she had no recollection of the events that had just transpired. Within the three months, the frequency of the events has increased happening about three times every week. Probably due to the frustration and helplessness as the client is unable to remember the events in wakefulness the client recently began expressing disillusionment. She frequently engages anyone close to her with an endless discourse on the vanity of life. During this period of memory loss, the client harms herself intentionally by hitting herself on hard surfaces and unintentionally by falling from her wheelchair. The client has reported increased insomnia. She is unable to sleep for up to 48hrs straight. For this reason, she has prescribed sleeping pills. However, in most cases, she refuses to take medicine and it is difficult to convince her that the medicine is good for her. The client exhibits alternations between intense anxiety and absolute passivity. The trigger for the sudden onset of current behavioral expression remains uncounted for. At home, the husband and children have tried to maintain a comfortable environment for her as much as possible. Her husband has delegated work and dedicated time to stay with her. She is less likely to panic when in the company of someone else. The time when her husband stays with her, she is more or less normal. However, anytime that she is left alone, she becomes either very aggressive or completely quiet. She also does not handle crowds too well and therefore it is challenging to go out with her as she can start shouting anytime. This means that the husband must stay with her at home. At the clinic, there were increased attempts to cater for her growing needs. Initially, there was the suspicion that she might have injured herself while alone in the house and thus the sudden mental change but no evidence for this. Various procedures including head scans have been carried out to ascertain that there are no physical challenges. So far, you have been little progress with the diagnosis. There has been an establishment of the presence of flashbacks because when the events happen in the presence of someone, there is the reference to actions that occurred during combat such as attacks and shelling and crying about an injured leg. By registering into Solidarity Clinic, the client hopes to be assisted in regaining control of her mental challenges. She hopes that the triggers for the observed reactions can be understood and managed.
Background
First Family
The client was born and raised among seven other siblings in the mountainous region of Appalachia. She is the third child in the family and the first daughter in a family of five boys and three girls. The family was relatively intact during all her childhood years. However, when she was 12, the father lost a large part of their farm to auctioneers due to massive debts collected over time. Although there was still sizable farm for sustenance, this event led the father to binge drinking, and he became violent. As a result, most members of the family began staying for as little time as possible within the compound. The bigger brothers left home as soon as they could when 18 and 16 years respectively. At this period, she was 13 years old. The violence, loss of property and rapid degeneration of the family affected her mother significantly, and she became very passive. Emily thus had to take numerous responsibilities in the homestead especially that of catering for the younger four siblings. Through this, she developed a sense of urgency and independence at a very young age. She has always had the need to have everything in control and does not believe in failing at anything. When she enlisted and went into the military at 18years, circumstances deteriorated at home, and she often contemplated quitting in the first years, but the salary she was getting was essential to keep her siblings in school. The mother died 15 years ago from an undetermined accident. The family has always suspected that the father had something to do with the death and therefore relationships with him further deteriorated. The older brothers are currently married with children and living in other states. The younger siblings are also independent apart from the last brother who still struggles with medical depression. The client has been worried that the brother’s circumstances will not improve. About five months ago, the brother was arrested for the third time for minor offenses of harassing people. Although it is not yet clear, it is suspected that he is using some drugs. The other siblings have gotten used to having Emily cater for the welfare of the family and therefore do not participate meaningfully in solving this challenge. She has therefore been worried that if she is not able to keep it together; the brother will deteriorate completely. Meanwhile, the father has been admitted into elderly care in Ney York. This is because he developed a kidney problem and therefore could not be catered well in the centers back at home. However, the father does not like the environment in the current center and frequently calls to ask to be taken back to the mountains. He claims that his health is better there and he is livelier because he has friends, who he can speak to, unlike the town where he feels like a stranger. In his opinion, it is better to be left alone to die among friends than to suffer in solitary confinement where not even his children want to come and visit him. Although there has been a difficulty with him, Emily still values her father and therefore does not want him to go back to the mountain. She has tried to speak to the siblings to see if they can come to visit him now and then but none of them is interested. The sister who follows her is the only one who is interested in his welfare. However, she works with a mission medical practitioner and was recently moved temporarily to the Central African Republic. This has also been challenging for the client because she worries that the sister may get caught up in the war. Although the sister is working within the United Nations premises, she is frequently agitated and looking for news about the region on the internet. Any news of destabilization affects her terrible, and in many cases, it is impossible to ascertain the health of the sister immediately because their internet connection in this region is very poor. Sometimes the client says that if she had not gone into the military, she would have been able to keep the family closer to each other and therefore blames herself for the antagonism in the household.
Current Family
The client’s current family made up of 6 individuals. Her husband James is 53 years old and owns a contracting firm. They met in her first year in the military when she was 19 and married the same year. Initially, James tried to make her quit military service and stay home with the children, but she did not agree. Eventually, they decided to have her continue with service up to 40years. Unfortunately, she had a tragic end of the career at 39 years old. James is mild and loves his family immensely. His firm is doing well, and therefore he can support the family financially. However, he often feels distressed because of the wife’s condition. He feels that if he had been able to pursue the attempt to make his wife quit earlier, the ultimate tragedy would not have happened. This distresses Emily because she does not want the husband to feel responsible for her tragedy. Their four children live with them. Although their first daughter Emma is having a rapidly growing career in law and could sustain herself, she prefers to stay close to the mother. This is because she worries about her too much when she is away especially after the onset of the present challenges. She has a boyfriend that is lawyer too and they have an engagement party coming up. Emily is mildly agitated about her inability to assist in the planning of this event for her first born daughter. She has disclosed that this makes her feel like she has never been the mother of her children. She spent most of their childhood years in combat and now she can not attend important meetings because of her health conditions. Whenever these thoughts come up, she develops disillusionment and becomes borderline suicidal. The second child Freddie is also doing well. He recently completed his architectural course and had an internship with a splendid firm. Although he is brilliant, he seems to have a social problem and dislikes any relationships and prefers to stay alone. He has expressed the desire to remain single for the rest of his life. He openly shows disproval for the fact that the mother left the father to cater for them most of the time and thus says he does not want a marriage where he will have to stay alone most of the time. The two youngest daughters Natalie and Jamie are still in school. Both of them have seemingly healthy teenage/young adult lifestyles. Sometimes, the children are uneasy about inviting their mother to their school activities. It is unclear whether it is because they are embarrassed or because they are afraid it will agitate her if she is unable to attend. Apart from Freddie who withdraws sometimes, the family is intact and shares dinner at a common time every evening.
The family’s major strength is its unity. Although sometimes Freddie disgruntles, the family is united and affectionate towards each other. All the members of the household do whatever is within reach to ensure that Emily gets the best available care for her needs. In numerous cases, the younger daughters cancel their plans if the father has to work to take care of the mother. However, the family is often at a loss of what to do especially in the recent developments. The closeness of the family means that something that affects the mother affects all of them. In numerous cases, the younger siblings have been ridiculed by their friends about the condition of the mother. Additionally, any anti-veteran sentiment in the media heavily agitates the family. This makes them tend to isolate from the society to avoid provocation.
Social lLife
The community of Manhattan where the client resides does not have many social integration opportunities. The majority of families have working parents and school going children who leave every morning and return in the evening. Besides, due of Emily’ long traveling away when working lasting relationships with her neighbors. This means that in most times, when her family leaves for their daily activity, Emily is left only with a young Latino woman that has been working for the family in the past year. The nanny does not speak much English and is not very social. Even when they talk, there is limited consensus, and therefore she is forced to wallow in loneliness most of the day. There are two older women in the neighborhood who are beyond 70 and are living in the area with their families. Since they are always in the area, Emily sometimes chats with them but again there is no common ground for dialogue. In most cases, she feels frustrated and un-understood. She feels like an outsider in her community. The only groups that the client related with strongly is a community support group for veterans and people with disabilities. In these groups, she feels understood. The major challenge in this community is that nobody has sufficient time to listen to the problems of another. The strengths are that the groups are equipped with better facilities to cater for the unique needs of the client. The infrastructure is good and she able to access medical facilities as soon as she requires it.
Detailed Clients information
Introduction
The client left the family of origin at 18 years when she enlisted in the military. Among the 21 years she spent serving in the Army, 16 were spent in various missions within the US while the last five were served in combat in Iraq. Her conclusion of the military career was not voluntary but occasioned by the loss of a leg in operations. One year into the military career, she encountered James who was then working in a contracting firm that was working with Department of Defense. They married soon afterward and had had four children together. The main point of conflict between them occurred at the beginning of their marriage when the children were younger. James felt that Emily should retire early to take care of the children. As the children grew older, the turmoil settled down, and the couple has not had any major disagreements. Their children are well adjusted, although Emily still experiences some form of estrangement from them every once in because she was absent for a better part of her life. The military experience was majorly significant in her life and is the chief cause of any predicament she faces today.
Developmental
Emily has always developed at a reasonable pace. Her father described her as one who grew up too fast. This is because she caught up with most of her brothers’ activities who were 5 and three years older than her pretty quickly. The unanticipated disintegration of her family also propelled her to a position she was more or less not ready for. However, she was able to handle the pressure graciously. Her brother’s define her as the pillar of the family because of her firm resolve and emotional stability.
Cultural Identity
In her earlier life, Emily attended an evangelic ministry church. However, when the family began disintegrating, attendance became sparse and finally stopped. The husband is Catholic but due to her career, and she does not attend the church frequently. Her condition now does not allow frequent movement, and therefore her attendance has even fallen greater. Her children also attend the Catholic Church infrequently. She often found her origin intimidating because of the hilly Billy association. However, she no longer associates with any Appalachian cultural heritage. He mission around the global has formulated a citizen of the world. She is comfortable with different communities and does not form deep connections with any particular segments. Her constant movement also established in her a sense of vanity in associations. Since she always avoided creating substantial encounters in a community because she was sure she should be sent to another region soon, she has the same difficulty presently.
Education
Her educational performance was above average. In fact, it is noted that she could have performed exemplarily well were it not for the challenges experienced at home. She especially performed well in mathematics and sciences. These subjects were also completed with good results in the military school where she was best in mathematics. In general, she has always achieved academic excellence at all levels.
Employment history
The client worked for the military since she was 18 until her unanticipated leave and therefore she has not had any other employment opportunity. Since she had already worked 20 years of full-time services, she is eligible for pension and her family has other sources of income. There are no financial hardships anticipated in the client’s case.
Health status
The client did not have any significant problems prior to the accident at the end of her career. Previously she received care in military hospitals but currently she visits many assorted health clinics. Until now, the major health challenge was the loss of a leg from the thigh downwards. This was lost in the last combat operation she was involved in Iraq. For about one year, the client has used prescribed pain killers for the constant headaches and occasional sleeping pills for persistent insomnia.
Alcohol and/or substance abuse
The client has no history of either alcohol or substance abuse.
Sexual history
There is not report on sexual harassment or abnormalities in the reproductive growth. The client reported that it was difficult to be a woman in the military which is a male dominated career. However, she remarks that there were no major incidences that upset her.
Religion
The client reports a distant relationship with the church. Initially, she attended an evangelical church in the Appalachia region. However, when the family started breaking up, she reports feeling victimized in the church community. When she got married to her Catholic husband, she began to attend services in the new church but has never actually integrated into the community. She says that her former faith still inhibits a complete acceptance of the new faith. This issue has a significant importance to her husband and she feels bad that she is unable to completely fellowship with him. She is also guilty that she was not able to accompany her children in faith because of her job.
Leisure
Due to her disability, the client is no longer able to participate in the rigorous activities she was used to. She reports this with a sense of loss because she describes herself as always being a runner. Now she watches movies all day which makes her feel unworthy. In the recent past, she has learned to swim and can swim very well even without one leg. She would like to be able to get out more often and move around the area.
Interpersonal and social relationships
Currently, her relationships are mainly with the family members and her nanny. She finds little common ground with others in the neighborhood, and she is not a solid member of any community group in the area. Besides, since she was always used to being strong, she is afraid that other people will see her as a burden in the current status. She also keeps away from her family of origin because she does not want them to feel overwhelmed by her current condition. Often she refuses help even when offered by her family and tries to be as independent as possible. She says that she feels most people try to interact with her out of pity rather than genuine affections.
Critical incidents of importance
There are three critical incidences in her life. One of this is the loss of property in her original family. This marked the genesis of challenges in her family and led to the subsequent shifting of responsibilities to her side. It marked the death of vital relationships in her life. The second is the decision to enter into the military. In the beginning, she was torn between staying back to cater for her siblings but decided to go to work to provide for them. She still wonders if the family would be more united if she had remained at home. However, she also recognizes that going to the military marked the genesis of the new family by providing the opportunity to meet James. The last significant incident was the final operation in Iraq where she lost her leg and numerous other friends that she had known for a long time. In the operation, she also lost her best friend that she had met in the first year of the military life. She still thinks that there are many things she could have done to ensure that the ultimate catastrophe does not occur.
Interaction with community resources
The client is involved wit one community support group in the community. However, she attends the meetings intermittently because mostly she feels that they do not understand her challenges.
Psychosocial Status
The client was passive when asked this question. She reported that she thought of herself as strong and unemotional. For her, emotions were associated with weakness; she reports that since a tender age, she was taught by her older brothers that crying was weak. If she cried, she would be mocked for being a girl and kept away from games, and therefore she got used to minimizing emotions. Even now, she does not like exhibiting emotions and keeps everything inside. For these reasons she does not show when she is offended or happy because she does not want to bother anyone.

ECOMAP
ECOMAP KEY:
The flow of energy
relationship
—————————Tenuous relationship
Blank (no line)No relationship
Colleagues

Father
Recreation
Church

Society

Husband

Job

Emma

Emily
Brother 5

Natalie

Brother 4

Freddie

Brother 3

Jamie

Brother 2

Sister1

Sister2
Bother1

ASSESSMENT OF THE CLIENT
General summary
Emily is an active client who has withstood significant changes in her life. She adapts very well to changes and can accommodate many challenges. She highly esteems her family, both former and current and is willing to sacrifice her life for the benefit and wellbeing of either of the two families. In a bid to achieve this, she is vulnerable to an emotional overload. She does not like expressing herself openly, and she feels this will burden the other people. She possesses an urgent need to be in control and support other people through difficulties. This can make it difficult to communicate to someone else including the therapist for fear of losing control. She is also suffering from memories of past traumatic events. This is not necessarily events within the army. They could be from her childhood but exhibiting through the flashback of the attack in Iraq. The most likely trigger for this was her sister’s migration to central Africa which aroused the possibility of death in a battlefield.
The current situation
Micro
Emily is suffering because of self-induced consciousness. She has learned to take control since the time her family broke doewn. She is, therefore, unable to talk about the challenges she is undergoing, and she feels she is the one who must solve the problems of the others. Her career has also disadvantaged her by disabling her ability to communicate with people. She does not hold social relationships with very high regard and therefore is always alone.
Mezzo
The first family is an impediment to the well-being of Emily. Although it depends heavily on her wellbeing, it does not attempt to assist in her predicament. It, therefore, drains her continually without an opportunity to replenish. Additionally, the community around her does not try to penetrate her wall even though she creates it herself.
Macro
The lack o mechanisms to diagnose the challenges faced by Emily are a chief cause of the problem for her and others. She is a victim of global politics that mandate her presence in Iraq where she got her injuries.
Aspects of diversity
Emily is very diverse from the local community and therefore dies not blend easily with fellow neighbors. In her working life, she stayed in more than ten different countries. She, therefore, has a mixture of the characteristic of values, likes, and dislikes collected across the globe. This gives her some form of restless because it means that she is no longer able to commune with people who are trying to help her deal with the circumstance. He constant allusion to how another culture somewhere faces its challenges makes any caregiver feel like she is always critical of the current service. In fact, the often multicultural dialogue has contributed to her lonesome nature since no one can connect with her desires which change quite often.
Solidarity Therapeutic Clinic
TREATMENT PLAN
Client Name: Emily Jefferson
Date: 10/11/2016
Date of next review: 24/11/2016
Problem One:
The current flashbacks that make her react are such as extreme way
Goal: To rid the client of the flashbacks that triggers the emotional breakdown through assisting her to internalize and externalize the events.
Objective 1: Reduce the frequency with which the flashbacks are occurring.
The method of Evaluation: Inquire on the particular number of times that the flashbacks are occurring.
Action Steps: Assist the client to internalize the trauma she underwent and be able to speak about the event.
Objective 2: Help those around her understand how to help the client in case of the reactivity.
The method of Evaluation: inquire on the positive development towards helping the client recover from the event.
Action Steps: Speak to the family members as well as Emily on the importance of giving support and the importance of accepting support respectively. Administer a test on improvements regarding care of the client when the reactivity spasms occur.
Problem Two:
The second challenge is the habit of the client to shoulder every burden in a bid to put everything under control and which contributes to the buildup of social pressure within her. The client does not understand that in doing so, she is just damaging herself unnecessarily.
Goal: make the client understand that they can relax and accept help sometimes because the world does not have to be under their care.
Objective 1: Encourage the client to trust.
The method of Evaluation: Administer periodic evaluations to see the level of which the client can let others take care of her without getting concerned that she will loose control and become a burden.
Action Steps: Give the client some activities and insist that she has someone else do the tasks for her. Talk to the client to make her understand that the world can go on without so much effort from her.
Objective 2: Assist other understands that she needs support even when she is acting strong.
The method of Evaluation: Evaluate the level at which other individuals interact with her with the aim of assisting her with personal challenges.
Action Steps: Speak to the client to ensure that they understand that accept help does not equate to weakness. Evaluate the ease with which the client understands the concept by assessing the ease with which they take assistance from others around them.
Problem Three:
The third challenge to look at will be the unresolved challenges between the individual and other people such as colleagues, former family, Freddie and her father.
Goal: help the client to face unresolved relationships within her life.
Objective 1: Establish communication between any feasible parties.
The method of Evaluation: Observe a change in overall perspective of relationships.
Action Steps: Establish a dialogue that focuses on evaluating the relationship of the client with a particular member and delve into the reasons why there are challenges in that relationship.
Objective 2: Help the client establish sublimation methods.
The method of Evaluation: Evaluate the number of recreational activity that the client begins to engage with.
Action Steps: Involve the client with activities that can help the client express their concern in for others in a way that does not become obsessive.
EVALUATION PLAN
Identified problem:
Emily has undergone several challenges which are manifesting through intrusive flashbacks and emotional breakdown. She is also very independent and therefore to supports everyone in her family without tiredness.
Identified Goal:
Emily will learn to internalize and externalize trauma and therefore will be able to resolve all the challenges she is facing.
Method of Evaluation: Single subject design
Independent variable: Enlist assistance to evaluate the progress by the former medical facility. The team should come once in a month.
Dependent variable: the client will visit the therapist once every two weeks for one-hour sessions. Meanwhile, in encouraging the client to take assistance more closely with others and to increase her reliance on people the therapy will continue even at home.
Type of single subject design: AB Single Subject Design
Baseline phase: The client will be required to report once a week on the progress of her relationships with to others and the frequency of individual blackouts.
Treatment phase: Clinical counseling of the client.
Visits Register
Session Duration REMARKS
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 78““
cON
Overall Remarks