This case study illustrates how Brian, who served in the Australian Defence Force for 14 years, healed from traumatic events during his deployments.
Suggested pre-reading: Assessing and Treating PTSD.
Related articles: Related articles: Epigenetics and Intergenerational Trauma, EMDR: Overview and Applications, Assessing and Treating Trauma.
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The story (from Brian’s perspective)
Disclaimer: This case study contains fictional names and modified details to protect the privacy and confidentiality of individuals and entities involved.
“I invested a lot of my early life in making sure people knew that I was tough. In my family it didn’t go too well for you if you showed weakness or that you needed something. So I came to regard people with anxiety or other mental illnesses as wimps: imposters that just needed a good kick in the bum to get going. I never imagined that I would become one of the “wimps”.
“By 20 I had signed up to serve in the ADF [Australian Defence Force]. It was baptism by fire. My first tour of duty was Afghanistan – not an easy deployment – but a few months after arriving I realised that I was born to soldier and I could be good at it. I was soon in a position of leadership, with some of the younger recruits taking orders from me and generally looking to me for guidance and leadership.
“After that first tour, I served in Iraq tours for most of the years we had forces there. When we pulled out from Iraq, I returned for another tour in Afghanistan. My wife and kids accept that that is my life, but even they were thrown by events in the last tour. We were sent into a tiny village just after the Taliban had left. The Taliban commander had heard that a couple of the villagers had helped out Western forces and wanted to teach the village a lesson. I saw enough horror during that one day to last a lifetime: people screaming and running; women wailing over the dead body of a loved one, mutilated but still live people, such as one tortured little girl; houses razed to the ground and thick, acrid smoke everywhere. My mates and I were quick to acknowledge: it’s all part of the job. Normally we would do it and move on, with an evening of drunkenness to forget what we’d seen, block it out. In this case, we did all the right things in the village: called for medical help and assisted with urgent chopper evacuations, put out fires, calmed the villagers, set up emergency shelter, and distributed food and blankets.
“But then as our unit was returning to base, we hit a bump. The IED [improvised explosive device, or bomb] went off, throwing five of us down. Incredibly, no one died. I copped it bad, losing consciousness, with shrapnel impact to my face and neck. I still can’t remember anything about the accident, but experienced confusion, terrible headaches, and vertigo for several days. Plus I couldn’t hear too well. After that I was diagnosed with TBI [traumatic brain injury]. My symptoms seemed to disappear over the next few weeks, and after a number of tests, they told me I would have no long-term cognitive impairment or perceptual loss, with the exception of some hearing loss in my right ear. The TBI was just the pre-show act, however. The real drama came along about five to six weeks after that terrible day, when I was already back home.
“I was now safely returned to my loving family, yet I just couldn’t get the images from that village out of my mind: especially the little girl whose arms had been cut off deliberately; she was left for dead, bleeding profusely but still alive. During the day the scenes from that terrible mission forced their way into my mind: not just memories – sometimes it was like I was right back at the scene again [flashbacks]. At night, I had unbearable nightmares, and even when I didn’t, I had trouble sleeping deeply. I felt totally on edge, unable to relax, and hopeless about my future. I was avoiding any thoughts or activities that even vaguely reminded me of the whole ordeal, such as walking in the fields near our home because the ground was uneven and any lump – however small – seemed capable of being another IED. Despite the avoidance, I still felt emotionally numb: just flat. I screamed at the kids for minor offences and shouted awful things at my wife. My thinking processes were all screwed up. I just wanted to lock myself away and not let anyone in. In short, I had become one of the “wimps” with mental health issues whom I had always scorned.”
“I was lucky, though. My wife is a fabulous woman and she figured out right away that I was probably suffering from PTSD. I didn’t even consider that possibility; I just thought I was losing my mind. But she persuaded me to contact the mental health services arm of the ADF. The day I saw the shrink I just bawled and bawled, like a baby. I don’t even know how he heard enough between sobs to diagnose anything, but I guess he got the main story. They performed a bunch of psychological tests on me and deemed me to have PTSD. At the start of the sessions, they gave me a bunch of leaflets to read about PTSD and I now know that people can recover from it, though I get that the road to recovery is long and difficult. I feel more hopeful now at the outset of this treatment than I have for some time. I really want to be back with my unit next year, leading a normal life.”
Clinical assessment
As Brian noted in his account, his loss of consciousness during the incident, severe headaches, confusion, vertigo, and memory and hearing loss led to a diagnosis of TBI, but one which would be temporary. As mental state testing continued over the course of the TBI treatment, he regained full cognitive capacity and mostly normal perceptual ability. When he began to experience the psychological symptoms at home, he was referred to the specialty PTSD team, who assessed him for PTSD, depression, and substance abuse using the following:
- Structured clinical interviews from the DSM-IV-TR (the DSM-5 had come out by that stage, but the DSM-IV interview templates, not yet updated, were still deemed valid).
- The PTSD Checklist (PCL)-Military Version
- The Beck Depression Inventory (BDI)
- Alcohol use was measured using the Alcohol Use Disorders Identification Test (AUDIT).
Brian met the criteria for PTSD (see Appendix below) and scored a 65 on the PCL (clinical range). He had either displayed or complained of a number of PTSD symptoms (e.g., distressing nightmares, angry outbursts, emotional numbing and/or withdrawal from those close to him, flashbacks, and avoidance of situations and activities reminding him of the traumatic incident). He scored a 20 on the BDI, which indicated (low) moderate depression. He reported no prior history of trauma before the military service.
Brian also screened positive for alcohol dependence, as he acknowledged consuming alcohol up to seven times a week with 10 or more drinks per setting. Just before his treatment began, Brian described himself as “getting drunk every day and blacking out two days every week”.
Treatment structure
Brian was initially given 12x 90-minute sessions with a clinical psychologist who specialised in the treatment of PTSD, with the possibility of assigning more sessions if evaluation at the end of the sessions deemed that more sessions were needed. The planned treatment regimen consisted of rapport building, psychoeducation, goal setting, and a basic PE (prolonged exposure) program which included imaginal- and in vivo-exposure to trauma reminders. There was some CBT and behavioural homework included as well.
Rapport-building and psychoeducation
Given that the foundation of Brian’s PTSD treatment was to be prolonged exposure, it was crucial to offer him early on in the sessions the opportunity to build solid rapport with the therapist. Exposure-oriented treatments require clients to face situations and memories that evoke intense emotional responses; this was most certainly the case with Brian. Thus, his treatment could succeed much more easily if he were to be held by a therapeutic relationship of rapport and trust (the latter generally being in short supply for traumatised people). Essential, too, were periods of psychoeducation, so that Brian would be able to understand the importance of re-exposure to painful situations and memories. He needed to understand why continuing to avoid such trauma cues would ultimately be harmful to him. Also, psychoeducation was crucial at the outset so that the therapist could instil hope in Brian and provide encouragement and positive reinforcement for engaging in treatment.
Prolonged exposure (PE) therapy
Brian’s avoidance symptoms (helping him to avoid situations, memories, images, and other aspects associated with the traumatic incident) were necessary for a diagnosis of PTSD. Sadly, however, avoidance behaviours are among the most resistant to change because avoidance reduces a person’s experience of negative emotion, thereby reinforcing the avoidance behaviours and increasing the likelihood that they will occur in the future. In fact, the tendency is for traumatised clients to begin avoiding increasing numbers of stimuli which they come to associate with the adverse incident. This tendency is problematic because it typically leads to increased physical and social isolation.
Exposure therapy, an effective treatment to counter avoidance, involves helping clients learn to tolerate their arousal (heightened emotional distress) at encountering trauma cues: that is, reminders of the traumatic incident. They only need to tolerate the trauma-related cues long enough to be able to extinguish the emotional trauma-related stimuli. When extinction is achieved, clients show little or no anxiety in response to traumatic memories or trauma cues which are objectively safe (e.g., walking in a field near one’s home where there have never been land mines). Thus the normal process of healing is enhanced by addressing and eliminating the client’s avoidance strategies.
Brian’s program
The therapist working with Brian generated a program similar to the evidence-based PE protocol for PTSD (Foa, Hembree, & Rothbaum, 2007). The sessions were planned and conducted as follows:
Sessions 1 and 2
Build rapport; do psychoeducation about why exposure is necessary, and how it will benefit Brian; include discussion of how avoidance is harmful. Set goals for the treatment. Work to engage Brian in treatment, instilling hope for a happier, trauma-free future.
Sessions 3 – 10
Collaboratively generate with Brian two hierarchical lists: A list of the intrusive memories, thoughts, and nightmares which were distressing Brian (i.e., seeing the mutilated young girl and experiencing the destruction of the village; being shattered by the IED blowing up). A list of the everyday life situations Brian was avoiding because they had come to be linked in his mind to the traumatic day (i.e., walking in fields near his home where the ground had lumps, being in the vicinity of smoke, hearing people scream – even screams of pleasure at their community swimming pool – and loud explosive sounds).
Imaginal exposure. The therapist explained what this is. Brian and the therapist used the list of memories, thoughts, and nightmares to come up with targets for imaginal exposure. The therapist then guided Brian (over most of sessions) through vivid recollections of the day in the village and the journey back to base where the IED was encountered. Brian was instructed to keep a journal of his experiences in session and also his moods and experiences over the week.
In-vivo exposure. After explaining what this is, the therapist worked with Brian to generate targets from the second list for in-vivo exposure. Practice tolerating the everyday situations ensued, moving (over most of the sessions) from the easiest sensations/situations to tolerate through increasingly more difficult ones. Brian was instructed to include in his journal notes on his experience of encountering in everyday life situations that had become trauma-evoking.
Sessions 3 – 6
Added agenda: Interoceptive exposure. During Session 3 when the therapist began to lead Brian back into traumatic memories and nightmares, Brian showed a low tolerance for the PTSD-related physiological arousal he was experiencing. Symptoms included racing heart, shortness of breath, and dizziness. The therapist knew that these symptoms were not dangerous in themselves, but as they were highly uncomfortable, their continuation could have put Brian at risk of dropping out of the treatment program. Thus the therapist decided to incorporate interoceptive exposure: that is, finding ways to mimic the symptoms in order to help Brian de-sensitise from them, and also to discourage him from over-interpreting their importance as somehow dangerous or making Brian “out of control”.
The interoceptive exposure included getting Brian to do jumping jacks, breathe through coffee straws, and spin in the therapist’s office chair. The therapist explained that, by being willing to have the symptoms induced ahead of time, Brian could habituate to them so that they would not be so overpowering when he was involved in the imaginal and in-vivo exposure work. The therapist introduced these in a light-hearted manner, doing some of the exercises along with Brian, greatly reducing his anxiety and helping Brian to feel more positive about the other exposure practices.
Sessions 11 – 12
Work with Brian on cognitive restructuring of unhelpful beliefs and thoughts. To collect a data base of these, Brian and the therapist trolled through Brian’s journals of the sessions and the therapist also shared his notes of irrational, limiting, or otherwise unhelpful comments Brian had made throughout the sessions. Together they reworked the cognitions. Brian was asked to consciously try to employ the more helpful, reframed cognitions in his everyday life. For example, when Brian had the thought, “You just can’t trust anybody”, he was encouraged to acknowledge the difficulty in trusting that was part of the PTSD, but respond to himself something like, “Wait a minute; that’s not true. My wife is totally trustworthy; so is my therapist.”
Close the sessions. Brian and the therapist reviewed what Brian had learned, how well he had met his treatment goals, how he was doing now at the end of treatment, and what healing tasks still remained for him.
Epilogue
Brian appeared to be much happier and functioning much better in his life by the end of the sessions. At Session 10 he was re-tested for PTSD and depression. He scored a 23 on the PCL (Military Version) and a 4 on the BDI, both of which were in the nonclinical range. He had been noting to the therapist in the latter sessions that he was feeling more and more “like a new man”, with significant decreases in symptoms.
At Session 11, it was noted that Brian had manifested significant improvement in the area of alcohol dependence, even though none of his treatment had specifically targeted his alcohol use. He said that he no longer had the urge to drink alcohol in order to avoid traumatic memories or to sleep. In fact, Brian noted that he now drank only at the social gatherings he had begun to attend again with friends and family (approximately once a week). He could not even remember the last time he drank more than five drinks at a single social event. The formal AUDIT was not re-administered because the counsellor was monitoring the situation through weekly contact; he would later remark in his notes that Brian’s decrease in substance abuse occurred around the same time as his decrease in stress from intrusions (owing, probably to the exposure therapy beginning to take effect).
Brian also remarked that he was feeling optimistic about what the future might hold, including continuing his career in the ADF.
Here are some of the comments Brian made in his twelfth and final session.
“By around Session 7 I noticed that those terrible scenes weren’t jumping into my head so much anymore [as flashbacks], although the memories stayed quite intense when I chose to think about that terrible day. The nightmares began to go down, too, and by Session 10 had stopped. I noticed that I was feeling a kind of lightness in myself that I hadn’t felt for a long time; the black cloud I’d had hanging over me before seemed totally lifted and I felt like I was being much more patient with my kids, much nicer to my wife. I think getting restful sleep again has helped me to relax and also cope with the sessions and the sometimes challenging homework. Somewhere by around Session 10, I realised that I felt like making love to my wife again, and even initiated a romantic dinner just to express how grateful I was feeling to her for putting up with everything. I no longer feel terrified trying to walk across the fields near our house, nor at the beach when I hear people screaming with fun. I even stayed calm recently when there was a fire in our neighbourhood and smoke covered the street. Loud noises that sound like explosions still startle me and send my heart racing for a moment, though. All in all, I acknowledge that I have been a “wimp”, but now I’m proud of it, because going into my wimpy side allowed me to seek help.
“The best thing is that I see I have a future, although I need to speak to the ADF again about how I might be deployed, as the hearing impairment I have now may change how I can serve. All in all, I am deeply grateful to ____ (the therapist) for giving me back my life.”
Trauma courses and resources
This case study was adapted from the Mental Health Academy trauma course, Case Studies in Trauma. This course – a case study companion to Working with Trauma – provides you with the opportunity to view, through the lives of three trauma victims, the particular constellation of symptoms that made recovery of wholeness post-trauma such a challenging journey.
Take a deeper dive on this topic with our micro-credential, Working with Trauma: Interventions That Foster Resilience. This 20-hour program, facilitated by Prof. Cirecie West-Olatunji, Ph.D., teaches you the key issues, current trends and most efficacious interventions in trauma counselling, with a special focus on the effects of trauma on marginalised groups, and how you can support them as a clinician.
Read other case studies:
- Case Study: DBT and Bulimia Nervosa
- Case Study: Narcissism in Family Relationships
- Case Study: Narcissism in a Romantic Relationship
- Case Study: Emotional Freedom Technique (EFT) for Burnout
Appendix
PTSD Checklist for DSM-5 (PCL-5)
The PCL-5 is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. The PCL-5 has a variety of purposes, including:
- Monitoring symptom change during and after treatment
- Screening individuals for PTSD
- Making a provisional PTSD diagnosis
The gold standard for diagnosing PTSD is a structured clinical interview such as the Clinician-Administered PTSD Scale (CAPS-5). When necessary, the PCL-5 can be scored to provide a provisional PTSD diagnosis.
For more details and to download the checklist, click here.
References
- Foa, E.B., Hembree, E.A., & Rothbaum, B.O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences. New York: Oxford University Press.