Chapter 8- Safety case study (1)

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CASE STUDY DETAILS Victor is a 27-year-old man who comes to you for help at the urging of his fiancée. He was an infantryman with a local Marine Reserve unit who was honorably discharged in 2014 after serving two tours of duty in Iraq. His fiancé has told him he has “not been the same” since his second tour of duty and it is impacting their relationship. Although he offers few details, upon questioning he reports that he has significant difficulty sleeping, that he “sleeps with one eye open” and, on the occasions when he falls into a deeper sleep, he has nightmares. He endorses experiencing several traumatic events during his second tour, but is unwilling to provide specific details – he tells you he has never spoken with anyone about them and he is not sure he ever will. He spends much of his time alone because he feels irritable and doesn’t want to snap at people. He reports to you that he finds it difficult to perform his duties as a security guard because it is boring and gives him too much time to think. At the same time, he is easily startled by noise and motion, feels physically panicked, and spends excessive time searching for threats that are never confirmed both when on duty and at home. He describes having intrusive memories about his traumatic experiences on a daily basis but he declines to share any details other than saying that he “doesn’t feel safe.” He also avoids seeing friends from his Reserve unit because seeing them reminds him of experiences that he does not want to remember. Time to treatment plan! 1. According to Herman, if this was your very first session, how would you want to start the treatment process with Victor (think of our last chapter!)? - conducting thorough and informed diagnostic evaluation - working on establishing safety, both physical and environmental safety - establishing a safety plan or something of the sort for times when he feels unsafe - building rapport (!!!!!) and working on forming that therapeutic alliance - discuss goals, set them, setting boundaries 2. Why is it important to ascertain and share a diagnosis with Victor? - knowledge is power, if he is able to put a name to his symptoms, it’s easier for him to understand that this isn’t something he is going through alone–others have been through this and healed, and he will too. - knowing that if there’s a name for something, there is most likely a treatment 3. How would you attempt to restore Victor’s control and begin to establish Victor’s physical safety in session? - I would want to see if basic health needs are being met, how long he is sleeping for, what he is doing when he cannot sleep, if he is engaging in any self-destructive or maladaptive behaviors, and if there are times of day or things that are triggering to him. - finding strategies to help sleep (especially if substances are involved) - I would further question his symptoms to see what I could do with any grounding techniques or other things I could share with Victor so he can use them out of session as

well. I might also look into medication to help him sleep or reduce hyperarousal/anxiety, if that is something he would be open to. 4. How might you attempt to support Victor in establishing a safe environment? - I would want to know more about his living situation with his fiancee, if he feels safe in his home. He is self-isolating, so maybe communicating with the fiancee to try to help him engage further with a support system. I would also talk through Victor’s job with him, if it hurts more than it helps and how he feels about being a security guard. 5. What might negatively impact progress for Victor in the beginning stages of treatment? - ruptures in the therapeutic relationship, issues in his relationship with his fiancee, problems at work, if he doesn’t choose to turn to his support system and engages in more isolation behavior, not having a supportive system of people, breaking boundaries, assuming process (moving treatment along too quickly). 6. If you were a novice therapist who did NOT read Herman’s book and started your work with Victor by exploring his traumatic memories (prior to building safety), what might occur? - If I were to start my work by exploring Victor’s traumatic memories, I do not think we would have a strong therapeutic relationship. I think Victor would probably not come back to sessions and would leave the ones he did come to feeling unsafe and exposed. Going over his traumatic experiences after he plainly stated he does not want to (and may never want to) would not lead to strong rapport building or helping him feel safe in his body and environment, could cause him to have more severe symptoms

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