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Case Study and Intervention Report: Post Traumatic Stress Disorder after a Motor Vehicle Accident Valerie Griffith

Case Study: Kristin This case study is about a 21 year old college student named Kristin. Kristin was being bothered by her friend for days to take her over the border to Canada to meet an online boyfriend. Kristin had a bad feeling about it so she kept denying to take her friend. After being bothered for many days, Kristin gave in and decided to help her friend out. The morning of March 9th, the two young adults went downstairs to the apartment complex parking lot where Kristins car was located. It had snowed an inch the night before, so they spent some time warming up the car and scraping the ice off before they set out on their journey. After successfully dropping off her friend at the ferry dock, Kristin set out to return back to the states. It was bumper to bumper traffic on the outside of Vancouver for a good 25 minutes. As the traffic eased up, Kristin was able to go the speed limit. After a few minutes, a minivan decided to switch lanes and get in front of Kristin where the driver preceded to slow down 10 whole kilometers. Kristin didnt understand why the minivan had slowed down so much and decided to switch lanes to pass the van. As she crossed the center line, Kristins car slid on ice and slammed into the barrier. She couldnt believe that this had happened to her. After the accident, Kristin fell into a deep depression. She was unable to find the motivation to do household chores. She suffered from migraines and isolated herself in her home. She replayed the day over and over in her head looking for some way she could have avoided this situation. She was irritable and would lash out at those who tried to help her. She had trouble sleeping, and when she did fall asleep she would have reoccurring nightmares that consisted of her crashing her car in different scenarios. She was petrified to get behind the wheel and would hyperventilate when in the passenger seat. Kristin was later diagnosed with posttraumatic stress disorder (PTSD).

Effective/ Ineffective Models/Interventions As Kristins case manager, I would approach her PTSD with hour long sessions, once a week for 10 weeks focusing on cognitive behavioral therapy. Cognitive behavioral therapy (CBT) is a psychotherapeutic approach that addresses dysfunctional emotions, maladaptive behaviors and cognitive processes and contents through a number of goal-oriented, explicit systematic procedures. Over the past decades, effective psychological treatments of PTSD have been developed. Trauma-focused CBT has repeatedly been demonstrated to be effective and is currently recommended as a first-line treatment for PTSD (American Psychiatric Association, 2004; National Institute of Clinical Excellence [NICE], 2005; Stein et al., 2009). Group and individual CBT are known to show success and early intervention is always the best. Session 1: Provide psychoeducation and review the clients self-assessment from the PTSD checklist for the symptoms of PTSD. Explain that PTSD is a normal reaction after trauma has occurred. Describe symptoms and the techniques that will be used to help her. Start relaxation training. For homework, assign a written description of the clients motor vehicle accident (MVA) as homework. Session 2: Review the homework and the clients understanding of PTSD to expose her to her intervention. Review the clients written description of the MVA. Continue relaxation training. Session 3: Review the homework. Have the client read their MVA description aloud. Discuss negative self-talk and begin working on coping self-statements. Continue relaxation training. Session 4. Review the homework. Introduce cognitive reappraisal (a coping strategy in which clients are taught to monitor and evaluate negative thoughts and replace them with more positive thoughts and images). Continue relaxation training.

Session 5. Review the homework. Introduce relaxation-by-recall. Discuss driving, cognitive techniques and their application, imaginal exposure as needed, and in vivo exposure. Ask the client to complete an assessment as a mid-treatment measure. Session 6. Review the homework. Introduce cue-conditioned relaxation. Continue working with CBT and the exposure model. Session 7. Review the homework. Introduce pleasant event scheduling, address existential concerns, anger, depression and isolation. Session 8. Review the homework and relaxation techniques. Session 9. Review the homework and cognitive techniques learned. Session 10. Review the homework. This is the termination session, unless the decision has been made to continue treatment. Review the reassessment and treatment interventions. Medication has a potentially important role in the treatment of PTSD. Medication should be started as early as possible. Benzodiazepines and other medications that cause sedation may impair driving ability and should be used with caution. Despite concerns about side effects, however, medication can sometimes improve a person's driving by lessening stress symptoms and breaking the vicious cycle that occurs when driving induces painful memories and reactions to the original trauma. Less effective interventions include waiting list and supportive therapy. A waiting list is a group of people who are the control group. This group is not receiving the medication that the active group is taking. This model is used to compare behaviors, but of course it is not going to be effective, when the clients arent receiving treatment for their PTSD. They will eventually receive treatment based on the success of the trial. Supportive therapy is a type of psychological therapy that aims to help the client to function better by providing personal support. In general,

the therapist does not ask the client to change; rather they act as a support person, allowing the client to reflect on their life situation in an environment where they are accepted. Supportive therapy can help ease the symptoms of PTSD, but they do not aid in changing how the person thinks, which is incredibly successful in PTSD treatment. Ethical Concerns According to McClam and Woodside (2006), in the helping professions, the obligation of confidentiality is fundamental to developing a relationship between the helper and the client (p. 270). However, when working with clients who are emotionally unstable, as a mandated reporter you are required under law to report suspected harm of the client upon themselves or others. The client may feel as if you have breached the confidential bond that has developed, but it is your ethical responsibility to make sure that your client does not hurt themselves or others. Client autonomy is a fundamental value in the case management process (McClam & Woodside, 2006, p. 281). When it comes to treating your clients, it is important to encourage client participation. This is their treatment and they have the right to decide the course of action. As their case manager, you have to respect this right and not force anything on them. The ultimate goal of your clients is to become able to manage themselves. It is best when the helper offers many different positive choices that the client can choose from, as to avoid possible dangerous decisions. Review of Population Individuals who experience a serious motor vehicle accident are at increased risk for psychological problems, particularly posttraumatic stress disorder. PTSD is an anxiety disorder that often follows a traumatic event involving actual or threatened death, serious injury, or threat

to the physical integrity of oneself or others (American Psychiatric Association, 2000, p. 467). For many clients, who experienced a serious motor vehicle accident, symptoms can include reexperiencing the trauma, such as intrusive thoughts about the accident and distressing dreams about the accident. Clients will try to avoid thoughts or situations that are connected to the accident, such as a reluctance or refusal to drive, and trying to keep busy as to avoid thoughts of the accident. Some experience numbing of emotional responsiveness, such as greatly reduced or nonexistent emotions and feeling detached from others. Also present, can be an increase in physical arousal, such as exaggerated startle, irritability and disturbed sleep. Norris (1992) conducted a large survey of four Southern cities (n = 1,000; response rate 71%) and found the frequency rate of PTSD to be 7.4% and that MVAs were among the leading cause of PTSD in her sample. This data, along with a lower rate of MVA-related PTSD found in a survey of relatively young Americans (Breslau et al., 1991), leads to an estimate that MVArelated PTSD may affect 2.5 to 7 million people in the United States, reflecting a significant public health problem (Blanchard & Hickling, 2004). Services, Laws and Policies First and foremost, clients with PTSD are usually diagnosed by a medical professional. They tend to seek treatment from mental health professionals and doctors. Those services consist of counseling and exposure therapy. Alongside therapy, some clients get prescribed medication. There are many different places in Whatcom County that provide mental health services, including Associates in Mental Health, Northwest Behavioral and Discovery Counseling Associates. In order to receive these services, you either have to pay out of pocket or have insurance that will cover the costs. Sea- Mar offers mental health counseling and allows you to pay for the services on a sliding scale. Sea- Mar also offers affordable insurance. Since Sea- Mar

is a non-profit, they receive funding from grants and donations. DSHS also offers insurance to those who qualify, and it is funded by the state. In todays technological world, more and more people are going online for support of their mental illness. These services can be free to a certain extent and arent guaranteed to cure PTSD. You can also find self-help books at the book store, which can be around $20 and can be helpful. Clients who are suffering from PTSD are protected under the Americans with Disabilities Act of 1990. The Americans with Disabilities Act (1990) states, The ADA prohibits discrimination and ensures equal opportunity for persons with disabilities in employment, State and local government services, public accommodations, commercial facilities, and transportation. It also mandates the establishment of TDD/telephone relay services (p. 1991). Meaning that if a client is diagnosed with PTSD, no job opportunity can deny them a position based on their mental status. Those with PTSD can also receive services and take advantage of public transportation without being denied. In conclusion, PTSD from a MVA is a common occurrence. The best practice in treating those who suffer from PTSD is cognitive behavioral therapy which usually tends to last between 8- 10 weeks. Some clients are prescribed medications alongside therapy. Less effective treatments are wait listing and supportive therapy, which do aid in relieving symptoms of PTSD, but are not nearly as effective as CBT. With anywhere from 2- 7 million people in the United States possibly having PTSD at some point in their lifespan, it is important to have mental health services within communities and resources out there to help those who need assistance in paying for those services.

References Americans with Disabilities Act of 1990, Pub. L. No. 101-336, 2, 104 Stat. 328 (1991). American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. (4th Ed.) Washington, DC: Author. American Psychiatric Association. (2004). Treatment of patients with acute stress disorder and posttraumatic stress disorder. Retrieved February, 2013, from Blanchard, E. B., Hickling, E. J. (2004). After the crash: psychological assessment and treatment of survivors of motor vehicle accidents (2nd Ed.). Washington, DC: American Psychological Association; 2004. Breslau N., Davis G.C., Andreski P., Peterson E. (1991). Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry. 48(3):21622. National Institute of Clinical Excellence (NICE). (2005). Post-traumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. Retrieved February, 2013, from Norris F.H. (1992). Epidemiology of trauma: frequency and impact of different potentially traumatic events on different demographic groups. J Consult Clin Psych. 60(3):409-18. McClam, T. & Woodside, M. (2006). Generalist case management: a method of human service Delivery. (3rd Ed.) Belmont, CA: Brooks/Cole, Cengage Learning.

Stein, D. J., Cloitre, M., Nemeroff, C. B., Nutt, D. J., Seedat, S., Shalev, A. Y., et al. (2009). Cape Town consensus on posttraumatic stress disorder. CNS Spectrums, 14(Suppl. 1), 5258