Case Presentation
The client, Miguel R., was referred to the counselor by his principal from the Elementary and Middle School. The principal referred Miguel for an evaluation and possible further treatment since the patient had trouble at home and his center of learning after the recent shooting incident at the High School. Family history is crucial for making an accurate diagnosis and treating the client effectively. According to Perich and Andriessen (2023), a family history of mental illnesses increases the likelihood of one developing such disorders. Therefore, as a clinician assigned to the case, I will have to evaluate Miguel’s entire family and its dynamics.
Family History
Miguel’s mother, Sosa, is 44 years old and was born in Puerto Rico. Currently, she teaches at the High School. Although she is pragmatic and practical, she takes time to nurture her children when they need it. Miguel’s father, Jose R., is 45 years old and was born in Florida. Currently, he is an orthodontist in a group practice. He is funny and likes cracking jokes to lighten the mood.
The client’s brother, Pedro R., is 16 years old and was born in Puerto Rico. Pedro R. is in the 10th grade at his mother’s workplace. He is focused, determined, and studious, and his dream career when he grows up is to become a surgeon. Pedro is frequently busy with his learning and after-school activities and is looking forward to good pre-med programs.
The client’s eldest sister, Tisha R., is 9 years old and was born in Florida. She is well-known in the High School and has thus been given the leadership role for the school’s cheer squad and class leadership. Tisha aspires to become a high school teacher when she grows up, and her mother is her role model.
Miguel’s other sister, Maria R., is 12 years old and was born in Florida. She is in the 7th grade at the Elementary and Middle School. She is an artistic and dreamy individual who loves butterflies and fairies, often wearing purple. Miguel is 10 years old, the youngest in the family, and was born in Florida. He is a 5th grader in the same school as Tisha, he likes doing things right, and his room is frequently orderly and neat. The client lives with his nuclear family and a maternal grandmother, Magdalena Cortez de Perez, who is 71 years old.
The grandmother was born in the Dominican Republic and is a widow. She lives with the family and provides in-home childcare and housekeeping services. She has always been the rock to the family, the main support, pragmatic, practical, and stoic. She does not tolerate emotional outbursts or nonsense from anyone. According to Lachhwani (2022), Hispanics from the Dominican Republic and Puerto Rico have a higher prevalence and severity of panic attacks and anxiety. I would need to clear my biases and stereotypes related to Hispanics and their history of anxiety and panic attacks.
Recent Incident
Nine months ago, there was a shooting incident at Miguel’s school. His best friend’s brother was seriously injured and rushed to the hospital. Miguel heard the news while he was with his best friend’s family, and they rushed him to the hospital. According to Bartlett and Smith (2019), children who have experienced trauma may have difficulties managing emotions, which is evident in the case since Sosa arrived at the hospital, Miguel was crying, frightened, and shaking. Tisha was gravely affected by the incident after one of her squad members, Ann, sustained hip injuries. She provided a statement to the police and had several encounters with the local media, which was stressful for her and the R. family.
Since the incident, Tisha has been having nightmares and has been seeing a therapist. Exposure to trauma can result in learning problems, such as low grades (Bartlett & Smith, 2019). Since the incident, Miguel’s grades have deteriorated from As to Cs. Moreover, he has become extremely sensitive to loud noises, yelling, and arguing, and easily becomes upset when there are weather or fire drills at school.
Systemic Intervention
Criterion A
Based on the principal’s report of Miguel’s behavior at school and home, he might be experiencing post-traumatic stress disorder (PTSD) symptoms. I made the diagnosis based on the DSM-5 diagnostic criteria for PTSD for people aged 6 years and above. According to Dreßing and Foerster (2022), based on criterion A for PTSD, the individual should have been exposed to a real or threatened death or serious injury in one or more of the ways that precede. One, the individual should have directly experienced the harrowing event.
Secondly, the patient should have witnessed the event occur in person or as it occurred to others. Thirdly, the client has learned that the horrifying experience happened to a close family member or friend. Lastly, the client should have experienced repeated or uttermost exposure to callous details of the horrifying experience. Miguel meets criterion A since his close friend’s brother was shot, and he was subjected to aversive details of the traumatic event.
Criterion B
Criterion B requires the presence of one or more intrusive symptoms linked to a traumatic experience. According to Cao et al. (2020), individuals should portray recurrent and intrusive memories of the horrifying experience involuntarily. There should be frequent agonizing dreams in which the contents are related to the experience. The client should display dissociative reactions, such as flashbacks, in which the individual feels as if the harrowing experience is recurring.
Moreover, the patient should have prolonged psychological distress at exposure to internal cues that symbolize the devastating occurrence. Finally, the client should display marked physiological reactions that resemble an aspect of the traumatic occurrence. Miguel qualifies for criterion B since he has been experiencing reactions such as shaking, becoming upset, and crying whenever there are fire or weather drills at school. He has become sensitive to loud noises, people arguing, and yelling.
Criterion C
Criterion C requires the patient to have avoidance behavior towards stimuli associated with the traumatic event. According to Fariba and Gupta (2020), the patient-client should display circumvention of distressing reminiscence and feelings about or closely related to the harrowing experience. Miguel qualifies for criterion C since Miguel displays efforts to avoid feeling associated with the distressing event and hides in a locker room whenever the door is slammed. Moreover, he often fakes a stomachache and wants to go home to avoid exposure to the traumatic environment.
Criterion D
Fariba and Gupta (2020) suggest that criterion D for PTSD involves negative adjustments in cognition and mood linked to the horrifying experience, evidenced by two or more symptoms. The client meets this criterion since he has a diminished interest in participation in significant activities, an inability to experience happiness, and a persistent emotional state. Miguel has a limited desire to learn, as he frequently seeks excuses to avoid school and consistently feels anxious. Criterion G suggests that disturbance should cause impairment in crucial areas (Olness, 2021). The patient’s academic performance has declined since his grades dropped from As to Cs and Ds.
Cognitive Behavior Therapy Recommendation
In Miguel’s case, cognitive behavior therapy (CBT) would be an ideal systemic intervention. According to Zayfert and Becker (2019), CBT is an ideal therapy for PTSD patients since it improves the patient’s functioning by changing their thoughts and behavioral patterns. The therapy is based on the tenet that improvement in one domain is beneficial for other categories. For instance, changing Miguel’s obstructive thinking can lead to a redirected focus on healthy behaviors and proper emotion regulation.
According to Held et al. (2019), CBT is the treatment of choice for PTSD and requires the therapist to engage with the patient in multiple sessions daily for three weeks. Several studies conducted by Esterer et al. (2023), Hoogsteder et al. (2021), and Tarren‐Sweeney (2021) indicated that CBT intervention in children aged 3-16 was effective and reduced PTSD symptoms. The therapist’s role would be to help Miguel change his perception of the shooting incident since every time he hears loud noises, such as slamming the door, he remembers the experience. Utilizing CBT would allow Miguel to change his negative association with shooting loud noises to a positive one.
Some CBT interventions include activity scheduling, cognitive reconstruction, image transformation, and psychoeducation. In Miguel’s case, I would use psychoeducation since this therapy allows the client to learn about their condition, thus making it easier to manage and provide better coping skills (Brouzos et al., 2022). Through psychoeducation, I will teach Miguel how to relax and talk about the exposure and how the trauma has caused his current symptoms. Moreover, this will aid the client in understanding that the way he feels is a common response to trauma and that he should move forward from the experience.
Ethical Considerations
Working with clients from diverse backgrounds requires adherence to the AAMFT Code of Ethics. Based on Miguel’s case, Standard 1.1 addresses non-discrimination, Standard 1.2 addresses informed consent, and Standard 2.1 tackles disclosing the limits of confidentiality that would be useful (“Code of Ethics,” n.d.). I upheld standard 1.1 by working with Miguel, a client from a diverse background. According to Ilonari (2021), family therapists should work with clients without discriminating against them based on age, ethnicity, nationality, or origin.
Moreover, standard 2.2, which focuses on written authorization to release client information, will apply in this case. Barnett and Jacobson (2019) suggest that family therapists should seek informed consent to therapy from clients. Since the client is a minor, his parents must provide authorization for him to participate in therapy. In South Carolina, confidential information for minors can be accessed by their guardians who issue consent (“S.C. Code Regs. § 100-4,” 2023). Consequently, Miguel being a minor would result in limited confidentiality of the information shared between the client and the therapist.
Incorporating Trauma Concepts
Throughout the course, I have learned more about PTSD. I have learned that certain traumatic events, such as terrorist attacks, child and sexual abuse, military experience, and homicide, can lead to PTSD. I applied the concepts to assess and discover Miguel’s cause of PTSD. The course presented skills on how to assess patients using DSM-5 and make accurate diagnoses. I have utilized this information by analyzing Miguel’s clinical manifestations and accurately formulated a diagnosis. I will use the in-depth analysis of the DSM-5 criteria to make a diagnosis upon encountering future patients.
The course equips me with information regarding ethics in trauma care, and I have applied concepts such as informed consent, non-discrimination, and confidentiality when dealing with Miguel, ensuring that he receives quality care. I will apply the ethical concepts I have learned when working with trauma clients from diverse backgrounds. Throughout the course, I have learned different psychiatric treatment modalities. Analysis of Miguel’s case allowed me to utilize some of the modalities, such as CBT, to treat clients with trauma symptoms. I have learned that CBT is an effective treatment modality for PTSD clients; hence, whenever I encounter them in the future, I will incorporate it into their management (Esterer et al., 2023; Hoogsteder et al., 2021).
Through CBT that I learned in the course, I have realized that my role as a therapist is to recognize and change how patients think and feel about trauma (Zayfert & Becker, 2019). My goal would be to make the patients realize that their negative thinking results in increased PTSD symptoms. I have learned that psychoeducation for trauma patients allows them to understand the cause of their symptoms (Brouzos et al., 2022). Working professionally as a therapist, I will apply psychoeducation to treat PTSD patients since it provides them with exceptional coping skills.
References
Barnett, J. E., & Jacobson, C. H. (2019). Ethical and legal issues in family and couple therapy. In B. H. Fiese et al. (Eds.), APA handbook of contemporary family psychology: Family therapy and training (pp. 53–68). American Psychological Association.
Bartlett, J. D., & Smith, S. (2019). The role of early care and education in addressing early childhood trauma. American Journal of Community Psychology, 64(3-4), 359-372.
Brouzos, A., Vatkali, E., Mavridis, D., Vassilopoulos, S. P., & Baourda, V. C. (2022). Psychoeducation for adults with post-traumatic stress symptomatology: A systematic review and meta-analysis. Journal of Contemporary Psychotherapy, 52(2), 155-164.
Cao, C., Wang, L., Wu, J., Bi, Y., Yang, H., Fang, R., Li, G., Liu, P., Luo, S., Hall, B. J., & Elhai, J. D. (2020). A comparison of ICD-11 and DSM-5 criteria for PTSD among a representative sample of Chinese earthquake survivors. European Journal of Psychotraumatology, 11(1), 1760481.
Code of ethics. (n.d.). American association for marriage and family therapy.
Dreßing, H. R., & Foerster, K. (2022). Diagnostic criteria of PTSD in ICD10, ICD-11 and DSM 5: Relevance for expert opinion. Psychotherapie, Psychosomatik, medizinische Psychologie, 72(6), 258-271.
Esterer, M., Carlson, J. S., Roschmann, S., Kim, H., Cowper, A., Cranmer-Fosdick, H., Ludtke, M., & DeCicco, B. (2023). Exploring early termination patterns and effectiveness of trauma-focused cognitive behavioral therapy for children in foster care. Children and Youth Services Review, 147, 106841.
Fariba, K., & Gupta, V. (2020). Posttraumatic Stress Disorder in Children. In S. Aboubakr et al. (Eds.), StatPearls. StatPearls Publishing.
Held, P., Bagley, J. M., Klassen, B. J., & Pollack, M. H. (2019). Intensively delivered cognitive-behavioral therapies: An overview of a promising treatment delivery format for PTSD and other mental health disorders. Psychiatric Annals, 49(8), 339-342.
Hoogsteder, L. M., Schippers, E. E., & M. Stams, J. J. (2021). A Meta-Analysis of the Effectiveness of EMDR and TF-CBT in Reducing Trauma Symptoms and Externalizing Behavior Problems in Adolescents. International Journal of Offender Therapy and Comparative Criminology.
Ilonari, K. (2021). Codes of Ethics and Medical Licensure in MFT. EurAsian Journal of BioSciences, 15(2).
Lachhwani, P. (2022). Anxiety in Hispanics. In R. Castilla-Puentes (Ed.), Mental health for Hispanic communities: A guide for practitioners (pp. 63-86). Springer International Publishing.
Olness, K. (2021). Trauma and PTSD in children who are refugees or immigrants. In C. Harkensee, K. Olness, & B. E. Esmaili (Eds.), Child refugee and migrant health: A manual for health professionals (pp. 47-55). Springer International Publishing.
Perich, T., & Andriessen, K. (2023). Factors associated with perceived helpfulness and use of mental health websites by Australian young adults with a family history of mental illness. International Journal of Psychology.
S.C. Code Regs. § 100-4. (2023). CaseText – CoCounsel.
Tarren-Sweeney, M. (2021). A narrative review of mental and relational health interventions for children in family-based out-of-home care. Journal of Family Therapy, 43(3), 376-391.
Zayfert, C., & Becker, C. B. (2019). Cognitive-behavioral therapy for PTSD: A case formulation approach. Guilford Publications.