John Smith is a 34-year old single White American man, a U.S. Veteran, with no children. He is an atheist. John resides in San Jose, CA, in a rented 1-bedroom apartment, and owns a private security company that brings him stable average income. John seeks treatment for the Post-Traumatic Stress Disorder that first started in 2012. He sought help only now because he has a strong desire to start a family, but is currently unable to initiate and maintain loving relationships with women. The presenting symptoms are persistent mild and daily anxiety, insomnia occurring about twice a month and lasting for a couple of days, at least one of two vivid nightmares about war monthly. Among other symptoms noticed by me is general mistrust to people and avoidance of discussion of the experienced traumas. These symptoms create constant mood swings and lack of self-confidence, which cause social withdrawal and constant feeling of inadequacy, which, in turn, inhibit his initiative to get acquainted with new people or communicate with friends and loves ones. His main goal is to get rid of anxiety, fears and social withdrawal, as well as to become open to relationships again.
John has been diagnosed with chronic PTSD four years ago and underwent the cognitive processing therapy (CPT) that did not work for him. His symptoms started during his army service abroad, weakened during and after the CPT until intensifying again last year. In addition to the CPT, low doses of Prazosin were prescribed to treat the reoccurring nightmares. He experienced mild side-effects normal for this drug and was generally very satisfied with its effect; however, the client stopped taking the medication after half a year because of the belief that his PTSD was cured. Currently, the client feels positive about treatment with medications and is ready to start taking drugs again. Apparently, the aforesaid complex treatment had definite positive effect on the symptoms, but the feeling of discomfort during the group CPT sessions and belief in their ineffectiveness led him to quit it.
I primarily aimed at developing the client’s trust because due to war trauma and long period of social withdrawal, he developed a strong belief in inherent bad nature of most people, as well as the fear of rejection. To help him, I strived for making our communication genuine and honest, as well as tried to make him feel accepted, understood and appreciated. Since I have never experienced severe traumas, I applied my empathic skills to understand what he felt and let him know about my efforts. Most importantly, in order to change the client’s negative view on non-medication treatment, I outlined to him my personal role and responsibilities in our relationships and asked for his opinion on it. I stressed that this treatment was goal-oriented and that he would be also in charge of reviewing the interim and final results and altering his goals. To make our engagement comfortable for John, I gave him an opportunity to choose the places of our meetings. During our meetings, I carefully listened to John’s concerns and fears and supported him partially by providing similar examples from other veterans’ lives, as well as noticed and praised his successes and coping skills. These methods were effective in building our relationship, while self-disclosure was ineffective, since John was a very independent man with the history of incomparable traumas and pain that could not be compared with my personal experience.
Before introducing the Strengths Assessment Tool to the client, I have explained to him the aim of strength assessment and how it would help him work towards his goals faster and more effectively. I have also explained that John would be able to be reassessed whenever he felt that changes have occurred. When conducting the assessment, I explained to John what each domain and column meant and together we filled in the form, with me playing a role of a discussion partner and an assistant in the process. As a result, John felt relieved because he has finally actualized his strengths. Supportive relationships, good health and spirituality were his priorities. John’s main strengths included independence, self-sufficiency, high level of intelligence, strong sense of purpose, well-developed communication skills, as well as a number of skills and interests, such as cooking, sports and hiking that helped him stay focused and positive. He also had very supporting family and two best friends, who knew about his condition and were willing to help. John wanted to get his life back on track after his military service. He had strong professional and personal aspirations that helped him move towards his main goal with courage. He wanted not only to be able to build relationships, but also to develop his personality and deepen his knowledge business management. In the past, he was quite an outgoing person, contributing to his community wellness by coaching children, which gave him a sense of purpose. Most of these strengths were identified by John without my help. The only domain that was harder to explore was supportive relationships. John blamed himself for his loneliness, and, for this reason, it was hard for him to recall how socially skillful he was in the past and how easy it was for him to communicate with people and make friends.
Personal Recovery Plan
After the client identified his main goal, I suggested the Personal Recovery Plan as a very useful tool to achieve the goal step-by-step without being overwhelmed and stressed. The chosen domain was “Supportive Relationships”, and the client showed initiative in devising the action steps. The client’s main concern was his inability to trust people, except for his family and best friends, and he stopped going out and making friends with new people since the onset of his illness. Moreover, he was especially reluctant to start relationships with women because he believed that the relationships would fall apart soon after their start, causing pain and more traumatic experiences. To meet his goal, I suggested that we first worked on the client’s gradual socialization by going out with people he trusted and felt comfortable with and by observing strangers and taking notes about them. Such activity met the client’s interest in psychology and would allow him to notice that people in general were harmless. The client also suggested to work towards his goal of getting a degree in business administration because it would allow him to spend more time around people, who shared his interests and aspirations. The client felt responsible for following the plan, while I and his friends shared this responsibility only twice, when accompanying him either to the mall, or to the bar. The initial plan consisted only of three action steps to be taken within 10 days, and the new action steps were initiated by the client when the previous ones were completed. The client admitted to have felt empowered and determined after the first three steps, as he discovered inner strength to be around people again without experiencing anxiety and panic. He was generally satisfied with the outcomes and wanted to continue this plan and creating a new one for other domains.
Summary of Process
The recovery process of the client was a very enriching experience for both of us. At the beginning of the process, the client was a distrustful man with social anxiety as a part of his PTSD. Nonetheless, he was willing to work towards the achievement of his goals. The client’s trust developed on the basis of genuine communication, and mutual respect and acceptance. I tried to be as empathic as possible to understand how he felt. When our mutual trust developed, it was time to introduce Strengths Assessment and Personal Recovery Plan, which the client met enthusiastically. The client felt acute anxiety again when he needed to communicate with strangers or be in crowded places, but it weakened each time he had positive experience. At the ending phase of the treatment, the client felt empowered, as he discovered his strengths and applied them in various social situations. He felt able to make friends without feeling anxiety, and wanted to go out more. During the helping process, I used such methods as empowerment, self-responsibility and positive reinforcement by discussing the client’s positive experience, successes, praising his strengths and discussing their application. The Personal Recovery Plan helped the client feel not only empowered, but also more responsible for the achievement of his goals and his recovery. Contextualizing method helped me reduce the client’s negative perception of himself, the world and his illness. Luckily, the client was already full of hope and aspirations, which boosted the process, while previous treatment of his PTSD gave him in-depth knowledge of the illness.
Reflections of a Recovery Minded Human Services Worker
The most memorable part of the process happened when the client was contacted by the school’s principal informing John that he could start coaching children in a week from then. I have never seen him so elevated, hopeful, purposeful and generally happy since the beginning of the process. I believe that was a crucial moment for his recovery, as it helped him approach his goals in several domains, giving him meaning in life, making him feel good about himself, enriching his leisure time and giving him an opportunity to communicate with students, who did not know about his PTSD. The best thing that worked well was the Personal Recovery Plan, as it made his recovery efforts structured. On the other hand, going alone to the mall for a couple of hours became a challenge because he was not ready for this experience after having spent months dividing time mostly between his office and his home. Next time I would try to be more empathic in order to prevent acute anxiety. To make the process more effective, I would also try to introduce John to other veterans with similar symptoms and personal histories approximately during the middle phase. We lacked this resource during the process, and I believe it could help make the recovery happen faster. The entire experience made me realize that patience, empathy, care and acceptance are four crucial aspects that need to be present to make the recovery of a person with severe and persistent mental illness faster. People with such diagnoses should be expected to relapse and should be explained that this is normal. Also, a social worker needs to always keep in mind that not every client’s move, action or words are necessarily symptomatic.