Stress is a concept used to denote a wide range of human conditions and actions that arise as a response to various extreme influences called stressors. The analysis of the vast clinical experience accumulated over many years on psychological disorders after severe stress (for example, military operations) was carried out. It allowed to establish that the victims have several common and recurring symptoms of mental disorders with pronounced delineation and specific features. Considering that these disorders did not correspond to any accepted nosological forms, it was proposed to distinguish them as an independent syndrome called post-traumatic stress disorder (PTSD). According to Brewin, Andrews, and Valentine (2000), the term PTSD has been actively introduced into practice since 1980. The researchers conclude that it affects several psychological and physiological levels, including biological, behavioral, and cognitive components.
Description of an elderly person with PTSD
As part of my volunteer social work, I was a nurse for an elderly man. He is a retired veteran of the Iraq War. After being subjected to a traumatic experience, he developed post-traumatic stress disorder. Modern combat operations are a vivid example of traumatic situations that result in PTSD. The means of destruction are becoming more powerful and more deadly, so the war leaves an indelible imprint on military personnel’s mental balance. The symptoms of combat stress in the man were transformed into post-traumatic stress disorder and persisted for years (Bloom & Sreedhar, 2008). Thus, military service was a risk factor for developing PTSD for an elderly man. The mental disorder occurred in the patient several weeks after leaving the combat situation. It is the remoteness of the consequences that distinguish PTSD from a psychogenic reaction to stress.
The impact of the trauma
After returning from the war, the man felt that he was significantly different from the others. He has developed a completely different system of moral values, and an extra level of spiritual development. Intuitive feelings of the insincerity of relations have become more acute. After returning from the war, everyone around began to notice changes in his personality. The patient developed a short temper and isolation; he began to neglect the work he liked earlier and lost interest in his hobby; the patient stopped enjoying life. First of all, the trauma affected the relationship with the family: the man’s wife and children said that it became tough to live with him. Any little things began to cause the uncontrolled outbursts of aggression. He laid hands on family members, shouted, then cried, felt very sorry for what he had done, and blamed himself.
A DSM-5 diagnosis and the criteria for it
In the fifth revision of the DSM, his diagnosis is defined as post-traumatic stress disorder and is classified as a psychiatric disorder associated with stress and mental trauma. The elderly man had many of the criteria listed in the DSM-5 for the disease (Macintosh & Whiffen, 2005). Thus, the category of symptoms A suggests that a person has PTSD if, in his experience, he has faced an actual death or a threat of death. The man witnessed such events: he saw people being killed in front of his eyes. The criteria of group B include the symptoms of recurrence. The patient often has flashbacks: for example, when he hears the roar of a motorcycle. It reminds him of the sound of a gunshot, and the man lies down on the ground. The criteria of group E (symptoms of excitability) are especially pronounced in the patient. He has outbursts of irritation or anger that are not comparable with the event that triggered them. A man begins to get very angry because of minor things, for example, because of a cat that jumped on the bed.
The evident-based treatment utilized
Such evidence-based therapy as cognitive-behavioral method was used in the treatment of the patient.
The empiricism of cooperation
The empiricism of cooperation was used which is a partnership process between a patient and a psychologist, resulting from which the patient’s automatic thoughts are revealed. According to Shannon, Wieling, McCleary, and Becher (2014), they are either supported or refuted with the help of various hypotheses. The meaning of practical cooperation is as follows: theories are put forward; multiple proofs of the usefulness and adequacy of cognitions are considered. Then a logical analysis is carried out, and conclusions are made, based on which alternative thoughts are found. The empiricism of cooperation was that the therapist and the patient are collaborators in studying facts supporting or refuting the patient’s cognitions. The basis of thinking on prejudices became evident to the patient when he realized alternative sources of information.
The Socratic dialogue was also used which is a conversation in the form of questions and answers that allow to identify the problem. It also assists to find a logical explanation for thoughts and flashbacks, understand the meaning of events and how the patient perceives them. The Socratic dialogue helps to assess the events that support cognition and the patient’s behavior (Berger, 2015). All these conclusions should be made by the patient himself, answering the questions of the psychologist. Questions should not be focused on a specific answer; they should not push or lead the patient to a particular decision. The Socratic dialogue was used according to the principle of “directed discovery.” This means that the therapist does not have any ready-made answer. He purposefully leads the client, but there is a willingness to help the client formulate this “discovery” independently.
The essence of the guided discovery was as follows: the psychologist helped the patient clarify problematic behavior, find logical errors, and develop a new experience. The patient has developed the ability to process information correctly, think adaptively, and respond adequately to what is happening. Thus, after the consultation, the patient began to cope better with problems on his own. The guided discovery was based on eight components, among which were intellectual modesty, empathic listening, and frequent questions (Shamai, 2015). In addition, it included trust in the client’s ability, redirection to maintain focus, various activities between sessions, highlighting helpful ideas, and periodic short explanations. The therapist did not act as a teacher or an expert; the therapy process was based on searching for new information. Guided discovery was the study of critical topics with the aim of possible improvements in rational thinking and adaptive behavior.
The technique of “Filling the void”
The cognitive technique “Filling the void” was used to identify cognitions. The psychologist divided the past events that caused a negative experience into several points. Point A denoted an event, point B meant unconscious automatic thoughts (the so-called “emptiness”), and point C stood for an inadequate reaction of the patient and further behavior. According to Ahern, Galea, and Vlahov (2004), the essence of this method is that with the help of a psychologist, the patient fills a “void” between the event that occurred. He also worked on an inadequate reaction to it, which he couldn’t explain to himself. For example, a man experienced incomprehensible anxiety in a large company and always tried to either sit unnoticed in a corner or quietly leave. The psychologist divided this event into points: A – the need to go to a parent-teacher meeting; B – unexplained automatic thoughts; C – a feeling of fear. It was necessary to identify cognitions and thereby fill the void. Thus, after a constructive dialogue-questioning, the psychologist was able to identify negative cognitions in the patient. They discovered an illogical sequence, contradictions, and other erroneous thoughts that complicated the patient’s life.
The man was afraid to look ridiculous in the eyes of his friends, colleagues, family members, etc. The existing problem of looking ridiculous developed in him so much that it spread to strangers. The patient was afraid of being ridiculed by sellers, fellow travelers on the bus, and passers-by. Constant fear made him avoid people, lock himself in a room for a long time. He became a reclusive loner so that negative criticism would not damage his personality. The essence of decatastrophization is to show the patient that his logical conclusions are incorrect. Having received an answer to his first question from the patient, the psychologist asks the next one in the form of “What if”(Quiros & Berger, 2013). Answering the following questions, the patient realized the absurdity of his cognitions.
Decentralization is a technique that allows to free the patient from the confidence that he is the center of events happening around him (Weens et al., 2007). This cognitive technique was used in connection with the anxious state of a man. His thinking was distorted, and he was inclined to personify even what had nothing to do with him. He was sure that everyone on the street observed him walking, so he felt constant anxiety, and discomfort. The psychologist suggested that he conduct a behavioral experiment: while on the street, do not focus on his emotions, but watch others. When the patient came to the consultation, he said that everyone was busy with their own business. He concluded that everyone is busy with their own affairs, and he can be calm as no one is watching him.
Reattribution was applied because the patient blamed himself for all the accidents in his family. He identified himself with misfortune and was sure that it was he who brought them, and it was he who was the source of all the troubles. This phenomenon is called personalization, and it was in no way connected with actual facts and evidence (Hartmann & Gone, 2014). The psychologist recommended that the client evaluate his contribution to the occurrence of the problem as a percentage on a scale from 0 to 100. Further, in the process of a Socratic dialogue, the psychotherapist encouraged the man to generate alternative explanations. After negative automatic thoughts were identified, an enhanced check for their adequacy and reality began. The patient independently concluded that all his thoughts are nothing but false and unsupported beliefs.
Resynthesis of early memories
Since the man’s relationship with his family suffered, work was carried out on family beliefs. The client listed the central ideas, principles, values, and attitudes that the family members adhere to. Together with the psychologist, most family members’ opinions were identified; they were reduced to several central principles. Family beliefs were compared with those listed in the main list of the client’s own ideas; comparable, similar, opposite, and synergistic directions were identified. Together with the psychologist, the client reviewed the main list of beliefs. The psychologist helped him to understand whether these thoughts help to solve urgent problems or vice versa. If the opinion did not help, a strategy was planned to change it. If once the belief was helpful, but now it is not, the psychologist helped the client realize the change.
Client’s response to the interventions
The psychopathological deviation of the elderly man was the result of an inaccurate assessment of events. The change in the evaluation of traumatic events led to a change in the patient’s emotional state. Cognitive-behavioral therapy taught the patient to react differently to situations that caused him panic attacks, outbursts of aggression, and other signs of anxiety. Irrational judgments that arose against the background of fear and indirectly supported it were partially eliminated by challenging their relevance. In general, negative emotional and behavioral patterns that were reactive due to psychological trauma were reduced. As a result of cognitive therapy, it was possible to effectively create a new mental model of life activity and rework and re-evaluate the traumatic experience. However, it was not possible to fully restore the patient’s sense of the integrity of his personality.
A genogram illustrating the dynamics in three generations
A genogram is a schematic representation of an extended family (including three generations of husband and wife, children, and parents). The genogram method is widely used in family therapy; it allows to identify specific crucial structural family elements, family behavioral patterns, and stereotypes that determine family behavior and family life.
The following could be read on the genogram of the man. His relationship with his late father is distant. This is due to the fact that his father drank heavily and was rarely sober. This man’s older brothers had the same relationship with the father. However, the late mother had a conflicting and super-close relationship with her husband since the marriage happened for great love. Still, the father, according to the patient’s description, also had PTSD, which caused his alcoholism. The mother was in a super-close fusion relationship with the man, while she had a warm relationship with her older sons. This gave rise to jealousy and coldness on the part of the brothers.
The man’s relationship with his wife is conflicted; the graph shows a miscarriage, to which both the man and his wife have a super-close fusion relationship. It was a long-awaited and desired child, conceived before the start of military operations in Iraq. It was the wife’s strong fear for her husband’s life that led to the fact that she lost her child. Therefore, a man feels a strong sense of guilt. The man also has two older brothers who have already died. The older brothers were in a super-close and codependent relationship with each other. The man had a distant, and cold relationship with his brothers.
The man has two children; the eldest daughter does not communicate with him; they are in a relationship of emotional rupture. After the man once again laid hands on his daughter, she decided to end her relationship with him. The daughter’s relationship with her mother is super-close and conflicted at the same time. The conflict in their relationship is due to the fact that the mother insists on the need for reconciliation of the daughter with the father. With her brother, the daughter has a distant, and cold relationship. This is due to the fact that he maintains a relationship with his father. The man’s younger son has friendly, good relations with his mother and the patient.
The psychological trauma received by the man became part of his past. He is at the last stage in the psychological correction of post-traumatic disorder, which is called an “environmental check.” At this stage, a person tries to live with a new experience. This stage is necessary so that the traumatic experiences do not return. During this period, the patient discusses with the specialist the changes in his life in connection with working on the trauma. Thus, there is a verification of how much a man has coped with post-traumatic stress disorder and how productive the therapy was for him.
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