Chapter 4. Michelle's Case: "My doctor must think I'm losing my mind"
4.1 Screen 1
1. Person is exposed to a traumatic event—death or threatened death, severe injury, or sexual violation.
2. Almost immediately after the traumatic event, person experiences at least 9 symptoms from the following groups of symptoms, lasting between 3 days and a month:
a) Intrusive symptoms such as:
• Repeated, uncontrolled, and distressing memories
• Repeated and upsetting trauma-linked dreams
• Dissociative experiences such as flashbacks
• Significant upset when exposed to trauma-linked cues
• Pronounced physical reactions when reminded of the event(s).
b) Continual avoidance of trauma-linked stimuli.
c) Negative changes in trauma-linked cognitions and moods, such as being unable to remember key features of the event(s) or experiencing repeated negative emotions.
d) Conspicuous changes in arousal and reactivity, such as excessive alertness, extreme startle responses, or sleep disturbances.
3. Person experiences significant distress or impairment.
(Information from: APA, 2013)
1. Person is exposed to a traumatic event—death or threatened death, severe injury, or sexual violation.
2. Person experiences at least one of the following intrusive symptoms:
• Repeated, uncontrolled, and distressing memories
• Repeated and upsetting trauma-linked dreams
• Dissociative experiences such as flashbacks
• Significant upset when exposed to trauma-linked cues
• Pronounced physical reactions when reminded of the event(s).
3. Person continually avoids trauma-linked stimuli.
4. Person experiences negative changes in trauma-linked cognitions and moods, such as being unable to remember key features of the event(s) or experiencing repeated negative emotions.
5. Person displays conspicuous changes in arousal and reactivity, such as excessive alertness, extreme startle responses, or sleep disturbances.
6. Person experiences significant distress or impairment, with symptoms lasting more than a month.
(Information from: APA, 2013)
- Repeated difficulty falling asleep or maintaining sleep
- Feeling as if individual is almost constantly awake
- Sleepiness during the day
- Trouble functioning effectively
1. At least 3 times a week over the course of 3 months, person experiences a heightened need for sleep or sleepiness, despite the individual having slept at least 7 hours each day.
2. Person experiences one or more of the following:
• repeated episodes of sleep or sleepiness within a day
• a 9 hours or more period of sleep that does not rejuvenate the person
• inability to wake up completely after awakening suddenly.
3. Person experiences significant distress and difficulty in thinking, work and social activities.
4. The pattern is not explained by other disorders or the effects of a drug.
(Information from: APA, 2013)
1. Within 3 months of the onset of a significant stressor, person develops anxiety, uneasiness, worry, and perhaps additional emotional and behavioral symptoms, that last for at most 6 months.
2. Person experiences distress that is far greater than the stressor warrants and/or experiences significant difficulties at work or in social setting or other spheres.
3. The pattern is not due to another disorder or to bereavement.
(Information from: APA, 2013)
What brought you in?
- Involved in a serious car crash 3 months ago
• Her car was hit head on
• She was in the hospital for 3 weeks → severe injuries, broken bones
• Taking a lot of pain medication
- Trouble sleeping
• Takes her at least an hour to fall asleep
• If she wakes up she has a hard time fall back to sleep
• Exhausted in morning
• Sleep issues present for the past 2 months
- Busy mom balancing work and family
• Has to get up early to get 3 children ready for school
• Tired → wants to quit job
• Husband suggested she see primary care Dr.
• PCP referred her here
Other concerns
- Finds it hard to concentrate at work because she is tired
- She feels like she has no more love to give her family
- Feels like she has to put on happy face
- She feels guilty that her love is not coming naturally
- Putting on "happy face" adds to her exhaustion
Accident
- She doesn't remember details of her accident
- Memory loss, painful injuries → broken bones → hospital
- Long Hospital stay → difficult for family
- Experiences sudden memories of crash
- Relives accident in dreams, wakes up feeling like she will die
- She was driving on highway in construction zone
• An SUV did not stop and hit her head on
• She was terrified
• She thought she would die
• No memory of the accident or the immediate aftermath
Flashbacks
- She feels like she's experiencing accident over and over again
- Vivid and jarring memories
- Sees person loaded on to stretcher and wheeled away → driver of SUV died
- Tries not to think about accident, but feels like she is back in car → re-experiencing the trauma
Relationship with family
- She is anxious about her kids' safety → especially when they travel by car
- Terrified to drive again
- Husband drives her to and from work
• Won't let him take the highway
• Avoids driving by accident site
• Takes forever and she spends more time in the car
• More time for her to feel anxious/husband to feel criticized
• Hasn't told husband about flashbacks → doesn't want to burden him
Childhood
- Her parents divorced when she was 8 → they had separated when she was 6
- Single mother, oldest with younger sister & brother
- Mom would withdraw with "sad spells" → Michelle cared for siblings
- She was nervous as a child and not open to new experiences
- Spent little time with father → he was harsh and insensitive to her fears
- Conflicting messages about how to best deal with stress
Feelings about treatment
- Feels like she doesn't need to be here
- Feels like she just needs to sleep → help her focus on family and work & “fight off” the memories
- Asked PCP for script for sleeping pills
- Sees herself as a strong person with good values
- Feels like she should be able to "get over" it
A conversational treatment used by psychodynamic therapists that uses treatment techniques such as free association, or letting the client talk about whatever comes to mind, and therapist interpretation, which involves giving insight and offering an opinion on patterns noticed in the client's free association and other things such as dreams or nightmares. A psychoanalyst would treat Michelle by seeing her 3-5 times per week for several years. Psychoanalysis is costly and it requires a long time commitment.
Cognitive therapy involves challenging distorted thoughts. A cognitive therapist works with patients to address their maladaptive thoughts. In Michelle's case, you would specifically address her thoughts that all cars are unsafe. Treatment would include monitoring her irrational beliefs and trying to come up with rational responses to counter these beliefs. Cognitive treatment would likely work best in conjunction with another type of treatment, such as behavioral therapy.
Behavioral therapy, first identifies the client's problematic behaviors, and then uses techniques from classical conditioning and operant conditioning, or modeling techniques to try to change those behaviors. A form of behavioral therapy, behavioral exposure techniques for PTSD would involve encouraging Michelle to remember the accident, often by writing out and then reading the account of her traumatic event. This technique diminishes the power of these memories over the client and helps reduce specific symptoms and improves overall adjustment.
Medication involves taking a chemical agent prescribed by a medical doctor to alter brain chemistry, which subsequently alleviates psychological symptoms. A psychiatrist who has a medical degree (MD) would be able to prescribe Michelle an anti-anxiety medication, which would help control her severe symptoms of anxiety, or a sleep aid to treat her insomnia. The psychiatrist would continue to meet with Michelle regularly to monitor her symptoms and to adjust the dose of her medication as necessary.
A behavioral exposure treatment in which the therapist guides clients to move their eyes in a rhythmic manner from side to side while recalling the images of objects and situations related to the trauma that they usually avoid.
A form of crisis intervention in which the therapist would help the client talk about feelings and reactions to the incidents during or immediately following the trauma.
Author: Taryn A. Myers, Ph.D. Virginia Wesleyan College
4.2 Screen 2
Please note: Clinical Choices allows you to enhance and test your understanding of the disorders and treatments covered in your textbook in a simulated case study environment. It is not intended to replicate an actual intake interview or therapy session, or provide training on therapeutic techniques. Clinical Choices is for educational purposes only and is not intended as a substitute for clinical training.
4.3 Screen 3
The receptionist hands you intake paperwork prior to your intake interview with your new client, Michelle, who was referred to therapy by her primary care physician. The referral includes the following information: "female patient in MVA (motor vehicle accident) 3 months ago, multiple injuries, experiencing recurrent insomnia." Click the button below to review the paperwork before you begin the interview.
New Client
Michelle: Case #11006
Psychological Clinic
Intake Paperwork
Client Name: Michelle
Age: 42 years old
Gender: Female
Ethnicity: Asian-American
Occupation: Part-time legal secretary
Current living situation: I live with my husband and 3 children
Why are you seeking services at our clinic?
My primary care doctor referred me for therapy because I’m having a hard time sleeping after a car crash.
4.4 Screen 4
You will now ask Michelle a number of questions you would typically ask during the intake interview. As you conduct the interview with Michelle, begin to think about her symptoms, what her diagnosis might be, and later, what type of treatment might be most helpful to her. Click the “play” button below the illustration to hear Michelle’s responses to your questions. To read the transcript for these answers, click on the “transcript” button. Take notes in the box provided as you listen to Michelle’s responses.
4.5 Screen 5
“Hi Michelle, it's nice to meet you. What we are doing today is called an intake interview. I'm going to have you tell me what brought you here today, and I'm going to ask you some questions that I ask everyone who comes to the clinic. This information will tell me how best to help you. This may mean continuing to see me for therapy at this clinic, or it may involve referring you to another mental health professional or facility. Let's start. Tell me about what brought you to the clinic today.”
Transcript
Michelle: [in distress] My doctor must think I'm losing my mind. I was in a really serious car accident 3 months ago. Another car hit me head on. I just haven't been myself since the accident. I was in the hospital for 3 weeks with multiple broken bones and other severe injuries. I was taking a lot of pain medication but after I was discharged I stopped taking most of it because I didn't like how it made me feel. For 2 months or so, I've been having trouble sleeping. It takes me at least an hour to fall asleep, and if I wake up in the middle of the night, it's really hard for me to fall back to sleep. [pauses]… Then of course I'm exhausted in the morning [feigns upbeat energy] but I have to be up and at 'em so I can get my kids ready for school then get myself to work. I am so tired at work ... I just want to quit… but … my husband made me see my primary care doc, and she referred me to you.
Question 4.1
Aw4Neimql6WiMoYbuJRsIoWYmUI0RI7zrHbz76SzMIbhWEDqh6ekegUlrs1Emw4+XZkUEXqAzYeD9ge9pFWce/4cOT0=Check Your Notes
What brought you in?
- Involved in a serious car crash 3 months ago
- Her car was hit head on
- She was in the hospital for 3 weeks → severe injuries, broken bones
- Taking a lot of pain medication
- Trouble sleeping
- Takes her at least an hour to fall asleep
- If she wakes up she has a hard time falling back to sleep
- Exhausted in morning
- Sleep issues present for the past 2 months
- Busy mom balancing work and family
- Has to get up early to get 3 children ready for school
- Tired → wants to quit job
- Husband suggested she see primary care Dr.
- PCP referred her here
4.6 Screen 6
“Your accident sounds very frightening, and the recovery process sounds like it has been very difficult for you. Has your trouble sleeping affected other areas of your life?”
Transcript
Michelle: It's hard for me to concentrate at work because I'm so tired. Also – and this sounds absolutely horrible, I know! – I feel as if I don't have any more love to give my husband and my kids. Intellectually, I know I love them, but I just can't feel that love for them anymore. So I have to put on a happy face to show them I love them, and it's so hard ... [sighs] and then I feel guilty that this feeling just doesn't come naturally. It's also exhausting, which doesn't help with feeling tired and the lack of concentration.
Question 4.2
Aw4Neimql6WiMoYbuJRsIoWYmUI0RI7zrHbz76SzMIbhWEDqh6ekegUlrs1Emw4+XZkUEXqAzYeD9ge9pFWce/4cOT0=Check Your Notes
Other concerns
- Finds it hard to concentrate at work because she is tired
- She feels like she has no more love to give her family
- Feels like she has to put on happy face
- She feels guilty that her love is not coming naturally
- Putting on “happy face” adds to her exhaustion
Question 4.3
Based on her initial report of her symptoms, which of the following stress-related disorders could Michelle be suffering from? Check ALL that are possible diagnoses for Michelle. Click on the disorder name to review the diagnostic criteria for each disorder.
| wCfH0QtRgXJ8o+c+ | Acute Stress Disorder (ASD) |
| bI0LPa9lfHQ+dYqk | Post-Traumatic Stress Disorder (PTSD) |
| bI0LPa9lfHQ+dYqk | Insomnia |
| wCfH0QtRgXJ8o+c+ | Hypersomnolence disorder |
| bI0LPa9lfHQ+dYqk | Adjustment disorder with anxiety |
Hint
Review your notes from the interview or revisit your interview with Michelle to review her symptoms. Think about the time frame and symptoms she is experiencing.
4.7 Screen 7
“I realize this may be difficult, and you don’t have to go into a lot of detail right now if it is difficult for you to discuss, but can you tell me more about your accident?”
Transcript
Michelle: I really don’t remember anything about it. That’s the weird thing. All I really remember is … my injuries and how painful they were. I had to stay in the hospital for quite some time. I know it was difficult on my husband and my kids with me out of commission. And of course I worried about my kids… but you know… [pauses] I do sometimes have memories of the crash. They come to me all of a sudden. I think I started remembering a few weeks after the accident. They come out in my dreams. I will finally fall asleep, after tossing and turning for hours, and then I wake up because I see the car speeding toward me and I’m thinking, I’m going to die. [begins to get teary and upset] All I can think about was the fact that my 3 children are going to have to grow up without a mother. [sobbing softly for a moment ]… I’m sorry...I’m sorry… [deep breath intake as she regains her composure] I – I think I can remember a bit more about the accident now… I was driving on the highway and there was only one lane of traffic because of construction. Even though I had the right of way I looked up to see an SUV driving at full speed towards my little car. I was terrified, paralyzed with fear. I thought I was going to die. I still don’t remember the accident [pauses] ... or what happened right after.
Question 4.4
Aw4Neimql6WiMoYbuJRsIoWYmUI0RI7zrHbz76SzMIbhWEDqh6ekegUlrs1Emw4+XZkUEXqAzYeD9ge9pFWce/4cOT0=Check Your Notes
Accident
- She doesn’t remember details of her accident
- Memory loss, painful injuries → broken bones → hospital
- Long hospital stay → difficult for family
- Experiences sudden memories of crash
- Relives accident in dreams, wakes up feeling like she will die
- She was driving on highway in construction zone
- An SUV did not stop and hit her head on
- She was terrified
- She thought she would die
- No memory of the accident or the immediate aftermath
4.8 Screen 8
“That must have been very frightening for you, Michelle. Sometimes when people have experienced a traumatic event, like your accident, they get what we call “flashbacks.” These are very vivid memories or experiences of the traumatic event that come to people all of the sudden. People might even feel like they are back in that moment. Have you experienced any such flashbacks?”
Transcript
Michelle: Oh my gosh! I didn’t know there was a name for that. [with recognition] Yes, yes! Sometimes I feel like I am back in that moment … and I can see someone being loaded onto a stretcher and wheeled away. It’s almost as if I’m there... I think… [pauses] I think it might be the driver of the SUV. He was killed in the accident… I didn’t find that out until later. …No matter how hard I try not to think about the accident, I still keep seeing it over and over again in my mind. Sometimes, it actually feels like I’m in the car, being hit all over again. I’ll wake up from a vivid dream about the accident in a cold sweat with my heart racing, and I’ll be too scared to go back to sleep.
Question 4.5
Aw4Neimql6WiMoYbuJRsIoWYmUI0RI7zrHbz76SzMIbhWEDqh6ekegUlrs1Emw4+XZkUEXqAzYeD9ge9pFWce/4cOT0=Check Your Notes
Flashbacks
- She feels like she’s experiencing accident over and over again
- Vivid and jarring memories
- Sees person loaded on to stretcher and wheeled away → driver of SUV died
- Tries not to think about accident, but feels like she is back in car → re-experiencing the trauma
4.9 Screen 9
“It’s understandable that this accident is still frightening for you. Has this experience affected your relationship with your family?”
Transcript
Michelle: Yes…yes…I am so much more anxious about my children’s safety now. This accident made me realize that even if you do the right thing it doesn’t matter -- there is danger all around us … your life could be over any minute. I worry about my kids, [emphasis] even when I’m not with them, and especially if they are going somewhere in a car. [Sharp intake of breath] … I haven’t driven since the accident because I’m terrified to get behind the wheel again… So my husband drives me everywhere, and I spend the entire time looking around to make sure no one is going to crash into us. I won’t let him take the highway… I don’t want to drive by where the accident happened. It takes forever to get to and from work, and my husband is trying to be nice but he is understandably aggravated by all of this. This means more time in the car for me to be anxious about getting into another accident, and for him to feel like I don’t trust his driving. I feel so bad about inconveniencing him that … [quietly] I haven’t told him about the memories or – what did you call them? Flashbacks? – because I don’t want to burden him anymore.
Question 4.6
Aw4Neimql6WiMoYbuJRsIoWYmUI0RI7zrHbz76SzMIbhWEDqh6ekegUlrs1Emw4+XZkUEXqAzYeD9ge9pFWce/4cOT0=Check Your Notes
Relationship with family
- She is anxious about her kids’ safety → especially when they travel by car
- Terrified to drive again
- Husband drives her to and from work
- Won’t let him take the highway
- Avoids driving by accident site
- Takes forever and she spends more time in the car
- More time for her to feel anxious / husband to feel criticized
- Hasn’t told husband about flashbacks → doesn’t want to burden him
4.10 Screen 10
“It sounds like your family doesn’t share your feeling of danger on the road. Speaking of family, can you tell me a little more about your own childhood? What was it like growing up in your family?”
Transcript
Michelle: My parents got divorced when I was 8 years old, but they separated probably 2 years before that. So it was just my mom for most of my life, raising me and my little sister and brother. My mom would sometimes get so overwhelmed that she would just lie on the couch for what seemed like weeks. She couldn’t do even the most basic tasks. When she had these “sad spells,” I would have to step it up and take care of my brother and sister. [sighs] I was a nervous kid… I was especially afraid to try new things. I didn’t have much contact with my dad growing up, but occasionally I would spend the weekend at his house. He wasn’t very warm. I felt really scared and alone at his house, but I was always afraid I’d cry because he’d get annoyed and tell me to just suck it up. I remember feeling really confused about how I should deal with these challenges in my life because when things got tough my mom would get overwhelmed and withdraw but my dad never seemed to deal with it either. He’d just act like nothing happened at all.
Question 4.7
Aw4Neimql6WiMoYbuJRsIoWYmUI0RI7zrHbz76SzMIbhWEDqh6ekegUlrs1Emw4+XZkUEXqAzYeD9ge9pFWce/4cOT0=Check Your Notes
Childhood
- Her parents divorced when she was 8 → they had separated when she was 6
- Single mother, oldest with younger sister & brother
- Mom would withdraw with "sad spells" → Michelle cared for siblings
- She was nervous as a child and not open to new experiences
- Spent little time with father → he was harsh and insensitive to her fears
- Conflicting messages about how to best deal with stress
Question 4.8
How could Michelle’s childhood have influenced what is happening to her now? More than one answer could be correct. Check all that apply.
| wCfH0QtRgXJ8o+c+ | Caring for her siblings made Michelle less empathetic to her own children. |
| bI0LPa9lfHQ+dYqk | Michelle’s anxiety as a child could carry over into how she reacts to stressful situations today. |
| wCfH0QtRgXJ8o+c+ | Her parents’ divorce made Michelle a very anxious person. |
| wCfH0QtRgXJ8o+c+ | Michelle’s father’s anxiety modeled anxious behavior for Michelle. |
| bI0LPa9lfHQ+dYqk | Michelle’s mother’s depression could have influenced how Michelle saw the world. |
Hint
Think about how the behavior of the most significant people in Michelle’s life may have affected her.
4.11 Screen 11
Question 4.9
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
Think about what piece of information you need to make a decision about whether you can proceed with treating Michelle.
4.12 Screen 12
“So, Michelle, how do you feel about coming to therapy?”
Transcript
Michelle: [sigh] I really don’t know that I need to be here. I think that if I can manage to get more sleep at night, I’ll be able to focus on my family…my work…I’ll have the strength to fight off these memories. I asked my primary care doc for sleeping pills, but he said I had to see you before I could get them. I don’t understand why I can’t just get over this – other people do. I don’t think I really need to see a shrink.
Question 4.10
Aw4Neimql6WiMoYbuJRsIoWYmUI0RI7zrHbz76SzMIbhWEDqh6ekegUlrs1Emw4+XZkUEXqAzYeD9ge9pFWce/4cOT0=Check Your Notes
Feelings about treatment
- Feels like she doesn't need to be here
- Feels like she just needs to sleep → help her focus on family and work & "fight off" the memories
- Asked PCP for script for sleeping pills
- Sees herself as a strong person with good values
- Feels like she should be able to "get over" it
4.13 Screen 13
Question 4.11
Which of the following symptoms describe Michelle’s experience? Check all that apply. Use your interview notes to help you remember!
| wCfH0QtRgXJ8o+c+ | A need to organize |
| bI0LPa9lfHQ+dYqk | Exposure to a traumatic event |
| bI0LPa9lfHQ+dYqk | Actual or threatened death |
| bI0LPa9lfHQ+dYqk | Serious injury |
| wCfH0QtRgXJ8o+c+ | Sexual violation |
| bI0LPa9lfHQ+dYqk | Recurrent, distressing memories |
| bI0LPa9lfHQ+dYqk | Recurrent, distressing dreams |
| bI0LPa9lfHQ+dYqk | Flashbacks |
| bI0LPa9lfHQ+dYqk | Avoidance of reminders of stressor |
| bI0LPa9lfHQ+dYqk | Forgetting part or all of stressor |
| wCfH0QtRgXJ8o+c+ | Exaggerated negative beliefs about herself |
| bI0LPa9lfHQ+dYqk | Persistent negative emotions |
| wCfH0QtRgXJ8o+c+ | Extreme startle response |
| bI0LPa9lfHQ+dYqk | Being on guard or hypervigilant in cars |
| bI0LPa9lfHQ+dYqk | Difficulty sleeping |
| wCfH0QtRgXJ8o+c+ | Sleeping more than usual |
Hint
Use your notes to guide your answers. Think about the symptoms Michelle described throughout her interview.
4.14 Screen 14
Question 4.12
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Hint
Think about the following symptoms Michelle is having:
- Difficulty sleeping
- Re-experiencing memories of the event
- Symptoms have lasted for longer than a month
4.15 Screen 15
Question 4.13
KsHeg416GwkdYuqlfAHArlQpRWO6c/GE28LLEpjRfoBFvNFlYF3uqrj8fIqoGeXC0tMAGgRNExnyWHSgs5cQIjsJbttxJ+6Nw3PJxsTv2uDzLkJ+TarH0B8FbbaxgyARgCB7K58LttUIRLjYx5naroGZ8LMtEHl9DwOjqjZ2YpUNfrn0Question 4.14
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Hint
Think about when Michelle’s symptoms started.
Question 4.15
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Hint
Think about Michelle’s previous experiences.
4.16 Screen 16
From the File. You remember a former patient who shared symptoms similar to Michelle’s. You review this case to confirm your diagnosis of Michelle.
Question 4.16
0H9r7/K7gq4+bcKV/GWvXJVTgSYe5FFHC7MNafWGAJw8W3dxDHjkp5K+MRGR3ee7Xp4e6mYq4qHn3rd9TKQna9u7aPuN3caYs2+tt6yhLmRVV/AIwNm+j9gHL5NvltUqcnXYjZOxDiGa2Acx1jAKTTxTNKyrmM+1+QR7hHYOFahZUSlZ9LLJIcVNTHhhB7f7gvwqJSUqvf/nuCCfVBxlq0WxdsHVoOrzyActLw==Question 4.17
AnJAQjjYVLR1ciDhMSQgKsC7tZbaucSB2KoHBJnEo1GErWM3VAjtoDoOgBCT+zklPaSkmUHKpqCCUNrFHH9klKAVwtGpbBlLEDvF/InIuTZ0f0f18/+0kUMi6nn4FVMnMxnKA9U68NVqNSsDdv43Hr16JoOJAvWSttRRMB/9CnSaJKEGRAt+Djz7IqzD1v+b1UzQGewGrdsc/9gGfhx9U+EEBGq3F5mzjyRjmhS4o59HlVcd299ERZsPer8t4DmYcy7AQ2b50O6zDWFVIU2j+2q9KuwwkNhBCcId/rHXl8zd//K6Sl4tTml50XUsXCdukRSPQhxZYcwZKFYZI0jH9m94okHVWVaGUJBOtCpl7EyEikTRChRzaI2EVeML9t7gFXqwfuR/VhNjymhC5FP+pEsNaVv2dwlSsYeq1uBtkNgODWu9UWyLmTWBXB3xjYD0G2Du/6q6pGQ+3Ui0+fdVs7HqQWoARUwc4.17 Screen 17
Question 4.18
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
Think about Michelle’s case as you answer this question.
Question 4.19
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Hint
Think about all the factors that might influence how someone responds to a traumatic event.
4.18 Screen 18
Question 4.20
Which of the following would be helpful treatments for Michelle? Note that there may be more than one answer. Click on the name of the therapy to display a brief description.
| wCfH0QtRgXJ8o+c+ | Psychoanalysis |
| bI0LPa9lfHQ+dYqk | Cognitive therapy |
| bI0LPa9lfHQ+dYqk | Behavioral exposure techniques |
| wCfH0QtRgXJ8o+c+ | Medication |
| wCfH0QtRgXJ8o+c+ | Eye Movement Desensitization and Reprocessing (EMDR) |
| wCfH0QtRgXJ8o+c+ | Psychological Debriefing |
Hint
In making your choice, think about the Michelle’s symptoms after the car accident and which type of therapy might be most helpful in addressing those symptoms.
4.19 Screen 19
Question 4.21
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
In making your choice, think about what technique would directly address helping clients face their symptoms.
4.20 Screen 20
EPILOGUE
As a therapist, you are trained in behavioral exposure techniques. You teach Michelle relaxation techniques before encouraging her to remember and recount the events of her accident, usually aloud and repeatedly. Michelle is nervous about remembering her accident, but you explain that although it is difficult at first to talk about the traumatic event, this type of therapy really works and will help reduce her symptoms. With your help, Michelle is able to remember the horrific details of her trauma and sobs in your office when she recounts the story for the first time. After she repeats the story over a few sessions, she is able to recount the accident without becoming so overwhelmed. She also finds that she is able to sleep better at night.
Eventually, you help Michelle tackle some of her distorted thoughts that resulted from the accident, such as her belief that her children will be in an accident every time they ride in a car. Michelle decides to stay at her job and enjoys the independence she feels when she is out of the house. Her biggest challenge was to try driving again, but you are able to use virtual reality to re-expose her to driving before she gets behind the wheel in the real world. After practicing in the virtual world, Michelle is able to drive with her husband in the car, a huge accomplishment for her. Although Michelle’s memory of the accident will never go away and some mental scars will remain along with the physical ones, Michelle finds she is able to feel genuine love for her family again and better communicate what she is experiencing to her husband.
4.21 Screen 21
Real World Application
Watch the following video about Veterans engaging in therapy for PTSD and answer the questions below.