Select one of the following and conduct an assessment. Must be in APA format and submitted by Sunday 10am 2/19/23

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Select one of the following and conduct an assessment. Must be in APA format and submitted by Sunday 10am 2/19/23

  • Eyes
  • Ears
  • Nose
  • Mouth

You may conduct the assessment on a fellow student, friend, or family member. Remember to secure their permission.

Collect both subjective and objective data using the process described in the textbook. Then, document your findings and bring them to class.

you will be given a public health policy/topic. The topic is gun violence. research and respond to the following questions.

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you will be given a public health policy/topic. The topic is gun violence. research and respond to the following questions.

  1. Search the literature for studies related to your policy
  2. What are the major findings of the evaluation?
  3. Was the policy effective in curbing the adverse practice?
  4. Which aspects of the policy were effective?
  5. What recommendations do you have to improve the policy?
    Describe your overall assessment of the policy/topic and the positives/opportunities for improvement

Type 1 diabetes is an autoimmune disorder in which beta cells are destroyed in genetically susceptible persons.

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Reply:

Type 1 diabetes is an autoimmune disorder in which beta cells are destroyed in genetically susceptible persons. This condition is usually diagnosed in children and young people so it is also called as juvenile diabetes age of onset from childhood. (Ignatavicius et al., 2021).

Type 2 diabetes is a progressive disorder in which the person initially has insulin resistance that progresses to decreased beta cell secretion of insulin.

Risk factors 

Age

Family history

Overweight

Pregnancy

Race and ethnicity

Environmental factor

Unhealthy lifestyle.

Age of onset :

Type 1 diabetes: At any age, significantly below 30 years.

Type 2 diabetes: Onset of diabetes at any age, but mostly above 30 years of age.

Pathophysiology :

Chronic hyperglycemia results from the impaired process in glucose regulation that includes reduced insulin secretion or reduced insulin action, or both. (Ignatavicius et al., 2021).

Clinical manifestations Type 1:-

Weight loss

fatigue and weakness

Nausea

vomiting

Irritability

Type 2 diabetes:

Weight loss

Nausea

vomiting

Irritability

Blurred vision

Dry itchy skin

The most important topic that must be taught to a diabetic patient’s health Education’

Health education :

It is necessary to treat and control diabetes. You have to make lifestyle modifications like exercising regularly, taking good healthy food, seeking medical assistance, and taking medications regularly.

Exercise has a significant role in treating diabetes. Exercise affects your blood glucose level. Check your blood sugar level before and after taking food. Maintain good personal hygiene. Avoid unnecessary wounds on your feet because diabetic patients take more time in wound healing.

Reply:

For Type 1 Diabetes, the pathophysiology is a chronic condition in which the pancreas (beta cells) is unable to produce insulin. The risk factors are autoimmune response and genetics. The age of onset is childhood. The clinical manifestations are polyuria, polydipsia, polyphagia, weight loss, hyperglycemia, and blurred vision (Ignatavicius et al., 2021).

For Type 2 Diabetes, the pathophysiology is characterized by insulin resistance and impaired insulin secretion. The risk factors are obesity, sedentary lifestyle, hypertension, and hyperglycemia. The age of onset is adulthood. The clinical manifestations are polyuria, polydipsia, polyphagia, weight gain, poor wound healing, fatigue, blurred vision, recurrent infection, numbness and tingling of hands and feet, and dry skin (Ignatavicius et al., 2021).

I think the most important topic that must be taught to the diabetic patient is proper diet. Diabetic patients need to be taught that food, specifically carbohydrates, are converted to glucose. Monitoring carbohydrate intake is very important. Having a proper diet is a big factor in diabetes management aside from monitoring the blood sugar.

Reference:

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2021). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care (10th ed.). Elsevier.

Your for the course project should be a 2-3 page APA  (not including title page and the reference page) that describes the clinical problem and the following:

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Your for the course project should be a 2-3 page APA  (not including title page and the reference page) that describes the clinical problem and the following:

  • Reason for choosing this topic
  • The PICOT question
  • Possible integration of the evidenced that you found in clinical practice
  • Methods to evaluate the effectiveness of implementation

 I need 15 case scenario to discuss in class, no more than 3 sentences each one, need to have CC (Chief complaint) , impression and treatment.

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I need 15 case scenario to discuss in class, no more than 3 sentences each one, need to have CC (Chief complaint) , impression and treatment. Any age, any illness. No more than 3 sentences each one. I will provide an example. Plagiarism free. don’t need to be APA stile. Word is ok. Not critical patient , just primary care patient. (common cold, eczemas, fractures, anemia, Meniere, bronchitis, pneumonias, psoriasis, bursitis, BPH, hypertension, diabetes, menopause, gastritis, constipation….)

Case scenario # 1

CC: ” I’m having diarrhea after a trip to Punta Cana”

ES, 56 y/o male returned from a short trip to Punta Cana presenting with severe diarrhea and abdominal cramps. He only ate very well cooked food and drank bottled soft drinks during his trip, But it was very hot, that he always add  ice to his drinks. Impression Gastroenteritis. Labs ordered: Treatment Ciprofloxacin 500 mg daily for 7 days.

In adults aged 65 and over (P) in acute care hospitals, how does the implementation of a multidisciplinary team-based approach (I) compared to the standard of care (C) affect the rate of falls (O) within a six-month period (T)?

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In adults aged 65 and over (P) in acute care hospitals, how does the implementation of a multidisciplinary team-based approach (I) compared to the standard of care (C) affect the rate of falls (O) within a six-month period (T)?

The PICOT question aims to investigate the effects of implementing a multidisciplinary team-based approach compared to the standard of care in acute care hospitals on the rate of falls in adults aged 65 and over within a six-month period. Falls are a major cause of morbidity and mortality in older people. Falls can lead to serious injury, increased healthcare costs, and reduced quality of life (Choi et al., 2023). The implementation of a multidisciplinary team-based approach may reduce the risk of falls through improved risk assessment, patient education, and targeted interventions.

The comparison intervention is the standard of care that is typically provided in acute care hospitals and may include patient education, environmental assessment, and other interventions. The outcome of interest is the rate of falls within a six-month period (Choi et al., 2023). By addressing this clinical question, we can gain insight into the effectiveness of the multidisciplinary team-based approach in reducing the rate of falls in older adults in acute care hospitals.

 

Reference

Choi, J.-Y., Rajaguru, V., Shin, J., & Kim, K. (2023). Comprehensive geriatric assessment and multidisciplinary team interventions for hospitalized older adults: A scoping review. Archives of Gerontology and Geriatrics, 104, 104831. https://doi.org/10.1016/j.archger.2022.104831

Using DSM-5 in Case Formulation

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Using DSM-5 in Case Formulation

Gary G. Gintner, Ph.D., LPC

Louisiana State University

gintner@lsu.edu

 

 

Case Formulation

• Case formulation is a core clinical skill that links assessment information and treatment planning

• It is a hypothesis about the mechanisms that cause and maintain the problem

• It answers the question, “Why is this person, having this type of problem, now?”

 

 

 

DSM-5 Informed Case Formulation Process

Assessment •DSM-5 Enhancements

•DSM-5 Organization

•DSM-5 Background information

Case Formulation

• DSM-5 Criteria Sets

•DSM-5 Background Information

Treatment Planning

•Best practice guidelines are often tied to a diagnosis

• DSM-5 measures to monitor progress

 

 

Fundamental Changes in DSM-5

Dimensional Approach

• The conundrum with categories

• Dimensional concepts:

• Spectrum Disorders

• Severity ratings

• Dimensional assessment tools

Lifespan Perspective

• Lifespan perspective is infused throughout the manual

• More attention to developmental differences in presentation

New Organization

 

• Data-informed reorganization

• Proximity reflects similarity

 

 

DSM-5’s Single Axis System

• There is one diagnostic axis on which all of the following can be coded:

– All mental disorders (formerly on Axis I and II)

– Other Conditions that May be the Focus of Treatment (V-codes; formerly Axis I)

– Medical disorders (formerly Axis III)

 

 

 

 

 

 

 

DSM-5 Tools and Enhancements

• Clinical rating scales

• WHODAS 2.0

• Cultural Formulation Interview

 

 

Clinical Rating Scales

• Rationale for adding: – Measurement-informed care – Dimensional assessment of severity – Assessment of broad range of symptoms – Adjunct to clinical evaluation

• Types – Cross-Cutting Symptom Measures – Disorder-Specific Severity Measures – Disability Measures (WHODAS 2.0) – Personality Inventories – Early Development and Home Background Form

 

 

 

Link to Online Assessment Measures

• Assessment measures can be freely used by clinicians for use with clients

• They can be downloaded at:

http://www.psychiatry.org/practice/dsm/ dsm5/online-assessment-measures

or

www.dsm5.org DSM-5 Online Measures.docx

 

 

 

 

 

 

Cross-Cutting Symptom Measures

• Assesses symptoms across the major domains of psychopathology

• Two types:

– Level 1

– Level 2

• Versions

– Adult self-report

– Parent/guardian-rated version (for children 6-17)

– Youth self-report (11-17)

 

 

 

 

Level 1 Cross-Cutting Symptom Measure

• Description: Adult version measures 13 domains of symptoms DSM-5 level1 assessment.pdf

• Rate each item: – How much or how often “you have you been

bothered by…in the past two weeks.” – 5-point rating scale from 4 (severe, nearly everyday)

to 0 (none or not at all)

• Scoring: Rating of 2 or higher (Mild, several days) should be followed up by further clinical assessment. On items for suicidal ideation, psychosis and substance use, a rating of 1 (Slight) or higher should be used.

 

 

 

Level 2 Assessment Measure

• Description: A brief rating scale for a particular symptom (e.g., anxiety, depression, substance use)

• Indications: When a Level 1 item is rated above the cut-off

• Can be readministered periodically to plot change

• Scoring instructions are available at the site

• DSM-5 Online Measures.docx

 

 

 

 

Disorder-Specific Rating Scales

• Description: Disorder-specific rating scales that correspond to the diagnostic criteria

• Indications: Used to confirm a diagnostic impression, assess severity, and monitor progress

• Versions: Adult, Youth and Clinician rated

• DSM-5 Online Measures.docx

 

 

WHODAS 2.0

• Description: A 36-item measure that assesses disability in adults 18 years and older

• Rating: “How much difficulty have you had doing the following activities in the past 30 days.” Rated 1 (None) to 5 (Extreme or cannot do)

• Scoring: Calculate average score for each domain and overall

• Versions: Adult and proxy-administered • DSM-5 whodas2selfadministered.pdf

 

 

Domains on the WHODAS 2.0

1. Understanding and communicating

2. Getting around

3. Self-care

4. Getting along with people

5. Life activities

6. Participation in society DSM-5 whodas2selfadministered.pdf

 

 

 

Cultural Formulation Interview (CFI)

• Description: A 16-item semistructured interview to assess the impact of culture on key aspects of the clinical presentation and treatment plan

• Indications: Use as part of the initial assessment with any client but is especially indicated when there are significant differences in “cultural, religious or socioeconomic backgrounds of the clinician and the individual”(p. 751).

 

 

 

CFI Domains

• Cultural definition of the problem

• Causes of the problem, stressors and available supports

• Coping efforts and past help-seeking

• Current help-seeking and the clinician- client relationship DSM-5 Cultural Formulation Interview.pdf

 

 

 

Clinical Applications of DSM-5 Enhancements

• During initial assessment: – Administer Level 1 Cross-Cutting Symptom

Measure – Complete intake including social history, mental

status, and diagnostic assessment – Administer Level 2 measures as needed – WHODAS 2.0 can be administered as indicated – Use aspects of the CFI interview throughout

• Follow-up sessions – Administer disorder-specific measures – Re-administer periodically to assess progress

 

 

DSM-5 and Case Formulation

• Biopsychosocial model in case formulation

• The Five P’s of Case Formulations

• Doing a case formulation using DSM-5

 

 

Biopsychosocial Model in Case Formulation

Case Formulation

Biological Factors

Psychological Factors

Sociocultural

Factors

 

 

The Five P’s of Case Formulation (Macneil et al., 2012)

• Presenting problem – What is the client’s problem list? – What are DSM diagnoses?

• Predisposing factors – Over the person’s lifetime, what factors contributed to the development

of the problem? – Think biopsychosocial

• Precipitants – Why now? – What are triggers or events that exacerbated the problem?

• Perpetuating factors – What factors are likely to maintain the problem? – Are there issues that the problem will worsen, if not addressed

• Protective/positive factors – What are client strengths that can be drawn upon? – Are there any social supports or community resources ?

 

 

 

The Five P’s in DSM-5 • Diagnostic criteria

– Disorder-specific criteria set (Presenting Problem) – Subtypes and specifiers (Presenting Problem)

• Explanatory text information – Diagnostic features (Presenting Problem) – Associated features (Presenting Problem) – Prevalence (Presenting Problem) – Development and course (Predisposing, Perpetuating and

Protective Factors) – Risk and prognostic factors (Predisposing, Perpetuating

Protective Factors) – Culture-related diagnostic issues (5 P’s) – Gender-related diagnostic issues (5 P’s) – Suicide risk (Presenting Problem) – Functional consequences (Perpetuating Factors) – Differential diagnosis (Presenting Problem) – Comorbidity (Presenting Problem and Perpetuating Factors)

 

 

Case of Helen

Helen was fired from her job one month ago because she started making numerous mistakes and had trouble concentrating. About three months ago she started feeling “down“ after a break-up with a man she had been dating for a few months. She has trouble falling asleep and has noticed a significant decline in her appetite. She feels like a failure and believes that no one will want to hire her again.

 

 

Helen Continued

She has thoughts of committing suicide but admits, “I could never do it.” The only thing that seems to help is when she participates in a bible-reading group every Tuesday night. She explains, “During that time I’m more like my old self and at least that night I can sleep.” She also reports that her mood improves when she visits her friends. However, she reports such low energy throughout the day that she is unable to schedule a job interview.

 

 

Helen Continued

She had a similar episode about two years ago after she was laid off from her former job. She reports that it took four months before she began feeling “normal” again and positive about herself.

Her history indicates that her mother had severe depression and was hospitalized on several occasions when Helen was young. She describes her as “negative” and often absent in her youth. However, Helen always did well in school and had an active social life. Her work history has been very consistent up to her lay off.

 

 

 

 

Diagnostic Work-Up • DSM-5 measures:

– Level 1(positive for depression, sleep problems and avoiding certain events)

– PHQ-9, Score = 20 (Severe) – WHODAS 2.0

• General Disability Score = 85 (2.36; Mild) • Subscale: Life activities = 14 (3.5; Moderate) • Subscale: Participation in Society = 28 ( 3.5;

Moderate) • Differential diagnosis: What are the possibilities? • Diagnostic Impression: 296.33 Major Depressive Disorder, recurrent, severe severity V62.29 Other Problems related to employment

 

 

 

Case Formulation • Why is she so depressed?

– Predisposing factors?

– Precipitating factors?

– Perpetuating factors?

– Positive or protective factors?

• How does the diagnosis and case formulation inform your treatment plan?

 

 

Guide to Case Formulation

1. State the problem or diagnostic impression.

2. State the precipitant

3. Describe critical predisposing factors

4. Include a statement about perpetuating or maintaining factors

5. Highlight protective and positive qualities

 

 

Write a Case Formulation

Helen presents with……(1) which appears to be precipitated by…..(2). Factors that seem to have predisposed her to depression include….(3). The current problem is maintained by….(4). However, her protective and positive factors include….(5).

 

 

From Formulation to Treatment

• How does the formulation inform the treatment plan? – Best practices for this disorder?

– Which types of interventions will address the predisposing, precipitating and perpetuating factors?

– How do you ensure that diversity factors are considered?

– How do you tailor treatments so that they are more strength-based?

 

 

Final Thoughts…

• Begin using DSM-5 enhancements

• DSM-5 can help you identify the five P’s

• Case formulation is a skill and has been tied to better outcome

 

 

 

 

References American Psychiatric Association. (2014). Online assessment measures. Retrieved from

http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures.

American Psychiatric Association. (2013a). Diagnostic and statistical manual of mental

disorders (5th ed.). Washington DC: American Psychiatric Association.

American Psychiatric Association. (2010). Practice guidelines for the treatment of major

depressive disorder, third edition [Supplement]. American Journal of Psychiatry. 167(10).

doi:10.1176/appi.books.9780890423387.654001

Craighead, W. E., Miklowitz, D. J, & Craighead, L. W. (2013). Psychopathology: History, diagnosis,

and empirical Foundations. Hoboken, NJ: Wiley.

Frank, R. I., & Davidson, J. (2014). The transdiagnostic road map to case formulation and

treatment planning. Oakland, CA: New Harbinger Publications.

Gintner, G. G. (In press). DSM-5 conceptual changes: Innovations, limitations and clinical

implications. The Professional Counselor.

Gintner, G. G. (2008). Treatment planning guidelines for children and adolescents. In R.R. Erk

(Eds.), Counseling treatments for children and adolescents with DSM-IV-TR mental disorders

(pp.344-380). Upper Saddle River, NJ: Prentice Hall Publishing.

Macneil, C. A., Hasty, K., K, Conus, P., & Berk, M. (2012). Is diagnosis enough to guide treatment

interventions in mental health? Using case formulation in clinical practice. BMC Medicine,

10, 111. doi:10.1186/1741-7015-10-111

In this assignment, you are required to evaluate Patient Experience Measurement Program in Saudi Arabia. 

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In this assignment, you are required to evaluate Patient Experience Measurement Program in Saudi Arabia. 

– you are required to apply the program evaluation processes in analyzing this program.

Note*: CDC’s Framework for Program Evaluation in Public Health has six connected steps that can be used as a starting point to tailor an evaluation for a particular public health effort at a particular point in time. It also has a set of standards that can be used to assess the overall quality of evaluation activities.

Step: 

1. Engage Stakeholders: Engage stakeholders, including those involved in program operations; those served or affected by the program; and primary users of the evaluation.

2. Describe the Program: Describe the program, including the need, expected effects, activities, resources, stage, context, and logic model.

3. Focus on the Evaluation Design: Focus on the evaluation design to assess the issues of greatest concern to stakeholders while using time and resources as efficiently as possible. Consider the purpose, users, uses, questions, methods, and agreements.

4. Gather Credible Evidence: Gather credible evidence to strengthen evaluation judgments and the recommendations that follow. These aspects of evidence gathering typically affect perceptions of credibility: indicators, sources, quality, quantity, and logistics.

5. Justify Conclusions: Justify conclusions by linking them to the evidence gathered and judging them against agreed-upon values or standards set by the stakeholders. Justify conclusions on the basis of evidence using these five elements: standards, analysis/synthesis, interpretation, judgment, and recommendations.

6. Ensure the Use and Share Lessons Learned: with these steps: design, preparation, feedback, follow-up, and dissemination. For additional details, see Ensuring Use and Sharing Lessons Learned as well as a checklist of items to consider when developing evaluation reports.

–Standards:

Utility standards ensure that an evaluation will serve the information needs of intended users.

Feasibility standards ensure that an evaluation will be realistic, prudent, diplomatic, and frugal.

Propriety standards ensure that an evaluation will be conducted legally, ethically, and with due regard for the welfare of those involved in the evaluation, as well as those affected by its results.

Accuracy standards ensure that an evaluation will reveal and convey technically adequate information about the features that determine the worth or merit of the program being evaluated.

– you are required to apply various feasible program Evaluation tools and techniques to analyze and interpret the contingency.

– you are required to interpret and discuss comprehensively the findings (ACTUAL) as compared with the theoretical information (literature).

In the Asian culture, there is often a belief that terminally ill patients should not be informed about their prognosis.

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In the Asian culture, there is often a belief that terminally ill patients should not be informed about their prognosis. Would you respect the cultural practice and not inform a patient about the prognosis? Is there a way for health care providers to balance the patient’s right to know with respect for the cultural practices and beliefs of the family? Is not fully disclosing information to the patient an ethical breach?

CLINICAL PRACTICE

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1 CLINICAL PRACTICE

GUIDELINEPTSD www.apa.org/ptsd-guideline

CASE EXAMPLE

Jill, a 32-year-old Afghanistan War Veteran This case example explains how Jill’s therapist used a cognitive worksheet as a starting point for engaging in Socratic dialogue.

This is a case example for the treatment of PTSD using Cognitive Behavioral Therapy. Cognitive Behavioral Therapy is strongly recommended by the APA Clinical Practice Guideline for the Treatment of PTSD.

Jill, a 32-year-old Afghanistan war veteran, had been experiencing PTSD symptoms for over 5 years. She consistently avoided thoughts and images related to witnessing her fellow service members being hit by an improvised explosive device (IED) while driving a combat supply truck. Over the years, Jill became increasingly depressed and began using alcohol on a daily basis to help assuage her PTSD symptoms. She had difficulties in her employment, missing many days of work, and she reported feeling disconnected and numb around her husband and children. In addition to a range of other PTSD symptoms, Jill had a recurring nightmare of the event in which she was the leader of a convoy and her lead truck broke down. She waved the second truck forward, the truck that hit the IED, while she and her fellow service members on the first truck worked feverishly to repair it. Consistent with the traumatic event, her nightmare included images of her and the service members on the first truck smiling and waving at those on the second truck, and the service members on the second truck making fun of the broken truck and their efforts to fix it — “Look at that piece of junk truck — good luck getting that clunker fixed.”

After a thorough assessment of her PTSD and comorbid symptoms, psychoeducation about PTSD symptoms, and a rationale for using trauma focused cognitive interventions, Jill received 10 sessions of cognitive therapy for PTSD. She was first assigned cognitive worksheets to begin self-monitoring events, her thoughts about these events, and consequent feelings. These worksheets were used to sensitize Jill to the types of cognitions that she was having about current day events and to appraisals that she had about the explosion. For example, one of the thoughts she recorded related to the explosion was, “I should have had them wait and not had them go on.” She recorded her related feeling to be guilt. Jill’s therapist used this worksheet as a starting point for engaging in Socratic dialogue, as shown in the following example:

Therapist: Jill, do you mind if I ask you a few questions about this thought that you noticed, “I should have had them wait and not had them go on?”

Client: Sure.

Therapist: Can you tell me what the protocol tells you to do in a situation in which a truck breaks down during a convoy?

Client: You want to get the truck repaired as soon as possible, because the point of a convoy is to keep the trucks moving so that you aren’t sitting ducks.

Therapist: The truck that broke down was the lead truck that you were on. What is the protocol in that case?

 

 

2 CLINICAL PRACTICE

GUIDELINEPTSD www.apa.org/ptsd-guideline

Client: The protocol says to wave the other trucks through and keep them moving so that you don’t have multiple trucks just sitting there together more vulnerable.

Therapist: Okay. That’s helpful for me to understand. In light of the protocol you just described and the reasons for it, why do you think you should have had the second truck wait and not had them go on?

Client: If I hadn’t have waved them through and told them to carry on, this wouldn’t have happened. It is my fault that they died. (Begins to cry)

Therapist: (Pause) It is certainly sad that they died. (Pause) However, I want us to think through the idea that you should have had them wait and not had them go on, and consequently that it was your fault. (Pause) If you think back about what you knew at the time — not what you know now 5 years after the outcome — did you see anything that looked like a possible explosive device when you were scanning the road as the original lead truck?

Client: No. Prior to the truck breaking down, there was nothing that we noticed. It was an area of Iraq that could be dangerous, but there hadn’t been much insurgent activity in the days and weeks prior to it happening.

Therapist: Okay. So, prior to the explosion, you hadn’t seen anything suspicious.

Client: No.

Therapist: When the second truck took over as the lead truck, what was their responsibility and what was your responsibility at that point?

Client: The next truck that Mike and my other friends were on essentially became the lead truck, and I was responsible for trying to get my truck moving again so that we weren’t in danger.

Therapist: Okay. In that scenario then, would it be Mike and the others’ jobs to be scanning the environment ahead for potential dangers?

Client: Yes, but I should have been able to see and warn them.

Therapist: Before we determine that, how far ahead of you were Mike and the others when the explosion occurred?

Client: Oh (pause), probably 200 yards?

Therapist: 200 yards—that’s two football fields’ worth of distance, right?

Client: Right.

Therapist: You’ll have to educate me. Are there explosive devices that you wouldn’t be able to detect 200 yards ahead?

Client: Absolutely.

Therapist: How about explosive devices that you might not see 10 yards ahead?

Client: Sure. If they are really good, you wouldn’t see them at all.

 

 

3 CLINICAL PRACTICE

GUIDELINEPTSD www.apa.org/ptsd-guideline

Therapist: So, in light of the facts that you didn’t see anything at the time when you waved them through at 200 yards behind and that they obviously didn’t see anything 10 yards ahead before they hit the explosion, and that protocol would call for you preventing another danger of being sitting ducks, help me understand why you wouldn’t have waved them through at that time? Again, based on what you knew at the time?

Client: (Quietly) I hadn’t thought about the fact that Mike and the others obviously didn’t see the device at 10 yards, as you say, or they would have probably done something else. (Pause) Also, when you say that we were trying to prevent another danger at the time of being “sitting ducks,” it makes me feel better about waving them through.

Therapist: Can you describe the type of emotion you have when you say, “It makes me feel better?”

Client: I guess I feel less guilty.

Therapist: That makes sense to me. As we go back and more accurately see the reality of what was really going on at the time of this explosion, it is important to notice that it makes you feel better emotionally. (Pause) In fact, I was wondering if you had ever considered that, in this situation, you actually did exactly what you were supposed to do and that something worse could have happened had you chosen to make them wait?

Client: No. I haven’t thought about that.

Therapist: Obviously this was an area that insurgents were active in if they were planting explosives. Is it possible that it could have gone down worse had you chosen not to follow protocol and send them through?

Client: Hmmm. I hadn’t thought about that either.

Therapist: That’s okay. Many people don’t think through what could have happened if they had chosen an alternative course of action at the time or they assume that there would have only been positive outcomes if they had done something different. I call it “happily ever after” thinking — assuming that a different action would have resulted in a positive outcome. (Pause) When you think, “I did a good job following protocol in a stressful situation that may have prevented more harm from happening,” how does that make you feel?

Client: It definitely makes me feel less guilty.

Therapist: I’m wondering if there is any pride that you might feel?

Client: Hmmm…I don’t know if I can go that far.

Therapist: What do you mean?

Client: It seems wrong to feel pride when my friends died.

Therapist: Is it possible to feel both pride and sadness in this situation? (Pause) Do you think Mike would hold it against you for feeling pride, as well as sadness for his and others’ losses?

Client: Mike wouldn’t hold it against me. In fact, he’d probably reassure me that I did a good job.

Therapist: (Pause) That seems really important for you to remember. It may be helpful to remind yourself of what you have discovered today, because you have some habits in thinking about this event in a particular way. We are also going to be doing some practice assignments [Challenging Questions Worksheets] that will help to walk you through your thoughts about what happened during this event, help you to remember what you knew at the time, and remind you how different thoughts can result in different feelings about what happened.

 

 

4 CLINICAL PRACTICE

GUIDELINEPTSD www.apa.org/ptsd-guideline

Client: I actually feel a bit better after this conversation.

Another thought that Jill described in relation to the traumatic event was, “I should have seen the explosion was going to happen to prevent my friends from dying.” Her related feelings were guilt and self-directed anger. The therapist used this thought to introduce the cognitive intervention of “challenging thoughts” and provided a worksheet for practice. The therapist first provided education about the different types of thinking errors, including habitual thinking, all-or-none thinking, taking things out of context, overestimating probabilities, and emotional reasoning, as well as discussing other important factors, such as gathering evidence for and against the thought, evaluating the source of the information, and focusing on irrelevant factors.

More specifically, Jill noted that she experienced 100 percent intensity of guilt and 75 percent intensity of anger at herself in relation to the thought “I should have seen the explosive device to prevent my friends from dying.” She posed several challenging questions, including the notion that improvised explosive devices are meant to be concealed, that she is the source of the information (because others don’t blame her), and that her feelings are not based on facts (i.e., she feels guilt and therefore must be guilty). She came up with the alternative thought, “The best explosive devices aren’t seen and Mike (driver of the second truck) was a good soldier. If he saw something he would stopped or tried to evade it,” which she rated as 90 percent confidence in believing. She consequently believed her original thought 10 percent, and re-rated her emotions as only 10 percent guilt and 5 percent anger at self.

REPRINTED WITH PERMISSION

Treating PTSD with cognitive-behavioral therapies: Interventions that work This case example is reprinted with permission from: Monson, C. M. & Shnaider, P. (2014). Treating PTSD with cognitive- behavioral therapies: Interventions that work. Washington, DC: American Psychological Association