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Assessment of Trauma Client Case Study

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Updated: Jul 22nd, 2021

The client has been exposed to various traumatic experiences he encountered during his lifetime. The interview method was adopted to obtain information about his traumas from the patient. At the beginning of the conversation, a series of simple yes or no questions was asked to elicit basic facts about the presence of psychological traumatization. Upon identifying its presence, questions of a more specific character were introduced, and the client gradually became involved in the conversations, during which he shared his life experiences.

In the course of the examination conversation, it was found that the client, a 77-year-old man, had repeatedly been exposed to physical abuse by his boyfriend, who the patient does not see anymore. The patient has often been hospitalized with physical traumas (broken wrist and arm). The client’s current life is lonely due to the separation from his partner. The client has three siblings, but they do not communicate regularly, thus he does not receive any family support. The cultural background of the client is marked by his origin; he is of Puerto Rican ethnicity, where the concept of machismo obstructed his acknowledgment of being gay. At present, the client is seen at Aspire Health Alliance for outpatient therapy and psychiatric care.

Diagnosis and Differentials/Co-morbidities

The client’s health history contains diagnoses of posttraumatic stress disorder related to the patient’s previous victimization by his boyfriend. However, as the examination shows, there are more profound and more severe issues the client is dealing with mentally due to his family history and incidents of prior traumatization, including harmful relationships within his family as a child. Thus, I agree with the current diagnosis, but not with the basis on which it was made. Therapy and treatment are influenced by the reasons a problem has occurred and the multiple factors that play a decisive role in a complex trauma resolution (Pearlman & Courtois, 2005). Therefore, I would not apply any differential diagnoses but would insist on more complex incorporation of several trauma experiences from the client’s early childhood and youth as they are impacting the mental condition of the client at present.

Since posttraumatic stress disorder is a complex issue, it often resembles the symptoms of other pathological states (Wahbeh, Senders, Neuendorf, & Cayton, 2014). As the examination of the client’s condition showed, he experiences a low level of energy, often loses temper, does not express any positive emotions, and is sometimes anxious and aggressive. These findings serve as a basis for suspecting a major depressive disorder. These facts will allow a therapist to understand the client better and engage in more meaningful communication during the therapy sessions. Also, such a multi-faceted perception of the patient’s condition allows for providing more effective treatment.

The Process of Engagement with the Client

The process of engagement with the client was rather challenging due to the instability of his condition and his frequent losses of temper when he was under the influence of alcohol. It was difficult to maintain a long, meaningful conversation due to the client’s tiredness, loss of track of thought, and difficulty with articulating issues verbally. To maintain effective communication with the client, a psychodynamic approach was utilized to build trustworthy relationships between the therapist and the client (Alessi & Kahn, 2017). Overall, the work has been collaborative because the patient showed eagerness to express his worries.

However, this happened only at times of clear consciousness and absence of blurred mind. To ensure safety and containment, measures for reconstructing the client’s overwhelming emotions were applied. In other words, a holding environment was created for the patient to feel encouraged to express his feelings; later on, when he had difficulty managing an experience he described and the feelings connected to it, the therapist reformulated the thought in a simpler way (Alessi & Kahn, 2017). In this manner, the patient felt that he was being understood and was able to keep track of his thoughts and emotions. To maintain adequate pacing during the sessions, the therapist reacted to the responses of the client and the overall stability of his emotional condition. Due to the complexity of the symptoms, each issue was addressed separately to ensure his comfort with the interventions.

The client is a gay man of Puerto Rican origin, which required a culturally sensitive approach to working with him. According to Osterman and de Jong (2007), “cultural competency skills are essential to either effectively treat or research … psychiatric disorders” because the issues of cultural background are closely related to a person’s worldview (p. 425). Therefore, I needed to apply the concept of machismo, which is common among men of Hispanic ethnicity, in order to engage the client in conversation about the challenges of being a gay man in an oppressive and insensitive community. The approach was successful, and the patient developed trust toward the therapist, which allowed for more effective cooperation for the sake of the client’s recovery.

Client’s Affective and Behavioral Regulation Assessment

The client has difficulty managing overwhelming emotions and feelings. During the meetings, he shared childhood memories of being victimized in the family (his father and uncle physically abused him at his mother’s request) and being raped by a preacher as a child. These memories are very traumatizing, and the patient showed a lack of power to maintain control over them. For example, he often loses temper, mumbles words, and shows signs of unclear thoughts.

Due to the long history of traumatizing experiences that started in childhood and led to constant feelings of loss of identity and guilt in adulthood, the client’s responses and symptoms are rather automatic. The burden of negative feelings and unresolved issues has been long suppressed, and it is challenging for the client to overcome the obstacles of protective mechanisms. That is why the patient often closes down and abandons a difficult topic under discussion. Trauma adapting behaviors that arose based on the client’s adverse experiences have transformed into maladaptive manifestations in the form of substance abuse. For example, the client stated that he used alcohol as self-medication and found relief in substance abuse. Such maladaptation has obstructed proper functioning and led to liver damage and overall poor physical health.

Description of Starting Phase for Treatment

To start treatment for posttraumatic stress disorder and major depressive disorder, it is essential to address problems with the client’s ability to conduct difficult discussions of his memories. Since people “avoid thoughts, feelings, conversations, people, places, or activities that are reminiscent of the initial event,” it is important to start treatment with practices that will allow for encouraging the client to engage in therapy (Wahbeh et al., 2014, p. 162). Distress reduction and affect regulation training could be an effective starting point for combating the client’s discomfort and difficulty with managing traumatizing memories (Briere & Scott, 2012). Also, addressing childhood memories in connection with current life experiences should be maintained from the perspective of psychodynamic therapy (Alessi & Kahn, 2017). Such an initial treatment will allow for further progress in the client’s ability to cope with difficult feelings and analyze them to reach recovery.

Vicarious Traumatization

During the work with the client, I have experienced a certain degree of vicarious traumatization. The current health condition the patient is experiencing is the result of life-long oppression and avoidance of resolving severe psychiatric problems. For the sake of therapy effectiveness, it is crucial to build a trusting and engaging relationship with the patient. I felt compassionate and reflective about the issues the client shared with me. Repeated traumatization throughout his life has adversely impacted both his physical and mental health. Therefore, the work with this client kept me in a constant state of preoccupation, which is energy consuming and stressful.


In conclusion, the client is a 77-year-old Puerto Rican man who was repeatedly admitted to the hospital with physical injuries as a result of his boyfriend’s abuse and was treated with outpatient and psychiatric care. The examination of the symptoms showed that the client suffers from a severe form of posttraumatic stress disorder that is accompanied by co-morbidity in the form of major depressive disorder. The communication between the therapist and the client was established based on developing the holding environment and ensuring containment.

During the conversations with the client, he shared trauma-related memories from childhood when he was exposed to physical abuse in the family and was raped by a preacher. Also, the patient discussed his experiences in adulthood of being discriminated against as a gay man living in a Puerto Rican community where the concepts of machismo and hypermasculinity are common. The client shows complex symptoms, such as difficulty engaging in a meaningful conversation, mumbling words, losing track of thought, and becoming aggressive and incomprehensive. To address the issues identified, one should apply culturally sensitive skills within the framework of psychodynamic therapy to reduce distress and improve the ability of the client to maintain difficult emotions related to the traumas he has experienced.


Alessi, E. J., & Kahn, S. (2017). Using psychodynamic interventions to engage in trauma-informed practice. Journal of Social Work Practice, 33(1), 27-39. Web.

Briere, J., & Scott. C. (2012). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment (2nd ed.). Thousand Oaks, CA: SAGE Publications.

Osterman, J.E., & de Jong, J.T.V.M. (2007). Cultural issues in trauma. In M.J. Friedman, T.M. Keane, & P.A. Resick (Eds.), Handbook of PTSD: Science and practice (pp. 425-446). New York, NY: Guillord.

Pearlman, L.A., & Courtois, C.A. (2005). Clinical applications of the attachment framework: Relational treatment of complex trauma. Journal of Traumatic Stress, 18(5), 449-459.

Wahbeh, H., Senders, A., Neuendorf, R., & Cayton, J. (2014). Complementary and alternative medicine for post-traumatic stress disorder symptoms: A systematic review. Journal of Evidence-Based Integrative Medicine, 19(3), 161-175. Web.

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