Case Summary
This case study is about Elaha, a 23-year-old lady whose symptoms indicate underlying trauma that needs to be addressed. Elaha has lived with her mother and four siblings in Australia for 10 years now. Her father was killed in Afghanistan, which is her native country. She shares information that culminates in subjective and objective data for an accurate diagnosis of her condition.
Subjective Data
Elaha reports that she recently started to experience traumatic responses after a home visit where she witnessed domestic violence in a home she visited as part of her legal profession. The experience left her mentally disturbed, and she experienced these symptoms. She visibly reacted to unexpected voices while at work. She also reports difficulty sleeping, which leaves her unable to attend to her work, particularly writing reports. She also narrates that she is unable to write down the report about the domestic violence incident that she witnessed.
Objective Data
The objective data drawn from Elaha’s experience is that she had a traumatic experience in her childhood due to the sudden loss of her father. As she grew, she was able to lead an everyday life. Elaha made strong friendships in high school; she learned English and even ranked in the top 10th percentile of her class. Her life continued on an optimistic trajectory as she went through her internship and is now a practicing legal officer. To this end, Elaha seemed to be doing okay. However, the subjective data indicate underlying trauma from her childhood and teenage life.
Case Conceptualization: Barbara Ingram’s Integrative Framework
Patient Background
The case conceptualization for Elaha’s medical condition is based on Barbara Ingram’s Integrative Framework for diagnosing trauma and developing effective interventions. This model dissects the case study into three parts: gathering information, defining problems, and setting specific goals for the interventions. To start with gathering information, the case study holds information about Elaha’s childhood, her current life as a young adult, and her mental state (Turner, 2021). Information on her childhood reveals that she lost her father in a conflict, and this was a traumatic event. This incident was a possible turning point in her life, as her family sought asylum before relocating to Australia.
Elaha’s childhood experience presents a traumatic experience that is currently affecting her mental well-being. Two psychological theories that apply to her case are the Grief Theory and the Attachment Theory. According to Kezelman & Stavropoulos (2018), one’s attachment styles are entirely informed by their childhood experiences and socialization.
On the one hand, Elaha seems to have a secure attachment style because she was able to cultivate friendships in high school. She lives with her family, suggesting she comes from a loving, caring family that provides her with social and emotional support. The experience of losing her father and the long-lasting impact that is just now revealed also indicates her strong bond with her father. Her secure sense of attachment has remained intact despite the drastic changes in her family loss and two relocations.
Trauma Causes
The death of Elaha’s father is the primary cause of her trauma, which is in part due to her attachment and partly due to a lack of proper grief. As a young child, Elaha may not have conceptualized her father’s death. She likely skipped the five stages of grief. Human beings go through denial, anger, bargaining, depression, and acceptance before they fully heal from the loss of a loved one (Mancini & Bonanno, 2012).
As a child, Elaha witnessed the cruel death of her father, but was not helped with processing her emotions. In line with this, Psychology Principles emphasize that with death comes an Existential Crisis. Elaha may be losing sleep trying to understand existentialism and also processing the loss of her father while connecting it with the domestic violence incident.
Besides the existential crisis and the accompanying psychological discomfort, Elaha is a victim of disrupted internal family systems. As a young girl, she never fully experienced her father’s love. She could have lived in fear for her safety following the death of her father and her remaining family seeking asylum. Due to this, she is prone to experiencing trauma stemming from loss of identity or belonging.
She might need to rediscover herself as she comes to terms with what she missed in her childhood. This process also requires her to grieve her father however way she likes fully (Fonagy et al., 2018). From a psychological point of view, she might need the support of her family to go through the grieving stages before she regains her inner self.
Phobic Anxiety
Having gathered information on childhood experiences, Barbara Ingram’s Integrative Framework leads to the definition of a patient’s psychological problems. According to Briere & Scott (2015), in Principles of Trauma Therapy, Elaha exhibits symptoms of Phobic Anxiety and PTSD. According to the book, Phobic Anxiety is the expression of irrational fears around places, people, or situations that remind one of their traumatic experience.
For Elaha, witnessing domestic violence reminded her of the insecurity through which she lost her father in her home country. The book also notes that patients with phobic anxiety will avoid the things that trigger the trauma memories. Elaha reports the same when she says that she is unable to continue with her home visits. The symptoms align with the manifestation of phobic anxiety.
Post-Traumatic Stress Disorder
Elaha also exhibits symptoms of Post-Traumatic Stress Disorder (PTSD) following her home visit. According to Briere& Scott (2015), PTSD manifests in three ways: re-experiencing the trauma event, avoidance of stimuli that provoke the trauma memory, and numbing of the memory and its emotions. In Elaha’s narration, she says that she witnessed significant violence against a woman, and the woman ended up in a medical facility. Witnessing this incident caused a flashback to the event where her father was murdered, and this indicates the first sign of PTSD (Music, 2014). Elaha also shows avoidance of the stimuli by failing to keep up with her home visits. The book also indicates psychological disturbances such as loss of sleep, which is also present with Elaha (Briere & Scott, 2015). Once Elaha takes the DSM-IV Diagnostic Criteria for PTSD, she is likely to test positive for PTSD as she ticks most of the criteria. She exhibits delayed onset PTSD because the symptoms have surfaced years after the incident.
Treatment Plan
Polyvagal Theory
Developing an informed treatment plan is the third and final stage in Barbara Ingram’s Integrative Conceptualization Framework. Given the identified issues, which are phobic anxiety and PTSD, interventions must seek to remedy the two conditions. The ideal recommendations for Elaha’s recovery are anchored in the Polyvagal Theory and Multiphasic Model.
Dana (2018) explains trauma therapy through the Polyvagal Theory. According to this theory, trauma responses are a result of the functions of the human body’s autonomic nervous System (ANS). This System comprises the vagus nerves, the sympathetic nerve, and the parasympathetic nerve. The three works communicate with the brain through neuroception to initiate safety-related action. This theory posits that PTSD, phobic anxiety, and other mental trauma-related disorders occur in the same way.
In light of the Polyvagal Theory, Elaha would need a Polyvagal-based trauma intervention. This intervention primarily works by helping her control how her body reacts to the trauma stimuli. One practical polyvagal theory intervention is to recognize her triggers. Recognizing her triggers also taps into the concept of mindfulness and mentalization.
Music (2014) educates that through mindfulness, a trauma-recovering patient needs to be conscious/mindful of their exposure to the trauma trigger for them to control their physiological response to the trigger. This intervention is recommended by Elaha as a starting point to encourage her to acknowledge the triggers so she can work on them. Knowledge of her triggers includes listening to her body’s reactions when she remembers or thinks about her father’s death.
Another intervention that is based on the polyvagal theory is the practice of self-regulation. Theoretically, the practice of self-regulation is usually a lifelong intervention because it impacts overall mental wellness, not just trauma recovery (Courtois & Ford, 2016). Elaha will need guidance with practical self-regulation exercises for three months, after which progress will be made. She will do the exercises whenever she notices physiological responses to the triggers.
The three activities she will be doing are taking deep diaphragmatic breaths, gentle touch on her chest to calm her heart, and yoga exercises. The three activities activate the vagus nerve, which, in turn, brings about realization. Over time, the interventions will accustom her body to not responding in a fight-or-flight manner to the triggers.
Multiphasic Model
The Multiphasic Model is premised on the idea that trauma therapy occurs in three phases. In the first phase, a trauma patient goes through safety and stabilization to regain their emotional state. In the second phase, interventions are put in place to support trauma processing. The final phase encompasses interventions that help to integrate and connect with others (Courtois & Ford, 2016).
For the first phase, Elaha will implement the metallization intervention. According to Allen (2018), mentalization is excellent because it places the patient at the center of the trauma intervention strategies. Through the process of metallization, Elaha will be guided to reflect on her childhood and her current situation. The reflection opens up her brain to the realization that she is in a safe place today and that there are no dangers like those she experienced in the past. This will help stabilize her emotions and thinking while reassuring her of safety.
Trauma processing, the second phase, will be carried out through Adaptive Information Processing. Adaptive Information Processing is a therapy-patient interactive session in which the therapist explains to Elaha the biological functions of her body that underlie her symptoms. Fonagy (2018) enlightens that mentalization-based approaches to trauma therapy improve the understanding of involuntary body processes that accentuate response to triggers. As such, Elaha will be provided with material to equip her with knowledge about her brain and the autonomic nervous System and the interplay of both in provoking trauma reactions. These lessons will take about 4 weeks, and Elaha will integrate the relaxation exercises to achieve better results. Combining knowledge and practical solutions will change her mindset and encourage her to implement the interventions as advised.
The third phase of the multiphasic model is integration and connecting with others. This phase assumes that a trauma patient has achieved significant healing to the point where they need social support for general emotional well-being (Fonagy et al., 2018). Elaha’s case study will thrive here because she already has strong friendships among her peers. However, therapy at this stage will involve engaging Elaha in group therapy. The therapist will look out for people who have suffered the same trauma as Elaha.
Elaha will join such groups and attend therapy sessions, sharing her journey to healing while also learning from others. Through group therapy, Elaha will achieve integration by practicing self-regulation, mentalization, and mindfulness because talking about her experiences might be triggering. The implementation of group therapy will only come at the end of her recovery journey, which may take about 6 months.
The process of conceptualizing Elaha’s trauma and developing functional trauma therapy interventions aligns with the psychodynamic theory of trauma. The psychodynamic theory of trauma states that trauma is caused by a life event that alters a person’s physiological responses because of the high intensity of the event (Kezelman & Stavropoulos, 2018).
The basis for the psychodynamic theory in this case is that Elaha experienced a traumatic event where her father was killed in a conflict. The event left her memory with a scar that now surfaces when she is exposed to violence. As with the psychodynamic theory, the impact of Elaha’s childhood experience is long-term because she experiences PTSD and Phobic anxiety 10 years later. Fortunately, Elaha has no somatic injuries from the experience but only psychological difficulties. The Polyvagal and multiphasic interventions work on teaching her brain to perceive her new reality as safe. Additionally, the interventions are practical, as they match neurological functions with solutions. These interventions will help her recover and also learn to manage the triggers long after recovery.
Strengths and Limitations
One of the strengths of both the polyvagal and multiphasic interventions is their holism. Both intervention approaches work from the basics of trauma therapy to more advanced interventions. For example, the polyvagal therapy approach is informed by the understanding of the human body’s neurological processes. Similarly, the multiphasic approach starts by stabilizing and recreating safety to temper nervous reactions that trigger the fight-or-flight response. Through this, the interventions can address the problem’s root cause.
Another strength is that both interventions consider long-term effective management of trauma. The multiphasic interventions work by creating knowledge systems that will always guide Elaha in managing her triggers and resuming work without the struggles. Introducing group therapy further solidifies knowledge and inspires confidence not only in managing oneself but also in helping others. Additionally, the polyvagal and multiphasic trauma therapies do not involve drugs such as antidepressant drugs. They focus on behavioral and learning approaches that are free of drug-related risks.
Possible limitations of the interventions include the need for Elaha’s active involvement. The interventions will only work if Elaha braces herself to take the initiative and the healing steps. This might mean that she needs extra support and reassurance, which will derail the process. It also means that the success of the interventions depends on her willingness to follow through with all the interventions (Maté, 2011).
Another limitation stems from the multiphasic trauma therapy interventions. The second phase, which involves Adaptive Information Therapy, requires the mental capacity to understand complex body processes. If Elaha is unable to comprehend the intersection of the autonomic nervous System and the brain and how they impact her recovery journey, the therapist will have to devise alternative ways to get through the second phase successfully.
Ethical Consideration
Proposed interventions are cognizant of the fact that therapy bears the risk of re-traumatization. For this reason, one ethical consideration will be to give Elaha time to express her emotions and how she feels about the intervention. Elaha is at liberty to change her mind about seeking therapy in case she finds it too difficult to re-live her trauma (Skovholt & Trotter-Mathison, 2016). In the same vein, alternative interventions will be explored while also giving her more time to achieve milestones to support her recovery.
The interventions will also be conducted in a safe and private space. This is because therapy requires one to be vulnerable to one’s emotions. The private space ensures that Elaha is not ashamed or embarrassed for experiencing an emotional breakdown, as she is currently feeling for asking for help. All information will be held confidential to protect the patient. In cases where a conflict of interest arises between the patient, the therapist, or the intervention, the patient will always be the priority. All decisions are aimed at supporting Elisa’s recovery and overall mental well-being.
References
Allen, J. G. (2018). Mentalizing in the development and treatment of attachment trauma. Routledge.
Briere, J., & Scott, C. (2015). Principles of trauma therapy: A guide to symptoms, evaluation and treatment (2nd ed., DSM-5 Update). Sage Publications.
Courtois, C. A., & Ford, J. D. (2016). Treatment of complex trauma: A sequenced, relationship-based approach. Guilford Press.
Dana, D. (2018). The Polyvagal theory in therapy: Engaging the rhythm of regulation. W.W. Norton & Company.
Dowie, T.-A., & Denning, N. (2022). An integrated approach to trauma treatment part I: Foundations of theory. Psychotherapy & Counselling Today, 1, 10-21.
Fonagy, P., Gergely, G., & Jurist, E. L. (Eds.). (2018). Affect regulation, mentalization and the development of the self. Routledge
Kezelman, C., & Stavropoulos, P. (2018). Talking about trauma: Guide to conversations, screening and treatment for health care providers. Blue Knot Foundation.
Mancini, A. D., & Bonanno, G. A. (2012). Differential pathways to resilience after loss and trauma. In R. A. McMackin, E. Newman, J. M. Fogler, & T. M. Keane (Eds), Trauma therapy in context: The science and craft of evidence-based practice (pp. 79-98). American Psychological Association.
Maté, G. (2011). When the body says no: The cost of hidden stress. Vintage Canada.
Music, G. (2014). Attachment, our brains, nervous systems, and hormones. In P. Holmes & S. Farnfield (Eds.), The Routledge Handbook of Attachment: Theory (pp. 127- 147). Taylor and Francis.
Skovholt, T., & Trotter-Mathison, M. (2016). The resilient practitioner: Burnout and compassion fatigue prevention and self-care strategies for the helping professions (3rd ed.). Routledge.
Turner, T. P. (2021). Belonging: Remembering ourselves home. Altimira.