Trauma Case Study

(Please note that while every question or statement may not be shown below or match word-for-word the way the assessments are worded, there is enough information below to make an informed decision using the assessment instruments. After carefully reviewing the assessments and narratives several times, if you do not see a particular criteria or statement answered by the narrative, you can safely assume that it is not part of the diagnostic picture for this client.)

John is a 27-year-old single man who served eight years in the Army (joining when he turned 18), and served three tours (each about 6-9 months) of duty in Iraq and Afghanistan, attaining the rank of sergeant first class (E-7).

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John came to the office about 25 minutes early and did a Beck Depression Inventory-2 (total score = 20, mild-to-moderate depression), the Beck Anxiety Inventory (total score = 15, mild-to-moderate anxiety), the Beck Hopelessness Scale (total score = 3, minimal hopelessness), and the Beck Scale for Suicide Ideation (total score = 0, no suicidal ideation). After doing a Mini-Mental Status Exam with him (total score = 30, normal cognitive functioning). He begins talking about why he has come to see you today . . .

He starts off with saying he’s “not sure why I’m coming to see anyone . . . I should be able to handle things myself. With as much training as I’ve been through, this is just another thing to conquer. But I can’t seem to shake it . . . my parents encouraged me to come and talk, so here I am.” He says he is currently living with his parents after his recent discharge (honorable) nine months ago, is in reasonably good physical health. He used to like to hike (which he laughs about considering how much he and his buddies hated the full-pack “hikes” when he was serving) and ride his mountain bike (each are quite a bit harder now because of his back and leg injuries), but he occasionally tries to jog and lift weights a couple of times a week. He mentions he “pretty much doesn’t want to do any of those things these days.” He is actively looking for an apartment or house to move into, but has had some trouble finding steady work. He acknowledges that his parents “are great people,” but he feels “stifled” and “babied” by his mom, due to his “nightmares and injuries” that still affect him from time-to-time. He is not currently in a relationship, but is “dating someone” (he calls her his “girlfriend,” but he’s not sure if she wants it to be serious at this time).

He says most of his patrols were pretty routine, he believes he participated in “easily more than 100 of them” (he had a “notch” on a stick for every one he went on, but it got lost when he was injured on his last patrol), and was in at least 61 or 62 “firefights” with enemy combatants. He really loved the “camaraderie of being with my team” and “knowing I could trust them with my life.” He does say that there were about 18 or 19 situations that have really stuck with him of where he and his team were ambushed and pinned down, where each teammate thought they could be killed or seriously injured (including the one where he was injured). He says during the total of 36 months that he was deployed “in-country,” he was under fire for over half of that, many times with their camp (when he was in the Korengal Valley) being showered with mortar or sniper fire until they could use counter-snipers to take out a target or get an assist from an “Apache” helicopter unit to get the mortar crew.

On at least four of the ambushes, he knows he and his platoon were surrounded by the enemy, and with all the “bullets flying around,” it was amazing that “everyone wasn’t hit.” He was very proud of his team, platoon, and the company he was in, being led by “really competent captains and “LTs” (lieutenants), along with great sergeants. Because he (and his company) were on so many patrols, especially around Ramadi and some in Tikrit, there were “so many times that someone was hit by incoming,” and when asked to give a number, he says “at least 40 to 50 times.” His company had one of the highest numbers for Purple Heart awards” (including two for himself), but they also “had a pretty high KIA (killed in action) and WIA (wounded in action) rate of about 30%.”

His final patrol was when he was riding with his team on the Eastern side of Baghdad, “in a bad part of town,” so they were “on high alert.” Things had “gone pretty smooth for the most part” and that they “had actually started to relax a little, looking forward to getting back to camp” when on the last half of their patrol, they were struck by an EFP (explosively formed projectile) and their Humvee was “blasted pretty bad.” Since he was the “tactical commander,” he was monitoring everything from the front passenger seat. When they were hit by the EFP, the Humvee did not roll completely over, but it still blew upwards, crashed hard back down, and then landed on its side, with him “pinned against the door, which was wrecked and twisted, and hot from the explosion.” The “shrapnel blasted through the bottom” and “tore up his feet and legs up pretty bad,” and the Humvee landing on its side severely injured his back, giving him “four cracked vertebra, but no spinal column damage, thank God.” One of his team manning the M240 at the turret was killed, and the other two were both injured.

Because of the injuries to his back and legs, he spent nearly six months in the VA hospital in the next city over from where he grew up, which allowed family and friends to visit him. The rehabilitation was moderately successful, but the Army determined he could not continue, so he was honorably discharged. He says that was “one of the toughest days I ever had. I felt ‘used and abused and put back on the shelf wet.’”

He says that the main reason he is here is that he keeps having nightmares about his experience, and he says he even has “vivid mental pictures” during the day when he is just sitting and watching television. He says he does his “best to push the images out of his mind, but they keep coming back.” The more he thinks about what happened, the more he realizes that he “should have been more careful, since it’s my job to protect my men.” He talks about the “guilt” he is feeling because since he’s the sergeant, “I needed to be at the top of my game at all times, and my failure cost the life of one of my guys.” The more he finds himself thinking about what happened the more he “feels on edge, watching out for anything that can happen, “‘blowing up’ and yelling at his family and friends for no good reason is happening every week now,” and “not meaning to, but pushing my girlfriend away because I just don’t have the energy to deal with another person or go anywhere.” When asked to explain the last statement a little more, he says he “emotionally is just not all there, maybe ‘numb’ is a good word; I don’t know how to explain it other than I don’t want to do anything and I don’t want to be around anyone else. I can’t concentrate or think straight; I just want people to leave me alone and stop asking me if ‘I’m alright.’ If I’m alright, would I be coming to you? I don’t feel like doing anything other than my usual: get up, do some work, go to bars and hangout, come home, go to bed, not dream, repeat.”

When asked about whether he wants to or has tried to hurt himself, he replies that “I wouldn’t do that, unless things got super-bad; but even then I don’t think I could do it. I like being alive too much. I just want this ‘hollowness inside me’ to go away. I’m not happy, but I’m not depressed.”

When asked about any alcohol or substance abuse, He mentions that while he was never a big drinker growing up, and he never used illegal substances of any kind, he did start “drinking a little more since I’ve been back than I did while serving,” and “staying out later and later at bars where other ‘old soldiers’ hang out” to be with people “who understand me.” While he says he has “woke up with more hangovers over the past six months that I ever had in the past six years,” he says he “likes ‘feeling the buzz’ because it helps me to forget for a little while.” When asked about whether drinking has caused any problems, he responds with a quick “no,” but adds “I have missed a few important family functions that made my parents mad at me, and my girlfriend has asked me to go places with her, and I say I will, but when I get to the bar time goes by and I forget. This has caused a lot of fighting between us, but she just doesn’t understand what I’m dealing with right now. How can anyone who hasn’t been over there? The drinking helps me to forget a little and hopefully keep my from dreaming when I get home” He continues that he has never been “falling down, sloppy drunk.” but has been a little apprehensive about driving when he’s had a “few too many, because I don’t want to ruin my good driving record and have my insurance go up.” When asked to elaborate, he says he “knows it’s dangerous to be driving when he’s had a few too many,” and while “I’ve run off the road a few times, I still always make it home in one piece.” Asked about accidents or near misses, he mentions that “I have had a few close calls with almost getting creamed by a ‘semi’ on the interstate, and I think I may have knocked someone’s mailbox over one time about a month ago, but I’m a good driver.” He looks around the office, then laughs and says, “honestly, I really wish I had a drink with me now as we’re talking about all this stuff.”

Returning to the reason he has come seeking help, he is asked how many times he has had the unwanted memories come back to bother him, and says “about 6-12 times over the past month. The dreams are worse.” In discussing the unwanted memories, he is asked about how real they seem, he responds that “it is almost like being right back in that war zone, and being back on patrol.” When the “vivid mental pictures start on the big screen in my head, it is like I’m living it all over again.” When asked about any reactions he has, he says his “heart starts beating faster, my chest starts hurting, my hands start shaking; I think I’m dying, even though I know I’m safe back ‘state-side.’” He says it “takes about 10-15 minutes to get back to normal afterwards, and I’m “constantly on guard” when I’m “driving or walking down the street. It’s like any little sound or noise or a car coming from nowhere makes me jump because I don’t know if there’s a bomb out there or an enemy who wants kill me. Then I spend the rest of the day trying to keep it out of my head; drinking helps, so that is what I end up doing.” When asked how he goes about avoiding the unwanted images, John says he “throws himself into any kind of physical work he can find: yard work, construction work, lifting weights, anything. I figure if I’m working my body hard, my mind does not have time to wander.”

When asked about having any “gaps” in his memory of the event, he responds, “I don’t think so; I remember it all pretty clear, although I am a little fuzzy about where and how the IED was placed. It’s like all my mind wants to do is focus on the explosion. Strange, I can’t even remember the street name we were on even though I had travelled it about 100 times on patrol. Weird, huh.” Asked about any emotions connected with the event, he looks away for a moment before responding, “I know it is all my fault. I was ‘topside’ at the gun, and I should have seen the IED before we got close to it. A man died because I was so stupid. We were in a dangerous place and I let my guard down. A good man would still be alive right now if it weren’t for me being lazy and stupid. I think that is the part that so hard to live with: I’m guilty! I’m angry at myself for letting everyone down! All of this didn’t have to happen if I’d just done my job!”

Asked to talk about the dreams, he describes the IED, the explosion, feeling the pain of his legs being shredded, feeling the Humvee flipping, and the excruciating pain in his back. He says he “wakes up sweating and breathing hard, and having the ‘shakes’ until I figure out that I’m still safe in my bed. I know I’m not going to be able to get back to sleep, so I’ll just go ahead and get up, even though I have three or four hours before I have to get up for work.” He says the dreams “started about one time a week a couple months ago, but now is happening about 2-3 times each week over the past month, and it’s just getting harder to ignore it.” When asked about his normal sleeping habits before the event, he says he was “always a great sleeper, getting around seven hours each night and greeting the dawn each day; now I’m lucky to get 3-4 hours.”

In closing, he is asked about his work and work schedule; he says when he “got home and recovered some,” he “did a few ‘odds and ends-type’ jobs to get some spending money.” He then “started working for a small construction company and really liked the physical labor he was doing. But once the nightmares started and I wasn’t sleeping, I started making big mistakes on the job, and the boss took me off full-time. Now I work only small part-time jobs for about 20 hours a week in my paycheck. It’s not much, but it tends to be enough to buy the beer.”

Asked about any others experiences, such as “things not feeling real or strange, like you’re standing outside yourself watching yourself,” he replies that “other than seeing his vivid mental pictures, he doesn’t remember feeling any of those things.”

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