Trauma-Informed Care: Amy's Clinical Assessment & Intervention
School
Walden University**We aren't endorsed by this school
Course
COUN 6336
Subject
Nursing
Date
Dec 10, 2024
Pages
6
Uploaded by CorporalTapirMaster1122
Case Study of Amy: A Clinical Assessment and Plan for InterventionAmy is a 25-year-old Native American and Caucasian mixed woman who presents with self-reported symptoms of anxiety and trauma. She seeks counseling for emotional distress, which she attributes to a traumatic experience from her past. In this case study, we will assess Amy’s primary concerns, evaluate the severity of her symptoms, and outline the next steps in her clinical care using evidence-based practices. This assessment will be guided by the principles of trauma-informed care, cultural competence, and the ethical guidelines outlined by James and Gilliland (2017).Presenting ConcernsAmy’s primary concern is the re-emergence of anxiety and panic symptoms, which she attributesto a sexual assault that occurred during her senior year of high school. She reports intrusive memories and flashbacks related to the assault, accompanied by significant anxiety, especially in certain situations or environments that remind her of the traumatic event. Specifically, she experiences panic attacks while walking on campus, which include symptoms such as hyperventilation, sweating, and difficulty swallowing. These attacks, which she describes as feeling like she is "going to literally die," are often triggered by walking alone to her car or beingin crowded spaces.In addition to her trauma-related symptoms, Amy struggles with low self-esteem and self-blame. She believes that she was responsible for the assault, and this belief has contributed to her feelings of shame and guilt. She often ruminates over the event, questioning why it happened andperceiving herself as “damaged goods.” Amy has also isolated herself from her family and friends, further exacerbating her emotional distress. Moreover, her fear of interacting with men
has impacted her academic and social functioning, creating a barrier to her relationships and participation in activities. This avoidance is particularly problematic in her nursing program, where she must work with male patients during clinical rotations.Amy also reports engaging in self-harm behaviors, including cutting, as a way to manage overwhelming emotions. She also consumes alcohol in moderation (one to two glasses of red wine a few times a week) to “numb out” her feelings. These coping mechanisms are concerning, as they indicate that Amy is struggling to regulate her emotions effectively and may need further intervention.Assessment of SymptomsUsing the Triage Assessment Form (TAF) as a guide, Amy’s symptoms can be evaluated on a scale from 1 to 30, with higher scores indicating more severe symptomatology. Amy’s overall severity rating can be broken down into the following domains:Trauma-related Symptoms (8/10): Amy’s flashbacks, intrusive thoughts, and emotional paralysis when recalling the traumatic event are indicative of PTSD. The persistent natureof her trauma-related distress, coupled with avoidance behaviors, places this domain at the higher end of the scale (James & Gilliland, 2017).Anxiety and Panic Attacks (8/10): Amy experiences frequent panic attacks, particularly in situations where she feels unsafe or triggered by reminders of her trauma. The physicaland emotional intensity of these attacks significantly impairs her ability to function, especially in public settings and during her academic activities.Self-Harm and Alcohol Use (6/10): While Amy’s self-harm behavior and alcohol consumption are concerning, they appear to be relatively moderate in frequency and
severity. However, these behaviors indicate that Amy is using maladaptive coping strategies to manage emotional distress and need to be addressed in therapy.Functional Impairment (7/10): Amy’s trauma, anxiety, and emotional struggles are significantly affecting her academic performance, relationships, and social functioning. Her avoidance of male classmates and withdrawal from social gatherings are impairing her ability to fully engage in her life and studies.Overall, Amy’s total score on the TAF would likely be 29/40, reflecting significant distress and functional impairment that necessitates immediate intervention.Next Steps in CareGiven the severity of Amy’s symptoms and the impact they are having on her functioning, the following clinical interventions are recommended:1.Safety Assessment and Risk Management: Amy’s self-harming behaviors, particularly the cutting, require an immediate safety assessment. It is important to assess whether these behaviors are escalating and to determine if there is any suicidal ideation present. If Amy reports increased self-harm or suicidal thoughts, a safety plan should be developed, and a referral to inpatient care may be necessary. Ongoing monitoring of her self-harm behaviors is essential to ensure she is safe throughout the therapeutic process.2.Trauma-Focused Therapy: The primary therapeutic intervention for Amy should be trauma-focused cognitive behavioral therapy (TF-CBT). TF-CBT is an evidence-based approach designed to help clients process traumatic memories and reduce PTSD symptoms (James & Gilliland, 2017). This treatment would assist Amy in confronting
and reprocessing the traumatic event, helping her to challenge irrational beliefs related to the trauma and develop healthier coping mechanisms.3.Cognitive Behavioral Therapy for Anxiety: Amy’s ongoing anxiety and panic attacks should be addressed through CBT for anxiety. CBT will help Amy identify distorted thinking patterns, develop skills to challenge these thoughts, and utilize techniques such as relaxation training and grounding exercises to manage her anxiety during triggering situations (James & Gilliland, 2017).4.Dialectical Behavior Therapy (DBT): Given Amy’s difficulties with emotional regulation and her tendency toward self-harm, DBTis a promising therapeutic option. DBT helps individuals develop emotional tolerance, improve interpersonal effectiveness, and reduce self-destructive behaviors (James & Gilliland, 2017). This therapy would be beneficial in helping Amy manage her intense emotions and improve her coping skills.5.Substance Use Intervention: Although Amy’s alcohol use appears moderate, it is important to monitor her consumption and intervene early if it escalates. A referral to a substance use counselormay be appropriate, particularly if her alcohol consumption increases as a way to avoid dealing with painful emotions.6.Cultural and Spiritual Support: Given Amy’s strong Native American heritage, reconnecting with her cultural and spiritual practices may play a key role in her healing process. Cultural competencein therapy is essential, and Amy may benefit from a referral to a spiritual counseloror involvement in traditional Native American healing practices, which could help her feel more connected to her identity and community.
7.Family Therapy: Amy’s close relationship with her family, particularly her sister, suggests that family therapycould be a valuable resource. Involving her family in therapy would allow them to better understand her struggles, support her healing process,and reduce feelings of isolation. This approach would also help open up communication and provide a space for Amy to share her trauma with trusted family members.8.Psychiatric Evaluation: Due to the severity of Amy’s PTSD, anxiety, and depressive symptoms, a psychiatric evaluationshould be conducted to assess the need for medication. Medications such as selective serotonin reuptake inhibitors (SSRIs)or serotonin-norepinephrine reuptake inhibitors (SNRIs)may be indicated to manage her anxiety, depression, and PTSD symptoms (James & Gilliland, 2017).ConclusionAmy’s case presents significant challenges due to the impact of trauma, anxiety, self-harm, and substance use. However, with appropriate intervention, including trauma-focused therapy, CBT, DBT, and substance use counseling, Amy has the potential to heal and regain control over her life. Additionally, involving her family, exploring spiritual practices, and considering psychiatric medication will provide a holistic approach to her treatment. By addressing both the psychological and emotional aspects of her trauma, Amy can begin the process of recovery and work toward a more fulfilling and balanced life.ReferencesJames, R. K., & Gilliland, B. E. (2017). Crisis intervention strategies(8th ed.). Boston, MA: Cengage Learning.