Art Therapy Opposite Cognitive-Behavioural Treatment - Case Study Example

Introduction The most affecting predicament during childhood is likely to be the death of a parent or a sibling. Life changes considerably after the violent death of a family member. The numbing shock of witnessing and realizing that a loved one is dead and has died violently can last a long time. The people who have witnessed the violent murder of their loved ones may suffer from trauma and stress disorder. In case a child loses a parent or a sibling, he/she may develop certain feelings, memories, and actions every time one reconstructs the image of the dead parent and sibling. Such is the case of Tumi. As a result, a child develops an inner representation that enables her to sustain the relationship he/she had with her parents or siblings during their lifetime. Though one experiences a permanent loss of his/her loved one, he/she changes the process of coping. Diagnosis of Posttraumatic Stress Disorder (PTSD) Tumi is suffering from Posttraumatic Stress Disorder (PTSD). According to Wilson & Keane (2004) PTSD is a pattern of reactivity that a person develops after exposure to an extremely stressful situation. These authors further observe that the affected person may re-experience phenomena, which involve cognitive processing, information storage, and retrieval from memory. Although diagnosis is an essential goal in most assessment, there are other important aims and actions in a complete evaluation of trauma survivors, including clinical management, functional analysis of problem behaviors, history taking, case formulation, and treatment planning (Wilson & Keane, 2004). According to Constructivist Self Development Theory (CSDT), psychological trauma is the experience of affect that overwhelms one’s ability to respond and the experience of threat to life or bodily integrity (Wilson et al., 2014). Learning about which event was most difficult is part of the therapeutic process with each client. In Tumi’s case, the most difficult event was the killing of her family members. This event will be an essential part of constructing a narrative, part of the healing process of creating meaning for Tumi. Tumi has also shown signs of panic disorder. Diagnostic Criteria PTSD Clinically, diagnosis involves adhering to diagnostic criteria and DSM-IV-TR guidelines. However, there are certain limitations to the DSM approach in general and limitations of the PTSD criteria specifically. In clinical settings a PTSD identification is component of a DSM-IV-TR multiaxial diagnosis; therefore, it should always conform to the official diagnostic criteria (Edna, Friedman & Cohen, 2012). The most appropriate diagnosis for Tumi is a comprehensive PTSD assessment that can evaluate all of the diagnostic criteria. Predisposing factors A therapist can identify predisposing factors by reviewing the development history of a patient. These may include important learning experiences that have been leading the patient to interpret symptoms and stressors in particular ways. For example, Tumi has a belief that the event of killing may recur. Tumi acquired such predisposing factors through direct experience of her parents and siblings. The act of witnessing those killings led Tumi to belief that the ones who killed her parents and siblings may come back. This is the reason Tumi has adopted the behavior of making sure that the doors are locked. There is evidence that Tumi’s family members were murdered. This evidence raises the possibility that Tumi possesses a predisposing factor to develop fear, with the type of disorder/problem depending on the type of environmental event that Tumi encountered. Precipitating factors Childhood adversity, inform of parental loss and lack of parental care appears to have precipitated subclinical PTSD along with intermittent bouts of depression. Tumi’s later movement to a foreign country may also serve as a secondary set of precipitating factors. According to Taylor (2006), precipitating factors for PTSD are those traumatic events. Tumi has a traumatizing history whereby that event of led to the development of maladaptive belief (i.e.. childhood adversity) and another event has contributed to the strengthening of these beliefs (experiences of being in a foreign country). These beliefs may have contributed to Tumi’s PTSD symptoms and to her depressive symptoms. Tumi has been exhibiting some symptoms such as heightened anxiety. Such symptoms are Tumi’s stressors and trauma cues. In Tumi, these precipitating factors may be showing because of Tumi’s interaction with predisposing factors. Heightened anxiety triggers Tumi to check whether the doors are closed. Heightened anxiety has precipitated PTSD in Tumi and associated irritability. In turn, PTSD and irritability may lead Tumi to disassociate with other people, which in turn may precipitate a depressive episode. Maintaining factors Maintaining factors are the factors that maintain the patient’s problems (Taylor, 2006). Tumi has developed maladaptive coping strategies in form of trauma-related fears and re-experiencing symptoms. These include locking the doors probably to keep the murderers outside. Assess Criterion A Edna et al. (2012) argue that it is extremely difficult to define trauma, and Criterion A has evolved considerably since PTSD was introduced in DSM-III. Criterion IA presents the first two elements. In the case of Tumi, the diagnosis will follow the first elements of A1, which involves the type of exposure which, in this case, Tumi witnessed the event (killing of her parents). Criterion A2 presents the third element where the killing of Tumi’s parents led to her movement to a foreign country. In the case vignette, Tumi’s social worker expressed concerns about Tumi’s bizarre behavior that includes fear of the red colour and avoidance of red objects (probably, Tumi relates colour red and red object to blood of her parents that she witnessed during the killing of her parents and siblings. Other behaviors include recurrent nightmares and a range of other behaviors. Another bizarre behavior includes washing her hands frequently (probably, Tumi feels as if she has her parent’s blood on her hands). Therefore, in Tumi’s case the syndrome is present, and the stressor meets Criterion A. Tumi’s case qualifies as a trauma. The primary goal for assessing Criterion A is to recognize one episode that meets Criteria A1 and A2, are useful as the index occurrence for symptom inquest (Edna et al., 2012). In Tumi’s case, two events in Criteria A1 and A2. First, Tumi witnessed the event and secondly, the event led to her movement to United States. The index event is the witnessing of the killing event. In additional to identifying the index event in Tumi’s case, it is also important to identify whether Tumi has been exposed to other traumatic events across her lifespan. It may be possible that Tumi has experienced other traumatic events because her family had been living in a country experiencing political turmoil. According to Edna et al. (2012), the trauma that an individual goes through influences reactions and actions to the index event. The most traumatic event for Tumi is witnessing the killing of her parents and siblings, and it should form the basis of diagnosis criteria and symptoms inquiry. Linking Symptoms to the Index Event In the 17 symptoms of PTSD, Tumi has some symptoms that include fear of the red color, avoidance of red objects, and recurrent nightmares. Because the individual symptoms have been established in Tumi’s case, an explicit link will be established between the symptoms she exhibits and the index event. The symptoms that are evident in Tumi contribute toward the diagnosis of PTSD. Therefore, these symptoms can be attributed to the index event. Case formulation model Tumi entered United States and is currently experiencing PTSD and paranoia. Her family was caught up in a bloody civil conflict which resulted in the death of her parents and siblings. The primary trauma related was the killing of her parents that may have contributed to her PTSD. As Wilson et al. (2014) observe, treating psychiatric patients when the clinician and the patient are from different cultures is a difficult task. The barrier in treatment can involve differences in language. Tumi has been severely traumatized, and her issues may be more difficult since avoidance behavior and exaggerated physiological response may make Tumi even more reluctant or unable to engage in treatment. However, the approaches to cross-cultural psychiatry have made remarkable advances (Wilson et al., 2014). The first step in formulating Tumi’s case is to list all the problems according to social worker’s report. Tumi’s problems include fear of the color red, nightmares that recur, and avoidance of red objects, recurrent nightmares, frequent hand washing, and checking the locks on the front and back door. Tumi’s diagnoses are PTSD and color phobia, and recurrent nightmares. Tumi’s memories of the earlier event of killing makes her to act in ways such as “I have to keep the doors closed all the time” and “People may hurt me as they did to my family members” may be further confirmed by her experiences in her country. Intervention and Treatment The broad goals of Tumi’s treatment are to help her overcome her PTSD and depression so that she could be able to resume her normal life and fit in United States. Her therapists subgoals are to deal with various issues in Tumi’s problem list. For example, the therapist should focus on reducing the frequency of nightmares in order to increase her ability to trust people. Given the fact that Tumi has not yet adopted to living in a foreign country, the therapist should work on improving her coping skills before exposing her treatment related to the killings. The therapist can start by having Tumi purchase a day planner in which she can schedule one activity per day that has brought her enjoyment in her life. Consequently, the therapist can introduce strategies and cognitive restructuring in which she can improve Tumi’s hope of recovering. Other targets of cognitive restructuring include Tumi’s beliefs that the killings may recur and that red color is only associated with blood. Other imaginal and situational exposure may be introduced later, focusing first on her experiences in the United States, and then on the event of murder of her family members as well as other experiences. Such exposures can help Tumi to wean herself from her safety behaviors such as ensuring the doors are locked. Treatment Setting The engagement must occur in a safe setting with no pressure to tell or not to tell the story. There should also be respect for the cultural values. The treatment setting for patients suffering from PTSD should be less restrictive. It is important to consider Tumi’s-specific factors such as symptoms severity, level of functioning, and available support system. It is also important to consider her personal safety, ability to provide adequate care for her, the ability for feedback provision, and willingness to participate in treatment. Tumi’s ability to trust the psychologist and the treatment process must also be established. To a greater extent, Tumi’s ability may be limited as a consequence of index event, cultural barriers among other factors. Therefore, the choice of treatment setting should be reevaluated on an ongoing basis throughout the treatment course. For Tumi’s case, this paper suggests treatment should be done on an outpatient basis in the most appropriate treatment setting. Hospitalization is not necessary because Tumi has not shown any sign of posing a serious threat of harm to herself or others. The psychologically traumatized person is aroused with intense anxiety and fears that the threat will return and scans the environment to negate or prove this (Wilson, Friedman & Lindy, 2014). Therefore, it is important to ensure that the setting is appropriate. Cross-Cultural Therapy According to Wilson et al. (2014), the treatment of disorders related to psychiatry across cultures begins with complex issues of assessment. However, in Tumi’s case, this role seems to have been taken care of by her social worker. The social worker can provide Tumi’s assessment to the psychiatrist. Appropriate sensitive evaluation proceeds as a dynamic process. The patient’s culture may influence the help-seeking behavior. However, further behavior in the interview will often be determined by the patient’s interpretation of the clinician as an individual. The style of the psychiatrist will highly determine the amount and type of intervention. Cross-cultural therapy requires special approaches. In Tumi’s case, the therapist needs to be flexible, appreciate her culture, and openly initiate discussions. It may be challenging to establish a therapeutic alliance with patients such as Tumi since she is from a foreign country which has been experiencing war and conflicts. However, establishing such an alliance is very important. According to Wilson et al. (2014), there are challenges and complexities that are related to treating patients with PTSD from other cultures. Tumi represents a minor with trauma from a conflict-torn country in Great Lakes region of Africa. She may be experiencing the difficulties of being a refugee and subjected to an ongoing stress of a new country. The preoccupations of traumatized persons are of horror, threat and helplessness that pervade their behaviors (Wilson et al., 2014). Although the cognitive therapy has been effective in treating PTSD, most therapists feel that severely traumatized individuals require much longer treatment than the relatively short-term approach of behavioral therapy (Wilson et al., 2014). Tumi’s treatment may involve telling her trauma story with reframing and reworking. However, the therapist should ensure that he/she conducts the treatment in a safe setting and time it appropriately. Cognitive-Behavioral Therapy versus Art Therapy An ideal therapy and the one that is increasingly being used with good results is art therapy (Wadeson, 2010). For example, Gantt and Tinnin have established Intensive Trauma Treatment, Inc., an outpatient facility where trauma is treated in a two-week intensive treatment protocol utilizing art therapy (Gantt & Tinnin, 2007). Wadeson (2010) recounts of her success in art therapy on a rape victim. Kevin was referred by a social worker to Wadeson. Wadeson states that “the social worker who had referred Kevin called me to say that the art therapy was helping him” (Wadeson, 2010). Art therapy is considered to be an important means of narrative communication. An earlier study had established fewer and less intense nightmares when patients are subjected to art therapy to express their nightmares (Morgan & Johnson, 1995). After taking the history of the patient, the therapist should provide an ongoing relationship. The therapist must be committed to the long-term goal and needs of Tumi. According to Wilson et al. (2014), the therapist in a PTSD case must be central and consistent throughout the treatment. This is particularly true for traumatized refugees such as Tumi for whom overcoming trauma in a new country is an extensive and a difficult process. Expectation to get well in a prescribed time frame (for instance. ten sessions) is unrealistic and leaves the patient with the possibility of being abandoned. References Edna, B., Keane, T., Friedman, M. & Cohen, J. (2010). Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. New York: Guilford Press. Gantt, L., & Tinnin, L. (2007). Intensive trauma therapy of PTSD and dissociation. The Arts in Psychotherapy, 34, 69-80 Morgan, A. & Johnson, D. (1995). Use of a drawing task in the treatment of nightmares in combat-related post-traumatic stress disorder. Art Therapy: Journal of the American Art Therapy Association, 12, 244-247. Taylor, S. (2006). Clinicians Guide to PTSD: A Cognitive-Behavioral Approach. New York: Guilford Press Wadeson, H. (2010). Art Psychotherapy. New Jersey: John Wiley & Sons. Wilson, J., Friedman, M. & Lindy, J. (2014). Treating Psychological Trauma and PTSD. New York: Guilford Press. Wilson, J. & Keane, T. (2004). Assessing psychological trauma and PTSD. New York: Guilford Press. Read More