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A: BASIC ATTENDING SKILLS

· CW:What brings you in today? (Open-ended question)

· C:I’ve been feeling down and not myself lately.

· CW:You look a bit tired and sad as you say that. (Reflection)

· C:Yes, it’s been hard for me to come back home.

· CW:You’ve just come back home? (Clarification)

· C:I was in Iraq for a year and came home last month.

· CW:You served in Iraq for a year and recently returned. (Paraphrase)

B: IDENTIFYING THE PROBLEM AND THERAPEUTIC INTERACTION

Identify the Precipitating Event:

· CW:What made you decide you needed to make this appointment right now?

· C:My mom told me that I am acting weird.

· CW:In what way weird? (Open-ended question)

· C:Last week I got up in the middle of the night and ran around the house shouting. (Identified precipitating event)

Explore Meanings, Cognitions, and Perceptions:

· CW:What are your thoughts about that happening? (First open-ended question to explore cognitions)

·
C:I must be a total looney.

· CW:In what way do your mean looney? (Explores new term)
· C:You know, crazy, normal people don’t do that.
· CW:What is your understanding of how you came to do something that you think of as crazy? (Continue to explore cognitions)
· C:I think I woke up thinking I was in Iraq and someone was attacking me.
· CW:What are your thoughts about that?
· C:Maybe I’m re-living a sexual assault that happened to me over there.
· CW:So you woke up in the middle of the night yelling and you thought you might be looney but now you think it might be related to a trauma you experienced in Iraq? (Clarifying summarization)
· C:I don’t want to talk about it.
· CW:What makes you not want to talk about it?
· C:I feel guilty, like it was my fault. I should have stopped it.

Identify Emotional Distress:

· CW:Sounds scary (reflection)

· C:You don’t know the half of it.

· CW:I’d like to. Especially if it prevents you from fully functioning. You said earlier that you’ve been feeling down too. It must be difficult to be around people feeling scared and sad. (Reflection of emotional distress)

· C:Yes, I don’t even want to hang out with my friends anymore.

Identify Impairments in Functioning in the Following Areas:

· 1. Social

· CW:So you aren’t seeing your friends. (Paraphrase). Have you done anything socially lately at all? How are things going with your family?

· C:Well, I pretty much only talk with this girl that I served with and sometimes I talk with my mom. I started school and it’s hard to talk with my classmates. I feel alienated and anxious a lot. No one understands me.

· 2. Academic

· CW:Oh, you’re in school. How are classes going? How are your concentration skills? Sometimes it can be challenging to focus after returning from a war zone.

· C:Yes, it’s hard. I have TBI (traumatic brain injury) because I was exposed to an intense explosion so my mind wanders at times. Sometimes I hear a noise and I get startled in class. It’s embarrassing.

· 3. Occupational

· CW:Are you working too or just focusing on college right now?

· C:Just college, it’s all I can handle.

· 4. Behavioral:

· CW:I know you said you are tired and depressed. Is this affecting your sleep pattern?

· C:Yeah, I can’t get to sleep most nights, the doctor gave me sleeping pills.

· CW:How about your appetite? Are you eating OK?

·
C:I sometimes find myself overeating just to keep me numb.

Identify Any Ethical Concerns:

· 1. Suicide assessment

· CW:You mentioned you feel depressed and wish to keep numb. I’m concerned that you may be feeling sad and perhaps have had thoughts of suicide. Have you thought of harming yourself or ending things? (Assess ideation)

· C:Actually, yes. It would make things easier to just go to sleep and forget everything.

· CW:Do you have a plan as to when or how you would do this? (Assess plan)

· C:Maybe take all my sleeping pills with vodka.

· CW:Do you have the pills and vodka available? (Assess means)

· C:Yes of course.

· CW:What has stopped you?

· C:My mom has been through enough with me being deployed and all. It would kill her.

· CW:Yes it would most likely be devastating to her. I’m sure you have developed inner strength to bear your pain as part of military training. But I’m glad you have come to talk to me so you don’t have to bear it alone.

· 2. Child abuse, elder abuse, homicide

· CW:You mentioned earlier that some things happened that you don’t want to talk about. I’m concerned about how you are dealing with what seems like a pretty traumatic situation.

· C:It’s not good. I have learned to really hate the military for how they handled things.

· CW:You sound pretty angry.

· C:Well they put the blame on the wrong person. As usual the jerk who caused the problem will get away with it. If I had my way, I’d handle him myself.

· CW:What do you mean you would handle him

· C:I’d like to make him suffer and feel my pain the way he made me feel.

· CW:Do you think you would ever take action against him physically?

· C:No, but I daydream about bashing his face in.

· CW:Sounds like you are very mad and want to hurt him, but that you won’t act on it.

· C:Yeah, I am still battling this issue in court so I will behave, but that’s why I came to see you.

· 3. Organic or other medical concerns

· CW:Sounds like your feelings to harm yourself and your wishes to hurt this man are under control for now. I am wondering about your sleep and eating however. Are you able to get out of bed, get ready, and function when you need to? Sometimes when people are depressed, they see a physician for an evaluation and possible medication.

· C:The doctor at the VA already suggested that I take antidepressants but I told him I only want the sleep aid for now. I can function OK.

· CW:Well let’s monitor that and let me know if you change your mind and I can provide with you a referral to a physician or psychiatrist if need be.

· 4. Identify Substance Abuse Issues:

· CW:You did mention earlier that your plan would be to drink vodka with those pills. I’m wondering if you have been drinking a bit more to help deal with your stress, or maybe using other types of drugs?
· C:Yes, I do like a cocktail at night, to get me through, you know. And sometimes me and my friends fire up a joint when we have weed.
· CW:Is this something that you think you need help with?
· C:Maybe, not sure if it’s a problem, but yeah sometimes I pass out.
· CW:Well there are twelve-step groups for people struggling with drinking issues and I can give you a list of places if you like.
· C:Let me think about it.

Use Therapeutic Interactions:

· 1. Educational comments

· CW:When someone is sexually assaulted, it is not uncommon to turn to drinking and drugging to help numb anxiety and feelings that are unpleasant. It takes time for the psyche to integrate a trauma like that. Additionally, you are also dealing with the trauma of being exposed to war, death, and other untold traumatic situations. Many of the symptoms you have mentioned are symptoms of Post Traumatic Stress Disorder. Researchers have suggested that these particular wars are incubators for PTSD because those serving never know when a fire fight will ensue or who the enemy is. It makes sense to feel helpless and get startled. The mind has to slowly learn to integrate these experiences. On top of this, you also have to integrate the sexual assault trauma.

· C:Yeah, I’ve heard about PTSD, but I don’t really like to see myself as crazy. I’m strong and can usually handle anything.

· CW:I’m sure you are and when you were serving your mindset was one of strength for the team and survival. Now, though you are safe and the same behaviors that were necessary when serving are not necessary. Also, when someone is sexually assaulted they often feel like it is their fault, but I’d like you to consider that a felony crime was committed against you and that sexual assault is about power and control. It is entirely the perpetrator’s fault.

· 2. Empowerment statements

· CW:Being strong and not focusing on feelings gave you power while in combat. Now, it is stripping you of personal power because it prevents you from living fully. You can take back power and control of your life by learning to openly deal with your PTSD and your traumas. Taking back your feelings and learning to master them usually leads to increased feelings of control. Although you were a victim of sexual assault, by talking about it and feeling the pain, you become a survivor.

· 3.
Support statements

· • CW: This is an extremely difficult situation, and I don’t take it lightly. I can only imagine the pain you are going through. I am so sorry this happened to you.

· • Please, let me be there for you; I care. It must feel pretty bad if you have thoughts of harming yourself. These kinds of traumas often make people feellike giving up. It is understandable that you feel alienated from others since they didn’t go through what you went through. However, there are people who have been sexually assaulted and understand that. There are many support groups that deal with sexual assault because it is so prevalent.

· 4. Reframes
· CW:It takes a lot of strength for you to feel this kind of pain. So all that strength you have been using to numb your pain can be harnessed to feel the pain and integrate it into your life. Instead of having a destructive effect, it can build you into a stronger person who has survived horrific trauma.

C. IDENTIFY CLIENT’S CURRENT COPING STRATEGIES AND ATTEMPTS

· CW:At this point, what are some things you think you would like to do?

· C:Well, maybe talk more about it.

· CW:Great. Any ideas about where or with whom you’d like to talk?

· C:I’m not sure, can I keep talking with you?

· CW:Sure, I’d like that. Can you think of anything else that might help you?

· C:One of my veteran friends went to a veteran’s group. What do you think?

· CW:That would be very helpful. Your campus has several groups. Why don’t you try the Veteran’s center there?

· C:I think I will.

Present Alternative Coping Ideas:

· 1. Refer to support groups, twelve-step groups

· CW:What would you think about going to a support group for sexual assault survivors?

· C:I’m scared that it may affect my case.

· CW:How so?

· C:Well my attorney said not to tell people about it.

· CW:Well certainly with me, anything you say is confidential. Maybe the group could wait until you confer with your attorney about going. Do you think a twelve-step group like Alcoholics Anonymous would be something you could benefit from?

· C:Maybe, but I don’t think I’m an alcoholic. I just drink when I’m really anxious.

· CW:OK, let’s keep our eyes open on your drinking and if it seems to become a bigger issue, we can revisit AA.

· 2. Refer to long-term therapy, family therapy

· CW:It sounds like you are open to continuing in counseling with me. Let’s keep that up for awhile and also you can visit the Vet center and see what services they think might be best for you. I know a therapist there who does Sand Tray therapy which is very helpful for PTSD and veterans.

· C:That sounds cool, I’ll go talk to them.

· 3. Refer to medical doctor or psychiatrist

· CW:I do want to keep an open mind about seeing a physician. If your symptoms become more serious, you might wish to consider another evaluation.

· 4. Legal referral
If you would like me to talk to your attorney I will. She needs to understand that you need to talk openly about what happened to you to help you overcome your suffering. Or you could inform her that you are in therapy and see what she says.

· 5. Refer to shelter, other agency
If you want another referral, I suggest you look into the community vet center. They have many services provided by veterans who can truly understand your experiences.
· 6. Recommend reading books and keeping a journal
· CW:Do you like to read? I know of some really good books that help explain more about what you are going through. Here is a list of books I recommend for you to read. Also, many clients feel more under control if they keep a journal while going through difficult times.

Obtain Commitment; Do Follow up:

When can you make another appointment with me? I’d like you to let me know when you have visited the veteran’s center at school.