Veterans returning from a conflict zone may use recreational substances to moderate strain. The process of returning home can easily add to the strain the veteran is already experiencing from exposure to war trauma. In this Discussion, you diagnose and plan treatment for a veteran.
To prepare: Review the Learning Resources on trauma treatment for veterans, and conduct research for additional resources on the topic. Then read “The Case of Jake Levy.” (ATTACHED)
In Jake’s case, the social worker has made several errors that delay Jake’s ability to get substantial help for some time and actually endanger his reaching a positive outcome.
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Jake Levy (31) and Sheri (28) are a married Caucasian couple who live with their sons, Myles (10) and Levi (8), in a two-bedroom condominium in a middle-class neighborhood. Jake is an Iraq War veteran and employed as a human resources assistant for the military, and Sheri is a special education teacher in a local elementary school. Overall, Jake is physically fit, but an injury he sustained in combat sometimes limits his ability to use his left hand. Sheri is in good physical condition and has recently found out that she is pregnant with their third child. As teenagers, Jake and Sheri used marijuana and drank. Neither uses marijuana now but they still drink. Sheri drinks socially and has one or two drinks over the weekend. Jake reports he has four to five drinks in the evenings during the week and eight to ten drinks on Saturdays and Sundays. Neither report having criminal histories. Jake and Sheri identify as being Jewish and attend a local synagogue on major holidays. Jake’s parents are deceased, and he has a sister who lives outside London. He and his sister are not very close but do talk twice a year. Sheri is an only child, and her mother lives in the area but offers little support. Her mother never approved of Sheri marrying Jake and thinks Sheri needs to deal with their problems on her own. The couple has some friends, but due to Jake’s recent behaviors, they have slowly isolated themselves. My first encounter with Jake was at an intake session at the Veterans Affairs Health Care Center (VA). During this meeting, Jake stated that he came to the VA for services because his wife had threatened to leave him if he did not get help. She was particularly concerned about his drinking and lack of involvement in his sons’ lives. She told him his drinking had gotten out of control and was making him mean and distant. Jake had seen Dr. Zoe, a psychiatrist at the VA, who diagnosed him with post-traumatic stress disorder (PTSD). Dr. Zoe prescribed Paxil to help reduce his symptoms of anxiety and depression and suggested that he also begin counseling. During the assessment, Jake said that since his return to civilian life 10 months ago he had experienced difficulty sleeping, heart palpitations, and moodiness. He told me that he and his wife had been fighting a lot and that he drank to take the edge off and to help him sleep. Jake admitted to drinking heavily nearly every day. He reported that he was not engaged with his sons at all and he kept to himself when he was at home. He spent his evenings on the couch drinking beer and watching TV or playing video games. When we discussed Jake’s options for treatment he expressed fear of losing his job and his family if he did not get help. Jake worked in an office with civilians and military personnel and mostly got along with people in the office. Jake tended to keep to himself and said he sometimes felt pressured to be more communicative and social. He was also very worried that Sheri would leave him. He said he had never seen her so angry before and saw she was at her limit with him and his behaviors. Based on the information Jake provided about his diagnosis and family concerns, we agreed that the best course of action would be for him to participate in weekly individual sessions with me and a weekly support group that was offered at the VA for Iraq veterans. I then offered a referral for couples counseling at the local mental health agency. I also printed out a list of local Alcoholics Anonymous (AA) meetings in his area if he decided he wanted to attend in order to address his drinking. He would continue to follow up with Dr. Zoe on a monthly basis to monitor the effectiveness of his medications. The following session, I spent time explaining his diagnosis and the symptoms related to PTSD. Jake said that he did not really understand what PTSD was but thought it meant that a person who had it was “going crazy,” which at times he thought was happening to him. He expressed concern that he would never feel “normal” again and said that when he drank alcohol, his symptoms and the intensity of his emotions eased. I explained to Jake that PTSD is a severe anxiety disorder that develops after a person has experienced an event that results in psychological trauma. The event may involve the threat or perceived threat of death to oneself or to someone else. I also explained that the disorder is characterized by re-experiencing the traumatic event, including the symptoms of increased arousal, and by the desire to avoid stimuli associated with the trauma. We talked about how his behaviors fit into this cycle of hyperarousal and avoidance, including his lack of sleep and irritability and the isolation and heavy drinking. He talked about always feeling “ready to go.” He said he was exhausted from being always alert and looking for potential problems around him. He told me he always felt on edge and every sound seemed to startle him. He shared that he often thinks about what happened “over there” but tries to push it out of his mind. It is the night that is the worst as he has terrible recurring nightmares of one particular event. He said he wakes up shaking and sweating most nights. He then said drinking was the one thing that seemed to give him a little relief. I gave him a handout on PTSD and reviewed the signs and symptoms. Jake seemed relieved to receive the information. I told him that naming the issue or concern was often helpful in the healing process. During the first few sessions my goal was to help Jake feel safe and validate his feelings. We consistently assessed his feelings of safety, including any potential suicidal ideation. He was reluctant to attend AA at that time, so we began monitoring his drinking and his behaviors after several drinks. Jake began his individual sessions practicing techniques I had shown him to help reduce his anxiety symptoms. We used deep breathing and guided meditation to help him remain calm and in the moment. We started to chart when he had intrusive thoughts about the war, potential triggers to his hyperarousal, and when he tried to dissociate or numb in reaction to these episodes. Jake slowly began to share his experiences while in combat. I helped to gently guide him through the events that seemed to haunt him the most. I explained that telling one’s story in effect helped him “own it,” and in turn it would be integrated into his life on his terms. I told him that the act of telling his story can actually change the processing of the traumatic event in his brain. I was careful through this process not to push him into talking about events that seemed too traumatic for fear of re-traumatizing him. There were many sessions in which he started to share a specific event and then stopped mid-story and had to begin his relaxation exercises. During this time he had also started participating in the veterans’ support group. Jake reported that he was uneasy during the first couple of meetings because he did not know anyone, but that the other vets were supportive. He said it was helpful to hear from others who experienced the same feelings he had since he returned home. He said he no longer felt alone nor did he feel “crazy.” Jake also shared that he had started attending AA meetings. While I did not participate in the couples’ sessions, Jake felt it was important that I hear about how these sessions were going. He told me the social worker at the local mental health clinic helped Sheri understand what he was going through by teaching her about PTSD. The social worker explained how PTSD affected not only the individual, but the whole family and, in turn, the home environment. Jake said Sheri admitted that she did not understand what he was going through but that he was not the same person when he returned home from Iraq, and this scared her. Jake said Sheri seemed to be empathetic toward him and appeared to be relieved when the social worker explained his diagnosis. Jake said he and Sheri worked together to address her main concerns. She felt he drank too much, was not communicating with her, was isolating himself from the family, and appeared to be depressed. She was particularly concerned about his lack of interaction with his sons and lack of interest in the current pregnancy. She worried that he would be uninvolved in caring for this new baby just as he was uninvolved with his boys. Jake shared that in another couples’ session, Sheri talked about wanting to be able to communicate with Jake without feeling that she was “nagging him” or fearful that she was making him withdraw. She said she avoided asking him things or talking to him for fear it would “set him off” and make him retreat to the basement on his own. As it stood, she did not think she could talk with Jake about her concerns. She told him she missed socializing with friends and having family outings and felt isolated. Jake said just keeping his intrusive thoughts at bay took all the energy he could muster, so making small talk with friends was not something he felt he could do right now. Sheri admitted that she did not know that socializing affected him that way. He said the social worker explained that for veterans with PTSD, oftentimes crowds, loud noises, and open spaces triggered intrusive memories and caused anxiety attacks. He said that he and Sheri had developed a plan that would improve their communication. He said they were going to slowly begin planning outings that he felt he could handle, and that they also agreed that if at any time he felt uncomfortable while out that they would leave. Through individual, group, and couples sessions, Jake was able to address his trauma and his PTSD symptoms abated. He realized that drinking was being used as a way to avoid his feelings and attended AA meetings regularly. He has been able to maintain his sobriety and found a sponsor who is also a veteran. Sheri gave birth to a healthy baby boy, and Jake shared pictures of his son. He continues to attend group sessions and has become involved in some mentoring with young vets here at the VA. He feels strongly in giving back and has suggested that the VA begin a program that has been piloted in another state.
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