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Provision of Mental Health Counseling Services Under Tricare Appendix F Case Summary Illustrating the Complexity of Mental Health Issues in the Military Population Kathryn Basham, PhD, LICSW The committee’s report notes that special challenges are associated with the diagnosis of and treatment for mental health problems in a military population. This case summary illustrates the complexity of intersecting physical, psychological, and psychosocial issues that affect returning service members and their families. Even with sound resilience, many veterans and their families may still face a wide array of covarying diagnoses and other daunting conditions and challenges. Case summaries are used as a teaching tool in clinical practice. This case1 focuses on an identified individual client (patient) but should be viewed in the context of his family and social environment. The content has been constructed as a composite clinical case; it is a fictitious account written for illustrative purposes only. IDENTIFYING INFORMATION Sgt. Carlos Arrozo, a 30-year-old Army veteran, returned from his 12-month tour of duty in Iraq 11 months ago. He worked as a communication specialist in charge of alerting convoys of transports to potential danger. On return to the United States, he received a medical 1 The case was adapted and expanded from a clinical vignette contained in Basham (2009).
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Provision of Mental Health Counseling Services Under Tricare discharge based on his physical injuries and mental health injuries of posttraumatic stress disorder (PTSD) and major depression. He suffered second-degree and third-degree burns and a broken pelvis as a result of an improvised explosive device (IED) blast that killed two of his fellow soldiers. Sgt. Arrozo lives with his 29-year-old wife of 10 years and his three young children—7, 5, and 2 years old—in a small city in North Carolina. After completing his high-school education focused on technical training, he enlisted in the Army, where he has served for the last 10 years. The family has a middle-income socioeconomic status. Maria Arrozo typically works on a part-time basis as a physical therapist. Both partners and their children are bilingual and speak Spanish and English interchangeably at home. The parents and children rely on their Catholic spiritual community as a source of hope, healing, and social support. PRESENTING ISSUES Individual In the last two months, Sgt. Arrozo described pervasive anxiety, insomnia, nightmares, a fear of crowds, and flashbacks. One flashback occurred while he was driving with his wife to the grocery store. As they drove along a major highway in the middle lane, Sgt. Arrozo maintained his 60-mph speed until he saw a young adolescent boy leaning over the edge of a bridge that traversed the highway just 30 ft ahead. Knowing that the only thing he could do was continue forward, Sgt. Arrozo started to hyperventilate, sweat profusely, and increase his speed on the highway from 60 to 70 to 80 to 90 mph as he screamed to Maria to duck and take cover under the dashboard. As they sped frantically beneath the bridge, Maria screamed out in terror for Carlos to stop the car. Neither of them understood that this flashback was triggered by odors of gasoline and burning rubber, which were reminiscent of a traumatic incident involving a burning truck in Iraq. He fears remaining jobless and incapable of locating work in his field of communication. Worries about the possibility of a divorce from his wife plague him regularly. Sgt. Arrozo also struggles with obsessional thoughts related to his guilt of surviving an IED blast that killed his fellow soldiers. He feels “dead to the world and deserving of death.” Deep feelings of shame overwhelm him as he recalls “accidentally killing a helpless young child”
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Provision of Mental Health Counseling Services Under Tricare in the course of the melee after an explosion. He suffers headaches, irritability, poor attention span, and poor concentration. Four months ago, he cried when his daughter Ana screamed hysterically after his futile attempt to pick her up to kiss her hello. He has not cried since. Every few hours, he experiences uncomfortable tingling and pain surrounding the newly grafted skin on his neck and arms. Although previously an avid reader, Sgt. Arrozo cannot sit still to read or concentrate for more than 2 minutes. Most of the time, he feels alternately “tense, nauseated, agitated, irritable, enraged, and numb.” He has trouble falling asleep, awakens fitfully throughout the night, and suffers nightmares and grogginess in the morning. He drinks eight beers with his buddies four or five times a week but is unconcerned about his alcohol intake. Family Psychosocial Issues His wife, Maria, reported intense fear of her husband’s “rage storms,” describing him as “worked up, very loud, accusatory, and threatening to destroy everything in the house.” She has warned him that if he fails to seek help, she will leave him and take the children to another state, and she has done that at least twice in the last 2 months. She has been experiencing insomnia, emotional volatility, and pervasive anxiety. The second-grade school teacher called the Arrozos about 7-year-old Antonio, who has started to talk back to the teacher and bully two of the smaller, quiet children in class. Delia, 5 years old, refuses to attend school and has started to wet her bed in recent weeks; Ana, 2 years old, alternates between playing joyfully and clinging anxiously to her mother’s legs when her father enters the room. Developmental History Developmental milestones appear to have been met adequately with no indication of childhood neglect or abuse. Elements of competence and resilience are noted in Sgt. Arrozo’s academic success, diverse network of friends, and athletic prowess developed throughout his childhood and adult years. When Sgt. Arrozo turned 8 years old, his beloved mother died of ovarian cancer. The family arranged for a very hasty funeral and had little opportunity to share their mourning. Since her death, Sgt. Arrozo has seldom cried in response to his loss.
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Provision of Mental Health Counseling Services Under Tricare Shortly afterward his mother’s death, his father married a woman who did not assume an active step-mothering role, and this contributed to Sgt. Arrozo’s sadness and deep sense of abandonment. Early on, he coped with his losses through sublimation in relation to his studies and athletics. Although he and his immediate family live several hundred miles away from his father and siblings, he maintains regular contact with them by telephone and e-mail. He also communicates regularly with his extended family in Puerto Rico. Family History Reared in Puerto Rico until the age of 6 years, Sgt. Arrozo moved with his parents and four siblings to the mainland in time for him to start elementary school. Although many Puerto Rican families lived in their community in the southeastern United States and provided strong social support, Sgt. Arrozo’s family suffered discrimination and financial hardship. His wife, Maria, was the eldest of four children of parents who moved from Puerto Rico during their childhood years. They lived in an affluent urban community in the Northeast, where she and her siblings pursued college educations. The two families share the importance of sustaining family connections, valuing education and productivity and emphasizing the well-being of children. Mental Status in Process Sgt. Arrozo appears to be fit and muscular, and he walks quickly and stiffly. His posture is noticeably rigid and upright in contrast with his casual, although clean and tidy, clothing that conceals any signs of the scarring covering his neck and arms. He is fluent in English and Spanish and speaks in a clear, coherent, and logical manner. Labile affect ranges from anxiety to sadness, despondency, irritation, agitation, and rage—all revealed in the course of 30-minute period. There is no evidence of hallucinations, delusions, or other symptoms related to psychosis. BIOPSYCHOSOCIAL ASSESSMENT Sgt. Arrozo struggled with a complex set of physical, psychological, and psychosocial issues, which both influenced and were affected
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Provision of Mental Health Counseling Services Under Tricare by interactions with his wife and family. Although they interrelate in a reciprocal manner, I will differentiate the various diagnoses and conditions of concern. First, in the physical “bio” realm, he suffered pain and tingling in the aftermath of his treatment for second-degree burns. Insomnia persisted with pain and stiffness related to his healing pelvis. His expressions of irritability, headaches, and difficulties with balance, memory, and concentration are associated with the mild traumatic brain injury (TBI) that he sustained during an IED blast. This assessment was concluded 6 months after the start of treatment. Symptoms of irritability, poor memory, limited concentration, and emotional lability are also suggestive of alcohol abuse. Sgt. Arrozo meets the criteria of the Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR) for substance abuse with failure to fulfill home and work obligations within the preceding year. Insomnia may be related to depression, pain, or substance abuse. Second, in the realm of mental health “psycho” challenges, Sgt. Arrozo meets the criteria of major depression: depressed mood and markedly diminished interest in most activities, insomnia, psychomotor agitation, fatigue, inappropriate guilt, and diminished concentration. In addition to those symptoms of clinical depression, Sgt. Arrozo has suffered traumatic grief in response to the loss of his two beloved buddies during an IED blast. Because his job involves detection of potential hazards, he assumed major responsibility for the deaths of his friends. Compounding his profound grief and loss was the plaguing awareness that he had killed a young child during the melee that followed the same IED blast. He could not forgive himself and suffered profound guilt. Earlier unresolved grief related to the premature loss of his mother to cancer was reactivated after the untimely, traumatic deaths of his buddies and the Iraqi child. Sgt. Arrozo also meets the criteria for PTSD with a full array of presenting issues related to the three clusters of re-experiencing (e.g., nightmares and flashbacks), avoidance (e.g., distancing from driving and shopping centers, detachment from children, and retreat from family), and hyperarousal (e.g., emotional lability, rage storms, and irritability). Third, in the “social” or “psychosocial” realm, Sgt. Arrozo faces imminent divorce while he and his wife struggle bitterly with poor communication, destructive verbal exchanges, and impulsive, rageful outbursts alternating with distancing and detachment. Each of the chil-
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Provision of Mental Health Counseling Services Under Tricare dren is expressing emotional distress. Seven-year-old Antonio may be carrying some unresolved intergenerational grief projected by his father, who at the same age lost his mother to death from ovarian cancer. Like many children who suffer anxiety and depression, they express their feelings behaviorally through aggressive bullying and negativity. Delia may also be responding to the forces of secondary trauma that affect family members who live with a traumatized person. Her heightened anxiety, evidenced by her fears of separating to attend school, mirrors Sgt. Arrozo’s intense fears engendered by the presence of her loud and agitated father. Sgt. Arrozo also worries about securing employment; in the meantime, the family suffers both financially and psychologically from accumulated stress. DSM-IV-TR DIAGNOSES Axis I Posttraumatic stress disorder Major depressive disorder Substance abuse—alcohol Axis II Deferred Axis III Mild traumatic brain injury, skin grafts on neck and arms after second-degree and third-degree burns, healing from broken pelvis Axis IV Severe stressors: deaths of his two combat buddies, marital separations and anticipated divorce, joblessness, financial pressures, distress for wife and children Axis V Poor level of functioning (GAF score: 40) evidenced by disruptions in his physical and mental health, marriage, parenting, relationships with friends and family, job seeking
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Provision of Mental Health Counseling Services Under Tricare TREATMENT PLAN Part I When Sgt. Arrozo agreed to seek mental health assistance, his wife, Maria, telephoned to access a mental health provider authorized by TRICARE. After receiving the name of a licensed nonmedical mental health clinician, Sgt. Arrozo was invited to attend an individual session to embark on an assessment. After a 1-hour meeting, the preliminary diagnosis of PTSD and depression was established on the basis of his medical discharge. To help Sgt. Arrozo to experience rapid relief from his combat-related psychological injuries, the clinician referred him to a colleague for prolonged exposure therapy. Goals of that therapy included reduction in nightmares, reduction in flashbacks, and increased capacity to drive and shop. The clinician also recommended 1 hour of individual psychotherapy each week to address the symptoms of depression. The treatment plan included psychoeducation related to PTSD and depression and the use of cognitive–behavioral therapy (CBT) skills to track depressed moods and challenge faulty attributions through journaling. Treatment goals included reduction in negative self-attributions and increased recognition of PTSD-related symptoms and behaviors. Although his general practitioner had prescribed Zoloft to address symptoms of PTSD and depression, the mental health clinician never sought consultation or collaboration with that physician. Sgt. Arrozo could not concentrate on his daily writing assignments and felt ashamed of his incapacity to improve. After 3 weeks of the combined treatment, flooding of emotions overwhelmed Sgt. Arrozo, and he decompensated, reporting intense suicidal thoughts several times throughout the day. He terminated his therapy. Clinical Impasse Was Sgt. Arrozo a failure, or were there unintended iatrogenic effects related to the absence of a thorough biopsychosocial assessment and differential diagnosis? Was there a failure on the part of the clinician to attend to the totality of this veteran’s struggles in addition to exploring his resilience in his social context? Apparently, his undiagnosed mild TBI interfered with his benefiting from a cognitive-behavioral method that requires reasonably sound cognitive functioning. Ignoring the presence
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Provision of Mental Health Counseling Services Under Tricare of an alcohol-abuse problem prevented the clinician and Sgt. Arrozo from addressing the adverse effects of alcohol on his overall functioning. Did the PTSD-related issues of sleep disturbance, irritability, and hyperarousal also mimic symptoms that are associated with alcohol abuse? How did his alcohol intake interact with the use of an antidepressant and pain medication? Did it negate potential positive effects? Was the pharmacologic intervention the most effective plan, given the complexity of his conditions? While ignoring cultural responsiveness, did the clinician explore the sociocultural meanings and stigma related to mental health problems for Sgt. Arrozo and his wife? Was consideration given to assessing social and community supports (e.g., extended family, church, work colleagues, and friendship network) to facilitate the family’s engagement in an effective treatment plan? Finally, the absence of attunement to the volatile relationship between the marital partners and between the parents and the children set the stage for increasing decompensation and further destabilization. Was a risk assessment completed? Are there aspects of intimate-partner violence that are concealed? Are Sgt. Arrozo, Delia, and Ana expressing symptoms of secondary trauma evidenced by signs of heightened insecurity, anxiety, and aggression? Part II After Sgt. Arrozo ended his treatment precipitously, he felt very wary of any potential usefulness of mental health treatment. Yet, when each of his children’s teachers called to express serious concerns about their emotional well-being, Sgt. Arrozo and his wife registered alarm and decided to work with another mental health professional. Once again, they pursued a referral recommended by TRICARE. This time, a female nonmedical licensed mental health clinician responded to Sgt. Arrozo and invited him to participate in a consultation session to discuss possible next steps. Although reluctant, Sgt. Arrozo was reassured to hear that he had not failed in his treatment. Instead, this clinician needed to explore a full biopsychosocial assessment that addressed many of his life challenges and supports. Collaborative consultative relationships and carefully selected referrals were initiated with a network of providers, including a general practitioner, a psychiatrist, a vocational counselor, a rehabilitation counselor, school counselors for the children, a couple/family therapist,
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Provision of Mental Health Counseling Services Under Tricare and a support group facilitated by combat veterans. A phase-oriented trauma-based treatment plan was instituted in the first session that, early on, attended to issues of safety, stabilization, self-care, and establishing a context for change. Clinical case management emerged as a primary modality during this period of crisis as the clinician established a treatment plan involving a deftly coordinated and collaborative treatment plan. Individual supportive psychotherapy was offered to Sgt. Arrozo to explore the most effective ways to establish his self-care (vis-à-vis his symptoms of PTSD, depression, and substance abuse) and to restore connections with his family and his faith-based community. Motivational interviewing was introduced to engage Sgt. Arrozo in discussions that focused on the role that alcohol played in his life. Treatment goals included demonstrating skills to reduce stress and anger, demonstrating skills in tolerating distress, applying stress reduction and relaxation techniques, communicating directly with his wife and children, recognizing feeling states that are associated with a traumatic stress response, recognizing the effects of alcohol on his daily functioning, developing a plan to work with a rehabilitation counselor in relation to his TBI. Within 4 months, progress toward all those goals was noted. Only when safety had been established, both individually and in the marital relationship, could Sgt. Arrozo engage with cognitive processing treatment, which allowed him to address the legacies of his combat trauma experiences in a titrated, balanced manner. That led to his greater understanding of the after-effects of combat trauma and how attachments and relationships can be dismantled by wartime combat. As he slowly reestablished his trust in his relationships with his wife and children, he recognized how a solid base of family and emotional support proved essential as well. Couple therapy focused on enhancing communication, addressing power differentials and shifting coparenting roles, and finally minimizing the potential for intimate-partner violence. With a more secure base, he started to address his profound grief associated with the losses of his buddies, the Iraqi child, and his mother. With a stronger scaffolding of coping measures in place, Sgt. Arrozo was able to bear the intensity of his mourning. As he discussed his experience of profound guilt, the clinician and Sgt. Arrozo explored his lapsed faith and a cultural belief that his warrior behavior represented a betrayal to family and community. With those complex issues openly addressed, Sgt. Arrozo gradually reported relief from deep sadness and pessimism while developing a more textured understanding of his combat role.
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Provision of Mental Health Counseling Services Under Tricare In summary, this sample treatment case reveals both the depth of pain suffered by Sgt. Arrozo and his family and their distinct resilience that enabled them to thrive and reclaim healthy, more positive and productive lives together. Such progress is noteworthy and can serve as an exemplar for many other veterans and their families who need and deserve high-quality mental health care. Although the first treatment plan missed important dimensions of Sgt. Arrozo’s presenting issues, the second course of treatment proved far more successful. That phase-oriented treatment plan stressed attunement to the therapeutic alliance, cultural responsiveness, knowledge and skills based on relevant evidence-based practice models, continuing collaboration and consultation, and flexibility to assess and treat a complex, multidimensioned set of conditions and challenges. To promote similar favorable outcomes in practice with service members and their families, each clinician needs to be prepared with satisfactory education from an accredited academic institution, ample supervised clinical experience with a broad array of clients, and certification, licensure, and privileging within a scope of practice. Given the serious adverse consequences of failed treatment, we must be vigilant in our evaluations of potential mental health clinicians. REFERENCE Basham K. 2009. Commentary on the keynote lecture presented by Dr. Jonathan Shay, Friday, June 27, 2008, titled “The trials of homecoming: Odysseus returns from Iraq/Afghanistan, and additional reflections.” Smith College Studies in Social Work 79(3&4):299-309.