Intervention Plan for Carlos

The foremost component of an informal evaluation of traumatized individuals entails semi-structured interviewing, in which the following details of the patient ought to be garnered:

• Demographic facts

• Employment history

• Medical history

• Educational history

• Social history and • Several specific facts.

Such an interview must be closely founded on minor and major trauma disorder facets (James, 2008). Particular questions to be posed to Carlos are linked to:

• Trauma nature and level of exposure

• Definite trauma integral to PTS (post-traumatic stress) symptoms

• Intrusive thoughts, recollections, emotions, imagery, responsiveness/awareness freezing, avoidance response and other similar symptoms

• Related elements of anxiety, depression, drug/alcohol abuse, anger or violent behavior

• Pre-morbid family and social life, and adjustment

• Familial history of psychological ailments. Essentially, therapists must seek comprehensive information on individual PTS symptomatology elements, identifying the nature, seriousness, content, rate, concise explanation and duration of symptoms.

The above-mentioned evaluation method is crucial as the information procured via interviewing of patients may be utilized as the base of client diagnosis and examination. With increased knowledge of Carlos's particular symptoms, PTSD (post-traumatic stress disorder) path and subtypes, the assessor's likelihood of validly and correctly assessing the ailment increases. Such a fundamental system may be implemented for individual kinds of traumatic stressors and distinct reactions. Further, one can extend it to encompass more in-depth information and secondary aspects (Peterson, Prout & Schwarz, 1991).

Trauma and trauma-inducing event-connected questions are vital to pose before clients from evaluation as well as intervention perspectives. Key questions to be posed to Carlos include:

Which life experience of yours would you deem as most traumatic?

How did this experience affect your life?

Did you believe, for any period of time in the course of such an experience, that your life or safety was seriously in jeopardy (i.e., that you would be physically harmed or killed)? What are your thoughts and feelings with regard to that particular experience? (Peterson, Prout & Schwarz, 1991)

Have you ever experienced an excessively disturbing, terrifying or awful situation in the course of your life, because of which, within the course of the last month, you:

• Always remained alert, vigilant, cautious or quick-to-startle?

• Had nightmares or unwelcome recollections of the incident?

• Experienced numbness or detachment from your surroundings, other people or activities?

• Strove hard to ensure thoughts about the incident don't enter your mind or evaded scenarios which call to mind the incident? (Wallace & Cooper, 2015).

The above questions are highly generic, but effectively assume that an individual has experienced some traumatic event in life and urge him/her to identify the worst. For answering the above questions, the patient (in this case, Carlos) needs to undertake a comparison and contrast of several distressing scenarios he has faced, which will potentially glean various associations. It is vital to pose such questions as the one aspect with the highest correlation to trauma is victims' cognitive assessment that their life or personal physical wellbeing was gravely jeopardized. Hence, the significance of the question pertaining to whether the victim sensed a likelihood of being killed or physically injured (Peterson, Prout & Schwarz, 1991).

In spite of such questions' significance, therapists need to carefully seek details on traumatic events from clients. It is a common, wrong assumption made by professionals and non-professionals alike that evaluation of a patient's trauma history entails an indifferent attempt at bringing to the surface detailed memories of possible traumatic events. Therefore, prior to interviewing the client (in this case, Carlos), he ought to explicitly know that there is no compulsion on him to reveal facts too uncomfortable or distressing to reveal. Therapists must ensure they don't use complex academic jargon or colloquial language, which might cause anxiety in the patient or cause him to interpret it differently. Further, he must be therapeutically guided when revealing possibly traumatic experiences to ensure the assessment process doesn't end up leaving him mentally overwhelmed or pressurized or stigmatized (Rosen & Freuh, 2010).

Formal evaluation of Carlos's mental health status within the assessment process to establish whether or not he has PTSD entails a standard procedure, which involves interviewing the patient on: orientation, motor functioning, sensory experiences, mathematical ability, moods and feelings, delusional behavior, judgment, proverbs, spatial-visual abilities and visual and aural memory. The facts gathered in mental wellbeing assessments usually offer key, relevant details connected with the patient's cognitive functioning (Peterson, Prout & Schwarz, 1991).

Formal Assessment Measures of Post-Traumatic Stress

Clinicians may employ the following formal PTSD evaluation measures:

• Structured SCID-IV/ DSM-IV Clinical Interviews. SCID's PTSD module (Spitzer, Gibbon, & Williams, 1996) represents the most frequently employed clinical interview for various types of trauma patients.

• IES or Impact of Event Scale is a fifteen-item scale that may be utilized for indexing avoidance and intrusive signs as well, in acute PTSD patients. This tool has strong psychometric properties and correlates with PTSD (Zilberg, Weiss, & Horowitz, 1982).

Any facts that were ignored or went unnoticed in the mental status assessment and structured interview stages may be garnered through formal assessments. Numerous formal assessments for trauma-connected ailments are available (Bryant & Harvey, 2000)

Clinicians and researchers are increasingly focusing on psychophysiological measures for complementing psychometric instruments and clinical interviews when assessing trauma patients. Key psychophysiological indices include blood pressure, heart rate, muscle tension, peripheral temperature, and skin conductance response and level. This evaluation technique proves beneficial, owing to its lower likelihood of response bias as well as its ability to identify processes potentially unidentifiable using other methods. A majority of PTSD related research works have indexed numerous psychophysiological activities as a reaction to trauma signs. Researchers concur with the fact that such reactions can help distinguish between traumatized and non-traumatized patients (Bryant & Harvey, 2000)

Current Issues Faced by Client- A Provisional Diagnosis

The patient, Carlos, is, at present, undergoing behavioral and emotional disturbances, owing to the traumatic abuse incident he was subjected to yet uncommon in his everyday life. He experiences apprehension, worry, edginess, and dread. He is constantly uneasy and expects something worse to happen to him since he was unable to identify his abuser for detention and the man still runs free. He suffers from crying spells, eye-contact difficulties, trembling hands, severe hyper-vigilance, and physiological arousal. He also exhibits withdrawal and avoidance signs, as evidenced by his statement that he is mortified to have been found in such a state by his parents and has taken to avoiding their company. It is possible that intrusive recollections of the incident frequent his mind as well. The above symptoms and the injury he sustained at the hands of the abuser are hindering his professional life as well (Dattilio & Freeman, 2000). Bearing in mind the above client history and symptomatology, a provisional PTSD diagnosis (referring to the DSM V) may be made (American Psychiatric Association, 2013). PTSD is marked by behavioral and psychological signs brought on by sexual abuse, near-death experiences or severe injuries. Carlos's symptoms resemble PTSD's DSM-V conditions:

• Experiencing traumatic stressors (condition A)

• Emergence of a distinct condition entailing reliving, numbness, hyper-arousal and avoidance symptoms (conditions B. to D)

• Duration of no less than 30 days (condition E)

• Clinically significant professional/social functioning impairment or difficulties (condition F).

But comprehensive patient evaluation is necessary for complete diagnostic confirmation.

Multidisciplinary Referrals for Client

Individuals often experience trauma both mentally and physically. It is a very effective idea to treat the body combined with psychotherapy. Hence, multidisciplinary PTSD treatment strategies are recommended. Educating traumatized individuals on fear psychobiology and natural ways to decrease stress proves beneficial as well. PTSD surfaces in individuals who are physically, psychologically and mentally overcome by feelings of dread, which are manifested and experienced in their body. The human mind cannot process chronic dread and ends up thinking irrationally. Such a state renders the individual's social, physical and professional functioning unfeasible. Carlos will have higher chances at a smooth, swift and complete recovery if his mind as well as body gets treated. This multidisciplinary PTSD treatment plan can drastically reduce symptoms and psychiatric drug consumption necessity. It is also promising in that it may accelerate healing and typically does away with the need to refer the patient for other psychosocial or psychological services (e.g., constant case management). The multidisciplinary evaluation will ideally incorporate psychologists, counselors, social workers, occupational therapists and nurses (Wallace & Cooper, 2015 Hence, in Carlos's case, certain multidisciplinary referrals would prove highly effectual in satisfying client requirements, including:

• Identification of a PTSD-trained mental healthcare professional capable of offering consultation, guidance, diagnostic and educational services, which is the foremost step. PTSD therapists may belong to diverse disciplinary backgrounds such as trauma therapy, clinical psychology, eidetic imagery and hypnotherapy.

• Second-line non-trauma-centered psychotherapy may prove useful. This includes stress inoculation instruction and guidance by the therapist to decrease patient stress.

• Drug therapy referrals to psychiatrists if the patient shows a reluctance or inability to participate in psychotherapy. Based on comprehensive evaluation, if the patient suffers from an acute comorbid disorder or related symptoms (say, acute depression), psychological techniques may not suffice in tackling patient distress or the patient may not adequately respond to only psychotherapy.

• Referring the patient (Carlos) to an expert to get his nerve injury treated since it's hampering his functioning at the workplace.

• Self-help and support entities can also aid the PTSD patient in enhancing his coping abilities, developing positive self-image, and honing his problem-solving abilities (Puleo & McGlothlin, 2014).

The following triple-therapy intervention plan has been recommended for Carlos:

Eye Movement Desensitization Reprocessing (EMDR)

This represents a type of psychotherapy which encompasses exposure-centered treatment (with several sporadic fleeting exposures to trauma-inducing matter), voicing and recollection of trauma-causing incident(s) and eye movement. Hence, it integrates a number of theoretic methods and approaches such as cognitive behavioral therapy (CBT) (American Psychiatric Association, 2010). EMDR attempts at transforming the earlier-distressing recollections and associated bad cognitions linked to a trauma situation into more pragmatic views of self and connected trauma experiences. But, just as in the case of hypnosis, the patient (Carlos) needs to know, prior to EMDR commencement, that this technique will probably render trauma-related facts they reminisce unacceptable as legal proofs at court.

EMDR's complete treatment protocol encompasses the following eight key steps or elements (Hillman, 2002):

1. Trauma history

2. Planning and preparedness

3. Negative cognition evaluation

4. Patient desensitization

5. Positive cognition development

6. Body Scan / Examination

7. Closure and

8. Reassessment

The foremost treatment element constitutes the preliminary therapeutic phases and the commencement of a therapeutic relationship. The next phase informs the patient about the EMDR process and seeks his assent. For preparing for strong emotional reactions on the patient's part, counselors must improve on patients' ego strengths via particular relaxation exercises, a review of reasonable expectations, and the cultivation of feelings of safety using mental imagery.

The third phase involves patient-counselor collaboration to ascertain the former's distinctive negative cognitions, feelings, sensations and emotions linked to a given traumatic experience (for instance, I have visions or dream of the perpetrator raising his knife on me) and associated negative thoughts (like, I'm a broken, pathetic individual who is unable to stand up to the terrifying thoughts plaguing my mind). Patient rating of the stressfulness of that memory will be sought, in addition to how realistic he perceives a more positive, impartial cognition is (say, I'm a strong individual irrespective of my response to the attack at the time; I at least did my best to ward him off). Also, sought will be patient rating of how far he has faith in a better cognition. The subsequent step entails the commencement of a range of eye movement exercises, with the patient made to recollect distressing memories or images whilst rapidly or "saccadically" moving his eyes. At different time periods, he will be made to pause and relate his experience. The typical experience reported is a reduction in their subjective distress, together with appreciable alterations in their views as against recollection of the incident. Step five entails more eye movement for replacing negative cognitions with positive ones. The client will be made to internally scan or assess his physical strain or tension in stage 6, followed by subsequent tackling using yet more saccades. A key point to remember is that EMDR is an active process that dynamically aims at exploring patients' aural, visual, physical, kinesthetic and olfactory associations with trauma events (Hillman, 2002).

Step 7, wherein certain closure is attained during the therapeutic session, is frequently not focused on by the media. Counselors appraise patients carefully to make sure they don't quit a session during a powerful abreaction. The process involves debriefing and repetition of the possibility of key matter coming to the surface during sessions. The patient (Carlos) will be required to maintain a log/journal for such emerging issues, to process and deliberate on in subsequent sessions. The protocol's last phase involves reassessment of the patient for symptom relief sustenance in an organized set of follow-ups (Hillman, 2002).

This is regarded as the ideal approach to PTSD treatment. In CBT, imaginal as well as in vivo exposure and cognitive reorganization (exploring and tackling dysfunctional feelings and thinking) prove to be the most salient features after anxiety management and psycho-education breathing retraining or muscle relaxation). The patient will be subject to strict, structured therapy devised by Creamer and colleagues (2005) whose basis was that therapists, psychologists and psychiatrists need to proficiently employ exposure, especially imaginal exposure.

Protocol of Trauma-focused CBT

Early on, the sessions (1-hour duration) will focus on forging a client-counselor relationship, client education, and relaxation skill development. Anxiety management tactics may also be addressed, including physical (for instance, breathing control, aerobics, relaxation strategies, reduced stimulant (nicotine, caffeine, etc.) consumption, etc.), behavioral (dealing with related issues like communication difficulties, insomnia and sleep disruptions, assertion, etc.) and cognitive (imagery, distraction strategies, etc.) interventions. It isn't compulsory to offer every strategy; the therapist must attempt to personalize it for the client. Further, the client will be provided a theoretical reason behind conducting exposure-centered therapy, which will be reiterated throughout treatment. Moreover, the SUDS (Subjective Units of Distress Score) principle, a 100-point rating system (0=no anxiety; 100 = excessive anxiety), will also be introduced and exposure targets defined.

Subsequent sessions will involve imaginal exposure, a process in which the patient (Carlos) will restate his traumatic incident comprehensively, followed by SUDS recording and "hot spot" identification, until anxiety reduces. Exposure sessions may be supplemented with cognitive restructuring, with an emphasis on identification, challenging and replacement of maladaptive trauma-connected beliefs and thoughts. Exposure sessions' number (duration= 1.5 hours) will be dependent on how severe the patient's distress is and the attainment of the goal of reduced anxiety. Homework tasks include the practicing of breathing or muscle relaxation techniques, and in vivo (dealing with dreaded though safe scenarios) and imaginal (everyday listening of an audio taped account of the incident) exposure. Therapy progress will ultimately be assessed and relapse avoidance ensured, followed by a review of therapeutic methods, assessment of their applicability/appropriateness and discussion of general termination matters (Polak et al., 2012).

Exposure Therapy

PTSD therapy should trigger or release processes which are natural to a smooth recovery. Prolonged PTSD-linked exposure (Foa, Hembree, & Rothbaum, 2007) functions via fear structure activation based on purposeful in vivo and imaginal trauma exposure (connected scenarios, thinking, imagery, etc.). Such exposure holds facts to modify negative patient self-perceptions and views of the world. Within PTSD-related exposure, facing or challenging traumatic recollection averts negative behavioral and cognitive avoidance reinforcement, decreasing a key PTSD-maintenance factor.

In vivo and imaginal exposure for PTSD treatment will aid the patient (Carlos) in distinguishing the traumatic situation from similar, but harmless scenarios, places or activities which may bring back recollections of the incident. This will enable him to perceive the particular bad incident as unique, thereby assisting him in countering the idea that he is feeble, vulnerable, inept or pathetic and that his surrounding world is completely dangerous (Rosen & Freuh, 2010).

Process of Exposure Therapy

The very first session will involve the counselor detailing the reason behind undertaking exposure therapy as well as the fact that there are a couple of chief factors maintaining PTSD; firstly, the avoidance of trauma-connected imagery, thoughts and trauma reminders. The counselor will also let the patient know that while avoidance successfully decreases short-term anxiety, PTSD persists as the patient is devoid of opportunities to mentally process and assimilate the traumatic memories. The other factor is: frequently mistaken and unsupportive beliefs which surface after the incident. A large number of trauma victims, for instance, mistakenly believe the whole world to be tremendously dangerous and themselves to be totally inept. Hence, exposure therapy attempts at changing wrong beliefs by allowing the patient (Carlos, in this instance) to acquire corrective knowledge disproving such beliefs through exposure or experiential learning. Also, incorporated into the foremost session is deep-breathing relaxation exercises prescribed as everyday homework for the patient.

The next session encompasses detailed discussion of the most widely witnessed trauma responses that facilitate patient understanding of his symptoms. In specific, examining common responses may assist Carlos with the realization that the condition is identified as PTSD, which the counselor knows how to cure, and that exposure therapy will help eliminate his symptoms.

Session three will involve therapist presentation of a comprehensive rationale behind imaginal exposure, followed by devoting about 45 minutes of that session to imaginal exposure, followed instantly by around fifteen minutes of a process known as after-exposure 'processing'. This involves discussing patient experiences in the course of imaginal exposure as well as a subsequent focus on lessons gleaned from this experience. The same standard procedure will be followed in the remaining sessions (4 -- 10), commencing with a review of the homework for the previous week.

In the last therapeutic session, patient progress will be evaluated, lessons learned discussed and a plan developed to ensure the patient maintains the gains he made in the course of therapy (McLean & Foa, 2011).