FOUR BASIC AREAS PSYCHOLOGICAL TREATMENT

APPROACH

  INTERPERSONAL THERAPY MODEL FOR TRAUMA AND LOSS AFTER MACHINE ROLLER ACCIDENT

THE 8TH ANNUAL PAN-AFRICAN PCAF PSYCHOTRAUMA CONFERENCE Immacolata M. Nyaga Clinical Psychologist & PhD Candidate, University of Nairobi Nyaga Counseling Services, Adams Arcade Email: mathiga@yahoo.com  

The reality of loss can be applied to the absence of anything that

is significant or meaningful to our existence. This can include

death of a loved one loss of a job ,loss of a body part that result

from a natural or imposed disaster.

 

INDIOGRAPHIC (PERSONALISED) DIAGNOSTIC

FORMULATION:

MR MOS is a 41 years old male married with three children who

presented with history of pain in a missing part of a limb,

abdominal pain and fear of dying, feeling dizziness, headaches and

fear of losing control with disturbed sleep and night mares. A

diagnosis of post-traumatic stress disorder following an accident

was ruled out.

 

HISTORYOF PRESENTING COMPLAINTS

MR MOS was well until one month after he got an accident in

his place of work when setting a type setting machine roller.

His hand stuck between the roller and was chopped, left

hanging supported by a piece of muscle. This led him to

hospital admission with amputation of the hand on the same

day. Two weeks after discharge from hospital, he reported

experiencing pain in the missing limb in spite of analgesic

drugs he used.  

He had disturbed sleep, un-explained chest pain with fear of

unknown and night mares. On a pastoral visit by his local

parish priest he requested to seek psychological intervention

and was referred to see a psychologist in the parish church.

Interpersonal Therapy model Psychological Treatment for Mr

MOS

IPT is a 12-16 weeks model; it is psychoeducation in nature to some

degree and has three phases. Each phase consists of three sessions.

The psychoeducation employed to MR MOS strictly followed the

four basic interpersonal problem areas of IPT; unresolved grief, role

transitions, interpersonal role dispute, and interpersonal deficits. The

goal of the therapist was to be the patient's ally and help the patient

manage the four basic interpersonal areas for healing to be successful.

 

Structured therapy by use of IPT for Mr MOS

Psychoeducation on description of grief and other emotional and

psychological demands that were causing symptoms were discussed.

These included talking about the loss of the hand, the grief period

and pre and post burial of the part of the hand according to the

patient’s cultural rituals. The therapist and patient attempted to

determine which of the four problems areas was most closely

associated with the onset of the current psychological symptoms. The

therapist explained to the client that he was to adopt a sick role.

The concept of the sick role was based on the notion that illness is

not merely a condition but a social role that affects the attitudes

and behaviors of the client and those around him or her. Over time,

the patient/client realizes that sick role has increasingly come to

govern his or her social interactions. Therapy was organized to

help the client deal with the difficulties in the primary problem

areas by use of the following:

Identification of problem areas

In the earlier session, the therapist and client attempted to

determine which of the four problems was most closely

associated with the onset of the current psychotramatic problem.

The therapist then organized to help the patient deal with the

interpersonal difficulties in the primary problem area by

encouraging the client to discover coping strategies to employ in

daily life in his situation. The patient came up with prayer as

one of the strategy. Muscle relaxation was discussed,taught and

done with the client.

Dealing with unresolved grief

An explanation of grief process was done to help MR MOS to know

what happens when dealing with unresolved grief, understand that

when in normal bereavement the patient may experience symptoms

such as denial and anger that may result to sadness, disturbed sleep

and difficulty functioning. At this time attention was paid to the

patients unique set of psychosocial stressors that were stigma of the

lost hand and effects of dealing with the family members who may

isolate themselves while at the same time dealing with consequences

of the problem.

With the application of IPT, this was expected to resolve in two to

four months. Therapist here is the patients allay and it was

important to observe the patient not to go into delayed grief which

has been postponed and then experienced long after loss, or it could

be distorted grief with no emotional symptoms and is often physical.

If this would have been identified as the primary issue, the therapist

would facilitate the mourning process by helping the client re-

establish interests and relationships that would begin to fill the void

of what had been lost.

Interpersonal role dispute

The therapist explained the client how and why disputes occur.

This will occur if the patient and at least one other significant

person have differing expectations of their relationship. Therefore

both patient and therapist focused on these disputes. The client

was helped to identify the nature of the dispute and decide on the

plan of action. He modified unsatisfying patterns and re-assed

expectations of the relationships. In this session the spouse was

involved for social and moral support during this time that the

client was still grieving the loss.

Interpersonal role transition

Therapist and patient discussed on how grief, loss and

depression associated with role transitions occur when the

patient has difficulty coping with life changes that require new

roles. (For example, Mr MOS’ job had also been terminated)

He was helped to give up old roles and express the

accompanying feelings of guilt, anger and loss for him to

acquire new skills and develop a new social network.eg

learning to use the left hand.

Interpersonal deficits (deficiencies)

The therapist and client reviewed patterns in relationships to try

to and elicit an interpersonal inventory. A review of the patient's

patterns in relationships, capacity for intimacy, and particularly

an evaluation of current relationships was done. The focus for

treatment then emerged from the last. The client had struggle

with a significant other (role dispute with a brother )He had

gone through some negative life change. (Role transition

feelings of uselessness).

Therapist and patient re-assessed expectations of the relationship.

The therapist then linked the target diagnosis to the interpersonal

focus.

For example,

MR MOS “As we have discussed, you are suffering from emotional

and psychological demands that are stressful as a result loss of part

of your limb. This will take a longer term treatment and is not your

fault. From what you have told me, your emotions and psychological

demands seems to be related to what's happening in your life right

now.

You stopped sleeping, and began to feel anxious and depressed after

you were amputated your hand and you have had difficulty in

coming to terms with that terrible re-experienced feelings of the

accident. We call that grief loss related trauma, which is a common,

treatable form of anxiety. I suggest that we spend the next 12 weeks

working on helping you deal with that bereavement. If you can solve

this interpersonal problem, not only will your life be better, but your

discouragement will improve as well as your health. This

formulation defines the need for therapy. The connection between

trauma and the negative emotional feelings is what is causing Post

traumatic stress disorder.

With the patient's agreement on this focus, treatment moved to the

middle phase where other facets of the opening phase included

giving the patient the sick role, a temporary status recognizing that

re-experiencing trauma is keeping the patient from functioning at

full capacity, and setting treatment parameters such as the time limit

and the expectation that therapy focused on recent interpersonal

interactions.

Treatment structuring-Beginning Phase (1-3 sessions)

This required the therapist to identify the target diagnosis of the

patient and the interpersonal context in which it presented. In

diagnosing Post traumatic stress, and other emotional and

psychological demands that were causing symptoms, the

therapist followed DSM-IV and employed severity measures

such as Beck anxiety inventory BAI ) to refer to the problem as

an illness rather than the patient's personal defects. It involved

teaching the client about the nature of his illness and the ways it

manifested in his life and relationship.

The symptoms were reviewed in detail and accurate naming of

the problem was important. The therapist explained the patient

the psychological symptoms and treatment and the need to adopt

the sick role. Mr MOS was explained that the concept of sick role

is based on the notion that illness is not merely a condition but a

social role that affects the attitudes and behaviors of the patient

and those around him. The patient overtime comes to see that the

sick role increasingly govern his social interactions.

Middle phase

The therapist used specific strategies to deal with four potential

problem areas of focus, resolving interpersonal struggle in a role

dispute by helping him mourn the loss of hand, assume a new role

by learning to use the left hand Within this focus, the therapy was

addressed on; (a) The patient's ability to assert his needs and wishes

in interpersonal encounters included going to visit the burial site of

his hand (b) To validate his anger as a normal interpersonal signal

(c) To encourage his efficient expression, and encouraging him to

take appropriate social risks.

Anger management was taught on skills like counting up to a

hundred when someone has angered him to reduce the feelings of

anger and making new friends whom he can interact with freely

when he is angry.

Assertiveness training- Mr MOS was taught on how this will help

him acquire the ability to communicate by expressing his thoughts,

opinions and feelings in a direct and assertive manner. It will help

understand the need to work on the psychological pains he was re-

experiencing from the amputated hand and be able to control his life

by making well informed decisions including positive behavior

change.

Coping strategies; Mr MOS was taught new coping strategies to

employ in daily life. This was tailored to his individual situation.

These included teaching him the ability to build assertiveness, self-

esteem that focus on reducing depressive symptoms to resolve life

problems, and personal vulnerability.

Muscle relaxation. This exercise was a voluntary way of letting go

the tension that is muscular or psychological due to stress from the

trauma that causes the individual feelings of irritability and muscle

clenching.

This was done through deep breathing exercises to help him learn

skills of muscle relaxation in order to release tension in the body

that precipitated anxiety.

TERMINATION WITH GOOD PROGNOSIS

END