The Trauma of Uncertainty

Abstract

In the presented case, “Daryl” experienced 12 hr of uncertainty regarding the safety of a friend before learning the friend was killed during the April 16th shootings at Virginia Tech. Treatment began 4 years following the shootings. Daryl has two previous premature terminations, was treatment resistant, and at high risk for dropping out. Prolonged exposure (PE) was postponed for nine sessions while comprehensive assessment and psychoeducation occurred. PE took place over 15 sessions, with follow-ups occurring at 3, 6, and 12 months following treatment. During PE, a second shooting and accompanying deteriorating sleep led to brief pauses and modification of treatment. Daryl showed marked reduction of posttraumatic stress disorder (PTSD) symptoms throughout the course of treatment, resulting in complete remission of PTSD at the end of formal treatment as he maintained gains during follow-ups. The case study demonstrates the usefulness of symptom monitoring, specific modifications used within treatment, and the importance of assessing for preparedness for treatment.

Keywords

PTSD prolonged exposure indirect exposure mass shooting

1 Theoretical and Research Basis

In the acute aftermath of the April 16th shootings, a number of adaptive recovery efforts were initiated, as described in previous reports (e.g., Jones, Donlon, Dugan Burns, Schwartz-Goel, & Law, 2012). In addition, Psychological First Aid was offered to the Virginia Tech community, while The American Red Cross dispatched dozens of crisis counselors. Virginia Tech counselors and psychologists offered services as well. Yet, despite these efforts, only 10% of those affected by April 16th sought some type of therapy or professional counseling (Hughes et al., 2011). A question often asked following traumatic events is why do so few individuals seek out treatment. It is a well-known fact that the use of mental health services is strikingly low following large scale displacement or gross destruction of infrastructure (Boscarino, Galea, Ahern, Resnick, & Vlahov, 2002). For instance, only 11.3% of individuals with a mental disorder obtained psychiatric assistance following the terrorist attacks in New York on 9/11 (DeLisi et al., 2003). Of those directly affected, only 15% sought out mental health assistance within a 6-month period post disaster (Stuber, Galea, Boscarino, & Schlesinger, 2006).

Many college students in need do not seek professional psychological assistance despite the presentation of significant impairment (Vogel, Gentile, & Kaplan, 2008). Fear of treatment (Kushner & Sher, 1989), desire to avoid discussing troubling or traumatic information (Vogel & Wester, 2003), avoidance of experiencing painful feelings (Komiya, Good, & Sherrod, 2000), and desire to avoid social stigmatization (Deane & Chamberlain, 1994) may reduce treatment seeking and negatively affect one’s expectations from therapy.

Among those who do seek treatment, premature termination rates are regrettably high (30% to 60% of all clients drop out of treatment prematurely; Swift & Greenberg, 2012). One common explanation for premature termination is that the benefit of treatment no longer outweighed the risk/cost. The challenge becomes delivering effective treatment while being sensitive to the balance between cost and benefit for the client. In addition, Flanagan, Miller, and Davidson (2009) found that “treating the chart” and a lack of personal information outside of the diagnosis are primary sources to stigma and early termination in mental health settings. This becomes particularly difficult in the treatment of posttraumatic stress disorder (PTSD). Exposure-based therapies, such as prolonged exposure (PE; Foa, Hembree, & Rothbaum, 2007), have a wealth of evidence base, as well as a substantial number of individuals who drop out. At approximately 20.5% to 32% (Hembree et al., 2003), the risk of premature termination is high in this difficult, but highly effective, treatment.

Comprehensive Assessment and the Effort Justification Hypothesis

Given what is known about hesitance on the part of the client to seek treatment, the likelihood of early termination, and the delicacy of balancing the cost and benefit of treatment, what is the best way to approach treatment? The logical approach would be to lower the risk of treatment by avoiding difficult topics, traumatic reminders, and facilitating a positive sentiment toward therapy. This is counterintuitive to the mechanisms of change shown to work within PE (an exposure base, direct treatment). There is, however, a way to reduce the risk of therapy (at least early on) while still increasing commitment and motivation.

The effort justification hypothesis, derived from cognitive dissonance theory, states that people tend to attribute a greater value to an outcome that they have put forth effort into acquiring. In the context of therapy, if a client is putting forth a high level of effort within therapy, a state of dissonance may arise between their exerted effort and their attitude toward the outcome (the benefit of therapy). To reduce that dissonance, the client attempts to justify the effort being expended through a number of routes: attitude changes through therapy, enhanced motivation to change, or coming to believe that therapy has a greater likelihood of success. They ask themselves, “why am I putting myself through this effort? It must be because I really want to improve.” This principle, coupled with other theoretically based considerations, was applied in the presented case.

2 Case Introduction

“Daryl” was a 24-year-old Caucasian male who was self-referred to a community clinic with problems due to “stress following a trauma.” Daryl lived with his long-term girlfriend and was a graduate student at a local University. Daryl was encouraged to seek treatment by a current girlfriend following her observations of him “waking from [his] sleep with uncontrollable sobbing, racing thoughts, and a sense that he was losing control.” Daryl had two prior attempts at therapy, both of which were prematurely terminated. During these two attempts, Daryl did not receive a formal diagnosis.

3 Presenting Complaints

At the time of intake, 4 years and 7 months after the events of April 16th, Daryl reported difficulty with emotions oscillating between numbness and overwhelming, uncontrollable anxiety. He also voiced feelings of guilt, cynicism, and an overly self-critical outlook resulting in significant loss of interest in daily activities, low motivation, poor sleep, nightmares, weight gain, and a loss of interest in sex. Although Daryl reported that these symptoms began in the months following April 16th, he repeatedly minimized the impact of the shootings and demonstrated little to no difficulty discussing this event during the initial intake session. However, Daryl’s symptomatology as well as the experience of Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV; American Psychiatric Association [APA], 1994) A1 criteria led to the diagnosis of PTSD.

Daryl had previously avoided treatment due to several sources of perceived stigma (e.g., fear of being seen as crazy by his friends, fear of losing job opportunities due to mental illness). In addition, he was at high risk of dropout due to two previously unsuccessful attempts at therapy as well as an initial verbal declaration that he may drop out of therapy after “a couple of sessions.”

Daryl reported having panic-like symptoms, increased and persistent anxiety, and trouble sleeping. In addition, he reported a number of negative cognitions (e.g., persistent guilt, diminished interest in activities, and feeling distant from others). However, despite reporting “stress after a trauma,” he repeatedly reported that his symptoms were not the result of the April 16th events. From his point of view, there was a stark disconnect between his impaired functioning and the events of April 16.

4 History

Education and Social Development

Daryl was a Caucasian male enrolled in a graduate program at the time of treatment. He opined that he had performed at an excellent level in his academic pursuits. Historically, he reported enjoying school and many related activities.

Daryl reported having typical social development and characterized himself as a “friendly guy.” In addition, at the time of treatment, Daryl reported having a close-knit group of friends whom he routinely spent time with as well as a long-term girlfriend. Although Daryl cited his group of friends as a source of support, he reported that he felt uncomfortable (and at times guilty for) discussing his mental health with the group. In addition, Daryl reported that he felt he could not talk about specific problems he was having in his life andrelied on his friends for distraction and sources of fun.

Medical, Mental Health, and Substance Use

Daryl reported that he had not incurred any significant injuries or illnesses. He also reported no major surgeries. Daryl reported no premorbid symptomatology prior to April 16, 2007. He also reported that neither he nor his family members had been formally treated for any psychological disorders. Daryl stated that he rarely drinks (one to two drinks per week). Daryl’s exercise was limited due to occasional pain in his back as well as a general discomfort with going to the gym. He also reported eating a balanced diet and has a normal appetite.

At the time of treatment, Daryl was not at risk of suicide and had no known family history of psychiatric illness. Daryl also denied any previous traumatic events prior to the events on April 16. In addition, given the nature of PE as well as Daryl’s symptomatology, he was routinely assessed for suicidality. During increased periods of stress (e.g., immediately following retraumatization), Daryl voiced general feelings of hopelessness but continually denied any suicidal ideation.

5 Assessment

A thorough pretreatment assessment extending for eight sessions, including the Anxiety Disorder Schedule–IV (ADIS-IV; Brown, DiNardo, & Barlow, 2004), Beck Depression Inventory–II (BDI-II; Beck, Steer, & Brown, 1996), Detailed Assessment of Posttraumatic Stress (DAPS; Briere, 2001), the Minnesota Multiphasic Personality Inventory–2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989), and Impact of Events Scale–Revised (IES-R, Weiss & Marmar, 1997), revealed a significant degree of PTSD symptoms.

ADIS-IV

The ADIS-IV (Brown et al., 2004) is a diagnostic semi-structured interview based on the DSM (4th ed., text rev.; DSM-IV-TR; APA, 2000) that assesses for anxiety, mood, and somatoform disorders. The interview uses a “branching format” that starts by screening questions to determine whether symptom-specific questions are relevant. The ADIS-IV has demonstrated moderate to high interrater reliability (DiLillo, Hayes, & Hope, 2006). The ADIS-IV has shown good-to-excellent interrater reliability (κ = .67-.86) for the various anxiety disorders it covers.

BDI-II

The BDI-II (Beck et al., 1996) is a self-report instrument used to assess the severity of depressive symptomatology. Clients respond to questions comprising various domains including hopelessness, sadness, and sleep patterns on the 21-item self-report questionnaire. Responses ranging from 0 to 3 are summed to obtain a total score: A total score of 1 to 13 falls in the minimal range, 14 to 19 falls in the mild range, 20 to 28 falls in the moderate range, and 29 to 63 falls in the severe range of symptomatology. The BDI-II has shown good internal consistency (α = .85).

IES-R

The IES-R (Weiss & Marmar, 1997) is a self-report instrument used to measure distress following a traumatic event. Clients are asked to rate their distress levels on a 0 to 4 scale. The responses are then used to obtain subscale scores for Avoidance, Intrusion, and Hyperarousal. Previous studies have demonstrated Cronbach’s alphas ranging from .87 to .94 for the Intrusion subscale, .84 to .87 for the Avoidance subscale, and .79 to .91 for the Hyperarousal subscale (Creamer, Bell, & Failla, 2003; Weiss & Marmar, 1997).

DAPS

The DAPS (Briere, 2001) is a 105-item inventory that yields probable DSM-IV-TR diagnostic statuses for PTSD and Acute Stress Disorder (ASD). It assesses for previous trauma exposure, as well as immediate psychological reactions (cognitive, emotional, and hyperarousal) and impairment related to the traumatic event. The DAPS includes two validity scales that measure symptom over-exaggeration and minimization, as well as three supplementary scales evaluating event-related dissociation, substance abuse, and suicidality, which are often associated with PTSD. The DAPS has been found to have good sensitivity (.88) and specificity (.86).

MMPI-2

The MMPI-2 (Butcher et al., 1989) is a widely used and empirically supported objective personality assessment. The assessment generates a comprehension profile that can be used to facilitate the therapeutic process. Examinees’ responses yield scores on various subscales (e.g., hypochondriasis) that can be particularly informative for understanding more about possible traumatic stress symptoms. Another strength of the MMPI-2 is its ability to detect examinees’ “fake” responses, symptom denial, and attempts to portray a particular impression. Cronbach’s alphas for clinical scales range from .34 to .85 (median α = .59) for men and from .39 to .87 (median α = .63) for women (Tellegen et al., 2003). Daryl was administered the MMPI-2 prior to Session 3.

Multimodal Life History (MMLH)

The MMLH (Lazarus & Lazarus, 1991) is used to obtain comprehensive background information about an individual and allows the clinician to gain a better understanding of a client’s behaviors, affective processes, sensations, images, cognitions, interpersonal relationships, and medical history. Daryl was given the MMLH prior to the start of his second session. Both the IES-R and BDI-II assessment tools were administered at the beginning of each assessment and treatment session.

Assessment Results

During intake, Daryl’s BDI-II score of 31, as seen in Figure 1, was in the severe range. His IES-R total score of 36 indicated a moderate level of posttrauma-related distress, as seen in Figure 2. On the DAPS, he identified “the experience that bothers you most now” was in the building next to Norris Hall where the shootings took place. The results of this assessment suggested that Daryl was experiencing a clinically significant level of PTSD symptoms.

Figure 1.

Baseline, treatment, and posttreatment outcome assessments: BDI-II and IES-R total scores.

Figure 2.

Baseline, treatment, and posttreatment outcome assessments: IES-R score.

During the PTSD/Acute Stress Module of the ADIS-IV, he reported having lost a close friend during the April 16th tragedy and, 2 years following, sustained a significant injury during a martial arts sparring match. Daryl’s level of symptomatology was first assessed with regard to the April 16th tragedy. He endorsed experiencing an avoidance of thoughts/feelings and activities/situations, as well as a loss of interest in significant activities, increased anxiety surrounding loved ones, and a sense of foreshortened future. In addition, Daryl endorsed chronic nightmares with themes including witnessing horrific events, paralysis, and futile attempts to save others. These nightmares, which he referred to as “night terrors,” had a significant effect on his sleep patterns and left him feeling exhausted most mornings. Most notably, Daryl indicated that following the events of April 16, he experienced a steadily increasing degree of hyperarousal culminating in symptoms such as an inability to have his back to the entrance of a room, habitual surveillance of crowds, avoiding eating in public, and constantly being armed with a handgun at all times of the day. He indicated that these symptoms had their onset since April 16th; however, he minimized the interference they produced on his day-to-day functioning. For example, he viewed several of his hypervigilance symptoms (i.e., carrying a handgun) as adaptive. Daryl was given a CSR (Clinician’s Severity Rating) of 8, indicating a severe level of interference and distress.

Sessions 1 and 2

Immediately prior to Sessions 1 and 2, Daryl was given the BDI-II and the IES-R. During Session 1, Daryl was given a review of the confidentiality agreement as well as his consent for service. In addition, the first session was largely used as a “get to know you” session in which the therapist asked very general questions regarding Daryl’s current issues as well as general life questions. During this time, Daryl appeared polite yet somewhat closed off from the therapist. Daryl frequently noted that he was experiencing problems (e.g., panic symptoms, insomnia, general anxiety, difficulty focusing and completing work) but was quick to minimize the severity and prevalence of the problems. For example, Daryl notes that he was frequently woken from his sleep with panic-like symptoms and that his girlfriend frequently commented on his broken, restless sleep but assured the therapist that it was not “that bad” and that he was still doing okay in spite of the problem. It was during Session 1 that Daryl reported to the therapist that he had two prior attempts at therapy, both of which he discontinued after two sessions. In addition, Daryl reported to the therapist that he was currently seeking treatment at the behest of his girlfriend and that he planned to “check it out” and was unlikely to continue for long. At the close of Session 1, the therapist acknowledged that Daryl may leave but requested that before he discontinued, he give the therapist a chance to get to know him better. Daryl agreed and, subsequently, returned to the following session.

Prior to the start of the second session, Daryl was given the MMLH. He was informed that this was a standardized assessment tool that covered large areas of an individual’s life and would free the therapist and Daryl up to maximize their time. When Daryl’s session started, he and the therapist continued their “getting to know you” period. The therapist asked Daryl whether he would be okay with answering some more structured interview questions. Daryl was given the rationale that these questions would help he and the clinician to better understand exactly what was going on as well what problems may be worse than others. Again, Daryl was agreeable to answering some questions. During Session 2, Daryl was given the ADIS-IV.

Sessions 3 to 5

At the beginning of Session 3, Daryl was given the BDI-II and the IES-R. At the start of the session, it was discovered that Daryl was bringing his loaded handgun into therapy with him. He reported understanding why that may make some uneasy but argued that there was the chance that he may be in danger while in the clinic. This revelation served as additional evidence of Daryl’s chronic hyperarousal and hypervigilance bordering on paranoia. To assess his commitment to his vigilance, he was asked to leave his gun in his car during Session 3. In the fourth session, he reported that he left the gun in his car and felt “okay.” However, in Session 5, Daryl became very uneasy when the therapist attempted to move Daryl’s bag onto a table, reporting that his gun was in the bag. He first reported forgetting he had it, later admitting that he was unable to go without it. When he was further encouraged to leave his gun in his car, he became agitated. This agitation suggested that Daryl was being pushed out of his comfort zone and offered the therapist a concrete example of the maladaptive nature of his hypervigilance. After a discussion regarding the handgun, Daryl continued on the ADIS-IV. In addition, at the conclusion of the session, Daryl was given the MMPI-2 to complete in the clinic. Daryl was given a private room to complete the assessment.

During Sessions 4 and 5, Daryl and the therapist revisited a number of modules on the ADIS-IV. In Session 4, the therapist and Daryl began a more formal discussion about Daryl’s anxieties as well as his panic-like symptoms. On the ADIS-IV, Daryl voiced general anxiety concerns and a number of panic symptoms while not meeting criteria for Generalized Anxiety Disorder (GAD) or panic disorder. During Session 5, the therapist began asking more specific PTSD questions. Daryl was agreeable while still defensive regarding his symptoms. These sessions were used in an effort to assess whether Daryl was minimizing problems or whether his symptoms really were “manageable.” It became clear to the therapist during these sessions that Daryl had a belief that he was handling his symptoms well and that he did not have a problem. However, these more informal interviews worked to aid Daryl in seeing the full range of his symptoms as well as in how many different areas they affect his life.

Session 6

Prior to the sixth session, Daryl was exposed to another violent, seemingly senseless murder in his community. On December 8, 2011, a gunman shot and killed a university police officer before taking his own life. Text messages were sent out urging those on campus to remain indoors, and Daryl’s school was placed on lockdown. At that time, Daryl was on campus. Shortly after receiving word about the shooting, Daryl lost cell service. From where he was located, he could see unmarked police cars. The events triggered flashbacks of April 16th.

Daryl arrived to his sixth session looking visibly fatigued, unkempt, and with poor hygiene. Despite carrying his gun, counting heads, and assessing every situation, Daryl found himself feeling completely exposed and vulnerable in light of the shooting. He reported, in the session, that his worldview had completely shifted from “pleasantly apathetic” to “crushingly cynical” as he described the world as a warped, dangerous, and unpredictable place. He continued to carry his gun into treatment and voiced passive suicidal ideation. Daryl denied having a plan and was able to list numerous reasons why he would not commit suicide.

Following his BDI-II and IES-R, Daryl was taught deep breathing and progressive relaxation. Daryl and the clinician also created a schedule mandating that relaxation and relaxing activities were made a priority. Had he not been in treatment at the time of the second event, Daryl reported that he feared he would have done something drastic: Inflicting damage toward himself or others.

Sessions 7 and 8

Sessions 7 and 8 saw a decline in Daryl’s depression. Each session began with routine assessment (BDI-II and IES-R) following by a review of Daryl’s week. Following this review, the therapist offered to help teach Daryl some relaxation techniques. In addition, Daryl was encouraged to practice these behaviors routinely throughout the week. By the eighth session, it can be noted that his BDI-II scores dropped whereas his IES-R scores increased slightly.

6 Case Conceptualization

Based on the comprehensive assessment, Daryl was experiencing an elevated level of traumatic stress primarily in response to the shootings of 4/16. As stated above, he reported a range of symptoms including chronic nightmares, hyperarousal, foreshortened future, avoidance, and loss of interest in significant activities. In addition, he reported significant levels of depression and hypochondriasis on the clinical scales of the MMPI-2. His MMLH indicated a normal childhood and no premorbid difficulties in functioning.

Daryl’s present symptom pattern might be best viewed from a cognitive-behavioral formulation. It is clear that previously neutral or positive stimuli became associated with anxiety-producing stimuli connected to the shootings of April 16th. In addition, reminders of the event (e.g., walking past the building where the shootings took place and thoughts of having to go inside the building) were paired with both internal and external triggers such as his frequent avoidance of activities (e.g., going to parties), situations (e.g., building where the shooting took place), and people. These PTSD symptoms resulted from the conditioned stimulus of the memories of the shooting.

Daryl’s depressive symptoms were maintained by his problematic attempts to avoid anxiety-arousing stimuli (e.g., avoided going to crowded places, avoided intimacy with his girlfriend). In addition, Daryl’s avoidant behaviors appeared to cause significant social stress, most notably with his girlfriend. This caused his depression toworsen. Given Daryl’s array of avoidant behaviors, as well as his displayed ability to verbally minimize and distance himself from his symptoms, the therapist decided to treat him using PE.

This empirically supported treatment strategy has been documented for its efficiency on numerous occasions in the research literature. There are numerous reports for its effectiveness (Difede et al., 2007; Foa, 2011; Resick, Nishith, Weaver, Astin, & Feuer, 2002). Theoretically, this form of therapy posits that exposure to fear stimuli will facilitate emotional processing that results in healthy adaptation of trauma-related information. Active ingredients of PE are in vivo exposure, where clients are encouraged to expose themselves to reminders of traumatic events in a gradual and systematic fashion. With respect to imaginal exposure, one is asked to repeatedly describe, in detail, the traumatic event. Within imaginal exposure, the therapist and client must be mindful of “hot spots.” Hot spots in imaginal exposure are areas of particular difficulty within the story. They often appear as lapses in time within the story, periods of sparse detail, or details that provoke spikes in anxiety. Hot spots must be noted, and later further explored, to better receive the desired effect of imaginal exposure. Exposure therapy is grounded in the theory that exposure to fear stimuli will facilitate emotional processing and allow for the healthy adaptation of trauma-related information (Foa, 2011). Both types of exposure enable clients to face harmless stimuli and to emotionally process the event.

PE was chosen over other trauma-focused treatments (e.g., Cognitive Processing Therapy) because of its unique combination of education and real-world practice. During the 4 years between April 16th and treatment, Daryl had created a vast array of avoidant behaviors that (to him) were extremely beneficial and seemingly adaptive. Early sessions made it apparent that Daryl was adroit at rationalizing his symptoms and minimizing their importance. It was feared that any therapy that focused on awareness and skill building without direct exposure to aversive stimuli might not have as strong of an impact on Daryl. The therapist believed that only by exposing Daryl to his aversive stimuli, and preventing his avoidant strategies, could real traction be gained. In addition, given Daryl’s depressive symptoms, the therapist believed that in vivo exposures from PE could also serve as behavioral activation and alleviate depressive symptoms. Many of Daryl’s avoided behaviors (e.g., exercising, intimacy with his girlfriend), when performed, have been shown to decrease depressive symptomatology. It was the hope of the therapist that PE would both reduce Daryl’s PTSD as well as alleviate his depression.

7 Course of Treatment and Assessment of Progress

Postassessment treatment occurred over the course of 15 sessions. A doctoral-level graduate student served as the clinician under the supervision of a licensed clinical psychologist trained in PE treatment. Treatment sessions typically lasted 90 min. The BDI-II and the IES-R were given prior to every session and used as tracking measures throughout treatment.

Session 9

In the ninth session, Daryl was presented with the planned course of action (the utilization of PE), a general explanation of trauma, and how the symptoms of PTSD maintain themselves, as well as how the treatment would work to undermine these maintenance features. In this presentation of treatment, the clinician also described the potential for increased depressive and PTSD symptom severity. Daryl was able to maintain a conversation about his own PTSD symptoms, citing their presentations in his own life, as well as articulate his understanding of the potential side effects.

Although the PE manual was referenced throughout treatment, several practical and theory-driven modifications were made to the standard PE protocol to address Daryl’s somewhat vague involvement in April 16th and his well-enforced maladaptive coping strategies.

Session 10

Consistent with PE protocol, Daryl established a hierarchy of anxiety-producing and anxiety-avoided situations. In the establishment of the hierarchy, he was able to come up with six avoidance situations and places that directly resulted from April 16th (e.g., being unarmed, the site of the shooting, the April 16th memorial).

Sessions 11 to 14

Daryl’s early in vivo exposures targeted avoidance of healthy living activities such as going to the gym and taking walks during the day, to build his confidence. In the meantime, he and the therapist worked to identify how to properly implement imaginal exposure. During the establishment of the in vivo hierarchy, Daryl revealed more of his relationship with his departed friend. He placed “physical intimacy/sex” on his list of avoided situations. When asked what specifically was being avoided, Daryl first had difficulty identifying the reason. However, there was a moment of revelation when he admitted that his first sexual experience was with his departed friend. The true depth of his avoidance, and the significance of his loss, became apparent. Physical intimacy and sex with his girlfriend became an early targeted exposure focus for him. Mild exposures such as handholding and shoulder massages were assigned in the first two in vivo exposures. Consistent with a graduated exposure approach, the first several exposure sessions placed an emphasis on increasing the intensity of the in vivo cues. In the case of physical intimacy, handholding was progressively advanced to massages, which was then gradually increased to intercourse. This approach was then utilized in his avoidance of the gym (simply going to the gym advanced to running at the gym once a week advanced to 1 hr several days a week at the gym) as well as his reliance on his gun.

During Session 12, Daryl and the therapist began imaginal exposures. Prior to his first exposure, Daryl appeared visibly anxious and reported feeling worried that he would have a panic attack. Daryl and the therapist engaged in deep breathing prior to the start of the exposure. In Daryl’s first imaginal exposure, he spoke for roughly 20 min. His story began the night before April 16th. After describing the prior night as well as the morning of April 16, Daryl quickly noted that he left campus when the shooting started and then ended the story. Daryl reported that he did not feel very anxious during the story and was relieved that it was not more difficult.

The therapist described to Daryl what a “hot spot” was. The therapist explained that there would be a number of areas that he will naturally avoid and may not even realize it. However, by identifying these areas and focusing more time on them, they become less difficult. The therapist asked Daryl to tell the story again, this time beginning on the morning of April 16th. This story detailed more of the events during the shooting as well as the moments following the shooting. Then, Daryl’s story jumped ahead 1 week as he discussed what appeared to be irrelevant details. For homework (along with his in vivo exposures), Daryl was asked to listen to a recording of his story (provided by the therapist) each day and try to identify hot spots.

In Session 12, Daryl and the therapist reviewed Daryl’s homework and began discussing Daryl’s impression of his story. Daryl found it difficult to identify hot spots in his story. The therapist encouraged Daryl to continue with the exercise as well as be mindful of hot spots during his next story. The session then focused on Daryl’s story of April 16th. This time, Daryl’s story began on the morning of April 16th with much more detail. Daryl’s story still had large gaps in the time line. At the conclusion of the story, the therapist and Daryl discussed hot spots again. The therapist asked Daryl what happened after he left campus (a missing piece of the story). Daryl, after some thought, reported that he was not sure. This was identified as a hot spot. Daryl told the story again with much more focus placed on the immediate events following the shootings. This was the first imaginal exposure in which Daryl began to show significant signs of distress. Daryl became teary-eyed and tense as he took many pauses to clear his throat, and at times, began to breathe very quickly. Daryl’s new story included a lot of detail regarding attempts he made to contact his friends. Still, there were a number of details missing. Per Daryl’s account, there were hours of that day where he has no memory.

During the 14th session, Daryl began to give more detail regarding the events following April 16th. Daryl, again, reported that he spent much of the afternoon trying to call people and get information about his friends. Daryl added that one of his friend’s parents was continually calling him throughout the day asking for information and pleading with him to find their daughter. This was also the first story in which Daryl described receiving the news that his friend had died. Immediately following the news, Daryl experienced a dissociative episode.

Session 15

When Daryl arrived for his 15th session, he reported that he had not slept well in several days and had begun to experience intense, vivid nightmares. Although none of the nightmares was a direct recap of April 16th, themes of these nightmares included murder, torture, and him being forced to witness grave injustices while being bound. He reported that these nightmares began roughly 2 weeks prior to the session and became progressively worse. Frequently waking up in a panic, he reported feeling anxious throughout the day, experienced increased muscle tension, and generally felt exhausted. He was afraid to go to sleep, as well as unable to function during the day. Daryl voiced a strong desire to bring his gun with him into the sessions but asserted that he had left it in his car.

Given Daryl’s significant increase in symptom severity and generally poor health, the therapist asked whether he wished to continue with his exposures. Daryl and the therapist discussed the advantages and risks involved in missing a session, and the ultimate decision to forgo an exposure session was Daryl’s to make, allowing him to maintain control even in a time of crisis. Consequently, at the client’s request, the 15th session focused on sleep hygiene with an emphasis on Daryl’s presleep routine (i.e., turning off electronics, avoiding eating late at night, showering before bed) and ways he could monitor his hours of sleep and the frequency/severity of nightmares.

Sessions 16 to 19

Prior to Session 16, Daryl reported that his nightmares had subsided and his new sleep routine (going to bed earlier, turning off electronics, etc.) enabled him to begin sleeping normally again. PE continued, consistent with the manual for Sessions 16 through 19. Daryl began to recognize progress as a function of his in-session habituation (during imaginal exposures), as well as awareness of declines in his distress levels (during in vivo exposures.)

Session 20

Daryl arrived to his 20th session in distress, reporting increased anxiety, poor sleep, low appetite, and increased depression. Further discussion revealed that he was experiencing increased guilt and regret for the years following April 16th. It appeared that a significant decrease in Daryl’s avoidance and hyperarousal (per his IES-R) had led to a flood of intrusive reminders and, subsequently, an overwhelming amount of regret and remorse over how he had spent the past 4½ years.

Session 21

After Daryl’s second crisis in session, it became clear that although progress was being made with his PTSD-related symptoms, other areas of difficulty were being ignored. In addition to missing two sessions of imaginal exposures due to increased stress, Daryl had multiple weeks in which imaginal and in vivo exposure homework was completed sporadically. When homework was not completed, Daryl often offered reasons such as increased stressed, running out of time, or being generally busy.

Prior to the 21st session, the therapist purchased a pocket-sized notebook and pen that he gave to Daryl and instructed him to record daily problems and ways in which he coped with them. He was also instructed to record successful and unsuccessful problem solving strategies. When his solution failed to solve the problem, or when no solution was arrived at, Daryl was to write that down as well. The therapist reflected on his impression that Daryl appeared to be unwilling to change aspects of his life unless forced to, letting stress build up day to day until it became unbearable. The notebook, then, was a way to help him keep an eye on problems in all areas of his life and not let any one problem dictate his day-to-day living.

Sessions 22 to 24

Daryl continued to engage in imaginal exposures in the sessions and completed daily exposure-related homework assignments. At the outset of Sessions 22 to 24, he discussed his daily monitoring of problem behaviors. During this time, various patterns were noted and articulated. A greater degree of compliance with imaginal and in vivo exposures was reported (from an average of 3 days a week to an average of 6 days a week). Daryl noted that he was beginning to feel good and, as a result, had recently found it easier to skip homework assignments. Daryl noted that he lost roughly 10 pounds, was eating better (using a fitness tracker on his phone to monitor his eating habits), and felt better about himself. Following the discussion on Session 21, Daryl noted that he began to take homework more seriously again with the knowledge that he wanted to continue making personal gains.

Session 25

To obtain a posttreatment assessment of this client’s functioning, an independent assessor using the ADIS-IV reassessed Daryl. The number of symptoms reported and their associated levels of distress and severity were significantly less than that of baseline. There were also significant drops on the IES-R and BDI-II. In addition, he showed significant improvement on a variety of secondary outcomes, including a significant increase in his research output and an improvement in his relationship. His girlfriend confirmed this improvement in a separate, independent session.

8 Complicating Factors

Enhanced stigma and hesitance preventing those indirectly exposed to a trauma presents a real obstacle for therapists. Although a client may be expressing several symptoms of PTSD, a therapist may become too attached to the literal interpretation of Criteria A, “exposure to a traumatic event.” In the case of those families and friends who were not directly present during the 9 min when the actual shootings took place, there was no loss of physical integrity.

Given the recently published DSM (5th ed.; DSM-5; APA, 2013), it is important to note what aspects of the case would be different under DSM-5 (Friedman et al, 2010). The revision of Criterion A1 in DSM-5 tightens the definition of trauma. Retaining A1 criteria would have not proved too restrictive and Daryl would have maintained his PTSD diagnosis. The exclusion of the A2 criteria (experiencing extreme fear, helplessness, or horror) would have made it less difficult for him to obtain the PTSD diagnosis. Daryl, like many others, did not experience intense fear or horror during the moments of April 16th. Under the strictest of definitions under DSM-IV, Daryl would have not been able to fully meet for a PTSD diagnosis. It is only under the “helplessness” stipulation that Daryl was able to meet A2 criteria. Several studies have found that the A2 criteria is not predictive of PTSD 6 months following an event (Brewin, Andrews, & Rose, 2000; O’Donnell, Creamer, McFarlane, Silove, & Bryant, 2010).

Another complicating factor was the reexposure to a traumatic event. As noted in the sixth assessment session, Daryl was exposed to a second violent incident. Being on campus and receiving a text message from the university that a gunman had shot and killed a Virginia TechUniversity police officer were particularly traumatizing for this client. This is indicated in elevations on both his IES-R and BDI-II scores in Session 6. This occurrence highlights the need for effective treatments for individuals experiencing trauma and for those who may be vulnerable to future exposures. It also raises the importance of clinicians being aware of the frequency at which such unexpected exposures may occur, as well as the importance of them incorporating coping procedures to lessen such unexpected distress. In this instance, deep breathing and progressive relaxation were found to be effective in lessening his acute symptomatology.

9 Access and Barriers to Care

It is important to consider the benefits of PE, as well as the associated risks involved in such a treatment. Future work should focus on potential systems of monitoring to ensure that a client’s well-being (i.e., sleep hygiene, interpersonal relationships) maintains a level sufficient enough to give him or her the strength to persevere throughout the treatment. In the present case study, retraumatization and deteriorating sleep hygiene posed barriers to treatment and required brief pauses from treatment to implement one-session interventions and subsequent monitoring. Allowing for this flexibility within the context of a scheduled treatment manual refocused treatment on the client’s well-being and symptomatology and subsequently led to significant gains from the successful completion of PTSD treatment.

In addition, using comprehensive assessment prior to PE had a number of benefits within treatment. Following the retraumatizing episode, Daryl was able to better define and articulate his symptoms as well as explain them in reference to the trauma. Daryl’s gained insights into his own symptomatology assisted him in being better able to report his difficulties as well as articulate what he needed to feel better. In addition, the early comprehensive assessment period appeared to increase Daryl’s commitment to, and belief in therapy. Following the completion of PE, Daryl was asked what elements of his treatment were the most beneficial. He reported that the early assessment period helped him to trust the therapist. Daryl went on to explain that he felt a connection with the therapist, one that developed during that assessment period. When things got bad, Daryl went on to explain, he felt he was able to come to therapy and speak honestly about his problems.

10 Follow-Up

Four in-clinic follow-up sessions were carried out to determine the maintenance of treatment, as well as address other areas of Daryl’s life (e.g., relationship issues, life transitions). These sessions were completed immediately following the completion of PE and occurred 1 week apart from each other.

Three months following his last in-session meeting, Daryl was contacted over the telephone for a follow-up. At this time, Daryl was administered the BDI-II and IES-R. Daryl reported feeling good and maintaining his treatment gains. Daryl returned to the clinic for a 6-month follow-up, during which time he reported some mild life stressors but otherwise was doing well. Finally, Daryl was administered a 1-year follow-up over the telephone, during which time he again asserted his wellness and maintained gains.

11 Treatment Implications of the Case

To our knowledge, this is the first published report demonstrating the effectiveness of PE following a student being exposed to mass school shootings. Given the apparent prevalence of such incidents, we highly advocate the adoption of this intervention. There are several implications for future clinical work that can be learned from the current case. First, this case highlights the importance of comprehensive assessment prior to engagement in treatment. Daryl was a high-risk client with a history of premature termination and significant posttraumatic stress symptoms. Consistent with our hypothesis, Daryl reported at the completion of treatment that his initial plan was to terminate treatment after “checking it out.” By engaging in a comprehensive assessment period, the therapist not only benefited from a better gestalt understanding of the nuances of Daryl’s functioning and presentation, but Daryl was also eased into treatment more gradually as he increased his buy in.

Second, although PE has been shown to lessen PTSD symptoms following a number of traumatic experiences, to our knowledge, it has not been applied to indirect exposure to a trauma where the “traumatic event” was the uncertainty for someone’s well-being. Modifications were required to properly expose Daryl to the feelings of uncertainty and to imaginally target-specific events in the wake of April 16th. The development of his imaginal exposure largely came from Daryl’s extensive assessment, as well as through early review of “hot spots” within Daryl’s story. By coupling known difficulties and symptomatology with behavioral observations regarding avoidance and physiological responses to certain aspects of his story, Daryl was able to develop an imaginal exposure that directly targeted his indirect traumatic event.

Finally, the present case offers a lesson in flexibility of diagnosis and the importance of focusing on presentation and functioning. During Daryl’s assessment, there was question as to whether this traumatic event qualified him for PTSD. However, Daryl displayed a number of hyperactive and avoidant behaviors, coupled with panic-like symptoms, somatic complaints, and depression that seem to be best explained by the traumatic experience. The advances made in DSM-5 allow for stronger identification of individuals suffering from posttraumatic stress. However, this case offers an excellent example as to the far-reaching impact of traumatic events beyond those who experience direct exposure, as well as the long-lasting implications that it could have for an individual. Another issue that needs to be addressed in future investigations of this nature is the symptom patterns during baseline.

12 Recommendations to Clinicians and Students

One of the most important lessons learned from this case study is the importance of assessing a client’s preparedness for treatment, as well as having an appreciation for the nuances of the client’s traumatic experience and subsequent impairment. By spending more time in the introductory phase, especially with a client reluctant to engage in treatment or with a history of premature termination, the therapist is better able to tailor the treatment to the client as well as display a stronger understanding of the unique struggles a client is going through.

In addition, comprehensive assessment may be particularly beneficial for clients who experienced an indirect trauma. In the presented case, Daryl acknowledged that he had a traumatic experience but did not view his symptoms as a manifestation of that trauma. Daryl instead viewed his behaviors (i.e., hypervigilance) as adaptive and important for his personal protection and did not see them as interfering with his life and leading to his deteriorating well-being. During the course of comprehensive assessment, Daryl was able to critically examine the manifestation of his behaviors as well as become an expert in his own symptomatology. Taking the time to evaluate his functioning, through assessment, and coupling it with psychoeducation gave Daryl insights into his own difficulties. In addition, this processes appeared to increase Daryl’s buy in when treatment was ultimately proposed. By the time the therapist proposed PE, Daryl was already an expert in his symptomatology, as well as PTSD, and was able to quickly see the benefit that PE may provide.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Michael F. Wusik is a doctoral candidate in clinical science at Virginia Tech. Hisresearch focuses primarily on avoidant coping, with an emphasis on self-handicapping, posttraumatic growth/deterioration and process goals in therapy.

Russell T. Jones is a tenured professor of clinical science at Virginia Tech and a clinical psychologist who specializes in trauma. He is the founder and director of REAACT (Recovery Effort After Adult and Child Trauma). His research focuses primarily on natural disaster as well as technological disaster and interpersonal trauma with an emphasis on posttraumatic growth and coping.

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