Assessment of a Patient with PTSD and Drug Abuse

This reflection highlights the case of a patient with PTSD and drug abuse, and the use of bio-psychosocial and spiritual assessment. The assessment was assisted by communication and cultural competence. The experience revealed the importance of being empathic, kind, and providing adequate support to the client.

In the following reflection, I will be highlighting the case of a patient with the pseudonym S.S.,
who is a 31-year old female of Asian ethnicity. S.S. has been suffering from PTSD (Post
Traumatic Stress Disorder) for the last two years. She also has been undergoing rehabilitation
treatment for drug abuse that started one and a half years ago. S.S. was very close to her father
and after his death; she found it extremely difficult to cope with the situation. She has had an
abusive childhood with her mother who used to beat her up for minor faults. She was then
indulged in drug abuse after she entered into a relationship with her ex-partner. This led to her
admittance in the rehabilitation center from where she even once tried to escape. Currently, she
is undergoing intensive care at the rehabilitation center.
Trauma, as described in MHCC (2013) could be experienced due to single or several events of
any causes. Complex trauma in particular is crucial to my assessment of the client because it
refers to the interpersonal violence a person suffers including the ones on an individual’s ‘sense
of self’. S.S. was admitted in 2017 in a rehabilitation center for drug abuse. During the initial
treatment, a psychiatric attended her to examine her mental condition. After that, she tried to
escape from the center but was rescued by the staff. I visited her in January this year and
undertook the bio-psychosocial and spiritual model of assessment because this type of
assessment helps in finding not only about drug abuse but also biological functioning,
psychological health and physical health().
While undertaking the bio-psychosocial and spiritual assessment, I used the interpersonal skills
based on the guidelines provided in Harms (2015) where the author talks about the assessment
skills. I received much help from the assessment case studies provided by Harms (2015)
especially the one where the therapist was client-centered, empathetic, kind and respectful but no
use to the client. The reason was the therapist’s lack of understanding of the client’s needs. The

client wanted to learn how to cope with traumatic situations in the future but the therapist
provided no clue. From this, I understood that I should provide my client with an opportunity to
express herself, her needs and problems and then provide relevant solutions. I made sure that she
felt calm and secure throughout the assessment and trusted me with her secrets well because I did
not want her to feel traumatized again by forcing her to reveal anything from her past.
In my assessment, I also made sure that I understand her cultural background, which is one of the
core principles of trauma-informed care and practice. As mentioned in MHCC (2013), ensuring
cultural competence is one of the eight core principles to follow while assessing a client with
PTSD especially complex trauma. S.S. comes from an Asian background and hence, her views
about the world would be different from mine. While the assessment session, she talked about
her close relationship with her father and how she feels guilty of disrespecting him by not
honoring his death and engaging in ill practices such as drug abuse.
Throughout the assessment, I maintained an empathic communication while making sure that I
do not ask her questions that would make her feel uncomfortable or reluctant. I asked her about
what she wants or wanted to achieve in life and in what way she uses to fulfill her father’s
dreams. I used the concept of ‘use of self’ especially my spiritual use of self as explained by
Harms (2015) wherein the author states that those who value spiritual elements of their lives
achieve a positive outcome related to health and wellbeing. I used this after analyzing the client’s
thoughts about not being able to cope with her father’s death due to her distancing from her
spiritual beliefs and values. Jacobson and Wright (2008) also talk about the association of drug
or substance abuse with culture. The authors highlight that cultural nuances are important to be
included in conventional treatment to make these effective.

My assessment was also assisted by the use of communication as explained by Harms (2007) as I
was able to make the client feel that I was not above her and that I too am like her. Initially, she
was reluctant to talk and was aggressive in her approach, as she did not want anyone to talk to
her. Gradually however, I made her feel that she could trust me and then she began to respond to
my queries. I engaged with her in a casual conversation so that she could feel accepted and safe.
I even used the Conversational Model Therapy technique and made the situation lighter by
engaging in humor and laughter with S.S. McLean et al. (2018) also talk about the effectiveness
of conversational technique in dealing with patients suffering from PTSD wherein they state that
humor and laughter had therapeutic benefits. S.S. responded well to this and showed signs of
comfort and interest in the conversation.
The session with S.S. helped me identify the benefits of engaging in a healthy, casual
conversation with clients going through traumatic history and drug abuse. The experience also
revealed that health workers who deal with such clients must not impose their beliefs and values
onto the client rather acknowledge and respect the client’s perspective. I also learned that being
empathic and kind while dealing with the client is not enough and that I should provide adequate
support to the client for her to have a clear vision of her future. The experience further helped me
in identifying my personal skills of being humorous and reliable as important for an effective
assessment. My ability to make the client relate to me came from building affinity with the
client. This allowed S.S. to become less aggressive and feel accepted, which in turn made her
feel safe and calm throughout the assessment. Maintaining a grounded attitude throughout the
assessment is essential in dealing with clients suffering from traumatic history and drug abuse.

References:
McLean, L., Kornhaber, R., Holt, R., West, S., Kwiet, J., Visentin, D. and Cleary, M., 2018.
Introducing a conversational model therapy approach as a team model of care: the clinician
experience in a sexual assault service. Issues in mental health nursing, pp.1-8.
Harms, L. 2015, Chapter 4. Skills for your 'use of self' (in) Harms, L.: Working with people :
communication skills for reflective practice, Oxford University Press, South Melbourne
Jacobson, H., Wright, B., 2008, 'Hot potato : when alcohol, drugs and mental illness are laced
with culture', Synergy : newsletter of the Australian Transcultural Mental Health Network, 2, 19
Harms, L. 2015, Chapter 9. Assessment skills (in) Harms, L.: Working with people :
communication skills for reflective practice, Oxford University Press, South Melbourne
MHCC (2013). Trauma-Informed Care and Practice: towards a cultural shift in policy reform in
mental health and human services in Australia. [online] Mhcc.org.au. Available at:
https://www.mhcc.org.au/wp-content/uploads/2018/05/ticp_awg_position_paper__v_44_final__
_07_11_13-1.pdf [Accessed 11 Mar. 2019].
Harms, L. 2007, Chapter 2. Understanding communication and change, pp 46-47 (in) Harms, L.:
Working with people : communication skills for reflective practice, Oxford University Press,
South Melbourne