Extraction Vignette Learning Points

Issues Raised in Vignette A Special Forces team leader in Iraq, is ordered to extract an Iraqi interpreter and his family by helicopter to a safe house. The interpreter unexpectedly brings along many orphans who cannot be accommodated in one helicopter. He makes a split second decision for the helicopter to take off without the orphans, resulting in the enemy killing all the children. He is deeply disturbed and feels guilt, anger and irritability about his decision to leave the orphans.

After the Sergeant redeploys back home to his family, he struggles with PTSD symptoms including flashbacks, avoidance, isolative behavior, hyper-arousal and intrusive thoughts. He has difficulty controlling his temper, and has angry outbursts directed at his two daughters. They become fearful of his unpredictable moods. The Sergeant attempts to control his family by not allowing his daughters to have music or friends at home.

He physically abuses and sexually batters his wife. She becomes fearful of him. The wife and daughters seek the assistance of a family therapist to deal with the Sergeant’s angry outbursts. His wife admits to the family therapist, feeling ashamed, that her husband has sexually battered her during intercourse; requiring medical treatment. When the Sergeant experiences flashbacks while driving, he is arrested by sheriff deputies for erratic and unsafe driving, and is put in jail.

He decompensates while in jail, and becomes emotionally distraught, irritable, and agitated, and is placed in restraints. Served with a restraining order and separated from his family, he withdraws and is isolated from his family members, spending extended periods of time sitting alone in trees or parts of his house. With the realization that he has lost his family and his peace of mind, the Sergeant decides to begin therapy.

a.Family therapy: Family members are encouraged to openly communicate feelings of fear and loss, validating the feelings of all family members. His wife and children are fearful of his angry outbursts and violent behaviors. The entire family is anxious and frustrated about the destabilizing changes in their family and home. Issues Addressed in Therapy

The Sergeant bottles up and denies his feelings. He feels that his wife and daughters have the “problem,” and denies having any problems himself.

b. Individual Therapy: Wife: She feels sadness and pain, and grieves the uncertain and hopefully temporary change of her loving and previously stable husband. She is fearful of her husband’s violent and erratic behaviors. She is ashamed, embarrassed, and physically injured from his aggressive sexual behavior. She feels obligated to protect her children, self and family by filing a restraining order.

Husband: The Sergeant is depressed, hyper-vigilant, and feels guilty and unable to control his angry impulses. He has been temporarily separated from his family by a court order. He seeks individual therapy with Dr. Jones, who provides him with empathy and an opportunity to express his feelings of guilt and shame. The Sergeant begins EMDR, and responds well to the therapist’s ability to help him expose and identify his feelings.

He successfully responds to cognitive reframing; going from “I was responsible” to “I saved some people.” The Sergeant responds well to therapy (Exposure Techniques), and begins the extinction of uncomfortable feelings. She encourages him to normalize his life and reconnect with his wife and two daughters, and eventually the family reunites.

Questions What were the turning points that allowed him to progress through the Stages of Change? What could have been done differently? What would the prognosis be if his family wasn’t supportive?