1. FOUR BASIC AREAS PSYCHOLOGICAL TREATMENT APPROACH INTERPERSONAL THERAPY MODEL FOR TRAUMA AND LOSS AFTER MACHINE ROLLER ACCIDENT THE 8 TH ANNUAL PAN-AFRICAN PCAF PSYCHOTRAUMA CONFERENCE Immacolata M. Nyaga Clinical Psychologist & PhD Candidate, University of Nairobi Nyaga Counseling Services, Adams Arcade Email: mathiga@yahoo.commathiga@yahoo.com FOUR BASIC AREAS PSYCHOLOGICAL TREATMENT APPROACH INTERPERSONAL THERAPY MODEL FOR TRAUMA AND LOSS AFTER MACHINE ROLLER ACCIDENT THE 8 TH ANNUAL PAN-AFRICAN PCAF PSYCHOTRAUMA CONFERENCE Immacolata M. Nyaga Clinical Psychologist & PhD Candidate, University of Nairobi Nyaga Counseling Services, Adams Arcade Email: mathiga@yahoo.commathiga@yahoo.com

2. 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. 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.

3. 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. 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.

4. 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. 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.

5. 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.

6. 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. 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.

7. 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. 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.

8. 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:

9. 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. 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.

10. 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. 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.

11. 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.

12. 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 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.

13. 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 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.

14. 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). 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).

15. 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. 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.

16. 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.

17. 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.

18. 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. 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.

19. 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.

20. 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. 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.

21. 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. 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.

22. 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. 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.