This is a case conceptualization I wrote for my Cognitive-Behavioral Therapy for Children and Adolescents course. Enjoy :-)
Carl Grimes is a 14 year old boy dealing with a significant amount of stress and symptomology as a result of having experienced a number of traumatic events in the past two years due to the onset of the zombie apocalypse. Carl is the son of Rick and Lori Grimes, and has an infant sister/half-sister, Judith. Each day brings a new struggle as Carl is confronted with painful memories of his past experiences, as well as the gruesome, life-threatening situations that have become his present reality. This leads him to be in a constant state of fear of the world around him, other people (both human and zombie, or “walkers”), and himself at time in regards to the decisions he has made and the impact they have on who he is today.
Carl’s presenting problem began at age 12. At this time he was a middle school student growing up in King County, Georgia with his mother, Lori, and father Rick, who was a police officer at the time. Carl and his mother were at home when they found out that his father was shot and resided in the hospital in a coma. Carl was left devastated, only hoping that his father would soon awake. Shortly after a disease outbreak occurred where much of the human population began reanimating as what can only be described as flesh-hungry corpses that walked among the living. These creatures posed a threat to all other humans that may be bit or scratched by these zombies, or “walkers” as they would come to refer to them. At this time his father’s partner in the police force, Shane, approached Carl’s mother and told them that his father Rick was dead, and that they had to go to Atlanta, which was thought to be free of walkers. Lori and Carl are again left devastated in dealing with the perceived finality of Rick’s passing.
After traveling to Atlanta, they soon realize the city has been over-run, leaving Shane, Carl, and his mother to take shelter among other survivors that set up a camp in outskirts of the city in the mountains. In this time Carl is very shy, and somewhat reserved, only interacting with a small group of authority figures that he trusts in the camp, Shane, his mother, and another older male of the group, Dale. Carl exhibits several behaviors that indicate how frightened he is of the new world around him, and has a difficult time adjusting to this change, realistically. He often seeks support, and comfort in his mother. At this point of personality development, Carl is characterized by an unconditional kindness and caring for others that he is close to, especially when they are in need of emotional support. His father Rick comes back into his life when he is brought to their campsite by other members of their group. Carl is elated to learn that he is alive, and is emotional upon seeing him for the first time.
Carl is soon confronted with the harsh realities of this post-apocalyptic world when their campsite is overrun by walkers, and he is forced to witness the gruesome deaths of several people in his group. After this point he begins to develop a bolder, more brave outlook on life, and feels somewhat less frightened of the world due to constant exposure to a variety of life-threatening events being on the road. Months later, during a horrible hunting accident, Carl was shot and badly wounded. Luckily his father and the rest of the group were able to seek refuge at a farm with an older man, Hershel, and his family. Hershel was trained medically, therefore able to perform surgical procedures that saved Carl’s life. After this near-death experience we see a huge shift in Carl’s personality development. He begins to react with coldness, and hopelessness. These and other maladaptive negative thought patterns begin to emerge, reinforcing Carl’s initial core belief that the world around him is not safe. He also shows differences in his religious beliefs and begins to question the existence of God in light of these awful times, which worries his mother. He grows increasingly emotionally distant, and begins to regularly disrespect authority figures. His emotional distance and coldness becomes increasingly more evident after he learns that another child in the group, his friend Sophia, has turned into a walker, and was subsequently killed before his eyes.
Despite the emotional distance he has utilized in order to cope with the trauma he has experienced, he actively pursues an authority position within the group, and seeks to prove himself to the rest of the group. He accompanies the men of the group in gun training so that he can be ready to do what he needs to do in the event of an attack. While he does show great gains in his development independence and logic in his actions, he also exhibits a great deal of pessimism, and rudeness towards others in the group due to his inability to emotionally come into contact with his past trauma. One example of which is an incidence where he insults Carol, a female adult in the group, for talking about heaven, and the existence of a higher power. These outbursts of anger, and insensitivity towards others occurs frequently during this time, however he does show signs of feeling guilt for his actions, and reports feeling shame and apologizing afterwards. In his time on the farm, Carl is confronted with a several other significant traumatic events directly involving him, which cause him to question himself and his decisions. The first of which being his indirectly causing the death of one of his closest friends in the camp, Dale, who was killed by a walker that Carl failed to kill the previous day. Carl experiences an immense amount of guilt, and negative thoughts such as “I am a failure”, and “This is my fault”. Soon after he is forced to shoot and kill Shane, after he turns into a zombie and goes after his father. It is at this point that Carl further internalizes the idea that in this world he will have to mature in order to survive.
Months later, we see Carl developing into the role of a child soldier, and has subsequently hardened in many ways. After having spent months practicing and developing his skills with firearms, and tactical abilities he has begun to mature and become an integral part of the group, and grew into manhood in a sense here. He also has grown into a strong protective force for his mother, who was pregnant during this time. The group sought refuge in an abandoned prison in order to maintain safety in the months that Lori would give birth. Unfortunately, during a walker invasion of the prison, Lori went into labor, only accompanied by Carl and another adult female, Carol, who both had to assist in delivering the baby. During childbirth, Lori passed away. In order to ensure his mother would not reanimate as a walker, Carl was forced to take it upon himself to shoot his mother in the head. This served as a significant traumatic experience for Carl, as his mother was perhaps his most consistent emotional support throughout all of his prior experiences. With this action there is also a great deal of emotional confusion. Carl is deeply affected by having to kill his mother, grieving her death, dealing with his father’s extreme emotional reaction to her passing, while also being confronted with some positive emotions in regards to the birth of his sister, Judith. The action Carl had to take by shooting his mother also acted as a reinforcing event, confirming his belief that in this new world he has to make difficult choices in order to stay alive, and keep others around him safe.
Carl’s grieving process only increased this sense of coldness, and lack of child-like activity in daily living. His group begins to settle into a relatively safe environment within the walls of the prison; however Carl continues to experience thoughts that he is not safe anywhere in this world. Though he is very comfortable with those in his group, it becomes increasingly clear that he is reluctant to trust newcomers. This overarching fear led him to compensate in two different ways. The first by rejecting others that attempted to befriend their group. This is specifically shown in one instance when Carl shot and killed a boy from another camp that approached them with a gun, even though the boy had surrendered. His explanation to both Hershel and his father being that he did not want to make the same mistakes they did, and allow others to bring harm to their group. The second way in which Carl over-compensates for his fear of unfamiliar people is by engaging in high risk behaviors in order to keep those around him safe. He became increasingly brave, and helped bring others to safety, even when it put his own life at risk.
As Carl turned 14 years old, his father stepped down from a position of leadership within their group, in order to pursue a more neutral position within their microcosm of society, farming and producing food for the group. Rick made this decision in part due to Carl’s experience in this world, and his desire for Carl to be able to “be a kid again”. Carl was cooperative, and took joy in helping his father, however, he missed being able to carry his gun, and feel as though he could defend himself, and others should there be an attack. This caused Carl to be somewhat resentful, and to question who he was now that he could not assume the cold soldier or protector role that he once had. Due to a recent threat made by someone from an opposing camp, the Governor, Carl often felt anxious that any day an attack could be made, threatening his life, and the safety of their entire group. His environment acted as both a safe-house against the walkers, and other potential threats, and also as a source of anxiety because someone may try to take it from them.
The most recent traumatic events Carl has experienced are two that represent his current symptomology, and further solidify his experience of Posttraumatic Stress Disorder. Some months after the Governor’s threat, the prison in which Carl’s group was staying experienced a disease outbreak, leading to the quarantine and subsequent deaths of many people that Carl came to care about. Carl was not infected; however he came into direct contact with those grieving the loss of their loved ones, and the repercussions of such a gruesome event, that occurred in what he had conceptualized as a “safe place” up until this point. This again confirmed his core belief that “Nowhere is safe”. Due to this outbreak, Rick allowed Carl to resume his prior role, and allowed him to carry a gun again. This left Carl feeling more secure until days later when the Governor arrived outside of the prison gates with a coalition of people ready to open fire on his home. In the standoff between the Governor and Carl’s father, he was left to stand and watch with his group, as negotiations were attempted. Carl soon realizes that the Governor has taken hostage two of their own group member, Hershel and Michonne, two adult members of the group whom he is closest to. During this time Carl experienced extreme emotional distress, and felt as though he could not move, only clutching his rifle tightly. Despite his father’s efforts to plead with them, the Governor retaliated by decapitating Hershel as everyone watched. Gunfire ensued and the majority of Carl’s group were separated. He fought his way through the others and found his father critically injured. He was forced to carry his father out of the fighting to find his sister Judith. Unfortunately upon their return to the prison all that could be found was Judith’s empty, blood-covered car seat. Rick and Carl were further emotionally overcome, and were subsequently forced to escape the prison to look for new shelter on their own.
Since these events Carl and his father Rick have settled in a home together for the time being, devastated by the loss of everyone closest to them. Carl experiences intrusive thoughts about the battle at the prison, including vivid nightmares. He also exhibits persistent symptoms indicative of increased physical arousal including difficulty staying asleep, irritability, outbursts of anger, and an exaggerated startle response. There is also some evidence to support a feeling of detachment from others in regards to his relationship with his father now compared to before the most recent traumatic event. He blames him for what happened at the prison, and often experiences moments of depersonalization when his father tries to talk about what happened with him. He consistently avoids stimuli associated with the traumatic event, and finds it difficult to function as he must in everyday life. The continuous experience of traumatic life events, coupled with his anxious presentation and symptoms in reaction to these events suggest Carl is experiencing Posttraumatic Stress Disorder (PTSD), as defined within the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; APA, 2000).
Carl has experienced an excessive amount of trauma within the past two years of living in a post-apocalyptic world, and his avoidance of emotional information relating to the traumatic experiences have been used as means of maintaining and coping with since their onset. Carl’s exhibited symptoms of PTSD would be best treated by an intervention in which trauma is specifically targeted, as well as his means of coping with such trauma. This type of treatment would not only benefit him in relation to his present, and past trauma, but it may also help to establish core skills in order to better handle future trauma, that is likely to occur in such an environment. An intervention focusing on his behavioral disengagement, and negative thought processes and maladaptive core beliefs would also be beneficial for Carl’s development. For this purpose, Trauma-Focused Cognitive Behavioral Therapy will be utilized to target specific symptoms (TFCBT; Cohen, 2005).
Goals of Treatment:
- Psychoeducation to define what trauma is, why it occurs, different types, and the effects of trauma. This will help Carl to understand his experience more thoroughly, and begin to relate to it, and process through it more openly.
- Use of relaxation training and thought stopping to combat negative thought patterns and better cope with anxiety response.
- Teaching healthy ways of expressing emotions, and how to better regulate emotional reactions.
- Development of a trauma narrative of the most recent trauma to help Carl confront the feared stimuli associated with the event itself and become desensitized to the re-experiencing of the event by processing through it cognitively in much detail.
- Behavioral interventions to get Carl to engage in more adaptive behaviors, and do things that he once found enjoyable.
- Parent training sessions to prepare Rick for Parent-Child sessions, and a discussion of Carl’s trauma.
- End-goal of treatment is to allow Carl to have fully processed the most recent traumatic event, thereby encouraging him to be more emotionally expressive about his negative emotional experience, and relate to the trauma in a less extreme way cognitively, affectively, and behaviorally.
Possible Barriers to Treatment
There are several potential difficulties that arise in treating Carl’s PTSD symptoms. Firstly, his environment is not entirely conducive or supporting of emotional change. This zombie-ridden world is certainly not a safe place; therefore challenging Carl’s negative core beliefs about the world around him may not be relevant given the state of the world at the time. Along this same thought, Carl’s means of coping with the world may not be necessarily considered problematic in some ways. Due to the experiences he has had, and is forced to confront to some extent each day, it may be the best option for him, given the circumstances, to switch into the child soldier role in order to ensure survival. Practically, another obstacle to treating Carl would be in keeping regular appointments. Due to the nature of a post-apocalyptic world, it may not be convenient to come to weekly sessions when his family is forced to relocate constantly in order to stay safe from walkers. Another barrier that may influence therapeutic outcome is the fact that there have been numerous trauma’s, and this recent trauma may only be one incident contributing to his symptomology. He is also at significant risk to experience subsequent traumas, therefore, the effect of treatment may be little in relation to the other experiences he has had in the past, and will inevitably have in the future. Lastly, the idea that Carl is grieving the perceived loss of several influential people in his life could certainly have an impact on the effectiveness of TFCBT. It may be beneficial to also focus on grief in relation to the PSTD symptomology at hand in order to see the most positive change.
Below is a brief dialogue of what a session may look like with Carl. The topic of this session is centered on having Carl effectively identify, and express emotions in various situations with a secondary focus on regulating his emotions in healthy ways in that moment. There are also some cognitive processing techniques used when appropriate.
Therapist: Okay, Carl. So I remember you saying before that you don’t like showing others how you’re feeling.
Carl: Yeah, I don’t.
Therapist: Especially when what you’re feeling isn’t happy right?
Carl: Right. I didn’t like everyone else in the group seeing me upset. Or my Dad, or anyone.
Therapist: Okay. So when you’re upset, I might not know it by looking at you?
Carl: Yeah. I guess not. I get quiet sometimes. That’s usually how my Dad knows I’m sad, or I don’t want to be bothered.
Therapist: How about when you’re scared?
Carl: Especially when I’m scared. That happens. When we were with the rest of the group, I didn’t like everyone to think I’m scared. I wanted them to think I was brave, and that I could help.
Therapist: Hmm. So what you were thinking was, “If they see that I’m scared right now, then I won’t seem as brave”.
Carl: Yup. That’s what I thought. I want to prove to them that I can help.
Therapist: I understand. But I wonder, do you think it’s possible, to be brave, and be scared too?
Carl: Um. I don’t know. (pauses) I mean. I guess my Dad’s scared. I still think he’s really brave. Daryl is brave, and sometimes I can tell he’s scared. Hershel was scared too.. but he did really brave things. They helped a lot. They were leaders.
Therapist: They sound like really brave people. So, maybe it’s possible to be brave, and do brave things, but still feel scared. And that’s okay.
Carl: Yeah. Maybe.
Therapist: Okay. So let’s stick with “scared”, when was a time you felt scared recently?
Carl: When my Dad and me were getting into the new house we’re in now. We were boarding it up and checking it for walkers. I didn’t know what was going to happen. I’ve seen walkers before. I’ve killed lots of them before. I still get scared though.
Therapist: Did you hide that you were scared like you said before?
Carl: Yeah. That’s what I always do. Walkers are part of life now, I guess showing I’m scared would make me look like a kid.
Therapist: So, you pushed down that scared feeling? So you wouldn’t look like a kid?
Therapist: I wonder, what did you do after that?
Carl: After we were done, I went off by myself for a while.
Therapist: Did you tell your Dad how you were feeling?
Therapist: Did being alone make you feel better?
Carl: Yes. After a while. I felt scared for a while though. And then I had a nightmare about walkers that night.
Therapist: Sometimes being alone helps, but there are a lot of other things you can do to help you feel better when you’re scared. Like talking to your Dad, writing about it, drawing something. There are a lot of ways you can express your feelings that can make you feel better. Sometimes holding them in makes them worse.
Snow day laziness at its finest
In honor of tonight, my main man #WalkingDead #thegovernor #lessthan1hour
Most attractive intern award goes to.. #selfie #nofilter #attractive
Best Valentines day card #ever #valentine #nopantsRthebestpants
Tattoo convention hangs #darthvader #philly @caspoorly
Fresh #tattoo #numero4 #diefighting @pbandjaybird ‘s handwriting :)
He loves the Walking Dead #kitty #walkingdead #cuddles
Because she’s perfect #wcw #cobiesmulders