[removed],

Case of Amy Amy is a 25-year-old Native American and Caucasian mixed single woman who is seeking counseling due to self-reported anxiety symptoms. She presents as well kept, and was dressed casually wearing a blouse and jeans and fringed leather boots. She has olive skin and light brown medium length hair and smiles as she steps into the office. She sat in a corner on the largest sofa and quickly picked up a decorative pillow which she held in her lap. She stated she lives in an apartment with her pug mix dog named Bandit and has several close family members and friends nearby. Her family upbringing was stable despite living in poverty while on the reservation. Her parents divorced when she was a teen and she relocated with her mother and siblings when she was 15 to a smaller town in North Dakota. She stated her father was a heavy drinker when she was growing up and her mother smoked some cannabis to “mellow” out since “she too struggles with anxiety.” She states that she has a strong spiritual background which is rooted in her Native American beliefs but has felt disconnected as she does not currently participate in religious ceremonies of her culture. In addition, she has a brother and sister who live nearby, and they see each other and her nieces and nephews most weekends as the family (including extended local relatives) often gather together. She currently works at a local medical clinic doing billing about 32 hours a week and stated she recently went back to school to pursue an associates nursing degree. She stated “I have been struggling with bad thoughts and panic / worry when I am on campus walking to class.” Upon further evaluation Amy admits that she has flashbacks when walking around on campus to a time when she was on vacation for spring break with her senior class in high school and was sexually assaulted by a former male “friend,” a classmate that she had known for years. She stated that sometimes while walking to class or to the student union building on campus where there are a lot of students milling about she has flashbacks and recalls being physically and emotionally paralyzed, unable to scream or ask for help despite hearing all kinds of people being nearby at a party. While on campus, she often hyperventilates and feels flush and unable to swallow for several minutes until she can get to her car for “safety.” She stated it “feels like I am going to literally die.” She reports that this occurs more often when she has evening courses and walks alone to her car in a nearby parking garage on campus. She reports that she hasn’t dated or had a relationship since that time but had not “really struggled” with any symptoms except mild anxiety until now as she started talking to a male colleague who recently asked her to go out on a date. She also stated she moved away shortly after the incident (barely graduating high school due to missing so much and not wanting to attend) and has only told her sister because the young man who violated her was the city judge’s son and she was afraid of repercussions. She admits her main reason for coming in is because of the horrible flashbacks and anxiety and she doesn’t want to fail school but also she feels her time is “running out” to try to have a “normal” relationship with a man. She struggles with thoughts like, “Why did I let it happen? Why was I so stupid? I am damaged goods now. No one is ever going to love me.” Even though she is really close to her family, she mentions that she has “found myself not going around as much because I know they will notice something is different about me.” She feels disconnected from her spiritual beliefs and instead has started to “drink a few drinks at night to help numb out.” When asked about her drinking, she looked away and was quiet for a few minutes before replying that she would typically have one or two glasses of red wine in the evening and that this would occur from one to three times per week. In looking at her wrists, you notice some red whelps and she quickly puts the pillow over her wrists and drops eye contact as she says “it is not a big deal. I just cut sometimes to help release my feelings.” She states she has extreme difficulty even talking to men in class. When asked what generally occurs when men approach her she reports, “I start to sweat, mentally go off to la la land and I stutter in attempt to get away.” As she speaks, her knees are shaking, and she is clenching the pillow and talking rapidly. “I get mad at myself because I truly want to have a relationship with a man!” Plus she adds, “How am I going to do my medical rounds if I can’t be near men?”