Behrooz is a twenty-seven year old man originating from Iran and residing as a refugee in the Netherlands. He was referred by a general practitioner with complaints of impulsivity and aggression outbursts. He was suffering from these problems for many years, but has not sought help earlier. The practitioner suspected Behrooz from ADHD, and asked for diagnostics and treatment. At time of the referral, it was unknown how and when Behrooz ended up in the Netherlands. The only information available was that he had lived illegally in the country for a long time, and that a residence permit was granted to him four years earlier, when the immigration department legalized all illegal immigrants through a general pardon.
During his first interviews, Behrooz stood out because of his loud speaking and agitated behaviour. He was, in particular, angry about the way the Dutch society and politics had treated him. As Behrooz gained more confidence in the therapist, and realised that he was not unfamiliar with the lengthy and impersonal asylum procedures and their impacts on an individual, he started to disclose more about his remarkable past.
Behrooz was born a few years after the Islamic revolution in Iran. His family was liberal and had been politically active for generations. As the youngest son, Behrooz started to participate in their political activities already at a very young age. He attended secret meetings and helped distributing leaflets in the streets. At the age of twelve, he was arrested and jailed by the Iranian secret service. He was brutalized and tortured for days, until he was released because his family had paid a ransom. Shortly after his release, the family arranged for Behrooz to leave Iran illegally and escape to neighbouring Turkey via the mountains. This turned out to be a frightening experience because he got lost on the way, and failed to meet the contact person who would guide him across the border.
In the therapy sessions, Behrooz denied being bothered by these events. He stated repeatedly that so many people from Iran had similar experiences. He felt he was no exception and therefore should not be bothered by them. In Turkey, he eventually found domicile with an older man who gave him odd jobs, such as collecting scrap metal and selling it, in exchange for food and lodging. In company of this man Behrooz found protection and a sort of mentorship. This was important as he was still young, separated from his family, and illegally in the country with no rights whatsoever. Behrooz quickly got streetwise, learned about how to survive, and became a specialist in small businesses and arranging odd jobs for others.
At the age of sixteen, his family in Iran informed him that the Netherlands has a separate asylum procedure with extra protective rules for minor refugees and that within this procedure his chances to be recognized as a refugee were substantial. They advised him to leave Turkey and join an aunt who was already living in the Netherlands for more than ten years. On arrival and asking for asylum, Behrooz was placed in a small-scale shelter, got a mentor and went to school, where he learned Dutch fluently in a short period of time. However, his asylum procedure did not fare well. The immigration authorities did not believe his narrative of flight and his request for protection, partly because of the young age at which he claimed to have been politically active and because of the length of time he had spend in Turkey.
As a consequence, Behrooz was forced to leave the shelter immediately after his eighteenth birthday and, yet again, forced to find his way in illegality. He lived as a squatter for five consecutive years. He was seriously disappointed and outraged, as this situation reminded him of the time he had spend in Turkey. Moreover, he had developed different expectations about his future in the period he was accompanied as a minor asylum seeker. At the age of twenty-three Behrooz was finally granted a residence permit within a general pardon. He expected to be happy, but on the contrary felt seriously disappointed in himself and what he had achieved in life. Due to illegality he could not complete a vocational training and was obliged to find a layman's job as quick as possible or all his social benefits would be stopped.
When the therapist inquired about his complaints, Behrooz indicated that he was mainly concerned about the fact that he had so little self-control and that he could rapidly become extremely verbally aggressive to other people. He felt very guilty and ashamed about it. In these outbursts he would accuse the other of being unreliable, lying and intentionally aiming to harm him. He added that being out of control also terrified him, because he had not any recollection of what had been said by himself or by others afterwards. This led to the hypothesis that he experienced dissociative phenomena (which was later confirmed in the therapy). The suspected ADHD was confirmed by a diagnostic interview, and extensive inquiries were made on PTSD. However, Behrooz denied suffering from nightmares or other re-experiencing phenomena. He insisted on being angry over the particular period in his life when he fought for the residence permit and felt abandoned by the Dutch society and the minister of immigration.
The first intervention in a course of the treatment was to prescribe Behrooz a psycho stimulant (Dexamfetamine). This lead to reduction of the sensation of chaos in his head and a better control of emotions. Medication also caused that he became more accessible for constructive exploration of his life and emotions as he no longer got overwhelmed by anger during the sessions.
Eventually Behrooz started to share his experiences from Iran and Turkey, and admitted for the first time that he has also occasionally suffered from nightmares for many years. As it turned out, he consciously wanted to keep that information to himself, because he developed a personal theory about the function of his nightmares. He suffered from them from the age of twelve, and believed that the nightmares were a way of dealing with his past. He also had the expectation that they would disappear when he worked through them. After re-evaluation of his complaints, the therapist concluded that Behrooz fulfilled criteria for the PTSD diagnosis and an inventory was made of his traumatic experiences.
Behrooz received psycho-education about the symptoms of PTSD, such as hyper arousal and its similarities and differences with hyperactivity and impulsivity complaints of ADHD. These symptoms are often difficult to distinguish in patients with both disorders, especially in those who have been traumatized at a young age. In the follow-up sessions, the traumatic recollections were treated with EMDR. As a result, the nightmares disappeared and Behrooz also reported changes in his state of hyper alertness, a phenomenon he was never aware of as he had grown up with it and did not know better. After the trauma-focus treatment, Behrooz continued with his therapy and contributed a personal signification to his experiences. He redefined the survival skills he mastered in the forming periods of his life to personal capacities. Behrooz achieved a so-called posttraumatic growth. He began to create a newly balanced personal and professional future in which he started a vocational training as an electrician. The therapist played hereby an important role, advocating for Behrooz with the local government which paid the costs of the training.
The rationale for development of specific symptoms in the course of Behrooz's life only became apparent when the therapist was able to build a trust relationship and together with Behrooz carefully and patiently map his personal history. He originated from an action-oriented family, had an inherited disposition to ADHD, and was tortured and traumatized at a very young age, leading to the evolution of survival strategies and dissociative phenomena of which he himself was unaware. As it showed during the therapy, his way of living was dictated by coping with PTSD with dissociative characteristics, expressing themselves in impulsivity and aggression. From the moment he got a residence permit, Behrooz relaxed and had more time to think and reflect on his life. Disappointment about what he had achieved dominated his thoughts, and the unanticipated continuation of his impulsivity and aggression drove him to find help. Although Behrooz has already made great progress in his therapy, the process is still not completed as the psychological damage inflicted at a young age demands prolonged consolidation and help in shaping a stable personal and professional future for himself.