Special Considerations in the Treatment of Traumatized Patients

In the past decade, environmental factors of mental illness have often been neglected. Patients with a history of traumatic stress are notoriously treatment-resistant. Restitutio at integrum is rare. I have previously pointed to the fact that trauma-related psychopathology and/or trauma-related behavioral patterns may be on the rise (Novac, 2001). Consequently, the prevalence of a variety of comorbid mood dysregulations (including mixed bipolar and atypical depression) and residuals of posttraumatic stress disorder (PTSD) is expected to increase in the future. This prompted the release of practice guidelines by the International Society of Traumatic Stress (Foa et al., 2000). A glance at the table of contents shows the numerous treatments currently used for PTSD. Specialized trauma centers tend toward a multimodal eclectic approach, further supporting the variability in treatment response of patients with PTSD (Foa et al., 2000).

Treatment Setting

Psychotherapy should be conducted in a predictable, quiet environment. In treating trauma patients, therapists should evaluate the office for possible reminders of the traumatic event (Clinical Case 1). Minor details can be very effective in making the patient more comfortable. For instance, the same receptionist should always be available for trauma patient intake. Here, more than anywhere else, familiarity, predictability and individuality create an atmosphere conducive to healing.

Most often, trauma patients want to know what the therapist's personal experience with trauma has been. Such credentialing is important for many trauma patients before they can open up and trust. A concise presentation of how the therapist understands and respects trauma patients is necessary. This can be done safely without creating boundary problems and will lead to a strengthening of the therapeutic alliance. Such personal revelations are advisable and seem to be a major difference between treating trauma survivors and other patient populations (Wilson and Lindy, 1994).

Acutely dysphoric patients may have a resonating effect on the hyperaroused patient with PTSD. Hence, polytraumatized individuals may need to be separated from dysphoric crisis patients.

The importance of addressing the impact of trauma on marriage and family early in treatment has been recognized (Figley, 1988). Supportive and active techniques are most commonly used. Marital and family therapy aims toward the preservation of the family unit as an important support system for patients with PTSD. The possibility of secondary traumatization of family members, including that of children (intergenerational transmission of trauma) should also be systematically explored (Clinical Case 2).

The Treatment Team

Currently, most trauma patients are privately treated by one clinician. Tertiary institutions should serve as a support for the trauma community. Case presentations, educational events and communication between trauma therapists are excellent network enhancers. In teaching hospitals, trauma services should be led by more seasoned clinicians with good ties to the community of practitioners. They also must be well versed in the dynamics of groups and organizations in order to rapidly address difficult cases of countertransference. Experienced trauma clinicians should always be available for consultations in the form of support, debriefing and professional supervision (Clinical Case 3). Unfortunately, in spite of a large body of theoretical literature, too often empathy is discussed late in student and resident training. At times, overworked nursing staff exhibit empathic failure and diminished listening skills.

Symptoms of trauma patients and some Axis II patients are sometimes considered part of the same continuum. However, in recently traumatized patients, ego-dystonic symptoms are prevalent. Empathy cannot be separated from the transference/countertransference paradigm.

In this regard, Atwood and Stolorow (1984) described two common situations: 1) conjunctive countertransference, where the patient's experience resonates with and is assimilated by the internal experience of the therapist, which enhances empathy and facilitates the therapeutic process and 2) disjunctive countertransference, whereby the therapist alters the meaning of the patient's experience in accordance with their own history, which can result in the patient feeling misunderstood. To correct disjunctive countertransference, the therapist can create new points of reference and reset themselves into an empathic mode of understanding the patient's subjective experience.

Empathic strain may often lead to premature termination of therapy, neglect and retraumatization of the patient. A permeable boundary -- a flexible balance between empathy and limit setting -- will encourage the development of healthy boundaries for the injured person. McCann and Colletti (1994) referred to the alternation between an empathic position of the therapist and the phenomenon of being understood by the patient as an "empathic dance," which facilitates understanding and propels the effectiveness of the therapeutic process.

Countertransference

The regressive effect of trauma often gives rise to a transference that associates the therapist with victimhood, shame and demanding assumptions. Therapists may respond with complementary reactions. Two major patterns have been described: 1) avoidant countertransference, in which the therapist distances themselves from the traumatic stories and the patient and 2) overidentification countertransference, in which faulty boundaries may lead to the therapist feeling overwhelmed, exhausted and ineffective (Wilson and Lindy, 1994).

A multitude of factors can influence the particular type of countertransference invoked: the nature of stressors, the trauma stories, the therapist's personal beliefs and perceptions, the patient's demographics or personality characteristics, and institutional factors such as attitudes toward trauma patients and adequacy of resources. With special trauma patients (e.g., victims of genocide or war), countertransference factors may originate in the greater societal context, i.e., prevalent attitudes toward certain events or trends in psychotherapy. In the case of man-made traumatic events, the therapist has to confront the evil side of mankind, which has been referred to in the literature as existential shame (Danieli, 1994). Under such circumstances, the countertransference often becomes directed toward the trauma per se.

A good knowledge base of the historical context of traumatic events is tantamount. Danieli (1981b) described an early reaction to survivors of the Holocaust, where psychotherapists, families and society adopted a suppressive attitude, referred to as a "conspiracy of silence." The failure of therapists, families and society to share part of the patient's pain has been referred to as a second injury to victims (Symonds, 1980).

The therapist's adverse reactions to trauma patients has been described under different constructs: burn-out (Freudenberger and Robbins, 1979), which includes symptoms of depression, cynicism, boredom, loss of compassion and discouragement; secondary victimization (Figley, 1983), where therapists and others who are close to the victim develop symptoms similar to that of the victim, including PTSD; or countertransference (Danieli, 1981a; Lindy, 1988).

Drawing on constructivist self-development theory, McCann and Pearlman (1990a) described a profound change in some therapists who work with traumatized individuals. Here the therapist's beliefs, expectations and assumptions about the world are changed by repeated exposures to the patient's traumatic events. Such therapists may become distrustful, suspicious, cynical and often adopt thoughts and images about their own personal vulnerability. At times, images similar to those reported by their patients may be triggered by relatively benign stimuli outside work (McCann and Pearlman, 1990b). Therapists affected by vicarious traumatization may develop diminished esteem for other people or the human race in general, which results in feelings of bitterness and pessimism. In time, vicarious traumatization deeply affects the therapist's personal life and the ability to maintain a therapeutic stance.

Intervention must be preventive, by a modified type of case conference in which countertransference can be processed (McCann and Pearlman, 1990b). Personal consultation, psychotherapy, support groups and professional organizations may all maintain the functionality of the trauma community, especially when centered around a local tertiary teaching hospital.

Conclusions

The treatment of traumatized patients is complex and necessitates adequate training, an eclectic and flexible approach toward the patient, and an adequate support structure for therapists by other professionals, community and tertiary referrals. Extensive knowledge and understanding of countertransference, empathy and secondary traumatization is crucial. In spite of the many pitfalls, including consequences on the mental well-being of a trauma therapist, there is a great potential for personal growth, pioneering research and professional mastery in the field of traumatic stress.

References:

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