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).
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.
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