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Psychological reactions to trauma: working with patients

Part one of this article, published in the last issue of Nursing in Practice, described some of the diagnostic features of a traumatic reaction. Here, Ashley Conway addresses some of the clinical issues, dividing them into three areas: sensitivity, clinician's comfort level and further therapy

Ashley Conway
BSc(Psychol) PhD(Psychol)
Chartered Counselling Psychologist, Harley Street, London

Sensitivity is paramount in both detecting the existence of a traumatic reaction and in encouraging disclosure from the patient. One traumatic experience can set off a reaction from an earlier one, so we can often be dealing with a response that is multi-layered, and may sometimes seem out of proportion to events. It is important to be aware that symptom appearance may have delayed onset. Patients may present with symptoms soon after a trauma, or many years later.

Traumatic responses can be triggered by apparently benign cues. A sadly common example of a benign trigger that might be encountered by nurses would be taking a smear test. If a patient seems very avoidant, or extremely distressed by the prospect of undergoing this procedure, it would be sensible to wonder why. For a woman who has experienced a sexual trauma, any such invasion of her body would be likely to trigger a traumatic reaction. It is wise to be sensitive to apparent over-reactions to any physical procedures.

In this case, noticing the woman's reaction is the first step, followed by consideration of the possible explanations for the behaviour that you observe, without judgement. Then you have to decide what you are going to do next! Sensitivity is important at this stage, in deciding whether to ask questions to prompt disclosure. Of course it will often be appropriate to refer on (see below), but a nurse might well be the first point of revelation of a trauma, and good handling at this early stage will help to provide a very good start to positive therapeutic change.

So, what do you say and what do you not say? In the early stages, do not ask specific or invasive questions, such as, "Have you ever been raped?" Do ask open, general and noninvasive questions, such as, "Does this remind you of something?" "Has there been a time when you have felt like this before?" You can also ask patients if they experience flashbacks or nightmares, or symptoms of hyper arousal such as an exaggerated startle response or sleep disturbance. Then you have to give patients time to talk. If they need more time, make a further appointment (perhaps booking a double slot) soon, and follow up the conversation. Traumatised patients generally need more time than others.

So, over-reactivity to a procedure might be a clue to a traumatic history, and, paradoxically, so might under-reactivity. Patients with histories of repeated trauma (particularly in childhood) may have learned to dissociate – to separate out their thinking, feeling and perception. A patient who had been abused for years during his childhood described to me his strategies for dealing with physical trauma. He would imagine himself shrinking down to a dot the size of a full stop, something too small to feel anything, or he could feel himself drift up to the ceiling and casually observe what was being done to the body below him. In this way he had undergone a number of medical and dental procedures without anaesthesia (and clinicians were thinking that he was "brave"). It is possible to get an idea if a patient is really relaxed with a procedure or dissociating by asking a few trivial questions. Is the patient oriented in time and place? If not, ask yourself what is really going on.

One of the common features of a traumatic reaction is avoidance, which may be of places, things, thoughts or speaking about reminders of the trauma. Therefore, it is good to be aware that patients may be understating their story, or minimising their symptoms.

Full symptoms and histories may not be volunteered easily. A patient was violently assaulted in a pub brawl. He told me that a piece of glass embedded in his scalp was making it difficult for him to rest his head comfortably, and so his sleep was disturbed. When the piece of glass was removed I asked him if he was more comfortable now. He replied: "Yes, because the other pieces don't bother me so much." Unfortunately, neither I nor the GP had thought to ask if there were other pieces, and this information had not been volunteered by the patient at the outset.

If you do get information that a certain procedure re-activates a trauma, there is something immediate and practical that you can do: give the patient control. This is what they will have lost during the trauma.Give it back to them. Let them choose when to have a procedure and if they want somebody else there, and, importantly, give them a way of saying "stop", either verbally, or with a signal such as raising a hand.

Do stop if they give you that signal, and then begin again when they are ready. This simple method of giving some control back to the patient can in itself be very therapeutic.

Working within your level of comfort and expertise
The patient needs to be able to feel safe to make their disclosure, but often it is difficult to really listen to somebody talking about a major trauma. A good listener needs to be able to bear the pain and distress of the patient. This is not easy.

Listening to a patient talk in detail about a rape, assault, or childhood abuse can be traumatising to the clinician. It is important for the therapist and the patient to take care of this risk of secondary trauma. For the clinician it is helpful to get supervision from a colleague experienced in the field, or at least have a place to discuss the issues with a trusted peer. It is important for patients, too, because often they will be exquisitely sensitive to distress in the person that they are talking to. If they feel distress in the listener, they may stop their account or revert to understating the story and its consequences.

Sometimes, because of the nature of traumatic memory, the patient can be uncertain about some details or events, and seek clarity from the listener. "I have this picture in my head, so it must be true, mustn't it?" The answer to this question is "I don't know." Psychologists now believe that traumatic imagery may be a literal representation of what was seen or even imagined (I have talked to patients with very vivid images of events that took place in the dark, and could not have been literally seen), and imagery may be metaphorically true (for example, a patient who had been physically abused by her mother had a very strong image of herself being stretched on a mediaeval torture rack, with her mother in charge of the machine). As clinicians we have to be able to tolerate the uncertainty of not knowing what is true, and respectfully not be drawn into a discussion about being certain.

Dealing with traumatised patients is best carried out with a team approach including the primary care team, probably a specialist psychologist, perhaps a psychiatrist, and it may be appropriate to involve social services.

Further therapy
Although it is not recommended in the first instance, drug therapy may be appropriate in some cases (see National Institute for Health and Clinical Excellence (NICE) guidelines). Antidepressants and hypnotics in particular may be helpful, and if the patient is self-medicating with alcohol or other substances, specialist treatment for these problems is advisable.

Often, partners and family will be struggling to deal with a traumatised individual. The patient's comfort with feelings and intimacy may be compromised, and it is often helpful to invite family members in for the provision of information and support. NICE guidelines recommend that sufferers of post-traumatic stress disorder be offered a course of trauma-focused cognitive behavioural therapy. This style of therapy may include:

  • Psycho-education about the consequences of trauma.
  • Attention to negative cognitions (eg, for somebody who was injured in a road traffic accident, "If I go in a car again I'll get killed").
  • Behaviour (helping a patient to re-engage with situations that they had been avoiding).

It might also include strategies such as breathing retraining to help patients calm their physiology as they begin to face the feared situation, and assertiveness training to help patients to express their feelings appropriately and safely. Eye Movement Desensitisation and Reprocessing (EMDR) is another specialist technique recommended by the guidelines.

My personal observation is that there is a risk of omitting the factor that may be the hardest on the therapist – the emotion. A father whose child had been murdered was "being strong" for other family members, and giving himself no space for his own feelings. He began to experience numerous somatic symptoms.

His sessions with a psychologist became the safe place where he could cry. After a few sessions of crying his symptoms began to improve.

Trauma frequently causes a disintegration of consciousness, memory, perception and feelings, and good therapy is about bringing about re-integration of these various parts. To achieve this usually requires a multilayered, multidisciplinary approach. Nurses on the frontline are well placed to be an active part in helping patients heal traumatic experiences.

Reference
1. National Institute for Health and Clinical Excellence (NICE). Post-traumatic stress disorder (PTSD): The management of PTSD in adults and children in primary and secondary care. London: NICE; 2006.

Further reading
Schiraldi GR. The Post-Traumatic Stress Disorder Sourcebook. New York: McGraw-Hill; 1999.