TREATING THE TRAUMATIZED
PATIENT AND VICTIMS OF
Richard P. Kluft, M.D.
Sandra L. Bloom, M.D.
John D. Kinzie, M.D.
Published in Bell, C. C. (ed), (2000). Psychiatric Aspects of Violence: Issues in Prevention
and Treatment. New Directions in Mental Health Services 86, Summer, pp.79‐102.
The profound impact of traumatic experience on the health, well being, and
development of the individual has been recognized since recorded history. The current
understanding of the effects of traumatic experience is a result of the recognition of a
delayed post‐traumatic response among a significant proportion of the returning
Vietnam veterans. The simultaneous recognition of the potentially devastating effects of
child abuse, rape, domestic violence, disaster, kidnaping, torture, terrorism, and crime
victimization led to a recognition that there is a universal human reaction to
overwhelming stress. Further, it has been learned that reaction is psychobiologic and
then mediated through complex individual and social contexts, all of which determine
the final outcome of the adaptive process for each individual.
Trauma occurs when both internal and external resources are inadequate to cope with
an external threat (van der Kolk, 1989). Trauma involves the experiencing, witnessing,
anticipating, or being confronted with an event or events that involve actual or
threatened death or serious injury, or threat to the physical integrity of one's self or
others (American Psychiatric Association, 1994). The event or events lead to a response
involving intense fear, helplessness, or horror. Children may express this response in
disorganized or agitated behavior. To a great extent, trauma responses can be
understood as normal reactions to abnormal stress. However, some persons exposed
to insufficient trauma to satisfy the DSM‐IV definition will nonetheless develop a trauma
response syndrome, indicating some role for individual differences in vulnerability.
Most agree that it is normal to develop some symptoms associated with posttraumatic
conditions transiently, but concur that when symptoms persist this may represent
persistent damage and constitute a mental disorder. Shalev (1997) has hypothesized
that traumatic stress disorder (PTSD) is best understood as a "biopsychosocial trap" in
which there is a permanent alteration of neurobiological processes resulting in
hyperarousal and excessive stimulus discrimination, the acquisition of conditioned fear
responses to trauma‐related stimuli, and altered cognitive schemata and social
apprehension. In addition, the forms of trauma have a interpersonal and
transgenerational impact, and give rise to identifiable and treatable forms of distress
and dysfunction in the concerned others and in the offspring of the victim of violence.
ECONOMICS OF VIOLENCE
Medical bills for the acute care of the child abuse patient averaged $35,641 per case.
Tragically, even at this cost 70% died and 60% of the survivors had severe residual
morbidity (Irazuta et al, 1997). Every incident of child sexual abuse has been estimated
to cost the victim and society at least $99,000 (Miller, Cohen, and Wiersema, 1996).
Domestic crime against adults accounts for over $67 billion a year (National Institute of
Justice, 1996). The National Safe Workplace Institute reports that the average cost to
employers of a single episode of workplace violence can amount to $250,000 in lost
work time and legal expenses (Anfuso 1994). Further, 111,000 incidents of workplace
violence cost employers an estimated $4.2 billion in 1993 (Yarborough 1994). Annually,
gunshot wounds cost an estimated U.S. $126 billion, while knife wounds cost another
U.S. $51 billion (Miller and Cohen, 1997). When the cost of pain, suffering, and the
reduced quality of life is taken into consideration, the cost of crime to victims is an
estimated $450 billion a year (Miller et al. 1996).
Violence is commonplace, and claims many victims. Lifetime exposure to traumatic
events in general American population ranges from 60‐70 percent (Kessler et al.1995;
Norris, 1992; Resnick et al, 1993). It is estimated that 21 percent of Americans have
experienced a traumatic stressor in the last year. For example, one out of every eight
adult women is raped, and 39 percent of them are raped more than once (National
Victim Center, 1993). There is an overall lifetime prevalence of 6.5 percent for
posttraumatic stress disorder, and a 30 day prevalence of 2.8 percent (van der Kolk,
McFarlane, and Weisaeth, 1996).
The kinds of exposure vary. The most common traumatic events, affecting about 15 to
35 percent of the people surveyed were witnessing someone badly injured or killed;
being involved in a fire, flood, or other disaster, and being involved in a life‐threatening
accident. Also common were life‐threatening experiences like robbery, and the sudden
tragic death or injury of a close relation (Solomon and Davidson, 1997).
According to the American Medical Association (1994) more than 25 percent of the
women in the United States will be abused by a current or former partner some time
during their lives. In homes where spousal abuse is occurring, children are abused at a
risk that is 1,500 percent higher than the national average (National Victims Center,
1993). The latest National Incidence Study of child abuse indicates that the incidence of
maltreatment quadrupled between 1986 and 1993 (DHHS, 1996). Multiple studies have
found that one‐fifth to one‐third of all women reported to have had a childhood sexual
encounter with an adult male (Herman, 1981). Jenkins and Bell (1997) report on several
studies done between 1982 to 1995 in which 26 to 55 percent of youth surveyed
reported they had witnessed a shooting or stabbing. One out of every four employees
was harassed, threatened or attacked at work between July 1992 and July 1993
(Yarborough, 1994). Statistics from the United States Department of Justice that 83
percent of Americans will be victims of violent crime at some point in their lives and
about 25 percent will be victims of three or more violent crimes (Walinsky, 1995).
Patients with mental Illness may be predisposed victimization. Both the stigmatization
of the mentally ill and the increased vulnerability associated with deficits associated
with severe mental illness render those suffering mental disorders more likely to be
victimized (Bell et al, 1988; Jenkins et al, 1990).
THE GAMUT OF TRAUMA RESPONSES
Overall, 20 to 25 percent of those exposed to DSM‐IV criterion trauma develop PTSD.
Because victimization and traumatization are common human experiences occurring to
persons with a wide range of premorbid personality styles, ego strengths, diatheses for
mental and physical illnesses, social supports, intercurrent stressors, and cultural
backgrounds, there is no universal profile for victims of violence. Millions of
traumatized individuals go unrecognized and untreated. Further, many specific
populations are highly traumatized, including refugees, who in addition to trauma, also
face the social and psychological disruption of losing their homeland. Studies
demonstrate between 30 to 50 percent of refugees suffer chronic PTSD symptoms. Yet,
while the core symptoms of PTSD occur in all cultures, their expression may vary widely
The more one is exposed to trauma, in terms of severity and duration, the more likely
one is to develop PTSD. For example, among American soldiers in Viet Nam, merely
being a soldier was associated with a 17 percent rate of PTSD; experiencing median
levels of combat with 28 percent PTSD; and of those exposed to heavy levels of combat,
65 percent developed PTSD (Van der Kolk, McFarlane, and Weisaeth, 1996). Early
and/or prior experiences of trauma makes a trauma victim more vulnerable to develop
posttraumatic symptoms, and may increase the severity of those symptoms. Thus,
when PTSD is complicated by both childhood and later adult trauma, it is one of the
most difficult and complex disorders to treat, and may have strong characterologic
components as well.
Although many people appear to recover from trauma without Intervention, many do
not, and require ongoing attention to their distress and dysfunction. Some trauma
victims experience the delayed onset of posttraumatic symptoms, even decades after
the exposure to DSM IV criterion trauma. Posttraumatic symptoms may wax and wane
in intensity and there may be asymptomatic periods. Reactivation or exacerbation of
posttraumatic symptoms may be triggered by anniversaries of the traumatic events,
other stressors including trauma failing short of the DSM‐IV criterion trauma, and both
gross and subtle stimuli reminiscent, suggestive, or symbolic of the criterion trauma.
The short term sequelae of trauma may include re‐experiencing the traumatic event in
several ways, avoidance of stimuli associated with the trauma, defensive numbing,
dissociative symptoms, symptoms of increased arousal, problems with affective
regulation, somatization, demoralization, and psychobiologic abnormalities, such as
extreme autonomic responses to stimuli related to the trauma. Long term sequelae of
trauma may include the persistence of the short term sequelae, with, in addition,
chronic characterologic changes such as chronic guilt and shame, a sense of personal
helplessness and ineffectiveness, the sense of being permanently damaged, difficulties
trusting or maintaining relationships with others, vulnerability to re‐victimization, and
becoming a perpetrator. Autonomic dysregulation, neuroendocrine dysfunction, and
neuroanatomic lesions may occur.
THE ELEMENTS OF THE TRAUMA RESPONSE
1. The traumatic event is persistently re‐experienced in one or more of the
following ways: recurrent and intrusive distressing recollections of the event,
and/or dreams of the event, and/or acting or feeling as if the event were
recurring, and/or distress and or psychophysiological reactivity upon exposure
to inner or outer cues that symbolize or resemble aspects of the event(s).
Avoidance of stimuli associated with the trauma and numbing of general
responsiveness as manifested by: efforts to avoid thoughts, feelings, or
conversations associated with the trauma; and/or efforts to avoid activities,
places, or people that arouse recollections of the trauma; and/or amnesia for
aspects of the trauma; and/or diminished interest or participation in significant
activities; and/or detachment or estrangement from others; and/or restricted
range of affect; and/or a foreshortened sense of the future. Meaningful
attachments may be lost, and the person may fail to participate in planning or
preparing for the future.
3. Dissociative symptoms, such as numbing, detachment, or an absence of
emotional responsiveness; a diminished awareness of one's surroundings (e.g.,
"being in a daze" or "trancing out"); problems with concentration and
attention; derealization; depersonalization; and dissociative amnesia.
Persistent symptoms of increased arousal, such as difficulty falling or staying
asleep, irritability or outbursts of anger; difficulty concentrating; hyper
vigilance; and exaggerated startle response.
5. Problems in regulating affective arousal, such as chronic affect dysregulation,
difficulty modulating anger, self‐destructive and suicidal behavior, difficulty
modulating sexual involvement, and impulsive and risk‐taking behaviors.
Somatization, including so‐called "body memories," in which the physical
sensations associated with traumatization recur in a manner analogous to a
flashback, without conscious connection with the traumatic scenario in which
the physical sensations were experienced.
7. Chronic characterologic changes, such as: alterations in self‐perception,
including chronic guilt and shame, self‐blame, a sense of personal helplessness
or ineffectiveness, a sense of being permanently damaged; alterations in one's
perception of the perpetrator, including adopting distorted beliefs and/or
idealizing the perpetrator; and alterations in relationships with others,
including an inability to trust or maintain relationships with others, re‐
victimization, and victimizing others.
Alterations in one's systems of meaning, such as: loss of trust, hope, and sense
of energy (i.e., despair); loss of "thought as experimental action"; loss of
previously sustaining beliefs; and loss of belief in the future.
9 Psychobiologic abnormalities, including extreme autonomic responses to
stimuli reminiscent of the trauma, hyperarousal to intense but neutral stimuli,
elevated urinary catecholamines, decreased resting glucocorticoids and
glucocorticoid responses to stress, decreased serotonin activity (animal
studies), increased endogenous opioid response to stimuli reminiscent of
trauma, decreased hippocampal volume, and activation of the amygdala and its
connections and sensory areas during flashbacks.
Increased vulnerability to physical illnesses and other mental disorders. Some
forms of victimization also predispose victims to re‐victimization. Those
persons traumatized by those to whom they also have affectionate and
dependent ties often develop a constellation of severe symptoms, problematic
dynamics, socialization to failures in self‐protection, and cognitive distortions
that make them more vulnerable to be victimized once again.
There is an considerably high rate of comorbid psychiatric disorders in the victimized
population. Patients with PTSD were two to four times more likely than those without
PTSD to have virtually any other psychiatric disorder, particularly somatization (Solomon
and Davidson, 1997). In the study by Breslau and colleagues (1991).those with PTSD
were more than six times as likely to have some other psychiatric disorder. Kessler and
others (1995) found that those with PTSD are almost eight times as likely to have three
or more disorders ‐ 88 percent of men and 79 percent of women with PTSD had a
history of at least one other disorder. Kessler’s study also showed men with PTSD were
six to ten times more likely and women four to five times more likely to have affective
disorders than those without PTSD. Similar figures appear with anxiety disorders with
men three to seven times more likely and women two to four times more likely to have
another anxiety disorder along with their PTSD. It has also been shown that between 25
percent and 58 percent of those seeking substance abuse treatment also were comorbid
for PTSD (Grady, 1997). Prolonged exposure to combat, torture, captivity, death and
destruction, and repeated sexual abuse can also bring about long‐lasting personality
change (Herman, Perry and Van der Kolk, 1989; Perry et al., 1990; Pollack et al., 1992;
Southwick, Yehuda, & Giller, 1993). Further, a number of studies have also found
correlations between trauma exposure and panic disorder (Pollack, et al. 1992); suicide
attempts (Angst, Degonda, and Ernst, 1992); eating disorders (Connors and Morse,
1993); depression, bulimia and generalized anxiety (Bushnell, Wells, and
Oakley‐Browne. 1992); chemical dependency (Ellason, et al. 1996); and increased risk
for lifetime diagnoses of major depression, panic disorder, phobia, somatization
disorder, chronic pain and drug abuse (Leserman, Toomey and Drossman, 1995; Walker
et al., 1992). The high rate of comorbidity presents particular challenges in assessment
of victims. Comorbid disorders, such as depression, may be the victim's primary reason
for seeking treatment. Thus, in the face of such high rates of comorbidity, the history of
trauma can often be overlooked.
The evaluation and treatment of victims of violence also requires a team of medical and
psychiatric care givers. Victims present significant difficulties for medical providers who
often misdiagnose their medical problems as psychiatric, thus compounding the
psychiatric and medical problems. Alternately, they may over diagnose medical
problems that have a psychiatric origin, thus exposing the patient to unnecessary
medical and surgical procedures, and an increased risk of prescription drug abuse.
Many victims also experience physical problems that may be related to the effects of
chronic stress on various organ symptoms or the somatic equivalent of the intrusive
sensory phenomena so often associated with PTSD. Sexual and physical abuse results in
a greater number of hospital admissions and surgical procedures, somatization, and
hypochondriasis in adulthood (Salmon and Calderbank, 1996). Victimization,
particularly exposure to chronic trauma, has been associated with many kinds of chronic
gastrointestinal symptoms (Drossman, 1995; Fukudo, 1993; Irwin et al., 1996;
Lesserman, 1996; Walker et al., 1992; 1996 ‐ See Chapter 6), chronic pelvic pain (Badura
et al., 1997; Drossman, 1995; Plichta and Abraham, 1996 ‐ See Chapter 6; Walling et al.,
1994; Walker et al, 1996 ‐ See Chapter 6), chronic pain syndromes (Benedikt and Kolb,
1986; Geisser et al. 1996; Pecukonis, 1996 ‐ See Chapter 6; Walling et al., 1994):
fibromyalgia (Amir et al., 1997) asthma (Davidson et al., 1991); and peptic ulcer
(Davidson et al., 1991). Koss et al (1991) found that compared with non‐victims,
victimized women reported more distress, less well‐being, visited the doctor twice as
frequently and had outpatient costs that were 2.5 times greater.
Recognizing victim’s of violence requires alertness on the part of the examiner to the
elements of the trauma response and the symptoms of disorders associated with
victimization, a keen appreciation of the fact that many forces may cause a person to
withhold a victimization history, and taking enough time to build rapport and perform a
comprehensive assessment. Some victims' distress is evident to the observer, while
others contain their pain. Victim’s of violence should receive an initial evaluation that
evaluates all aspects of posttraumatic symptomatology and all posttraumatic sequelae
and all comorbidity thought to be relevant. It is important not to rely on the presence
of intrusive symptoms and fail to give attention to those symptoms associated with
avoidance. Imaging techniques to assess for possible changes in brain neuroanatomy,
neuroendocrine dysregulation, and neuropsychological assessment of cognitive
functioning may be necessary. Specialized interviews to assess the degree of
dissociative psychopathology, which commonly accompanies the victimization response,
and is frequently overlooked may be indicated. Often victims’ treatment founders
because the full spectrum of posttraumatic sequelae has not been identified and
On occasion the patient may be able to recount an accurate history of past victimization
at the initial interview. However, the clinician cannot be guaranteed that such
information will be forthcoming for several reasons. Shame, memory difficulties,
ongoing re‐victimization or fear of danger, insufficient rapport, and/or failure to make
the connection between life experiences and current symptoms all lead to information
being withheld or unavailable. A thorough evaluation may require several visits, the
review of records, interviews with ancillary sources, and additional consultations (e.g.
neurological assessment, psychological testing, family interviews). Given these potential
barriers, the clinician must retain a high index of suspicion, even in the absence of
historical details, if the stigmata of victimization are present. At the same time, it is vital
that the patients' boundaries be respected and that they be given the opportunity to
explore and reveal their own history at the pace that is safe for them to do so.
If the patient's safety cannot be assured, either because they cannot control their
impulses towards self‐harm, they cannot self‐protect, or they are living in circumstances
that are life‐threatening, then the first step in treatment is to achieve safety while
properly evaluating the situation. The question of safety is a broad one, encompassing
various levels of safety including physical, psychological, social, and even moral safety
(Bloom, 1997). The initial evaluation must focus on the establishment of a safety
contract that may include family and friends as well as the patient. Obvious suicidal
ideation or attempts must be taken seriously, regardless of their past frequency. A
more subtle differentiation may have to be made in the case of other self‐destructive
behaviors like self‐mutilation, binging and purging, compulsive sexual behaviors, or
compulsive risk‐taking behaviors that are attempts to manage overwhelming affect.
More important than whether or not they self‐mutilate may be whether there has been
a change in the patterns of self‐mutilation which may signal a loss of affect control and
impulse control that is potentially life‐threatening. The level of safety will determine
the level of care: inpatient, intensive outpatient, partial hospitalization, and outpatient.
Victims are often reluctant to seek treatment and therefore their situation is often
critical by the time they actually get to a care giver. As a result, it is not unusual to find
that survivors of victimization, particularly if chronic, require an inpatient hospitalization
in order to stabilize their mental and physical condition, achieve a sense of safety, and
begin the process of reeducation and integration. The clinician, however, must be able
to assure the patient that the hospital stay itself will not duplicate previous victimization
experiences of captivity, powerlessness, forced dependency, and disempowerment.
This mandates that the clinician have available hospital‐based resources that can
adequately respond to the needs of victims without causing "sanctuary trauma" (Bloom,
1997; Silver, 1986).
Much of the outcome of the evaluation may hinge on how educated the patient is about
his or her disorder. Educating the patient from the beginning of treatment about the
effects of trauma is in itself a powerful intervention. Since the experience of
helplessness is key in understanding the trauma response, efforts should be made from
the very first contact that encouragement self‐empowerment, self‐efficacy, and
self‐control. Patients who have become familiar with the course of their own treatment
and who are playing an active role in their care can often provide a clinician unfamiliar
with their history, with valuable information as to their present level of safety.
Many diagnostic errors occur when the clinician, unfamiliar with flashbacks, severe
dissociative states, complicated bereavement and the other intrusive symptoms of
trauma, mistakes these symptoms for those of psychosis. Obtaining information from
friends and family members, or previous care givers, can be an asset in these cases. A
patient who has been victimized may appear to be paranoid and unreasonable if the
historical details of their experience are lacking, particularly if the attitude of the
interviewer triggers their underlying distrust and fears of re‐victimization. Responding
to a terrified trauma victim as if they were a dangerous and irrational psychotic can re‐
traumatize the patient and create secondary problems. Inappropriate medication with
antipsychotic drugs can produce iatrogenically‐induced resistance to further treatment.
At the same time, however, psychosis and trauma‐related syndromes may co‐exist, and
sometimes the use of antipsychotics can break the cycle of escalating hyperarousal and
It may be necessary to take a trauma history many times. In the treatment of
complicated cases, it may be necessary to retake the history because initial amnesia or
other factors such as shame or apprehension may preclude discussion of certain events
and reactions early in treatment. Trauma checklists may be useful in this regard.
THE STAGE‐ORIENTED TREATMENT OF TRAUMA
Treatment works, especially when it is made available shortly after the traumatization
as chronicity and comorbidity may complicate responsiveness to treatment. Some
trauma victims can only tolerate supportive therapy as even reviewing their traumata in
detail may be too disruptive to them. For these patients, accepting the severity of their
situations and being with them is the most viable therapeutic stance. As the victim of
violence is often in a vulnerable and precarious state, it is important to observe the
Hippocratic axiom, “First, do no harm”.
There is general consensus that when psychotherapeutic intervention is warranted, it
should follow the model of Herman (1992) in which a first stage of safety is followed by
a second stage of remembrance and mourning, and then by a third stage of
reconnection. The stage of safety is designed to help the patient feel safe, understood,
protected, and empathized with. It must result in the patient's tolerance of the intimacy
in the therapeutic environment (Lindy, 1996). Traumatic material should not be
approached until the goals of the safety phase of the treatment, including the
establishment of a firm therapeutic alliance, have been achieved. The patient should be
willing to approach the material and have rational motivation to do. In the context of
this holding environment, the patient is strengthened and supported, and helped to
learn and master new coping strategies and methods of symptom containment. In the
stage of remembrance and mourning, the patient is helped to tell his or her story, to
express feelings associated with and about the trauma and its sequelae, to process the
experience in a manner in which it can be integrated with the patient's identity, and to
grieve the impact of the trauma and the losses associated with the experience of
traumatization on the patient himself or herself, as well as to grieve those who may
have been lost or injured in the traumatic event. Despite the controversies associated
with traumatic memory and recovered memory, this stage of treatment must address
the patient's subjective experience of traumatization. Although it may not be clear that
the traumatic material that is presented is historically accurate, and additional material
of uncertain veracity may emerge in the course of the therapy, this material
communicates the patient's narrative of his or her experience, and it must be
addressed. If efforts must be made to lift an amnesia in order to address some
symptoms or problem areas, it is crucial to explain to the patient that any material that
may be recovered must be regarded as tentative, and of uncertain historical accuracy.
Informed consent should be obtained before proceeding with such efforts. It is
important to appreciate that in many patients, most traumatic material will never
receive either definitive confirmation or disconfirmation. Although many deplore the
difficulties and discomforts associated with this stage of therapy, most authorities
concur that full recovery is unlikely to occur in its absence. Memories must be
processed in order for continuity of personal identity to be restored, and for the patient
to make sense of what has befallen him or her. The final stage, reconnection, involves
the bringing together of the patient's identity, the reintegration of the patient into his or
her social roles and responsibilities, and the resolution of the impacts of the various
dysregulations associated with the trauma response. To as great an extent as possible,
the patient's sense of having been damaged, demoralized, and made different in a
negative and shameful way as a result of the trauma must be mollified and eliminated.
THE ORIENTATION OF THE TREATMENT
Treatment must be individualized, and accept the unique configuration of strengths,
vulnerabilities, comorbidities, values, cultural factors, and existential and spiritual
concerns of the patient. Consequently, in treating chronic posttraumatic stress it may
be necessary to develop a treatment plan that involves many modalities of treatment in
concert. Short term treatments may prove ineffective, inappropriate, and raise false
hopes, which, when dashed, may further complicate the patient's treatment. While
some such therapies may proceed smoothly within a given modality, many treatments
come to resemble a series of short‐term psycho therapies imbricated within a single
long‐term psychotherapy. Continuity of care is an important aspect of long‐term
treatment, and the object constancy and reliability of the therapist may be one of the
most important factors in treatment success. When managed care organizations dictate
a brief or limited treatment, the psychiatrist should try to address the need for more
extensive care with that organization. In treating the patient, it may be necessary to
rely more heavily on medication and symptom reduction and have briefer or more
spread out sessions than is considered appropriate care.
Treatment of the victimized patient must be supportive and exploratory while having a
here‐and‐now focus in addition to addressing traumatic material. This combination test
the capacity of the patient and the therapist to collaborate. It is useful to address
traumatic material early in the session, reserving the final third of the session for the re‐
stabilization of the patient. The status of comorbid conditions should be optimized. The
therapist should have the requisite skills, and the logistics of the treatment should be
capable of supporting the effort. In unusual circumstances the therapist may conclude
that even though a patient is unstable, only work with particular traumatic material will
make stabilization possible. When a decision is made to proceed in this manner, it is
essential to address only the amount of trauma that must be dealt with before returning
to work on stabilization (Kluft, 1997). In a given treatment, the unique situation of the
patient, the stage of the treatment, the material under discussion, life circumstances
(stressors, crises, and supports) and comorbid conditions will determine how the
treatment should be directed. The therapist must be prepared to be flexible and
responsive as circumstances change.
In general trauma patient populations are on a continuum regarding comorbidity and
intactness. Some patients are relatively intact and have had little or no comorbidity
accompanying his or her posttraumatic sequelae. The trauma is either recent enough so
that major characterologic changes have not occurred, or, if they have, they have not
solidified. Such patients are more likely to have, overall, a more exploratory than
supportive therapy, unless they recover with a brief period of support. Their difficulties
are mostly in connection with the trauma, and the trauma must be a major focus.
Another group has considerable comorbidity and/or some compromise of ego strength
and/or more severity and chronicity of the posttraumatic response. This group may be
more depleted, and/or have had less ego strength. Its course is likely to be more up and
down, and more prolonged, with more attention to coping and here‐and‐now issues
which often proves to have a trauma‐based origin, and will alternate between an
exploratory and a supportive focus, moving forward with the trauma work at
advantageous and stable moments, which Briere (1985) has described as windows of
opportunity. Often the patient will require long periods of work on issues related to
comorbid conditions and situational crises. At the end of the continuum is a group has
great severity and or chronicity in the trauma response, and severe ego weakness
and/or comorbidity. Such patients often are destabilized by trauma work. Most of the
therapy is directed at efforts to keep the patient stabilized, and to coach the patient
through the vicissitudes of day to day life. There may be occasions in which the
traumatic material is briefly addressed, but in general, as soon as it has been dealt with
acutely, the focus of treatment returns to a supportive focus. With such patients the
treatment is palliative and limited in its goals. As therapy progresses, patients in each
category may change their characteristics and be able to shift into another category.
It is often helpful to intervene with the trauma victim's family and/or partner both to
help concerned others both support and cope with the situation and behaviors of the
traumatized person, and also to address the interpersonal consequences of traumatic
sequelae, such as difficulties with intimacy or anger management.
Many traumatic incidents are recalled very clearly, some are recalled only partially, and
some may be absent from available memory for long periods of time. Generally when
traumata are recalled, the general nature of the events, "gist memory," is well retained,
but details may be absent or supplied by a reconstructive process. Most so‐called
recovered memories of trauma do not take place in or in association with therapy.
There is evidence that some recovered memories are inaccurate (called confabulations
or pseudo memories), some are rather accurate, and some involve admixtures of
accurate and inaccurate components. There are no data to indicate what percentage of
so‐called recovered memories are inaccurate, but there is data to indicate 47 to 95
percent of recovered memories of conventional child abuse are confirmed, while only 1
to 3 percent of bizarre abuse memories are confirmed (Bowman, 1996a & b). A recent
study demonstrated that 74 percent of recovered memories could be confirmed
(Dahlenberg, 1996). No characteristics of memories, such as their being clear,
emotional, detailed, or held with conviction, are definitively associated with veracity.
Accordingly, considerable controversy surrounds the impact of trauma on memory, the
accuracy of memories of trauma, and the accuracy of memories of trauma that enter
awareness after a period of amnesia (ISTSS, 1998). Despite this fact, since dissociative
disorders are usually associated with trauma, the issue of memory must be addressed.
Notwithstanding the difficulties associated with autobiographical memory, especially
when elements of memory are recovered, most authorities concur that unless
memories are processed it is difficult to bring about a full recovery in which continuity
of personal identity is restored and the patient is able to make sense of what has
befallen him or her. As treatment begins, the patient's accounts of his or her
circumstances should be heard with empathy and respect. It is not appropriate to begin
treatment with efforts to document or disconfirm the patient's allegations of
traumatization, although a decision may be made to do so if it is the patient's wish to do
so. It is not appropriate to assume that other sources' disagreement with the patient's
given history invalidate it, especially if these other sources might be culpable if the
patient's allegations were accurate. Therefore, this therapeutic work is pursued, but
appropriate cautions about memory issues are provided to the patient (acknowledging
both the importance of work with autobiographical memories of trauma in the
treatment of trauma, and the difficulties that may be encountered in work with human
memory), whose treatment occurs under the aegis of informed consent which is
documented. It is not appropriate for the therapist either to assume that an allegations
of trauma is true or false, or that all continuously held memories are accurate, and all
memories returning to awareness, or emerging in the course of therapy are false.
Clinicians should be aware that the only proof of the accuracy or inaccuracy of a
memory Is reliable corroboration by external evidence or witnesses other than alleged
abusers. Without corroboration, legal action on the basis of memories that emerge in
the course of therapy are usually contraindicated.
THE STANCE OF THE THERAPIST
The stance of the therapist should be warm, friendly, and engaging in order to make an
outreach to the patient, who may feel damaged, shamed, guilty, and defective. The
therapist must have firm boundaries without being punitive or rejecting. Many victims
experience boundary violations, however trivial, as hints that the treatment situation is
dangerous and that the therapist cannot be trusted. Trauma treatment can be painful
in and of itself, and must be conducted in a carefully paced manner that respects the
strengths and vulnerabilities of the patient, and preserves and enhances function as
much as possible.
The trauma victim must be treated in a way that is sensitive to and respectful of the
culture, cultural signifiers, and cultural values of the victim and the victim's family. It is
vitally important that the therapy be conducted in a manner that does not estrange the
victim from his or her family and community on these grounds. Notwithstanding the
availability of effective trauma treatments, their application with certain groups may
have an unacceptable cost‐benefit ratio and may prove either unsuccessful or
deleterious. For example, in some Southeast Asian populations, contrary to the case for
North Americans and Europeans, it may be contraindicated to attempt to identify and
process traumatic experiences.
As in any form of psychotherapeutic intervention, the stance of the therapist in relation
to the patient is critical in determining outcome (Blank, 1994). The clinician must be
someone who understands post‐traumatic syndromes as related initially to external
events that are then worked upon by the particular dynamics, fantasies, experience, and
meaning‐making of the individual patient. Any therapist who hopes to be successful in
the treatment of complicated trauma‐based syndromes must be willing to develop an
understanding of repression, dissociation, isolation of affect, amnesia for parts of
events, disguised traumatic dreams, holding of traumatic memories, conflicts and
impacted affects in the unconscious over time, symbolic expression of anxiety, and
identification with the aggressor (Blank, 1994). Therapists must recognize that by
definition, trauma is a boundary violation and therefore violated patients may have no
concept of normal boundary formation or maintenance (Kluft, 1993a, p. 26). It will
therefore be the responsibility of the therapist to define and protect boundaries within
the therapeutic context. This may necessitate early and open discussion of the
therapeutic frame including length and time of sessions, fee and payment
arrangements, the use of health insurance, confidentiality and its limits, therapist
availability between sessions, procedure if hospitalization is necessary, patient charts
and who has access to them, the use (or non‐use) of physical contact with the therapist,
involvement of the patient's family or significant others in the treatment, discussion of
the therapist's expectations concerning management by the patient of self‐destructive
behavior, legal ramifications of the use of hypnosis as part of the treatment (i.e.,
material recalled in trance is not likely to be admissible evidence in any legal action
undertaken by the patient), among others (ISSD, 1997).
Trauma survivors are often driven to unconsciously and nonverbally reenact their
experiences within the context of close relationships and this traumatic re‐enactment
may drive the therapeutic relationship to destruction if it is not properly understood,
analyzed, and transmuted. Even experienced clinicians may find themselves unwittingly
drawn into scenarios in which they are alternately playing out the roles of helpless
victim, powerless rescuer, or malicious perpetrator. The management of such complex,
nonverbal enactment often necessitates ongoing consultation with trusted colleagues in
the form of individual or group supervision which can play a vital role in helping the
therapist maintain balance and maintaining the safety of the therapeutic alliance
The treatment of the traumatized has the potential to make a strong impact upon the
therapist. The clinician who works with traumatized individuals must make efforts to
monitor his or her counter transference, and to monitor him or herself for secondary or
vicarious posttraumatic stress also referred to as "compassion fatigue" (Figley, 1995a &
b), "vicarious traumatization" (McCann & Pearlman, 1990; Pearlman, 1995; Pearlman &
Saakvitne, 1995), and co‐victimization (Hartsough & Myers, 1985). People, who are
repeatedly exposed to the effects of violence, even though only secondarily, can be
traumatized themselves and even experience symptoms similar to victims of
post‐traumatic stress. It is somewhat different from "burnout" which is a state of
physical, emotional, and mental exhaustion caused by the long‐term involvement in
very emotionally draining situations (Pines and Arnson 1988). Burnout emerges
gradually while secondary traumatic stress can emerge suddenly and without much
warning, often accompanied by a sense of confusion and helplessness (Figley 1995a &
b). In such cases, exposure to a traumatizing event experienced by one person becomes
a traumatizing event for the second person. The hallmark of vicarious traumatization is
a disrupted frame of reference. Repeated exposure to man‐made violence can impact
on our willingness and ability to relate to others, on how we make sense of a frightening
world. As a result of exposure to victims of violence, clinicians may experience
disruptions in their sense of identity, world view, and spirituality that may interfere
dramatically with treatment if not addressed in some way, often through peer
supervision (Pearlman, 1995; Pearlman and Saakvitne, 1995).
THE PRINCIPLES OF GOOD TRAUMA THERAPY
Traumatized persons with posttraumatic conditions have become "stuck" on the trauma
and its sequelae. The treatment aims "to help them move from being haunted by the
past and interpreting subsequent emotionally arousing stimuli as a return of the trauma,
to being fully engaged in the present and becoming capable of responding to current
exigencies" (van der Kolk et al, 1996, p. 419). They must regain control over their
emotional responses and place the trauma in perspective as a historical event or events
that occurred in the past and can be expected not to recur, if they take charge of their
lives. They must come to integrate what has occurred, however ego‐alien,
unacceptable, terrifying, and incomprehensible into their self‐concepts; and they must
make these elements integrated rather than dissociated, so they are no longer intrusive
and destabilizing. Their anxieties must be de‐conditioned, and they must change their
views of themselves and the world by establishing a sense of personal integrity and
control (van der Kolk et al, 1996). Typically, intrusive experiencing, autonomic
hyperarousal, avoidant and numbing strategies, emotional dysregulation, difficulties
with learning and mastery, problems with amnesia and dissociation, aggression toward
self and others, and somatization will have to be addressed.
Kluft (1996a) put forward several principles for the therapist who deals with the
traumatized. 1) As trauma involves the breaking of boundaries, an effective trauma
treatment will have a secure treatment frame and firm consistent boundaries; 2) As
trauma imposes dyscontrol and helplessness, a successful treatment will focus on
mastery and the patient's active participation in the treatment process; 3) As trauma is
imposed involuntarily, a successful trauma therapy will build and maintain a strong
therapeutic alliance; 4) As trauma leads to dissociation and a failure to integrate
experience into memory and identity, what has been hidden away must be returned to
awareness, and associated emotional responses verbalized with feeling; 5) As trauma
often leads to dissociated alternate perceptions or narratives of life events, these must
be clear communication and efforts to integrate disparate perceptions; 6) As trauma
often results in the shattering of basic assumptions (invulnerability, life is meaningful,
and self esteem), positive efforts must be made to restore morale and to inculcate
realistic hope; 7) As trauma overwhelms a patient's resources and supports, treatment
must be carefully paced making efforts to minimize avoidable overwhelming
experiences and aggressively address issues of hyperarousal; 8) As trauma often is
related to the irresponsibility of important others, the therapist must model, teache and
reinforce responsibility; 9) As trauma usually induces shame, the therapist must take an
active, warm, and flexible stance, that emphasizes empathic connectedness with the
patient. 10) As trauma often interferes with learning and cognition, therapy must
address and attempt to correct defective cognition and work strenuously to help the
patient find words that match his experiences.
Because the target symptoms may be numerous and involve all manner of
psychobiosocial matters, eclecticism and the collaboration with other colleagues who
may have contributions to make to the treatment are essential. For example,
dissociation disorders usually require specific treatments in order to achieve resolution.
Whether a dissociative disorder is the main manifestation of the trauma response or a
comorbid condition, the therapist should be prepared to either provide specific
treatment or to collaborate with a colleague who can provide this element of the
It is important to appreciate that these principles apply to all treatment modalities and
across all treatment settings. Hospital units that address the treatment of the
traumatized must model these goals, attitudes, and principles if they are to participate
meaningfully in the continuum of care for trauma patients.
HOSPITALIZING THE TRAUMATIZED PATIENT
The inpatient milieu treatment of these patients deserves special mention since their
rate of hospitalization can be quite high. Likewise, on any general psychiatric inpatient
unit, a significant proportion of the population will have experienced a history of
traumatic events that may be playing an important and unrecognized role in the
development and maintenance of their psychiatric symptoms. Bloom (1997) has written
about the implications of what is described above as "good trauma therapy" for the
short‐term inpatient unit.
suicidality/homicidality; 2) psychosis; 3) affective instability/deterioration of a mood
disorder to the point that function is impaired; 4) a significant problem with the
outpatient treatment team and/or dynamic which places the patient at risk e.g.
therapist is in trouble; 5) diagnostic clarification i.e. psychotic disorder versus/and/or a
dissociative disorder versus/and/or a medical problem; 6) significant re‐enactment
behaviors which are interfering significantly with home/work/parenting/relationships
and not responding to usual outpatient interventions; 7) other self‐destructive behavior
(i.e. self‐mutilation, binging & purging) that is escalating and increasingly out of the
patient's ability to control; 8) serious threat to patient's life and well‐being secondary to
a violent relationship.
indications for hospitalization of the trauma patient include: 1)
The patients who end up hospitalized often suffer from very complex clinical pictures
and therefore benefit enormously from the power of a team approach to evaluation and
treatment. The purpose of hospitalization is to build a better outpatient (Kluft, 1996b),
and this is effectively accomplished by mobilizing a group of people to look
simultaneously at various aspects of the problem, including medical ones. Due to short
hospital stays, treatment planning must be well‐organized and supervised. Goals must
be clearly defined and limited to what is attainable during a brief stay. Usually, the
major goal is the achievement of safety with self and others and the patient must be an
active agent in all treatment decisions. As much as possible, nothing should be done
that encourages further helplessness and regression. All interventions must be directed
towards the empowerment of the patient in service of the restoration of self‐control.
Everyone in the milieu must maintain clear and well‐defined boundaries and
expectations, while providing an environment that is open to the construction of a
narrative that helps put the traumatic experience into perspective. The safety of the
inpatient unit is necessary as memories of the past flood into consciousness, producing
overwhelming hyperarousal and unmodulated affect. The restoration of memories
should only be encouraged if the patient has demonstrated sufficient capacity for safety
that regression will not occur (Bloom, 1997).
The power of the therapeutic community, even in a short‐term unit, should be drawn
upon to help patients mobilize their own internal resources and draw on the strengths
of others. Extensive efforts should be made to education everyone in the milieu, usually
through psycho educational groups, about the effects of trauma, the responsible use of
medications, the hazards of self‐destructive coping skills, and the need for withdrawal
from self‐medication, self‐mutilation, and other forms of destructive attempts at affect
Given the fact that these patients frequently need much more time in a protective
environment than they can currently get, it should come as no surprise that there is a
high rate of "recidivism" in this population. Good communication between inpatient
and outpatient therapists can at least make necessary transitions as positive as possible,
despite the current, often extreme, limitations of the system.
MODALITIES OF TREATMENT
Traumatized individuals may manifest extremely complex presentations accompanied
by considerable morbidity that changes over time. It is essential to individualize
psychotherapy and to anticipate using different modalities over the course of the
treatment. Since additional modalities provided by additional therapists may prove
essential to the treatment, it becomes essential for the primary therapist to maintain
rapport with the patient even when many parties may play a role in the treatment and
even while the application of some additional modalities may temporarily interrupt
work with the primary therapist. The socializing of the patient to the therapy and the
discussion of the therapeutic alliance should address from the first the possibility of
involving additional mental health professionals as the treatment proceeds.
Although cognitive‐behavioral techniques have been researched most thoroughly, many
specialized approaches to trauma are currently being developed and applied. Hypnosis
has a venerable history in the treatment of trauma, and remains a useful tool not
withstanding controversy about its impact on memory. Eye Movement Desensitization
and Reprocessing (EMDR) is gaining popularity and appears quite useful. Single
modality approaches have been most successful for single adult traumata. However,
with patients exposed to extensive childhood trauma, trauma has not only had its usual
consequences, it often has interrupted developmental processes. When dissociative
psychopathology is a significant aspect of the posttraumatic symptomatology,
approaches specific to the resolution of dissociative difficulties should be introduced. In
addition to a basic individual psychotherapy, and other technique‐oriented individual
interventions, ancillary approaches such as group psychotherapy, art therapy,
movement therapy, music therapy, and body‐oriented treatments may play a valuable
role for some selected patients. Treatment should be begun as rapidly as possible in
order to event both psychobiological consequences and demoralization.
Symptom reduction is extremely important both to treat posttraumatic and comorbid
conditions, and to stabilize the patient sufficiently to proceed to and manage the stage
of remembrance and mourning. In this regard medication may play a valuable role.
Symptom reduction, especially for intrusive symptoms and sleep difficulties, may also
facilitate the engagement of the patient in therapy.
There is no definitive psychopharmacological treatment for trauma‐related symptoms,
understandable given that so many different neurobiological systems seem to be
involved in post‐traumatic disorders. So far, it appears that PTSD at least, is associated
with abnormalities in the adrenergic, hypothalamic‐pituitary‐adrenocortical, opioid,
dopaminergic, and thyroid systems, and possibly with alternations in the serotonergic,
gamma‐amino butyric acid‐benzodiazepine and the N‐methyl‐D‐aspartate systems
(Friedman & Southwick, 1995). Medications may help some of the symptoms of
posttraumatic stress; they are much more successful in alleviating depression, sleep
disorders, anxiety, and hyperarousal symptoms than they are helping withdrawal and
numbing. To complicate matters, many patients with trauma‐related syndromes use a
variety of substances in an effort at self‐medication. Among treatment‐seeking patients,
from 60% to 80% suffer from alcohol or drug abuse/dependence. There are relatively
few controlled, double‐blind studies of the efficacy of medications in these disorders
and those that have been done has largely been tried on combat veterans.
Davidson and van der Kolk (1996) have suggested drug therapy based on utilizing a
rationale grounded in the major biological models for PTSD. Adrenergic dysregulation
suggests the use of antidepressants of all groups (MAO inhibitors and tricyclic
antidepressants) may be helpful. Other drugs like clonidine ‐ an alpha 1 agonist that
reduces hyperarousal symptoms and nightmares by reducing central nervous system
norepinephrine may also be used. Further, many dissociative patients often do well
klonazepam or other benzodiazepines. It is important not to misdiagnose dissociative
phenomenology as psychosis and initiate a regimen that will not lead to the resolution
of the dissociative symptomatology. Beta‐adrenergic blockers might also be used for
adrenergic dysregulation. Serotonergic dysfunction suggests the use of serotonergic
drugs such as SSRIs which has been supported by recent clinical trials. The kindling
hypotheses for traumatic stress suggests the use of anti‐kindling drugs like
carbamazepine. Finally, the increased startle responsiveness suggest the possibility that
clonazepam and buspirone may be effective.
According to these authors, the purposes of medication in PTSD are as follows: 1)
Reduction of frequency and/or severity of intrusive symptoms; 2) Reduction in the
tendency to interpret incoming stimuli are recurrences of the trauma; 3) Reduction in
conditioned hyperarousal to stimuli reminiscent of the trauma, as well as in generalized
hyperarousal; 4) Reduction in avoidance behavior; 5) Improvement in depressed mood
and numbing; 6) Reduction in psychotic or dissociative symptoms; 7) Reduction of
impulsive aggression against self and others. In selected patients a wide variety of
medications and many combinations of medications can prove useful. In view of the
myriad psychobiological lesions associated with trauma, it is not surprising that
polypharmacy is usually necessary in order to achieve maximal symptom reduction.
In practice, it is important to remember that no drug cures trauma and that medication
is generally directed at the treatment of depression, anxiety, obsessions, compulsions,
and psychosis ‐ all of which can co‐exist with, or be a part of, trauma‐related syndromes.
The symptom relief often enables the person to move ahead in therapy and achieve a
higher degree of function when used in concert with other forms of treatment. It is
especially crucial that the psychiatrist avoid both the Scylla and Charybdis of the
psychopharmacology of the traumatized ‐either under medicating a seriously distressed
patient or trying to make the medication a substitute for an appropriate trauma
Mental health professionals should promote awareness of victimization, a
biopsychosocial phenomenon, as important in the development of psychopathology,
increased comorbidity for both mental and physical disorders, and economic costs to
society. Accordingly, psychiatry should advocate for education about victimization,
trauma‐related disorders, and the treatment of the victimization in residency training.
In addition, psychiatrists should advocate for insurance to provide trauma victims with
access for care adequate to their need, which are often long‐term. Psychiatrists should
support the systematic assessment of patients for histories of trauma, for trauma‐
related disorders, and for the sequelae of trauma as part of routine psychiatric, medical,
and medical emergency assessment. This includes encouraging psychiatrists in practice
to obtain up‐to‐date knowledge about trauma, its consequences, and its treatment.
Psychiatrists should support both clinical assessments and research that studies the
impact of trauma on the individual, family, and community, and that studies factors
associated with an individual's being vulnerable to disruption by trauma, and with
resilience. There needs to be increasingly robust science of memory as it is relevant to
the treatment of the traumatized, which clearly indicates the polarized positions that
recovered memories are inherently reliable and that recovered memories are inherently
unreliable, are inconsistent with established data.
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