“What cannot be talked about cannot be put to rest. And if it is not, the wounds will fester from generation to generation.”
–Bruno Bettelheim, Surviving and Other Essays
Posttraumatic stress disorder (PTSD) develops in some individuals after seeing or living through an event that caused or threatened serious harm or death. Symptoms include flashbacks or bad dreams, emotional numbness, intense guilt or worry, angry outbursts, feeling “on edge,” or avoiding thoughts and situations that remind them of the trauma (1, 2). Although the traumatic experience is commonly considered the main cause, etiological research into PTSD has identified a large number of biological and psychosocial factors that contribute to the development and maintenance of this disorder (3). Individual factors interact with environmental factors over time to constitute risk and/or protective factors for the development of impairment or the enhancement of resilience (4). According to this model, PTSD would be considered a disorder that can be facilitated or precluded by contextual factors. Psychiatric engagement and intervention may be considered one of the contextual factors that impacts prognosis.
“What type of treatment have you been receiving?” Dr. Thomas inquired of Ms. Johnson, a young woman presenting to the Posttraumatic Stress Disorder Clinic a year following a robbery and sexual assault during which she was seriously injured and her best friend was killed.
“Supportive therapy, I think,” she replied. “The therapist was very supportive, and the case worker helped me get the medical care I needed. I feel very guilty that they gave me so much, and I just haven’t been as appreciative as I should be. My parents keep pointing that out. They have been supportive, too. I know that I should be getting better, but I still feel constantly on edge. And all of this support makes me feel obligated.”
Ms. Johnson recounted her symptoms in a mechanical fashion to Dr. Thomas. On a PTSD symptom scale, she scored in the clinically significant range for a host of symptoms, including sleep difficulties, intrusive memories, startle reactions, emotional numbing, and feelings of guilt. She had recently lost her job as a bank teller due to difficulties concentrating and poor interpersonal interactions with her customers.
“You have been through hell,” Dr. Thomas noted sympathetically.
Ms. Johnson looked up quickly, surprise in her eyes. “What?”
“I’m sorry,” Dr. Thomas smiled sheepishly. “I was just thinking about how awful this past year must have been for you.”
“Well, yes, I guess. At least I’m still alive–that’s more than I can say for my friend,” Ms. Johnson noted wryly.
“Do you ever wish you had been the one that died?” Dr. Thomas tentatively inquired.
“How did you know that?” Ms. Johnson queried, incredulously.
Dr. Thomas hesitated, his gentle eyes connecting perceptively to those of Ms. Johnson. “Perhaps you communicate better than you think,” he mused.
There is an emerging literature on the topic of social support and interpersonal connections with relationship to the acquisition and severity of PTSD symptomatology. Several meta-analyses (5, 6) have suggested that an individual’s interpersonal connections and social supports serve as powerful predictors of the level of, and disability from, PTSD-related suffering for one that has undergone serious trauma. In clinical work with PTSD patients, “the patients’ struggles with shattered views of others, ‘the world’ and with themselves all prominently relate to contexts and interactions” (3). The effectiveness of interpersonal communication leading to enhanced connectedness is a powerful moderator of PTSD symptomatology.
Of some paradox in the social support literature is that sometimes receiving support may actually lower one’s self-esteem or draw more attention to the problem (7). As illustrated in the vignette above, at times the experience of receiving support may foster feelings of dependence and vulnerability that can be quite uncomfortable. For this reason, some investigators have suggested that “invisible” support (i.e., support that the provider delivers but the recipient does not experience as receiving) may be more effective in decreasing depression and anxiety than visible support (support that the recipient reports being given) (8, 9). Context and the perception of the individual receiving the support are of crucial import. Maisel and Gable have postulated that the therapeutic ingredient of a supportive transaction is the perception by the individual receiving the support that it is responsive to her/his unique individual needs (10).
Several active elements are required on the part of the treater for the recipient to perceive support as responsive to his/her needs. One is active listening—attentive and empathic listening that allows the listener to hear what is being said as well as to notice the unspoken language that communicates emotional tone, hopes, and fears that are not able to be spoken directly. A second component is acknowledgment. An individual, whose pain and suffering is acknowledged and validated, has a much better prognosis for recovery from disabling PTSD symptoms than an individual that feels blamed and shunned. Social support, acknowledgment of the trauma, and the recognition that a dramatic emotional reaction may be expected following trauma may have a healing effect and decrease the potential for chronic PTSD.
Active listening occurs when the listener is immersed in the process of hearing what another is disclosing—the verbal as well as nonverbal communication. Attentiveness conveys respect and caring. The therapist that listens attentively to the patient’s narrative, interrupting for clarification, but not redirection, is most likely to understand the patient’s suffering and disability, as well as characteristics of strength and resiliency. Active listening is crucial to all therapeutic encounters. However, patients suffering from the symptoms of guilt, shame, and anxious hyperarousal associated with PTSD are likely to be exquisitely sensitive to the potential of feeling misunderstood, blamed, or uncared for. Active listening is especially crucial to the engagement process of these patients (11).
One particular injustice to which PTSD patients often refer is their perception of not being recognized as trauma victims or survivors (12). Trauma survivors benefit from social acknowledgment—the appreciation by close family and friends, treaters, as well as society as a whole—that they have been through a very difficult experience from which they may be expected to be struggling emotionally. Posttrauma, most victims are exquisitely sensitive to the reactions of others toward them, including attributions about the nature of the traumatic event and the role the victims may have played (13). If these ascribed meanings are perceived as negative or blaming, the victims’ aversive responses to re-experiencing the trauma may be intensified. Avoidance may develop as the primary coping mechanism for the survivors, exacerbating the experience of social isolation. Thus, the extent to which victims’ experiences are consensually validated or invalidated by their families or their societal milieu may have a profound impact on their psychological adaptation and cognitive processing related to the traumatic stressor (13). Empathic social acknowledgment is the antithesis of societal disapproval, critique, or rejection. Perceived social acknowledgment has been correlated with less severe PTSD symptoms. Social disapproval has been identified as a risk factor for social alienation and more severe and chronically disabling PTSD (12). A prime example of this phenomenon is the finding by Fontana and Rosenheck (14) that social rejection at the time of homecoming after a traumatic experience was a significant predictor of PTSD severity in Vietnam veterans.
Perceived responsiveness is a subjective experience for the traumatized individual. The trauma victim’s supporter must be experienced by him/her as having a basic understanding of the traumatized individual’s unique needs. The support must be focused on these specific individual needs. Support may foster resentment if it is perceived as being offered for the self-aggrandizement or self-promotion of the provider. Particularly during times of highly publicized trauma, the outpouring of support is only perceived as such to the victims if the support is provided without the shroud of secondary gain. The provision of support must take into consideration the wishes and needs of the traumatized individual—and if and how they may desire intervention.
Working with trauma survivors is arguably one of the most emotionally intense and therapeutically challenging experiences in psychiatric practice. Many patients, having suffered serious trauma and resultant PTSD, have difficulties trusting, engaging in treatment, and accepting support. The experience of feeling vulnerable may be so aversive that the individual avoids accessing the help and support that may improve the symptoms. Effective communication (Table 1) is crucial to assist the individual suffering from PTSD to feel comfortable and in control, so that he/she will be able to engage in the types of treatment that may enhance life functioning and satisfaction.
Table 1.Tips for Optimizing Communication With Individuals Suffering From PTSD
| Add to My POL
|• Active listening is crucial for forming a treatment alliance, identifying unique individual needs, and providing responsive support and treatment|
|• Acknowledge the pain and trauma, while refraining from sanctioning the disability and maladaptive coping patterns|
|• De-mystifying the symptoms with medical information, and by providing options for treatment, affords the trauma-survivor the crucial experience of being in control|
|• Responsive support is optimally provided in an “invisible” (nonintrusive and subtle) manner, or by joint identification of needs and addressing them concretely via this support. If assistance is not accepted, be sure to let the individual know that support may be accepted at a later time|
|• Be clear about the limits of your authority or ability to respond to a person's needs or requests. Refer to other supports, as appropriate|
|• Fluctuating symptoms and approach-avoidance patterns of engagement are common, and may be anticipated in the doctor-patient relationship|
Active listening is the first ingredient in therapeutic engagement, and allows for optimal understanding of the individual and his/her symptoms and disability, as well as strengths and resilience. Acknowledging the trauma and resulting emotional (and sometimes physical) pain, is also crucial to the healing process. Engagement of family and/or close friends in this process may be of benefit. Public advocacy for a warm and welcoming reception for individuals returning from combat is an effective public-health approach to decreasing PTSD disability. In addition, effective communication may include working with the media to minimize the stigma and potential for “blaming the victim” that has sometimes been the response to victims of domestic and sexual violence and bullying.
Support provided to PTSD sufferers must be tailored to the individual’s needs, and provided in a manner that allows the recipient to maintain dignity and a sense of control. Responsive support may be more difficult in highly publicized tragedies, where there is substantial risk for the event to become politicized and for interventions to be poorly coordinated. The psychiatrist is in a unique position to inform support measures by maintaining a focus on the individual’s needs. As in all therapeutic encounters, clear, honest, and transparent communication is key.