By J. Scott Janssen, MSW, LCSW
When most social workers are asked about the origins of psychological trauma they are likely to think of frightening events like an automobile accident, assault, or combat. Some may point to the potentially traumatizing impact of ruptures in attachment bonds or a chronic lack of safety occurring in early development, or of longstanding emotional or physical abuse. Few are likely to consider treatment in a hospital emergency department or waking up in an ICU after surgery.
The idea that medical treatment can be traumatic may seem counterintuitive. We tend to associate medical care with expertise, skill, and advanced technology in service of healing, not harming. Maybe that’s why it has only been in recent years that social workers, researchers, and other health care professionals have begun understanding the ways that medical interventions and interactions with medical staff during times of crisis can result in severe and persistent traumatic stress.
According to Barbara Ganzel, PhD, MSW, of the Bronfenbrenner Center for Translational Research at Cornell University, “Medical traumas are psychological traumas that result from medical diagnosis and/or medical intervention. Threat of serious injury or threat to life due to illness is now encompassed within the DSM definition of psychological trauma. This means that medical patients can be evaluated as having illness-related trauma disorders.”
To illustrate, Ganzel recalls a study of dialysis patients. “Many of these individuals reported events associated with their current illness as a trauma, and nearly all of these reported it as their worst trauma—even among those who had experienced combat traumas, serious accidents, assaults, and other types of extreme events.”
Though the symptoms of medical trauma—e.g., hypervigilance, avoidance behavior, anxiety, intrusive memories, intense emotions, emotional numbing, exaggerated startle response—may be identical to those stemming from other traumatic events, its origins can make it difficult to recognize. In severe cases medical trauma may meet the clinical criteria for acute stress disorder or PTSD and, as with other forms of psychological trauma, it can manifest in a range of physical complaints such as gastrointestinal distress or insomnia as well as other mental health issues such as depression.
When one considers the potential emotional and psychological distress of an unforeseen diagnosis and the physically invasive nature of much medical care, not to mention the prevalence of the experience of immobilization; physical restraint; loss of control; clouded mental function due to shock, anesthesia, or medications; a sense of being dehumanized; and unfamiliar environments filled with surreal technology and unknown faces, it is easy to see how such experiences—whatever the intention—can create traumatic stress.
Though research into medical trauma is still in its infancy, studies have found elevated psychological distress, including PTSD and symptoms thereof, in patients who have undergone surgery, treatment for cancer, dialysis, and cardiac care; women undergoing childbirth (especially if there are complications); and those being treated in emergency departments and acute care units (Kaasa et al., 1993; Sanders, Starr, Frawley, McNulty, & Niacaris, 2007; Tagay, Kribben, Hohenstein, Mewes, & Senf, 2007; Granja et al., 2008; Wake & Kitchener, 2013, Hall & Hall, 2013; Hall, 2014; Tulloch, Greenman, & Tassé, 2015).
ICUs in particular have come under close scrutiny. According to Hatch, McKechnie, and Griffiths (2011), “Extended follow-up has confirmed that many patients suffer physical and psychological consequences of the ICU treatment up to 12 months after hospital discharge. PTSD in particular has become increasingly relevant in both the immediate and longer-term follow-up care of these patients.”
In an effort to better identify and prevent ICU-related trauma, the American College of Critical Care Medicine (ACCCM) recently established criteria for postintensive care syndrome (PICS), which includes symptoms of PTSD, anxiety, and depression, along with cognitive and neuromuscular impairments. Ganzel says the ACCCM has outlined common ICU practices likely to contribute to PICS including “frequent use of sedatives, physical restraint and immobilization, endotracheal intubation, and interruption of the sleep/wake cycle.”
Michelle Flaum Hall, EdD, LPCC-S, an assistant professor in the department of counseling at Xavier University and coauthor of the forthcoming book Managing the Psychological Impact of Medical Trauma: A Guide for Mental Health and Health Care Professionals, agrees that the attention given to ICUs is important but is quick to point out that “Medical trauma can take many forms and can occur in any level of care; it is not a phenomenon that is limited to emergency departments and ICUs.” These other levels of care include experiences with first responders and in multiple hospital settings, physicians’ offices, clinics, and residential settings, such as nursing homes, where medical care is routinely given.
Many factors may affect a person’s vulnerability to medical trauma such as a preexisting mental health diagnosis, perceptions about the quality of care, level of trust in one’s medical team, and factors related to treatment (e.g. the length of a hospital stay and types of medications used). Hall says another important factor is the sensitivity of medical staff. “When care is not patient-centered, empathic, and sensitive to patient’s emotional health, patients can suffer as a result. The sensitivity of a professional’s communication plays a central role in how people experience traumatic medical events and how they cope with the decontextualization and disempowerment of being patients.”
Children may be at elevated risk due to developmental vulnerabilities, lack of control, or limited understanding. According to the National Child Traumatic Stress Network (NCTSN), children may experience medical trauma in response to “pain, injury, serious illness, medical procedures, and invasive or frightening treatment experiences. These responses may include symptoms of arousal, reexperiencing, and/or avoidance. They may vary in intensity, are related to the subjective experience of the event, and can become disruptive to functioning.”
Parents watching as children endure medical interventions, many feeling helpless to protect a son or daughter from suffering, are also at high risk. The NCTSN reports that 20% to 30% of parents in such situations experience persistent traumatic stress reactions.
For social workers in pediatric settings, the NCTSN offers resources including the Pediatric Medical Traumatic Stress Toolkit for Health Care Providers, a comprehensive guide for understanding, assessing, and preventing medical trauma in children (www.nctsn.org/trauma-types/medical-trauma).
“People with a history of trauma—medical or otherwise—are at greater risk of experiencing medical care as traumatic,” Hall says.
Ganzel explains that in patients with past traumas, “Increased symptoms of PTSD are associated with increases in reported pain, anxiety, depression, and anger, along with an escalation of avoidance and/or hyperreactivity in response to trauma reminders. For example, a medical patient with a prior history of rape may respond negatively to the use of vaginal suppositories for medication delivery.” Because of this, she says, “Understanding a patient’s history is a critical step towards avoiding trauma reactivation and patient retraumatization.”
Ganzel, who is currently working with a group of clinicians nationally to study the use of eye movement desensitization and reprocessing in treating psychological trauma in hospice patients, says patients near the end of life may be at increased risk of medical trauma as well. “Hospice patients, by their nature, are more likely than the general population to have been diagnosed with a life-threatening disease and to have experienced intensive medical intervention. Thus they are more likely to have experienced recent, medical-related trauma.”
Despite growing knowledge, medical trauma often goes unidentified. According to Hall, there are many reasons for this. “I think it can be easy for social workers and other mental health professionals to miss the presence of medical trauma because current roles of these professionals within the health care setting can be quite fixed, and not allow for the assessment and intervention needed to manage medical trauma,” Hall says. “Further, we often must rely on health care workers to make the initial observations and identify medical trauma, and it is typically the physical health needs that take precedence, eclipsing the mental health needs of patients and their families.”
As with trauma generally, medical trauma can manifest in a wide range of psychological and somatic complaints for which there may be other suspected causes. “Medical trauma can look like sleeplessness,” says Malissa Turney, LPC, SEP. “It can look like waking with a startle that does not settle throughout the day. It can look like hypervigilance. It can look like obsessive-compulsive disorder. It can look like panic attacks. It can look like abandonment fears or obsessive thoughts about the safety of family members.”
Even in instances in which psychological trauma is recognized due to an event preceding medical care such as an injury, the implications of medical treatment in fueling posttraumatic stress often go unappreciated. Turney recalls a client who survived a near-fatal automobile accident in which a friend was killed. Despite the psychological trauma of this event, when she processed this experience with the client what was most traumatizing, “was the look of shock on the paramedic’s face that he was still alive, and that he was being transported to the hospital in the same type of vehicle he had just been injured in and that had killed his friend.”
“We can also miss the presence of medical trauma,” Hall says, “because many patients likely suffer the effects in silence. We are socialized to endure medical treatment and often we expect both ourselves and others, especially adults, to ‘just deal with’ the emotional effects of care on the psyche. We ask, ‘How is your pain?’ or ‘Any side effects of the medications?’ rather than inquiring about fear, sadness, worry, and the myriad emotions people face as a consequence of their medical event or illness.”
To aid clinicians in identifying medical trauma, Hall helped develop The Experience of Medical Trauma Scale, a Likert scale tool for the assessment of distress experienced by patients in the acute-care setting. “Items,” she says, “fall along four dimensions: communication, physical discomforts, environmental discomforts, and emotional experience. In addition to assessing levels of distress, the tool requires the clinician completing it to create an action plan with the patient and team members to address distressing items.”
One of the hopes is that as understanding of medical trauma grows, its prevalence will be reduced though prevention and risk reduction strategies. According to Hall, one way to accomplish this is to expand the focus of medical interventions to include a more patient-centered approach to care in which sensitive communication and an understanding of the causes and signs of traumatic stress are priorities. “Patients,” she says, “are best served when health care and mental health professionals work collaboratively and proactively to ensure that care is integrated and holistic.” She advocates taking an ecological approach aware of the interplay between patient, diagnosis, treatment needs, the medical staff, and the medical environment.
Regarding prevention,” Hall continues, “we can improve how we identify risk factors for medical trauma (e.g., prior trauma history, preexisting mental health issues) and intervene to help patients prepare for an upcoming hospital stay by providing tools and resources to help patients learn how to better manage stress and anxiety (teaching mindfulness-based stress reduction techniques, for instance). In cases when patients experience medical trauma as a result of unforeseen medical crises, clinical social workers and mental health counselors can intervene and provide services to patients and their families during the hospital stay, as well as ensure that patients and families are linked to community mental health resources upon discharge.”
— J. Scott Janssen, MSW, LCSW, is a social worker with the Hospice and Palliative Care Center of Alamance-Caswell in Burlington, NC.
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