by Harold J. Wain, PhD
Many individuals return from the combat zone with some psychological symptoms. Fortunately, for many, these symptoms dissipate over time.
As part of the medical trauma team, staff members from the Psychiatry Consultation Liaison Service (PCLS) at Walter Reed Army Medical Center (WRAMC) routinely see all combat casualty inpatients. As an important part of the therapeutic intervention, the PCLS emphasizes the mental health provider as an ally and advocate. In addition, to destigmatize mental health, all patients are seen under the name Preventive Medical Psychiatry (PMP).
Because of the nature of the injuries sustained by amputee soldiers, a biopsychosocial approach to treatment is needed. Initially, stabilization of the patients’ medical condition must generally be the first priority. Then, ensuring their psychological well-being and confident reintegration into society rapidly becomes the next overriding objective.
One psychiatric approach for dealing with patients is called Therapeutic Intervention for the Prevention of Chronic Psychiatric Stress Disorders (TIPPS). This approach emphasizes the importance of normalizing the patient’s psychological experiences, supporting healthy defenses, and providing empathic exposure and appropriate hope while monitoring for psychiatric symptom development. To achieve success, it is important to destigmatize psychiatry, to integrate mental health resources directly into the medical-surgical trauma team on a routine basis, and, as mentioned earlier, to use the name Preventive Medical Psychiatry. It is essential that patients see psychiatry as an ally rather than as a stigmatizing force.
Patients are screened for psychiatric symptoms in a benign manner, and no formal consult is required. Once they are in a safe environment, patients frequently recount their trauma experiences, which helps to normalize them. Patients’ assets and strengths are emphasized and reinforced when appropriate, and they are taught to escape to a safe place by using hypnotic-relaxation techniques. They are taught that they have the capacity to distance themselves from the trauma, integrate their experience, and master the symptoms. Other aspects of the program include reframing techniques education, pharmacology, and individual and group support.
The PCLS’s PMP approach also emphasizes support for the patients’ loved ones who are present during their treatment. A staff member from the service is assigned to each family and provides the family members with individual support. Family support groups are also offered.
Patients who stay at the guest housing on post awaiting further medical treatment and those returning to WRAMC for follow-up medical treatment are also followed by the PMP service. After discharge, follow-up of patients occurs through telephone calls conducted 30, 90 and 180 days subsequent to their discharge.
It is extremely important for the mental health liaison to develop a therapeutic relationship with the medical-surgical patient. Because of the skepticism of this type of patient toward mental health, developing a therapeutic alliance is perhaps more important for this population than for patients in a traditional outpatient treatment setting. Developing an alliance where the patient perceives the clinician as an advocate allows for a trusting of the therapeutic process and makes the patient more comfortable about seeking treatment if problems arise.
Allowing patients to maintain appropriate psychological defenses and offering them sufficient hope and alternatives when appropriate is necessary in treating amputee patients. Breaking down denial can be harmful since the clinician could be seen as adversarial rather than as an ally. During the initial stages, it is important to avoid confrontation and irrelevant insights until a relationship develops. Focusing initially on the patients’ physical problems can help. Then, the intervention can shift from the patients’ physical needs to their psychological issues, which can develop from exposure to trauma.
After forming this alliance, attending to the needs of patients and helping them overcome their pain and sleep problems can lead to successful intervention. The use of pharmacology and hypnotic techniques should also be prominent. It is important not to label soldiers’ sleep disturbances as pathological since they have been taught to minimize their sleep while in theater and before their injury. Sleep may also be disrupted by medical and nursing personnel who are always checking on them.
Because of amputee patients’ loss of body integrity and the trauma that accompanied their amputation, cooperative interventions by all clinical services are required to attempt to return them and their family to a preinjury physical and psychological level. Many soldiers become gainfully employed, and some return to active duty once they have recovered from their injury.