Trauma — natural disasters or human-made catastrophes — produces psychological as well as physical wounding. Its victims often suffer from Post Traumatic Stress Disorder (PTSD). Two elements characterize this least known and least appreciated of the anxiety disorders: depersonalization, the stripping away of one’s individuality and humanity, and entrapment, the sense that all escape routes from the trauma are extremely dangerous, costly, or nonexistent.¹

Trauma can vary from a single incident, involving loss of control over one’s life during a tornado, train accident, rape, or mugging, to the repeated traumatization over time experienced by hostages, torture victims, combat soldiers, battered wives, persons diagnosed with HIV,² or employees who work in physically and psychologically unsafe environments. Whatever the original source of the trauma, symptoms may be triggered by an event reminiscent of the initial event. Agonizing self-doubts and fears kick the autonomic nervous system into overdrive, as the event is reexperienced through flashbacks. Trauma victims may experience symptoms of hyperarousal — surges in heart and respiratory rates; elevated blood sugar and muscle tension; and rapid, shallow breathing. And in one study, women and men with PTSD were twice as likely to experience at least one current nonpsychiatric medical condition when compared to men and women without PTSD.³

Nevertheless, many individuals who suffer from PTSD remain unidentified and without adequate help. Nurses may be the first professionals in a position to recognize the symptoms and to help victims to seek therapy that will allow their wounds to heal.

Approaches to healing

PTSD can render people helpless and erode self-esteem. Symptoms may interfere with normal functioning and a sense of safety. The treatment goal for PTSD is to improve self-confidence and the sense of being able to cope with life.¹ Nurses in all clinical settings can assist victims to feel a sense of personal power and provide them with a safe and supportive environment. Appropriate action can help individuals express their thoughts and feelings in constructive ways, manage stress, and become more assertive. Discussions of the existential, spiritual, or moral issues, as well as the sociopolitical and legal context of the trauma are also helpful.

Although always based on assessment, treatment approaches are constructed to —

l. Strengthen survivors’ sense of control over their lives by —

• Familiarizing individuals with the symptoms of PTSD and their basis.
• Teaching coping skills that channel anger and manage stress.
• Assisting with activities of daily living (ADLs) and basic self-care skills, including proper nutrition and sleep habits.
• Allowing survivors to make as many decisions as possible based on their ability.

2. Create a sense of safety. For example, develop an emergency exit plan for those who are in abusive or potentially abusive situations, devise physical safety measures for those in dangerous jobs, identify signs of potential suicidal or homicidal behavior, and provide a reliable contact or hotline number.

3. Provide support. Because physical and psychological wounding and loss accompanies trauma, its victims need a chance to grieve their losses so they can move forward with their lives. Nurses can help survivors through this process by listening to and clarifying their reactions, which may progress through shock, disbelief, anger, depression, and acceptance.

4. Encourage attempts to form meaningful goals and connections with other people. For instance, nurses can help by teaching problem-solving skills and encouraging social activities.

5. Identify how current life struggles have been affected by the trauma and its aftereffects. Comparing life before and after the trauma puts the trauma in proper perspective in their lives.

6. Reframe the trauma and its effects in less self-blaming ways. Survivors need to be in a therapeutic situation with nurses who have advanced psychiatric skills to overcome dysfunctional modes in thinking — intolerance of mistakes in others and self, denial of personal difficulties, all-or-nothing thinking, and continuation of survival tactics — that result from PTSD.

Early intervention is best

As a nurse, you may be in a position to first identify PTSD and encourage individuals to obtain therapy. Although they may be afraid to risk sharing their feelings, you can encourage them to test the waters by sharing one of their least intense or threatening reactions with a supportive other, possibly you. Help them see that taking a few emotional risks now can save them long-term scars. Nevertheless, it can take years before some survivors are ready to deal with traumatic experiences or their aftermaths.

Jim was 8 years old when he witnessed the brutal shooting death of his father. At the time he entered treatment his wife had recently revealed that she had an affair 15 years earlier. Jim usually buried his feelings, like the memories of his father’s death, finding them too hurtful to discuss. When his wife brought up her affair, he panicked, tried to kill himself, and was brought to a psychiatric nurse by his trembling wife. The nurse worked with Jim and his wife together and individually.

At first Jim denied that anything was wrong. After four therapy sessions and the use of a relaxation/self-hypnosis tape and journal writing between meetings, he began to talk. Jim described the anger he felt because he had “allowed such things to happen.” He repeated over and over again: “I shouldn’t have let this happen. I won’t ever let anything like this occur again. I don’t want to make any mistakes again. I should have had a grip on myself.”

Much later, he was able to talk about his feelings as a child, how he had witnessed the shooting of his father and yet hadn’t tried to intervene. Eventually, he recognized that his wife’s affair and his feelings of loss and abandonment were a trigger for past, unresolved feelings about his father’s violent way of leaving him. It took many sessions before Jim was able to forgive himself, his wife, the man who killed his father, and his father (for not adequately protecting him from danger).

All survivors need to receive a clear message that, unlike in traumatic events, they are now in safe situations where they have more choices. They can choose to forgive themselves and others. They can work to resolve hurtful feelings by discussing the trauma in detail and by learning new coping strategies.

The therapeutic alliance

Collaboration — the ability to work together toward commonly defined goals — is particularly important in working with PTSD survivors. Whether you are interacting as a nurse or a therapist, successful collaboration is achieved through building a trusting, therapeutic relationship. Several steps can help.

1. Clarify your role and establish boundaries. The first step in forming a therapeutic relationship is to have a clear notion of your role as a supportive and helping caregiver. Effective, comfortable therapists know in advance what they can and can’t do for these individuals. For example, you can’t substitute good parenting for the abusive experiences victims may have had as children. You can gently point out counterproductive aspects of victims’ behaviors, such as when they become overly dependent or angry. Therapists also help by setting and maintaining rules for the relationship. Many survivors have been in abusive situations where rules were changed arbitrarily, or there were too many or none at all.²

2. Build trust, but monitor the flow of information. Be cautious about the amount of information initially exchanged. Some survivors may feel unsafe if they share too much at one time. Advise individuals to disclose only what they feel comfortable relating. While some individuals may immediately talk about memories or experiences with you, others may be more cautious, testing you with relatively benign accounts to see how you will respond to them. Will you judge them harshly, deny such a thing happened, blame them, change the subject, or listen intently?

3. Be aware of your feelings. Attend to your own psychological issues and know in advance how you feel about rape, incest,

torture, and other traumatic situations. If you have been troubled by trauma yourself, be sure to seek help. Because victims may not only focus on a provider’s words, but also facial expressions, body movement, and tone of voice, you should note how you present yourself. Know your own limitations and refer the client to someone else if necessary.

4. Remain nonjudgmental, but act legally. Victims may tell you unbelievable things. However, what actually occurred is not as important as what clients believe happened. If you display disbelief, they will sense your doubt and trust will be damaged.

PTSD survivors may also reveal illegal behaviors that need to be confronted immediately and directly. The client must report violent acts, such as child abuse or the intent to murder, to the authorities, either in your presence or by you with the client’s knowledge and consent. Behavior that is legal, but destructive, such as self-mutilation, poses a different set of challenges.¹ If you develop a proactive stance and a supporting rationale, you can act confidently and stay neutral.

5. Avoid a “blame the victim” mentality. Steer clear of behaviors or techniques that reinforce a sense of unworthiness.⁴ Many survivors have already heard from others that they need to grow up and take responsibility for themselves; they don’t need to hear it from a healthcare provider.

6. Let survivors set the pace. Honor their coping strategies, including placation, provocation, and manipulation. However, if you can teach them new, more effective skills, they will need dysfunctional strategies less and less.

7. Encourage discussion, but don’t push. Always ask survivors if they want to talk to you about their experiences, and respect their wishes not to. Some leading comments include —

• As a child you were told never to tell, but I want to help you feel safe here to share. I am inviting you to talk, but it is your decision.
• When you’re ready, I’m here to listen.
• At some point, it would be helpful for you to tell somebody what happened. I am ready to listen. If you choose to talk to someone else, find someone who is supportive and has had experience with trauma.

As a busy clinician, you may not have the time, inclination, and/or skills to listen adequately. In that case, you may want to find a mental health practitioner, such as an advanced practice mental health nurse, psychiatrist, psychologist, or social worker, to whom you can refer the individual. In that case, you can say: “These are some practitioners you can contact for help in dealing with your feelings and reactions.” Survivors may choose to confide in someone other than you. That does not necessarily mean that you were not helpful. You may have helped them through a leg of their journey. Remember that a good experience with you may give them the confidence to pursue further work with a mental health practitioner.

8. Reinforce survivors’ strengths. Respond with comments such as: “Thank you for trusting me enough to tell me...”or “It takes courage to share what you have just shared. I admire you for that.”

9. Encourage survivors to express negative and uncomfortable feelings. Assure them you will not reject them for sharing. You may be the first person to let them express negative feelings without retaliating. It is always useful to pepper your comments with phrases such as: “What do you think about what I said?” They provide a check of progress, to make sure you haven’t given an unclear message, and assist clients to identify their feelings.

10. Obtain consultation when necessary. If you find yourself getting angry because a survivor continues self-destructive behaviors, talk it over with an advanced psychiatric/mental health practitioner. If you work regularly with trauma patients, a support group to deal with these issues outside the treatment setting or a mentor is necessary. If your own feelings are not suitably dealt with, they may eventually affect your ability to be useful to survivors.

Countering damaging effects

The management of PTSD-related symptoms includes teaching survivors to cope with trigger reactions, anger, reexperiencing phenomena, intrusive thoughts, sleep problems, numbing and dissociation, anxiety and panic attacks, and self-mutilation.

Trigger Reactions: Trauma survivors experience difficulty when a current event reminds them of past trauma and elicits a fight or flight response. Because the reaction is the same for real and remembered threats, individuals can feel as angry, confused, or threatened as they did at the time of the original event.²

The first step to controlling this reaction is to recognize the triggers, which may be people, places, objects, and even emotional situations. When the individuals are feeling calm and able to learn, teach deep breathing and relaxation skills. By practicing these measures prior to flashbacks and trigger situations, they can counter the reactions. Find out if your nursing education department has relaxation tapes that can be used, or ask a staff development nurse to help you make your own.

If sitting quietly produces a flood of traumatic memories, relaxation and meditation may not be the best approach. In those cases, physical exercise, such as aerobics, swimming, walking, running, or tennis, can be suggested to reduce tension and anxiety.

Anger: Survivors often have unresolved anger about what’s happened to them. They need to be told that anger is a normal, human sequelae of trauma, which can be dealt with constructively. Anger management techniques, including writing or drawing a picture of their anger, can control the emotion so that whatever situation they are in becomes manageable.¹ Letters, which need never be sent, can be written to the source of the event.

When overwhelming anger wells up, survivors can learn to employ time-outs — leaving the room or immediate situation to do something else, such as taking a walk or some other exercise. They can announce time-outs to partners, spouses, family members, friends, and even nurses.

Another useful tool is an anger diary, noting people, places, and situations that result in anger and positive actions that relieve the emotion.

Reexperiencing Phenomena: As survivors talk about their symptoms, memories, and their significance, there is less need to unconsciously repeat the trauma through nightmares and flashbacks.¹ Writing about the experience or expressing it creatively through music, art, or dance can also be helpful.

Intrusive Thoughts: PTSD sufferers frequently complain of not being able to turn off intrusive thoughts. One counter measure is the rubber band technique. Give the individual a rubber band to wear around a wrist. Whenever an intrusive thought occurs, just have the individual snap the rubber band and visualize that the thought is gone — sent out of the mind with the sting of the snap.

When this doesn’t work, individuals can give themselves permission to dwell on the thoughts for a short, specified period of time, but then focus on deciding whether they want to continue thinking the intrusive thought.

Sleep Problems: Sleep problems are the most persistent PTSD symptoms.¹ Management suggestions include:

• Physical exercise during the day, but not right before sleeping
• Relaxing music or a relaxation tape at bedtime
• Prayer or meditation
• Elimination of stimulants such as coffee, tea, cola drinks, and chocolate
• Use of the bed only for sleeping and at a regular time

Advise clients that they should not stay in bed if they are unable to sleep; they can get up and write in a journal or read a book until they are sleepy.

Numbing and Dissociation: To avoid situations reminiscent of the trauma, survivors may feel emotionally numb and mentally drift away from their current situation. The first step in controlling these symptoms is to have them keep a log of when they felt “dead inside” or “in a faraway world.” Measures that can bring them back to reality include changing clothes; taking a bath or shower; touching a safe object, such as a stuffed animal; stretching or doing setups; completing some ordinary chores; journaling; or talking to a supportive significant other.

Anxiety and Panic Attacks: These symptoms can usually be handled through anxiety reduction techniques, such as deep breathing; muscle relaxation; positive self-talk, which can help replace negative comments about the self with positive

ones; journaling; systematic desensitizaing, identifying and countering steps leading to anxiety; stress reduction exercises; visualization; assertiveness training; and nutrition counseling to reduce the intake of foods or substances that can make people feel jittery or tense.⁵ Occasionally, pharmaceutical agents such as alprazolam (Xanax), topiramate (Topamax) or trazodone (Desyrel) are prescribed.⁶

Self-Mutilation: Working with self-mutilation, such as burning  with cigarettes or cutting oneself, requires advanced practice skills. A psychiatric/mental health advanced practice nurse might use measures to reduce the behavior that include reframing, or viewing things positively instead of negatively; identifying present behaviors that cause shame; substituting a less harmful behavior; reducing emotional intensity with rage dumps, which use imagery to place harmful emotions in a faraway place where they can’t affect the patient; using imagery; countering depersonalization; and preventing revictimization.

Although not every nurse has advanced practice mental health skills, nurses in most clinical situations come in contact with trauma survivors. Nurses can help them by listening intently, sending positive messages, and obtaining appropriate consultation or making referrals. By polishing the skills to aid these individuals, you can pride yourself on being a useful bridge for trauma resolution.