Reflections of a Psychology Resident in Trauma and Acute Care

• The Intensity: Extreme Presenting Problems
• The Intricacies: Working in Medicine
• The Adjustment: Clinical Work
• Clinical Interventions
• In Closing, For Now

“I can’t believe this is happening right now! I need to pinch myself” is a thought that has passed through my mind multiple times during my residency in trauma psychology at a level 1 trauma center. I knew it would be different from typical outpatient psychotherapy and assessment, but I still hadn’t anticipated the intensity and intricacies involved, or the adjustment required to my clinical approach. In traditional settings, we tend to encounter people months or years after major medical crises and life-changing injuries are sustained. The cases I now faced in the trauma center were acute, often causing visceral reactions that weighed on my heart in ways I hadn’t experienced before, and they stretched and sometimes fell beyond the schemas provided by my graduate training.

The Intensity: Extreme Presenting Problems

Most of the patients I saw were admitted for treatment of injuries following vehicle collisions, falls, gunshot or stab wounds, pedestrian or bicycle vs. auto accidents, self-inflicted incidents, and periodically complex and life-threatening medical problems. The range of stories and circumstances I encountered on a regular basis were like the far-removed scenarios portrayed in entertainment or reported on the evening news, including brutal suicide attempts, physical and sexual assaults, attempted murder, hostage situations, home invasions, drownings, and almost stunt-like accidents. Some of the most disturbing, though, were the most seemingly innocuous accidents that resulted in unfathomable and devastating consequences.

It’s no surprise that returning daily to a workplace like this one would have a personal, cumulative effect. I noticed that I drove a bit more carefully. I evaluated my own financial situation while envisioning my own hypothetical future in which I or my spouse was in the hospital under circumstances similar to those of my patients. I imagined how I might feel, pacing the hallways, gazing at a loved one in a hospital bed, or being delivered painful news. The flip-side of being empathetic, a trait so many clinicians possess, is that we can see ourselves in the suffering of others. So, seeing the look in the eyes of those who are told they will never be independent again (e.g., due to complete SCIs-spinal cord injuries), or who are grappling with the reality that a loved one’s injuries are not or were not survivable, or when they learn they were the cause of another’s death, was profoundly painful on a human level. The mirror neurons facilitating our shared humanity fire, and someone else’s current predicament and threat of mortality became my existential discomfort and personal grief as well.

The Intricacies: Working in Medicine

In anticipation of encounters with our clients, we therapists typically wonder, “Will Sarah show up for her appointment today?” or “I wonder if Frank remembered his homework?” Questions I often found myself wondering in the trauma center went something like, “Is Jennifer in surgery again?”, “Has David been extubated yet, so we can converse?” or “What is Joe’s GCS (Glasgow Coma Scale) and/or Rancho score, and is it high enough to permit engagement in meaningful conversation?” Moreover, privacy was minimal, and I had to grow accustomed to visits with patients being interrupted by other essential (trauma surgeons) and often also comparatively non-essential (custodians) staff. I learned to discern when and how to defend our time and request, “Could you come back in 15-20 minutes?” while taking patient priorities into consideration.

Discernment was also required for determining the level of engagement with a patient and/or family based on their location in the stages of acuity. Was the patient just admitted? Is the family in the midst of the most acute stage of shock or grief? Is the patient really needing mental health triage? For some, answering questions posed by a relaxed professional is reassuring and distracting; for others, it may feel insensitive. My initial visits typically involved collecting a brief psychosocial history, but doing so is simply not appropriate with, for example, families grieving the anticipated passing of a loved one. In those cases, I simply helped the family to become aware of available support.

Often in trauma cases, physical recovery must make headway first, but sometimes emotional needs are salient from the get-go. Once, I visited a woman the morning after a terrible car accident. She asked her family to leave the room, allowing us to visit for the next hour or so. She had questions about pre-existing anxiety, acute stress, psychotropic medication, psychotherapy, faith, and how to overcome grief associated with another’s death from the same accident. It was perhaps one of my most memorable visits with a patient, and one of those therapeutic encounters in which what we have to offer and what the patient needs align perfectly.

I have often joked, “Which has more acronyms, the field of psychology or the military?” I think the military takes the cake on that one, but medical jargon is nearly as unfamiliar to a professional outsider without formal medical training. Terms used regularly during our morning multidisciplinary “dispo” meetings were often totally foreign: NG tubes, pigtails, cannulation, fasciotomies, TPN, rhabdomyolysis, dysphagia, Miami j collars, to name a few. What I found particularly entertaining and surprising was the assumption on the part of the medical staff that I understood what they were talking about when providing me with updates about a patient or explaining medical procedures and their complicating factors with technical language. Other concepts were easier to understand, such as “we sucked peas out of his lungs.” The first task entailed learning what many of these terms meant.

The second task was to determine if and how medical concepts might have significance for my work with the patients. Sure enough, many did. Ventilator weaning and “high flow” trials have particular significance in spinal-cord-injured patients, as these processes often elicit substantial anxiety due to uncomfortable physical sensations and often subsequent, though inaccurate, fears of suffocation. This anxiety can stall or slow progress towards independence from life support and therefore potentially shift discharge plans such as whether to consider short-term rehabilitation or long-term care. Other medical conditions also have clinical implications. Proximity of amputations (e.g., foot vs. leg) has bearing on functional outcomes and emotional adjustment. Fistulas, such as gastrointestinal fistulas, are abnormal openings between or within internal organs and other structures, often resulting as collateral damage from surgery. They are difficult to repair and complicate or substantially delay discharge plans, demoralizing many patients afflicted by them. Ostomy bags, which may be necessary for patients with fistulas, are another cause of maladaptive adjustment, especially for younger patients. Perhaps one of the most severe situations is the need for a patient’s placement on the ECMO (extracorporeal membrane oxygenation machine), a “hail Mary” medical effort to save a patient’s life. The ECMO machine functions as total life support, providing cardiac and respiratory functions, and is intended to be a bridge to other treatment. Psychological support is provided every time a patient is expected to be an ECMO candidate.

Communication with medical staff in the trauma center is not entirely dissimilar to the communication with medical staff in primary care settings which many mental health professionals are more familiar with. However, determining what is useful for them to know in the trauma surgery department strikes me as much more difficult. Conversations are not about outpatient weight loss, smoking cessation, and medication compliance, but about behavioral, psychological, and emotional factors that happen to be deeply embedded in a unique and intense medical system. Life and death issues are more often at the forefront. Much of what we discussed with patients’ treatment teams was problem-solving patient-specific challenges that might require increasing patient morale or adapting the environment to fit a patient’s needs. It goes without saying that we were asked to evaluate patients when apparent psychological comorbidities were interfering with treatment progress or even when ambiguous patient behaviors left their treatment teams puzzled (e.g., reported the loss of sensation or movement in limbs with no apparent medical evidence to support such deficits).

The Adjustment: Clinical Work

The sights, smells, and sounds in the hospital are unparalleled elsewhere. Gnarly bruises and X-fixes, splashes of blood on the floor, bloodshot eyes, genitalia, unidentifiable bodily fluids collecting in clear containers hooked on the end of hospital beds, the occasional stench of excrements in hallways, beeping alarms of bedside machines, images of damaged body parts from post-explosive incidents, a deceased child’s body. Once I visited a man after an assault. His eyelids were sutured closed because of the nature of the injuries his face sustained. While we were talking, he coughed, and the pressure immediately caused blood to stream from his eyes. He commented, “I think my eyes are watering…” I paused before responding. I didn’t want him to panic, but I knew my subsequent departure to get help would probably sound the alarm anyway. “Actually, I’m afraid you’re bleeding a bit. I’m going to get your nurse,” I said. He started whimpering, the panic rising. “Don’t worry; we’ll take care of you right away! Take a couple deep breaths.”

As is the case in some other settings, our clients or patients were not always seeking mental health services. While some had requested it, patients in the trauma center typically are not looking for mental health care and occasionally are not very receptive to it. Normalizing talking to a psychologist right off the bat is important. So, after introducing myself and with a sincere but wry smile on my face, I tended to say something along the lines of, “Most people don’t plan on coming to the hospital, let alone the ICU. It’s pretty overwhelming. While everyone else’s job here is to take care of you physically, I’m here to check in to make sure you’re doing okay otherwise--to make sure that your time here is as smooth as possible.” The goal is to make interacting with a psychologist seem routine (as it often is) and easy, in part because there is not always much time to build rapport.

Understandably, many of the conversations center around the cause for hospitalization and related injuries and treatment. Follow-up questions will entail quality and amount of sleep, pain levels, appetite, and mood. The mode of interacting with patients, at times, differs substantially from what happens in traditional psychotherapeutic settings. Unless there is a glaring reason not to, I responded with a hug when prompted, asking no questions. And I cried with grieving families when sincerely felt waves of emotion welled up, though I made sure to not cry more than they did! While sitting in one family meeting in which the trauma surgeon described clearly how he had exhausted all options to save the teenage boy’s life after falling ill suddenly just several days earlier, the family broke down in tears. The patient’s nurse, my practicum student, and I could not help but also freely shed tears with them. Due to the intensity of patients’ medical circumstances and threats to life, withholding expressions of genuine emotion appears cold and overly clinical, practically inhuman.

Clinical Interventions

A state mandate requires psychological care for brain and spinal cord injured patients. In addition to those patients, we evaluated and treated patients experiencing psychological symptoms that are affecting treatment or having trouble with general coping while hospitalized. These included generalized or situational anxiety, depression, acute stress and adjustment difficulties, grief/loss (life, limb, or function), and suicidality/risk (specifically if there is a need to place a patient under suicide watch and pursue involuntary psychiatric hospitalization). Additionally, we screened patients for psychiatry services and evaluate for capacity in medical decision-making. Occasionally, particularly unique cases would come up, such as when a treatment team cannot determine a medical cause for a patient’s altered mental status. Lastly, we were consulted to provide family support when needed and to authorize child visits to loved ones in the ICU-when they were younger than 13 years old.

Due to the constraints of the setting (limited privacy, limited time per visit and number of visits, physical limitations and particular focus of stressors), many of the interventions were supportive and patient-centered. Donald Winnicott’s notion of providing a holding or “containing space” for whatever a patient needs comes to mind. Interventions frequently involved psychoeducation and coping skills development, such as relaxation strategies (deep breathing and visual guided imagery) that serve multiple purposes, from facilitation of sleep to anxiety and pain management. The monitors showing a patient’s heart rate provided accessible biofeedback to assess impact. Naturally, and unfortunately, deep breathing is not possible for intubated/ventilated patients. I encouraged patients to identify other coping skills. For example, one patient described how much she loved music, so we discussed how incorporating periods of time to listen to her favorite music each day would help to improve her mood. Also, I occasionally suggested patients utilize affective labeling1, either privately or in conversation with others, to reduce emotional distress.

It was particularly rewarding to find ways of adapting traditional psychotherapy techniques and concepts into concisely-packaged interventions in this setting. Basic cognitive-behavioral concepts could be explained to patients in ways that are easily understandable and immediately applicable. Unpleasant circumstances could be positively reframed. The relationship between automatic thoughts and emotional and behavioral consequences could be briefly outlined, and even cognitive distortions could be gently pointed out with the purpose of promoting more adaptive adjustment while under inpatient care. I might say to a patient, “You are absolutely faced with objectively legitimate physical challenges right now. That said, sometimes the particular ways in which we react to our circumstances can actually create additional obstacles that we just don’t need to deal with as well. Let me describe a bit more about what I mean, and you can tell me what you think.”

Since this was a trauma environment, and nearly all the patients we saw had undergone major traumatic events, I got particularly excited to find ways of packaging evidence-based trauma treatment interventions or concepts for accessible use - Cognitive Processing Therapy (CPT), being a particular favorite. After providing basic psychoeducation about acute stress and normalization of such responses, I liked to use a variety of analogies to further illustrate what acute stress responses are and how one might consider responding to them with the goal of healing in mind.

To illustrate why re-experiencing symptoms occur:

• Our lives are generally like flat lines, stable and constant, with occasional blips (reflecting moderate stressors such as interpersonal conflicts and illnesses), and traumatic events are a major blip on that line. (This is consistent with the phenomenon of flash-bulb memories.)
• A file folder (traumatic event) remains outside of the filing cabinet (narrative of one’s life, full of other experiences) until it can be adequately sorted and placed (This is an analogy borrowed from the CPT manual materials.)

To illustrate why avoiding avoidance and emotional processing are important:

• Physical wounds require tending (cleaning, stitching, ointment) because, without this, they can become infected or heal improperly. Emotional wounds are similar, needing attention and care, in the form of emotional processing, for the sake of closure.
• As children, when we learn to ride bikes, we often fall off, maybe skin a knee or bruise a thigh. If not coaxed into getting back on, fear of riding a bike will maintain or even increase. But if the fear is managed and overcome, the new skill is mastered, and the fear dissipates. (This is especially so for patients after car accidents, for instance.)

On several occasions, I noticed that maladaptive automatic thoughts-or cognitive distortions had already developed in the wake of a major trauma. From a CPT framework, these are called “stuck points” and are either “assimilated” (past-focused, typically on traumatic incident) or “over-accommodated” (present/future-oriented statements). These are problematic because they will likely interfere with healthy post-trauma adjustment. The major themes of trauma are often apparent and include control, responsibility, intimacy, trust, and safety. I recall a few instances of talking to husbands of female patients who blamed themselves for vehicular accidents that were entirely due to extenuating, external factors. Their self-concepts, characterized by competence and accomplishment, paired with immense love for their spouses, meant they pinned the blame squarely on their own shoulders, despite intellectually understanding otherwise. Emotional reasoning at its finest. I hoped that outlining some of these cognitive and emotional responses and challenging these stuck points empathically planted seeds for greater self-awareness and supported progress on a more adaptive, long-term trajectory.

Of important note, conversations about trauma in the acute phase such as this are not the same as structured crisis incident stress debriefings that are largely unsupported or even contraindicated in the literature. Patients and family members are left to determine whether or not they want to discuss the traumatizing incident, and emotional reactions are rarely therapeutically explored in significant depth. While conducting a mental status assessment, I would ask patients if they recall the incident, while informing them I am not asking them to tell me about it, though they can do so should they choose. This provides them with more control and a greater sense of security when discussing their mental health status.

Other psychotherapy skills we learn as clinicians were relevant in this setting, including:

• recognizing the time and place for silence
• identifying and therapeutically pointing out avoidance (or when the molehill is the cover for the mountain)
• utilizing empathy without becoming consumed by it
• consulting when faced with ambiguity and ethical quandaries
• getting creative in efforts to connect with others from different walks of life
• permitting oneself to not have all the answers
• being resourceful in clinical problem-solving, particularly in a multidisciplinary setting

In Closing, For Now

The trauma, acute care setting left me with a resounding sense of gratitude (which I also find is a terrific inoculator against anxiety and apprehension). In observing the enormity of human suffering, I was humbled when counting my blessings and reflecting on the dedication and compassion displayed by so many members of the medical teams. Friedrich Nietzsche famously stated, “He who has a why to live for can bear almost any how.” The existential significance of this work was not lost on me. What amazed me is not just that people find a way to face another day under truly dire circumstances, but that so many do. I have come to accept that, in this context, I may not always have been able to treat the diagnosis and cure all the symptoms. The environment and physical conditions provided ever-present limitations. But I developed a tremendously deep appreciation for the resilience of the human spirit and appreciated the significance, and perhaps inherently healing effect, of sitting with others during their darkest moments.

Related References
Kircanski, K., Lieberman, M. D., & Craske, M. G. (2012). Feelings into words. Psychological Science, 23(10), 1086-1091. 
Resick, P. A., Monson, C. M., & Chard, K. M. (2014). Cognitive processing therapy: Veteran/military version: Therapist and patient materials manual. Washington, D.C.: Department of Veteran Affairs
 

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