Trauma and Stress-Related Disorder

POSTTRAUMATIC STRESS DISORDER

Posttraumatic stress disorder (PTSD) is a disturbing pattern of behavior demonstrated by someone who has experienced, witnessed, or been confronted with a traumatic event such as a natural disaster, combat, or an assault. A person with PTSD was exposed to an event that posed actual or threatened death or serious injury and responded with intense fear, helplessness, or terror. Box 13.1 is the “Life Events Checklist” that is used to screen individuals with a history of exposure to some type of trauma.

Clinical Course

The four subcategories of symptoms in PTSD include reexperiencing the trauma through dreams or recurrent and intrusive thoughts, avoidance, negative cognition or thoughts, being on guard, or hyperarousal (Shalev & Marmar, 2017). The person persistently reexperiences the trauma through memories, dreams, flashbacks, or reactions to external cues about the event and therefore avoids stimuli associated with the trauma. The victim feels a numbing of general responsiveness and shows persistent signs of increased arousal such as insomnia, hyperarousal or hypervigilance, irritability, or angry outbursts. He or she reports losing a sense of connection and control over his or her life. This can lead to avoidance behavior or trying to avoid any places or people or situations that may trigger memories of the trauma. The person seeks comfort, safety, and security, but can actually become increasingly isolated over time, which can heighten the negative feelings he or she was trying to avoid. Box 13.2 is the PTSD Checklist that details many of the symptoms people experience.

In PTSD, the symptoms occur 3 months or more after the trauma, which distinguishes PTSD from acute stress disorder, which may have similar types of symptoms but lasts 3 days up to 1 month. The onset can be delayed for months or even years. Typically, PTSD is chronic in nature, though symptoms can fluctuate in intensity and severity, becoming worse during stressful periods. Often, other life events can exacerbate PTSD symptoms. In addition, many clients with PTSD develop other psychiatric disorders, such as depression, anxiety disorders, or alcohol and drug abuse (Shalev & Marmar,

2017).

PTSD can occur at any age, including during childhood. Estimates are that up to 60% of people at risk, such as combat veterans and victims of violence and natural disasters, develop PTSD. Complete recovery occurs within 3 months for about 50% of people. The severity and duration of the trauma and the proximity of the person to the event are the most important factors affecting the likelihood of developing PTSD. One-fourth of all victims of physical assault develop PTSD. Victims of rape have one of the highest rates of PTSD at approximately 70% (Shalev & Marmar, 2017).

Related Disorders

Adjustment disorder is a reaction to a stressful event that causes problems for the individual. Typically, the person has more than the expected difficulty coping with or assimilating the event into his or her life. Financial, relationship, and work-related stressors are the most common events. The symptoms develop within a month, lasting no more than 6 months. At that time, the adjustment has been successful, or the person moves on to another diagnosis (Katzman & Geppert, 2017). Outpatient counseling or therapy is the most common and successful treatment. Acute stress disorder occurs after a traumatic event and is characterized by reexperiencing, avoidance, and hyperarousal that occur from 3 days to 4 weeks following a trauma. It can be a precursor to PTSD. Cognitive–behavioral therapy (CBT) involving exposure and anxiety management can help prevent the progression to PTSD (Carpenter et al., 2018).

Reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) occur before the age of 5 in response to the trauma of child abuse or neglect, called grossly pathogenic care. The child shows disturbed inappropriate social relatedness in most situations. Rather than seeking comfort from a select group of caregivers to whom the child is emotionally attached, the child with RAD exhibits minimal social and emotional responses to others, lacks a positive effect, and may be sad, irritable, or afraid for no apparent reason. The child with DSED exhibits unselective socialization, allowing or tolerating social interaction with caregivers and strangers alike. They lack the hesitation in approaching or talking to strangers evident in most children their age. Grossly deficient parenting and institutionalization are the two most common situations leading to this disorder (Hauck, Gleason, & Zeanah, 2017).

Etiology

PTSD and acute stress disorder had long been classified as anxiety disorders, though they differ from other diagnoses in that category; they are now classified in their own category. There has to be a causative trauma or event that occurs prior to the development of PTSD, which is not the case with anxiety disorders, discussed further in Chapter 14. PTSD is a disorder associated with event exposure, rather than personal characteristics, especially with the adult population. In other words, the effects of the trauma at the time, such as being directly involved, experiencing physical injury, or loss of loved ones in the event, are more powerful predictors of PTSD for most people.

This is particularly true of single-event trauma, or triggering event, such as natural disasters. However, lack of social support, peri-trauma dissociation, and previous psychiatric history or personality factors can further increase the risk of PTSD when they are present pretrauma (Lies, Lau, Jones, Jensen, & Tan, 2017). In addition, people who participate in posttrauma counseling right after the event decrease their risk of PTSD.

Studies of adolescents with PTSD indicate they are more likely to develop PTSD than children or adults. Age, gender, type of trauma, and repeated trauma are related to increased PTSD rates. Adolescents with PTSD are at increased risk for suicide, substance abuse, poor social support, academic problems, and poor physical health. Trauma-focused CBT is beneficial and can be delivered in school or community-based settings. It also has positive long-term effects both with PTSD and other comorbid conditions (Gutemann, Schwartzkopff, & Stell, 2017). PTSD may disrupt biologic maturation processes contributing to long-term emotional and behavioral problems experienced by adolescents with this disorder that would require ongoing or episodic therapy to deal with relevant issues.

The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see the following corresponding criteria.

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).

2. Witnessing in person the event(s) as it (they) occurred to others.

3. Learning that the traumatic event(s) occurred to a close family member or a close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or

accidental.

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).

Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures unless this exposure is work-related.

B. Presence of one (or more) of the following intrusion symptoms

associated with the traumatic event(s), beginning after the traumatic

event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the

traumatic event(s).

Note: In children older than 6 years, repetitive play may occur in

which themes or aspects of the traumatic event(s) are expressed.

2. Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event(s).

3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as though the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)

Note: In children, trauma-specific reenactment may occur in play.

4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).

3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame him or herself or others.

4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

5. Markedly diminished interest or participation in significant activities.

6. Feelings of detachment or estrangement from others.

7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.

2. Reckless or self-destructive behavior.

3. Hypervigilance.

4. Exaggerated startle response.

5. Problems with concentration.

6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Children are more likely to develop PTSD when there is a history of parental major depression and childhood abuse. Psychopathology in the parents results in a stress-laden environment for the child and is much more likely to end in a PTSD diagnosis. These risks are diminished when postevent counseling occurs soon after the trauma. Parental participation in treatment significantly enhances the benefits of CBT for traumatized children. It also improved depressive symptoms commonly seen in parents (Tutus, Keller, Sachser, Pfeiffer, & Goldbeck, 2017).

CULTURAL CONSIDERATIONS

Research indicates that PTSD is a universal phenomenon, occurring in countries around the world. There is less information about the meaning of one’s culture on PTSD, treatment, and recovery. People leaving their countries for reasons of political oppression experience mental defeat and alienation and lower levels of resilience, which are associated with PTSD as well as poorer long-term outcomes (Georgiadou, Morawa, & Erim, 2017). People with a stronger sense of self and cultural identity are less frequently diagnosed with PTSD and have better long-term outcomes when PTSD was present. This may indicate that strong cultural identity and allegiance to culture contribute to resilience and are therefore highly positive factors.

The assessment and treatment of PTSD can be culturally tailored to patients (Rosen et al., 2017). Specifically, therapists should try to understand the patients’ help-seeking behaviors as well as their expectations for treatment. Effective treatments, such as CBT, should be strengths-based, client-driven, and include the patient’s culturally relevant beliefs about the illness, its symptoms, and how that intrudes in daily life.

Treatment

Counseling or therapy, individually or in groups, for people with acute stress disorder may prevent progression to PTSD. Therapy on an outpatient basis is the indicated treatment for PTSD. There are some medications that may also contribute to successful resolution, especially when targeting specific issues, such as insomnia. A combination of both therapies produces the best results (Greenbaum, Neylan, & Rosen, 2017). Inpatient treatment is not indicated for clients with PTSD; however, in times of severe crisis, short inpatient stays may be necessary. This usually occurs when the client is suicidal or is being overwhelmed by reexperiencing events, such as flashbacks. Short hospitalization for stabilization is discussed later in this chapter.

CBT and specialized therapy programs incorporating elements of CBT are the most common and successful types of formal treatment. The choice of therapy can depend on the type of trauma, as well as the choice to seek formal individual or group counseling. Self-help groups offer support and a safe place to share feelings.

Exposure therapy is a treatment approach designed to combat the avoidance behavior that occurs with PTSD, help the client face troubling thoughts and feelings, and regain a measure of control over his or her thoughts and feelings. The client confronts the feared emotions, situations, and thoughts associated with the trauma rather than attempting to avoid them. Various relaxation techniques are employed to help the client tolerate and manage the anxiety response. The exposure therapy may confront the event in reality, for example, returning to the place where one was assaulted, or may use imagined confrontation, that is, mentally placing oneself in the traumatic situation. Prolonged exposure therapy has been particularly effective for both active military personnel and veterans (Horesh, Qia, Freedman, & Shalev, 2017).

Adaptive disclosure is a specialized CBT approach developed by the military to offer an intense, specific, short-term therapy for active-duty military personnel with PTSD. It incorporates exposure therapy as well as the empty chair technique, in which the participant says whatever he or she needs to say to anyone, alive or dead. This is similar to techniques used in Gestalt therapy. Despite the short six-session format, this approach seems well tolerated and effective in reducing PTSD symptoms and promoting posttrauma growth (Yeterian, Berke, & Litz, 2017).

Cognitive processing therapy has been used successfully with rape survivors with PTSD as well as combat veterans. The therapy course involves structured sessions that focus on examining beliefs that are erroneous or interfere with daily life, such as guilt and self-blame; for example, “It was my fault, I should have fought harder” or “I should have died with my fellow Marines;” reading aloud a written account of the worst traumatic experience; recognizing generalized thinking, that is, “No one can be trusted;” and regaining more balanced and realistic ways of appraising the world and themselves (Stayton, Dickstein, & Chard, 2018).

Medications may be used for clients with PTSD to deal with symptoms such as insomnia, anxiety, or hyperarousal. Studies show that selective serotonin reuptake inhibitor (SSRI) and serotonin and norepinephrine reuptake inhibitor antidepressants are most effective, followed by second-generation antipsychotic, such as risperidone. Evidence is lacking for the efficacy of benzodiazepines, though they are widely used in clinical practice (Friedman & Bernardy, 2017). A combination of medications and CBT is considered to be more effective than either one alone.

ELDER CONSIDERATIONS

PTSD can be diagnosed at any age (Bloch, 2017). Traumatic events such as

natural disasters are not clustered in any particular age group. Elder people

who fall and fracture a hip can experience PTSD. In addition, the current

population of elders includes veterans of World War II who experienced

PTSD, though it was not recognized as such at the time. Often, it was called

combat fatigue or shell shock. PTSD was identified as a common disorder in

the elderly in Europe, linked to the war, as well as the resulting occupation.

Veterans of the Vietnam War, now in their 60s, are among some of the first

people to be diagnosed with PTSD.

Many among the elderly population have impaired quality of life from

PTSD, including a negative impact on physical functioning and general

health. Chronic PTSD may be associated with premature aging and dementia.

Therefore, it is essential that the elderly receive adequate treatment for PTSD

(Jakel, 2018).

Community-Based Care

Most care provided to people in the aftermath of traumatic experiences is done on an outpatient basis. Individual therapy, group therapy, and self-help groups are among the most common treatment modalities. In addition, both clients and families can implement many self-care interventions to promote physical and emotional well-being. These suggestions are discussed in “Client and Family Education.”

CLIENT AND FAMILY EDUCATION

• Ask for support from others.

• Avoid social isolation.

• Join a support group.

• Share emotions and experiences with others.

• Follow a daily routine.

Set small, specific, achievable goals.

• Accept feelings as they occur.

• Get adequate sleep.

• Eat a balanced, healthy diet.

• Avoid alcohol and other drugs.

• Practice stress reduction techniques.

Mental Health Promotion

It is not possible to avoid many of the traumatic events in life that can potentially cause mental health problems. Natural disasters such as earthquakes and hurricanes are beyond human control. It is also not possible to avoid all the man-made traumatic events that occur; people have been victims of trauma while shopping, watching a movie, or during any other ordinary daily activity. One of the most effective ways of avoiding pathologic responses to trauma is effectively dealing with the trauma soon after it occurs.

In addition to first aid responders for disastrous events, counselors are often present to help people process the emotional and behavioral responses that occur. Some people more easily express feelings and talk about stressful, upsetting, or overwhelming events. They may do so with family, friends, or professionals. Others are more reluctant to open up and disclose their personal feelings. They are more likely to ignore feelings, deny the event’s importance, or insist “I’m fine; I’m over it.” By doing that, they increase the risk of future problems such as PTSD. It is essential to have an accurate diagnosis of PTSD. Stress immediately after an event is acute stress disorder, while PTSD is delayed in onset. Some individuals will report “having PTSD” but are self-diagnosed. They may have autism spectrum disorder, a grief reaction, or any variety of problems. Effective treatment is possible only with accurate, professional diagnosis.

DISSOCIATIVE DISORDERS

Dissociation is a subconscious defense mechanism that helps a person protect his or her emotional self from recognizing the full effects of some horrific or traumatic event by allowing the mind to forget or remove itself from the painful situation or memory. Dissociation can occur both during and after the event. As with any other protective coping mechanism, dissociating becomes easier with repeated use.

Dissociative disorders have the essential feature of a disruption in the usually integrated functions of consciousness, memory, identity, or environmental perception. This often interferes with the person’s relationships, ability to function in daily life, and ability to cope with the realities of the abusive or traumatic event. This disturbance varies greatly in intensity in different people, and the onset may be sudden or gradual, transient, or chronic. Dissociative symptoms are seen in clients with PTSD (Lowenstein, Frewen, & Lewis-Fernandez, 2017).

• Dissociative amnesia: The client cannot remember important personal information (usually of a traumatic or stressful nature). This category includes a fugue experience where the client suddenly moves to a new geographic location with no memory of past events and often the assumption of a new identity.

• Dissociative identity disorder (formerly multiple personality disorder): The client displays two or more distinct identities or personality states that recurrently take control of his or her behavior. This is accompanied by the inability to recall important personal information.

• Depersonalization/derealization disorder: The client has a persistent or recurrent feeling of being detached from his or her mental processes or body (depersonalization) or sensation of being in a dream-like state in which the environment seems foggy or unreal (derealization). The client is not psychotic nor out of touch with reality.

Dissociative disorders, relatively rare in the general population, are much more prevalent among those with histories of childhood physical and sexual abuse. Some believe the recent increase in the diagnosis of dissociative disorders in the United States is the result of more awareness of this disorder by mental health professionals. Whether dissociative identity disorder is a legitimate diagnosis is still a controversy among psychiatrists in the field (Reinders et al., 2016).

The media has focused much attention on the theory of repressed memories in victims of abuse. Many professionals believe that memories of childhood abuse can be buried deeply in the subconscious mind or repressed because they are too painful for the victims to acknowledge and that victims can be helped to recover or remember such painful memories. If a person comes to a mental health professional experiencing serious problems in relationships, symptoms of PTSD, or flashbacks involving abuse, the mental health professional may help the person remember or recover those memories of abuse. Some mental health professionals believe there is danger of inducing false memories of childhood sexual abuse through imagination in psychotherapy. This so-called false memory syndrome has created problems in families when clients made groundless accusations of abuse. Fears exist, however, that people abused in childhood will be more reluctant to talk about their abuse history because, once again, no one will believe them. Still other therapists argue that people thought to have dissociative identity disorder are suffering anxiety, terror, and intrusive ideas and emotions and therefore need help, and the therapist should remain open-minded about the diagnosis.

Treatment and Interventions

Survivors of abuse who have dissociative disorders are often involved in group or individual therapy in the community to address the long-term effects of their experiences. Therapy for clients who dissociate focuses on reassociation, or putting the consciousness back together. This specialized treatment addresses trauma-based, dissociative symptoms. The goals of therapy are to improve quality of life, improved functional abilities, and reduced symptoms. Clients with dissociative disorders may be treated symptomatically, that is, with medications for anxiety or depression or both if these symptoms are predominant.

Short Hospital Treatment for Survivors of Trauma and Abuse

Clients with PTSD and dissociative disorders are found in all areas of health care, from clinics to primary care offices. The nurse is most likely to encounter these clients in acute care settings only when there are concerns for personal safety or the safety of others or when acute symptoms have become intense or overwhelming and require stabilization. Treatment in acute care is usually short-term, with the client returning to community-based treatment as quickly as possible.

General Appearance and Motor Behavior

The nurse assesses the client’s overall appearance and motor behavior. The client often appears hyperalert and reacts to even small environmental noises with a startle response. He or she may be uncomfortable if the nurse is too close physically and may require greater distance or personal space than most people. The client may appear anxious or agitated and may have difficulty sitting still, often needing to pace or move around the room. Sometimes the client may sit very still, seeming to curl up with arms around knees.

Mood and Affect

In assessing mood and affect, the nurse must remember that a wide range of emotions is possible from passivity to anger. The client may look frightened or scared or agitated and hostile depending on his or her experience. When the client experiences a flashback, he or she appears terrified and may cry, scream, or attempt to hide or run away. When the client is dissociating, he or she may speak in a different tone of voice or appear numb with a vacant stare. The client may report intense rage or anger or feeling dead inside and may be unable to identify any feelings or emotions.

Thought Process and Content

The nurse asks questions about thought process and content. Clients who have been abused or traumatized report reliving the trauma, often through nightmares or flashbacks. Intrusive, persistent thoughts about the trauma interfere with the client’s ability to think about other things or to focus on daily living. Some clients report hallucinations or buzzing voices in their heads. Self-destructive thoughts and impulses as well as intermittent suicidal ideation are also common. Some clients report fantasies in which they take revenge on their abusers.

Sensorium and Intellectual Processes

During assessment of sensorium and intellectual processes, the nurse usually finds that the client is oriented to reality except if the client is experiencing a flashback or dissociative episode. During those experiences, the client may not respond to the nurse or may be unable to communicate at all. The nurse may also find that clients who have been abused or traumatized have memory gaps, which are periods for which they have no clear memories. These periods may be short or extensive and are usually related to the time of the abuse or trauma. Intrusive thoughts or ideas of self-harm often impair the client’s ability to concentrate or pay attention.

Judgment and Insight

The client’s insight is often related to the duration of his or her problems with dissociation or PTSD. Early in treatment, the client may report little idea about the relationship of past trauma to his or her current symptoms and problems. Other clients may be quite knowledgeable if they have progressed further in treatment. The client’s ability to make decisions or solve problems may be impaired.

Self-Concept

The nurse is likely to find these clients have low self-esteem. They may believe they are bad people who somehow deserve or provoke the abuse. Many clients believe they are unworthy or damaged by their abusive experiences to the point that they will never be worthwhile or valued.

Clients may believe they are going crazy and are out of control with no hope of regaining control. Clients may see themselves as helpless, hopeless, and worthless.

Roles and Relationships

Clients generally report a great deal of difficulty with all types of relationships. Problems with authority figures often lead to problems at work, such as being unable to take direction from another or have another person monitor performance. Close relationships are difficult or impossible because the client’s ability to trust others is severely compromised. Often the client has quit work or has been fired, and he or she may be estranged from family members. Intrusive thoughts, flashbacks, or dissociative episodes may interfere with the client’s ability to socialize with family or friends, and the client’s avoidant behavior may keep him or her from participating in social or family events.

Physiologic Considerations

Most clients report difficulty sleeping because of nightmares or anxiety over anticipating nightmares. Overeating or lack of appetite is also common. Frequently, these clients use alcohol or other drugs to attempt to sleep or to blot out intrusive thoughts or memories.

Data Analysis

Nursing diagnoses commonly used in the acute care setting when working with clients who dissociate or have PTSD related to trauma or abuse include:

• Risk of self-mutilation

• Risk of suicide

• Ineffective coping

• Posttrauma response

Chronic low self-esteem

• Powerlessness

In addition, the following nursing diagnoses may be pertinent to clients over longer periods, although not all diagnoses apply to each client:

• Disturbed sleep pattern

• Sexual dysfunction

• Rape-trauma syndrome

• Spiritual distress

• Social isolation

Promoting the Client’s Safety

The client’s safety is a priority. The nurse must continually assess the client’s potential for self-harm or suicide and take action accordingly. The nurse and treatment team must provide safety measures when the client cannot do so (see Chapters 10 and 15). To increase the client’s sense of personal control, he or she must begin to manage safety needs as soon as possible. The nurse can talk with the client about the difference between having self-harm thoughts and taking action on those thoughts; having the thoughts does not mean the client must act on them. Gradually, the nurse can help the client find ways to tolerate the thoughts until they diminish in intensity.

Helping the Client Cope with Stress and Emotions

Grounding techniques are helpful to use with the client who is dissociating or experiencing a flashback. Grounding techniques remind the client that he or she is in the present, is an adult, and is safe. Validating what the client is feeling during these experiences is important: “I know this is frightening, but you are safe now.” In addition, the nurse can increase contact with reality and diminish the dissociative experience by helping the client focus on what he or she is currently experiencing through the senses:

• “What are you feeling?”

• “Are you hearing something?”

• “What are you touching?”

• “Can you see me and the room we’re in?”

• “Do you feel your feet on the floor?”

• “Do you feel your arm on the chair?”

• “Do you feel the watch on your wrist?”

Helping Promote the Client’s Self-Esteem

It is often useful to view the client as a survivor of trauma or abuse rather than as a victim. For these clients, who may believe they are worthless and have no power over the situation, it helps to refocus their views of themselves from being victims to being survivors. Defining themselves as survivors allows them to see themselves as strong enough to survive their ordeal. It is a more empowering image than seeing oneself as a victim.

Establishing Social Support

The client needs to find support people or activities in the community. The nurse can help the client prepare a list of support people. Problem-solving skills are difficult for these clients when under stress, so having a prepared list eliminates confusion or stress. This list should include a local crisis hotline to call when the client experiences self-harm thoughts or urges, and friends or family to call when the client is feeling lonely or depressed. The client can also identify local activities or groups that provide a diversion and a chance to get out of the house. The client needs to establish community supports to reduce dependency on health care professionals.

Local support groups can be located by calling the county or city mental health services or the Department of Health and Human Services. A variety of support groups, both online and in person, can be found on the internet.

SELF-AWARENESS ISSUES

It is essential for nurses to deal with their own personal feelings to best care for individuals affected by traumatic events. These events may be horrific in nature. Natural disasters can affect thousands of people; attacks on individuals or groups are sometimes senseless, random violence; and combat experiences in war can devastate on the individuals involved. If the nurse is overwhelmed by the violence or death in a situation, the client’s feelings of being victimized or traumatized beyond repair are confirmed. Conveying empathy and validating clients’ feelings and experiences in a calm, yet caring professional manner is more helpful than sharing the client’s horror.

When the client’s traumatic event is a natural disaster or even a random violent attack, the nurse may easily support the client, knowing the client had nothing to do with what happened. When the traumatized client causes a car accident that injured or killed others, it may be more challenging to provide unconditional support and withhold judgment of the client’s contributory.

Remaining nonjudgmental of the client is important but doesn’t happen automatically. The nurse may need to deal with personal feelings by talking to a peer or counselor. Points to Consider When Working with Abused or Traumatized Clients

• Clients who participate in counseling, groups, and/or self-help groups have the best long-term outcomes. It is important to encourage participation in all available therapies.

• Clients who survive a trauma may have survivor’s guilt, believing they “should have died with everyone else.” Nurses will be most helpful by listening to clients’ feelings and avoiding pat responses or platitudes such as “Be glad you’re alive,” or “It was meant to be.”

• Often clients just need to talk about the problems or issues they’re experiencing. These may be problems that cannot be resolved. Nurses may want to fix the problem for the client to alleviate distress but must resist that desire to do so and simply allow the client to express feelings of despair or loss.