13

Managing Crisis

Acute Care and Hospitalization

Severely traumatized patients maintain a tenuous homeostasis between numbing and intrusion, control and dyscontrol, and interpersonal connection and alienation. They often have brittle defenses that shatter in the face of stress or changes in the external environment. Current stresses or losses may plunge patients into isolation, despair, and suicidal impulses. Reminders of a past traumatic event may result in powerful intrusive symptomatology. In addition, even effective therapeutic efforts may actually increase symptomatology, as patients feel intensely vulnerable and panicked over fears of being abandoned, hurt, or violated. Changes in the patient’s external environment are frequent precipitants for decompensation. The loss of critical relationships or important external supports, either temporarily or permanently, can precipitate a crisis. The vacation of a therapist, the breakup or deterioration of a relationship (even a dysfunctional relationship), the sudden lack of availability or loss of an important person (or a pet), or the ending of a job or other regular sustaining activity are frequent causes for decompensation. When patients are at risk for serious harm, or become so symptomatic that they are unable to function, they may need acute psychiatric care. Traditionally, such care has been provided in a hospital setting but is now sometimes also provided in residential or partial hospital settings.

Traumatized patients experience one particular personal dilemma that merits special emphasis. Patients’ flight into isolation from others results in a profound experience of aloneness. Although such a course may seem safest to patients, it leaves them with only themselves—and their self-hate. Behind many complicated scenarios of decompensation in traumatized patients lies a simple formulation. Patients who are left alone with their own self-blame and self-loathing often turn to self-destructive activities or other dysfunctional behaviors as a way of alleviating an intolerable internal experience.

ASSESSMENT AND FORMULATION

It is always crucial to evaluate psychiatric decompensation in patients with complex PTSD and dissociative disorders in the context of psychosocial issues and the patient’s external environment. Given the common formulation of psychosocial stressors resulting in increased symptomatology and dysfunctional attempts to cope, comprehensive treatment must be focused not only on the symptomatology but also on ameliorating the stressors that precipitated decompensation. That is, there is an important difference between accurate diagnosis and a formulation of the patient’s current situation. Clinicians should understand the patient in terms of background, symptoms, strengths and vulnerabilities, and the circumstances that led to the current difficulties. For example, a patient may present with symptoms such as traumatic nightmares or flashbacks. In addition to attempts to contain and alleviate these symptoms, attention must also be directed toward their precipitants—for example, the loss of an important supportive relationship or the presence of a current abusive relationship that repetitively destabilizes the patient. The following case illustrates some of the complexities of assessment:

Lucy, a 27-year-old married woman with dissociative identity disorder (DID), was admitted to the hospital in crisis. Internally, she heard the voice of a persecutor personality who threatened to hurt her. She also was having nearly constant flashbacks of sexual molestation that occurred when she was a teenager. Lucy was initially uncommunicative on the unit and had to be physically restrained on two occasions when she was having flashbacks and began banging her head into a wall. She reacted angrily to the restraints and accused staff members of being abusive. She managed to convince her inpatient therapist that she needed to work through her adolescent rapes. However, after a week of tumultuous and frightening abreactions, Lucy actually appeared to be more regressed and was acutely suicidal.

As her treatment did not appear to be helping Lucy, the treatment team conducted a careful review of her circumstances. It was eventually ascertained that an incident of somewhat aggressive sexual contact with her husband before admission had been very frightening to her. Lucy had told her outpatient therapist about this in the next session, after which the therapist announced he would be going on vacation. The acute symptoms began at this point. In reviewing the events prior to admission, it was clear that the patient had been triggered by the sexual interaction with her husband, which was then compounded by the vacation (perceived as abandonment) by the therapist. In view of this information, the treatment team shifted approaches. The outpatient therapist was brought in as part of the treatment team, and the husband was engaged in a series of couples meetings to negotiate safety at home. On the unit, active efforts were made to help Lucy with grounding techniques to control her florid dissociative symptoms. Aftercare arrangements were a focus of the treatment, and Lucy was discharged without incident after a few days.

A focus on both the current symptoms and the dynamics of their underlying cause is particularly important when working with patients with complex PTSD and dissociative disorders. Their intriguing and shifting presentations may often hide the ordinary realities that cause their current distress. In many ways, such therapeutic difficulties are not surprising. After all, posttraumatic and dissociative defenses are utilized to distance and disavow stressful experiences; the psychological gain is in not attending to them. However, any successful resolution of a crisis situation will necessitate both symptomatic control and restoration of a safe and stable external environment.

Another area of importance is the ongoing outpatient treatment. Acute intensive treatment such as hospitalization offers the opportunity for consultation to the ongoing treatment. Although acute care may be routinely necessary for unstable patients who are receiving thoughtful, sophisticated, and competent therapy, some hospitalizations are precipitated when therapy is poorly conceived or implemented. Consultations must be performed with great sensitivity, as there appear to be particular characteristics of severely traumatized patients and their therapy that normatively result in painful clinical dilemmas (see Chapters 9 and 10; Chu, 1988; Davies & Frawley, 1994; Kluft, 1988; Pearlman & Saakvitne, 1995), and even well-meaning and competent therapists can fall into difficult clinical traps. As a result, clinicians who provide the long-term, ongoing therapy can find themselves beleaguered, emotionally drained, and uncertain, and defensive about what they are doing. Issues regarding the pacing of the therapy, transference-countertransference binds, defining treatment goals, setting limits, and maintaining boundaries are all common dilemmas in ongoing treatment. Given that patients generate similar dynamics and reenact similar scenarios in both the inpatient and outpatient settings, the inpatient treaters are in a unique position to be able to empathize with the dilemmas posed by the patient and to consult with the outpatient therapist. If this kind of consultation is done sensitively, supportively, and effectively, the beneficial effects of inpatient hospitalization on the patient’s treatment may extend well beyond the hospital stay.

DIAGNOSTIC ISSUES

Hospitalization offers the opportunity to reassess the accuracy of a patient’s diagnosis. In some instances, the failure of the outpatient treatment to contain the patient derives from interventions that do not take into account a hidden underlying condition (e.g., a presentation that appears to be trauma-related but is actually caused by an undiagnosed mood disorder or psychosis, or vice versa). Inpatient treaters have a unique opportunity to tease out how various presentations mimic the symptoms of others or obscure their expression.

The differential diagnosis of posttraumatic disorders from mood disorders can be subtle. Time-limited assessment of patients in an office setting may fail to distinguish between traumatized patients and those with more biologically based major depression. Patients who feel subjectively depressed, hopeless, and helpless on the basis of complex trauma-related issues may present in office appointments in a way that is similar to nontraumatized depressed patients with many of the classic vegetative signs of major depression: lack of energy, motivation, and interest; guilty and suicidal thoughts; and appetite and sleep disturbances (Chu, Dill, & Murphy, 2000). On an inpatient unit, some interesting differences between trauma-related dysphoria and a major depressive episode may emerge. For example, although patients with trauma-related dysphoria may appear quite classically depressed in interviews with the unit staff, they might be observed to be animated and engaged in interactions with other patients in ways that are uncharacteristic for classic major depression.

There can be confusion about differentiating the symptoms of bipolar disorder from those of severe dissociative disorders such as DID. The switches in self-states often seen in severe dissociative disorders may mimic the mood changes of bipolar disorder. In general, the state switches of dissociative disorders are much more frequent and abrupt than the mood changes in bipolar disorder—even in so-called rapid-cycling bipolar disorder. In addition, although in some cases of DID personalities that appear grossly disorganized or hypomanic can emerge, there is rarely the kind of sustained energized, grandiose, and delusional presentation that is characteristic of true mania. And, although sleep disturbance is common in both posttraumatic and dissociative disorders, total sleep time is maintained at a minimum of four to five hours per night on average. Sleep disturbances that persist at levels less than two or three hours per night are more consistent with mania or hypomania, particularly in the presence of high energy upon awakening. In the hospital setting, actual sleep times can be observed to differentiate between patients’ subjective reports (e.g., “I didn’t sleep more than an hour all night”) and the nursing observations of several hours of interrupted sleep.

As discussed in Chapters 2 and 3, symptoms of some posttraumatic and dissociative disorders may also mimic psychotic symptomatology. Our study of adult psychiatric patients (Chu & Dill, 1990) demonstrated a correlation between childhood abuse experiences and an elevated level of psychotism on the Minnesota Multiphasic Personality Inventory (MMPI), which might be explained by the observations of some investigators that symptoms such as hallucinations and even Schneiderian first-rank symptoms of schizophrenia frequently occur in severe dissociative disorders (Dell, 2009; Kluft, 1987a). Recurrent “brief reactive psychoses” should be examined as to whether they might be better understood as posttraumatic flashbacks or dissociative state switches. Intense visual, auditory, somatic, and olfactory illusions or hallucinations are frequent components of flashbacks, and auditory hallucinations are common in severe dissociative disorders as parts of the self talk internally to other dissociative self-states. Differential diagnosis concerning auditory hallucinations may be sharpened by the characteristics of the hallucinations. Dissociative hallucinations almost always are heard as coming from inside the head and are generally recognized as a familiar set of voices over time. Psychotic auditory hallucinations tend to be more bizarre (e.g., voices from the radio or TV), heard from both inside and outside the head, and variable over time.

Differential diagnosis is further complicated in situations where there is true comorbidity (i.e., two or more disorders), not simply one disorder mimicking another. Very often, the patient will present with pronounced posttraumatic or dissociative symptoms rather than clear evidence of the other disorder. One hypothesis for this kind of presentation is that because PTSD and dissociative disorders are responses to stress, the onset of another disorder such as a mood disorder or acute psychosis creates high levels of psychological stress, thus increasing the posttraumatic or dissociative responses. In virtually all situations in which there is true comorbidity of an Axis I disorder, such as a mood disorder or psychosis, the trauma-related disorder has secondary importance in the hierarchy of treatment. The following case illustrates this principle:

Peter, a 36-year-old married attorney, was admitted to a unit specializing in the treatment of psychosis. The presenting symptoms included long periods where he appeared to be in a trance—staring off into space, his mouth sometimes moving (apparently speaking unheard words)—from which he could be aroused only with difficulty. Though he was a highly functional individual in both his work and socially, his functioning had progressively deteriorated, having difficulty performing his job and becoming increasingly isolated at home. Peter’s outpatient treaters had believed him to be quietly psychotic and arranged for him to be admitted to the psychosis specialty unit. Once he was admitted, the unit staff thought his presentation was atypical for psychotic disorder and asked me to evaluate him for possible PTSD or a dissociative disorder.

When I interviewed Peter, I found him to be a quiet, soft-spoken young man who was well organized and articulate. I asked him about his internal experience when he was observed in the trance-like state, and to my surprise he admitted that he actually induced those states deliberately. All throughout his life, he had the ability to retreat to a pleasurably numb, depersonalized state whenever he felt under stress simply by relaxing deeply and visually focusing on his folded hands; he had clearly taught himself autohypnosis. He recalled doing this as a young child when he hid in his room during screaming, drunken battles between his parents that occurred frequently until they divorced when he was 10 years old. In the months leading up to the hospitalization, he had been self-inducing trance more frequently as he found himself having less energy to do his work and be with his family. He felt tired all the time, and although he was not hungry, he had gained 20 pounds and was sleeping 10 to 12 hours per night. He felt badly about what his situation was doing to his family and had thought of suicide, but instead retreated to his trance states as a way of not acting on his self-destructive impulses. With this history, I made the diagnosis of underlying major depression, which was subsequently successfully treated with medication.

HOSPITAL PRACTICE FOR TRAUMA-RELATED DISORDERS1

Specialized inpatient units dedicated to the treatment of trauma and/or dissociative disorders may be particularly effective in helping patients in crisis. These programs are often able to do more than stabilization and crisis management, providing specialized diagnostic evaluations and trauma-focused training in symptom management and the skills that are necessary for treatment and personal growth. However, the treatment of complex PTSD and most cases of DID and similar dissociative disorders should be within the capabilities of most general inpatient psychiatric units if certain treatment principles and clinical practices are observed and implemented.

The complex posttraumatic and dissociative symptoms of traumatized patients are often difficult and challenging problems to professionals who work in inpatient settings. In addition, the atmosphere of crisis and the involvement of many members of the inpatient treatment team usually complicate an already complex treatment. In order for treatment to be productive, the philosophy and structures of inpatient hospitalization must be clearly understood, and some of the potential pitfalls that seem to be part of the treatment of severely traumatized patients should be anticipated and addressed.

Therapeutic Philosophy

A general acceptance of trauma-related disorders is essential for the successful hospital treatment of patients with posttraumatic and dissociative disorders. Program leadership with hospital administrative support is necessary to provide the resources for the sometimes intensive treatment interventions (Kluft, 1991a; Ross, 1997). In addition, the risks involved in treating patients who are chronically self-destructive and impulsive must be understood by the hospital’s clinical administration and the risk management department. The senior clinical staff of the unit—specifically including the program director, medical director, and/or nurse manager (different hospitals have variations in the configuration of roles)—must be supportive and knowledgeable about the treatment of trauma-related disorders. Without such support, the treatment team will be unable to sustain the treatment approaches and staff cohesion that are necessary for productive treatment. The professionals on the treatment team who provide the psychotherapy for individual patients must also have a high level of acceptance about trauma-related disorders as well as sophistication about treatment. In the case of DID, it is less essential for each member of the staff to have a high level of expertise concerning the diagnosis, as long as there is agreement to pursue a unified and coherent treatment approach (Kluft, 1991a; Steinmeyer, 1991). This kind of approach is crucial, as the potential for conflicts in the treatment teams of patients with DID is high. In fact, without active efforts to maintain a unified and coherent treatment approach, it is common for the treatment to founder as the treatment team begins to reflect the projected internal fragmentation of the patient.

In addition to the acceptance of the diagnosis, the therapeutic milieu must place a high value on respect and collaboration, as opposed to authoritarian attitudes and control. In actual practice, this type of philosophy is extremely difficult to maintain. The out-of-control behaviors of many traumatized patients often invite more than the limit setting needed to stabilize the treatment. Too often, inpatient units respond to patients’ dysfunctional behaviors with an ever-increasing array of rigid rules and policies that eventually make any kind of flexibility or collaboration impossible. Basic unit rules concerning important treatment issues are essential, but care should be exercised to avoid the tendency to collude with patients’ compulsion to reenact the abusive relationships of their childhoods in the milieu. Especially because inpatient protocols to maintain patient safety can be experienced as controlling and intrusive, special care must be exercised to allow patients to maintain as much personal dignity and autonomy as is possible and appropriate to their clinical status.

Interpersonal relationships should have a high value in the treatment of traumatized patients. In addition to relationships between patients and their treatment teams, important relationships include those among patients, as well as outside relationships such as those involving community therapists, families, spouses, partners, and other persons who provide social support. The treatment of traumatized patients should include all of the important individuals in the patient’s outside life. Specifically, anyone living with and interacting with the patient should be involved in the treatment, and the unit should make active efforts to involve community therapists and to foster and maintain outside therapeutic relationships.

Personal responsibility should be a hallmark in the philosophy of inpatient treatment of patients with posttraumatic and dissociative disorders. Before admission, patients are frequently overwhelmed by the burdens of maintaining control, such as refraining from impulsive and self-destructive behavior and modulating symptomatology. To some patients, being in the hospital often may seem to be a welcome relief from having to stay in control and an opportunity to let down their defenses. This often results in their letting go of personal responsibility and placing hospital staff in the position of taking care of them. This shift of therapeutic responsibility is untenable, and patients must be willing to assume as much personal responsibility as possible during their hospitalizations. It is unworkable and regressive for the inpatient staff to have to take full responsibility for such issues as personal safety and behavioral control. Patients should be expected to monitor their own capabilities and seek out help should they need it. Simply put, it is impossible for the staff to keep all patients from harming themselves all of the time without some element of cooperation and shared responsibility from the patients.

Psychoeducation

Psychoeducation about the process of treatment is extremely important in the inpatient treatment of patients with complex PTSD and dissociative disorders. In particular, patients must learn and understand how to pace the therapeutic work. Virtually all traumatized patients who are admitted to inpatient settings are in early phases of their treatment, and some are attempting to do destabilizing abreactive work before building adequate psychotherapeutic foundations. In some cases, patients are flooded with memories and are spilling their recollections in therapy—sometimes even if their therapists are urging containment. In other cases, patients—and sometimes with the support of their therapists—have been attempting to purge themselves of their abusive childhood experiences long before they have built up the requisite relational skills and coping capacities that make productive abreaction possible. The task for most hospitalized patients with complex PTSD and dissociative disorders is to learn how to maintain control—letting go and letting down defenses is very rarely a problem.

Current accepted models of treatment staging (see the treatment model described at length in Chapter 6) emphasize that safety, containment, and stabilization are prerequisites for abreaction of trauma, which will most likely occur outside of a hospital setting. Any attempts at abreaction of past traumatic experiences during episodes of acute care must be approached cautiously. A very few patients who have mastered the tasks of early phase treatment may benefit from a circumscribed amount of abreactive therapy in the hospital. However, this kind of work should be limited in scope and carefully monitored, because patients are prone to becoming once again overwhelmed. There are common clinical situations where patients must be able to discuss some of the memories of past abuse, because not to do so would create only more problems. In these kinds of situations, the patient and the hospital staff must share the burden of limiting the extent of work about the traumatic material and must avoid the trap of believing that just one more piece of abreactive work would result in full resolution of the current difficulties. In past years, elective hospitalization has been used to support patients in later phases of treatment during particularly difficult abreactions (Kluft, 1991a; Sakheim, Hess, & Chivas, 1988). This kind of support has often been very helpful to patients while working through horrendous past experiences. However, given the economic realities of the health care environment, such elective admissions are likely to become increasingly rare.

Limits and Boundaries

Although authoritarian attitudes and controlling stances are not productive in the treatment of patients with posttraumatic and dissociative disorders, clear limits and boundaries are essential to minimize regression and foster therapeutic growth. Limits and boundaries are crucial to help preserve the treatment frame, to help patients exercise control of dysfunctional behaviors, and to maintain the hospital therapeutic milieu. Limits and boundaries are particularly important given the intensity of involvement between traumatized patients and staff. These patients often require a high level of involvement with staff members, because problems such as managing reexperiencing phenomena and personality switching often requires considerable time and effort. The mistrust with which traumatized patients approach relationships may require some additional involvement on the part of staff members in order to help patients feel safe. However, the extent of staff involvement needs to have realistic limitations both to prevent staff exhaustion as well as to encourage patients to learn to meet some of their own needs for care and reassurance.

Out-of-control behaviors should not be tolerated in patients with PTSD and dissociative disorders, including repetitive self-harming or self-destructive behaviors, verbal abuse or violence, and prolonged abreactions. Patients should be expected to conform their behavior to unit norms as a condition of their treatment. Placing limits on patients puts the burden on them to find alternate ways of expressing themselves and to contain posttraumatic and dissociative symptoms to appropriate settings. Patients must begin to work with the treatment team around achieving these goals. Intermittent lapses in control are inevitable because of the nature of patients’ difficulties and are expectable and understandable. However, lapses caused by patients’ failure to strive for control are not therapeutically acceptable.

Dissociative Disorder Issues

The characteristics of inpatients with dissociative disorders predispose their treatment to particular difficulties. As Putnam (1989) noted:

Once a patient is admitted, perceptions of the hospital can change dramatically and rapidly. Within a short time, most [DID patients] will have alters emerge who experience the hospital as a frightening and traumatizing place. Normal hospital procedures and routines, such as medications, milieu activities, privilege status, pass restrictions, and other unit rules are perceived as coercive and traumatizing. (p. 272)

Patients with complex PTSD who have difficulty building supportive alliances often engage with hospital staff in a way that reenacts the control struggles and abuses of their childhoods. In addition, patients with DID may also project their internal fragmentation onto various staff members, resulting in a particularly intense form of “staff splitting” (Braun, 1993; Putnam, 1989; Steinmeyer, 1991). Some staff will be viewed as hostile and abusive, whereas others will be seen as nurturing and understanding. This problem is sometimes aggravated by the tendency of staff to have markedly differing views of patients with DID (Kluft, 1991a). Some staff may view the diagnosis skeptically, whereas others may be overly accepting of patients’ difficulties in controlling switching and maintaining control.

The initial assessment of patients with dissociative symptoms is crucial, particularly for patients with DID symptoms. Historically, relatively few patients were admitted to hospitals with a diagnosis of DID. However, in recent years, it has become necessary to determine both when a patient has DID and when a patient does not have DID. It is also important to distinguish between patients with full-blown DID and the many patients who have a lesser degree of dissociation or some other kind of posttraumatic disorder. After all, treatment should be designed to decrease dissociative symptoms and should not reinforce dissociative symptoms that are consciously or unconsciously exaggerated. Clinicians also should consider the possibility of factitious or malingered DID, particularly in a forensic context or where there is compelling secondary gain (see Chapter 15; Brick & Chu, 1991; Chu, 1991a; Coons & Milstein, 1994; Kluft, 1987c; Thomas, 2001 for further discussion of this issue).

All therapeutic work with DID patients must be approached as work with a single (although fragmented) person rather than with individual personalities. During a time of crisis such as hospitalization, all work with personalities should emphasize conflict resolution and stabilization. The patient’s cooperation must be obtained in this venture, and hospital staff must encourage and reinforce interpersonality communication, understanding, and acceptance. Patients with DID must not learn that having DID makes them special—after all, an identity even as a special psychiatric patient is far from optimal. Furthermore, even though the hospital environment buffers patients with DID from some of the demands of the outside environment, they do need to exercise some control to respond to routine demands of their surroundings. Psychiatrist Colin Ross, MD (1997), has some excellent practical suggestions:

We expect our patients to follow regular ward guidelines and procedures. They do not have special rooms, they eat with other patients, and the consequences for unacceptable conduct are generally the same as for other patients. (p. 368)

Ross suggests that out-of-control switching should not be allowed on the unit milieu and that child alternate personalities should generally be allowed to have executive control only in psychotherapy. As a general rule, patients with DID are expected to conform to the usual adult standards of behavior in the public areas of the hospital unit.

Nursing Practice

Hospitalized patients with histories of severe traumatization often are very fearful that they will be subject to excessive control and mistreatment. In a hospital setting, members of the nursing staff bear the brunt of this mistrust because of their role in monitoring and managing the milieu, and their inherent authority and control over patients’ daily lives. Thus, nursing staff have a major responsibility for establishing and maintaining a therapeutic alliance with patients. The staff should have a sophisticated understanding of the effects of early abuse and should be able to empathize with the difficulties experienced by patients. They should be able to project the therapeutic attitudes of acceptance and respect. They should be skilled in bridging mistrust during control struggles and in setting limits and establishing boundaries. The negotiation of the therapeutic alliance begins at the time of admission, when issues such as privileges, rooming arrangements, and unit rules are areas of potential conflict. Patients should be treated respectfully, but patients must also respect the judgments of the staff and the real limitations of the hospital environment. For example, attempts should be made to accommodate the patient in terms of comfort and privacy (e.g., room location or roommate), but nursing staff also must be allowed to consider and weigh the clinical needs of all patients and to make decisions based on their assessments. Similarly, patients with DID should be accorded the respect of being called what they choose. However, it is an unrealistic expectation that every staff member consistently recognize (or even remember) each patient’s different alternate personalities (Kluft, 1991a).

During a hospitalization, many traumatized patients experience distress from intrusive reexperiencing of past abuse. Patients suffer with overwhelming affects such as despair, panic, and rage, and they may have impulses to flee, strike out, or hurt themselves. Effective nursing interventions are critical. Daily structure can be helpful for patients who are experiencing intrusive symptoms such as flashbacks and nightmares. Planned activities as well as rest and recuperation are important components of a daily structure. Emotional support and medication should be provided as necessary. It is helpful if the hospital setting has flexible rules about sleep and rest. Many patients are afraid of sleeping at night in a darkened room (especially if their abuse occurred at night). The use of nightlights should be permitted, and patients should be allowed to get out of bed and sit quietly in an area close to staff for brief periods. Patients may need to sleep for brief periods during the day if they did not get sufficient sleep during the previous night, although nursing staff should be careful not to allow patients to completely reverse their sleep/wake cycles.

The management of flashbacks and other forms of traumatic reexperiencing involves the use of grounding techniques (see Chapter 8 for further discussion of grounding techniques and Benham, 1995, concerning nursing practice). Patients may find it helpful for a staff member to approach them and maintain contact with them until the flashback is over. Staff members should let the patients know that they are there and orient the patients to time and place. Staff members may need to speak firmly and give specific instructions to help anchor the patients in the here-and-now. The following clinical example illustrates some common grounding techniques:

Ellen, a 26-year-old woman with DID, was found huddled in her closet shortly after admission. She appeared quite frightened and refused to speak to the nurse who found her, and instead stared at the wall while sucking her thumb. The nurse said, “You look very frightened and very young. You seem to be reliving something very frightening. My name is Sally, and I am a nurse in this hospital. I am here to help you, and I will not let you be hurt. I’d like you to try to understand that you are safe. I’d like you to try to look at me and remember that you know me as a safe person. I’d like you to try to look around you, and to feel yourself here with your feet on the floor, and to remember that you are safe in the hospital.” Ellen was able to engage with the nurse and was able to calm down and emerge from the closet. She was observed closely until she could begin to talk about her distress and reengage in the milieu.

The psychoeducation that patients receive on how to manage their symptoms often occurs through nursing interventions in the milieu. Nursing staff are often the principal teachers of grounding techniques and other ways to help patients achieve control of dissociative symptoms and to pace the process of abreaction. They can help patients who are overwhelmed by past abusive events by encouraging containment of painful memories to therapy sessions. In addition to grounding techniques, nursing staff can use nonverbal means (e.g., imagery such as visualizing shutting the door on memories until therapy sessions). When patients become flooded, they can be encouraged to use artwork or journals for brief periods and then put them away.

Nursing staff are in the unique position of being with patients during periods of crisis—often in the evening or at night. During such times they have the opportunity to reinforce important messages such as, “It wasn’t your fault that you were hurt.” Nursing staff are able to participate in helping patients achieve crucial skills in self-care and self-soothing by maintaining adequate food and fluid intake, accessing medical attention, or simply taking a warm bath, reading, watching television, or going on a brisk walk. Nursing staff also have the critical task of helping patients utilize other people during periods of crisis, especially by making contact with them and encouraging patients to trust their support.

Individual Therapy and Case Management

Individual therapy or case management is critical in the treatment of complex patients with posttraumatic and dissociative conditions. The individual therapist or case manager can be a central figure in formulating a dynamic understanding of the patient’s difficulties and implementing a productive treatment plan. Therapists or case managers should be given the autonomy and authority to make important decisions about and with the patient during an acute care episode. Patients often are able to better tolerate hospitalization when decisions that affect them are made by someone who has taken the time to develop a trusting relationship, rather than when decisions are based on inflexible and rigid unit rules.

If possible, patients should be provided with individual therapy during their hospital course, as some therapeutic gains are best realized in an individual trusting relationship. Therapists or case managers also are able to provide services such as specific interventions (e.g., negotiations between alternate personalities in a patient with DID), liaison with outpatient professionals, family work, and aftercare planning. The individual therapy should be well integrated into the remainder of the inpatient treatment, and the work should pursue treatment goals that are consistent with the overall treatment plan. Although individual treatment is valuable, much of the therapy during the course of a hospitalization is derived not only from individual therapists but also through contact with many other members of the hospital staff, especially nursing staff.

Ongoing contact with outside treaters should be encouraged as practical and appropriate, and the community therapist should be involved as much as possible as part of the inpatient treatment team. Often, covert problems in the ongoing therapy become apparent during an inpatient hospitalization. For example, if a patient consistently appears destabilized following sessions with the outside therapist, it can be an opportunity to examine what processes are occurring that should be reexamined and potentially changed. Unacknowledged ambivalence about the therapy can also become apparent, as in the following example:

Sarah Jane, a 41-year-old woman with DID, was admitted to the hospital because of increased suicide risk. Although she seemed to be managing well at work and at home with her husband and three children, several of her alternate personalities had left messages for her therapist threatening to kill or harm herself and to warn the therapist to “keep your nose out of our business.” In discussions with various hospital staff members, Sarah Jane talked about her ongoing treatment, and an interesting split developed between various staff members concerning opinions about the community therapist. Sarah Jane described how helpful the work with her therapist had been and how flexible the therapist could be, responding to emergencies, extending session time, and even occasionally meeting outside the office around specific community-based tasks. While some staff members felt that the ongoing therapy was useful and helpful, others voiced the opinion that the outside therapist was “just crazy” and was, at a minimum, allowing violations of the treatment frame and overgratifying the patient. The therapist was able to attend a brief meeting with members of the inpatient treatment team, where she described her perspective of the treatment, and it appeared that all alterations in the usual boundaries of therapy had been carefully considered and discussed (even utilizing the resources of a consultant to the therapy). It then became clear that the split in the opinions of the staff was primarily a reflection of Sarah Jane’s ambivalence about the therapist, probably based on her sense of vulnerability as she began to share sensitive information about her life and feelings. The therapist saw this as an opportunity to address those issues in the ongoing treatment.

Group Treatment

The use of verbal groups in the acute care of traumatized patients has been controversial. Although group treatment for posttraumatic disorders has a long tradition (van der Kolk, 1993), the use of groups with dissociative disorders has been discouraged (Kluft, 1991a; Putnam, 1989). In clinical practice, certain kinds of verbal groups are regressive, whereas others appear to be more helpful. Traditional process-oriented psychotherapy groups that focus on relationships within the group and psychoanalytically based groups that tend to mobilize intense affect are contraindicated because they are far too overwhelming for patients who have intense relational difficulties and affective instability. Groups that encourage or permit the discussion or details of past abusive experiences are also countertherapeutic because patients often are triggered by other patients’ stories into reexperiencing their own trauma.

Verbal groups that are focused on particular tasks appear to be quite useful for many traumatized patients. Some of these groups deal with current symptomatology and the effects of past experiences but explicitly do not permit detailed discussion of past abuse. These groups have a psychoeducational and skills-training focus and discuss ways of coping with posttraumatic and dissociative symptoms, expressing and containing intense feelings, controlling impulses, finding ways to remain functional, and making and sustaining relationships. Some cognitive-behavioral groups (e.g., assertiveness training, relaxation, or anger management groups) or gender-related groups (e.g., women’s issues) can also be helpful. Finally, the role of groups that involve activities is enormously valuable. Certain rehabilitation-oriented or expressive groups can be extremely helpful for patients who are regressed or who struggle to use verbal modalities. Their self-esteem can be enhanced by accomplishing concrete goals, and they can express intense nonverbal feelings and impulses in art, music, or movement. Recreational activities are a welcome relief from the heavy burdens of psychotherapeutic work and are a good reminder that treatment is intended to improve the quality of patients’ lives, not to consume them.

Both inside and outside the hospital, some patients with complex PTSD and DID can make good use of 12-step groups such as AA, NA, or Al-Anon when addressing comorbid substance abuse problems. However, involvement in 12-step incest survivor groups or self-help groups for trauma patients are generally contraindicated, because their process and content are unregulated, resulting in emotional flooding and other psychological distress. In some of these groups, there are not adequate structures concerning boundaries between group members, and there is the potential for enmeshed, intrusive, and/or exploitative relationships.

Family Work

Inpatient hospitalization often brings family issues into the treatment arena. Current families and other persons who are part of the patient’s social support system almost always should be involved in the treatment. Spouses or partners simply may need support and education. Often, however, significant relationship problems exist, ranging from a partner who reenacts abusive or neglectful relationships, or conversely, a partner who is overinvolved, overfascinated, and/or overprotective. Significant others often need counseling and advice concerning the delicate balance of being sensitive and involved with their partners who have complex PTSD or DID, but also understanding they should not enable dysfunctional behavior. Spouses or partners sometimes need to be reminded of their appropriate roles and that they should never function as an adjunctive therapist.

Children in the home should be assessed as to whether they are at risk as a result of the patient’s difficulties. Although many traumatized patients are exemplary parents, others are extremely overprotective, involve their children in the transgenerational cycle of abuse, or neglect them through self-absorption in their own difficulties (Kluft, 1987b). In the hospital setting, staff members have an obligation to report any clear evidence of neglect or abuse of patients’ minor children to the local or state child protective agency. If this needs to occur, it should generally be done with the full involvement of the patient (and partner or spouse) in the context of providing the needed additional supports for appropriate parental functioning.

In situations where there is a history of childhood abuse, contact with families of origin is extremely problematic. Sometimes when the patient can be sure of a positive response from a family member (e.g., a supportive brother or sister), disclosure can be appropriate and helpful. However, premature disclosure of the abuse secret to family members is destabilizing to families’ equilibrium and can often result in the family closing ranks around the denial of the abuse and essentially ostracizing the patient. Most experts in the field of treatment of childhood abuse survivors suggest that disclosure and confrontation of a perpetrator should occur only when it is the patient’s clear choice, and relatively late in treatment—not during episodes of decompensation and acute care (Courtois, 2010; Herman, 1981; MacFarlane & Korbin, 1983; Schatzhow & Herman, 1989).

Seclusion and Restraint

Despite the potential for reenacting traumatic abuse, there may be times when seclusion or restraint is necessary to prevent self-harm to patients with complex PTSD and dissociative disorders. For example, if a patient is unable to stop head-banging or other forms of self-harm, physical intervention may be necessary. Of course, seclusion or restraint is used only when other alternatives—verbal, behavioral, or pharmacologic interventions, or increased monitoring such as constant observation—have been ineffective. Seclusion or restraint is usually very upsetting not just to the patient involved but also to other patients who feel tenuous and fear loss of control. In situations where these interventions are necessary, care must be exercised to deal with the effect on the inpatient milieu and other specific patients who may be destabilized as a result.

In recent years, in conjunction with the efforts of many state mental health departments, many hospital systems have instituted initiatives to minimize or even eliminate the use of seclusion and restraint. Training staff to use de-escalation and crisis prevention measures, to sometimes allow patients to win control struggles, to encourage time-outs, and to never use restraint and seclusion as punishment has often resulted in dramatic decreases in the frequency and duration of these interventions. Careful planning in advance can be helpful in working with patients to develop crisis plans or personal safety plans that involve various interventions to avoid seclusion and restraint. These interventions may include listing personal posttraumatic triggers and individualized measures that provide reassurance, soothing, and a sense of safety. Medications for anxiety and/or agitation, such as benzodiazepines or neuroleptics, can be part of the plan.

In the early years of the development of treatment models for DID, the use of voluntary physical restraints to control a violent alternate personality while a patient worked through trauma was proposed. This type of intervention is clinically inappropriate because it neglects patients’ responsibility in controlling their own actions and violates the regulations of the mental health departments of many states.

Staff Support

Working with traumatized patients requires considerable personal involvement on the part of staff. Staff members must be willing to extend themselves to empathize with patients and to struggle with them to overcome their difficulties. This can be a psychologically exhausting task. Sometimes just sitting with someone who is reliving trauma may be difficult for staff members who may have to confront their own dysphoric feelings or who are reminded of their own painful past experiences. In addition, patients bring their intense emotions into the treatment arena and even reenact the abusive relationships in the hospital setting. The anger and rage that often results from childhood abuse may be overwhelmingly intense, and patients may displace their anger onto hospital staff.

Hospitalized patients with PTSD and dissociative disorders are often in crisis. Difficult situations that are common in the hospital include episodes of self-destructive behaviors. These may include suicide gestures or attempts, self-harming activities, substance abuse, eating problems, violence, and out-of-control behaviors that may require restraint and even actual flight from the hospital. All of these kinds of crises create high levels of anxiety, anger, and guilt in hospital staff. Commonly, staff feel that they should have been able to prevent crises from happening, and they question whether they are competent to treat these patients. They also can become upset or withdrawn, feeling violated when patients act out against themselves or others and anxious about being held responsible for the patients’ destructive behavior.

Given that the treatment of traumatized patients subjects hospital staff to significantly stressful experiences, it is essential that there be a supportive environment for all staff, particularly for nursing staff. An important component of support is staff empowerment. For example, staff members must be given the authority to make decisions in their area of expertise and must be supported and guided in their work. In order for staff to encourage patients’ growth, they must also be validated and empowered. This model of empowerment of staff must have the full cooperation of the clinical leadership and administrative staff associated with the unit.

Hospital staff must be given permission by the unit leadership to express the feelings that are engendered by work with traumatized patients. In addition to positive feelings, staff commonly experience exhaustion, frustration, anger, and even dislike. Such feelings must be expressed in a responsible manner, as opposed to being acted out in the milieu. Staff must learn to differentiate anger about patients’ behavior from dislike for patients themselves. Even when staff actually dislike patients, they must find appropriate ways to express their feelings privately so that they can continue to work with patients with a nonjudgmental and empathic approach. Staff must also be given the opportunity to express their anger and fear. In order to maintain a safe and supportive milieu, staff must be able to set limits on inappropriate behavior and cannot be immobilized by their anger or worry excessively about retraumatizing patients. In fact, one common reason for failure to set appropriate limits is staff members’ fear that they are acting out their feelings of anger and sadism.

Periodic staff meetings open to all staff are essential to maintain unit functioning. Although some of the meeting may be used for unit or hospital business, there should always be an opportunity for staff to discuss the feelings generated by working with patients. Just as it is important to provide education for patients about their illness and symptoms, it is necessary to provide adequate education for staff. Staff members must learn that it is normal for them to sometimes feel abused, burned out, or depleted, and how to support each other. Staff members must also learn about the process of the treatment so they understand and appreciate the importance of the work they are doing, how it helps patients, and how it affects them. It is part of the job of unit leadership to provide a sense of mission that can guide and inspire the work of the unit staff.

Informal availability of senior staff is perhaps one of the most important ways to support and reassure staff. If all therapists and senior clinical staff leave the unit at the earliest opportunity, nursing staff are left feeling burdened and unsupported. It is very helpful if senior staff are consistently available to nursing staff (even for brief periods) to help with problem solving and to actually intervene and provide informal supervision and role modeling. Formal supervision for all staff is also helpful, and staff should constantly be given the opportunity to learn more about their work and the treatment of patients with complex PTSD and dissociative disorders.

The principles and practices outlined in this discussion are easier to maintain on specialty units dedicated to the treatment of patients with posttraumatic or dissociative disorders. However, patients with trauma-related disorders can be successfully treated on general, mixed-diagnosis psychiatric units. On general psychiatric units, individualized treatment plans must be implemented for traumatized patients, as their treatment may differ significantly from the treatment of other patients. For example, a psychotic patient may need more control and structure from staff, whereas a trauma patient may need to be more engaged in collaborative treatment planning. A treatment team that is particularly knowledgeable about PTSD and dissociative disorders and clear leadership around treatment issues are helpful on a general psychiatric unit.

Many other kinds of patients can be treated with traumatized patients. However, two groups of psychiatric patients do not seem to mix well with them. Highly agitated, acutely psychotic, and intrusive patients may be extremely difficult for patients who may be reminded of abuse from frightening and unpredictable individuals. Patients who are sexual predators are also often problematic, sometimes frightening traumatized patients, but sometimes engaging them in seductive and abusive reenactments.

The hospitalization of patients with complex PTSD and dissociative disorders often appears to magnify the normative difficulties of outpatient treatment. However, a well-grounded understanding of the principles of treatment, clear and compassionate interventions, and measures to sustain the treaters can make the inpatient treatment a productive and growth-enhancing experience for both patients and staff.

1 I would like to acknowledge the contributions of Karen Terk, MS, RN, who has been my colleague for nearly 25 years and co-founded the Trauma and Dissociative Disorders Program at McLean Hospital with me. Her extraordinary clinical skills and intuition and her common-sense approach formed the basis for the treatment philosophy and interventions that are described in this chapter. She was the primary architect for many innovations in nursing practice for patients with complex PTSD and dissociative disorders.