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Psychiatric Intervention for the Battle-Injured Medical and Surgical Patient Following Traumatic Injuries

Chapter 16

PSYCHIATRIC INTERVENTION FOR THE 

BATTLE-INJURED MEDICAL and

SURGICAL PATIENT FOLLOWING 

TRAUMATIC INJURIES

HAROLD J. WAIN, PhD*; SCOTT C. MORAN, MD†; MARVIN OLESHANSKY, MD‡; ANDREE BOUTERIE, 

MD§

; and CHRISTOPHER L. LANGE, MD¥

INTRODUCTION

INJURIES AND THE STRESS OF TRAUMA

THERAPEUTIC INTERVENTION FOR THE PREVENTION OF PSYCHIATRIC 

STRESS DISORDERS

INDIVIDUAL THERAPEUTIC COMPONENTS

TREATMENT

SUPPORTING MEDICAL STAFF WHO CARE FOR MEDICALLY INJURED 

TRAUMA VICTIMS

SUMMARY

*Chief, Psychiatry Consultation Liaison Service, Building 2, Room 6238, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, 

DC 20307-5100

†

Major (P), Medical Corps, US Army; Psychiatry Residency Training Program Director, Psychiatry Consultation Liaison Service, Building 6, Room 

2060, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307-5100

‡

Colonel, US Army (Retired); Staff Psychiatrist, Psychiatric Outpatient Service, Department of Psychiatry, Tripler Army Medical Center, 1 Jarrett White 

Road, Honolulu, Hawaii 96822; formerly, Staff Psychiatrist, Psychiatry Consultation Liaison Service, Walter Reed Army Medical Center, Washington, DC 

20307-5100

§

Staff Psychiatrist, Psychiatry Consultation Liaison Service, Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 20307-5100

¥

Lieutenant Colonel, Medical Corps, US Army; Program Director, National Capital Consortium Forsenic Psychiatry Fellowship Program, Department of 

Psychiatry, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Building 6, Room 3038, Washington, DC 20307; formerly, Staff Psychiatrist, 

Psychiatry Consultation Liaison Service, Walter Reed Army Medical Center, Washington, DC
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Combat and Operational Behavioral Health

INTRODUCTION

Trauma, whether resulting from the actions of humans or nature, as a precipitant of medical and surgical 

injuries can be emotionally overwhelming, not only for 

the patient dealing with the medical issues, but for the 

family and caregivers as well. Each will have to cope 

with the trauma of the event leading to the injury as 

well as the subsequent psychological sequelae. In the 

hierarchy of needs regarding patient care, stabilization of the medical physical injury of the patient takes 

precedence. However, often ignored are the psychiatric 

after-effects that traumatic injury may elicit. 

For years the Psychiatry Consultation Liaison 

Service (PCLS) at Walter Reed Army Medical Center (WRAMC) has been helping patients deal with 

the psychiatric and psychological consequences of 

medical and surgical disease. Since the beginning of 

the global war on terror in 2001, the goal for the psychiatry consultation liaison service at Walter Reed has 

been two-fold: (1) decrease the psychiatric manifestations of trauma that may disrupt medical treatment, 

and (2) decrease the chronic and disabling psychiatric 

disorders that may occur as a result of trauma. Several 

chapters and articles describing in detail the PCLS 

approach to meet these goals have been published, 

including discussions of Gulf War I,1

 the Pentagon 

attacks,2 the bombings of the US embassy in Nairobi,3

and the current wars in Afghanistan and Iraq.4 Since 

2003, PCLS has seen over 3,000 battle-injured patients 

using the methods described in these chapters.

One of the main features of effective mental health 

intervention in polytrauma (or any consultationliaison psychiatry setting for that matter) is for mental 

healthcare providers to ally themselves with the patient, the patient’s family, and the patient’s treatment 

team. Since the start of the global war on terror, PCLS 

has been a routine part of trauma care at WRAMC. 

Immediately following the attack on the Pentagon 

on 9/11, casualties who required extended inpatient 

management of their injuries were admitted to civilian 

hospitals closer to the Pentagon than WRAMC. During 

that time, PCLS deployed teams to these facilities to 

assist in their clinical management. The PCLS teams 

were recognized consultants to the endogenous medical team of the local hospitals.

Trauma patients are routinely seen upon arrival at WRAMC and followed with the trauma 

team throughout the hospital stay as integral part 

of the medical care. Mental health interventions are 

provided to assist these patients in processing their 

trauma and its aftermath, support the family members who provide critical emotional support to these 

patients, and facilitate interactions with their treatment team for an optimal clinical outcome. All this 

happens as the patients undergo medical and surgical 

care and seek to adapt physically and mentally to the 

new realities imposed upon them by their traumatic 

injuries. Thus, a comprehensive program designed 

to help the medical institution as a whole respond 

to the psychological demands of a traumatic event 

must take into account the needs of not only the 

patients, but also the patients’ families and medical 

staff involved in their care. 

This chapter focuses on the psychological and psychiatric issues of medical and surgical patients suffering from traumatic injuries. This approach to care for 

these patients, their family members, and medical care 

providers, was developed by the PCLS, and is based on 

the experience of the authors and their colleagues in 

the care of these patients, family members, and treatment teams at WRAMC over the past 30 years. 

INJURIES AND THE STRESS OF TRAUMA

Soldiers wounded in combat in Operation Enduring 

Freedom (OEF) and Operation Iraqi Freedom (OIF) 

receive immediate lifesaving intervention on the battlefield or in the battalion aid station by a combat medic, 

further treatment at a combat surgical hospital, and 

then aeromedical evacuation to Landstuhl Regional 

Medical Center. The military air evacuation system 

facilitates transfer of the patient to WRAMC following injuries in theater and stabilization at Landstuhl. 

Because of advances in medical care on the battlefield 

and through far-forward surgical interventions and 

advances in critical care transport, casualties survive 

wounds that in previous wars would have lead to 

certain death. Casualty rates have dropped from 1 

in 2 in the American Civil War to 1 in 16 in OIF. This 

means many more patients survive to deal with the 

psychological after-effects of traumatic injury. 

The nature and severity of traumatic injuries vary 

depending on the inciting event. Terrorist attack 

victims suffer from injuries that include severe and 

extensive burns, blunt trauma, multiple wounds from 

fragments or broken glass, and smoke inhalation injuries. Combat trauma includes gunshot wounds, fragment wounds, abdominal wounds, brain and spinal 

cord injuries, and amputations. Many of the soldiers 

injured in OIF and OEF have multiple categories of 

wound and are referred to as polytrauma patients.

The resulting injuries from the traumatic event often 
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Psychiatric Intervention for the Battle-Injured Medical and Surgical Patient Following Traumatic Injuries

represent the end of life as the patient knew it, and the 

beginning of a painful and arduous ordeal with an 

uncertain outcome. The surviving patient is subject 

to a broad range of psychological stresses throughout 

the process of recovery. Pain is exacerbated by frequent 

wash-outs and debridement, dressing changes, skin 

grafts, plastic surgery, and the need to exercise damaged limbs to avoid contractures. Medical treatments, 

including the use of narcotics, can often interfere with 

patients’ motivation. The patient may need to be 

isolated until the danger of infection has passed, and 

extensive bandaging further reduces environmental 

contact, especially for facial or ocular wounds. A tracheotomy or traumatic brain injury (TBI) may interfere 

with communication.

Initial medical and surgical care is essential for the 

recovery of the trauma victim. The patient and the 

family report that this clinical care is often experienced as a significant ongoing stressor, and, in severe 

cases, as an extension of the trauma itself. The mental 

healthcare provider must take into account not only 

the effects of the traumatic event, but also the effect of 

the stressors arising from their medical and surgical 

management in the wake of trauma, in order to prevent 

or minimize psychological sequelae and to optimize 

clinical outcome.

Neurological and physiological disturbances and 

behavioral changes often follow traumatic injury that 

has resulted in amputations, brain injury, spinal cord 

injury, facial disfigurement, burns, blindness, and 

mutilating and castrating wounds of the external male 

genitalia.5

 Stressors including pain, complications 

arising in the course of the patient’s treatment and 

recovery, infection, the need for repeated incision and 

drainage or revision of surgical wounds, development 

of decubiti in the bedridden, side effects from medications, hospital-acquired infections, delays in recovery 

and prolonged hospital stays, and uncertainty in the 

outcome and time course are just a few of the emotional 

and psychological effects on the patient. 

The Effect of Trauma

Trauma results in the normal adaptive mechanisms 

being compromised when psychological defenses cannot be employed.6

 Self-integrity, self-confidence, and 

self-esteem may be undermined as a consequence of 

trauma. Trust of others is diminished, critical judgment 

is suspended, feelings of helplessness, dependency, 

and regression may occur. Feelings of rage, anger, and 

frustration may also result. Personality structures and 

defenses are pushed to their limits. Trauma may also 

recreate previous maladaptive patterns of behavior 

that had been dormant. 

To facilitate patient care it is critical to obtain a 

good biopsychosocial and developmental history. 

The patient or the patient’s family, or both, may have 

previous trauma or mental health issues that affect the 

response to trauma following injury. It is facilitative if 

the clinicians are aware of the underlying personality 

structures and defense mechanisms that the patient 

utilizes to personal advantage to help facilitate mental health interventions. The method of gaining this 

information needs to be different than traditional approaches with nontraumatized patients. A directive 

approach may cause a revivification of the trauma 

and contribute to regressive behavior that may disrupt 

medical care. A normal supportive conversational tone 

with humor (if possible, and if the provider is comfortable) is advocated.

Traumatic injuries may result in both short- and 

long-term emotional trauma, most of which are acute 

stress reactions and posttraumatic stress disorder 

(PTSD). Studies conducted at WRAMC have shown 

that the level of physical severity of injury may be correlated with the development of depression and PTSD 

following traumatic injury.7

 It has also been well documented that traumatic injury in the civilian healthcare 

setting often results in stress disorders.8,9 Rates of 

PTSD following traumatic injury vary from 12% to 

30%, but at WRAMC battle-injured service members 

had a 4% prevalence at 1 month, and 12% prevalence 

at 7 months following injury.7 Trauma victims may 

also experience a variety of psychological responses 

that occur independently or simultaneously with the 

above disorders. Other diagnoses, including affective, 

anxiety, and somatoform spectrum disorders as well 

as TBI, may also occur.10 Some of these responses that 

have been observed by the authors include separation anxiety, grief, anger, rage, fear, frustration, regret, 

shame, dissociation, regression, denial, and shattered 

ego integrity. 

Soldiers in combat have a battle mindset while in 

theater. This mindset includes many psychological 

symptoms that, although helpful in a war zone, are not 

helpful when returning home or following evacuation 

for injury, as many of these symptoms may mimic acute 

stress disorder. These may include difficulty sleeping, irritability, hypervigilance, exaggerated startle 

response, and motor restlessness. Other symptoms that 

may develop (and that can be detrimental) are poor 

concentration, fear, helplessness, horror, anxiety, detachment, absence of emotions, numbing, and anxiety. 

Cognitive symptoms may consist of recurrent dreams, 

thoughts, and flashbacks. Behavioral symptoms can 

include avoiding people, places, activities, thoughts, 

emotions, conversations, or television programs 

reminiscent of the event. Typically these resolve over a 
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Combat and Operational Behavioral Health

period of time, but may persist after the initial trauma 

is over in a significant percentage of patients, and do 

not rise to the level of clinical diagnosis of acute stress 

disorder or PTSD. 

PCLS routinely assesses patients for these symptoms and provides psychoeducational interventions, 

normalization of the responses, and empathic exposure 

as a means to develop resiliency and return patients 

to mental health. The clinician’s awareness of the effect of these responses to the patient facilitates the 

development of therapeutic alliances with the patient 

that improve treatment outcomes and reduce stigma 

associated with mental health providers. 

The severity of the injury and body part affected 

may also help to determine the patient’s response 

to the traumatic injury. Injury to parts of the body 

with real or perceived significance may increase the 

patient’s stress.11 Therefore, PCLS routinely assesses 

patients for body image and physical integrity issues 

following trauma. Phantom limb pain is often treated 

with a combination of medications and hypnotherapy 

performed at the patient’s bedside. Patients are also 

taught self-hypnosis techniques to manage their pain. 

Patients with facial disfigurement and spinal cord 

injuries often have the most severe body image reactions to their injury. PCLS providers attempt to address 

these issues early in the course of treatment. In addition to the patient’s emotional reaction to these types 

of injuries, medical and surgical providers also have 

difficulty with these types of injuries.

 Trauma patients who experience severe pain 

are less likely to be amenable to psychotherapeutic 

interventions. Schreiber and Galai-Gat12 identify 

uncontrolled pain as a stressor that, if not treated 

effectively, may result in the development of PTSD. 

Uncontrolled pain may also lead to the development 

of anxiety, depression, loneliness, hostility, and sleep 

disturbances.13 Studies at WRAMC have also demonstrated that increased pain may be a predictor for the 

development of PTSD and depression in battle-injured 

soldiers.14 PCLS uses many interventions to reduce or 

eliminate pain. As mentioned above, hypnotherapy is 

often practiced at the bedside. Other therapies—such 

as cognitive reframing, antidepressant medications, 

and stimulants—are recommended to the treating 

trauma team as adjuncts to manage pain. 

Physical loss of a limb brings with it the added 

anxiety of potential social and interpersonal difficulty. 

Trauma patients are described by Blum15 as experiencing a loss of identity, self-confidence, self-esteem, 

self-reliance, and ideal self. Horowitz16 and Landsman and colleagues17 noted that patient’s reactions 

to traumatic injury can be similar to bereavement. In 

addition to concern regarding physical appearance, 

patients sustaining an amputation may be concerned 

with the reactions from peers, the ability to earn a 

living,11 socialization, dating, and sexual behavior.10

Trauma victims are at risk for developing psychiatric 

illnesses based on these factors: exposure to trauma, 

intensity of exposure, psychiatric history, gender, and 

level of education.18

The need for early psychiatric intervention was recognized following the attacks on 9/11.4,19,20 Hoge and 

colleagues21 demonstrated that the greatest deterrent to 

soldiers exposed to trauma who may need psychiatric 

intervention is their perception of psychiatry. To destigmatize mental health for the battle-injured soldier, 

the PCLS service was redesignated as Preventive Medical Psychiatry (PMP) to gain greater acceptance by 

patient, family, and staff alike. This change addressed 

the need for the mental health team to be seen as any 

other medical service,20 and ensured that every patient 

from OIF/OEF hospitalized on a medical surgical unit 

at WRAMC was evaluated and followed. Integrating 

psychiatry into the trauma team and providing routine preventive psychiatric interventions with trauma 

patients may prevent psychiatric symptoms from 

becoming disabling. The benefit of this program is 

demonstrated by the fact that the rate of PTSD development among medically injured patients treated at 

WRAMC is lower than noninjured soldiers exposed to 

trauma.7,21 Furthermore, early psychiatric intervention 

may also alleviate the stigma associated with being a 

psychiatry patient and allow appropriate psychiatric 

intervention to occur when necessary, often after the 

patient has left the hospital.

Hospitalization and the Meaning of Injury

 In the period immediately following injury, patients 

often report a sense of shock, denial, and disbelief. 

The feeling of being dependent on others can become 

intimidating and overwhelming. Fear over loss of life, 

limb, or capability, as well as a feeling of loss of control 

is a common occurrence. Apprehension of being abandoned prior to regaining control or receiving help can 

be very overpowering. Once help has arrived and the 

fear of being alone is relieved, a sense of initial comfort 

develops, along with potential dependency needs. 

Based on the severity of the injury, patients may not 

be aware of all that has transpired until they awake in 

the hospital. Some patients are initially elated at being 

alive. After a time, however, the elation may fade and 

anxiety and depressive symptoms may appear. Others 

who suffer brain injuries or loss of consciousness may 

never remember the event or the trauma and wait for 

others to fill in the gap. 

In general, a patient who is exposed to trauma can 
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Psychiatric Intervention for the Battle-Injured Medical and Surgical Patient Following Traumatic Injuries

experience a threat to both physical and emotional 

integrity. Loss of body parts and threat of death or annihilation are also significant fears for these patients. 

They become vulnerable and dependent, a state many 

patients have not experienced in many years. Fear or 

discomfort with strangers may also become prominent 

because of the unknown effect of the disfigurement on 

the new relationship. Fear of not having as many loved 

ones around and leaving a safe environment are also 

major concerns for patients being discharged from the 

hospital. Patients’ perceptions can result in childlike 

patterns of behavior, which lead to conflicts with the 

nursing and medical staff. Regression and dependency 

needs are frequently observed in traumatically injured 

patients, and an overwhelming sense of narcissistic 

injury is frequently present.

Complicating these factors are the anxieties of the 

patient’s loved ones. The family’s needs must be addressed so that their anxieties do not affect the patient 

and thus exacerbate an already emotionally complicated situation. For example, family members often 

choose to sleep in the patient’s room rather than leaving them alone at night. This, however, can result in 

the patient later having difficulty sleeping if someone 

isn’t in the room.

An individual’s adaptive functioning may be 

compromised by the traumatic event. Most patients 

eventually find ways to deal with the emotional effects of traumatic injury, and although personality 

features that have been effective as coping styles in 

the past may become overwhelmed initially, patients 

usually self-correct. Patients with poor or disordered 

personality structures may have conflicts with staff 

or families and are at risk for developing maladaptive behaviors or psychiatric illnesses. These patients 

may respond in a less-than-optimal manner because 

medical or traumatic injuries can be an overwhelming 

stressor. These patients and families are vulnerable and 

need support and guidance from caring individuals. 

Developing a therapeutic relationship with them is 

imperative. Utilizing warmth, caring, empathy, and 

support can go a long way when attempting to form 

an alliance with the family and the patient, and can 

facilitate healthy behaviors and responses.

The Role of Psychiatry Following Trauma

Nearly all survivors exposed to traumatic events 

briefly exhibit one or more stress-related symptoms.22

In many instances these symptoms dissipate within a 

reasonable amount of time. However, symptoms persisting for a prolonged period following a traumatic 

event increase the probability of developing PTSD or 

other stress-related psychiatric disorders. Koren8 found 

that injured soldiers were more than five times as likely 

to develop psychiatric symptoms than were those 

only exposed to trauma. Though the initial goal of the 

mental health team is to facilitate medical treatment, 

a secondary goal is to prevent or decrease the probability of chronic debilitating psychiatric symptoms. 

To meet these goals in treating the medical-surgical 

patient following a traumatic injury, new approaches 

were adapted at WRAMC.2,10

Rather than waiting for consultations to be received 

before intervention occurs, the PMP at WRAMC developed a therapeutic interaction to overcome the 

stigma of being seen by psychiatry. Overcoming this 

obstacle is important because many patients tend 

to downplay their distress and underreport their 

symptoms for fear of being labeled a psychiatric patient. (As discussed above, the PMP was developed 

to decrease the stigma associated with mental health 

and psychiatry). 

Case Study 16-1: A 36-year-old soldier with a soft-tissue 

injury to the right eye, fractures to the left femur and tibia, and 

a right-leg below-the-knee amputation (BKA) responded in a 

sullen manner to his orthopaedic and physical therapy teams. 

Upon the initial visit by a psychiatrist he denied any problems 

as a result of the improvised explosive device (IED) blast. 

He claimed he did not need psychiatric intervention and was 

upset that the team referred him. When he became aware 

that the psychiatry approach was routine and preventive in 

nature, he began describing his concerns about his decisionmaking process while in theater that may have led to his unit 

receiving the blast it sustained. He continued to describe his 

concerns, and the psychiatry team worked to reframe what 

had happened while maintaining an advocacy role. As he 

accepted the routine of the psychiatry approach, he began 

to respond more favorably, assimilated the intervention, and 

cooperated more fully with his rehabilitation.

THERAPEUTIC INTERVENTION FOR THE PREVENTION OF PSYCHIATRIC STRESS DISORDERS

The PMP service at WRAMC employs the Therapeutic Intervention for the Prevention of Psychiatric 

Stress (TIPPS) disorders model.10 The approach draws 

upon many tools used by the mental health provider 

in the consult–liaison setting. This intervention was 

developed to address the psychological needs of 

trauma victims, provide support to the individuals 

and their families, assess psychiatric status, provide 

early intervention when needed without stigmatization of the patient, and support the staff. To help with 

the clinical process, objective instruments are given 

to patients while they are in the hospital. The questionnaires are helpful in providing objective data and 

facilitating follow-up.
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Combat and Operational Behavioral Health

The major components of the TIPPS approach are 

mental health becoming a routine part of trauma 

care, empathetic exposure therapy, developing a 

strong therapeutic alliance with the patient and family, normalizing the experience and the psychological 

response to the trauma, reinforcing resiliency, and 

promoting positive coping behaviors. TIPPS has been 

used successfully at WRAMC since the attacks on the 

Pentagon on September 11, 2001. Studies infer the effectiveness of this approach for reducing the prevalence 

of mental health disorders in battle-injured soldiers 

treated at WRAMC.7 Other significant components 

of the intervention include recognizing personality 

styles and psychological defenses, countertransference 

and transference issues, normalizing events, cognitive 

reframing, educating patients and families, prescribing 

appropriate psychopharmacology, and utilizing hypnotic and relaxation techniques. Reinforcing patients’ 

strengths regarding their survival was also a primary 

theme of this approach. A review of some of the principles of TIPPS follows.

Routine Consultation and Therapeutic Alliance

The patients are initially approached with an informal style and avoidance of traditional psychiatric 

jargon. A typical introduction may begin by saying, 

“Hello, I’m Dr ____ from Preventive Medical Psychiatry. Welcome back. We are sorry you had to experience 

your injury and we all thank you for what you did. 

You took care of us by being there. It is now our turn 

to take care of you.” Family members are also greeted 

in a similar manner if they are present. The provider 

is introduced to the family as staff of the PMP service. 

The provider also lets the soldier and the soldier’s 

family know that mental health assessment is part of 

the routine care for returning OIF/OEF patients. This 

approach frequently sets patients and families at ease. 

Providers are trained to be cognizant of the variety of 

reactions to mental healthcare that patients and families 

may have and adjust their approaches accordingly.

The therapeutic alliance is built with the patient and 

families over time, as patients are seen briefly several 

times per week. PMP involves the entire family unit in 

adjusting to, and recovering from, the traumatic event. 

The family may be seen separately from the patient 

as well as together. Understanding their position and 

problems is necessary. PMP social workers also follow 

patients and their family members twice a week. The 

child and adolescent psychiatry service joins the PMP 

for rounds and sees families with children of injured 

soldiers to assess the family support structure and to 

help the family deal with the effect of trauma. 

Patients are asked to rate how they are feeling, their 

pain, and their sleep, and if they are having any nightmares or feelings about the trauma. The development 

of the therapeutic alliance cannot be underestimated. 

It facilitates the assessment of psychological symptoms and treatment while in the hospital and allows 

for easier follow-up treatment if problems arise for 

patients or their families upon discharge. This helps 

ensure that patients feel comfortable approaching 

psychiatry for help, if needed.

Transference and Countertransference in the 

Therapeutic Relationship

Understanding the interpersonal interaction between clinician and patients facilitates evaluation and 

treatment.20 Patients’ responses to clinicians will often 

be expressed in various manifestations of transference. 

At times the transference can be modified by the actual 

behavior of the therapist. The need to elicit a therapeutic alliance and a positive transference from the 

trauma patient is crucial. This will likely occur when 

the clinician is perceived as both good and helpful in 

the here-and-now situation. Negative transferences 

are more likely to recreate spontaneous reenactments 

due to rapidly shifting mood, affect deregulation, and 

disconnection within self. The potential for revictimization may be enhanced or diminished by the negative 

transference experience of the patient. With a negative 

transference, the trauma patient may come to categorize the clinician as a past perpetrator. This occurrence 

may likely contribute to a regression or oppositional 

style to medical treatment. This is detrimental in 

particular for the wounded soldier because medical 

stabilization and recovery is of necessity. It is clearly 

essential for the clinician to recognize the significance 

of the transference responses and react in an appropriate therapeutic manner. During the early stages of 

therapy with trauma patients, the immediate goal is 

to establish the holding milieu for the emergence of 

positive transference. 

Clinicians can also develop countertransference issues that need monitoring. Clinician overindulgence 

of patients’ needs, silence, avoidance, and overidentification with the patient or family members can cause 

disruption in the recovery of the patient. The concept 

of neutrality can be lost and patients can feel revictimized. In general, being aware of patients’ transference 

or countertransference issues and the effect on the 

therapeutic process allows for greater clinical clarity 

and appropriate interventions. Awareness of countertransference issues also allows the PMP clinician to be 

a more effective clinician and consultant. Knowledge 

of these skills can help colleagues in other services in 

their interactions with their patients. 
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Psychiatric Intervention for the Battle-Injured Medical and Surgical Patient Following Traumatic Injuries

INDIVIDUAL THERAPEUTIC COMPONENTS

Empathic Exposure

Providers allow the patient to process the trauma 

through empathic supportive exposure therapy. In 

other words, in an empathic manner, patients are asked 

to reflect on their traumatic experiences, suggesting that 

description at present is helpful in the future. Empathic 

exposure may help them integrate the past trauma into 

their present stream of consciousness. Patients are usually seen three times per week for 15 to 20 minutes. The 

frequency of this empathic exposure appears to allow 

for the normalization of the event and consolidation of 

the experience in the patient’s memory.

Providers are trained to offer rapid empathic responses to patients’ recall of their trauma and injuries. 

As the patients continue to relate their trauma, empathic reinforcing statements are made about their psychological assets. These statements reinforce their positive 

behaviors during their descriptions. Nonthreatening 

techniques are employed and confrontational approaches are avoided. Comments that demonstrate 

patients’ positive assets are quickly reinforced, such 

as, “How did you know to do that?” or, “Where did 

you learn that?” Traditional psychotherapeutic interventions aid the provider in supporting the trauma 

patient. Acceptance, respect, empathy, warmth, advice, 

praise, affirmation, and a sense of hope are qualities 

and characteristics the clinician is encouraged to display while working with these patients. Providers need 

to be viewed as genuine in their concern and support 

of the patient, while offering empathic validation 

and encouraging patients to elaborate on reactions 

relevant to the trauma. These techniques reinforce the 

therapeutic alliance and treatment. In summary, while 

the patients are relating their traumas, clinicians find 

a way of reinforcing their assets. Providers continue 

this procedure each time they see these patients. Supportive reinforcing statements regarding their assets 

while they are describing their trauma may help them 

integrate the conflict in a more productive manner.

Hypnotherapy

Hypnotic techniques are taught while the patients 

are in their beds. Providers have them practice breathing and then utilize a rapid hypnotic induction that 

patients can repeat to themselves. This can, at times, 

allow for management and control over symptoms 

such as pain, hypervigilance, and anxiety. It may also 

allow for distancing from the trauma—giving patients 

some control in finding a safe mental place where they 

can begin processing thoughts and feelings about the 

trauma. The clinician can facilitate the patient’s going 

to the imaginary safe place to process and reframe 

traumatic events. Subsequently these patients can get 

to their safe place on their own. These techniques can 

also be an outstanding adjunct to help pateints integrate their conflicts with phantom-limb pain, sleep, 

and smoking cessation in a facilitative manner. Many 

of the trauma patients at WRAMC smoke even when 

they know smoking disrupts wound healing.

Group Therapy

As a supplement to individual therapy, groups 

can provide beneficial support and help many of the 

patients begin working through the process. Group 

therapy was demonstrated as an effective technique 

for treating Vietnam-era veterans with PTSD.23 At 

WRAMC, groups are held twice a week in the hospital 

ward and led by providers. The groups are open to the 

medical and surgical injured patients. Topics such as 

anger, expectations, recognition of limitations, sexual 

fears, separation anxieties, survivor guilt, losses, family concerns, and public responses are discussed after 

initiated by a patient. 

Pharmacological Interventions

Pharmacological approaches are often used to facilitate mental health recovery from traumatic injury. 

Physical trauma results in significant somatic pain and, 

according to Schreiber and Galai-Gat,12 uncontrolled 

pain may result in the development of PTSD. Some 

patients associate pain with the severity of their injury, 

which may also lead to the development of anxiety, 

depression, loneliness, hostility, and sleep disturbances.11,13 Studies at WRAMC have demonstrated that 

patients with increased levels of physical injury are 

more likely to develop PTSD and depression following 

injury.7

 Furthermore, patients experiencing pain are 

less likely to respond to traditional psychotherapeutic 

interventions.13 Thus, prompt pain control is critical in 

trauma patients and must be addressed early with judicious use of analgesics. PMP often recommends several 

adjunct treatments to the trauma team to manage pain, 

including tricyclics and other antidepressants, hypnotherapy, and relaxation therapy. Myriad pharmacological interventions are available to treat patients with 

psychiatric diagnoses or symptoms such as agitation, 

anxiety, or perceptual disturbances. Some of the agents 

utilized are antipsychotics, atypical antipsychotics, 

selective serotonin reuptake inhibitors (SSRIs), and 

serotonin-norepinephrine reuptake inhibitors. 
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Combat and Operational Behavioral Health

Insomnia

Insomnia in the polytrauma patient is a near universal observation. Insomnia can be attributed to delirium, nursing care interventions, lab draws, pain, fever, 

and doctors’ rounds, among other things encountered 

in the hospital. Benzodiazepines, anticholinergic medications, and antidepressants can interfere with clarity 

of thought and prevent psychological integration of 

the traumatic event, as well as foster the development of a delirium. Insomnia in the trauma patient is 

treated with a variety of interventions. First, orders 

are reviewed to ensure that nursing care interventions 

(such as q4 hour vitals) are not still ordered when no 

longer necessary. Patients are given permission to close 

their doors and put signs up instructing that they not 

be disturbed. The nursing staff is encouraged to allow 

for uninterrupted sleep. Patients are also educated on 

sleep hygiene, and relaxation techniques are taught to 

help them rapidly induce sleep. 

Often, however, these measures are insufficient. 

Medications for insomnia can be extremely useful 

in the hospitalized setting. The choice of medication 

is often based on the patient’s symptoms, medical condition, and preference. For nightmares and 

sleep maintenance problems, Seroquel (quetiapine; 

AstraZeneca US, Wilmington, Del) is often used 

in low doses, 25–100 mg. There has only been one 

small open-label study published looking at Seroquel and sleep quality, which showed effects on 

nightmares and sleep maintenance. The experience 

at WRAMC shows this approach to be effective and 

well-tolerated by patients. However, there have been 

a few patients who experienced elevations in their 

liver-associated enzymes due to Seroquel. There are 

other drawbacks. Seroquel is expensive and is an 

atypical antipsychotic; there is debate about its cost 

effectiveness and the risks of dyslipidemia, bloodsugar abnormalities, and extrapyramidal symptom 

disruptions. In treating thousands of patients at 

WRAMC with this medication, there have not been 

observed instances of these problems. Other antipsychotics have been employed somewhat successfully for the treatment of sleep disturbances with 

nightmares. Other medications may be indicated 

in the presence of flashbacks or disorientation and 

emotional dysregulation from multiple or high-dose 

pain medications or other medical issues.

Ambien (zolpidem; Sanofi-Aventis, Bridgewater, 

NJ) has not been found to be as useful as Seroquel in 

patients at WRAMC. The half-life of Ambien is short 

and patients quickly develop a tachyphylaxis. Also, 

Ambien does not seem to work as well for stressinduced insomnia. When insomnia is associated with 

anxiety or depression, mirtazapine can offer relief. 

Nightmares, when overwhelming, have been reported 

to respond well to prazosin, though caution should be 

exercised due to its hypotensive properties. One small 

study of 10 patients showed some alleviation from 

nightmares in patients with PTSD using prazosin. A 

discussion on the use of pharmacotherapy is provided 

elsewhere in this volume. 

TREATMENT

As described earlier, a variety of psychotherapeutic 

and psychopharmacologic interventions, techniques, 

and styles are utilized. In the PMP service, the mechanism of normalization of feelings is a fundamental 

aspect of treatment. Soldiers in the initial phases of 

trauma recovery are not generally willing to discuss 

their feelings with the providers, but with the mandatory screening and monitoring that the service provides, patients become “used to” someone coming in 

and normalizing some of their “potential” emotional 

responses. After some time, they may often choose 

to speak more freely, knowing they are going to be 

listened to and understood.

The first step is to allow these patients to fully describe their losses. It is only through this step that the 

necessary information can be gathered to determine 

if their depression is from grieving, from a sense of 

helplessness in not knowing how they are going to 

handle a change of life as a result of their injury, or if 

there is a truly endogenous depression. In these initial 

few sessions, mental health professionals can learn 

a great deal about value systems, usual responses to 

adverse life events, and expectations and fantasies of 

what would happen in the next few months of these 

patients’ lives.

These soldiers, regardless of the etiology of their 

situations, must be given a chance to mourn their 

losses. An essential aspect of working through this 

is identifying the loss, the importance of that loss in 

their lives, and its effect. In each of these “grieving sessions,” the psychiatrist needs to focus on the recurrent 

themes and begin to lay foundations for growth and 

resiliency despite the loss. As these patients discover 

that life does not halt because of the loss, they realize that the traumatic incident is another chapter in 

the rest of their lives. They can then begin to recover 

their sense of purpose and well-being. Some soldiers, 

despite psychotherapeutic interventions, continue to 

have depressive or anxiety symptoms, and require 

pharmacological interventions. Fortunately, soldiers 
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in these situations typically respond well to the usual 

treatment course of antidepressants.

Depression and Mood Disturbances

Being a patient often precipitates a sense of loss that 

many cannot verbalize. Because soldiers are taught 

throughout their military training to “bottle up” their 

feelings, their sense of loss can manifest itself though 

behavioral problems. This section addresses the various ways that loss can be experienced by these patients, 

how the process of normalization of experiences can 

allow them to work through their sensations, and effective treatment strategies for the more recalcitrant 

cases.

From the very beginning, battle-injured soldiers will 

generally indicate that they are simply “happy to be 

alive.” However, this statement is often followed by a 

second statement: “I guess I was lucky.” The progression of this thought is stunning; soldiers will seem 

genuinely relieved at their fortune, but an overriding 

sense of guilt actually visibly appears to overtake them, 

and they must attribute this fortune to luck to again 

regain their emotional control over survivor guilt. 

The reality of survivor guilt has been well established 

in patients who are covictims in traumatic events. In 

soldiers, this guilt is intensified by the ubiquitous code 

of teamwork that military service requires of its members. This feeling is often stronger in those patients 

who have minimal injuries compared to the death or 

severe maiming of their peers.

Loss of functioning goes well beyond the mere 

physical loss of limbs. Many of these soldiers tend 

to be athletic and active in their preinjury lives. They 

perceive their lives as “forever changed” because of the 

amputations, and frequently believe they will have no 

ability to engage in their former activities. Although 

there is some basis in reality with this thought, unless 

they move through this phase, they will not be able to 

see the abilities they still have or may regain.

Case Study 16-2: AB was a 22-year-old Army sergeant. 

He was the team leader for four other infantry soldiers. The 

unit had been together in theater for 7 months when they 

were attacked by an IED on a routine patrol. AB was knocked 

unconscious by the blast, but awoke with a BKA of his left 

leg. He learned that two members of his team had perished 

in the blast, another had an amputation of his right arm and 

leg, and the fourth one had suffered a TBI and his status 

was unknown to the patient. AB spent 3 weeks in a facility 

before being transferred to WRAMC. In that time he had 

minimal exposure to mental healthcare, primarily because 

of his statements that he was “doing fine.” However, after 

his air evacuation to the United States, AB stated that he 

was “surrounded by the reminders of his loss,” and became 

tearful during his history and physical with his primary team. 

They requested a consultation. AB spoke of his loss of his 

own limbs, but realized that he was “lucky.” However, this 

conflicted with his sensation that he “should” feel more for 

his soldiers than for his own self. He stated that this was 

the reason that he spoke little of his feelings in his previous 

hospitalization, believing that if he focused on himself, he 

would be perceived as weak. AB was deeply troubled at 

his change of lifestyle, but extremely worried that he would 

need to “forever show his grief” when he was at his unit to 

pay homage to his team soldiers. Determining that he would 

“never be happy,” he fell into a state where he would not 

participate in activities, have outside visitors, or speak with 

his unit liaisons as they visited in the hospital.

Anxiety

During the acute period of hospitalization of battleinjured soldiers, the PMP service observes a range of 

symptoms in the anxiety spectrum of disorders. Most 

commonly seen are those symptoms that are consistent 

with acute stress reactions. In particular, the reexperiencing of traumatic events through nightmares, 

flashbacks, intrusive thoughts, and recurrent images 

are common. Equally common are symptoms related 

to hyperarousal, such as difficulty falling or staying 

asleep, hypervigilance, increased startle response, 

irritability, and poor concentration. Obsessive rumination themes in the injured soldiers include worries 

regarding the threat to physical integrity, the effect 

on current and future functioning, and the effect on 

family members and friends. Soldiers removed from 

theater often worry about unit members left behind 

and are distressed by their perceived inability to help 

their friends in the field. Many soldiers hear the sound 

of the blast or the gunshot that injured them replayed 

over and over either in their minds or in dreams. Others may ruminate over the death of friends and are 

overcome by survivor guilt. Very frequently battle 

scenarios are reviewed over and over and soldiers 

wonder what they might have done differently to 

have effected a different outcome. Some of the most 

distressing memories for patients include seeing fellow soldiers die, seeing dead children, and exposure 

to body parts. Finally, shame may lead to emotional 

conflicts that may ultimately feed anxiety. 

In the absence of traumatic or anoxic brain injuries, where patients have no recollection of traumatic 

events secondary to organic causes, few patients seem 

concerned about overt dissociative symptoms (such 

as not recalling important aspects of the trauma or a 

feeling of emotional numbing or detachment) in the 

acute period. Indeed, it appears that most patients, 

at least in the initial period of hospitalization, seek to 

reconnect with family members and loved ones and 
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are particularly comforted by contact with commanders and unit members still in the field. Although some 

hospitalized soldiers may avoid television or movies 

that remind them of traumatic events, it is less common for patients to overtly avoid reexperiencing the 

traumatic events by refusing to discuss the trauma, 

or feelings and thoughts about the trauma. When this 

overt avoidance occurs, it should be particularly worrisome to the mental health provider and consideration 

for further intervention should be given. 

In addition to symptoms that are consistent with 

acute stress disorder, anxiety may manifest in the 

form of specific fears or phobias, such as a fear of 

falling asleep (usually reported as fear of dreaming), 

fear of being alone (separation anxiety), or fear of being in the dark. Overt anxiety and panic attacks are 

observed infrequently. Often these are aggravated 

in soldiers with prior personal or family histories of 

anxiety disorders.

Rapid eye movement sleep behavior disorders 

are not uncommon where patients report acting out 

combat-related scenes, presumably during rapideye-movement sleep. Hypnogogic and hypnopompic 

phenomena and other perceptual disturbances may 

occur and may represent hyperarousal symptoms. 

The service member has just traveled across multiple 

time zones and may be undergoing frequent painful 

surgical procedures and necessary nursing interventions throughout the day and night (which continue 

to promote disturbance of the sleep–wake cycle). The 

utility of other treatments, such as image rehearsal 

therapy (where dream endings are more positively 

construed), are also being explored to address sleeping 

concerns and nightmares. 

In the acute treatment setting, when these symptoms appear, it may be difficult to make a specific 

anxiety-disorder diagnosis, given that very frequently 

the service member does not meet full criteria for any 

one specific diagnosis. Additionally, there are many 

confounding factors, such as pain, pain medications 

(opiates, benzodiazepines, or anesthetics) or other 

medications or substances, head injuries, and other 

treatment factors that may account for, exacerbate, or 

create any of the aforementioned symptoms. Above 

all else, it is important to determine whether a general medical condition, particularly associated with 

delirium, is not causing or contributing to the anxiety 

symptom. For this reason, very frequently a diagnosis of anxiety disorder not otherwise specified may 

be given if one or more symptoms are particularly 

apparent and troublesome but the patient does not 

meet full criteria for a specific diagnosis. Additionally, 

a diagnosis of adjustment disorder with anxiety may 

be made, although in some cases it is difficult to deem 

that one person’s response is in excess of what might 

be expected for such an extreme situation. 

Later in the course of medical stabilization, almost 

all of these symptoms lessen for most patients but may 

persist for a few. For example, patients may continue 

to reexperience traumatic events, particularly through 

nightmares. Likewise, new anxiety symptoms may 

emerge as patients are exposed to new situations outside of the hospital room. Another common example 

is when they may realize that they have less ability 

to emotionally connect with others and may have 

more social withdrawal, such as difficulty tolerating 

crowded areas. In a few cases, patients have refused to 

leave their hospital rooms altogether when medically 

deemed physically capable. As patients physically heal 

and develop more cognitive reserve, more standardized treatment strategies may be utilized (such as more 

formalized cognitive behavioral therapy) for the identified disorder. They may then participate in supportive 

group therapies or perhaps engage in psychodynamic 

therapy if more developmental and interpersonal 

concerns appear to be affecting the current condition. 

The importance of early and consistent treatment of 

these disorders is borne out by the fact that between 

12.2% and 12.9% of soldiers at WRAMC with serious 

combat injuries returning from OIF or OEF will go on 

to manifest full criteria for PTSD, with the injury itself 

being a major risk factor for ultimate development of 

the disorder.7 Without these interventions it is likely 

that these numbers would be even higher.

The general approach to the acutely battle-injured 

soldier with anxiety begins, as for all patients, with 

an empathic stance that focuses on the building of a 

therapeutic alliance. Building early rapport helps the 

patient identify mental health specialists as part of 

the medical team and facilitates patient comfort with 

providers. Additional social assistance is provided 

where necessary to mobilize and establish a support 

network and resources for the patient in the hospital. 

The medical needs of the patient are reviewed and an 

understanding of the illness or injuries or both from 

the patient’s perspective is explored to help identify 

beliefs and concerns (and perhaps any doubts or misgivings) that the patient may have regarding care or 

prognosis. 

Psychoeducation is provided to help build a framework for treatment and to normalize current feelings 

and emotions. Supportive psychotherapy is offered to 

identify and engage patient strengths and to bolster 

ego defenses. Patients are encouraged to discuss the 

trauma “when they are ready,” at which time providers reinforce what the patient did well throughout the 

traumatic event. Cognitive techniques are employed 

to help patients reframe thoughts about traumatic 

experiences so that anxiety is better understood and 

tolerated. Relaxation techniques may be taught and, in 
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Psychiatric Intervention for the Battle-Injured Medical and Surgical Patient Following Traumatic Injuries

certain instances, hypnosis may be added to help patients achieve a deeper sense of relaxation and mastery 

of emotions. Particular attention is paid to pain control and sleep, as any inadequacy in these areas may 

hinder the patient’s ability to employ effective coping 

strategies. For this purpose, recommendations for the 

adjustment of pain medications or for the addition of 

new ones may be made to the primary medical team. 

Prior to making any medication recommendations, it is 

important to consider the patient’s underlying medical 

condition, current medications, and allergies. Medication interaction checks should always be performed, 

given that most psychoactive medications have the 

propensity for interactions with multiple other drugs 

and antibiotics. 

SSRIs remain the drugs of first choice for PTSD, 

generalized anxiety disorder, panic disorders, and 

social phobia. They may also be utilized for severe, 

prolonged acute stress, and for adjustment disorders, 

although some of the newer non-SSRI antidepressants 

such as venlafaxine and mirtazapine have also been 

used successfully. Of the SSRIs, sertraline and citalopram are generally preferred given their tolerability 

and relatively decreased potential for drug–drug interactions. Benzodiazepines are generally avoided 

where possible, particularly in PTSD, given the lack 

of data to support their use and the potential for addiction and worsening of PTSD in the long term. They 

are, however, occasionally used for the temporary 

relief of severe anxiety and panic attacks. Frequently, 

patients will already have benzodiazepines prescribed 

for other indications such as muscle spasms or phantom limb pain. In this latter case, patients should be 

educated on the effect of benzodiazepines on anxiety 

and the effects should be monitored. Treatment for 

persistent conditions may ultimately extend beyond 

the period of hospitalization. It is therefore important 

on a consult-liaison service to work closely with the 

medical team on aspects of discharge planning so that 

there is a seamless transition of care between inpatient 

and outpatient mental health providers. 

Cognitive Disorders

Approximately one third of service members 

injured in OIF and requiring medical evacuation to 

WRAMC are found to have a TBI. Of these, about half 

are classified as mild TBIs and the other half are rated 

as moderate to severe. Many of the TBIs occur in the 

setting of polytrauma. All service members with an 

injury history that may be associated with a TBI (such 

as an IED blast exposure, a moving vehicle accident, 

or falls) are screened during the initial phase of their 

hospitalization for a TBI by a specialized team from 

the Defense Veterans Brain Injury Center. Additionally, as part of the routine screening by PCLS/PMP 

of all injured service members who are admitted to 

WRAMC, a further psychiatric assessment of these 

inpatients is performed. A multidisciplinary team 

from neurology, physical medicine and rehabilitation, 

psychiatry, physical therapy, occupational therapy, and 

speech pathology provide ongoing assessment and 

treatment of these patients.

The role of the PMP includes clinical assessment 

of the TBI and treatment of associated behavioral 

sequelae. This begins in the intensive care unit (ICU) 

for more severely injured service members who arrive at WRAMC on ventilator support. In addition 

to the common problems of disorientation and frank 

delirium seen in patients with polytrauma as they are 

weaned from sedation, patients with TBIs may take 

considerably longer to wake up, may be more agitated 

and disorganized, and are generally less able to participate in their own care. Family members of injured 

service members with TBI are provided information 

that the prognosis for moderate-to-severe TBI is hard 

to predict and may be very frightening and upsetting 

to loved ones. In addition, therapeutic nihilism in staff 

members treating severe TBIs is not uncommon and 

frequently needs to be addressed by the consultation 

liaison psychiatrist. Recommendations for treatment 

of delirium and agitation often involve modification of 

the intravenous pain regimen, minimization of external 

stimulation, addition of neuroleptic medication, and 

restraint when other modalities fail. Sleep disruption is 

common and may be associated with other symptoms 

of hyperarousal. Preemptive treatment of sleep disruption with low-dose atypical neuroleptics has proven to 

be especially effective in decreasing hyperarousal.

On the medical and surgical wards, psychiatric 

evaluation of TBIs focuses on the ongoing assessment 

of cognitive function and the emotional adjustment of 

service members to their wartime experiences, their 

injuries, and their futures. The interplay of cognitive 

deficits and organic mood and personality changes 

with acute and posttraumatic stress disorders provides 

diagnostic and therapeutic challenges. Conversion 

disorder is not uncommonly seen in the context of 

mild TBI and takes the form of embellishment and 

exaggeration of cognitive deficits, sensory and motor 

abnormalities, gait disturbances, and stuttering.

Case Study 16-3: GQ is a 32-year-old active duty E6 

with 13 years in service. He was injured by an IED explosion 

while on a mission in OIF that resulted in a penetrating head 

injury. At a combat support hospital in Iraq, he underwent a 

left frontoparietal craniectomy for removal of an embedded 

fragment and duraplasty, and placement of an intracranial 

pressure (ICP) monitor. The patient was then transferred 

to Landstuhl Regional Medical Center in Germany where 

his ICP was noted to be increased to 15–22 mm Hg, but 
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interval head computed tomography (CT) was unchanged. 

Patient was noted to be combative when attempts were 

made to wean him off sedation. Once his ICP stabilized and 

the monitor was removed, the patient was transferred to 

WRAMC, where he arrived intubated and sedated. Following the patient’s admission to the WRAMC ICU, his wife was 

seen daily at his bedside by the PCLS staff. Several days 

into the hospital stay, his wife became extremely distraught. 

She reported that she had been told by the ICU house staff 

that her husband’s prognosis was guarded. Additionally, she 

was shown his head CT scan and interpreted the large area 

of skull loss from the craniectomy as massive brain loss. 

She did not know if she could live with her husband “being 

a vegetable.” A meeting with the patient’s wife, PCLS, and 

the ICU team was useful in correcting her misunderstanding 

of the CT scan and providing her with a better understanding 

of his prognosis. The patient was subsequently extubated 

and was initially agitated and moving only his left side. Over 

the next month he made a gradual recovery, with resolution of posttraumatic amnesia and return of speech and full 

motor activity. He denied flashbacks, hyperarousal, anxiety, 

depression, or other symptoms of acute stress disorder, with 

the exception that he had difficulty sleeping. He was treated 

with increasing doses of Seroquel up to 75 mg for his sleep 

difficulty. He actively participated in physical therapy, occupational therapy, and cognitive therapy with speech pathology, 

and was transferred to a Veterans Administration center for 

cognitive rehabilitation. He made an excellent recovery, had 

a cranioplasty for his skull defect, and eventually resumed 

working in his previous capacity, albeit in a nondeployable 

status.

Follow-Up Contact

All patients are given a contact number and encouraged to call the PMP office at WRAMC should 

concerns develop for the patients or their families. 

They are also called 30, 90, and 180 days following 

discharge from the hospital. One of the early goals has 

been to make psychiatry an ally to the patient. When 

patients have returned to their homes they have found 

it easier responding and receiving intervention, and 

when crises occur they appear more willing to accept 

referral recommendations. In general, patients who 

need treatment upon leaving WRAMC are referred to 

resources within the military, veteran’s health system, 

or civilian community. 

The Trauma Patient’s Family

Family members also experience psychological 

trauma as a result of the injury of their loved ones.24–27

Families typically know little about the extent of the 

injuries or their prognosis, and therefore experience 

more anxiety and feelings of helplessness.11 Crisis intervention for the family members of trauma victims 

may be needed.

It is difficult to predict how family members will 

react to the trauma and the injuries sustained by the 

patient. The experience of having a family member 

injured may exacerbate family malfunctioning.17

However, the interventions to assist these families in 

coping with the traumatic event may lessen the family 

member’s chance of developing secondary PTSD.26

Trauma patients need as much support as possible, 

and family members are often better at providing 

emotional support and reassurance to the trauma 

patients than the staff.24 Effective therapeutic family 

interventions may not only help the family members 

cope with the traumatic events but may help the patient as well. The family’s anxieties tend to exacerbate 

the patient’s conflict. Negative family behavior may 

also have a deleterious effect on the nursing staff. But 

if the family remains stable and supportive, the patient’s anxiety is decreased and outcome is improved. 

The family’s built-in support system may need to be 

augmented with professional help.28 The purpose of 

the family crisis intervention is to build up the family’s 

coping skills and resolve symptoms associated with 

psychological trauma. Sharing meals with families of 

other trauma patients, for example, also provides the 

family with additional support.26

Initially it is important that family members of the 

injured soldier have access to food, clothing, and shelter. A family assistance center is available 24 hours a 

day at WRAMC. This alleviates any additional stress 

and allows the family to focus its attention on the 

patient and deal with the ongoing events.26 Each institution needs to provide personnel to help with this 

task. At WRAMC, PMP social workers are advocates 

for patients and their families.

Brief supportive counseling has also been proven 

effective at reducing anxiety in family members of 

trauma victims.11 PMP staff will often spend time 

with family members interviewing and supporting 

them emotionally. Support groups formed specifically 

to assist these families provide an outlet for them to 

address their needs and feelings.28 When developing 

family groups, Harvey and colleagues28 found that 

families were more willing to attend when the group 

focus was on education and families sharing their stories. Families attending these support groups realized 

that they were not alone and were able to support each 

other. Additional benefits the families received from 

attending these groups included the ability to share 

feelings, reduce anxiety, instill hope, and gain a better understanding of their family members’ injuries, 

medical treatments, and hospital procedures. PMP 

social workers also started a group for spouses and 

other family members of injured soldiers to allow for 

empathetic sharing and support. Groups are offered 
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Psychiatric Intervention for the Battle-Injured Medical and Surgical Patient Following Traumatic Injuries

twice weekly for spouses and other family members. 

Topics include fear, frustration, the need to protect the 

injured patient, depression, anger, education, coping 

with disabled spouses, and feelings of alienation and 

disappointment. 

Based on experiences at WRAMC, families are 

also seen by a provider in PMP in the hospital. Family members are assessed to determine how their 

children are adjusting, and how parents educate 

their children about the patient’s injury. Many of 

the techniques used with patients are often effective 

with families. Empathic listening, reassurance, and 

normalization are usually enough to help family 

members through their initial emotional response to 

the trauma. Staff members of the child and adolescent psychiatry service routinely see the families and 

assess their psychological response to the trauma. 

Education and support to the children is provided 

as needed. 

Case Study 16-4: BB is a 35-year-old male with BKAs 

from injuries sustained in OEF. The patient was flown to 

Germany and then air evacuated to WRAMC. Initially his wife 

was very supportive and attentive, but as the rehabilitation 

progressed, greater frustration was observed. Ambivalence 

about her role and problems with her in-laws became prominent. Therapeutic interventions were undertaken and as a 

result she began to understand the normalcy of her behavior. 

This allowed her to understand her conflict and recommit 

herself to the marriage. The wife was given the PMP phone 

number for follow-up. 

There has been relatively little research conducted 

regarding the psychological impact that working 

with trauma victims has on medical staff29,30 and 

the resources available to them. Taylor31 suggests 

that, on average, there are three major disasters per 

week worldwide. By responding to the needs of 

these disaster victims, nurses and clinicians may be 

placing themselves at risk of experiencing secondary 

trauma. Dyergrov32 suggests that among disaster 

workers, 80% are likely to experience emotional 

disturbances following the event, although only 3% 

to 7% are likely to experience significant psychological disruptions. 

The myth that those in the helping profession are 

somehow immune to the stresses experienced by those 

they help, and therefore are unaffected, was debunked 

by Bamber.33 Professionals, however, may be reluctant 

to seek help.34 To help destigmatize mental health, PMP 

has routine visits with the clinical staff. For example, 

groups have been established in which nurses share 

their conflicts. Mutual support is also received. Nurses 

are included as team members in PMP and visit the 

wards to work with the nursing staff. Education about 

stress and responses are given when appropriate, and 

formal lectures are also provided. 

Often overlooked is the stress the physicians experience, which may be exhibited during “curb-side” 

conversations.35 Colleagues at times are wary about 

intervening and invading another’s privacy. Providers 

are often concerned that their records or promotions 

will be affected if they seek help from the PMP. They 

also worry that others might see them as “weak.” For 

instance, a surgeon walking in the hallway asked, “Can 

I ask you a question about one of my colleagues? He 

is not sleeping and has been irritable. What can I give 

or tell him?” While the psychiatrist should respond 

as if the advice is for the surgeon’s colleague, there 

should be an awareness that the question may be about 

the surgeon. After maintaining the relationship, the 

surgeon could be asked if the conversation was really 

about a colleague. The psychiatrist could then offer to 

see the surgeon in the PMP office. In general, offering 

support and time to talk is necessary. 

Physicians are, at times, reluctant to talk about their 

fears and frustrations. Giving lectures to the medical 

staff and maintaining a professional, empathetic relationship are essential to medical and surgical providers 

seeing mental health as a resource for themselves. At 

times, it has been helpful to hold groups for physicians prior to their morning rounds, where support 

is offered and difficult cases are discussed. E-mail 

messages and notes about stress are also distributed 

via department channels. These approaches have been 

extremely helpful.

A similar approach has been undertaken with administration and command staff. Maintaining a close 

working relationship with command is imperative 

for the needs of the service and for its commander’s 

needs as well. Many forget that the commanders are 

under stress and may not have any outlet. Keeping 

them informed, as well as being available for their 

concerns, will help contribute positively to a successful approach. 

Last, but not least, the mental health providers also 

need support. Reinforcement of their skills and keeping them educated about providing new approaches 

is helpful. Maintaining a positive esprit de corps and 

sensitivity to each other’s needs also helps. Giving 

them time off and the use of humor, lunches, and 

dinners may also help. It is imperative that leaders 

keep an open door and be sensitive to the frustrations 

and countertransference issues of the providers. In 

SUPPORTING MEDICAL STAFF WHO CARE FOR THE MEDICALLY INJURED TRAUMA VICTIM
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Combat and Operational Behavioral Health

particular, this is important with younger physicians 

and other staff that may be deployed. Sensitivity to 

these concerns is incumbent upon members of the 

PCLS/PMP staff. 

SUMMARY

Physical injury as result of a trauma is an overwhelming experience that results in a life-changing 

event. Exposure to the trauma of war may result in 

psychiatric sequelae, but exposure to both physical and 

emotional conditions can have a geometric effect on 

psychiatric symptoms. Though most trauma patients 

adjust well and recognize that symptoms dissipate, 

others need psychiatric intervention. Based on past 

experiences, psychiatry staff at WRAMC developed 

an early intervention treatment plan for responding 

to injured soldiers. Traditional debriefing (classical 

incidence stress debriefing) interventions were not 

effective in this population. A new approach, under 

the umbrella of therapeutic intervention for prevention 

of psychiatric stress symptoms, was developed. This 

program entails intervening early without a formal 

consultation, destigmatizing mental health, adhering 

to a biopsychosocial approach, recognizing the importance of the therapeutic alliance using condensed 

aspects of traditional psychotherapeutic techniques, 

reinforcing patient assets, using relaxation or hypnotic 

techniques, prescribing appropriate pharmacology, 

and using empathic exposure. Though the goal is to 

avoid inappropriate pathologizing, treating psychiatric 

symptoms is necessary. 

In an attempt to destigmatize mental health, a subsection (PMP) of the psychiatry service was created. 

Other goals of the intervention are to decrease the 

effect of disabling psychiatric symptoms, facilitate a 

speedy recovery, initiate integration of trauma into 

a normal stream of consciousness, ease symptoms, 

teach mastery or control techniques, and recognize 

and treat psychiatric illnesses early. Being able to refer 

patients for treatment if required after they leave the 

hospital is also a major component of this intervention. 

The development of a program for combat casualties 

necessitates the inclusion of patients’ family members, 

hospital staff, and hospital leadership, as well as the 

mental health team serving this population. Besides 

the immediate positive therapeutic outcomes, a therapeutic alliance facilitates the acceptance of referrals by 

patients and family members upon discharge from 

the hospital. 

Finally, based on the experience at WRAMC, becoming a part of a trauma team and being seen as 

member of PMP further expedited intervention and 

allowed psychiatry assistance for the patient without 

the typical stigmatization. Walking rounds further 

solidified patients, family members, and staff seeing 

PMP service staff as members of the trauma team. A 

similar plan can be developed at any hospital treating 

large volumes of trauma patients.

REFERENCES

1. Wain HJ, Jacaard JT. Psychiatric intervention with medical and surgical patients of war. In: Ursano RJ, Norwood AR, 

eds. Emotional Aftermath of the Persian Gulf War: Veterans, Families, Communities, and Nations. Washington, DC: American 

Psychiatric Press; 1996: 415–442. 

2. Wain HJ, Grammer GG, Stasinos JJ, Miller CM. Meeting the patients where they are: consultation-liaison response to 

trauma victims of the Pentagon attack. Mil Med. 2002;167(9 suppl):19–21.

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