Various Themes Related to Training and Research Papers Psychother Psychosom 1990;53:156-160
©1990 S. Karger AG. Basel 0033-3190/90/0534-0156S2.75/0
Psychotherapeutic Approach to the Management of the Severely Injured Patient ./. C. C. Badenhorsl Synnvside. South Africa
Introduction Humpty Dumpty sat on a wall Humpty Dumpty had a great fall All the king's horses and all the king's men couldn't put Humpty together again Mother Goose
Humpty Dumpty one of the most familiar nursery rhymes from our youth symbolizes the dilemma of injury appropriately. Injury to the body is not merely physical it is also psychological and social. Injury, especially severe injury, is existential. Severe injury drastically changes the dimensions and timespan of our existence. Previous pleasurable activities or sensations disappear, our once faithful companion becomes a stranger, a serious enemy preoccupied by an indifferent
force. During severe injury the body ceases to be a medium, it becomes an object. In most instances the treatment of a se verely injured patient is directed on an ex clusively physical level, very little attention is given to the psychosocial factors influenc ing the severely injured individual. Life sav ing and extension of life has been the major aim of focus in many treatment settings and remains a primary attitude amongst many medical and related personnel. Whilst an awareness of the need for the promotion and enrichment of life as an albeit important focus has been recognized by some health caregivers, the visualization and acceptance of the severely injured individual, a human being, and entity within an environment, from a qualitative, rather than a quantitative
Downloaded by: Monash University 130.194.20.173 - 9/25/2017 4:16:51 PM
Abstract. In this modern day and age. severe injury has become the dire consequence of an ever-increasing number of motor vehicle, industrial and mining accidents as well as sport-, military- and terror-related incidents that occur. The management of the severely injured patient is mostly directed on an exclusively physical level. Often, very little attention is afforded to the psychosocial factors that prevail following physical trauma. The author describes and discusses how holistic multidisciplinary intervention within the medical milieu facilitates a more psychotherapeutic approach to the management of severely injured patients. This approach facilitates physical recovery and increaeses the rate of readjustment and reintegration into society, of those who have sustained severe injury.
Psychotherapeutic Approach
Severity of Injury Medically speaking any patient with mul tiple injury affecting various bodily systems or any patient in a life-threatening position could be seen as being severely injured. This definition does not hold when looking at injury from a psychological point of view. Whilst the implications of severe disabling conditions such as head injury or paralysis may be recognized, the importance of less dramatic injury is mostly overlooked. Whilst working with injured patients we should re member that patients experience bodily trauma differently, they assign multiple meanings to injury. A patient’s experience and the meaning he assigns to injury is highly influenced by personality factors, in terpersonal factors, the doctor-patient rela tionship. the hospital milieu, the context in which the injury was sustained, previous in jury as well as unconscious factors - appre hension about pain, loss of bodily form and function, stigma, dependency and the like. Since these psychological factors are of utmost importance with regard to outcome, specific attention needs therefore to be given to what may be seen as one of the major rea sons for unfavorable recovery despite excel lent medical surgical intervention. Psychological intervention is applicable to basically all cases of injury where a pa tient’s basic self-esteem, body image or psy chological balance is threatened. The sever ity of injury is a far cry from the amount of systems concerned or the threat to life which the injury imposes. The severity of injury is
the aforementioned and more. Severity of injury is not merely physical, it is also psy chological. Severity of injury is not only con cerned with life and its maintenance it is concerned with livelihood, quality not quan tity. As such it calls for some specific aware ness amongst members of the treatment team. Severity of injury is manifest in what we cannot see, it is contained within the patient’s total experience.
Biopsychosocial Approach The successful management of a patient with severe injury is highly dependent on the combined efforts of a closely knit team of ‘superspecialists’ from the disciplines of medicine, occupational therapy, physiotherpy, orthotics and prosthetics, social work and psychology, whilst the importance of the medical and paramedical personnel is well recognized the inclusion of the psychologist may be frowned upon or even dismissed as an unfounded ‘luxury’ by outsiders or the uninformed. In recent years medical specialists have however gradually discarded their prior ex clusive biological approach toward injury and begun to consider psychological and so cial factors that influence the outsome of treatment. The utilization of psychologists in general hospital and specialist treatment set tings has emerged as a major contributing force in the biopsychosocial approach to the treatment of patients suffering from severe injury. In this holistic approach to the treatment of patients with severe physical injury, psy chological perspective forms an integral part, of a patients response to injury and its treat ment.
Downloaded by: Monash University 130.194.20.173 - 9/25/2017 4:16:51 PM
perspective, looms as vividly as the fragmen tation of Humpty. and the dilemma, of all the king’s horses and all the king’s men.
157
158
Psychological Service within an Orthopedic Department The Medical Psychological Division in the 1 Military Hospital. Pretoria. South Afri ca, delivers a formalized consultation-liaison service in the Department of Orthopedics and Rehabilitation. Psychologists are responsible for the delivery of a consultation-liaison service within the Department of Orthopedics. Psy chologists are integrated with various or thopedic firms. Within each firm the psy chologist participates closely on ward rounds and clinics during all stages of hospitaliza tion. rehabilitation and follow-up. Whilst the bulk of psychological information is gath ered through individual interviews, group discussions and social reports, psychometric evaluations may also be performed in an
attempt to get a better estimate of a patient’s sick role behavior and readjustment ability. Findings are evaluated and integrated with applicable verbal or printed feedback to members of the multidisciplinary team en semble or individually. Psychological intervention is character ized by its investment in upper limb, lower limb, spinal and chronic pain patients. The inclusion of psychologists in what was pre viously an exclusively medical domain has assisted in the establishment of a more com prehensive and integrated patient care sys tem in this major military hospital on the African Continent.
Psychological Intervention Acute phase (passive rehabilitation) psy chological intervention is aimed at: (a) pre vention of the exacerbation of emotional tur moil associated with the traumatic event (crisis intervention), (b) defusing of negative emotions in family members and emotional support and positive attitude formation of these individuals with regard to their nextof-kin’s physical loss and rehabilitation, (c) basic psychological care of the patient in the adjustment to the hospital milieu and injury-related gadgetry. (d) revision of a pa tient’s unrealistic ideas regarding physical injury and its consequences, (e) consulta tion-liaison support for all members of the multidisciplinary team by furnishing of info related to patient treatment (personality, reaction, psychodynamics, rehabilitation aims), (f) motivation of the patient towards the setting of attainable goals with regard to return to unit or transfer for active rehabili tation. and (g) monitoring psychological ad justment during treatment.
Downloaded by: Monash University 130.194.20.173 - 9/25/2017 4:16:51 PM
Whilst the medical specialist/s may be viewed as the coordinating agent regarding all the physical aspects of a severely injured patient's treatment, the psychologist may be viewed as the coordinating agent regarding all the psychological aspects of a severely injured patient’s management. The psychologist is in the best position to provide various members of the multidisci plinary treatment team with appropriate in formation on psychological variables such as a patient’s reaction to injury, experience of pain, response to treatment and numerous other specific factors. The role of the psy chologist has developed from that of an eval uator only, to the rendering of a comprehen sive service entailing assessment, therapy, liaison and research throughout the entire spectrum of a severely injured patient's preand postoperative management.
Badenhorst
Psychotherapeutic Approach
After Care (a) The patient has to be assisted in ex ploring and utilizing all the resources which are available to maximize his personal read
justment and reintegration into the main stream of society, (b) The patient has to be supported in the amelioration of those as pects that prove to be problematic in the long run. (c) Follow-up of patients encoun tering at reintegration into society problems on various levels of personal functioning is an after care facility provided by the psy chologists in orthopedics.
Conclusion Since the ‘severely injured patient' is con fronted with a significant number of losses other than the mere loss of health, a psycho logical approach to the management of the severely injured patient becomes an impor tant function with regard to the prevention of detrimental attitude formation, extreme psychopathology and various other treat ment-related problems. During hospitalization the ‘severely in jured patient' has to learn to cope with a variety of changed dimensions. The patient has to: (a) come to terms with the trauma which has caused hospitalization, (b) accept the change in his prior to injury status (de pendency, immobility, limitations, body image change), (c) learn to cope w'ith the hos pital gadgetrv. instrumentation, surgical pro cedures. prolonged bed rest, medication, splints, sepsis and many other factors, (d) maintain interpersonal relationships. (e) set new goals w'hich are realistic and in relation to limitations, (f) develop positive attitudes regarding the body, self and envi ronment. and (g) prepare for the goals of rehabilitation and return to society. Severe injury constitutes a major change in both body and life experience. It creates new' dimensions and necessitates the under
Downloaded by: Monash University 130.194.20.173 - 9/25/2017 4:16:51 PM
Active rehabilitation psychological inter vention is aimed at the following, (a) Provi sion of psychoeducation input to all newly transferred patients via a psychoeducative orientation program. This program is aimed at: first, assisting patients to formalize their own rehabilitation needs, second, to bring patients to a point where they have a clear knowledge and understanding about all the activities and goals of the different disci plines involved in rehabilitation, and third, to guide each patient towards having realis tic expectations with regard to his rehabilita tion and to indicate how these expectations could be fulfilled through an individualized rehabilitation program, (b) All patients arc interviewed and evaluated psychometrically. (c) Rehabilitation needs are established and goals arc set in accordance with each pa tient's physical limitations, vocational abili ties, personality characteristics and other relevant information, (d) A profile of each patient’s rehabilitation goals and relevant personal, psychological, vocational, social information is presented during weekly mul tidisciplinary treatment team clinics, where applicable info is included in the manage ment of individual programs of patients, (e) Motivation, acceptance of disability, preparation for return to society and evalua tion of problem behavior limiting effective patient management is the focus of individu alized psychological interventions, (f) Re search and development projects in a multi disciplinary fashion are engaged in.
159
Badenhorst
160
standing of new meaning for the patient and each team member alike. Quantity is to be replaced by quality. Being-in-this-world is rekindled to renew from within in each case, be it patient, or team member. In this way, the psychological approach to the manage ment of the severely injured patient ensures that an optimal level of mental health is maintained in society as a whole. That ideally speaking: All the king's horses and all the king's men
can put Humpty together again.
Badenhorst JCC: Medical psychological intervention in a general hospital. MILMED. 1986. Badenhorst JCC: Psychological intervention in upper limb orthopedic rehabilitation. 4th Psychological Association of South Africa Congress. 1986. Badenhorst JCC, Ahp KLEU: A rehabilitation orien tation programme for patients with orthopedic injury. 4th Psychological Association of South Africa Congress. 1986. Badenhorst JCC: The psychological rehabilitation of the severely injured patient. MILMED. 1988. Badenhorst JCC: Psigologiese Pcrspektief t.o.v. Kroriese Lae Rugpyn. Psychological Association of South Africa Congress. 1988.
References
Dr. J.C.C. Badenhorst PO Box 29188 Sunnysidc 0132 (South Africa)
Downloaded by: Monash University 130.194.20.173 - 9/25/2017 4:16:51 PM
Badenhorst JCC: A Psychological Study of Amputees; thesis University of Pretoria. 1984. Badenhorst JCC: Psychological sequelae to severe body insult. MILMED. 1984. Badenhorst JCC: A multidisciplinary approach to the rehabilitation of the amputee. Rehabilitation in South Africa. 1986.
©1990 S. Karger AG. Basel 0033-3190/90/0534-0156S2.75/0
Psychotherapeutic Approach to the Management of the Severely Injured Patient ./. C. C. Badenhorsl Synnvside. South Africa
Introduction Humpty Dumpty sat on a wall Humpty Dumpty had a great fall All the king's horses and all the king's men couldn't put Humpty together again Mother Goose
Humpty Dumpty one of the most familiar nursery rhymes from our youth symbolizes the dilemma of injury appropriately. Injury to the body is not merely physical it is also psychological and social. Injury, especially severe injury, is existential. Severe injury drastically changes the dimensions and timespan of our existence. Previous pleasurable activities or sensations disappear, our once faithful companion becomes a stranger, a serious enemy preoccupied by an indifferent
force. During severe injury the body ceases to be a medium, it becomes an object. In most instances the treatment of a se verely injured patient is directed on an ex clusively physical level, very little attention is given to the psychosocial factors influenc ing the severely injured individual. Life sav ing and extension of life has been the major aim of focus in many treatment settings and remains a primary attitude amongst many medical and related personnel. Whilst an awareness of the need for the promotion and enrichment of life as an albeit important focus has been recognized by some health caregivers, the visualization and acceptance of the severely injured individual, a human being, and entity within an environment, from a qualitative, rather than a quantitative
Downloaded by: Monash University 130.194.20.173 - 9/25/2017 4:16:51 PM
Abstract. In this modern day and age. severe injury has become the dire consequence of an ever-increasing number of motor vehicle, industrial and mining accidents as well as sport-, military- and terror-related incidents that occur. The management of the severely injured patient is mostly directed on an exclusively physical level. Often, very little attention is afforded to the psychosocial factors that prevail following physical trauma. The author describes and discusses how holistic multidisciplinary intervention within the medical milieu facilitates a more psychotherapeutic approach to the management of severely injured patients. This approach facilitates physical recovery and increaeses the rate of readjustment and reintegration into society, of those who have sustained severe injury.
Psychotherapeutic Approach
Severity of Injury Medically speaking any patient with mul tiple injury affecting various bodily systems or any patient in a life-threatening position could be seen as being severely injured. This definition does not hold when looking at injury from a psychological point of view. Whilst the implications of severe disabling conditions such as head injury or paralysis may be recognized, the importance of less dramatic injury is mostly overlooked. Whilst working with injured patients we should re member that patients experience bodily trauma differently, they assign multiple meanings to injury. A patient’s experience and the meaning he assigns to injury is highly influenced by personality factors, in terpersonal factors, the doctor-patient rela tionship. the hospital milieu, the context in which the injury was sustained, previous in jury as well as unconscious factors - appre hension about pain, loss of bodily form and function, stigma, dependency and the like. Since these psychological factors are of utmost importance with regard to outcome, specific attention needs therefore to be given to what may be seen as one of the major rea sons for unfavorable recovery despite excel lent medical surgical intervention. Psychological intervention is applicable to basically all cases of injury where a pa tient’s basic self-esteem, body image or psy chological balance is threatened. The sever ity of injury is a far cry from the amount of systems concerned or the threat to life which the injury imposes. The severity of injury is
the aforementioned and more. Severity of injury is not merely physical, it is also psy chological. Severity of injury is not only con cerned with life and its maintenance it is concerned with livelihood, quality not quan tity. As such it calls for some specific aware ness amongst members of the treatment team. Severity of injury is manifest in what we cannot see, it is contained within the patient’s total experience.
Biopsychosocial Approach The successful management of a patient with severe injury is highly dependent on the combined efforts of a closely knit team of ‘superspecialists’ from the disciplines of medicine, occupational therapy, physiotherpy, orthotics and prosthetics, social work and psychology, whilst the importance of the medical and paramedical personnel is well recognized the inclusion of the psychologist may be frowned upon or even dismissed as an unfounded ‘luxury’ by outsiders or the uninformed. In recent years medical specialists have however gradually discarded their prior ex clusive biological approach toward injury and begun to consider psychological and so cial factors that influence the outsome of treatment. The utilization of psychologists in general hospital and specialist treatment set tings has emerged as a major contributing force in the biopsychosocial approach to the treatment of patients suffering from severe injury. In this holistic approach to the treatment of patients with severe physical injury, psy chological perspective forms an integral part, of a patients response to injury and its treat ment.
Downloaded by: Monash University 130.194.20.173 - 9/25/2017 4:16:51 PM
perspective, looms as vividly as the fragmen tation of Humpty. and the dilemma, of all the king’s horses and all the king’s men.
157
158
Psychological Service within an Orthopedic Department The Medical Psychological Division in the 1 Military Hospital. Pretoria. South Afri ca, delivers a formalized consultation-liaison service in the Department of Orthopedics and Rehabilitation. Psychologists are responsible for the delivery of a consultation-liaison service within the Department of Orthopedics. Psy chologists are integrated with various or thopedic firms. Within each firm the psy chologist participates closely on ward rounds and clinics during all stages of hospitaliza tion. rehabilitation and follow-up. Whilst the bulk of psychological information is gath ered through individual interviews, group discussions and social reports, psychometric evaluations may also be performed in an
attempt to get a better estimate of a patient’s sick role behavior and readjustment ability. Findings are evaluated and integrated with applicable verbal or printed feedback to members of the multidisciplinary team en semble or individually. Psychological intervention is character ized by its investment in upper limb, lower limb, spinal and chronic pain patients. The inclusion of psychologists in what was pre viously an exclusively medical domain has assisted in the establishment of a more com prehensive and integrated patient care sys tem in this major military hospital on the African Continent.
Psychological Intervention Acute phase (passive rehabilitation) psy chological intervention is aimed at: (a) pre vention of the exacerbation of emotional tur moil associated with the traumatic event (crisis intervention), (b) defusing of negative emotions in family members and emotional support and positive attitude formation of these individuals with regard to their nextof-kin’s physical loss and rehabilitation, (c) basic psychological care of the patient in the adjustment to the hospital milieu and injury-related gadgetry. (d) revision of a pa tient’s unrealistic ideas regarding physical injury and its consequences, (e) consulta tion-liaison support for all members of the multidisciplinary team by furnishing of info related to patient treatment (personality, reaction, psychodynamics, rehabilitation aims), (f) motivation of the patient towards the setting of attainable goals with regard to return to unit or transfer for active rehabili tation. and (g) monitoring psychological ad justment during treatment.
Downloaded by: Monash University 130.194.20.173 - 9/25/2017 4:16:51 PM
Whilst the medical specialist/s may be viewed as the coordinating agent regarding all the physical aspects of a severely injured patient's treatment, the psychologist may be viewed as the coordinating agent regarding all the psychological aspects of a severely injured patient’s management. The psychologist is in the best position to provide various members of the multidisci plinary treatment team with appropriate in formation on psychological variables such as a patient’s reaction to injury, experience of pain, response to treatment and numerous other specific factors. The role of the psy chologist has developed from that of an eval uator only, to the rendering of a comprehen sive service entailing assessment, therapy, liaison and research throughout the entire spectrum of a severely injured patient's preand postoperative management.
Badenhorst
Psychotherapeutic Approach
After Care (a) The patient has to be assisted in ex ploring and utilizing all the resources which are available to maximize his personal read
justment and reintegration into the main stream of society, (b) The patient has to be supported in the amelioration of those as pects that prove to be problematic in the long run. (c) Follow-up of patients encoun tering at reintegration into society problems on various levels of personal functioning is an after care facility provided by the psy chologists in orthopedics.
Conclusion Since the ‘severely injured patient' is con fronted with a significant number of losses other than the mere loss of health, a psycho logical approach to the management of the severely injured patient becomes an impor tant function with regard to the prevention of detrimental attitude formation, extreme psychopathology and various other treat ment-related problems. During hospitalization the ‘severely in jured patient' has to learn to cope with a variety of changed dimensions. The patient has to: (a) come to terms with the trauma which has caused hospitalization, (b) accept the change in his prior to injury status (de pendency, immobility, limitations, body image change), (c) learn to cope w'ith the hos pital gadgetrv. instrumentation, surgical pro cedures. prolonged bed rest, medication, splints, sepsis and many other factors, (d) maintain interpersonal relationships. (e) set new goals w'hich are realistic and in relation to limitations, (f) develop positive attitudes regarding the body, self and envi ronment. and (g) prepare for the goals of rehabilitation and return to society. Severe injury constitutes a major change in both body and life experience. It creates new' dimensions and necessitates the under
Downloaded by: Monash University 130.194.20.173 - 9/25/2017 4:16:51 PM
Active rehabilitation psychological inter vention is aimed at the following, (a) Provi sion of psychoeducation input to all newly transferred patients via a psychoeducative orientation program. This program is aimed at: first, assisting patients to formalize their own rehabilitation needs, second, to bring patients to a point where they have a clear knowledge and understanding about all the activities and goals of the different disci plines involved in rehabilitation, and third, to guide each patient towards having realis tic expectations with regard to his rehabilita tion and to indicate how these expectations could be fulfilled through an individualized rehabilitation program, (b) All patients arc interviewed and evaluated psychometrically. (c) Rehabilitation needs are established and goals arc set in accordance with each pa tient's physical limitations, vocational abili ties, personality characteristics and other relevant information, (d) A profile of each patient’s rehabilitation goals and relevant personal, psychological, vocational, social information is presented during weekly mul tidisciplinary treatment team clinics, where applicable info is included in the manage ment of individual programs of patients, (e) Motivation, acceptance of disability, preparation for return to society and evalua tion of problem behavior limiting effective patient management is the focus of individu alized psychological interventions, (f) Re search and development projects in a multi disciplinary fashion are engaged in.
159
Badenhorst
160
standing of new meaning for the patient and each team member alike. Quantity is to be replaced by quality. Being-in-this-world is rekindled to renew from within in each case, be it patient, or team member. In this way, the psychological approach to the manage ment of the severely injured patient ensures that an optimal level of mental health is maintained in society as a whole. That ideally speaking: All the king's horses and all the king's men
can put Humpty together again.
Badenhorst JCC: Medical psychological intervention in a general hospital. MILMED. 1986. Badenhorst JCC: Psychological intervention in upper limb orthopedic rehabilitation. 4th Psychological Association of South Africa Congress. 1986. Badenhorst JCC, Ahp KLEU: A rehabilitation orien tation programme for patients with orthopedic injury. 4th Psychological Association of South Africa Congress. 1986. Badenhorst JCC: The psychological rehabilitation of the severely injured patient. MILMED. 1988. Badenhorst JCC: Psigologiese Pcrspektief t.o.v. Kroriese Lae Rugpyn. Psychological Association of South Africa Congress. 1988.
References
Dr. J.C.C. Badenhorst PO Box 29188 Sunnysidc 0132 (South Africa)
Downloaded by: Monash University 130.194.20.173 - 9/25/2017 4:16:51 PM
Badenhorst JCC: A Psychological Study of Amputees; thesis University of Pretoria. 1984. Badenhorst JCC: Psychological sequelae to severe body insult. MILMED. 1984. Badenhorst JCC: A multidisciplinary approach to the rehabilitation of the amputee. Rehabilitation in South Africa. 1986.
![[The severely injured patient].](/assets/img/hold.png)
