Journal of the American Academy of Physician Assistants:
Harold Kudler is associate director of the VISN 6 Mental Illness Research, Education, and Clinical Center at the Durham (N.C.) Veterans Affairs Medical Center, and an associate professor in the Department of Psychiatry and Behavioral Sciences at Duke University in Durham, N.C. The author discloses that this work was supported in part by a grant from the Department of Veterans Affairs (VA) Office of Mental Health Services to the VA Mid-Atlantic Health Care Mental Illness Research, Education, and Clinical Center.
How does the nation train and retain a high-capacity, highly experienced professional work force to support the deployment-related health needs of service members, veterans, and their families?
The answer lies in rethinking an important dimension of modern medicine. Definitions and treatments of deployment health problems such as posttraumatic stress disorder (PTSD) are progressively more research-based and less patient-centered. In evidence-based psychotherapies, the patient's problem is defined in terms of mistaken cognitions and inappropriate behaviors; the answer is “in the manual” and less consideration is given to the patient's individuality or the clinician's personal responses.
Rifts and tensions in the therapeutic relationship were once generally acknowledged as potentially important indicators of factors that neither the physical examination nor diagnostic tests could reveal. When Francis Peabody pointed out that “the secret of the care of the patient is in caring for the patient,” he wasn't just talking about compassion; he was reinforcing his earlier statement that ignoring the personal and interpersonal aspects inherent in medical practice was simply “unscientific.”1
I would argue that our modern tendency to pathologize our patients' responses to trauma has been paralleled by a growing tendency to pathologize our own clinical responses to those patients. This reflects a failure to be truly scientific.
The VA has succeeded in an historic roll-out of evidence-based psychotherapies for PTSD and can demonstrate that trained clinicians deliver these treatments under expert supervision and with strong fidelity to their respective manuals.2 There is no doubt about the efficacy of these therapies, but there is concern about burnout among VA clinicians working with trauma survivors.3 In response, since 2007, the VA Mid-Atlantic Health Care Network's Mental Illness, Research, Education, and Clinical Center for deployment mental health has conducted a novel group supervision program via a monthly national teleconference for VA clinicians working with trauma survivors. The program's focus has been on clinical situations in which the therapist experiences significant stress in working with a particular patient (that is, “takes the patient and his or her problems home” in some way). More than 500 VA clinicians have participated in the program, with attendance per call ranging from 40 to more than 100 clinicians from across the nation. Many if not most of these clinicians have had VA training in at least one evidence-based psychotherapy.
Our consistent finding in this program is that the clinician's specific concern (for example, “I feel hopeless with this veteran,” “I dread seeing this veteran,” or “I feel protective of this veteran in ways that make it hard to confront her as I know I should”) provides vital and highly specific information about that patient and offers a basis for next steps in the treatment. The program has evolved through practice rather than theory to challenge and reframe the clinician's frequent sense of being overwhelmed, off-balance, and even incompetent. We have found that the “problem” experienced by the therapist is precisely what helps make sense of that veteran's individual trauma narrative. This perspective supports and empowers clinicians and builds morale among a national, interdisciplinary team of colleagues.
Patients may not express important aspects of trauma in words, but rather express these aspects nonverbally through the therapeutic relationship (transference). Similarly, the clinician may have responses that are felt and sometimes acted upon before they can be formulated in words (countertransference). These concepts from psychodynamic theory and practice are complementary to the theories guiding evidence-based psychotherapies. Patient and clinician must also contend with the existential reality of trauma. Clinicians need support for the courage, compassion, and professionalism required to bear with their patients' suffering. This framework stands in stark contradistinction to the current trend of pathologizing both patient and therapist with diagnostic labels (in the clinician's case, a potentially career-ending “diagnosis” of burnout) rather than understanding their reactions as part of a normal and normalizing process of working through trauma.
These considerations are not meant to devalue the concept of burnout or its companion concepts of vicarious traumatization and compassion fatigue. Rather, they are an effort to consolidate more than a century of clinical progress into integrated theory and practice that fully respects and empowers patients and clinicians. If we persist in thinking of trauma as a psychic germ that infects patients (causing PTSD, depression, and other diagnoses) and may spread through them to their clinicians (causing burnout and related disorders), we miss an essential and ancient clinical understanding: In caring for our patients, we, as clinicians, must remain open to their suffering, bear pain alongside them, and make disciplined use of their responses and ours in ways that help patients heal and help us become wiser, more capable, more resilient clinicians.
1. Peabody FW. Landmark article March 19, 1927: the care of the patient. JAMA. 1984;252(6):813–818.
2. Karlin BE, Cross G. From the laboratory to the therapy room: national dissemination and implementation of evidence-based psychotherapies in the U.S. Department of Veterans Affairs Health Care System. Am Psychol. 2014;69(1):19–33.
3. Beder J, Postiglione P, Strolin-Goltzman J.Social work in the Veterans Administration hospital system: impact of the work. Soc Work Health Care. 2012;51(8):661–679.
© 2014 American Academy of Physician Assistants.