May, 2022. In these challenging times, the terms trauma and stress apply very personally to just about all of us. COVID surrounds us, but instead of being vanquished, it changes its costume. Wearing masks gets tiresome and robs us of in-person face time. Getting vaccinated helps, but some of us choose not to seek this protection. Attempting to resume life as usual (shopping, theater, ball games, backyard barbeques) has its own stresses—Who are these people in the grocery aisles? Are they vaccinated or not? What’s the matter with that guy who has his mask below his nose? Or that woman who isn’t wearing a mask and is coughing and sneezing—is she vaccinated? And on and on.
But that’s just COVID. Then there’s the invasion of Ukraine and the tsunami of heartbreaking news headlines, photos, and live coverage of the unthinkable slaughter of innocent lives. How can we understand the callous tyrant who seems to care not at all about his own people? And it’s not just “over there,” since we are now one world, with real-time views of the dead in the streets. Sophisticated weapons of war now exist that can reach our own shores from just about anywhere, never mind the ever-present nuclear threat—especially if in the control of hotheads.
If those 2 mega-stresses aren’t enough, then there’s the polarized political world right here at home, with constructive bipartisan leadership in alarmingly short supply. Given these and many other relentless stresses (inflation, climate change, Roe v Wade, inequities, voter protection, etc.), probably most of us could benefit from a little psychotherapy, either for the first time, or as a tune-up. But there are many of us who, in addition to the stressful drumbeat of today’s world, have risk factors that make us particularly vulnerable to stress, or who have experienced severe personal trauma, on top of the noisy backdrop of the times. Then, an unwelcome symptomatic and disabling disorder may emerge, for which urgent and expert help may be needed. It is particularly welcome, therefore, to include in this issue of the Journal the wisdom of a master clinician, Mardi Horowitz, who eloquently describes a set of stages of psychotherapy for trauma and stress-related disorders, utilizing a framework called “configurational analysis.” He argues that, for a wide range of trauma and stress-related conditions, we now need “cross-theoretical formulations that lead to individualized choices of techniques … as patients go through the stages of recovery.” Horowitz describes 6 stages of psychotherapy—assessment, support, exploration of meaning, re-narration, re-schematization, and termination. The elegant fabric of this approach is reflected in its coherence, sequential logic, flexibility, and person-centered shaping and application of therapeutic technique, sensitively configured to match the needs of the patient in the room and the skills of the therapist. A strong therapeutic alliance, so essential for all effective psychotherapies, is greatly enhanced by the very nature of this approach.
Also in this issue of the Journal, Potik and colleagues provide a guest psychotherapy column describing effective psychotherapeutic work with a patient with posttraumatic stress disorder and fire-setting behavior; Journal of Psychiatric Practice’s psychotherapy columnist, Eric Plakun, provides a brief Afterword. A separate report by Pomerleau and colleagues focuses on cognitive-behavioral therapy augmentation of Intensive Case Management, and an integrated functional rehabilitation treatment model for patients with complicated physical and psychiatric conditions is described by Orme and colleagues. Finally, the theme of psychotherapy is continued in the report by Spruch-Feiner and colleagues on the effects of patient suicide on mental health therapists. Such an event is an almost inevitable tragedy that occurs at some point in the work of the busy clinician, and one that spells trauma and stress for the family and loved ones of the patient who is lost, as well as, not insignificantly, for the treating clinician.
Finally, the ubiquitous nature of trauma and stress affects us all and can destabilize patients with persistent illnesses such as bipolar disorder. In this issue’s Psychopharmacology Column, Preskorn reviews how an understanding of the underlying neurobiology led to the development of a novel compound to reduce agitation in bipolar patients. Preskorn is first author of the scholarly report of this work, just published in the February 22, 2022 issue of JAMA (https://jamanetwork.com/journals/jama/issue/327/8).
JOHN M. OLDHAM, MD