Content area
Purpose
– The purpose of this paper is to describe and discuss interventions of stabilisation of emotions and behaviour in adults with post-traumatic stress disorder (PTSD). This topic is understudied in persons with intellectual disability.
Design/methodology/approach– The aim of this study was to investigate interventions of stabilisation in persons with more severe intellectual disability; i.e. persons with moderate or severe intellectual disabilities. Five patients in a specialised psychiatric inpatient unit for patients with intellectual disabilities were included. Information about treatment of the patients was collected through case files, observations, and interviews. The authors of this paper followed a training programme for trauma therapists in addition to the inpatient treatment of the five patients.
Findings– Six main areas of stabilisation of emotions and behaviour were identified: validation, anxiety relief, treatment of depressed mood, increased mastering of daily activities, protection against anxiety triggers, and facilitated staff communication. Protection from anxiety triggers seems to be a core element of milieu therapy interventions. Interventions for neurotypical PTSD patients, such as exposure therapy may be contraindicated for patients with more severe intellectual disabilities.
Originality/value– Research on interventions of stabilisation towards adults with more severe intellectual disabilities is still in its infancy. The case reports may help milieu therapists to facilitate interventions towards patients with moderate or severe intellectual disabilities.
Introduction
Post-traumatic stress disorder (PTSD) is currently defined as exposure to a traumatic event in which both of the following have been present: the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and the person's response involved intense fear, helplessness, or horror. PTSD in persons with intellectual disabilities has gained increased interest within the last decade, though publications on this topic are still few (Mevissen and de Jongh, 2010). It is suggested that people with intellectual disabilities are more likely to develop PTSD than persons in the general population due to problems with information processing (Mitchell et al., 2005). Few publications explore what kind of events may cause PTSD, especially in persons with more severe intellectual disabilities. It has been reported that adverse life events such as residential replacement (moving from the parents or being moved from one residence to the next), and consented adult sexual experiences have lead to traumatic reactions in adults with intellectual disabilities (Tomasulo and Razza, 2007). However, the relationship between adverse life events and traumatic reactions remains unclear as long as existing study methodologies still are at descriptive levels (Wigham et al., 2011). It is suggested that individual characteristics are more important than characteristics of the traumatic event (Tomasulo and Razza, 2007). Hence, a broad range of negative events may cause PTSD. Furthermore, the behavioural symptoms such as disorganised or agitated behaviour, self-injurious behaviour, signs of distress, sleep-problems, social withdrawal, or a general decline in functioning, may easily be confused with a psychotic disorder or bipolar disorder.
Persons with intellectual disabilities, who are exposed to traumatic events especially during childhood, may develop persistent dysfunctional affect regulation due to interaction effects (Tomasulo and Razza, 2007). Persistent dysfunctional affect regulation may manifest as challenging behaviour, which may include head-banging, crying, self-mutilation, aggression towards people or objects, or persistent unrest. Challenging behaviour may lead to the implementation of behaviour modification such as limit setting or physical restraints. These interventions, although occasionally necessary to avoid self-harm or assault to others, may suppress the traumatised persons need to be in control of the surroundings. Being able to have control over every-day life, is found to be vital for traumatised persons in order to feel safe (Davidson et al., 2005).
There are a number of different treatment methods for PTSD. Sufficient evidence does not yet exist to support or refute the effectiveness of combined psychological therapy and pharmacotherapy compared to either of these interventions individually (Hetrick et al., 2010).
The literature on interventions for people with intellectual disabilities and PTSD is still sparse (Mevissen and de Jongh, 2010). Case reports present positive outcomes in clients with mild intellectual disabilities using modified interventions developed for neurotypical clients, such as exposure therapy in a safe situation while accompanied by a therapist (Fernando and Medlicott, 2009; Lemmon and Mizes, 2002); psychotherapy (Cook et al., 1993); group therapy (Mitchell et al., 2005; Peckham et al., 2007; Razza and Tomasulo, 2005); EMDR (Rodenburg et al., 2009) and cognitive-behavioural approaches (Kroese and Thomas, 2006; Turk et al., 2005; Willner, 2004).
There is a lack of published reports on milieu therapy for people with intellectual disabilities and traumatic experiences. To our knowledge, the articles published describe patients with mild or moderate intellectual disabilities (Lemmon and Mizes, 2002; Mitchell et al., 2005; Peckham et al., 2007; Razza and Tomasulo, 2005). Reports of successful treatment for people with more severe intellectual disabilities, who have experienced trauma, are nearly non-existent (Turk et al., 2005).
Treatment of PTSD will usually follow a three-step procedure, which includes the following: stabilisation, processing of traumatic memories (usually through exposure therapy), and rehabilitation (
Stabilisation is found to be a vital component for traumatised people. The term stabilisation is used to describe the processes that leads to improved affect regulation, stress management, management of symptoms such as flashbacks and nightmares, and normalisation of daily living by regaining self-care and work or other occupation. The practical side of stabilisation will include enabling the patient improve basic daily skills related to activities such as preparing a meal, preparing for sleep, and executing personal hygiene. Stabilisation also includes finding meaningful tasks in daily life that balance activity and rest. Psycho-education adapted to the patient's cognitive level may help the client understand that what happened was not his or her fault. Stabilisation after trauma may enable the patient to feel safe. Distraction is recommended during situations that involve physiological arousal or anxiety. Persons in the general population may learn distraction manoeuvres from a therapist and may use them on their own after rehearsing. In our experience, this will not work the same way for people with intellectual disabilities; these patients will need a professional caregiver who is trained in trauma-focused stabilisation to accompany them.
For patients in the general population, guidelines for assessment and treatment of PTSD are available, for example the English NICE guidelines for management of PTSD (National Institute for Health and Care Exellence, 2005). In Norway, there are no national guidelines. However, the public regional centres for violence and traumatic stress, provide updated information about assessment and treatment (
In a previous article, we presented a case study including the same five patients as in this paper (Bakken et al., 2014). PTSD was identified in the patients by using DM-ID criteria; Diagnostic Manual – Intellectual Disabilities. A Textbook of Diagnosis of Mental Disorders in Persons with Intellectual Disabilities (Fletcher et al., 2007). Additionally, the Lancaster and Northgate Trauma Scales (Wigham et al., 2011), was used to systematise information from case files and interviews with key informants: family, milieu therapists, and caregivers in community settings, and observations through inpatient admission. The topic of the present paper is interventions, mainly stabilisation of emotions. The vignettes in this paper for the most part encompass interventions (for more information about the patients, please see Bakken et al., 2014).
As this paper is to discuss stabilisation interventions, we wanted to answer the following questions:
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1. What may be adequate stabilisation techniques conducted by milieu therapists?
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2. How do interventions for patients in this sample differ from interventions for patients in the general population?
Patients and setting
The present study is a result of a training programme for health professionals working in the psychiatric services in Norway, which is called Safer Trauma Therapists (
The five patients are from about 25 to about 40 year of age, and have moderate or severe intellectual disabilities (see Bakken et al., 2014, for more information). Due to confidentiality reasons, more accurate background information is not provided, as the actual inpatient unit is small, and it is the only such unit in the Oslo area.
As this paper's topic is stabilisation during inpatient stay, milieu therapists play the main role in the therapeutic activities. Milieu therapists in the study setting include nurse specialists, nurses, intellectual disability nurses, pedagogues, and nurse assistants. The patients for the most part suffer from severe and complex conditions. Hence, the milieu therapy encompasses a compensatory care system especially emphasising task relief and non-offensive staff-patient interaction. Validation and anxiety relief are core elements of the milieu therapy.
Procedure
Information about the patient's interventions of stabilisation were collected mainly from case files. Each of the five participating patients are individually known to at least one of the authors conducting this study. The scheme for the case reports includes background, symptom presentation, diagnostic assessment, treatment, stabilisation, and outcome.
Ethical considerations
Permission to conduct the study was given by the following authorities: the director of the specialised psychiatric department, and the hospitals Privacy Protection Supervisor. Close relatives of the patients gave their informed consent for participation. Due to confidentiality reasons, background information of the patients used in this paper may be slightly modified.
Case reports
Patient A, a woman aged about 30 with moderate intellectual disabilities, grew up with her mother and two siblings. Symptoms of mental illness were first observed in her teens. She was admitted to inpatient psychiatric treatment a number of times due to severe aggressive behaviour, and did not re-enter school. She lived with her mother until the age of 25. She was diagnosed with PTSD during inpatient stay at a specialised psychiatric inpatient unit. Thorough assessment revealed several incidents of sexual abuse. She was earlier suspected to suffer from a psychotic depression. Main symptoms included depressive mood, frequent anxiety attacks, and flashbacks – especially linked to being in buildings with large rooms. She also had very low body mass index (BMI).
Treatment: patient A was medicated in accordance with her depressed mood. Exposure therapy was considered contraindicated, as she was hardly contactable; and out of touch with the staff, during inpatient stay. While she was hospitalised, a plan for coordinated community services was established, including medication, and stabilisation interventions. An ambulatory community team cooperated with the specialised psychiatric unit through admission, and continued thereafter. The patient was offered supportive psychotherapy, but refused. Interventions aimed at anxiety relief and preventing continuous high arousal were implemented. This entailed 1:1 staffing during the day from 10 a.m. until 9 p.m. Strategies related to coping with everyday activities included preparing meals and buying food. Shopping was regarded as a possible trigger before discharge, but shopping worked out nicely; it had been a favourite activity when patient A was younger. Self-care, sleep monitoring, and dietary regulation were suggested as the main counselling topics for the community team. It was further important to keep patient A away from places that could trigger flashbacks, such as municipality buildings and sport venues, and secluded psychiatric units. These places resembled places where sexual assaults had taken place. Patient A had previously several stays in secluded psychiatric wards, which probably had re-traumatised her.
Outcome: patient A slightly gained her self-care skills along with increased body weight. A few months after discharge she managed to make her own meals with minimum guidance. After one year her BMI was more or less stable at 20. The depressive symptoms and anxiety attacks occurred infrequently.
Patient B, a woman of about 25 with moderate intellectual disabilities, grew up with her mother and three siblings. She managed to work during her late teens, which was adjusted to her cognitive level. She did not work after a series of negative events, including severe bullying at school and several incidents of sexual abuse by a “friend”.
She had previously been diagnosed with a personality disorder. Frequent anxiety reactions to trigger situations – especially in demanding situations, information about threatening situations, frequent nightmares and low mood, resulted in a diagnosis of PTSD. These symptoms developed after sexual abuse. Patient B displayed anxiety symptoms especially related to demands and directives.
Treatment: the previous diagnosis of personality disorder resulted in a system in her residence including a strong structure and demands for solving tasks. A gradual decline of quality of life was observed. During specialised inpatient treatment, medication was terminated. Patient B was given supportive psychotherapeutic sessions twice a week. Communication and relationships with her caregivers were major issues. Validation was the core element of stabilisation through the concept of “being” and that being is good enough. Patient B was encouraged to participate in activities on a voluntary basis. Initially patient B talked mostly about somatic problems. Over time, she talked about her fear of death, fear of being alone, and of her frequent nightmares. Stabilisation aimed at improving her regulation of emotions through mastering of activities of daily living. Through daily communication with the milieu therapists, acceptance of difficult feelings of shame and guilt were processed. Strategies of anxiety relief included talking to the staff member on the nightshift if she woke up after a nightmare. Psycho-education using pictures and pictogrammes especially facilitated for people with intellectual disabilities was provided, emphasising common reactions to sexual abuse, what anxiety is and what it means to be accepted.
Outcome: patient B's level of negative thoughts decreased. The physical and mental slowness observed was reduced and she joined in several activities. The patient's desire for self-care and her fear of expectations from other people were reduced or disappeared during inpatient admittance.
Patient C, an about 35-year-old man with severe intellectual disabilities, was referred to an institution for “mentally retarded” people when he was ten years old, and he was transferred to the adult section at the age of 12 because of severe attacks on peers. Temper tantrums and violent behaviour were reported from the age of ten. Problematic behaviour was reported throughout the years. He was earlier suspected to suffer from psychosis as he manifested severe fall in global functioning. However, older case files combined with observation of severe unrest, anxiety reactions, and identification of trigger situations (being asked to go to bed, being alone in dark rooms, and some particular sounds) established a diagnosis of PTSD.
Treatment: in addition to medication, treatment encompassed milieu therapy; predominantly stabilising interventions. Observations during inpatient admission in cooperation with staff in patient C's residential home aimed at identifying triggers and developing a set of protective interventions. The protocol established that no staff member should verbally suggest patient C should rest or go to bed, etc. Instead, he was lead by the hand and the staff member gave him a special pillow, which made him lie down. Furthermore, patient C's intervention plan also stated that he should not be alone in rooms with low light. A 1:1 staffing during day- and evening shift was established. It was noticed in patient C's residential home that he was calmed down by tactile stimulation, especially by being scratched on his back. This intervention was systematised, which included back-scratching as a part of his daily plan both morning and night. It was observed that patient C needed a break during his afternoon walk. Taking frequent breaks during activities of daily living tasks, such as meals and walks, reduced episodes of anxiety.
Outcome: after hospital discharge, the frequency of anxiety attacks decreased, but did not totally disappear. The diagnosis of PTSD was quite useful for the staff members in patient C's residential home, because they learned to recognise flashback triggers.
Patient D, a man aged about 40 with moderate – severe intellectual disabilities, was raised by foster parents. He developed daily periods of strong restlessness around 18 years of age. At age 20 he started to eat in secret and to collect food remains. He began collecting nappies and ladies’ underwear. By the age of 23 he was referred to adult habilitation services because of violent aggression towards other people. Patient D was diagnosed with bipolar disorder before arriving at the specialised psychiatric unit. Then D's persistent physiological arousal and frequent high levels of anxiety was linked to insufficient care, abuse, living with foster parents, and living in a childcare institution, where he was sexually abused. A diagnosis of PTSD was concluded.
Treatment: the patient's hoarding food was interpreted as a way of expressing that he needed to care for his own needs. Likewise, self-mutilation was linked to emotional pain being eased by physical pain. The aim of the treatment plan was to make the patient feel safe and was provided through milieu therapy. The staff response was emotional neutrality (non-affective response to the patients outbursts or self-mutilation) to help regulate the patient's emotions. After patient D was discharged, counselling was provided residence staff every month for 1.5 years. The patient moved to a more suitable residence. Daily aggressive behaviour required 3:1 staffing. The patient was medicated for bipolar disorder. Patient D had experienced constant staff turnover and had lived in many places, which most likely aggravated his fundamental insecurity. The aim of stabilisation was to regulate his emotions to provide an increased sense of security. This was conducted through validation of his long-standing problems being a part of devastating experiences, rather than a part of his personality. Predictability through plans for daily activities was implemented. Establishing a therapeutic relationship through staff interaction, which was impacted by low expressed emotion (EE), was emphasised: staff members being warm, supportive, and calm. In addition, corrections were emphasised by avoidance of pressure and control, in conjunction with positively structured task solving. Mastering self-care and daily activities were handled in cooperation between the patient and staff members.
Outcome: after discharge, patient D soon experienced a decline in global functioning. However, after approximately 1.5 years of cooperation between the special unit and the community caregivers, the patient revealed significantly less challenging behaviour. The residential staff members gained a new understanding about the patient's traumatic experiences, which reinforced the need for continuously stabilisation.
Patient E, a woman in her 40's with moderate intellectual disabilities, had a history of challenging behaviour spanning two decades. After several stays in acute psychiatric wards, she was referred to a specialised psychiatric inpatient unit due to suspected psychotic symptoms and threatening behaviour. She was diagnosed with PTSD during inpatient stay. It was revealed that she had been sexually abused by a former caregiver. This story of abuse was previously interpreted as fantasy or psychotic and paranoid ideas. Previously, the patient's constant retelling of the story was considered inappropriate.
Treatment: various treatments aimed to stabilise patient E's condition and behaviour. She was allowed to talk freely about her traumatic experience. It was emphasised that she herself was in control of how much information she wanted to reveal, and to whom. Patient E received supportive psychotherapy, which was adapted to her level of functioning, and preferred modes of communication, mostly focusing on grounding and stabilising. The patient revealed gradually more information about the abuse. The antipsychotic medication was reduced very slowly due to the many years of use. Ensuring the patient felt safe and in control of her own situation was the key goal. Validation included acceptance of patient E's story as true, in addition to containing her anger and fears. The hospital staff used basic grounding techniques when the patient was disoriented; this reoriented the patient to the current situation. Reassurances from the staff included reassuring the patient that she was safe, that she was being taken care of, and that no one would harm her. The staff used an approach consisting of expressing empathy for her difficulties while focusing on the traumatic experience as being completed, as well as attesting to the patient's safety in the current situation. Patient E was reassured that her abuser would not come to the ward, that he did not know she was there, and that the staff would never let him in. There was a constant focus on the fact that the patient was in control of the information concerning the abuse.
Outcome: after one year of treatment, the patient expressed feeling safer, as well as an improvement in the feeling of self. There were periods with little or no challenging behaviour; both severity and frequency was reduced. The stabilisation led to the patient being able to seek help for somatic illness, which her challenging behaviour previously obstructed her from accessing. Her medication was reduced. Her family relations have improved.
Discussion
The five patients were, for the first time, assessed for a possible diagnosis of PTSD when they were admitted for inpatient treatment in a specialised unit for people with intellectual disabilities. In this department, both the milieu therapists and individual therapists (psychologists, psychiatrists, and others) were trained in both the assessment and treatment of trauma in patients with intellectual disabilities (Bakken et al., 2014). Inpatient stay allows more thorough observation, especially regarding identification of triggers, but also testing and implementing interventions in safe settings with skilled therapists (Bakken and Martinsen, 2013).
These patients had been carrying their traumatic experiences for many years, even decades, before the trauma was identified and a new understanding directed treatment and follow-up procedures. Hence, we believe that awareness and knowledge about PTSD is necessary in psychiatric services for people with intellectual disabilities. Beside the core symptoms, the five patients had symptoms that also are commonly seen in persons with PTSD in the general population: depressed mood, aggression, and self-injury, and inability to conduct daily tasks that were performed prior to the trauma; the latter revealed through older case files and interviews with close relatives.
Stabilisation – the core of specific trauma-focused treatment
Stabilisation of emotion regulation and behaviour was the core treatment aim for the five patients. Each patient received a broad range of different interventions, including medication, and psychosocial treatment. There were six main areas of stabilisation: validation, anxiety relief, treatment of depressed mood, increased mastering of daily activities, protective interventions against triggers, and, finally, facilitated staff communication. Examples of staff stabilisation acts are found in Table I. Specialised psychiatric services, including both inpatient and outpatient services, involved a long period of time between one and three years for the five patients. Cooperation between specialised psychiatric services and community services continued for an extended period after discharge from inpatient treatment; between six months and two years.
Validation refers to a process in the patient's environment that affirms the patient's individuality through the treatment program (Gunderson, 1983). Validation means to apply respect to the patient's mental illness. A key element of validation is that the staff members will attribute patient outbursts and fatigue to the mental condition. This is especially important in the case of a patient with PTSD and concurrent intellectual disabilities, as persistent dysfunctional affect regulation manifested as aberrant behaviour may be overlooked as a symptom of mental illness (Jopp and Keys, 2001). Validation calls for each and every staff member to be empathic, sensitive, and tolerant. For patients with PTSD, less focus on directives and demands are favourable, and staff may help the patient through task solving when the patient signals reluctance (Bakken et al., 2004). Minor signs of aberrant behaviour may be overseen. Validation was the most general intervention of stabilisation for the patients included in this study.
Interventions aimed at anxiety relief were possible to implement once anxiety was recognised. For three of the patients, their atypical anxiety symptoms had been mistaken for challenging behaviour, not a mental health problem. Interventions specifically aimed at anxiety relief comprised (at least) 1:1 staffing during periods of massive patient anxiety, and grounding techniques were modified and conducted while staff members were present. The most commonly used technique was to stomp the floor. However, none of the participants managed these techniques independently. Two of the patients profited from use of a heavy quilt filled with small balls during their anxiety attacks. Medication was administered when needed. Clinical experience underpins training to handle anxiety attacks during periods with less prominent symptoms. Breathing techniques, also referred to as “grounding”, may improve affect regulation. These techniques include standing up so the patient feels he or she is “grounded” to the floor, staring at a fixed point, or holding a certain object. Persons with intellectual disabilities may use such techniques. However, clinical experience indicates that it is necessary that a therapist accompany the client for a long time before the client will benefit from these techniques. Patients with more severe intellectual disabilities may have problems with recognizing the signs of high physiological arousal; therefore, they may not be able to use the grounding techniques on their own.
Interventions of depressed mood were mainly resolved by using newer generation antidepressants and providing validation through therapeutic communication (see below). In two patients who had experienced frequent depression, a low-maintenance dose of antidepressants was given.
The mastering of daily activities was slowly implemented. For example, patient B started with one task. Initially patient B sought out staff members to care for her much like a toddler. Patient B became quite upset when the staff encouraged her to solve self-care tasks such as washing and brushing her teeth. The mastering of getting out of bed in the morning without getting into conflict with staff members was chosen as the first task. Conflict was, for the most part avoided by staff through the use of validation. The staff mentioned that they wanted to spend the day with patient B, but she had to get out of bed. She was given a drink and a snack while she was still in bed for motivational purposes. For each step, emphasis on mastering an activity was balanced by the need for acceptance and validation.
Triggers that elicit flashbacks, panic attacks, or temper tantrums constituted a wide range of objects and situations. Triggers included the following: being in a large room or building, following directives, and demands related to task solving (being asked to go to bed or to rest), being alone (in rooms with low light), being with unknown people, or setting a limit for the patient, being provided care by a male caregiver. For example, the triggers for patient E included caregivers standing over her when the she was sitting or lying down, and getting help from a male caregiver while conducting personal hygiene tasks. Patient E also had an increased startle response, which meant that any abrupt change or sudden sharp or loud noises could work as a trigger during vulnerable situations. Identification of these triggers made it possible to help the patients avoid situations that might provoke trauma recollection. Avoiding triggers made it possible for these patients to maintain an attachment to reality, which counteracted distress, anxiety, and flashbacks. For example, for patient C, all staff members avoided asking the patient to rest or go to bed even when they saw that he was quite tired; staff indicated that he could lay down on his couch or bed by using a specific red pillow as a marker. This intervention was based on observations that patient C used this red pillow when he was resting and then daily panic attacks decreased significantly.
Effective staff communication may not be a specific intervention, but it is found to be a key element related to symptom relief in people with intellectual disabilities and severe mental illness (Bakken et al., 2008). The staff members caring for the patients in this study aimed at communication with a low level of EE; that is communicating with a low level of hostility, criticism, and emotional over-involvement (Smeby, 1998). Low EE is found to be an effective communication style when the client is severely mentally ill (Marom et al., 2005). Two patients in this study demonstrated high levels of anxiety when they were given directives. Directives may be perceived as criticism (stressful) by the patient, even when the staff attempted to help the patient to master the task at hand. In addition, limit setting may be perceived the same way by the patient. Setting limits should be used only when absolutely necessary.
Augumentative devices were needed in the patient-staff communication. The actual inpatient unit uses a wide range of augmentative devices as the unit admits patients with bordeline, mild, moderate, severe, and profound intellectual disabilities. A specialised communication system including pictures of staff members, a book called “my story”, and pictures/pictogrammes, is in everyday use. For sexually abused patients, a special augmentative system including pictures and drawings is used.
Will interventions for this group differ from interventions towards neurotypical clients?
What distinguishes interventions towards people with intellectual disabilities compared with interventions suitable for neurotypical clients? Research concerning PTSD in persons with intellectual disabilities is still sparse and most are case presentations. Interventions presented in published case reports mostly describe modified interventions used for patients in the general population. Regarding stabilisation, the patients described in this report illustrate how interventions developed for neurotypical patients cannot necessarily be adapted for patients with more than mild intellectual disabilities. For example, stabilisation and insight therapy or exposure therapy conducted in parallel may be contraindicated. Exposure therapy may be completely contraindicated. For example, after more than 20 years patient C still reacts with intense fear when someone nicely asks him if he would like a nap. Such a reaction indicates that exposure therapy would not provide a good outcome for the patient. Patient C does not have the cognitive capacity to understand that the institutions for people with intellectual disabilities are shut down, and that strapping him to his bed will never occur again.
Hence, avoiding triggers may be adequate for clients with more severe intellectual disabilities, or additional mental illness, which may aggravate initial cognitive impairment. As long as the traumatic event(s) remain unintegrated, it may be necessary to help the client from re-experiencing these situations. In order to prevent re-experiencing these situations, possible triggers must be identified and then avoided. For example, patient A had been re-traumatised when she was admitted to inpatient psychiatric secluded units, which had happened a number of times. It was observed that her fear was intense, but until PTSD was identified, persistent physiological arousal and anxiety attacks were not connected to anything specific. After her triggers were identified, most of her treatment was given as an outpatient, and she was taught how to avoid places or situations that would trigger flashbacks.
Stabilisation interventions will, for the most part, be provided for this group of patients by professional caregivers, both in community and familial settings. The emotional climate in the patient's residence is of significance. People with intellectual disabilities and PTSD are vulnerable and, therefore, are sensitive to directives and demands. An emotional climate characterised by a low level of anger and aggression, and staff control, has been found to be favourable for psychotic patients in psychiatric ward (Friis, 1986), who are also vulnerable. The results from a previous study by Bakken et al. (2008) indicate that the findings related to research on emotional climate are relevant for patients with severely impaired language skills and intellectual disability. On a practical level, it is important that the milieu therapists are able to identify and respond adequately when the patient presents with anxiety symptoms or aggression.
Further research
Controlled studies on interventions for patients in the general population may be a suitable starting point for effective studies on such interventions and should be adapted to persons with intellectual disabilities. Another interesting topic is investigation of dissociation, which is often explained as a mental state of a lack of integration of memories of traumatic incidents (Anstorp et al., 2010). Little or nothing is known about dissociation in persons with intellectual disabilities. Dissociation means that the person will appear as “not contactable”, a state that easily may be misinterpreted as psychosis.
Fixed Table I
Table IInterventions of stabilisation in milieu therapy; examples
Fixed Table I
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