This commentary is a follow-up to “Traumatic Stress Among Children After Surgical Intervention for Congenital Melanocytic Nevi: A Pilot Study” . This study found that Children with CMN Show a high level of post-traumatic stress disorder after surgery and that distress affects their mental functioning. These finding semphasizes the importance of actions for prevention and early treatment of PMTS. It seems that since the long therapeutic process for CMN requires continued compliance from the children and their parents, implementing that preventive actions might influence the success of the whole surgical and reconstructive process. In this article we will present a case study of preventive care for a child with CMN who suffered from symptoms of post-traumatic stress disorder following her medical coping.
Deborah, 8, was born with multiple necrosis in the back, hands, and face area and underwent a series of CMN removal surgeries from the age of one year. Her past medical processes resulted in many absences from kindergarten and later from school and required prolonged recovery periods. In addition, due to the visibility of the nevus, Deborah’s self-image was low and she experienced difficulty in self-acceptance and coped with anxieties in the social realm and with avoidance of social situations.
At the beginning of the treatment Deborah vehemently refused to talk about her difficulties and each time the issue came up she responded with a significant behavioral setback. After 3 months of treatment, a good relationship seemed to be established between Deborah and her therapist. During this period the therapist ranges from open conversations about the daily topics that occupied her, to practicing regulation skills and providing psycho-educational information about anxiety and trauma. Deborah renewed some of the social connections, and returned to attend school continuously. However, Deborah continued to report much depression, avoiding social gatherings, and parents also reported ongoing closure and restlessness. The therapist suggested that Deborah write her story as part of the therapy. Deborah received a psycho-educational explanation about the importance of processing and narrative work, and understood its meaning. Together with the therapist, she drew chapters for her story, and even wrote first chapters about herself, her childhood and her family. Along the way, Deborah was able to get closer to the CMN issue and its impact on her life. Slowly and gradually she brought to the meetings her experience of anomalies and the feeling that she was "spoiled." She recounted cases in which children mocked her appearance and the social rejection she experienced and shared that she believed something was wrong with her and that her appearance frightened people.
These conversations allowed Deborah to be in touch with the difficult thoughts and feelings she was experiencing and to go through a process of re-examining her self-perception. Slowly, Deborah began to bring in other parts of her personality for treatment as well. She told of academic success and a close bond formed with a new classmate that made her very happy. Simultaneously with these developments the parents reported that there is a resilience of Deborah’s avoidance patterns and that she is beginning to take part in social activities. In the meetings with the parents, guidance was given with an emphasis on developing the parents' ability to validate and on developing mentalization abilities in order to allow them to adjust to it more accurately. An important chapter in working with parents dealt with processing the parents' feelings of guilt around the decision on nevus surgeries. The parents felt confused about the decision to perform the series of surgeries. They said that because it was a plastic surgery related to aesthetic reasons and it was not clear how medically necessary it was, they doubted it was the right decision for Deborah. Deborah’s mother said that if she had known in advance how long and painful the process would be she might have given up the surgery. According to the parents, one of the hardest times in the process was when Deborah was dealing with an infection that forced her to be hospitalized for several weeks.
During this time Deborah hurled harsh accusations at her parents and the encounter with her aggression seemed to be very complex for them. Despite the difficulty the parents were able to see how this coping strengthened them as a family and made them understand what the strengths and family resources were and believe in their coping ability as a family.
In conclusion, the case report can be seen as a demonstration of the therapeutic principles in children with CMN who face emotional difficulties following their medical condition. After the initial stage of diagnosis and conceptualization, there was room for therapeutic contact and the construction of a therapeutic alliance. She then addressed the negative self-perception and processing of the experiences of social rejection and then narrative work was done that allowed the patient to work on processes of processing and merging the traumatic parts. At the same time, work was done with the parents with an emphasis on developing their ability to mentalize, and later on, they also processed the experiences they went through around the medical coping, emphasizing the family resources that helped them during the period. The treatment of Deborah and her parents lasted about a year and resulted in a significant improvement in the girl’s mental state.