Wellbeing for the broken. Part 2. St Emlyn’s

It is now several months after the event that I was so concerned had ‘broken’ me.  I am still at work.  I stayed at work.  I always felt I was safe to work, and maybe it even made me more vigilant than normal because of how I was feeling. I was definitely able to function although some days it felt like this came at enormous cost to myself. Am I fully recovered? 

Editor: If you’ve not read part 1 please do so now, click the link above.

Definitely not.  Am I almost recovered? I think so.  If we think of ourselves as a bucket, and that bucket is our ‘capacity of resources’ then I normally run at 100%.  Immediately after the event I was at about 5%, currently I am around 60-80%.  I believe I am growing stronger every day. I believe it will leave a big, permanent scar somewhere on my psyche forever.   I believe I have learned lessons.  I am hoping I am changed though not necessarily permanently damaged.  They are lessons and experiences I could have lived without.  It has hurt.

I have not had mental illness; I have had a mental health crisis as a result of this event.   I did not have clinical depression or PTSD.  I was not burnt out, though there was definite moral distress.  Ultimately, I was in a crisis caused by a work event.  This blog aims to explore possible suggestions that may assist in recovery from a crisis.  Recovery from a clinical mental illness diagnosis is a very separate issue and not something I am addressing here.  If you believe you are experiencing a crisis due to mental illness please go and seek help and support from a mental health practitioner and be with your family and friends.  You are important. Mental illness is an illness like any other. It does not define you.

So, why are we so impacted when something unexpected and disruptive occurs in our lives?  Assumptive World Theory (Janoff-Bulman, 1989) may be able to help us make some sense of this.

Assumptive World theory refers to the assumptions or beliefs each of us carry with us that secure, stabilise and orientate our lives.  Janoff-Bulman asserts that all of us use assumptions to build our lives which are ‘essentially our most fundamental schemas, deeply embedded without our conceptual systems that are usually outside our immediate awareness’ (p159).  Assumptive World theory drives the structure of our lives and organises our experiences and directs our behaviours e.g. I am going to get up tomorrow, go for a run, shower, go to work, see patients etc.  

In my working life within critical care, I understand this and also thrive in an environment that is ever changing and dynamic, dealing with whatever comes through the door on a day to day basis and not having a routine. However, I do always have an assumptive world narrative for myself that I can keep families in a crisis safe. I understand my work and can recognise issues and have always believed I could make a difference. I think I had always believed rather vainly and naively that ‘nothing will happen on my watch’.  The crisis I experienced with this event shattered my assumptive world and left me disorientated.  Understanding your own assumptive world theory can help you understand why you are so impacted and disrupted by an event. It will not make the crisis dissipate faster.  It may just help contain some of the emotions and offer assurance that recovery is possible.

The first four weeks after the event continued to be a series of very dark times, ruminations, insecurity, guilt, shame, floods of tears and a lot of play acting to the outside world that I was either ok, or at least ‘moving in that direction’ despite not feeling or believing this for myself.  After a month I realised I was sleeping better and that everything was becoming a little easier.  I had stopped being so emotional and raw, although if people approached me about the event I could easily slip back into that pain. On reflection the first two weeks were the worst, I can see that things were easier with time; I did not have that insight in the moment. I felt like I was drowning and I couldn’t find the surface.  What is apparent to me now is that I did have to actively FIGHT my way back.  This was not a passive or easy process.

So, on reflection this is what I think helped….

FAKING IT ‘TIL YOU MAKE IT.

I honestly think that the whole ‘faking it ‘til you make it’ has some real validity. Despite how I felt internally I dragged myself to work each day, dragged myself to the gym, and dragged myself through life.  There is some science that suggests ‘faking it til you make it’ is valid.  What the neuroscience tells us is that ‘what fires together wires together’.  It is called the .  Essentially when the brain recognises that it is attending work, or going to the gym or just going through life and functioning with a smile it enjoys those patterns.  Those neurons will fire and wire together and the brain tells you that you are ok. 

Correlation sometimes becomes causation.  Amy Cuddy suggests ‘fake it until you become it’.  Do enough until you actually become it and internalise’. We all become what we think we are. During this time, I worked really hard at not becoming what I was fearing.  I tried to remind myself of all the positive interactions I had experienced through my career, the thank you cards I had received, and generally how I was perceived by others.  I tried to embed myself in this positivity despite the negative ruminations that loomed.  It was a conscious effort and exhausting.  When I couldn’t do this for myself, I used my therapist, my trusted friends and my colleagues, all of whom would challenge what felt to me like my personal never ending negativity. 

Faking it: Amy Cuddy

Amy Cuddy also advocates to be mindful of your body language because we are also influenced by our own nonverbals, our thoughts and our feelings, and our physiology.  If I had surrendered to the first thought in my head each morning when I opened my eyes I would never have moved.  I would have lain in a pit of despair and anguish, overwhelmed by the pain of it all.  I had to dig deep and say to myself “you will be ok”.  I got out of bed.  I stood tall.  I did lots of weights at the gym.  I built a strong body structure in the hope it could hold my weak and broken mind. 

ROUTINE

For me, while I was in this crisis I found it hard to make decisions. I experienced cognitive overload very quickly. All my energy was taken up just surviving.  My routine became everything.  My routine kept me anchored to the world in a safe, containable, and tangible way.  

Having a strict routine so that I didn’t have to think ‘what will I do now?” or “what will I do next?” was literally a life saver.  When our brains are suffering from cognitive overload, we become decision fatigued very quickly. When you are feeling so sad and overwhelmed it is almost impossible to decide what exercise to do or what to eat, and so the temptation is to do nothing or make poor ‘easy’ decisions that are ultimately unhelpful. 

Even if you have never had a routine it may be helpful to write something down and stick to it.  After fitful, sometimes nightmare filled sleep, when the alarm finally sounded there was no decision to be made. I was booked into Pilates, or boxing or weights, or I was walking with a friend. I knew exactly what I was doing and where I was going.  A safety net to stop me completely falling.  To make sure I kept exercising, kept looking after myself and ultimately my children. 

On Sunday nights I went back to writing a menu plan for the week, something I had not engaged in since my kids were little. A menu plan meant I had a list for the grocery store, meant I could ensure I cooked each night for my boys and that we all ate nutritious food.   On the nights I felt completely spent I did buy takeaway, though not fast food, and I kept this to once a week.  Routine was my saviour.

SLEEP

I don’t do shift work so sleep for me is always night time.  Nights became this really frightening experience.  I have never been a great sleeper and during this time sleep evaded me even more.  Initially, as in the first few days, I didn’t sleep at all.  Then I slept fitfully for the first few weeks. Sleep was the time I couldn’t fight the visualisations, the haunting sights that felt burnt into my brain.  At night I re-experienced the event with all its horror over and over again in great, vivid detail. 

In desperation I decided I would exhaust myself to sleep.  I went to the gym early morning and late nights.  I was single and had no one to turn to or disturb.  So, I literally pushed my body until it had to rest.  Once your body gets back in the cycle, for most of us sleep will eventually return. I tried not to freak out when I woke at 2am after only two hours of sleep.  I read a book, I tried to meditate, I wrote ideas for upcoming talks in a notebook.  I NEVER did screens, no phone, no computer, no tv.  No matter how tempting.  The lights from screens stimulate your brain and lessen your chances of sleep.  I kept a strict routine with sleep and waking times.  I kept the room dark.   I tried to think about great memories.  To self soothe.  I had to actively work against reliving the agony of it all.  I forbade my brain to go there; I had to fight off the images, the sounds, the emotions.  (I still do, even as I write this).  I thought of songs, looked at old photo albums.  I tried to fill my brain with goodness and happiness.  Remind my brain that this was one memory.  Not THE memory.  That sleep was a place of respite and comfort not fear.It was hard.

SELF MEDICATION

It would be irresponsible not to mention the enormous temptation during a crisis to self- medicate with alcohol, drugs and prescription medications.  I have learned the hard way how devastating alcohol is when it is used to numb, avoid, soothe and pretend.  For me alcohol is a huge high however it is followed by an accelerated and devastating low. The day(s) after a big night of alcohol means no exercise, worsening sleep and poor eating.  Nothing I could afford to do, I could not afford to feel any worse.  When I am in crisis I avoid all alcohol.  I encourage you to be very careful as well.

Many of you reading this, as health professionals will have an arsenal of medications to help with sleep and anxiety.  Be very careful with self-medicating.  You may be a wonderful doctor to others, you are not meant to practise on yourself.  If you need medical advice seek it from a paid health professional, not a colleague (that’s a friend).  If you genuinely think you need medication talk it through with a doctor, not yourself – your judgement is currently impaired when it comes to yourself.

SELF EFFICACY

I had to remind myself on an hourly basis that my current survival rate for living through the worst moments of my life stood at 100%.  I have survived my fair share of broken hearts from friends and lovers, my brother having cancer, my baby being born anaphylactic to almost all foods for the first twelve months of life, rejection, disappointment, divorce. I have an impressive list of failures and disappointments.  I have ‘survived’ them all.  Not entirely unscathed but survived.

My parents used to read me a book when I was little called “The Little Engine That Could”.  It was about a little train that had to pull a heavy load up hill despite the odds.  When all the much bigger engines refused the little engine decided to try.  When the little engine was towing the heavy load he would say out loud “I think I can, I think I can” Just like the little engine, I was trying to overcome a seemingly impossible task.  I would say “I think I can, I think I can”” together with “I am having a normal response to a grossly abnormal event” over and over in my mind.  In a sense almost cheering myself on from the sidelines to just keep going. 

We are all a lot more resilient than we think we are.  When I was really unsure, I would look around at all the critically ill patients, babies and children, in our PICU, some as young as 38 weeks gestation fighting for their lives, their poor parents’ at the bedside. I would remember that I had obligations and a great life, so many things worth fighting for.  I would remind myself that adversity was a part of life, that all of us are in a battle of some nature.  That I had survived thousands of terrible days across the course of my life.  That I had witnessed tragedy far greater than I was experiencing and seen people survive.  That the odds were I would survive this well if I gave it time and space. I had to be a friend to myself instead of the harsh critic I wanted to be. I allowed myself to be sad, remained curious about my emotions, held myself gently and simultaneously fought incredibly hard to recover.

CONNECTION

When I read part one of this blog now, I am so shocked to see how isolated I felt.  This was never true.  Be exceptionally careful in a crisis not to isolate yourself.  I think when we are in crisis; we tell ourselves many things that are simply not true. My reality was not actually THE reality.  I have two fantastic children, wonderful family and an enormous network of friends and colleagues.  The feeling of isolation reflected how I felt at the time, not reality. 

Every time I did reach out it had some value. Did people understand? Often the answer was no.  Did people try and placate and reassure me?  Yes, and I needed to remind myself how their intention was one of love and a desire to stop my obvious distress.  Whether you have one good friend or one thousand it is irrelevant.  Reach out.  Call your mum or your dad or someone who is good at nurturing.  Let someone cook you a meal or come and sit with you.  People are not mind readers.  Let them ‘sit in the rubble’ with you.  Having someone around can be enough.  Also connect with a counsellor or therapist or your GP if you need to.  Hang out with your dog, hold the cat.  Whatever it takes to fight off the loneliness…. utilise it.

Connect with nature; put your bare feet in the soil or the sand.  Walk out and turn your face to the sky.  Remind yourself that you are part of something bigger.  Touch a tree, smell a flower.  Stay connected to life outside of work. Sit on the beach and be soothed by the sounds.  If you are spiritual use this connection.  Allow yourself to feel held in your beliefs and your community. 

Do whatever brings comfort. Connect with everything and everyone even when you don’t feel like it.  You don’t have to share how you are feeling, you just have to connect.

POSITIVITY

In a crisis there is an enormous temptation to surrender to the misery.  Fight with everything you have to get back to yourself.  Fight for those who love you. Here are some tips:

  1. GRATITUDE: remind yourself of all that you have. How work has also been a source of pride, happiness, a place of learning and humility, your community.  That this event does not have to become the sole narrative of your career.  If necessary, write down some of the fantastic opportunities and lessons and experiences you have had at work and provide an alternative narrative to your current crisis. 
  2. SEEK JOY:  Only read books and watch films that are uplifting and fun.  You have enough sadness and crisis in your life.  You do not need to add fictional misery to your thoughts.  Choose music that energises, skip through the heartbreaking wailing songs.  Spend time with people that fill your soul with love and nurture you.  Dance.  Skip. Run. Whistle. Smell the roses. Pat a dog, Cuddle a baby. Plant a tree.  Look at the sky. Find what brings you joy and immerse yourself in it.
  3. MAKE MEANING:  I had this crisis because I care, because my work means so much to me.  Because I was diligent.  Because I believe that people matter and that we all have a responsibility, especially to children.  These are not terrible attributes. Irrespective of what has created this crisis for you at work, connect with your intention for your career, that moment, that day.  If you made an error, if you bore witness to a tragedy, if cumulatively you feel worn out …….connect with all the purpose and intent and the values that brought you to this work. 

Is this crisis bringing you closer or further away from those goals?  Is there something to be learned?  I look at Martin Bromiley, whose wife died following medical error and how he chose to focus on human factors in medicine rather than pursue a legal pathway.  To Gill Hicks, who after receiving horrific burns and losing both of her legs simply because she happened to be a commuter on the London tube the day a terrorist boarded, has now dedicated her life to peace and spreading the message that what connects us as humans is greater than what divides us.  

I doubt this is how either of them felt in the crisis phase.  I doubt this is how they feel every day, yet this meaning gives them focus.  You won’t find meaning on day one, maybe not even until weeks or months down the track.  It is worth seeking as meaning can bring healing.  I acknowledge that not all events have a ‘meaning’ and there is nothing more soul destroying than trying to seek meaning and not find one.  However, if there is meaning to be found, search for it, embed it in your values.

COMPASSION

Writing both of these blogs has been a challenge.   It has forced me to relive something so incredibly awful. It makes me have a visceral as well as an emotional response every time. Part two is deliberately more sterile in the hope it provides you with a framework or some ideas on how to cope if you feel ‘broken’.  There was nothing tidy or sterile at the time.  It was messy and ugly and hard and soul destroying and I am getting better.  I never, ever want to have another experience like it.  Chances are I will.  Life is hard. People I love will die, life will change.  My beautiful therapist who played an important, almost weekly, role in my recovery kept reminding me that my pain and grief was solely because it had been important.  This was not a personal deficit.  It was a strength. It IS a strength.

For most of us this work is not simply a job or a way to just to pay the bills. We came to these jobs for an experience, to feel exhilarated and alive, to have a chance to make a difference, to be pushed and to grow, to feel respected and to contribute. It is a place of privilege, fascination, mastery, thrill, complexity, humility and duty.    You cannot have those experiences without the risk of heartache and sadness.  You run the risk of a personal or professional crisis – THAT event.  You may feel the crisis slowly burning away due to cumulative experiences or it may be sudden and overwhelming. 

As a very experienced and resourceful clinician I found myself engulfed in something beyond my control.  I was aware of it and powerless to stop a devastating outcome.  I have not been powerless in what happens next.   It has taken enormous energy and commitment and a community of people and resources (most of whom have been unaware of their role) to claw my way back.  Remember you also have resources.  Writing about this experience has been cathartic, just putting it all down on paper helped, it gave it structure and it may for you as well?

The purpose of these blogs has been to reach out and normalise what feels utterly foreign following an event at work.  A potential framework of suggestions to assist in recovery. 

It takes a village to do this work.  You are part of this village. We cannot function without you.

Finally, whenever you are hurting have an enormous COMPASSION for yourself.  Just as I hope you have eternal COMPASSION for others.

Liz Crowe

References

Ronnie Janoff-Bulman (1989). Assumptive Worlds and the Stress of Traumatic Events: Applications of the Schema Construct. Social Cognition: Vol. 7, Special Issue: Stress, Coping, and Social Cognition, pp. 113-136.


Janoff-Bulman, R. (1989). The Benefits of Illusions, the Threat of Disillusionment, and the Limitations of Inaccuracy. Journal of Social and Clinical Psychology,8(2), 158-175

https://en.wikipedia.org/wiki/The_Little_Engine_That_Could  The Little Engine That Could 

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Posted by Liz Crowe

Ms Liz Crowe BachSW, PhD(Candidate) is section lead for Wellbeing and Editorial Board Member on the St Emlyn’s blog and podcast. She is a wellbeing counsellor and educator. She works as an Advanced Clinician Paediatric Social Worker in the Paediatric Intensive Care Unit at Queensland Children’s Hospital. She is the author of “The Little Book of Loss and Grief You Can Read While You Cry”and “When a Child Dies – A Guide to Working with Bereaved Parents after the Death of a Child from Illness. She is currently completing a Doctoral Thesis in Staff Wellbeing in the critical care context. Examining risk and protective factors with a view to designing interventions that build capacity, psychological flexibility and resilience for staff proactively and reactively. She is an internationally renowned speaker on paediatric loss, grief, crisis and bereavement work. Her research interests include staff wellbeing, loss, grief, crisis and bereavement work in critical care, paediatric sepsis, moral distress, clinical debriefing following a critical incident, end of life care and advance care planning. You can find her on twitter as @lizcrowe2

    1. elizabeth robinson April 28, 2019 at 9:51 am

      Hi Liz,
      I just wanted to thank you for your post on well being in the broken. I have re-shared them on our hospital FB page, because in ED (but not exclusively!!), I think we’re all feeling a bit broken, some if not most of the time these days.
      Kindest regards and I hope things are continuing to get better and brighter for you.
      Dr Lizzie Robinson

      Reply

  1. Delia Parnham-Cope May 13, 2019 at 5:23 pm

    Hello Liz,
    thank you for your post- really interesting & practical-the idea of using the power of routine & ‘fake it till you make it’ are much more likely to appeal to resilient ED staff -supported by the network of colleagues who have all experienced work related emotional trauma & assimilated it into their practice
    Miss Delia Parnham-Cope

    Reply

Thanks so much for following. Viva la #FOAMed

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