Podcast – Wellbeing for the Broken with Liz Crowe

Welcome to the St. Emlyn’s podcast. I’m Iain Beardsell, and I’m Liz Crowe.

It has been a while, Liz, since we have chatted on a podcast. I think lots has been happening for both of us over the last few months and years, but it’s lovely to be back talking to you again. And talking about, well, quite a difficult topic, I guess.

Yes. Today, we decided that we’re going to discuss the never spoken about topic of what does well-being look like when you actually feel broken by the work that you do. And I think it’s important to set this point that we’re not talking about the everyday broken. We’re probably talking about that once in a career moment or happening that occurs to you out of the blue perhaps, catches you off guard, takes you completely by surprise, and knocks you completely sideways. I know that both of us have had occasions like this over the last year to 18 months, and we’ll probably touch on those. Regular readers of the blog will have already found two articles by Liz that discuss this topic in great depth, but in this podcast, we’re going to talk in person, expand on some of the themes, and give you some extra information inside which we hope will be useful. Liz, why don’t you start off? What does it mean to be broken?

First of all, I would like to say that this isn’t just that really bad day or something that feels rather sad or something that makes you feel disillusioned. What we’re going to talk about today is something that really has a major psychological and physical impact on you. In the moment when this is happening to you, it is so terrifying, and you feel completely isolated and alone, and we wanted to talk about it to try and break down some of those barriers and to perhaps normalise how awful it can feel in the moment. I think that this can happen, as you say, completely out of the blue, and for some people it can be cumulative. You have some big knocks, then you have too many big knocks, and it just stops. For me, I guess there’s probably been five times in my career where I’ve really felt hugely impacted to the point that I wasn’t sure that I was going to be able to continue with the job. However, something happened to me that really made me think that I might have to resign. There may be one or two people left in the world who haven’t heard of Liz Crowe and what she does. For that one or two individuals, why don’t you just tell us, Liz, about your everyday day job? What is your job? What does it mean? What does it mean day to day?

I’m the senior social worker in a pediatric intensive care unit. I also run a team of social workers who only work in critical care services such as ED, Burns, Cardiac, and the emergency department. I have worked across those areas clinically for the last 20 plus years—hard to remind myself that I’m that old. And so in intensive care, we basically are with the families the entire time, talking through what’s happening. We go to all the Met calls or code calls. We attend all the resuscitations. I would be involved in the death of a child every four days, and sometimes that’s an acute death, and sometimes that’s after we have palliated a child who has a chronic illness or an injury. I believe myself to be rather robust. I believe myself to be very resilient. It’s not like things happen that are sad, and I feel hugely impacted. I do always feel sad—sometimes it’s far more than others. I guess today what we’re going to talk about is when you feel really psychologically and physically impacted.

You’ve described there—in Australia, you call it a social worker, but in the UK that’s a term that we use slightly differently—really you’re a counsellor to some extent. A patient advocate, a staff support. You’re there to look after the patients, the relatives, the staff who are looking after them, to counsel them through, to help with communication—all of those things. You’re part of a child dying every four days. That is not a normal experience necessarily, but that is your experience of what you do for work. But again, what we’re going to talk about is on the background of all of that, what you cope with normally, which you cope with amazingly. There’s something that happened that just took you by surprise, and even you, on the background of all that experience, struggled to deal with.

I think what we’re going to discuss today is far more than just having a bad day or having a run of bad days or feeling disillusioned about the work. This is when you truly feel like you are no longer sure you’re going to be able to continue the work, where you feel real dread about going back to work, where you’re ruminating constantly about an event or a series of events, where it’s disrupting your sleep, it’s disrupting your life. It really feels like a mental health crisis. I think all of us at times have very difficult days. All of us are exposed to things that are tragic, sad, frightening, horrific, confronting. It feels awful in the moment, but within a couple of days, you’ve recovered. I guess for me, when I think about my own episode and just in reflecting and talking with others, that absolutely made me go from being high functioning, feeling really well, to feeling completely broken.

In the blog, you talk about the fact that you don’t believe you had a mental illness, a psychological illness when this happened to you. What is it that made you feel that this was not an illness but something different to that? And when can we recognize when we are actually psychologically ill?

You know it’s interesting. I think if I’d went to the GP, they probably would have diagnosed me with something. For me, I desperately hope that I would recover. I certainly am not opposed to going to the GP. For me, I think it was definitely a mental health crisis. I don’t think it was a mental illness. I don’t think I was depressed. I don’t think I had post-traumatic stress disorder. I think that I was exposed to something at work. It was just something so confronting and so horrific that I felt a level of responsibility for that completely broke my spirit, I guess you could say, that left me highly emotional, tremor in my hands, crying for nights on end. I kept functioning in that I went to work, and I believed that I was safe to work. However, I think it was taking an enormous emotional toll on me at the time.

So the details, as we’ve said, are on the blog post, and they’re for you to read. And let’s just take it that at that period in time, you were broken. And I’ve been in a similar place to you for completely different reasons, but at work, I had a similar type of thing happen to me. What we want to talk about now is practical advice about what we can actually do, both in the moment when it’s just happening to you and over the days, weeks, and months after, to find a place where you get to recovery, and you detail these beautifully in the blog. But let’s just talk about a few of them. If we can, let’s start on the day where you’re knocked off your feet. What would be your advice, both with your expertise and everything you’ve done for your PhD and having gone through it? What would you do on the day? What would you recommend people do to get through that first day when you just feel like you don’t know where to turn?

It’s only in reflection that you can be wise about these things. I wrote the blog one when I was in the midst of the horror of it all. I think it was day two in the middle of the night. I hadn’t slept for nearly three days, and I was in an absolute crisis. At the time, I kept seeking people out and then withdrawing. I really exercised a lot. I looked up at just loss. I don’t think I knew what I was doing. I guess the main message that I can say now in hindsight is that my judgment was dreadfully impaired. It was dreadfully impaired. I wasn’t responsible for what happened. I felt responsible. And so it didn’t matter how many people told me this wasn’t you. You did everything that you could. Don’t feel guilty. I did.

There are times in our career where people make a human error, where systems fail and something dreadful happens. And it doesn’t matter how you get to be here. I guess what I want to say to you, if you are in the throes of a crisis because of work, chances are, like me, your judgment is grossly impaired. You are paranoid and vulnerable. You believe that no one could possibly understand. No one could possibly support you. No one could possibly forgive you or see you in the same light. You’re wrong. If you are in the very acute phases of this, please go and talk to someone. If you feel like you can’t be your partner or it can’t be a friend or it can’t be a colleague, make it a GP, make it a therapist, make it your parent, make it someone who can sit with you and know that they’re not going to be able to remove your pain in the cuteness of it all. What we have to get used to if we’re going to attend our own well-being is to sit with the distress. What I went through was so completely abnormal. I don’t believe those same events will ever, ever occur to me again in my working life. Will I see other things that are frightening and terrible and traumatic and sad? Yes, I will. Will I see that? No, I won’t. So I was having a completely normal reaction to something that was horrifically abnormal.

And you describe a complete paralysis of decision-making. You were unable to do anything practical to find a way through it. I think there’ll be people listening who would think to themselves that I’m going to stop now, I’m going to move onand listen to something else because this is never going to happen to me. Hopefully it won’t. But probably what we’re going to say now is, think about what you would do if this does happen. Make a plan and use some of the hints and tips we’re about to talk about. Now sit down, spend half an hour to make a plan about what you would do, put it in a drawer, and if this should happen or something similar, you know where to go to get it. Liz is one of the most capable people I know. I’m moderately able to function on a human basis most days, but both of us have had things that meant that for a period of time we didn’t know what to do, we didn’t know where to turn. And I wish I’d had a plan. So let’s think about that plan. Liz, if you were going to advise somebody now, they have a piece of paper in their drawer that in that moment of huge crisis that knocks them off their feet—not every day, a once-in-a-career thing—what does it say on it? What is item one on the top of that list?

Item number one should probably be connection. In the moment, you really don’t think anyone can possibly get it. And I think I was a bit narcissistic about it. I think there are lots of people, and so many people in critical care and across health in general, could have these experiences from a varied amount of sources. I think what we do is quite unique compared to other occupations. It’s not like we’re upset at a grocery store because we’ve dropped 20 jars of pasta sauce and someone can say, just go back out the back and compose yourself, and you don’t have to see the customers for the rest of the day. It’s very rare that these things even happen at the end of the shift. These things happen in the context of our work, and we have to just keep going. When someone is in that level of crisis, listening is really important, not to placate, you know, and say, it’ll be okay. This wasn’t your fault. Allow the person to kind of divulge the story without interrupting. I think when we see people upset, our first instance is to shoot them away. You know, like, you need to look after yourself. Off you go, off you go. However, all of us need to respond differently to that. And that’s why I say part of our well-being plan has to be this acute self-awareness. The other thing that I think really saved me in the moment was routine. I’m quite an obsessive person at the best of times, and I do have a routine. However, during this, I couldn’t have functioned without the routine. It didn’t matter if I’d slept or I hadn’t slept. I could have 5 am, I still got up. I still went to the gym. I tried to take as many decision-making variances out of my life because I was just paralyzed all the time. What will I cook for dinner? I can’t decide. What am I going to do tomorrow at work? I can’t decide. So I went back to what I used to do with my kids a little. I made a meal plan on the Sunday, and then I bought the groceries according to that, and I stuck to it. Because when you are in crisis, you’ve really got cognitive fatigue. You’re in complete survival mode, and making any decisions beyond that was just—it was too hard.

I guess this is why we’re saying make a plan now because, at the time when you’re in the absolute midst of the crisis, it’s impossible to make decisions. You talk about connection, and from my experience, I think what I wanted to do was go and hide. This takes real bravery to get out there and go, and we’re not expecting solutions from the person you go and see. Actually, I would start off by saying you can’t stop my problem out, but please just sit and listen or just be with me. You don’t even have to listen—just help me get through the day. Being on your own in this situation is, I think, potentially incredibly dangerous and maybe even destructive, but for many, that’s what you want to do. I wanted to hide away. I’d been attacked on a hugely personal level, and I wanted to just crawl into a corner because I felt worthless and useless. I presume there is a period of time where you’re allowed a little bit of self-pity, but that can’t last long because life goes on. You look at the window, and cars are still driving up and down the road, and your kids still need picking up from school, so you have to be able to function. With connection, who would you go to? What would you say? How do you frame that conversation with them to make it what you want?

You know, I have said before publicly, and certainly on our podcast, about having a work wife and a work husband, and that, in the moment, was very helpful. I have some long-term friends. I honestly didn’t tell many people at all. I had an element of shame, guilt. I felt completely exposed, and I pride myself on being very resilient. I pride myself—I feel like I’ve got a public persona about being resilient and being robust. I felt shattered into a thousand different pieces where I couldn’t even find bits of me to put back together. That’s why I’m saying my judgment was impaired. I probably told a couple of people, and I was lucky that they just hung in there with me. When they rang, and I didn’t pick up the phone, they just kept on ringing. I’m also really lucky that I live with two teenage boys, and they are an enormous pull back to the world because I had to keep cooking for them, and I had to keep washing clothes and folding and ironing, and I was very teary in front of them. They kept saying, “What’s wrong? This isn’t like you. Do you want to talk to someone? Can we help you, Mom?” And it kind of just kept me putting one foot in front of the other, and I was really mindful then. I guess if people who live alone, I’m hugely extroverted, and for the first time in my life, I didn’t want to speak to anyone at all. Have a few cool people talk to them now, maybe share these blogs, and say, you know, these are the sorts of things that could happen in my career. Would you be my person? Could you be there for me? Go and see a GP, find a therapist in advance—all of these things are ways of providing a safety net or a safeguard should you get into trouble. You don’t need to tap into your connections only when you’re broken. You don’t need to just have a therapist or go and visit a GP only when you’re broken. I think this job can make us wobble quite a lot, and it’s good to put these things into practice way before there’s a crisis.

I’m going to pick up on one word you used then, which was shame. That idea of shame, I know I can relate to that hugely. I felt completely disrupted and like I’d lost a core part of my being. That shame part is really difficult. That’s hard to deal with. Have you got rid of that part of that yet, or did that take a lot of time before that went away?

I feel very teary just even recounting it, like I’m tachycardic at the moment. I can feel my voice is croaky. Shame is one of the most powerful emotions that a person can endure, and for me, that shame component is still very prominent, I guess, in how I feel because I feel like that—I feel like I was powerless. And, you know, that shame component is something that, for all of this, this is not a passive thing. You will want to lie in a bed and never get up, and you can’t afford to do that. You can’t afford to do that whether you have children or pets or family members that love you or friends or because of your job, but you can’t afford to do it for yourself. This has been an ugly, torturous, very difficult fight back, and it hasn’t been passive. I think that’s the other thing is that you have to literally claw your way back from this. And so when you feel that shame being triggered, and I’m hot here and everything, it’s not some a bit of a puzzle thing—I’m way too young for that. But when you feel that, you have to fight back because a lot of that, for me in particular, it’s irrational. It was not my responsibility, and yet that shame response is so huge. I have to have this internal battle with myself where I think, come on, stop being such a narcissist about it. You know, there were system failures, you were alerted, you tried everything in your power, you’ve got to ask yourself, what belongs to me, what belongs to the system, what belongs to this unique component of this job. And even if you were 100% responsible, in some ways, you are never 100% responsible when you belong to a team, a unit, a department, a hospital. All of us can make a mistake. And, you know, someone reached out to me on Twitter and said, “This is how awful your work can get. Why would we do it?” And I guess that was the other big thing that happened for me during the shame crisis is I had to reflect on, like, why am I doing this? I have lots of friends who have careers that even earn lots more money than me, don’t have this level of responsibility, don’t have this burden of responsibility, are not exposed to things. And for me, I still love the job, still passionate about it, still love the team, still love the children, still love the families. I’m humbled by it, and I wanted to fight my way back, not because I need to pay a mortgage, but because I bloody love that. And I didn’t

want to give up.

In your blog, you describe yourself as being maybe 80% recovered. Let’s now focus on what we can do to actively—and I think that again is really important. You can’t—this will not solve itself on its own, and you are the person who can get through this. What can you actively do? We’ve talked about routine, and I think that works for me as well. I know how thrown off I get when the children are on holiday from school because all of a sudden my day-to-day routine is different, and I don’t like that. Now, for others, that slightly off-the-wall, a little bit more laid-back thing might work, but your routine worked for you. So getting up, going to the gym, preparing meals, doing the shopping, making things more regular. So we’ve got routine. You’ve got to keep that going while you’re trying to survive through this episode. What other things would you recommend to people to try and get through, to help their recovery?

So for me, I guess people kept looking to know that I was okay, and I did a lot of fake it till you make it. I put a smile on my face, I came to work, I kept functioning, I kept saying to myself over and over and over again, “I think I can. I think I can. I think I can. I think I can. I think I can do this. I think I can get through the day. I think I can get to lunchtime.” I didn’t try to look too far ahead, you know. I didn’t try to think, “What if I still feel like this in three weeks’ time?” I kept thinking, “Let’s just get to lunch. Look at you. You’re going. You’re doing it. Let’s just get to the end of the day.” I would then get home and think, “Okay, I’ve survived another day. Let’s get the food on.” I tried not to have big plans, big goals. I tried not to overwhelm my things, so I think I kept—I know that neurons that fire together wire together, and I didn’t want to sink further into the hole, so I kept saying, “I’m doing well. This is an achievement. What I’ve done today is good. I’m okay.” I wasn’t sleeping for several weeks at all very well. I tried not to be panic-stricken about that. So I would try to go to bed at the same time. I literally exercised myself to exhaustion, and that won’t work for everyone, but it worked for me. I’d go to bed, and I’m trying to do some quiet meditations. I tried to read books that were really boring that would put me off to sleep. When I woke after two hours, I tried not to panic. I didn’t allow myself to look at any screens. I tried to be really disciplined, and I tried not to beat myself up any more than I already was.

So you’ve got exercise and sleep. These are the basic tenets of functioning generally, and you’ve got to keep a hold of those, haven’t you?

Yes.

Were you tempted to medicate, whether alcohol, pills, prescriptions? Would you suggest that?

For me, no, and I guess I said this in the blog. I’m sure you know a lot of the people who are listening to this are medics and nurses, and the opportunity to self-medicate is huge, or to self-diagnose is huge. Your judgment is hugely impaired. If you really think you need medication, go and see a doctor. Go and see a doctor and get a real opinion about where you’re at. If I had gotten to a point where it had literally been days, and I’d not had sleep, I would have gone and seen my GP. I wasn’t sleeping well. I wasn’t sleeping for long, but I was getting some sleep. I absolutely avoided alcohol. It was a massive temptation. God, I could have just opened a bottle of vodka and tipped it down my throat and hoped that the whole thing numbed and went away. I didn’t want to. I also know that with alcohol, it gives you a massive high and then a terrible downer, and then I would have missed exercise, and my routine would have been out. And I hate to sound like I was completely obsessed about sticking to my routine, but it worked for me, and I wasn’t prepared to do anything that could wreck that. So I didn’t touch one drop of alcohol during the whole event. I knew I was right on the edge, and I did nothing that could have tipped me over. Now, that doesn’t mean that I wasn’t tempted, and I’m definitely not a saint. I guess I was frightened. I was frightened of myself, and I would say to people, please, please, please be very, very careful with alcohol, drugs, illicit or otherwise, during this event.

Now, I approached mine a little differently, partly through necessity, but I went to see my GP, and I think we need to give GPs some credit. Absolutely. We in secondary care, we can be quite sniffy about what general practice is and what GPs do, but I received huge support from my GP, and the biggest thing I think I actually got was a validation that what I was feeling was not acceptable, but was okay and difficult, because somebody was able to say to me, “I’ve got qualifications. I’m medically trained, and yes, this is really hard.” And that meant a huge amount to me, actually, because otherwise I was thinking, “I’m just being weak here. I’m just being a bit crap because look at all my colleagues. They’re all still at work, and they’re all fine, and I bet they’ve gone through much worse than this.” And my GP said, “No.” And I actually did get signed off work with stress, whatever that is, but I did for a period of time. But my GP was really understanding. At no point did I go on to medication or do anything, but just to have a medical person tell me, “God, that sounds pretty tough, actually. I’m not surprised you’re struggling. I’m here, and we’ll get through this.”

I have used my GP in the past. For me, I also, in the last year, we have been seeing a counselor almost once a week, and I already had an established relationship with her. I made an emergency appointment with her when this happened. I saw her twice, I think, in the first week, and then I went back to her every single week. She also offered me, which was very generous of her, that I could ring her at any time. I could email her at any time, and I didn’t need to do that out of hours. But when I spoke to my therapist, she was exceptionally empathic, concerned, kept reinforcing about the natural fact how robust and strong I was, that my reactions were completely normal. And that validation is massive, to have another person say, “It’s not you. You’re not weak. This is not a deficit in yourself. This is an event that is enormous.”

So far, we’ve talked about a number of things that can help in the moment. We’ve talked about having a plan, and that will be individual to you, but that talks about having connection and finding that work husband, work friend, just a friend who can go to—they don’t have to be at work, but just somebody who can call. Having a routine that worked for me and Liz, it might work for you, but you’ve got to keep going. You’ve got to be active, got to keep doing what you’re doing. Life will go on around you, and you have to be a part of that. You have to feed yourself, you have to sleep, if you exercise, that’s great. And you have to keep doing those things, keep that life going. Don’t just let yourself crawl into a corner. Liz, you described faking it till you make it, and I think there is a lot to be said for that. And the thing I found hardest was, I could fake it in front of the children. God knows I didn’t actually tell them what was going on for six weeks. And that’s partly because of the shame of it. I didn’t want my kids to think I wasn’t the superdad I wanted them to believe I was. But after you faked it, which is tiring, and you go home and there’s no one to fake it for anymore, and there’s an hour before bed—that’s the bit I found hard. What tips would you have about getting through that part when you’re on your own, when you’ve expended all your energy, and you just don’t know what to do next?

I mean, some people would find huge comfort in numbing television, listening to music, doing meditation. For me, I did lots of, like, late-night walking, either at the gym or meeting a friend. And I’m sure people thought I was insane that I was at the gym walking it from 10 to 11 at night, but it just helped get rid of some of that nervous energy. For me, you can’t be prescriptive about this, and for lots of people, you know, they’ll say, “I run to control my stress,” or “I do this to control my stress.” In this, you have to utilize everything you’ve ever used before and then some. And you have to keep fighting, keep trying until you find something that works for you. Also, you need this enormous amount of compassion to yourself. You need to speak over the ruminating voice that’s saying, “You’re a loser. You’re a failure.” You know, I think I said in the blog, everything I’d ever done poorly at, everything that I’d ever been ashamed of just came piling in. You know, it’s just this peak, peak, peak. And I had to say, “Just stop it. Just stop it.” I was absolutely powerless at the time when this event happened. I haven’t been powerless since. I have had to call my way back, and there’s something to be said about that.

Liz, I think one other thing I’ve learned is that the world moves very quickly, and often your episode or your troubles can be forgotten by the rest of humanity in the world very fast. But you need to be patient. You and I have described ourselves as not quite there yet, not fully recovered. But to be fully healed takes a long time, and you’ll feel frustrated that everyone else seems to have forgotten it. They seem to have gone on with their lives, and here you are stuck in the middle of this thing. And I would say, be patient. I think this takes months, if not years, to fully understand and get through. And as people who work in critical care, we’re used to doing things in hours. If I wasn’t cured and helped within four hours in A&E in England, I’m in trouble, and I find that frustrating. But patience is required, isn’t it? And it takes time. How do you keep going when everyone else has moved on?

You know, one of the best lessons for me in all of this has been self-compassion. We have to treat ourselves like we would treat our patients or our friends or our loved ones. We wouldn’t expect, if someone told us a story that was similar to what had happened to ourselves, that they would be over in an hour, or a day, or a week, or a month. We would stay open and compassionate and caring and mindful and gentle with that person for as long as it took. And that’s the way I’m trying to treat myself. I was very strict about my routines. However, I tried to be very compassionate and gentle with myself and think, “This is worth it. It’s worth it to get it right. I’m worth it.” You know, that’s even hard to say out loud now, but I’m worth it. I owe my children, I owe my team, I owe my family, my friends, and mostly, I owe myself the time to recover.

I guess our message from St. Emlyn’s to you is that we may never meet you, but we can promise you that you are important. We can promise you that this does not need to be your life story. When you have an event like this at work, it’s very easy to believe that this is now your career narrative, and it’s not. You have to force yourself to think of the hundreds, for some of you, thousands of people that you have helped in the past. The people who, long after you have forgotten their names, their cases, their illnesses, they have not forgotten you. And then you have to think of all of the people who will come in the future and have their lives enriched, saved, helped in any way possible because of your skills, your knowledge, your compassion. And that’s why you have to fight your way back. And if you really get to a dark place where you feel like you need to take a break, take a break. There’s no shame in that. Again, it does not mean the end of your career, it just means a pause. And even if it’s a change in career, it’s not the end, it’s just a change. And I guess that’s my big take-home message is that this is what we can say worked for us. You find something that works for you. You believe that you’re important. You believe that your narrative actually is much bigger than work, that you’re someone’s sister, or brother, or daughter, or son, or cousin, or aunt, or uncle, or parent, a lover, or friend. You’re much more than a health professional, and you’re much more than the event that got you here.

Liz, I don’t think I can put it any better than that. Please do read the blog post if you haven’t seen them yet. Thanks for listening.