Working in healthcare and, or as first responders we are at risk of being exposed to abnormal events. Events for which we have no frame of reference and which precipitate acute stress responses and present challenges to our wellbeing.
You may already have read some of my previous St Emlyns blogs when I highlighted the journey I went through when this acute stress reaction became a chronic one. During the the therapy that assisted in my recovery, this emotional “why me” evolved into a more cognitive version of the same question. Some steps to this path of understanding were started right here at St Emlyns. There are podcasts with Iain and Liz talking about wellbeing and meaning making. In another podcast, Simon discussed the concept of moral injury with Esther Murray.
When looking into the science behind these concepts and principles, a number of themes developed. During our lives we develop an understanding of normal experience – our world view. We anticipate a degree of variation around this norm, but these views are at best incomplete and more probably flawed and so life presents experiences that we are unable to understand within the normalised view. These challenging experiences can either lead us to broadening our world view or can challenge our psychological wellbeing so much that if affects our whole existence.
Stress and strain
In physical sciences, this psychological response is analogous to deformation of solid objects. When materials are subject to a force – described as stress – the resulting change is described as strain. If the objects fails to accommodate this stress/strain it fails “catastrophically” – it breaks. Whilst these terms are somewhat less than gentle and no doubt a psychotherapist would cringe at hearing them, I have derived some comfort from the analogy. Interestingly, the term stress is common and analogous to both material science and psychotherapy. Let’s frame the word stress, and let’s lean into the team for help doing so.
Liz Crowe often refers to stress response being a normal result of exposure to an abnormal event. She goes on to explain that only rarely does this acute stress response develop into a chronic, pathological presentation of mental ill health. Liz describes stress as inevitable – and this has tremendous face validity. So what is stress and how is it that it can be problematic or not?
Let’s go back to the idea of a world view – does it have any scientific support? In this journey of discovery, I keep bumping into three concepts: those of assumptive worlds, moral injury and meaning making. Individuals will vary in how aware they are of their own world views.
Assumptive world theory seems to be a good place start things off: it describes our normal state. Comprising the three elements of: the overall benevolence of the world, meaningfulness of the world, and self worth. So, the world is an inherently good/just place, there is a purpose to our existence and we have value in the big picture. When we encounter experiences, they are judged through these three ideas. The experiences our inner judgements clarify as wrong are sources of stress, the amount of strain is determined not least by how far from our previous view of normal this new experience is.
This is where the concept of moral injury can be helpful. Moral injury (distress) results from aspect(s) of our assumptive world or global meaning becoming compromised by an experience. For us, this can result from a negative outcome to a case, seeing something that echoes too closely to our own lives, or something we react to as being just plain wrong. Injury results from our inability to re-frame this experience and accept it into our global meaning. You may find yourself expressing “it’s not fair” or more plainly “why” (or “why me”) when this is occurring.
So if the world is presenting these challenges to our views – why are we not all permanently broken? In understanding why this is not the case, the concept of meaning making can shed some light on our processes. The meaning making model describes how, with each experience, we have the opportunity to derive a new meaning (a new world view) as a result of the experience. In this instance, there is a period of adjustment during which time we may be experiencing some strain until the experience is re-framed as sitting within our normal frame. It this strain is significant enough, it would manifest as the acute stress response period. This is the normal, healthy, protective sequelae from experiencing stress(ful situations). When this adaptation (re-framing of “normal”) does not occur, a longer term – chronic – distress results. This chronicity increases our risk of developing mental ill health. At the point of chronic response, our assumptive world view is no longer that the world is an inherently good/just place, that there is a purpose to our existence or that we have value in the big picture. Nothing makes sense. That certainly rings true with my experience. When I was most unwell, the world felt meaningless, and I could not see my place/path in it.
Is normal, good?
There is another piece of the puzzle. This adaptation process is protective as we increase the accuracy of our understanding of the reality of the world, we are less likely to be negatively challenged by experiences. I believe that the more we evolve, the more we learn to evolve – I believe this is an important component of resilience. There is probably a limit at which the pace of change becomes an issue, but I am left with the abiding notion of “bend, not break”.
So, we can now accept that the acute stress response is triggered by a challenge to our world view, and that it is possible to adapt to them successfully. This is normal. Incomplete or unsuccessful processing of these challenges may lead to the development of chronic responses. This is not normal and this is where psychological wellbeing becomes compromised.
In my personal journey of discovery, the “why did this occur” question had now been answered in a generic sense. I still sought out the answer to the “why me” question. To understand that, it will be necessary to explore personal and emotional aspects of my experience and we shall do that on another day as even writing about this is draining.
Further material and references
Armstrong, A., Galligan, R., Critchley, C. (2011). Emotional intelligence and psychological resilience to negative life events. Personality and Individual Differences. 51 331–336. Available at: https://www.researchgate.net/profile/Andrew_Armstrong5/publication/229324277_Emotional_intelligence_and_psychological_resilience_to_negative_life_events/links/5bc6615aa6fdcc03c7893e1e/Emotional-intelligence-and-psychological-resilience-to-negative-life-events.pdf
Carley (2018) Moral Injury in Emergency and Pre-hospital care. Esther Murray on St Emlyn’s podcast. Available at: http://www.stemlynsblog.org/moral-injury-in-emergency-and-pre-hospital-care-esther-murray-on-st-emlyns-podcast/
Carley (2019). Wellbeing for the broken part 3, the Podcast. St Emlyn’s. Available at: http://www.stemlynsblog.org/wellbeing-for-the-broken-part-3-the-podcast-st-emlyns/
Crowe (2019a) Wellbeing for the broken. Part 1. Liz Crowe for St Emlyn’s. Available at: https://www.stemlynsblog.org/wellbeing-for-the-broken-part-1-liz-crowe-for-st-emlyns/
Crowe (2019b). Wellbeing for the broken. Part 2. Liz Crowe for St Emlyn’s. Available at: https://www.stemlynsblog.org/wellbeing-for-the-broken-part-2-st-emlyns/
Currier JM, Holland JM, Malott J. (2015). Moral injury, meaning making, and mental health in returning veterans. J Clin Psychol. 71(3):229-40. doi: 10.1002/jclp.22134.
Park (2010). Making Sense of the Meaning Literature: An Integrative Review of Meaning Making and Its Effects on Adjustment to Stressful Life Events. Psychological Bulletin. Vol. 136, No. 2, 257–301.
Janoff-Bulman, R. (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.