Editors comment: This is the first of two blogs written by our friend and colleague Liz Crowe. They describe a very painful experience and series of events experienced by someone close to us, and someone who you will also know through the blog and at conferences such as SMACC. As an editorial team we have debated at length whether to publish these blogs (as we debate all our posts). They give insight into a very personal journey and lay bare the emotional impact of our work. This blog comes with the warning that it may trigger emotions that you have experienced, or are yet to experience. It’s important that you read both parts.
This first blog will describe in raw detail the chaos and fluctuation of emotions you may endure. It is meant to highlight the extreme feelings and to assure you that it may all be terrifyingly normal. This first blog was written, for the most part, at 2am three days after the event and it may be confronting for some readers. If you are currently in a difficult place maybe read this with a friend or people around.
Part Two will address how do you claw your way back to wellbeing after such an event.
Specifically, Liz has asked that this should not be perceived as a call for sympathy, contact or pity. She shares the story here to help others through describing what is many ways a ‘normal’ response to work related stress.
Liz: Today I want to explore what wellbeing looks like in the context of an event or case at work that has such a profound impact on you that you are worried you may be temporarily or permanently broken. Whether it’s a little, or a lot, being broken takes every normal coping strategy you have and smashes it into little pieces. This often leaves you feeling vulnerable and fearful. It may even make you afraid that the job you often love, the job you may be completely dependent on for your livelihood has become impossible to do in the future…..that you will not be able to pick up the pieces of your life and function again. We are not talking about a photocopier jamming, or missing a plane when you have an important meeting to get to. This is where humanity feels foreign or when you believe your actions may have inadvertently caused the injury or loss of a life, or when the burden of responsibility or exposure to something so tragic feels like it has pulled you under water and it doesn’t feel like you can fight your way back to the surface.
This is something only a select few professions ever face. It is not something we talk about at dinner parties, and maybe something we never, ever say out loud to another human being. These are the events or cases that haunt us somewhere in our psyche. The fears and stories that we work hard not to give oxygen to, and usually only rear their ugly heads again when the next event occurs…… Recently I found myself back in that space for the first time in several years and it was suffocating and confronting and terrifying. A bloody awful place to be. Bound by sensitivity, confidentiality, legal processes and maybe shame, there are few places to turn and the next day at work looms. What the hell does wellbeing look like then?
Due to confidentiality no details will be shared about the event. What I will say is that I had suspected something clinically several years ago and despite my best efforts of raising concerns and advocacy over the course of over a year I was powerless to intervene. Several years later my worst fears were realised. It was the worst way to be right.
I have spent the last four and a half years working away at a doctorate dedicated to examining the wellbeing of all staff who work in critical care and it is my deepest hope that it will have wider ramifications for health and those in emergency services. I view myself as extremely resilient and robust and armed with all the psychological knowledge on this area and still I felt broken and suffocated by this event. I am sharing this experience not for catharsis or for empathy, I share it in the hope that it reaches others who need it to normalise reactions and remind you that you are not alone, nor weak. That this may be not career ending. That there may be a path out.
What I have discovered in my research and a comprehensive review of the broad literature on wellbeing and risk to health professionals is that we are in much better shape than people believe. Burnout may not be the pandemic everyone speaks of. It may be an indication of the emotional exhaustion most adults have to co-exist with given the challenges of modern life. The distances for commuting to work and schools, the long hours at work and the enormous expectations we place on ourselves across all the components of our lives in this fast-paced world, irrespective of occupation.
What I have also discovered is that burnout, when present, can be ‘cured’ or ‘minimised’ or ‘managed’ and that it frequently co-exists with joy, meaning and a sense of compassion satisfaction. Finally, burnout is rarely simply an individual deficit. Burnout is a complex culmination of system and leadership failures and these components are unfortunately not often explored in the context of burnout.
Wellbeing has an individual responsibility and a systematic, organisational and leadership responsibility. Currently there is too much focus on the individual and either no systemic or organisational response. Frequently what is offered by organisations is grossly under-resourced or provided by the goodwill of individual health professionals who have taken on the task in addition to their already busy working lives.
How we successfully work on wellbeing in health and more specifically healthcare professionals within critical care is complex because human beings are complex. Therefore, when addressing wellbeing there is no “one size fits all’ solution. Healthcare professionals within critical care require an acute self-awareness, almost a painful self-awareness, in order for them to understand what it is they require and when. Wellbeing requires a multifactorial response on the foundations of basic principles such as an awareness of personal health, sleep, eating well, being well hydrated, movement/exercise, collegial teams, understanding and connected leaders, wider connection with family and friends and a rich and fulfilling life outside of work (none of which is easy to achieve especially for those facing medical exams and doing constant shift work!).
All of these things, however, can be easily compromised and thrown into disarray when we hit THAT case. THAT scenario or event that is so confronting, so raw, so frightening and often so painful that none of our normal strategies seem to help.
It is irrelevant how you have come to this place. Medical error, cumulative grief, a misdiagnosis, a confronting assault to yourself, or what you have witnessed and treated at work, an accumulation of such events or a death that just will not stop being in your line of sight. You are here and it is terrifying.
A PERSONAL ACCOUNT
We Can All of Us Be Hurt And No One Is Exclusively Safe from Sadness And Worry”-Thee Sisters Brothers’ by Patrick de Witt
In the immediacy of the crisis I share the experience of the event with my valued colleagues. It means something different to them because they don’t have the history however it is still horrific for all of us in the moment, the hours, the shifts. We oscillate between grief, horror and black humour. All of us are desperately trying to find somewhere safe to put this event in our mind knowing we have several hours of our shift to go. Notes to write. Sense to be made of a senseless event. No one says out loud “how are we supposed to cope with this?”. When I look around the room everyone is holding on by a thread, we are trying desperately to be strong, professional, to hide our emotions. Eager to put on a brave face and remain present and aware of their colleagues present and the other dozens of patients and families and duties that lay outside of the room.
Everyone needs a work wife or husband. I go to mine. I am too distressed to contain how I feel and leave again. I run outside the hospital to ring a trusted friend. I can’t speak. I am sobbing. I briefly share, then contain. I am not placated and yet I am also not comforted. I put on my poker face and re-enter the world of ‘work’. This is critical care. You never have the luxury of saying “I am done for the day”, there are other patients to be seen, work to be completed, colleagues to check on. It is the job and it doesn’t pause for anyone or anything, there is no shutting the doors for the day.
Initially you can rationalise its omnipresence. Of course, it is natural to be shaken, teary in the toilet and/or feel physically ill. “Do not panic”, I tell myself. You know this stuff, it’s the core of your PhD, it has been your life’s work for over 20 years. “This is a normal response to a very abnormal situation” becomes the mantra I am saying over and over in my head. I try to use it as a ‘learning experience’ for others. I try not to grieve privately even though my grief is exceptionally rare (which is what I desperately want to do), I allow myself to be teary in the tearoom and in our office to show the junior staff in particular that there is no ‘growing immune’ to these big events, that is it normal to feel this way, the reality is all I want to do is hide, grieve, give up. I feel ashamed and shamed beyond belief. I feel ashamed about the case, that I was powerless to change the outcome. Ashamed about my heightened emotions that I cannot seem to get under control. I feel ashamed to live in a world where atrocities such as this can happen. Ashamed. Shamed. About everything. I am a failure.
For me there is also guilt. The guilt is pervasive. It is not just the enormous guilt about not having been able to successfully intervene all those years ago. I feel guilt for the pain and suffering. Guilt that our systems do not always succeed. I have a sense of ‘survivor guilt’. Guilt that I have a blessed life compared to some of the families we work with who have so little? Why do I get to tuck my children in safely each night? Guilt that my children are privileged when others are not. Why do I feel so overwhelmed by this case when I willingly signed up for this work, this knowledge? My patients have never been afforded such luxury. Did I fail? How responsible am I?
Several days into the crisis I try and reflect on all the things that may help in a desperate attempt to get things ‘back under control’.
EXERCISE: Exercise is a huge part of my wellbeing strategy. I start each morning with exercise, seven days a week. I am comforted by routine. I also possibly have obsessive traits, which has both positive and negative ramifications. I believe powerfully in strong body, strong mind. Equally, I really love food so I have to move a lot, to eat a lot and NOT spend my life in an endless stream of clothes with elastic. The night after my latest ‘haunting’ I walked 12kms after work with a friend under the night sky. I look to the sky to remind myself that the world is so much bigger than my day, that night it was not of any help. I talk endlessly about everything but my day. I can’t. I am bound by confidentiality. I am sort of relieved for this. I can’t bear to say the words out loud. I don’t sleep. I am endlessly haunted by the event. The next day at Reforma Pilates I cry quietly during the session. I fear I am in trouble mentally. I feel completely raw and frightened. I resolve to keep exercising regardless of how I feel or how much I can or can’t sleep. I know the endorphins and routine will help. Even so, I know for this case, exercise alone will not be enough. I lift weights when I feel I don’t have the energy to do cardio. I walk and walk. I try to exercise away the pain. I will not give in to the desire to lie down and not move. My own children need me I cannot surrender to this.
SLEEP: It has been five days since the event. Sleep is evading me. It takes a long time to go to sleep, then I sleep restlessly, I grind my teeth. I have endless dreams where I am powerless and out of control. I wake too early. I wake fatigued. I wake with a headache. We know that nothing brings on the ravaging regret of rumination like the quiet that comes with bedtime, usually at night.
Pick, pick, pick. I lie awake picking at every psychological scar I have ever had. Why is it in a crisis like this we don’t just reflect on the event? Why do we have to think of every painful event that life and work has thrown our way? These events undermine who we are and what we do. The author of all these narratives lie solely with us. Rational brain knows this and scolds’ irrational brain. Irrational brain wins every time. Rational brain is a slight little rider or jockey. Irrational brain is a six-tonne elephant. The elephant sits on my jockey every time. Elephant 486, Jockey 0. I lie awake. Why am I such a failure? How did I fail this case so badly? I am losing confidence in myself in every aspect of my life. Let’s add bone-tired fatigue to my ever-growing grief and fear about this event. It is difficult to heal when you are exhausted. The cyclical nature of this is not lost on me. Sleep becomes another thing to fear. I am haunted by images most human beings will never have to see or even imagine.
FOOD: Fuelling your body is important. The old saying ‘you are what you eat’ rings very true. In a crisis food, fluid and of course alcohol play an important role in how we function. I am a huge comfort eater. I’ve eaten lots of ‘treat’ foods in the past five days. Ice cream, cake, biscuits, chips, French fries, anything that contains potato and salt is my kryptonite. I try to comfort myself with food. Maybe I am punishing myself? Foods not normally in my every day diet are being consumed mindlessly. I am trying to be non-judgemental of myself during this crisis. It is easy for this to be an added narrative of ‘failure’. I know persecuting myself about what I am and am not eating is rather unhelpful, I persecute myself anyway. I was supposed to go out for cocktails last night with friends. So very tempting to get smashed and turn off from this mess in my mind. For once past wisdoms won out. Alcohol for me is very soothing in the moment and then very depressive in the long term. I drive the car and do not drink. I am no longer in my 20s. I am learning from past mistakes about alcohol. Elephant 486, Jockey 1. I do eat a lot of chips, French fries and chocolate. I wish food could take away this torture. It doesn’t. The food I am consuming leaves me sluggish and heavy. It matches my psyche. I keep eating.
CONNECTION: Connection is very important. We crave it as humans. I am lucky to be blessed with great family and friends. However, I tend to be the ‘carer’ and ‘supporter’ rather than the seeker. This is a very uncomfortable role for me. I know I need help yet connection with others at the moment is difficult. I feel incredibly isolated and alone. This isolation is growing my grief. I question who I can legitimately share this with when it is bound in so many complex systems? I have to ask myself who amongst my family and friends can bear witness to this information and not be damaged by it as well? I do not want to vicariously traumatise my loved ones or my colleagues. The isolated few I can share this with are open and empathic. Though everyone continuously telling me “it wasn’t your fault’ is really unhelpful. Cognitively, I know I was not responsible. Emotionally the guilt and grief are consuming me. Unless people work in health they cannot possibly imagine. I want them to understand, I don’t want them to understand. It is complicated. I want to go inside a cupboard and shut the door and sit in the dark. I want to be held. I am not sure what I need. I just know that I need and I don’t know what to do about it.
REFLECTION: For the very first time in my career I see an external counsellor about work. I am caught between wanting to reflect and make sense of these painful emotions and the haunting images and feelings and just wanting to be completely pragmatic and shut it down. Talking about it was useful though the rehashing of the event so soon was almost too much. I am a little overwhelmed to relive it. I cry so much in the first session it exhausts me. I didn’t know I was capable of such raw, exhausting emotion. At least I shared with someone how bad things felt. Part of me wanted to stay all afternoon with the counsellor, lie in her safe room, feel contained. The other part of me wanted to run and never see her again, to never speak of the event again. I just want the whole thing to be over. I come home so drained from the session and yet I cannot sleep.
Day 6. Everything is presenting in extremes in my brain. My headache continues. I am starting to despair that I am truly broken. Every day I fight with myself about whether I will go into work. I am scared that if I don’t go to work, I will never return. I keep working. I see patients. I am empathic and caring and thorough. If anything, I am more hypervigilant than normal, I can’t make a mistake. I smile and I make jokes with my colleagues. I then go and sit in the toilet and cry. There is a tremor in my hands I can’t seem to still. If anyone raises the case, I am teary, I struggle to remain professional. I watch the other social workers in my office watching me cautiously. This is very new to them watching me suffer. It is very new to me.
During a crisis such as this fear is pervasive. Fear of the constant flashbacks and memories. Fear of the ruminations and ‘what ifs?’ Fear of being unable to return to work due to systemic investigations (a real threat for some) and the scrutiny of colleagues (imagined or real) or just those who want to know ‘what happened?’. There is also a churning fear of being unable to return because you no longer have the resilience and robustness or the appetite for the work…. Let’s face it, it is just fear of everything. Suddenly I am so very scared of EVERYTHING. It has been a week and if anything, I am deteriorating rather than getting better. I am worried someone will notice so I work harder at being ‘normal’.
The images of the event are burnt into my retinas. I have to work and engage with people all day while carrying these images. I am suffering. All of a sudden other images from work are rearing their ugly heads. Cases I haven’t thought of in years. Years of absorbing grief and trauma feel like they are filling my body. Every part of me is disintegrating. All that is left is sadness.
The fear of not being able to continue in this work is all consuming. For many of us this work is an enormous part of our identity, of what creates meaning and purpose. I start to worry what it would mean if I could no longer do this work or if I kept working and no longer did it well? If I was no longer a social worker in critical care? All the things I would lose and miss? How else I could possibly earn money? How could any other job compare? I fear that everything in life could change and be lost. I realise that I will not be able to complete my thesis in ‘staff wellbeing’ after ‘breaking’. How can someone have a PhD in wellbeing if they are too unwell to work?….oh the irony. I have talks and workshops and conferences coming up. I would have to walk away from it all. It would be loss upon loss. Fear on fear. I am the fraud I always feared I was.
“This is a normal response to a very abnormal situation”….I say it to myself over and over again
The weekend arrives. Thank God I don’t have to go to work. I think this will bring relief. It doesn’t. suddenly I have no structure and everything becomes amplified. I am crying for hours on end. My kids start to feel worried and try to make things ‘better’. They have never really seen me distressed. I am really frightening myself. I try to remember past cases that have ‘broken’ me. Were my reactions this strong? Did they last as long? I can’t remember?
I go to Church. This is not a regular nor an uncommon experience. Crisis Orientated Faith is a real phenomenon. It is when we turn to faith beliefs, often from childhood, only during times of crisis. I like the peace and tranquillity of Church. The rituals are comforting. I look at the statues and other icons. I pray about the event. It is distressing. It is comforting. The pain persists long after Mass is over. Nothing appears to ‘fix’ this pain.
I have ‘survived ‘ 8 days post the event. I look the same to everyone else. I cannot recognise myself.
Re-reading this several months down the track I cannot recognise myself. I am tempted not to post this. I will do it for the SOLE purpose of reaching others who may be currently feeling or have felt this low. Despite this overwhelming sense of fear and loneliness, the reality was I was not alone. If you are feeling any of the above emotions please reach out to someone – personal or professional. Keep yourself safe. You are important. Part Two is all about clawing your way back from feeling like this. You can survive this. You will have to fight your way back. There will be people and things that will help.
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
The Sisters Brothers: de Witt https://www.goodreads.com/book/show/9850443-the-sisters-brothers
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