Full transcript below – or watch as a video with subtitles.
Health and social care professionals who work with people who’ve suffered traumatic experiences are themselves at risk of vicarious traumatisation.
So what can you do to understand and protect yourself from this?
This week Dr Paula Redmond is joined by Anne McKechnie, an independent Consultant Forensic and Clinical Psychologist.
The pair discuss the psychological impact of being in a caring profession and the differences between vicarious traumatisation, secondary trauma, compassion fatigue and burnout.
Anne also outlines steps we can take to prevent vicarious traumatisation at organisational, team and individual levels.
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Transcript
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Paula: Hi, I’m Dr. Paula Redmond, a clinical psychologist, and you are listening to the When Work Hurts podcast. On this show, I want to explore the stories behind the statistics of the mental health crisis facing healthcare professionals today, and to provide hope for a way out through compassion, connection, and creativity. Join me as I talk to inspiring clinicians and thought leaders in healthcare about their unique insights, and learn how we can support ourselves and each other when work hurts.
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Health and social care professionals who work with people who’ve suffered traumatic experiences are themselves at risk of vicarious traumatization. My guest this week is Anne McKechnie, an independent consultant, forensic and clinical psychologist who has a wealth of experience in this field. In this episode, she outlines what vicarious traumatization is and how we can recognize and prevent it. I began by asking about her professional background.
Anne: I’ve got to that age where my background takes a good hour.
[laughter]
I’ll give you a condensed version. As you said, I’m an independent consultant, forensic and clinical psychologist. Before I retired from the NHS, I was a consultant within a forensic mental health service here in Scotland. Dealt with everything from high-secure in prisons to low-secure, medium-secure people who had committed very serious offenses but were also unwell and requiring extra mental health services, specialist mental health services. I’ve always had an interest in that interface between offending and trauma, because you can’t work with offenders and not understand that actually, they generally don’t come from great, happy, secure childhoods.
I’ve always had the interest and my last post was actually I headed up a criminal justice arm of a trauma service dealing with people who had committed offenses. Where there was an awareness that lots of their offending and lots of their risk was related to the fact that they had had experiences of complex trauma. Where they had been abused by people upon whom they’re dependent. The definition of complex trauma is, it’s complex because of the nature of the relationship you have with somebody, with the person who perpetuates the offense. You can’t get away from them essentially.
Alongside that, I’ve also been on the parole board for Scotland. I was asked to be involved in Time to be Heard, which was a preliminary exploratory study for how we manage people who’ve been abused within the care system in Scotland. I worked in a children’s secure care center for 10 years, so I’ve had a very varied and very, very enjoyable career. I’m happy to say at the grand old age of 60, I’m still very much enjoying it. I’m very privileged to be working with the Scottish Child Abuse Inquiry. I work with Judicial Institute in Scotland.
We’re trying to do some training through the NHS Education Scotland in helping judges and the legal processes to become more aware of how you can alter your systems to become trauma-informed. You can’t talk about the trauma that’s been experienced by our patient group, if you like, without being aware that actually it has an impact indirectly on people who work with those people who have themselves been through trauma. It’s not something you can go in, do lightly, just get really engaged in it, and then walk away and not be in some way impacted.
The issue about vicarious or secondary traumatization, compassion fatigue, burnout, all of these phenomena is intrinsically linked to the fact that we’re hearing and seeing sometimes situations where there has been extreme suffering.
Paula: I think that is something that I work a lot with health professionals, who are very much in a health context, and I think one of the problems I come across is that bit is just not voiced. People are being exposed to and working with trauma all the time, and that bit about being able to acknowledge and understand the impact of that on workers is not there. I think if we are lucky enough to work in a trauma-informed service, then that is much more part of the discourse. I really wanted to unpack that issue of vicarious trauma with you, because I think it’s a very overlooked issue for healthcare professionals broadly.
You mentioned a few terms there, which I think can overlap, and sometimes we might muddle up together. We’ve got vicarious trauma, secondary trauma, burnout, compassion fatigue. It’d be great to get your perspective on how we define those things and where they might be different and the same.
Anne: Yes, absolutely. I think that we often tend to think that trauma only refers to the big stuff, so in terms of healthcare, we only think that trauma will only refer to people who work in emergency departments. I’ve also done some work in the past with our Air Ambulance Service here in Scotland, and we think it’s got to be the big really bloody trauma if you like. My brother’s a maxillofacial surgeon. To him, when I talk about trauma, I can see him thinking, “There’s no blood and guts that can’t possibly be traumatic,” [laughs] but actually often what we see is that low, slow, steady ground of distress. Which could be everything from your certainly emergency departments-
It equally applies to GP practices. That particularly applied during the pandemic. Where you saw that continual managing of distress, fear, and threat was extremely difficult for people who were in services where you might not obviously consider that they actually have to be trauma-informed. Now, we’re very fortunate in Scotland and, in fact, I would urge your listeners to look this up as NHS Education Scotland, have produced– Are doing what they call the trauma training framework. I’ve been extensively involved in that and some wonderful people at NICE, who are rolling this out.
The idea is that we want people across the workforce in Scotland to have a basic understanding about how trauma impacts on the patients that we deal with. Alongside that is the recognition that trauma isn’t just outside, trauma happens to people in health and social care settings as well. The idea being that actually if you can begin to understand where somebody’s coming from, what the presentation might actually be symptomatic of things that you don’t know anything about yet or they might not be willing to ever acknowledge. It actually gives that element of that how can we meet people in that way. That’s been very, very helpful. I think we’re trying to instill that in lots of health and social care staff.
Paula: Could you give us a definition of vicarious trauma?
Anne: I suppose as it says on the tin, it’s vicarious in that it’s actually not directly. You’re not directly experiencing the trauma. My understanding, a lot of the work came from the states when there was Pearlman who first became aware of this concept. It seemed to be rated directly with working with people where there was lots and lots of traumatic behavior. I saw it in full technicolour if you like, when I was working in the secure care setting, where we had young people who were coming in, who were distressed, who were angry, who were violent. Who were displaying all sorts of risky and challenging behaviors.
The process of managing that, being around that, having often that direct threat to self amongst staff, alongside hearing and seeing evidence of what they’d been exposed to in terms of their own trauma. The children’s own trauma, young people’s trauma, led to this presentation. I suppose we have a continuum from burnout through compassion fatigue, secondary traumatization to vicarious traumatization. Vicarious traumatization is a much more, it changes your world view. It’s linked to that continued and close exposure to the sort of distressing materials we’ve talked about. Constantly having to read accounts of abuse or view the police are particularly vulnerable to this.
For example, people who are dealing with internet child pornography, that continual no break, no change from it, and that sense that you begin to see the world differently. If you’ve gone into a profession where, for example, you’re caring and you’re concerned, and you believe fundamentally in human nature. A symptom of vicarious traumatization, whereas when you become suddenly or you’re continually cynical, you think the whole world’s out to get them. You actually won’t let your children be babysat because you’re convinced that every single person who wants to babysit, well, is a potential abuser.
You see single parents in the park and don’t assume it’s a single parent, but you assume it’s somebody who’s snatched a child and is going to abuse them. It’s that really distressing change in how you see the world, and a change in your own personal view. Some people are perhaps naturally a bit more cynical than others. I tell everybody this, my nickname when I worked in forensic was Pollyanna, F-ing Pollyanna was the full title,[laughs] but I was known as Pollyanna because I have that view that it’ll all be fine. Everybody’s genuinely really a nice person and we just have to give them the right.
For me, that would be if I was becoming overly cynical, but if somebody started off being cynical and stayed that way, that wouldn’t necessarily be evidence of vicarious traumatization. It’s a really a fundamental shift in your view of the world. It’s a fixed shift rather than something that might be temporary.
Secondary trauma is the next one that’s also linked to constant exposure. You get symptoms. It’s less about your general view of the world, but actually what you do is you find that. Again, I can think of clinical experiences where I’ve actually had particularly heinous events that I’ve had to deal with and I can’t stop thinking about it.
You would expect there to be some processing that goes on. You’d expect there to be some reflecting in the immediate aftermath of that experience. Where actually you can’t get it out of your head and you find that you’re actually avoiding anything that’s a reminder of that. For me, some of the worst offenses I had to work with were ones where there had been infants involved. Where there was one particular offense where there had been neonatal homicide, neonatalcide.
The most important thing I ever did in my life was to have my children. That thought of, I couldn’t get that image out of my head for a while. Now there are things to do. There’s a difference between being disturbed for a few days a week even and having something you can’t get away from. Also, accompanying that with secondary trauma would be finding that you couldn’t stop being anxious or you were overly irritable for a long period, or you were very tearful. It’s a much more clinical presentation, whereas vicarious trauma, traumatization is much more about that shift in your worldview. You might not necessarily have that affect impact but you would have that view.
I think we can think of examples in the healthcare, police prisons, perhaps you can see that where there are people have been around situations for such a long time that actually they begin to think that all offenders are lying, and that all victims are making it up. There’s that blanket view of that comes in which is symptomatic vicarious traumatization. Whereas secondary trauma is much more of that clinical personal feeling of distress that’s associated with it.
Paula: Thank you. That’s really helpful distinction. I suppose the next category in that continuum, you mentioned is compassion fatigue. Can you say a bit more about that?
Anne: That really it’s what it says in the tin. It’s that reduction in that ability to be empathic. I think what’s really fascinating is that actually we are naturally empathic. Human beings are social animals first and foremost, and we have a desire and a need to connect to others. I think particularly in the caring professions in health and social care settings that is what attracts us. That’s what draws us in, is that sense that we like to connect with other people. Empathy is natural. If people are overly exposed again to distressing situations whether that’s the context in which they work, or the materials that they’re working with, the people that they’re working with, then we have a reduced ability or willingness to be empathic.
It’s that sense that I don’t have any more to give. I’m worn out. I don’t have anything else. It’s usually towards one group or one situation. Vicarious traumatization is your worldview. Secondary traumatization is a sense of a clinical feeling of it not being right and encompassing lots of things that you do in your life. Compassion fatigue would be towards one group of people. I think at the risk of sounding political for a moment, we’re seeing a bit of that in terms of people thinking people’s reactions to refugees. There’s a sense that actually and it’s difficult to keep in that place where you feel really sad for a particular group of people.
What you’ll see with compassion fatigue is not being interested anymore. Just not wanting to know about that group or that situation rather than encompassing all aspects of your life or society. I think the thing is as well to be clear that these aren’t fixed permanent conditions. We all swing in and out of them. During the course of a day, I could start off being quite sympathetic towards the situation, quite empathic. Then halfway during the day, usually when I eat my lunch I find that actually I really don’t want to hear it anymore. I cannot cope with anymore. I recognize I need to have a bit of a break, and so I can come back. It’s often a fluctuating condition and burnout is a particularly fluctuating condition. It’s not a clinical diagnosis.
I think a lot of the time we want to find a clinical name for it. It is on a spectrum. It’s a presentation rather than a diagnosis but it is linked to anxiety, it’s linked to low mood, it can be linked to substance misuse. It’s characterized by emotional exhaustion and cynicism and a bit of interpersonal disconnect. Everything’s on something of a spectrum. There was a lovely slide that I have used, thanks to a wonderful researcher called Carly Trevor, who’s done lots of work in fact with compassion fatigue in Australia with judges. She’s a doubly qualified clinical psychologist and a lawyer.
She’s done some really interesting work and she talks about this continuum of over-involvement and under-involvement. I think we can generally plot ourselves on that, which is at the under-involvement level, it’s that cynical victim blaming, displacing onto other issues. People saying, “This is not about the fact that I’m actually under-involved and I’m worn out and I’m tired and I’ve got no energy anymore.” It’s about the fact that the managers are rubbish, and it’s about the fact that actually, the government doesn’t do enough for that.
Now, there might be an element to which that’s true, but it all becomes all about actually, maybe I’ve just had enough. I think we can put people into those categories. We might even be supposed to say that there are certain disciplines, certain professions that go into that category. Certainly, in some of the work that I’ve done with justice systems, we see lots of that sense. We see that all the time in terms of some management of some rape and sexual assault cases. The person put themselves in that situation. Historically, we’ve had situations where people have said, “Well, that girl was wearing a mini skirt, therefore, she must have been asking to be raped.”
Thankfully, that’s becoming a rare thing. For me, that would be an indication that somebody was really at the under-involved level of empathy, and perhaps was showing signs of vicarious traumatization. At the other extreme, we’ve got that over-involved. I think lots of people who come in from a very compassionate and caring stance often become over-involved, in that sense that is only me can treat this patient. I’ve got a special relationship with them. We used to hear this a lot in care settings as well. All you need is me to come in and I’ll fix this person, which is puts a huge level of responsibility on that individual.
It also undermines the person that perhaps needs treatment, undermines their ability to get it from elsewhere, and also undermines the rest of your system. That’s an indication to me of vicarious traumatization, secondary trauma, burnout, all of these issues and also trying to fix everything. People who come in and think, “This all needs to be done and we’ll do this and this.” That’s because often they’re overwhelmed by the need of that particular situation that patient that’s in front of them. I want to fix everything.
The thing that I see most often is overly excusing other people’s behaviors. This came across a lot in some of the trauma work that I did where people had had terrible histories, really terrible histories.
There has to be an element to which you say, “Yes, you’ve had a really difficult time but actually, it’s not fair on me to excuse your behavior all the time. It’s not fair of me to do that to you because ultimately you have to start accepting responsibility.” One of the mantras that I say repeatedly, special isn’t good. If somebody’s treated as special, children who are abused are special to their abuser. Special isn’t always something that’s nice and makes you feel nice and warm and cared about. Often it’s about a manipulation.
Getting into that sense of overly excusing others’ behavior, other people’s behaviors is the result of over-involvement, is often related to that sense. They need special treatment and actually particularly people who’ve been abused in childhood are most difficult people to engage and to treat because of their extensive level of mistrust and fear. If we treat them as special, it’s repeating lots of those dynamics of the abuse that has been perpetrated.
Paula: That’s a really good point and I think that’s something that is always helpful, a question that’s useful to hold in supervision thinking about people who do therapeutic work. Are you doing something different for this client than you might do for anyone else? Just noticing why that might be.
Anne: Unfortunately, I don’t know that lots of the supervision that we are supposed to provide looks at that. There’s a lot of confusion amongst some professions about the difference between task-centered supervision and reflective supervision. I think you have to have reflective supervision. I would be so bold as to suggest that’s more important than your task-centered because most people know what they’ve got to do. If they’re not doing it, that’s often to do with some blockage in how they’re feeling and how they’re coping rather than because they don’t know that they’ve got X reports to write or somebody knows to complete.
Paula: I think it would be great to maybe think more about that when we maybe think about how we can prevent and respond to vicarious traumatization. I know you’ve touched on some of these things, but I wondered if we could just look in a bit more depth into what the signs are of vicarious traumatization. How we might identify that that might be going on for ourselves or for others.
Anne: I suppose it’s probably less important that we label, whether it’s vicarious or secondary trauma than we actually think about what would be the signs for somebody. The signs would be finding that you can’t sleep after a certain amount of time. That your sleep is disturbed. That your mood has differed. That you are either working too much or working too little, avoiding work. If you find that your interest in your normal activities and hobbies has gone, I think the people that you’re closest to, your loved ones, your colleagues that you’re close to, them being able to recognize that something has changed.
Something has shifted in you, if you’re excessively tired. If you find that you are either– I know when I’ve got to compassion, to fatigue, burnout level when actually I’m quite interested in current affairs and when I really don’t want to know anymore. When I make a concerted effort to avoid all the news apps because I just can’t cope with anymore. It’s that sense of having an insight and understanding that you are different than you normally are, and people around you are saying there’s something not right. There’s a variety of symptoms if you like. I think it’s a change in how you feel, how you’re managing your emotions, how you’re managing your activities, your interests, what your thought processes are.
If you don’t have the energy, if you’re tired, if you really just can’t think straight, these are all things to be on the lookout for. Just that shift. As I say, I would challenge any health professional to not have that at some point. It’s a risk that we run in the work that we do because you can’t be going in and giving that empathy. I’m sure you know Brené Brown’s work, she’s done a lovely video on empathy really. It’s really lovely. Again, I would urge your listeners to look that up. It’s that sense of we want to be beside people. It’s not about looking down and saying, “Oh dear, that looks terrible and why don’t you do this and why don’t you do that?”
It’s actually saying, “This is really tough and I’m going to be with you on this, I’m going to hold your hand, and I’m going to sit beside you. We’re going to go through this together.” That’s what empathy is. That is so, so draining. It’s so draining. You can’t possibly give of yourself so much and then not expect it to have some impact. We can look out for the signs, but sometimes the situation’s gone too far before we recognize it. We should be really working in a very preventative way to make sure that we don’t get to that. One of my concerns of what we often do with health services and so on is that we have occupational health that come in. By the time they come in, it’s not too late, but you’ve got much further to come back from.
Paula: I’ll come back to that and unpack that idea a bit more. I also just wanted to check in with you whether you’re likely to see those kind of more classic trauma-type symptoms of intrusive thoughts. Intrusive images, nightmares, the reliving experiences. Is that something you might see as well?
Anne: Yes. I think that’s often. The other thing, we’ve got to remember is that people have lives that go on outside work. I’ve seen this more when people have had– For example, for my personal situations, I say it was when I could feel some personal resonance because having had my children, and that people will see certain points in their lives. Their children will be getting to certain stage or they might have other life events going on, bereavements, even nice life events like weddings and so on. Where actually, you are more vulnerable to that.
You’re more invulnerable to that intrusive experience. People will see. I couldn’t get that out of my head. I found that I was obsessing about it. I wanted to look up more and more on the internet about that particular case if just I became really enmeshed in it. I certainly have seen that.
Paula: Just thinking about some of the people I’ve worked with where you’ve been through or worked within a really traumatic clinical staff. Whether that’s in health or therapeutic setting, which has been tough. Sometimes it’s the organizational response to that. That is the thing that really sticks with them. How an organization maybe hasn’t listened when concerns have been raised. Or has had a very punitive response and that becomes a traumatic experience in itself that when they needed help they were punished almost. Is that something you’ve seen?
Anne: Oh yes, absolutely. I’ve done a lot of work with the School of Forensic Mental Health here in Scotland, to do work about what we call keeping staff safe. I think we have to make a distinction between– After every, say any major incident, for example, or some incident that requires some recording. In forensic settings, there was lots of staff assaults. Lots of patients assaulting one another. Everyone had to be recorded. There’s often a need to go in and back in and get the facts if you like.
What we drew was the distinction between the fact-finding so that you could then determine whether or not errors had been done. That simple de-stressing, we didn’t call it debriefing, we called it de-stressing because there was a sense that debriefing was a specific phenomenon that was put together. There’s been some mixed evidence as you’ll know about the validity of debriefing. What we used to say is, “People just need to have an opportunity to sit around and have their emotions validated, and have their sense of that experience validated.”
Everybody has a different way of looking at things. You could have five people involved in an incident. [chuckles] Particularly as a psychologist, you’ll get 12 different opinions of what goes on. [chuckles] You will get these and you have to be able to validate that because if there’s a sense from managerial settings that they’ve got to cover their backs, that they’ve got to make sure it doesn’t happen again, it becomes very much a blame culture. I would venture to be boldest to say that most people who go into a caring profession if something has gone wrong on their watch, they feel dreadful about it. Really do feel dreadful about it. There has to be an acknowledgment. Actually, this must be really tough for you.
If you have a more compassion-focused, trauma-informed way of working, you’re more likely to get better information from people. We’re seeing this in the courts, we’re seeing this in legal settings. If you actually have that sense that actually, if we’re supportive and we understand what somebody’s going through, we’re actually probably going to get better information than if we go in with a very high-handed judgmental risk of our sway. Where we’re looking for somebody to blame, where we’re not actually saying, “You know what? This probably happened as a result of a whole system that was going wrong at that time.”
Things very rarely happen in isolation, but you’re going to get a better response if you’re going with a more compassionate way. You’re also going to protect your staff better because, at the end of the day, these health and social care settings are dependent on the people that work there. If staff fell sick, you don’t have a service.
Paula: Maybe that brings us to thinking about the question of how we can prevent vicarious traumatization in our healthcare. I’d like to think about that with you on individual, we can do as ourselves, what we might be able to do within teams and then more broadly and an organizational level. Maybe we can work backwards. Maybe we could start with the organizational bit. What would you say is really important for organizations in order to prevent this?
Anne: I think the most important thing is that you have senior management who buy into it. A lot of the time, we try to do things from the bottom up, so to speak. We try to do it from the staff or on the floor. Actually, you need to have senior management buying into it and you have to have senior management engaging in it. With the organizations I’ve worked with where they’ve had most effective, I would say the most effective processes for preventing the vicarious traumatization because that’s the– The best thing you can do is to try and prevent it, and have systems in to recognize it. Those systems were actually the people or the senior team are walking the walk, as well as talking the talk, and where it’s actually demonstrable to others. To the rest of the team, they can see senior team going in for the training or their reflective practice.
That’s the most important aspect, so you have to have that element of acceptances is important. Because not only does that then lead to them facilitating it in terms of providing staff to help support the measures, but it also means actually they’ve got the resources there to provide that backup for when the staff are off the floor to look at the measures that you’ve brought in. Now, the measures that I’ve brought in are an element of teaching, psychoeducation. Sitting down and talking to people about how trauma impacts, and talking about what to locate for personally in terms of curious and secondary traumatization. That’s what we do, so that’s simple didactic teaching session. Lots of information left, lots of stuff left on your central drive where people can look up and just check with themselves.
What we’ve also setup is reflective practice groups, and that is groups of individuals of a similar level of responsibility and similar job activity. It really is just as it says on the tin I think it requires external facilitation because you might know yourself, Paula. Reflective practice can very quickly deteriorate into sort of morning session or gossip session, so it has to be facilitated by somebody who understands what we mean about reflective practice.
There are some organizations that don’t do that naturally. I have to say that criminal justice backgrounds are not naturally inclined towards reflecting it. It’s something that we’re trained in health and social care to do. It’s interestingly enough, it’s been introduced to legal training in Australia, which is really, really interesting. How we’ve introduced it, now I’ve explained it to lots of organizations is that really, this is also about you having a chance to learn, because if you don’t– Learning’s not just about doing, it’s doing, and thinking about what you’ve done, and thinking how you might been differently or what you’ve got from it. It’s sold if you like as an opportunity to learn, and to consider, and to contribute to your professional development and your personal development, but it’s also an opportunity in a safe place to discuss what might be difficult for you.
I’ve had some people who’ve been so reluctant to come into GRP group effective practice, where they’re literally kicking the door as they come in like some accustomed teenager, and not wanting to do it at all. The mantra we have is, everybody must attend, but there’s no pressure to speak. Even if you don’t want to speak, somebody else might say something that resonates with you, so that might be helpful. What we also have built-in is opportunities for people to seek individual support if you like from somebody who’s within the organization.
Now, certainly with the organizations I work with because I’m in with the bricks, they know me and it’s not– People do anything to avoid seeing the psychologist, don’t they? Really, it’s [unintelligible 00:34:28] torture for lots of people. [chuckles] Can teach a clear room, or have people left in the room that really you think actually, they don’t want to start this conversation. [chuckles] A very quick aside, I was at a wedding once years and years ago and this chap got talking to me. He said, “What do you do for living?” I said, “I’m a clinical psychologist.” He said, “That’s very interesting, very interesting.” I could see he was desperate to start talking. I said, “Before you go any further, I only deal with children and adolescents, so bed-wetting’s my specialty actually.”
[laughter]
Anne: It’s best to avoid any of that. I think if a psychologist is around or in an organization and people see that you’re on the floor, and you’re talking, and you’re having a cup of tea, and you’re not in some kind of lofty tower or somewhere. People are more likely to come along and to talk about things, because I think we have to normalize the fact that work is hard. It really is hard, and I think it’s getting harder for health and social care than it ever has been. I think it demands– Extraordinary demands, so it’s getting harder and harder. I think to have some sense that there’s somebody around whose role is to– And not just appear when you’ve got attendance management meetings or any of these things that people go in, but to actually be there all the time and to say, “You know what? Let’s come in. Let’s have a chat.”
Most of the time what I find is people just need a reminder of what they value in their lives, what makes them feel better, what restores them, what’s restorative. Whether that’s a walk in the country, whether it’s going to the cinema, whether it’s having a drink with friends, whatever it is. Remind them actually it’s okay to do that. A reminder as well that– Somebody used this analogy years ago and I use it a lot myself. It’s a bit like when oxygen masks fall down in a plane. You’re told quite specifically, you put yours on first because you can’t help somebody else if you don’t have enough oxygen. It’s the same with our caring profession. We have to recognize actually. We have to be signed for us to be able to do our job, and the system has to recognize that.
The organizational level, it’s senior management buy-in, it’s teaching, it’s mandatory reflective practice, and it’s availability of somebody should somebody want to have that little bit extra time. It’s always a balance because I think particularly as a clinical psychologist, I can’t get into doing the sorts of therapy with people who are ultimately colleagues. It really is just a tweaking, and advice-giving, and a little bit of reminder of what we know about the impact through the works that we do. If it’s anything more then obviously people have to go down a more clinical route. My experience has been actually that helps people from going down that slope.
Paula: I guess one of the things you mentioned earlier was about supervision as well. I guess that fits in with that, and that needing to be again supported from the top down, and a kind of expectation that that’s part of the work. I think as psychologists, we’re quite– We can’t get away with not having supervision. I love supervision, can’t get enough, but I guess for other professions, that isn’t as embedded, and I think that can be–
Anne: I think for lots of other profession, I think clinical psychologist get it right, and that supervision is seen as supportive. It’s seeing something that facilitates your development as a clinician. To be good, it should be very personal. You shouldn’t be trying to produce a whole lot of clones who all do the same thing, but I think other professions are not quite so good at that. They think supervision is about, this how you must do this. This is the only way to do it, and it becomes– It can feel punitive, it can feel judgmental, it can feel task-driven, and it can feel like performance management, and it’s not performance management. It really should be– My view is that, you need a bit of that as well. That’s where the difference between a manager and a supervisor is quite different.
A manager is much more about what you’re doing, how you’re doing it, how you’re getting on with it. Supervision is about how you’re feeling about that, how is that going, what you’re struggling with, what you’re feeling really happy with, and a little bit of how are you personally. They say you can’t separate the worker from the individual and all their aspects outside life. I think supervision is absolutely essential, but I think that it has to be prioritized, so it can’t be something that let slip. If you’ve got arrangements for monthly supervision, that has to be kept to it. If it’s not happening, the organization has to think what’s happening? The supervision arrangements are not been [unintelligible 00:39:51] Are the demands on the clinician too much? Are the demands on the supervisor too much? Do we not have facilities and space to do it? What’s going on that this isn’t happening, but it is absolutely crucial.
Paula: The other thing you mentioned a bit earlier was about post-incident responses, and thinking about how we might also just normalize that, normalize the fact that after something really horrible happens, people might be upset, and what they need might be different, but making space and validating that in, again, an embedded organizational way.
Anne: Well, the forensic service I worked with, we set up a process, and unlike reflective practice, which is generally led by a clinical psychologist, the debrief sessions or distressing sessions were run by somebody who was from the same discipline because I think that most of the time, the people who were involved in the– this was in a forensic ward setting, most of the people who were involved in those incidents were nursing staff and that that’s one of the realities of, unfortunately, being a nursing staff in a forensic setting is very, very rare that a psychologist or a psychiatrist would be assaulted because you’re–
Certainly in Scotland, as one of my nurses said, if they have a go at you on the U lot, there’ll be on their way pretty quickly to the big [unintelligible 00:41:24] the state hospital is called. It wasn’t often that we were involved in it, but nursing staff were, and often because forensic patients were often were with the hierarchy, it will be the ancillary staff level that they would have a go at. What we found was better was actually for those distressing sessions to be facilitated promptly within 36 hours by nursing staff who were trained in understanding the impact of doing this work, and understanding what to tell people, how to facilitate a discussion, and how to warn people what signs to look for, because if you go in quickly, and you validate and you support, and you understand, then people are far less likely to go off with the thoughts that I’ve done something really wrong, I’m a terrible nurse, I’m a dreadful clinician, I’m going to be sacked next week, all of these terrible, catastrophic beliefs that often we’re left with after something pretty horrible.
Apart from the reality that you might actually have witnessed something that was pretty horrible to witness. If you witness somebody being assaulted, if you yourself have been assaulted. We had one incident in the ward where we had this woman who was really, really difficult, who during a particularly awful assault turned to the female nurse who was looking after her and was foul, accused her of all sorts, absolutely foul, and turned to the male nurse on the other side who was restraining her and said, “You all right, son,?I hope I didn’t hurt you.”
That splitting, that’s going to make the male nurse think, “Oh, gosh, that’s terrible. She liked me, and she was awful to my colleague, and the female nurse in that situation thinking, “Oh, my God, I must be really terrible because she hates me, and she likes him.” All of those reactions and responses need to be heard and validated and understood alongside some information about– Over the next couple of days, you’re going to find you can’t stop thinking about it, you’re going to find that you probably can’t sleep very well, you might be quite anxious about coming onto the ward, you might be quite irritable with your family, these are all the things to look out for, and these are all perfectly normal.
If after three months because you know yourself the definition of Post Traumatic Stress Disorder is a three-month interference in your normal functioning, if after three months, that’s still a problem, and you still are anxious, then we really need to think about this, and this is what we need to do. We know that actually, if you can put in those measures, people are less likely to have some long-term impact on the functioning, whether it’s compassion fatigue, vicarious traumatization, full-blown PTSD, they’re far less likely to happen if you have those systems. My argument is if you invest in that at the start, you get better stuff, you get a more stable, more secure, more resilient workforce.
Paula: Anything, Anne, to add to that in terms of the team, therefore, how we might be able to support the colleagues that we work with closely in terms of preventing?
Anne: Yes. I think having lots of information around, I think that having that sense that you don’t necessarily need these particularly special measures, but if we’re keeping an eye on one another, so if we can hear that somebody’s had a particularly difficult session, again, in the forensic setting, I was talking about this actually yesterday that the person who actually did most for us as a clinical team because we would be involved in pretty horrendous cases. The person who did most of the supporting was actually a girl on the reception who once the waiting area was cleared, she would essentially sit there and listen to us offloading.
Having that acceptance that actually, it wasn’t her job, she just did it naturally, but she was very caring and very compassionate and very concerned. She would sit and she would say, “How did it go today, then?” You would have that sense that actually this was important, that actually you needed to leave because what you need to be able to do in a health and social care setting is to be able to leave it behind, you need to have that sense, actually, you have a way of processing or starting the processing in the workplace.
So often, we finish our patients at five o’clock, we run out the door, get in the house, start getting everything ready for dinner, kids, all the rest of it, and actually, we haven’t processed. It’s about processing and that ability, we know again, from studies about how people develop Post Traumatic Stress Disorder and complex Post Traumatic Stress Disorder is it’s the inability of the brain to process those memories and to log them and to file them away. Having these processes that are about reflective practice, simple offloading, having a buddy system at work, all of that is about processing and making sense of what’s happened to us, so that we can pick ourselves up the next day and go back in again.
Paula: I guess those are things that as individuals we can draw on and make use of those things where they exist. What are other things might be helpful for individuals to keep in mind if we’re working in these environments? What can we do to help ourselves?
Anne: What we’ve done is we’ve introduced a sponsor. The other thing is that people need to know that there’s a time in which there is no discussion of traumatic things. I think in busy health and social care settings, we tend to use our lunch hours to talk about difficult cases, or to talk about situations that happened and work, and actually, we need to give people permission to not do that.
In the trauma service I worked in, I’ve implemented this in other organizations, we had to sign up which said, “Give everybody a break. No trauma talk between 12:00 and 2:00.” People were going into the kitchen area. Again, we need to have areas that are there for staff to be able to sit down and get a break, and the conversation would revolve around everything from strictly to bake-off, to politics, to what we were doing at the weekend, but a sense that actually we need to have a break. We cannot be immersed in misery the whole day, we can’t be immersed in horrible human behavior and horrible physical conditions all day, we have to have a break, and alongside that, we’ve provided magazines, up-to-date magazines, I would say.
I think I once gave evidence. I’ll tell you this very quickly, I once gave evidence in a very remote court in Scotland, and long story short, I sat down to wait to be called to give evidence, and there was a magazine sitting there, and I thought, “Oh, the [unintelligible 00:48:50] looking well.” That magazine was 14 years old. We have to have staff because again if you do that, it says to people that you value your staff. I go into my dental practice and it’s called The Lovely Magazines on the table. We’re just getting back to that post-COVID, of course, but Lovely Magazines, which says to me actually they value me as a patient. Whereas if you’ve got all dog-eared copies of whatever it is, that it says actually we don’t care, so up-to-date magazines.
We’ve also introduced mindfulness coloring cards, we’ve had jigsaws, we’ve had books that people have brought in, often just coffee table books, but just a sense, let’s make this a really nice space for people to come in and be able to feel that they can destress, they can switch off and they can feel human and encouraged. We also have had settings, and this isn’t always possible where you’ve got forensic settings who wouldn’t do this, but where you’ve got pictures of people’s kids up on the wall. Something to just make it feel that little bit more, that this is a safe space where people can go and they can wind down, and that’s really, really important.
Paula: It’s interesting because we saw a lot of that bubbling up in hospitals during COVID especially sometimes they were called wobble rooms, kind of a place where you could just go, and have a break, and be nurtured and there might be nice snacks and nice environment. Sadly, I’ve heard a lot of that now being taken away, now being used to offer space and people just don’t have spaces and time for breaks.
Anne: I was just saying, and yet in some of our private sector organizations, they do that. Now it might well be a ruse to keep people into work longer. I’ve heard about big banks who’ve got hairdressers, and dentists, and all sorts on site. Actually, it does make people feel nurtured and cared for. I think we’re at risk and I can say this as a retired NHS consultant, I think we are at risk of taking for granted the very people who look after us. I think we’re at risk of forgetting that actually this is a vocation and people really see it as something to which they are drawn not for financial gain, let’s be honest, nobody goes into the NHS hoping to make a buck. It’s not going to happen but you really are drawn in and you really want to care for people. You genuinely, genuinely want to make a difference, but you have to be supported to do that because we’re not a dispensable commodity as people who work in health and social care. We’re not, we have to be recognized as valuable.
Let’s face it, we spend a lot of money on training health and social care staff, a lot of money. I’m, unfortunately, hearing about a lot of people who are leaving the country. Now we’ve invested a lot of money in training, doctors, nurses, social workers, police, all sorts of really, really valued professions who are leaving because they don’t feel valued. Now is it easier to have to train more and more staff or is it easier to set up your wobble rooms? To set up a facility to make people feel actually we know this is really tough and we’re therefore going to provide support for you so that actually you can do the job that we value you doing.
Paula: There’s something about finding spaces to talk as well as spaces maybe not to talk and just to decompress, be human, have a break from the stuff in work. I’m wondering about what things are helpful for people outside of work, ways of leaving things behind, ways of processing.
Anne: I think my view is that you have to do something that’s not related to your job. I have occasional, have flat moments of thinking, “Oh, gosh I don’t do enough. I should go down and volunteer at the local food bank,” but actually I need to do something that is a break from the caring work that I do, if you like, the therapeutic work. For me it’s walking, it’s having my dog, it’s going away for breaks, seeing my family cooking, reading, gardening. I love gardening. I think it’s the only time I’m truly mindful. I would say to people that actually what you need to do is to do something that’s different, but also something that you enjoy. I think we’re under a lot of pressure to join gyms, and to run up and down hills, and all the rest of it actually idea of hell, personally, running up and down a hill.
We’ve got to say, if that’s what you enjoy doing then you do that and you take time, and you make time for yourself and not to feel guilty about that to actually think you know what?If you are restoring your sense of what makes you happy and makes you feel content then you’re actually contributing to your job by doing that. It’s not self-indulgent. I think when we come across such a lot of harsh and miserable situations in our work setting it’s easy to think, actually, I feel guilty about the fact that I’m going out for a meal, or I feel guilty about the fact that I’ve bought myself a new cashmere jumper or whatever it happens to be. Actually that is part of what keeps you going.
Paula: I guess coming back to that empathy thing that maybe what enables you to stay alongside people.
Anne: Yes. If you don’t have empathy for yourself you can’t have it for somebody else, because empathy you don’t forget is actually that connection and that ability. It’s facilitated, I think there’s always with wonderful studies now that we can do with imaging and so on, it’s facilitated by those tiny mirror movements that we make in our facial expression. If we are preoccupied, if we’re tired, we’re not going to be that engaged with somebody, we have to be engaged to be in passing. You have to pick up what’s going on, and we pick up what’s going on by those tiny mirroring that we do in our own faces and our own expressions that tells us what’s going on with somebody. If we’re preoccupied, if we’re tired, if we’re burnt out, if we’re just have had enough, we won’t do that and therefore that person will pick up that we’re not interested.
One of the things about dealing with people who’ve been through complex trauma is their go-to position is I am worthless. You’re going to hurt me. They will pick up fatigue as disinterest, blaming, and potential threat. There are certain settings, and we don’t know, even in a emergency department you don’t know what somebody’s background is when they come in, you don’t know that they haven’t been abused by their parents from a very early age. You don’t know that. It’s that universal precautions that we talk about where let’s just assume that everybody has been through that, and then we can’t upset anybody. In the same way that we’ve created situations where all houses have got to have disability access, that all buildings have got to be designed for people who might need a wheelchair. There’s not a sense of feeling different.
We have to go in with that sense that anybody we work with might be in that position, and at best if somebody has been with a clinician who’s not empathic they might think, oh, they have had a bad day and they’re not a very good clinician. At worst they’re going to think that person doesn’t like me, they don’t care about me, and I’m not going to go back for my cancer treatment. That’s the price that we pay by not doing that. It shouldn’t be seen as indulgent. It shouldn’t be seen as spoiling yourself. It should be okay, this is me topping up my reserves because I need them when I go into work.
Paula: I guess another aspect of that is particularly for people who have very cognitively complex work, that if we’re holding a lot of stuff it takes up a lot of head space and kind of get in the way of our judgment. I guess if I was on the operating table I’d much rather have a surgeon who had been taking breaks and looking after themselves so that I was in safe hands.
Anne: Yes. That’s very useful what you see about that cognitive functioning, because I think that again as clinicians we often think well, I’ve got half an hour, I should be reading the latest journal and I should be attending conferences. Yes, we need to do that, but that shouldn’t be at the expense of the other stuff as well.
Paula: Anne, I’m curious you mentioned some of your leisure stuff, but is there anything else that you have in place or that you draw on that supports you, that gets you through the work that you do?
Anne: Yes I have a supervisor. Somebody who’s more experienced than I am, who has been retired a good number of years, is a psychotherapist. Absolutely marvelous. I couldn’t do it without that because it’s my opportunity, and it’s not– I sometimes think, oh, I’m going to talk about [unintelligible 00:58:39] month to six weeks, and sometimes think I don’t what I’m going to talk about. It’s amazing because it’s whatever I want to bring to the table. It’s just so restorative, it makes me really, really value that. Recently she said to me, “You’re going to have a holiday?” I said, “Yes, I’m taking a week.” She said, “Np, no, no, you need three weeks, Anne.” I came back absolutely inspired and really we can’t do that every single time. It can only happen once a year, but it really is. That and listening to your supervisor but I also have peer supervision, so I’ll have a couple of colleagues who I meet with which is much more about case-centered stuff.
I think that element of thinking there’s no end to that chain of supervision. Those people who are supervising need their own supervisors who need their own. There has to be this endless chain of people who are looking after one another. That is absolutely vital because I think there’s sometimes a risk of thinking well I’ve been doing this for 40-odd years that actually I don’t need this. I know what it’s all about. No, you can never say that you know it all, you can never say that you don’t need supervision because it is what keeps you steady, and grounded, and able to reflect.
Paula: Thank you for listening. If you enjoyed this episode and you’d like to help support the podcast, please do share it with others, post about it on social media or leave a rating and review. I’d love to connect with you, so do come and find me on LinkedIn or Twitter. You can also sign up to my mailing list to keep up to date with future episodes and get useful psychology advice and tips straight to your inbox. All the links are in the show notes. Thanks again, and until next time, take good care.
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