Moving on after trauma

Megan Drysdale on her unusual role in an inpatient drug and alcohol service, starting with the service user perspective.

15 September 2023


Attending your first-ever trauma therapy group can bring up lots of emotions. You’re sitting in an unfamiliar room with a group of people you do not know. You are unaware whether the content will be triggering, whether you will have to share your experiences, as well as trying to gauge the other attendees. Are they going to judge what you say? How will they perceive you, and will they relate?

The facilitator reassures the group that no one will be asked to share their experiences and it is important to keep ourselves safe. We are told the focus will be on learning how trauma is processed and skills to help us manage the symptoms. The group starts by discussing the definition of trauma and what symptoms we may experience. The group shares ideas such as nausea, anxiety and increasing the use of alcohol; all of which I relate to. I had no idea that trauma could have such a physical impact on our health.

The facilitator explains what happens to the body when in our fight and flight response. They go on to say how trauma can keep us in that state, even after the event has happened. It helps me understand why I am so easily startled. We talk through some grounding techniques and finish the group with a progressive muscle relaxation exercise. I feel safe and regulated, I feel understood and I feel ready to engage.

I’m an Assistant Psychologist (AP) on an inpatient drug and alcohol detoxification and stabilisation ward. The scenario you have just read is pulled together from feedback I’ve had from our patients. These are people living with a dual diagnosis, defined as having both a mental health and substance use problem, who often slip through the gaps in services.

Over 70 per cent of those in drug and alcohol services identify as having a mental health need (Delgadillo et al., 2012). A further 54 per cent of suicides in people experiencing a mental health issue, involve those with a substance use background (NCISH, 2016). With a large amount of this population with co-occurring conditions being excluded from services (CQC, 2015), people commonly find themselves trapped in a cycle with very little support.

This called for change. The government commissioned Dame Carol Black for an independent review on drugs which enabled the creation of Project ADDER. Project ADDER focuses on drug treatment, recovery and prevention as well as the creation of many new job roles, including my own. My role is the first psychological role to be based on the ward, and one where there is no Clinical Psychologist physically present, alongside.

Helping to set up a new mental health provision within the prison service in my previous role, I had some experience, but this role certainly came with its own challenges. My job role has so many positives, and our team are continuously working together to develop our service. Nonetheless, with a new job role in a new environment and no previous AP to shadow, my resilience was put to the test.
‘Not a mental health ward’?

When I started my role, I had my job description and guidance from my Clinical Psychologist Supervisor, but instructions on how to fit into the ward did not exist. I learned very quickly that clinical staff on the ward were very unfamiliar with psychological staff and had no conception about how I would fit in on the ward. Many staff believed that the two to three weeks that patients were with us were to physically detox, and this was not the time to be exploring their mental health. On a couple of occasions when seeking advice, I was met with we are ‘not a mental health ward’.

With my confidence gradually decreasing and my instinct to seek help and support from the team, I ended up moulding to the absent role of the group facilitator. The team had been without a group facilitator for a couple of months and our HCAs were burnt out from covering the group programme trying to cover the content. So, I stepped in. I created new content for the group programme and trained in delivering MOAT (Moving on after Trauma) groups.

Many of our patients, especially in the first week, can find it very difficult to engage in an hour long group whilst feeling so physically unwell. Going through a detox, patients will be experiencing withdrawals and exhaustion. We typically have up to 10 patients on the ward and with limited support staff available, I was frequently facilitating these groups on my own. After around six months of this routine, my confidence grew as my ability to manage a large group setting on my own improved. I became more knowledgeable and comfortable with the material that I was delivering. It was rewarding to work with patients who are so passionate and motivated to learn and move forward in their recovery.

Even though I gained so much joy from facilitating the group programme, there was still a part of me feeling misunderstood and underappreciated by the team. The support I received from my manager and supervisor were requisite in me moving forward. However, even with this support, I was continually aware that solely doing groups was never intended to be my role.
Arrival to discharge

I wanted to become familiar with what my role should look like. There was no other NHS inpatient units in the surrounding area, and therefore no one with my role. I got in contact with my Supervisor to see if they had knowledge of any similar roles. I was given the contact for an AP in an inpatient detox unit in Manchester. This team had a wider Psychology team with a Psychologist present, which educated me on the potential our ward held. Moving forward, I started to attend more training to widen my skillset and build my relationships with wider teams. This is when I started to increase my understanding of what my role should look like.

I created an ‘arrival’ questionnaire to complete with patients on their admission, to gain an understanding of their mental health need. Where applicable, psychometric measures would also be completed. I engage in 1:1s with patients which mostly involve teaching healthy coping strategies and together forming a plan for when in crisis and/or distress. As well as this, I created a ‘discharge’ questionnaire to go through with patients to monitor how their mental health need had progressed throughout their stay with us.

Many of our service users will have a history of developmental trauma, which can be difficult without a Clinical Psychologist on the ward. There was no option of going back to the office for a reflective de-brief amongst your Psychology colleagues. That being said, being within a team all working all in the same environment naturally created a safe space to provide each other support. My clinical supervision is key in navigating these experiences and prioritising my self-care. I quickly learnt that I was able to reach out to my Supervisor or call any of the Community Psychology Team when required.

Whilst I was developing and building my role, we had a group facilitator join the team, which really helped with my capacity. My relationships with the team were stronger and I was able to be boundaried regarding the work I was now carrying out. With time, staff were beginning to understand the purpose of my role and started to seek out my knowledge when a patient was in distress. I felt empowered having got to this place in my role, considering my feelings when I started. The challenges I now faced was having the capacity to provide 1:1 work to all of our patients as well as any unprecedented situations we face on the ward. We started to grow the Psychology team on the ward and once a week I had a Psychology student and another AP supporting me. Although staffing levels vary, the presence was growing.

I was approached by a Clinical Psychologist, enquiring about co-facilitating a CBT group on our ward. Knowing the benefits and impact this could have, we were very quick to implement this. Due to capacity, we started to trial the group by having the Clinical Psychologist link in virtually. This was very new to us – we had not used any technology in our groups up until this point. We have now been doing this group for around a year, collecting feedback from patients to gather their thoughts. Generally, the feedback has been really positive, with patients scoring it an average of 15/20. It was anticipated that hosting the group virtually would raise some comments. However, only one person had mentioned they would have preferred the facilitator in person. We hope to continue this and plan to keep this routine enduring.

I am now at a place where I am building on my existing skills and pushing myself further. This includes co-facilitating training to drug and alcohol services in our area, co-facilitating research, leading an AP group within our trust and future plans to share at conferences. Each day will continue to bring new challenges and learning opportunities. I am very grateful to be in the role I am and look forward to what comes next.

References

Care Quality Commission (2015) Right here, right now.

Delgadillo, J., Godfrey, C., Gilbody, S., & Payne, S. (2013). Depression, anxiety and comorbid substance use: association patterns in outpatient addictions treatment. Mental Health and Substance Use, 6(1), 59-75.

The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Annual Report 2016: England, Northern Ireland, Scotland and Wales October 2016. University of Manchester.

SOURCE:

https://www.bps.org.uk/psychologist/moving-after-trauma(accessed 16.10.23)

For some, experiencing trauma may act as a form of cognitive training that increases their mental control

That which doesn’t kill you makes you stronger… It’s an adage that’s backed up in part by studies of people who’ve been through a trauma, such as a car accident or a robbery. While it’s true that around 7-8 per cent of trauma survivors develop chronic PTSD and experience persistent intrusive, unwanted memories of the event, most people recover quickly, and some even report better mental health than they had before (generally when the trauma has been moderate, rather than severe). But what underpins so-called “post-traumatic growth?” A new paper in the Journal of Experimental Psychology: General, argues that it has to do with trauma triggering a form of mental training that increases some survivors’ control over their own minds.



“Our findings suggest that traumatic experiences – as horrible as they may be – might naturally contribute to the adaptation of cognitive control skills, thereby improving survivors’ later resilience, at least [for] those who experienced only moderate levels of trauma,” write Justin Hulbert at Bard College, US, and Michael Anderson at the University of Cambridge. If these researchers are right, there could be implications for the treatment of PTSD.

Two studies, each of 48 students, suggested that those who had experienced a relatively high number of traumas (including witnessing or experiencing accidents, violence, and the death of significant individuals) before the age of 18 showed a greater ability to inhibit, when instructed, their memories of a word pairing they had previously learned, compared with those who reported no or little trauma.

The participants initially viewed a set of 60 word pairs, which consisted of a neutral cue word (such as “violin”) and either a neutral or a negative response word (such as “street” or “corpse”). They were given up to three training cycles to correctly recall at least half of the response words. Next, they were given a series of “Think/No Think” trials. If a cue word was presented on the screen in green, they had to say the response word as quickly as possible. But if the cue word appeared in red, they were told to avoid both thinking about and saying the response word for the next four seconds. Then came some surprise recall tests. This time they were given either the original cue word, or a new semantic cue plus the initial letter of the response word – such as “anatomy c_____” for “corpse”.

Hulbert and Anderson found that while those in the high and low trauma groups were equally good at learning the initial word associations, those in the high trauma group showed superior performance on the subsequent “No Think” trials, indicating they had a “robust ability” to forget the specific response words when required to do so. This held for both neutral and negative words, “suggesting that this effect reflects a generalised skill at suppression, regardless of valence,” the researchers write.

The data is consistent with the idea that experiencing trauma – at least for this group of people who successfully made it to university – may encourage resilience by training the ability to inhibit unwanted memories, in particular, and perhaps even a general inhibitory control mechanism, which could extend to unwanted emotions and actions, Hulbert and Anderson propose.

If these new findings are reliable – and obviously the study requires that we trust the students’ self-reports of their history of trauma – then they could have implications for how to optimise CBT treatments for trauma. Standard cognitive-behavioural therapy for PTSD encourages patients to confront reminders of their experience and the memories that are triggered by them – the idea being that over time this exposure will lead the traumatic memories to become less distressing. However, Hulbert and Anderson believe their results suggest that while it is important not to avoid reminders of the trauma, it may actually be beneficial to practice suppressing the memories that are triggered by them (mirroring what seems to happen naturally for people who experience post-traumatic growth). “Training in retrieval suppression may augment the benefits of cognitive-behavioural therapy,” Hulbert and Anderson write, “by enabling patients to confront reminders and redirect to more benign thoughts.”

People who do not recover well from a trauma and who develop chronic PTSD may perhaps have general deficits in inhibitory control, or an impaired ability to adapt control mechanisms over time, perhaps in part because of a genetic variation in cortical plasticity, Hulbert and Anderson suggest. However, the new results suggest that “… for many victims living with trauma, efforts to achieve emotional balance by down-regulating intrusive thoughts may act as a natural form of cognitive training.”

SOURCE:

https://digest.bps.org.uk/2018/08/22/for-some-experiencing-trauma-may-act-as-a-form-of-cognitive-training-that-increases-their-mental-control/(accessed 3.9.18)

Art can heal PTSD's invisible wounds

Trauma silences its victims, says creative arts therapist Melissa Walker, but art can help those suffering from the psychological wounds of war begin to open up and heal. In this inspiring talk, Walker describes how mask-making, in particular, allows afflicted servicemen and women reveal what haunts them — and, finally, start to let it go.

Watch talk:

http://www.ted.com/talks/melissa_walker_art_can_heal_ptsd_s_invisible_wounds