Trauma The Hidden Wound and the Importance of Trauma Informed Care in the NHS

What exactly is trauma, do you always know if you’ve been traumatised, does it always have hallmarks, what are its consequences?  And do healthcare professionals, nurses, hospital doctors and GPs  – across the board – know how to recognise someone who may be suffering from trauma, how best to help them and to avoid retraumatising  them?

It was probably no surprise to most people when psychological trauma hit the news in the summer last year.  In the wake of the terrifying Grenfell Tower fire in London on the 14th June 2017,  the Guardian reported 2 August 2017 that thousands of people  may suffer psychological trauma as a result e.g. adults and children who survived, families of those who survived and those who didn’t, passers-by, fire crews, helpers and so on. People were complaining of problems like insomnia, difficulties eating, anxiety, depression, feeling disconnected  and PTSD (post traumatic stress disorder –  distressing flashbacks).

Most of us I think can understand trauma occurring as a result of this horrifying event but what is less well known is that you can become traumatised from less obvious experiences, that trauma is much more widespread than we think, and underpins many  mental and physical health problems blighting lives. There is increasing recognition of this and big changes are underway in how the NHS helps people recover from trauma.

Shortly after the fire I went to an excellent conference held by the Queen’s Nursing Institute ‘Managing Psychological Trauma in Healthcare’ 5th July 2017  https://www.qni.org.uk/news-and-events/events/managing-psychological-trauma-healthcare/

I found the presentation ‘Bringing A Trauma Informed Care Approach (TIC) into the NHS’  by Jonathan Ogram a nurse expert in mental health and trauma who works for the Tees Esk and Wear Valleys  (TEWV) NHS  Foundation Trust, a large mental health provider, illuminating and full of hope.

Trauma,  when you experience something as threatening and dangerous and feel overwhelmed by it can become embedded. The distressing memories are not properly laid to rest, keep resurfacing either obviously so or below  conscious awareness.

And that can result in physiological  changes in the brain. The amygdala the fear centre in the older emotional part of the brain becomes exquisitely sensitive  to any possible sign of danger and may increase in size; meanwhile the hippocampus which helps store memories  may shrink in size and blood flow to the left side of the prefrontal cortex (often called the top brain) may reduce affecting language whilst blood flow to the right side increases which may make you feel more moody, sadder and angrier.

The upshot of all this  is that you’re likely to feel on red alert all the time which is exhausting, you can’t think straight and  feel you can’t cope with life. And you can be affected not only mentally but also physically, emotionally and socially. It’s like a hidden wound says Jonathan which can wreak havoc in people’s  lives leading to e.g. domestic violence.

Whether you become traumatised by something depends not so much on the event itself  but critically how you experience it which in turn links to various factors e.g. your coping resources what’s happened to you in life, how genetically resilient you are and when the event occurred – a toddler may for instance be distraught if they’re left alone in a cold room whereas a teenager may just be mildly annoyed.

Seen this way the journalist Deborah Orr’s recent account in the Guardian  23 September 2017 makes sense. She says she was diagnosed with complex post traumatic stress disorder last year but the original trauma she’d suffered was years ago. “It took me 50 years to realise that being duped and robbed of my gold christening bracelet the first time I ever left my home alone, at the age of three was traumatic”. And you can become retraumatised if things in the present stir up memories of the original trauma.

Trauma informed Care (TIC)  is being rolled out across the whole of the TEWV Trust,  probably the first to do so,   by  consultant clinical psychologist Angela Kennedy after a successful pilot in the Trust showed its benefits (she was a co-author of a paper published in 2016 ‘Trauma-informed mental healthcare in the UK; what is it and how can we further its development’  http://www.emeraldinsight.com/doi/full/10.1108/MHRJ-01-2015-0006 ).

It’s a recognition of the fact that trauma can affect everyone including staff,  is often hidden from view and that the majority of people who seek help from mental health services have been traumatised, there’s also a strong association between trauma and childhood abuse and poverty. Angela  says current NHS practice which sometimes involves coercion, control and forcible medication can retraumatise people and that has to change. Angela also points out that trauma can affect not just the mind but the body too and may underpin health problems like obesity, heart disease, alcohol misuse and diabetes. A feature I wrote in 2014 for Nursing Standard ‘Easing ICU trauma’ looked at the trauma suffered by some patients after going through intensive care. Hospitals are also very stressful places generally for some people and may trigger retraumatisation in some people. And in the GP surgery,  trauma may be the root cause of a patient’s problem  manifesting itself in perhaps psychological and/or physical symptoms.  So staff working in all healthcare settings not just mental health ones need to be better informed about trauma and to understand they too can become traumatised in certain circumstances.

TIC principles are based first and foremost on support which involves helping people feel safe physically and emotionally. They can then start to take control of their lives, says Jonathan who is helping to implement TIC. You don’t start by asking about symptoms, about what’s wrong with someone. Instead you give them space and time so they can tell you their story so you better understand what lies behind the symptoms and what has happened to them. And you need to make sure you don’t retraumatise  by bringing up something which can trigger the original trauma.  Alongside this various techniques like breathing exercises are offered to help people feel more in control.

When the time is right trauma  treatments like EMDR (eye movement desensitisation and reprocessing) a NICE approved treatment can be offered  where a therapist  gets you to move your eyes quickly side to side. These mimic the eye movements in rapid eye movement sleep allowing distressing memories to be reprocessed and put back in the past where they belong. There’s good evidence for its effectiveness but it’s not right for everyone says Jonathan who is also an EMDR therapist. The good news is that there are various mind/body therapies (NICE also recommends trauma-focused cognitive behavioural therapy) which help you recover and move on with your life.

*Good books to read include: ‘Making Sense of Trauma How to tell  your story’ by psychologists Dr Nigel Hunt and Dr Sue McHale;  ‘The Body Keeps The Score Brain Mind and Body in the Healing of Trauma’  by psychiatrist and trauma expert Bessel Van Der Kolk; ‘Post-Traumatic Stress Disorder’ by psychologist Professor Kevin Gournay; ‘Post-Traumatic Stress Disorder  Recovery after accident and disaster’ by Professor Kevin Gournay

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Mindfulness and meditation, what are they and do they work?

It has to be good news that there is a new book out which examines the hard evidence for the benefits or otherwise of meditation. ‘The Science of Meditation’ by Daniel Goleman (who wrote the renowned book ‘Emotional Intelligence’ trained as a psychologist and became a science journalist) and Richard Davidson (also trained as a psychologist and is a neuroscientist) covers issues such as the various forms of meditation of which mindfulness is just one – but which are all united by focus on a single point be it breath or whatever which you keep coming back to when your mind wanders – and define meditation at various levels in its ancient more intense forms where the aim is to change yourself profoundly to lighter more modern forms to help with depression, anxiety and so on. What is the hard evidence for the benefit of each form and what claims are based on thin air?

Mindfulness is everywhere. It’s big business. I’ve practised it for the past 8 years or so to help me cope with anxiety. When I first read the book ‘Full Catastrophe Living’ by Jon Kabat-Zinn (who developed a stress reduction course using mindfulness meditation – tailored to make it more palatable to Westerners in the modern world – and other tools to help people cope with stress, anxiety and depression at the University of Massachusetts Medical Centre many years ago ) I thought I could do mindfulness on my own.  I would follow instructions for a sitting instruction and promptly fall asleep. It was nice because it felt mindless. After some time I realised I wasn’t getting it and that I needed more guidance to practise it. So I signed up to do the 8 week mindfulness based stress reduction course with an instructor registered at the Mindfulness Centre, Bangor University in Wales.

What I found and liked is that Mindfulness is secular, there are no rights or wrongs to it save the misunderstanding that the aim is to banish thoughts from your mind which is impossible. And there is no guru in charge of it – it is up to each person to decide for themselves whether they find  it helpful. And the only way to do this is to experience it.

I found it hard initially to do and still do. It’s not a quick fix cure-all solution. But I keep doing it like cleaning my teeth because it’s a tool which slowly ever so slowly has helped me see myself and the world in a different light which I find beneficial. But I don’t want to live in cloud cuckoo land so I’ve just started to read the book, hopefully with an open mind, there may be some findings which surprise and/or  challenge me.   I’m glad that mindfulness and the other meditation methods are being put under the spotlight and tested as rigorously as is possible with our current state of knowledge so that people are not misled by false claims and know the facts about the benefits or otherwise of the various types of meditation.

 

 

 

 

 

GETTING THE BEST CARE AT THE END OF YOUR LIFE?

Shouldn’t everyone be entitled to this? The answer is surely ‘yes’. However a report by the Care Quality Commission this year ‘A different ending: Addressing inequalities in end of life care’ says that palliative care should be personalised and tailored to each person’s needs  – yet some marginalised people (e.g. those who are homeless or living in poverty, who have mental health problems , refugees and asylum seeker, lesbian, gay bisexual and transgender comunities)get poorer care because there is a lack of awareness and understanding about their individual needs. Steps need to be taken to redress this says the CQC.

Palliative Care Expert Jane Carpenter is doing just this. She is the Macmillian clinical outreach nurse specialist for the Macmillan Cancer Care and St Helena ‘Safe Harbour Project’ set up in February this year see  https://rcni.com/nursing-standard/features/improving-end-life-care-marginalised-groups-63296. It’s a ground-breaking service which aims to increase good end of life care (this means letting people know what is on offer, their options, organising appropriate services and support, in the hope of avoiding crisis management and inappropriate hospital admission) to people who are marginalised  and may feel rejected and alienated by society.

She goes to where her clients are which means working across boundaries and working in NHS settings, in the community and with voluntary groups.  Her most important task is to build a relationship with each person based on trust and respect and to understand that those she is reaching out to have often suffered huge losses and may well be deeply  suspicious of her. Her aim is to have an open mind set her judgements to one side and to apologize if she’s got something wrong and to say let’s start again.

 

 

 

 

PRESCRIBING GARDENING TREATMENT

I’ve always loved gardening but I never thought it would one day  be prescribed as a health treatment. My latest feature for Nursing Standard 3rd August 2016 ‘Gardening Your Way to Health’ was as a result of a  King’s Fund report ‘Gardens and Health Implications for Policy and Practice’ published in May this year which concludes there is a huge amount of evidence about the beneficial effects of gardens on both physical and mental health.  In my online feature https://rcni.com/nursing-standard/features/gardening-your-way-better-health-61206 18 August 2016 I looked at several examples of how gardening is being offered as a therapy e.g. by Macmillan Cancer Care and by GPs e.g. the Sydenham Green Group Practice in Lewisham London, has been offering gardening therapy to patients for 14 years for a range of around 18 conditions including mental health problems, dementia. sleep disorders, cancer and  heart disease, referring patients to the nearby Sydenham Gardens Community gardening project where people can work on a range of projects. GP and mental health lead in the practice Dr Jim Sikorski says it’s an appropriate health intervention , backed by evidence of benefit which can transform people’s lives for the better. Hopefully gardening therapy/treatment will be considered completely normal in the not too distant future.

Dementia – suffering in silence with pain

Pain is often not recognised when it comes to dementia and there is little understanding of how people with dementia are affected not only mentally but physically. Symptoms for instance such as aggression and agitation are often put down to dementia when in fact they may be due to e.g. an infection. See ‘Support to live a good life with dementia’ Nursing Standard 2 July 2014.

And more people living with dementia also have cancer as the risk of both conditions increases in older people and more people  are living longer. The first ever UK Macmillan dementia nurse consultant Lorraine Burgess says ‘all too often dementia is blamed when patients become distressed or agitated when in fact the reason someone is behaving like this is becauses they may be in pain or discomfort from the cancer and/or its treatment side effcts but can’t articulate this. The result is they suffer in silence.’ Many healthcare professionals are unaware of the issues. She also points out that dementia patients are at greater risk of developing delirium with symptoms like agitation, restlessness and hallucinations and the risk increases if they  go into hospital for treatment  There are many causes of delirium but the commonest ones are pain, dehydration and lack of nutrition, very relevant to dementia patients with cancer who may have stopped eating and drinking because they have untreated pain (see ‘Consultant role bridges the gap’ Nursing Standard online 26 August 2015 https://rcni.com/nursing-standard/features/consultant-role-bridges-gap-56166.)   Always consider pain as a possible cause when it comes to symptoms, never underestimate its impact and make sure it’s properly treated says Lorraine.

THREATENED WITH DEREGISTRATION BY MY GP PRACTICE FOR NOT HELPING WITH ITS FINANCIAL TARGETS

My GP practice is first and foremost a business operation which I’ve been made aware of only too keenly in the last few months  and I’ve felt bullied as a result.

Registered  for a long time I’ve had little contact with them over the past few years. Just before the start of the new financial year  I found a short peremptory message from the practice on my phone on a Sunday afternoon. They had no blood pressure measurements for me in the past 5 years, this was a minimum NHS healthcare requirement and I was to let the practice know in 2 days time, by the lst April 2015 whether I or someone else had taken my blood pressure. The tone of the message was unsettling, ‘do as you’re told’ was the message.

I didn’t want to get involved in talking about blood pressure readings with the Practice and  explained this to them and  asked whether what this was all really about was meeting financial targets such as QOF (quality and outcomes framework) incentive payments explained so well by Margaret McCartney in The Patient Paradox.  ‘Yes’ came the answer, the practice was disappointed I couldn’t help.

Out of the blue I received a handwritten note through my front door last week saying the Practice wanted a written copy of one blood reading and the date taken. I reiterated my views to the Practice  but had further emails requesting blood pressure measurements.

Then I was reprimanded in no uncertain fashion – why was I being negative, why couldn’t I supply readings, the Practice  had a duty to provide what was deemed good patient care by NHS England and if I was obstructing them doing so, they would have to discuss this with me – they had to reach certain targets and I was stopping them doing so, my refusal to provide a reading could not be accepted without  ‘good reason’ If all patients took my view the practice would not reach its targets and that could not be tolerated I was told.

Alarmed and upset I rang NHS England. My questions were am I compelled to give blood pressure readings, could I be struck off for not doing so and did I have to give reasons for my decision? The answers were I was not compelled to give readings, could not be struck off for refusing to do so, did not have to give a good reason let alone any for doing so. I was told the reason I was being chased by the Practice was to do with its financial management.

I relayed all this by phone to the Practice, explaining  I was very distressed by the whole business and please could they respect my wishes and leave me alone. Some acknowledgement has now reluctantly been made of that but I’ve been told  they need patients to  help them achieve their targets and it’s possible I could be asked to de-register if I’m getting in the way of them doing so. What all this has to do with good patient care escapes me. I feel caught in a tickbox system which the Practice says is imposed on them and which is the key to their financial health but the way they operate it  undermines the claim that the patient is at the heart of the NHS and puts the financial rewards for the Practice first and foremost. My trust in them has been dented.

ALL CHANGE – A NUANCED MESSAGE ABOUT HRT

First it was good for you, then bad for you but now the message is different.
I remember a time when HRT was promoted as the best thing since sliced bread. Every woman should have it, even those without significant menopausal symptoms – it would prevent heart disease and help women stay young and healthy. If you didn’t take it you would dry up and crumble away. I was wary of it because my mother who had been on oestrogen only HRT for a long time and loved it, was diagnosed with ovarian cancer in the early 1990s and shortly afterwards died when she was in her early 70s. I wondered about possible side effects and discovered a small study which suggested an increased risk of developing the cancer for women who had been on oestrogen only HRT for more than 5 years.
Then two big studies came along in 2000 and 2002 calling into question HRT’s safety. Women taking it were reported for example to be at increased risk of strokes, clots and breast cancer and HRT did not protect against heart disease. Consequently women stopped asking about HRT and many doctors stopped prescribing it.
But numerous studies since have concluded that HRT when taken in the early years after the menopause and at the right dose is safe for most women says Kathy Abernethy, nurse expert in the menopause.
The first ever NICE clinical guideline on the menopause is due out in 2015 making it imperative that healthcare professionals get up to speed about this she says. The message about HRT now is that it’s for women who suffer significant menopausal problems and it should be started for the first time within 10 years of the menopause. Taken at the lowest effective dose, the risks are much fewer and HRT does not cause heart disease and may indeed be protective. Most women come off HRT by the time they’re 60 because their hormones have stabilised says Kathy. But HRT may be more risky if you want to take it for the first time ten or more years after your menopause. In the intervening years fatty deposits may have built up in your arteries increasing the risk of cardiovascular problems so you need to be carefully assessed to see whether you can safely take HRT.
Good menopausal care means holistic personalised advice about the conventional and alternative options open to women, the importance of lifestyle advice and the need to respect women’s choices stresses Kathy. This is all to the good because in my mother’s case all those years ago she wasn’t offered any other options – whenever she tried coming off HRT her horrible symptoms returned with a vengeance so she went back on HRT – for far too long. For my own part I think the watchword that still comes to mind when thinking about HRT is caution.
See my piece ‘HRT is just right for some women’ Nursing Standard 10th September 2014,
http://rcnpublishing.com/doi/abs/10.7748/ns.29.2.25.s28