Life Lessons and Trauma Informed Care

Trauma and experiences in life that challenge us are increasingly being recognized as the most important factors in understanding and helping people who are emotionally distressed.  The evidence consistently supports the view that the most important thing we can do is acknowledge what has happened to people. Arbitrarily attempting to classify and group people into pseudo-scientific categories serves only those who might gain in some way by doing so. Denying the relevance of life experiences only serves to allow us to avoid collectively addressing our society and the abuses it permits, how it labels people already discriminated against, and how it enables people to ignore poverty, ignore inequality, hypocrisy, and greed.

We hear more and more evidence from around the world that when we change our perceptions and harness the empathic skills that we all possess as human beings, we can all make a profound difference.  We can open our eyes, our ears, and our hearts.  This then has to be true for us all, all our life experiences, our reactions to them and the responses of those around us who influence who we are, how we feel, think and behave. They shape how we see the world and those around us, our beliefs, our hopes, and our fears.

My first real introduction to the world of madness and “mental illness” was when I was 21 years old and I left home to start my mental health nurse training. Reflecting on my own experiences has led me to consider how the trauma of participating in the psychiatric system can affect the way we care for others.

As part of our induction, in the first two weeks of my nurse training, we had a tour of St Audrey’s Hospital which had been created as the County asylum in 1829.  I don’t think anything I had experienced in my life up to that point could have prepared me for my first exposure to a psychiatric ward.  We were shown through the locked doors of a ward for older women who were diagnosed with dementia, and the scene that met us was, for me, shocking.  The woman’s bodies were emaciated and twisted as they were sitting in padded, high sided wheeled chairs called G chairs, all tilted backwards in reclining positions. Trays were attached to the front. I learned later that the trays and the reclined position were designed to act as restraints.

The cleaners were working on the ward and had moved all the chairs to the middle of the dining area. There had been no regard for the fact that people occupied the seats. They were randomly pushed to the centre of the linoleum so that the number one task of cleaning could be completed as per routine. Thinking back, I know that I was deeply shocked, but I had no words for that shock.

My first placement was on an acute admission ward at St. Clements Hospital in Ipswich, and halfway through the first day, I became aware that something was going on.  There was a rush of activity and concerned faces. Male nurses from other wards were called upon to come over and assist.  They arrived in the staff room and began to roll up their sleeves, unclip their ties, remove their watches and prepare for action.  They had an air of anticipation, adrenaline, and ritual that I could only liken to when I was part of a team that was about to go on the pitch for a football match.  It was a familiarly male atmosphere thick with tension, cigarette smoke, and bad taste humour. They were preparing themselves for action, I think secluding someone and giving them an injection.

Again I was shocked and frightened but coped by switching off from the feelings and the consequences of feeling that way. Perhaps if I were aware I would have to do something about it, and my young self didn’t have the wherewithal to react. I wonder now whether I was reacting to feeling trapped. Trapped by the decision I had made to be a part of this world, and not knowing what would happen if I walked away.

My traumas are of course mine, and I am very aware that having heard the stories of many other people’s lives over the years, my traumas are relatively small in comparison. I have had the good fortune not to have experienced the terrors and the horrific life challenges that so many people have had to face. However, my traumas, my experiences and personal challenges have inevitably influenced and shaped who I am and how I see the world. Many of my challenges and traumas I have experienced at work.

On that first placement on the acute inpatient unit, I made my first real connection with someone who was there for help. She was a middle-aged woman who was diagnosed as being depressed. I would often sit with her for long periods, usually in silence as she appeared to gain some comfort just from having someone close to her, sometimes she would cry, occasionally she would tell me about her life, and I would listen.

She was then prescribed modified electroconvulsive therapy (MECT).  This frightened her and was something that she didn’t want.  I had been asked about MECT in my interview, and although ignorant of its reality, I had tried to answer with an open mind. If it helped people, as I had been told, it could be a good thing, right?

Such was her fear this woman refused to have it.  I think it was fear, but in the depth of her despair, she wasn’t able to articulate her reasoning, just her refusal to have the treatment. The response to her refusal was to put her on a Section of the Mental Health Act and to force her to have treatment.

On the first day that she was due to have her treatment, we were ordered to observe her continually so that she couldn’t eat or drink.  People have to be fasted before treatment, as it involves having a general anaesthetic and a muscle relaxant before applying the electric current to the brain. Continual observation meant staying alongside someone within touching distance at all times.

This was to be a significant day in both our lives. Me as a shocked and bewildered observer, but I know now, complicit in my passivity. She as the victim of violence and oppression in the name of care and treatment.

One thing that is significant to what was happening, and informative about the culture within the services then, and probably now, was that no one considered changing the routine of administering treatment.  There was no thought of what this woman would be going through, except to stop her eating and drinking.  MECT always started at a set time and therefore she was had to be kept under observation before this time. No one said let’s change the routine. The routine or probably more significantly the Psychiatrist and the Anaesthetist routines were more important than patient comfort, and this was not to be questioned.  The feelings and fears of this terrified woman were not the number one consideration.

I remember that morning like you remember a nightmare. I think, when I look back on it, I probably did sleepwalk through most of my early psychiatric experiences.

The woman was small, slim, and wiry with long grey hair. She had large features and big eyes that sat deep in their sockets. When I took over my observation duty she did not speak, she hadn’t for the previous days but acknowledged me with a small nod of her head.  She sat on her bed in the dormitory, her legs not crossed but twisted, wringing her hands and twisting her head.  She would occasionally stand suddenly, making me jump, pace backwards and forwards, looking out of the three panels of the window that looked out onto the car park.  She would then return to her place on the bed.

After around 15 minutes, half way through my time of being with her, she did not return to the bed.  She left the dormitory and went down the dark corridor leading to the day room.  She then quickly jumped into one of the bathrooms and tried to shut the door.  I had been warned about not letting her get to the taps to drink but wasn’t alert to what she was thinking. She attempted to shut the door on me, and I tried to stop her, we were pushing on either side of the door.

I will never forget the look in her eyes; it was one of pleading desperation and anger, and I think she could see in mine that I was confused, frightened and that I did not know what I was doing.

After what seemed like a frozen moment in time where you aren’t sure whether minutes or seconds have passed, she suddenly released her pressure on the door, stood upright and came out of the bathroom.  She didn’t speak, all I could say was “thank you.”

I was unable to process what had happened, because in a way that part of me wasn’t there, the part that could make some sense of things. I know that I spent extended periods of my training disconnected from how things made me feel as I don’t believe that I had the resources to do anything else.  I was, and am now, considered to be a laid back person and to be taking things in stride.  However, this can often be a disguise for disassociation, and a is clearly part of my survival strategy.

What I am now able to reflect upon, and which is something that I have observed many many times during my career in others who are in the midst of incredible stress, and emotional turmoil, is this woman’s compassion, empathy, dignity, and respect.  At that moment, struggling with the pushing on the door, she was able to act upon what she saw in me and care for me!  She saw my distress, she responded to me, she took care of me, to the detriment of herself. Although we didn’t ever discuss that moment and I know people could want to interpret her actions differently, I know from the way that she looked at me, that she responded to how I felt, and that this was an act of enormous grace, courage, and compassion.

I went on that day to witness that woman carried into the treatment room, held down on a bed until the anaesthetic was given, and then “treated” with MECT.  It was one of the most distressing days of my whole working life because of what happened to her, my complicity in it and my failure to speak out on her behalf.

I felt guilty, but I don’t think I properly thought through why. Others told me that it was for her own good, that she was ill and that sometimes you have to act in people’s long-term best interest. I know I listened to this and could see this was an attempt at justification, but I just didn’t believe what I was being told, I didn’t argue, as I didn’t have anything else to say other than “surely what just happened can never be right.”

I am left to wonder whether, in understanding and recognising trauma and the effect that life has upon us all, in this crazy world, maybe we could all acknowledge that this also applies to the people working with individuals who have experienced or are experiencing distress.  We must ask to what extent the exposure to other people’s, and our own pain, influences the “science”, the therapy, the research and the theory that we use. To what extent does the life experiences of the worker influence what they do long before they even start their work, set out their goals, and make decisions about the paradigms they are working within?

Maybe we can begin to accept that people, life, feelings, creativity, cultures, beliefs, behaviours, minds, and souls are so complex and unique that they are out of reach for explanation by current science, research, facts, or truths. Perhaps this acceptance could enable us to be more accepting of difference and less fearful. We could even look closer to home for explanations of people’s struggles and acknowledge that poverty, inequality, discrimination, bullying and abuse challenge people profoundly and that these difficulties have consequences.

While we all look for explanations that can reassure and provide a sense of stability and certainty, we must take care that they are not seen as universal truths and that they are not tarnished by discrimination that then enable traumas to be compounded. We must be sure that our explanations do not comfort those in power at the expense of those without.

 

Author’s Note: Some of the descriptions included in this piece have been altered to protect the identity of others.