What to do when life interupts

Mental Health Week acknowledges the many traumas and interruptions in life, notes clinical psychologist Roger Bretherton - who analyses how we might respond to them.

Roger Bretherton

Roger Bretherton is Associate Professor of Psychology, at the University of Lincoln. He is a UK accredited Clinical Psychologist.

A blurred exposure of a person under a hood turning their head to the side.

Photo by Ehimetalor Akhere Unuabona on Unsplash.

For over a decade I worked, as a Clinical Psychologist in a service treating people who had suffered trauma. I clocked just under ten thousand hours of clinical contact with people who had been through the worst situations imaginable. One thing I learned during that time is that trauma often occurs to us as an interruption.

Most of us live our lives to some script, a set of assumptions of how we think things should be, our expectations of what is about to happen next - and trauma shatters those assumptions. Over and over again, people who had been through trauma told me how their view of the world had been violated. The narrative that defined their life, the story they thought they were in, changed genre unexpectedly. The romcom became a horror movie; the adventure became a hideous farce. The story called walking home at night turned into another one called being mugged. Driving to the supermarket became, having a crash. A day out at the beach, became delivering CPR. All of them illustrate how trauma sends an earthquake through our view of what we thought our lives were and, if we survive, leaves us in the rubble picking up the pieces.

In one fell swoop it gave an insight into why it is that trauma occurs to us, not just as an event or a set of events, but as an interruption to our whole sense of reality.

Back in the early days of researching AI systems one study illustrated the catastrophic effect that even the mildest contradiction of our expectations can have on our entire view of reality.

In the quaint old days, when Chat GPT was a nightmare for a future generation, an expert system was developed with one simple aim in mind: to identify birds. Such a simple task. The specifications of various species of animal were entered and, by applying a broad array of criteria, the system would indicate whether the said species was a bird (or not). But not all its criteria were accurate. One of the rules of thumb the system developed was: ‘all birds fly’. Which worked fine until it was required to categorize a penguin. In the first attempt it followed its own rules and concluded that penguins were not birds. But when forced by the programmers to categorize a penguin as a bird, the system went into meltdown attempting to reconcile the contradiction with its own criteria. To resolve the anomaly of the penguin being flightless and yet still being a bird, it concluded that no birds could fly. In one fell swoop it gave an insight into why it is that trauma occurs to us, not just as an event or a set of events, but as an interruption to our whole sense of reality.

The nightmares, the flashbacks, the apprehension, irritation and sense of foreboding, the numbing and the terror. All of these are an attempt to make sense of a world that no longer makes sense. Of course, it would be heartless to suggest that the agony of trauma is little more than a glitch in our information processing. Reducing it to a bug in our programming would conveniently trivialise the horrors that can befall human beings. I have no desire to sanitise or diminish the horrors that can haunt us, but trauma is at least this - a hiatus, a shock, an interruption.

The agony that intensifies our fears, depressions and compulsions is often the torturous comparison between who we thought we were and who we have become.

It is not just trauma that interrupts us. Life specialises in throwing wildcards and anomalies into our path. Just when everything seems to be going swimmingly, when we seem to know what we are doing, when the future seems mapped out before us, the unexpected and the unwelcome occurs. The best way to make God laugh, goes the saying, is to hand Him our five-year plan. I’m not sure I have ever spoken to anyone with insight into their own psychological distress who doesn’t to some extent experience their pain as an interruption. The agony that intensifies our fears, depressions and compulsions is often the torturous comparison between who we thought we were and who we have become. Our imaginary ideal self, the person we thought we would be, waltzes away into a future of freedom, light and joy, and leaves us behind in doubt and uncertainty.

Mental Health Week could in some ways be viewed as an acknowledgement of the interruptions in life. I can only imagine what has interrupted you. I can only hazard a guess at what it is or was that derailed the smooth trajectory of your predicted life. Was it bereavement or aging, sickness or betrayal, disappointment or assault, redundancy or financial ruin? Whatever it was, it may not be reversible. This is one of the reasons for the burgeoning of mindfulness practices in mental health treatment. We don’t just need a technology of change to help us get better, we equally need a technology of acceptance to be able to live with what we cannot change.

I’ve lost the ability to firmly believe that the future can be planned out, that the straight line into the next few years cannot be shattered without warning at any moment.

For me, the lockdown was an interruption from which I have never really recovered. I hesitate to say this because I worry I might be the only person who feels this way. I know it’s all supposed to be over. We’re back to work and acting like the world is rational and predictable again. But the great reset just doesn’t work for me. My mind is ready to go, but my heart just hasn’t got the memo. I’ve lost the ability to firmly believe that the future can be planned out, that the straight line into the next few years cannot be shattered without warning at any moment. There is a hesitancy in all my plans, an uncertainty in my ambitions. The solid arrow of time is dotted, if not broken. Experts in trauma call it the sense of a foreshortened future. The disruption of our capacity to self-transcend, to bridge ourselves towards the person we may become. Our once lucid image of a better self flickers and grows dim, no longer compelling or believable.

And if that’s not confession enough, I have another one. One that makes me sound like a rehab resident in a young adult drama. In the midst of the lockdown craziness, I was forced to slowly and reluctantly uncover a gift. Like a treasure buried in a field, or a priceless pearl concealed among the worthless tat of a car boot sale. Something so crashingly obvious and cringeworthily twee that I can hardly bear to put it in writing. Many of my plans and ambitions were imaginary, just plain illusion. I was no happier achieving them than I was pursuing them. But I started to glimpse, that if I could overcome the grief of losing them, I would be better off without them. If I could put words to it, I would say that I came to a deeper appreciation of grace – iit’s not a bad thing just to be. We can be so busy trying to become something that we fail to notice that we were before we even began. This has now become a daily contemplative practice for me. I call it being present to The Presence in the present. Somehow, I came to a deep inner settlement that I no longer needed to work to justify my existence, but could work out of a present moment in which my existence was already justified. I came to accept acceptance.

Article

Care

Change

26 July 2024

6 min read

Are we forgetting how to care?

The profound act at the heart of nursing.

Helen Cowan

Helen is a registered nurse and freelance writer, writing for audiences ranging from the general public to practitioners and scientists.

A nurse bends beside a bed and talks to a patient

Marie Curie.

Recently, at a nursing leadership programme in Oxford, attendees focused on the fundamentals of care. Have we forgotten how to care? What can we re-learn from those who pioneered an ordinary yet profound act that affects millions?

Anam Cara is an old Gaelic term for ‘soul friend’, a person with whom you can share your innermost self, your mind and your heart. It is a term that Tom Hill, former chief executive at Helen House Hospice in Oxford, used to describe the relationship between his staff and the thousands of children and their families who passed through their ‘big red door’ in its first twenty-five years. The hospice (or ‘loving respice’ as it became known) had been founded by Sister Frances Dominica in 1982.

Other care in this country can also trace its religious roots. Between 1048 and 1070 in Jerusalem, the Order of St. John was founded for the purpose of helping pilgrims (“our Lords, The Sick”) who had become lost, weary, or beset by other difficulties while on their way to the Holy Land. Today, in the United Kingdom, the British Association of the Order has extended care to older people first in almshouses and later in care homes. A trustee for ten years was John Monckton, a man of ‘considerable talent, enormous integrity and deep religious conviction’; his tragic murder in 2004 led to the creation of the John Monckton Memorial Prize, which recognised and rightly celebrated commitment to care by care workers.

Today, across the world, seen and unseen, nurses, carers and families continue to provide compassionate care. “Assisting individuals, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge” is the very essence of nursing, captured by ‘architect of nursing’, researcher and author Virginia Henderson in 1966. Meeting more than basic needs such as breathing, eating, drinking and eliminating bodily waste (which are of essential importance), Henderson recognised the role of the nurse in enabling humans to communicate with others, worship according to their faith, satisfy curiosity and sense accomplishment.

In the desire for modernisation and professionalisation, have we lost sight of the core values and activities central to patient care?

An uncomfortable truth brought out in healthcare reports such as the Final Report of the Special Commission of Inquiry (The Garling Report) 2008, and the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (The Francis Report) 2013 is though that this type of nursing is too often done badly or even missed, leading to pressure injury, medication errors, hospital-acquired infection, falls, unplanned readmission, critical incidents and mortality. According to nurse scientist and scholar Professor Debra Jackson, “missed care occurs much more frequently than we might think”. She cites a systematic review in which ‘care left undone’ on the last shift ranged from 75 per cent in England, to 93 per cent in Germany, with an overall estimate of 88 per cent across 12 European countries’.

In one offensively-titled paper, “Shitty nursing - the new normal?” (in which the authors apologise for the title but not the questions raised), real-life pen portraits are drawn of patients lying for hours on hospital trolleys, immobile through infection or injury, ignored by staff. Whilst acknowledging contextual factors for poor care, such as a shortage of nurses and resources, the authors argue that circumstances cannot be the sole cause of missed nursing care.

A report published by the University of Adelaide, School of Nursing, has called for nurses to ‘reclaim and redefine’ the fundamentals of care. It asks whether the cause of the problem (of missed nursing care) lies “deep in the psyche of the nursing profession itself?” “Has something happened to the way modern nursing views and values caring?” it continues. “Indeed, is nursing in danger of losing its claim to care? In the desire for modernisation and professionalisation, have we lost sight of the core values and activities central to patient care? Or is this a broader social pattern where individuals are less inclined to show kindness, compassion, and care for others even if it is a necessary requirement of the job?”

Compassion, he emphasises, is more than empathy - and way "less fluffy" but much more measurable than kindness.

Writing in the British Medical Journal, Professor of critical care medicine Peter Brindley and Consultant in intensive care Matt Morgan wonder whether doctors also “too often default to high-tech and low-touch” when patients are dying – a time “when community and connection matter most”. They powerfully begin with a mother’s comment: “Humans are gardens to tend – not machines to fix.”

Professor Sir Al Aynsley-Green, the first National Clinical Director for Children in Government and former Children’s Commissioner for England, and past president of the British Medical Association, suggests that we as a society need a “momentum for compassion”. Struck by the extremes of compassion witnessed during his wife’s treatment in the last years of her life, Sir Al wants to see a cultural transformation in healthcare: for compassion to be a key operating principle in NHS and care settings, led by the Chief Nurse’s Office; for every organisation to promote the importance of compassion at the professional level; for the views of patients and families to be sought regularly; for much earlier and better focus on compassion in undergraduate and postgraduate teaching programmes for all staff; for compassion to be inspected against by the Care Quality Commission; and for a willingness to encourage staff at all levels to expose poor practice as well as celebrating excellent care.

Compassion, he emphasises, is more than empathy - and way "less fluffy" but much more measurable than kindness. “It’s putting yourself into somebody else’s shoes – and doing something about it.” Recently appointed the UK’s first Visiting Professor in Compassionate Care at Northampton University, at the age of 80, Sir Al certainly is doing something about it. He has made it his new purpose in life to “embed compassion into every aspect of care”.

Like Sir Al, Queen Elizabeth II, the UK’s longest serving monarch, espoused compassion, in word and deed. Living a life of compassionate service, the Queen made clear that her Christian faith was her guiding principle. She speaks of Jesus Christ as ‘an inspiration,’ a ‘role model’ and ‘an anchor’. “Many will have been inspired by Jesus’ simple but powerful teaching,” she said in her Christmas Broadcast, 2000. “Love God and love thy neighbour as thyself – in other words, treat others as you would like them to treat you. His great emphasis was to give spirituality a practical purpose.”

When nurses do unto others as they would have done unto themselves, and act as role model to colleagues, not only do patient experiences of care and their outcomes improve – but so does job satisfaction for nurses: a critical factor in nurse recruitment and retention – the biggest workforce challenge faced by healthcare organisations. Across the UK, there are currently more than 40,000 nursing vacancies, and thousands of burnt-out nurses are leaving the profession early. Whether nurses decide to stay or go is driven in part by their daily experience at work. The late Kate Granger, Consultant in medicine for older people, inspired Compassionate Care Awards in her name, envisioning that such a legacy would drive up standards in care - and surely also help retain nurses, through restoring a sense of pride, achievement and fulfilment to the nursing workforce.