Episode 129: How to Cope with Trauma on the Frontline with Dr Caroline Walker
As healthcare professionals we know it’s part of the job to be around trauma, whether directly or indirectly — something we often expect ourselves just to cope with. In reality, witnessing traumatic situations has an impact on all of us, no matter the profession. Just like the care you give your patients, it’s important to extend compassion to yourself so you can move forward.
Dr Caroline Walker joins us again in this episode to discuss how trauma affects healthcare professionals working on the frontline. We explore the different kinds of trauma we can encounter, and the surprising ways it can show up in our lives after the event. We talk about some steps we can take to help ourselves and each other process traumatic situations in healthy ways, including an “ABC” of actions to take immediately. We also emphasise the difference access to help and treatment can make in managing our trauma response.
If you want to know how to deal with trauma healthily, stay tuned to this episode.
Here are three reasons why you should listen to the full episode:
- Find out what things cause a trauma response in us.
- Learn the difference between a normal acute trauma stress response and PTSD.
- Discover the three things you should do immediately following any traumatic event.
[05:31] The Inherent Trauma in the Field of Healthcare
- The work involved in the healthcare industry is inherently traumatic.
- Healthcare professionals face life and death and heavy emotional content daily, resulting in unresolved trauma we have yet to process.
- Witnessing the impact of a traumatic situation on someone else brings secondary trauma.
- Healthcare professionals experience both medical and non-medical trauma, but we don’t talk about it enough.
[05:53] ‘When you’re going through something [traumatic], you can often feel you’re the only one. What we found, really, was everybody really identifying with each other and feeling less alone.’ – Click Here to Tweet This
[10:05] Trauma in the Professional vs Personal Life
- The trauma you experience in your personal life can feel like it has a greater meaning. However, the brain doesn’t distinguish how it responds to trauma.
- PTSD can develop from both mild or severe trauma.
- Tune in to the full episode to hear about Rachel’s traumatic story about an out-of-hospital cardiac arrest patient.
[12:08] Normal Trauma Response
- The first weeks after the traumatic event are the worst. It’s also normal for the nervous system to be on a more heightened alert.
- Most people gradually settle over the next four to six weeks. Otherwise, you may have developed a less helpful trauma response.
- If your trauma response starts interfering with your life, it’s time to get some help.
[14:58] Coping with Repeated Trauma
- Healthcare professionals get accustomed to repeated trauma on some level.
- Consequently, some develop unhealthy coping strategies. It becomes problematic when these become a habit and impact your life negatively.
- Talking with someone can help you piece things together.
- Remember that trauma responds to treatment better compared to other conditions.
[16:11] ‘It’s important to remember that trauma is really treatable… People often feel a bit hopeless, like they’re always going to be carrying this with them and feeling on edge, but you don’t have to.’ – Click Here to Tweet This
[17:15] Recognising Trauma
- Sometimes, it can take a bit of digging around to reflect on what has happened.
- Tune in to the episode to hear the common medical- and non-medical-related trauma that many healthcare professionals experience.
- Trauma is anything that threatens your sense of self, safety, and integrity. It doesn’t have to have a bad ending or directly impact you.
- Many doctors go through traumatic situations without having the chance to talk about and heal from them.
[18:56] ‘Trauma, essentially, is anything that’s gonna threaten your sense of safety or integrity, your sense of self, your sense of safety in the world, and it doesn’t have to have a bad ending.’ – Click Here to Tweet This
[21:49] Trauma Processing
- You don’t need to talk about everything immediately.
- Most trauma processing happens between friends and family members. If you’re finding it hard to talk about it, it may be a good time to get professional help.
[22:56] Normal Stress Response vs Acute Stress Reaction vs PTSD
- Normal stress response typically lasts two to six weeks before gradually settling down over a few weeks.
- An acute stress response occurs when the feeling of shock doesn’t settle down. It impedes your daily life.
- Post-traumatic stress disorder or PTSD develops when the symptoms happen long term. The three major symptoms are reliving experiences, hyper-arousal, and avoidance.
[24:50] How Trauma Is Treated
- Primary treatment for PTSD includes trauma-focused CBT and EMDR. These treatments are around 85% effective.
- Some medications can also help with other symptoms.
- For normal stress responses, reassurance helps reground the brain so that it won’t lead to acute stress reaction.
- Dealing with acute stress reactions requires more care and support from the people around you.
[27:01] Other Reactions from Traumatic Events
- Around 40 to 50% of people with PTSD will have depression as well.
- Trauma may also trigger a psychotic response in individuals with underlying illnesses, like bipolar disorder or schizophrenia.
- It’s often difficult to recognise which type of trauma response you’re experiencing because you’re in the middle of it. It’s when professional help becomes helpful.
[28:26] Tips on Dealing with Traumatic Situations at the Time and After
- Remember ABC.
- A is to connect with anyone to reground yourself.
- B is for breathing to bring yourself back down into parasympathetic mode. If breathing exercises make you anxious, you can focus on other body parts.
- C is to cancel some engagements for the next few days and weeks.
- Look after yourself. Carrying on as usual without taking the time to process what happened will leave you at risk of developing PTSD or depression.
[31:22] ‘The best thing you can do for everybody is to just look after yourself in that immediate aftermath, just go really gently, be really super kind to yourself and reassure yourself.’ – Click Here to Tweet This
[32:42] The Role of Team Debriefing
- Forced debriefing after a traumatic event can be harmful.
- Team debriefing is advisable at the closest time possible to the event but not immediately.
- It gives way for a gentle, non-mandatory space where people can talk through what has happened.
- Signposting is also helpful in giving individuals options that suit them best.
[35:04] Connecting with Your Normal Support Network
- We heal best and naturally when connected with our normal support network.
- Simply checking in with people will help keep them connected. Model and normalise basic human compassion.
- Sometimes, we need permission from others to take time off.
[35:07] ‘We heal best when we’re in connection with our normal support network — our friends, our family.’ – Click Here to Tweet This
[38:57] How to Give Yourself Permission to Thrive
- The free webinar will happen on the 14th of July at 8 pm.
- It’s about how to give yourself permission to deal with your trauma and look after yourself without feeling guilty.
[41:06] Caroline’s Top Three Tips for Coping with Trauma
- Normalise that it’s hard to experience some of the things we experience.
- Talk about it with anyone you feel you can trust.
- Keep a gentle eye on coping strategies that might help short-term but can worsen things in the long run.
About Dr Caroline
Dr Caroline Walker is an NHS-based psychiatrist, therapist, speaker, trainer, and coach. She is also the founder of The Joyful Doctor, a platform that helps support doctors’ mental health and well-being. They also provide speeches and talks that aim to break mental health stigma and offer healthcare professionals the support they need.
For over ten years, Caroline has been helping overworked and burnt-out doctors towards creating happier, healthier, and fulfilled lives.
You can reach Caroline on her website, Facebook, Instagram, Twitter, and LinkedIn.
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Caroline Walker: I think the nature of the work we do is inherently quite traumatic, isn’t it? We’re faced day in, day out with life and death and an awful heavy emotional content. One of the hardest burdens we can bear is an untold story. I think that is the case for many, many, many doctors — that we have gone through circumstances, traumatic situations ourselves, as individuals, and we’ve held those inside ourselves, and not necessarily had chance to share what that was like and experience the healing that that can bring.
Rachel Morris: Have you seen stuff at work which has affected you deeply? Have you experienced trauma working on the frontline, which you haven’t fully processed yet? Do you sometimes wonder if keeping calm and carrying on as usual, is possibly not the best thing to do?
Working on the frontline means that you are necessarily involved in the ups and downs of other people’s lives and are often there to experience the best and worst of humanity. Experiencing difficult and traumatic situations can be part of the job, but for some reason, we’ve internalised the idea that this trauma, whether primary or secondary, won’t affect us like it might affect other people. We don’t afford ourselves the time, space and kindness that we need to properly process the difficult stuff we come up against almost on a daily basis.
In this podcast episode, I’m joined again by Dr Caroline Walker, a psychiatrist specialising in the well-being of doctors, to discuss how trauma affects people, particularly healthcare professionals and those working on the frontline. It’s fair to say that some specialities and professions deal with trauma much better than others, but all of us can take some steps to help ourselves and each other process what’s happened in healthy ways, rather than turning to unhealthy coping strategies, such as chocolate and Netflix. We discuss what should be in our trauma first aid kit, and the difference that accessing help and treatment can make.
Listen to this episode to find out what sorts of things can cause a trauma response in us, what the difference is between a normal, acute trauma stress response and when it is turning into post traumatic stress disorder, and the three things you should do immediately following any traumatic event.
Welcome to You Are Not A Frog, the podcast for doctors and busy professionals in healthcare and other high stress jobs if you want to beat burnout, and work happier. I’m Dr Rachel Morris, a former GP, now working as a coach speaker and specialist in resilience at work. Like frogs in a pan of slowly boiling water, many of us have found that exhaustion and stress are slowly becoming the norm, but you are not a frog. You don’t have to choose between burning out or getting out. In this podcast. I’ll be talking to friends, colleagues, and experts, all who have an interesting take on this, and inviting you to make a deliberate choice about how you will live and work.
Many of us are struggling with overwhelming workload at the moment, and it can sometimes be difficult to see the light at the end of the tunnel. That’s why it’s so important for those working on the frontline to put their own oxygen mask on first, so that they can serve that patients, clients, colleagues and families to the best of their ability. For some reason, we’re happy showing kindness to others but really struggle when it comes to ourselves, feeling guilty for taking timeout and attending to our own needs. If that sounds like you, we’d love to invite you to a free webinar, How To Give Yourself Permission To Thrive, with me and Dr Caroline Walker, our guests on today’s podcast. It’s happening on the 14th of July at 8 PM. You can sign up through the link in the show notes. If you can’t make it or you’re listening to this episode after that date in July, then sign up anyway, and we’ll send you the link to the recording.
It’s wonderful to have with me back on the podcast again, Dr Caroline Walker. Welcome, Caroline.
Caroline: Hi, Rachel. It’s really great to be here.
Rachel: To those of you that have not met Caroline before, Caroline is a psychiatrist trained in the NHS. She works with practitioner health. she specialises in the well-being of doctors and what else, come on, you are the Joyful Doctor.
Caroline: Yeah, I founded the Joyful Doctor nearly five years ago now, I can’t believe it, how quickly that time has gone. Yeah, we help doctors with all sorts of well-being related issues through coaching and training and speaking. You can find us on social media as well, doing a lot of anti-stigma campaigning, trying to break down that all too common stigma around what it feels like to be a doctor who is struggling.
Rachel: Oh, wonderful, and it’s lovely to have you here. Caroline and I do a lot of work together. We’ve got together really in COVID, didn’t we, to produce webinars and podcasts. We run a community for doctors together called Permission To Thrive, and that’s one of the reasons I’ve got Caroline on today, because we did a recent webinar with our Permission To Thrive community for doctors, all about trauma. I must say, I was quite shocked about the level of trauma that people had experienced, or were experiencing in our community. Now, I know you said to me earlier that you weren’t shocked at all.
Caroline: Yeah, I think the nature of the work we do is inherently quite traumatic, isn’t it? We’re faced day in, day out with life and death and an awful heavy emotional content, the work we do. So, yeah, It doesn’t surprise me at all.
It’s part of the reason I wanted us to do the webinar and share about it a bit more today on this podcast episode because I think when you’re going through something like that, you can often feel you’re the only one actually. What we found really was when we did the webinar, everybody really identifying with each other and feeling less alone, had lots of comments really saying, ‘Hadn’t realised, it wasn’t just me.’ It’s not just me that gets home at the end of the day and just feels like, ‘Whoa, what just happened’.
Rachel: I think it’s interesting as well, I think the doctor community as a whole, particularly some of the slightly older doctors, like me, who can still remember what it was like to be a junior doctor in the late 90s, early noughties, have gone through a bit of a collective trauma recall having watched the Adam Kay series, this is gonna hurt on the BBC.
It’s absolutely fantastic. I read the book quite a while ago, I love the book, the book was hilarious. One of my friends gave it to me and said, ‘Oh, you know, Rachel, you should read this.’ I read it, and I went back to her, I said, ‘It’s all true. All this stuff, just is exactly how I remember it as a junior doctor.’ For some reason, I didn’t find the book quite as traumatic as watching the series, it suddenly sort of brought it all, I think, back to me. I started to think, ‘Oh, my goodness, do I have all this unresolved trauma that I just haven’t dealt with, just from working like that?’
Caroline: Yeah, I think a lot of us do, to be honest. I certainly remember my traumatic earlier years as well like that. I think when it’s on TV like that all your senses are flooded, aren’t they? You get the visual, and you can almost smell it, it was like smellivision, that kind of remembering what it was like to walk the corridors of the hospitals and all the different bodily fluids everywhere and all of that stuff. It just brings it… It taps into our brains in a much more visceral way and kind of makes us relive things.
Whereas the book, you can sort of slightly stay a bit distant from it, and there is a lot more humour generally. The TV series? Yes, certainly, I heard from a lot of doctors who found it quite dramatic, and many who still haven’t actually been able to watch it because they’re just sort of avoiding it and aversive to anything that’s too close to home. Yeah.
Rachel: Looking back as a junior doctor, there was some really, really difficult times, particularly on labour ward, working A&E. I don’t work on the frontline anymore. As a GP, you do see quite a lot of stuff, but not quite as much as you see, day to day, that very visceral stuff in A&E, but but you do have to deal with the trauma of seeing families, reactions of families coping with death and bad news and all that sort of thing.
Caroline: I think you get a lot more what we call secondary trauma, that kind of hearing about it, or witnessing the impact it’s having on someone. Actually, we can be traumatised by that ourselves, as well. I think it’s important we don’t minimise that because we get that, as I say, day in and day out as doctors, it’s not just you, physically being there present when something traumatic happens, even just hearing about it or reading about it. I remember reading a particularly traumatising discharge summary from a psychiatric patient once that really stuck with me and still sticks with me today because of the graphic description of the things that have happened to this person in their life.
Yeah, I think when we start to talk about trauma, which we don’t very often, we often avoid talking about it, it all comes out the woodwork, doesn’t it? The medical trauma that we experience, that kind of loss of control in scary situations, the loss of life, loss of limb, all of that stuff, but also in the non-medical stuff as well. Of course, there’s doctors we all experienced the same traumas as everyone else does as well, sudden bereavements and car accidents and all that sort of thing. Yeah, it’s far reaching, and I think not talked about enough amongst doctors and healthcare professionals.
Rachel: Do you think there’s a difference between the trauma you experienced on the frontline in your everyday work? If you’re working in the emergency department, you will see people with sudden death, you will see people who’ve come in with road traffic accidents and people have had really horrible things happen to them in your professional life. Then, if something happens to you in your personal life, outside of work, is there any difference between the reactions that you have, or is it already one of the same?
Caroline: I think it can feel more personal. It can feel more like it has a greater meaning, sometimes but actually, interestingly, the way the brain responds to trauma, it doesn’t distinguish. You’re going to get a trauma, an unhelpful trauma response, so you say something like PTSD, that could happen from either. It doesn’t distinguish between what we might see as a mild or severe trauma, it doesn’t matter. It doesn’t matter where it happens, who it’s happening to, you can still get the same sorts of responses. I would say you might, at the moment, experience it at the time it’s happening, slightly differently if it’s personal, but that actually, the impact it has on the brain. It doesn’t doesn’t distinguish between the two.
Rachel: Yeah, I can totally get that. Yes, we’ve both had experiences of trauma, haven’t we?
Rachel: You’ve had, sort of, more longer term PTSD, and I’ve had, which will be really interesting to hear about in a minute, I’ve had a shared this in various places, an incident of a cardiac arrest, out of hospital cardiac arrest, where I was the only doctor present. It was in the middle of nowhere, with somebody I knew, and it had a happy ending. We did manage to resuscitate this person, but it was really shocking at the time, for all sorts of reasons, not just that it was awful thing that happened to them. I think that responsibility of thinking, ‘I’m the only doctor here, I’m in charge,’ ‘what happens if,’ ‘what happens if,’ and I had a much more severe reaction than I ever thought I would have had to that.
Initially, it was like, up and down and up and down and just crying for absolutely no reason, for a couple of weeks, getting very triggered by loud noises. About a week after, I went clay pigeon shooting for somebody’s birthday, and they showed us how to do it. I got this gun and I shot this thing, and that was it. I could not cope. I was like, I’m out of here, literally ran out, which is very unlike me. Is that normal?
Caroline: Totally normal. Yeah, I think what you had, Rachel, was what we’d call a normal trauma response or a normal stress response. The first couple of weeks are the worst, and you can feel completely preoccupied thinking about what happened, very on edge, very sensitive to noises and things. It’s a very horrible experience, actually, and people think they’re going mad, often, but what happens and I think happened to your cases, and they’re kind of just gradually gently settles over the next sort of four to six weeks.
As I say, most people have that kind of response, and we saw it recently with the war in the Ukraine. A lot of people watching that unfold on television in this country have mild trauma response, they’re very preoccupied, on edge, difficulty sleeping, but it gradually settles over a few weeks for most people. If it doesn’t, then you might be thinking about wanting to go and talk with somebody about it, because you may have developed one of the less helpful trauma responses.
Rachel: That’s interesting, because the other thing I found that, it was a while ago now, it was maybe three months ago, I feel right as rain, but there have been a couple of instances where I’ve reacted really weirdly, that’s really triggered me. When I was walking on the street, and someone was on the floor, having a fit, they had people around them, and they had there was an ambulance just pulled up and I stopped. I said, ‘Do you need help?’ And they said, ‘No, we’re fine, this person was safe’. The paramedics were there, but I immediately turned, it was really weird reaction. I thought, gosh, maybe I’m not as well as I thought I was.
Caroline: Well, again, I think it’s quite normal in the months after a particularly traumatic event, just be a little bit more on edge and a bit more sensitive. It’s like your nervous system is just a bit more on heightened alert. You might bump your car, gentle little bump in your car that wouldn’t normally bother, you actually get a really strong physical reaction to you might get, suddenly your heart’s pounding, and then your throat, and you feel a bit on edge and it takes a little while to settle down. It’s incredibly common.
That should, over time, again, just gradually ease and you’ll get back to a normal baseline, but if it’s happening all the time, or it’s interfering with your life, or it’s really bothering you, then that’s the time to think about maybe getting some some help to talk you through. I think what you did, Rachel, was great. You mentioned it to close friends like myself and we just chatted it through and that’s the key thing. If you want to talk about it, then talk about it, if you don’t and you don’t have to. In fact there some instances of forcing yourself to talk about it, if you don’t want to, unhelpful and can actually make it worse. In those first few weeks or months, just talk if you want to, don’t if you don’t.
Rachel: Now, I’m very aware that what I witnessed and what I had to deal with was just a one off and hopefully, I will never have to deal with anything like that again. What about people that it is their job just to deal with this again and again and again? How do they how do they cope?
Caroline: Well, a variety of measures. We all, to some degree, get a bit accustomed to repeated trauma on some level as all doctors, I think do. I think over time, you just habituate, it becomes your new normal. I think some of us reach for slightly unhealthy coping strategies, sometimes if you’ve had a really bad day, you might go home and have extra glass of wine or extra few balls or chocolate, or you might shut yourself away from the world for a bit, and a little bit of that is absolutely fine. It’s not problematic, but I think, again, if you’re noticing you’re doing that a lot, so every night, you’re kind of shutting yourself away from the world.
I know I was doing that for a time when I have my PTSD, I was mugged a couple of times, once at medical school, and once as a doctor and I just became quite withdrawn, and I stopped wanting to go out and about, particularly at night, or were unknown places, and just drinking a little bit more than usual. At the time, sadly, I didn’t have any idea what was going on. I didn’t place the two together, because they’d happened a little bit apart, which is often the case that you might think you’ve got over the initial trauma bit, but then a few months later, you find yourself a bit more withdrawn and struggling. That’s where, again, talking with someone can help piece it together for years, as it did for me.
It’s important to remember that trauma is really treatable if you are struggling with, say, PTSD or one of the other trauma responses. Its absolutely responds really well to treatment compared to other conditions. People often feel a bit hopeless, like they’re always going to be carrying this with them and feeling on edge, but you don’t have to.
Rachel: That’s good to know that it’s pretty treatable. Caroline, I did just want to ask you because obviously, being mugged, you can go, yeah, ‘that’s traumatic’. Having to resuscitate someone, that’s pretty traumatic. Seeing somebody come in who’s been in a car crash in the emergency department, that’s really traumatic as well. I think what we realised on the webinar that it was all sorts of different traumas that people were experiencing, and maybe they were thinking, ‘Well, I shouldn’t really be traumatised by that.’ Commonly, what sorts of things are you noticing with your patients that people are experiencing, that they are having a trauma response to, that maybe they wouldn’t recognise it because it’s not necessarily the thing you would associate with trauma?
Caroline: Sometimes, it can take a bit of digging around to think what was going on around the time, what was going on a few months ago. I think the themes we see coming through are things like situations where people feel a sense of being out of control. So perhaps they’re witnessing something or that they can’t do anything about that can be really tough, particularly for doctors and healthcare professionals who love to be helpful and love to try to prevent bad things happening.
We also see people struggling when something happens very suddenly. So you’re going along okay, you think everything’s alright, and then out of the blue, suddenly, there’s something in front of you like the person in the street or things like in medicine, we see a lot things like [inaudible], stuff that happen very suddenly, very dramatically, where there’s a lot of heightened emotion around, generally, can be really quite overwhelming. We had a lot, didn’t we Rachel, of people just remembering patients that had died young, that’s another common one, actually, in medicine, or things that seem unjustified, things that have a meaning behind them, like it felt unfair that this happened to that person that can often sit very uncomfortably with doctors.
Yeah, so we see a lot of common medical themes, but also non-medical stuff as well, a lot of transgenerational trauma, particularly in doctors, from other cultures, who perhaps, come over to work here, but bringing with them stories of their families going to war or being made homeless, or all these sorts of awful life traumas, as you might call them going on as well, as well as the other things like abuse, domestic abuse, incredibly common amongst doctors as well not talked about. Yeah, it can be really anything.
Trauma, essentially, is anything that threatens your sense of safety or integrity, your sense of self, your sense of safety in the world, and it doesn’t have to have a bad ending, like you witnessed with your cardiac arrest. You said, that was what I was gonna mention, it had a happy ending. You might think, ‘well, that’s okay, then I’m not going to be traumatised’, but of course, the experience itself was traumatic, and you didn’t know it was going to have a happy ending at the time.
Yeah, when it was actually going on, there would have been a lot of thoughts going through your mind you may or may not have been aware of that were really catastrophic in a really awful, facing the death of a friend, and wondering how you are going to cope with that, and that even a happy ending doesn’t necessarily take that away, where it’s actually coming and talking with someone can really help to settle those symptoms down.
Rachel: Interestingly, we were at a conference recently, weren’t we, when we’re hearing about doctors and frontline health care workers in COVID, and the trauma that people were experiencing through seeing people dying, which is traumatic anyway, but specifically seeing people dying alone, and not being able to speak with their loved ones. That was interesting to me that people were actually identifying that as trauma, and I just wonder how many other people have been feeling really awful having seen that, but not realise that they’re having a trauma response to that sort of thing.
Caroline: Absolutely, yeah, because it doesn’t have to directly impact on you. Again, it can be something you witnessed in others and seeing them go through something incredibly traumatic. We listen to Rachel Clarke speaking, didn’t we, beautifully, the palliative care doctor, an author, who spoke about this moment she realised that when these patients came in COVID, they were masked up, all the staff were masked up, and this realisation that for many of them who were going to go on to die, that they would never see another human face again before their death. That in itself, just the thought of that was traumatic enough.
Yeah, I think there is a lot of unspoken trauma and trauma we don’t realise is trauma. She shared that beautiful Maya Angelou quote, didn’t she, ‘One of the hardest burdens we can bear is an untold story.’ I think that is the case for many, many, many doctors that we have gone through circumstances, traumatic situations ourselves as individuals, and we’ve held those inside ourselves, and not necessarily had chance to share what that was like, and experience the healing that that can bring.
Rachel: I think for doctors and other people on the frontline, it is part of the job, and so, we often have that mindset. ‘Well, because it’s part of the job, I’ll just accept it, I’ll just bury it, and I’ll just just get on with it.’ I’m thinking that’s probably not so helpful, but on the other hand, you can’t be debriefing and talking through everything that you see. Otherwise, you’ll just be doing it all the time, you’ll spend your entire life in therapy, right?
Yeah, yeah. You don’t need to, you really don’t need to talk about everything. I think it’s just a matter of if you notice something is staying with you, or is bothering you, then you might want to think about talking about that. And it doesn’t have to be with a professional, okay? Actually, most trauma processing happens between friends and family members, you meet at home at the end of the day. You offload that you had a tough day with your flatmates or your partner and that’s absolutely fine as well.
Not everybody needs professional help. I think if you’re finding it very hard to talk about it, but you have a sense that you probably need to, then that can be a good time to come and get professional help, because we have ways to really supportively help people to open up and go to that horrible, scary place, but in a safe way that is going to help them to feel better.
Rachel: A lot of the stress responses we have are normal stress responses, but earlier you were telling me that there’s the normal stress responses, an acute stress reaction, there’s PTSD, and there’s other stuff. How do you know the difference between all of these ones?
Caroline: Well, first of all, most of us will have a normal stress responses similar to you, had first two to six weeks, preoccupied, on edge, not sleeping, but all settles down gradually over a few weeks.
If it’s not settling, or if it’s really severe, so it’s kind of really getting in the way of you being able to go about your day to day life, you might be having what we call an acute stress response. That’s usually in the first few days, and it’s so severe that you almost go into like a daze or it’s the kind of thing you see on movies, when people have been through something traumatic, and they look a bit like a bit shocked in days and they can’t function, that might be an acute stress response.
If you’re getting symptoms longer term, so things like reliving experiences where you feel like you’re back at that time, and that trauma was happening either in your body or you’re getting images or nightmares, and that’s happening longer term, so over several weeks or months, and not getting any better. Then, you might be developing what we call Post Traumatic Stress Disorder, where you get in three main symptoms, essentially, reliving experiences, hyper arousal, so that she kind of being really on edge, jumpy, not maybe not being asleep as well, bit irritable, and avoidance is another classic thing with trauma that we get.
You might be avoiding driving down the road where the accident happened or avoiding going to work or avoiding seeing certain patients. We sometimes see that in A&E or something, you might be cherry picking off different patients because you can’t face seeing that particular condition, things like that. If you’re identifying with any of those symptoms, avoidance, hyper arousal, or reliving experiences over a period of time, then you might well be experiencing a bit of PTSD and again, really worth knowing, it is incredibly treatable.
It’s not the easiest thing to face, so you might find yourself very, very nervous going to get help, but I promise you, it’ll be the best thing you ever do, certainly best thing I ever did.
Rachel: What is the treatment for PTSD?
Caroline: Mainstay of treatment is talking therapy-based treatments, either trauma-focused CBT, where they get you to essentially talk through what happened in a particular way, which is helpful to the brain to file away the memory. In a calmer way, what is something called EMDR, eye movement desensitisation, which you might have seen it, people talk about finger wagging or tapping on different sides, and it’s again, they just get you to kind of relive what happened, whilst getting your brain to process it in a more helpful way. These are both about 85% effective in treating PTSD, so really, really effective.
There are some medications that can help, but they don’t tend to kind of cure or treat the PTSD, they tend to help with some of the other symptoms. So they might help with a bit with the low mood and withdrawal, or the anxiety or they might make it just a bit easier for you to go and have the therapy, but you see the mainstays, different types of talking therapy.
Rachel: For a normal stress response and an acute stress reaction, presumably, you don’t necessarily need therapy, just talking and resting and being kind to yourself and all that sort of thing.
Caroline: Yeah, definitely normal stress response, just reassure yourself. So as someone with PTSD, I consider myself to have a bit of a vulnerable brain to trauma, so when traumatic things happen, I’m a little bit more sensitive than someone who hasn’t had PTSD. I remember when the war broke out in the Ukraine, I started to get a few nightmares, but it was okay, because I was able to reassure myself, I was able to say, ‘Okay, this is normal, it’s alright, this is probably going to get better over a few weeks.’ If you can just reassure yourself, stay connected as well to your normal support networks. Stay talking to your family and your friends going about your day to day life as normal, that will help your body and brain kind of reground itself into the present moment and not be so caught up in the trauma.
With an acute stress reaction, that more severe acute reaction, you need a bit care and support. You’re probably gonna need someone around you to help you kind of eat and drink and get back on track for a few days, and then your natural healing mechanisms will kick in, and you’ll carry on processing like as normal usually.
Rachel: I know you’ve mentioned some other types of reactions that we can have.
Caroline: Yeah, it’s very commonly you get things like depression, about 40, or 50% of people with PTSD will have depression as well. You might, rarely, you get, like a psychotic response if somebody’s got an underlying illness, so like bipolar disorder, or schizophrenia, it might trigger them into an episode, they’re a little more rare. The most common ones we see are the normal stress response, which we try not to medicalise and treat, as you say, PTSD, and then yeah, things like depression alongside it quite common.
Rachel: Thank you, so good to, I guess, recognise which one you might be in really? And then…
Caroline: Yeah, although it’s often hard to do that. So I would say if you’re not sure, get help because it’s often very difficult for you to know, because you’re often in it. So you’re feeling the fear and you’re feeling all the symptoms, but you’re not quite sure what’s what. What is this? Is it normal? Is this not? If you’re not sure, then do just come and ask, get some help from GP, or if you’re a doctor at Leaving, come to one of the practitioner health service, for example, to have assessment.
Rachel: What should you do? So say, you’re at work tomorrow, something’s come in. It was really stressful, really traumatic, and you think to yourself, ‘I want to do this right. I want to make sure that I’m self-aware and looking after myself.’ What tips do you have at the time and then a bit after?
Caroline: It’s a bit like physical health problems. At the time, you need an emergency first aid kit, really. For trauma, I’d say the first things you need to do are to connect with somebody else. Connect with somebody, whether it’s sending a text to a friend or going next door to talk to a colleague. Just reground yourself by connecting with anybody in your circle. We know that this is really important, from things like major disasters from natural floods and earthquakes and terrorist attacks and stuff.
The most important thing you can do for someone who’s just been through something really traumatic is connect them with their support network. Connect with anyone – thats your A, if we’re going to do an ABC. Connect with anyone.
B is for breathing, so remember, this is a trauma response is often a very physical response. It’s in your sympathetic nervous system’s going into overload. You want to bring yourself back down into parasympathetic mode. So a bit of slow rhythmic breathing, something like box breathing would be really good, or whatever you go to breathing exercises. Just a quick note, one in 10 people find breathing exercises make them more anxious. If that’s you, focus on something else like your fingertips or your toes, but just focusing on something slowly and calmly for a little bit will help.
Third one, the ABC, the C is cancel some stuff. Cancel what you can because for that first few days to a couple of weeks, you’re gonna be feeling more an edge, more stressed. You’re going to be struggling, so try and take some stuff off your plate. Look ahead to the next day the next few weeks, think ‘Okay, what could I put off, what can I postpone or what can I cancel.’ The ABC, connect with anyone, breathe, ground yourself and C, to cancel some stuff.
Rachel: I think that cancel stuff is really important. A couple of weeks ago, I felt quite overwhelmed, and I just had a very, very busy week and I looked through just cancelling a few things made all the difference in the week. I know nobody wants to be flaky, and we want to keep the things that we said we would keep, but sometimes people don’t mind saying, ‘Actually, do you mind, if we put that back a week,’ you can ask.
Caroline: I love it. I absolutely love it when someone cancels on me, I’m like, ‘Wow, I’ve got an hour free to do something else.’ It’s amazing.
Rachel: We do have such an aversion of cancelling stuff. I think maybe we’re so responsible, aren’t we, and cancelling patients is all for you, you don’t like doing that, but other people don’t really mind, particularly, there’s quite a good reason for it or whatever.
Caroline: Actually, you got to think what you’re gonna feel like if you don’t, because if you carry on as normal, with all the stresses and strains of a normal day to day life as a busy doctor, maybe, you’re a mum or caring for others as well, it’s really tough and you’re not going to give your brain the space it needs to process what just happened. That’s gonna leave you at risk of developing things down the line, like the PTSD and the depressions, and actually, going to end up needing to take more time off anyway.
Actually, the best thing you can do for everybody is to just look after yourself in that immediate aftermath, just go really gently, be really super kind to yourself and reassure yourself. It’s completely normal to be off your game for a couple of weeks and let things settle. If, as I say, down the line, things aren’t settling, then that’s when it’s probably worth coming in finding someone to have a chat through what’s going on, see if there is, it would be helpful to have some more kind of formal treatment support.
Rachel: I was just thinking when we talked about the cancelling thing. One of the reasons I don’t cancel stuff, it’s a bit of FOMO, bit a fear of missing out, but what I’m really trying to embrace at the moment is a bit of JOMO, having read that 4000 Weeks book, Oliver Berkman, and if people haven’t read that yet, just go get go read it.
Caroline: The TED Talk’s great, it’s brilliant on audio, he has a lovely voice to listen to, as well. Just important we notice the joy of missing out, yes, that actually not doing that thing leaves you open to really prioritising and focusing and enjoying other things.
Rachel: We can’t do everything, and if you need to cancel some stuff to look after yourself, that’s really really important. Caroline, I did want to ask you, what if you’re in a department that regularly has debriefs or knows that something really dreadful has happened, it’s good to have a team debrief? What’s the role of debriefing in all of this?
Caroline: Yeah, so it really, really interesting question. We know actually that forced debriefing of individuals after a traumatic event can actually be harmful, can make things worse. But team debriefing, and not really immediately, they do suggest you do it as sort of close to time as possible to the to the event, but not, like, literally five minutes later, usually sort of end of the shift, or within a few days. Getting the team together and allowing a non-mandatory space where people can talk through what’s happened can be really helpful.
I think there’s different types of debriefing, right? There’s kind of clinical debriefing that kind of what did we do wrong, what can we do better, that sort of stuff. That’s not so much, that’s fine, that doesn’t really stray into the realms of the psychological processing, and the more sort of helping somebody with the mental and emotional impact of trauma. For that, you need a sort of a, say, non-mandatory, gentle space and invitation to say, ‘come along, if you want to talk about it, you can. If you don’t want to, you don’t have to’. You can listen to the rest of the team, that can be really quite helpful. For that sort of thing, often, it can be helpful to leave a little bit of time, maybe a few days or a week or so just to be able to get that tiny bit of distance from the original traumatic event and have a bit of time to just think and process.
Again, really important is it’s not mandatory, though. It might be mandatory to go to the meeting, but don’t force people to talk. You don’t need to go around the room and get every single person to share what they’re feeling. Some people will want to talk, some won’t, and that’s okay. Just signposting, at that point, can be really helpful as well. If you find yourself struggling or if you don’t want to come to this, there is this other option, you could get one to one to chat through what’s happened.
Rachel: I think it’s really important that we recognise that we can do this for our colleagues as well. I do remember quite a few years ago, one of my close colleagues died very suddenly, and we came into work the next week, he wasn’t there and everyone was just, sort of, sat at their desk and no one really said anything. I think eventually someone said ‘Let’s go get a coffee,’ and then we did and we talked a bit, but I think some people don’t know what to do, don’t know what to say and just get on with stuff.
You can be the person going, ‘Hey guys, I think we just need to get some donuts and sit down and just have a coffee. What do you think?’ and obviously, like you said, don’t force people, but you can be the one that suggests that as well. It doesn’t need to be official, does it?
Caroline: No, absolutely not, and I think actually, as I said earlier, we heal best when we’re in connection with our normal support network — our friends, our family. It’s the reason why in really traumatic situations, the first thing people do is a ring, they get the mobile’s out and they desperately ring their loved ones to tell them how much they love them, things like that, because we naturally heal through connecting with our tribes. Yeah, it can be, your colleagues at work can absolutely do that for you.
I remember, still, awful story of how I heard about a doctor that are very sadly was unwell, and they’d realised and had got quite depressed and ended up dying by suicide at their own hands on shift in the hospital. The on-call team, doctors, the nurses were obviously called as a cardiac arrest, to come and try to resuscitate this doctor and were unable to, and then they were just expected to go back about the day, their job. I think that’s always stayed with me.
Caroline: Total lack of recognition of the impact that that kind of thing can have on a team, and, of course, you’re gonna have to think about the short term safety management of the patients in the hospital. I think just recognising that when something that difficult happens to us, we need a little bit of space and time and connection with others, but yeah, you can do that for one another. Absolutely.
Rachel: Yeah. I think, yes, that, see, applies to work as well as you can cancel some work or say, ‘I need not to be here, right now’, recognise for the people. I remember when we were doing this webinar, actually, with the Permission To Thrive guys, people saying, what should we do if someone’s refusing to go home or not taking any time off? What should we do? That was quite a tricky one.
Caroline: Yeah, it is really tricky, isn’t it? Essentially, if they are still safe to be working, then there is nothing you can do. I think if you feel that there is safety issues, then you kind of have to override that, right? Just make sure, someone isn’t providing patient care. It’s rare that that’s the case. Actually, usually, if people are really unsafe, they will actually take themselves off because they realise that they can’t concentrate or focus.
What’s more common is that somebody is perhaps trundling along with a little bit of baseline low level trauma symptoms, and they’re just getting by, and maybe they’re just surviving, and they’re just kind of getting through and, and often, then we, as doctors and healthcare professionals, we tend to be like, ‘Oh, I’ll be all right, I’ll just get through to my next holiday.’ Again, I think one of the most helpful things we can do is role model and normalise and just say, ‘Look, I’ve struggled, and I got some help, and it really helped me,’ or ‘Hey, I heard about this great service practitioner health. I thought you could give them a call, maybe some time,’ or just checking in with people will help to keep them connected, and sometimes it just takes time.
I think time is a great healer, with all things. It won’t completely cure PTSD, it might make it slightly more liveable with, so I would say that it’s been years and years is still worth going to get treatment and support. Just a bit of role modelling, normalising, ‘It’s okay.’, ‘Can I help?’, just that normal, basic human compassion can be really, really of help.
In my experience, I think people also just carry on and don’t stop because they’re feeling guilty about leaving their colleagues in the lurch. If you are one of those colleagues, and you know that a person just experienced some trauma or something really difficult to just happen, just saying, ‘It’s totally fine. You go ahead, and we’ll cover that shift.’ Permission to cancel, permission to go home.
Caroline: Sometimes, we need that from others, when we’re in that situation. We can’t give ourselves permission to go home, so we need it from others. And speaking of permission, I think we were hoping anyone listening to this might want to come along to our our next Permission To Thrive webinar. Remind me when that is, Rachel?
Rachel: We’ve got a free webinar on the 14th of July at eight o’clock, and that is all about how you give yourself permission to do all this stuff as a doctor — permission to thrive, permission to deal with your trauma, permission to take timeout when you need to because we’re not very good at doing it, quite frankly.
Caroline: Yeah, no, we’re great looking after other people, aren’t we, but struggle of it when it comes to ourselves. It isn’t easy as a doctor when you’ve got people waiting in the waiting room and tasks on your to do list that need doing. So we really like to give sort of lots and lots of different practical tips that you can try them out, see which ones work for you and which ones don’t. Take what you like and leave the rest. We’ve got the webinar coming up, you said the 14th of July at eight o’clock. Lovely, and then I think we’re starting on six monthly webinars series on the…
Rachel: 19th, 19th of July at eight o’clock again.
Caroline: Lovely, and we start with thinking about how we design a life that we love, because so rarely, as doctors and health practitioners, we get time to sit back and actually think about what do we want, and what little changes could make a difference. If you’d like to join us, we’d love to see you there.
Rachel: Yeah. Do check out the links in the show notes. Join us for the free webinar. If you’re interested in the Permission To Thrive membership, then click on the link there. It’s such a lovely, warm, warm community full of people that have been through it all that are wanting to support each other and give themselves permission. We talk about the G word a lot, we talk about with guilt a lot, don’t we? How we embrace that guilt rather than be crippled by it otherwise?
Caroline: Absolutely. I mean we’re not psychopaths. If you feel guilty, it means you’re a good person, you care and you want to do more. How do we do that? How do we keep giving but without the sacrifice of our own well-being?
Rachel: Brilliant. We’ll put all those links in the show notes. Caroline, I think we need to wrap up, but before we go, what would your top three tips be for coping with trauma when you’re working on the frontline or in any job or you’re experiencing people in distress, I think?
Caroline: I think number one would be just to normalise that, actually, it is really hard to experience some of the stuff you experience. Number two would be if you want to talk about it with anyone that you feel you can trust. Number three is just keep a gentle eye on those coping strategies that might actually be helping short term but might be making things a bit worse in the long run, so things like the excess alcohol or avoidance or drinking, eating, things like that. If any of those things are bothering you, yeah, just reach out for help, because it really is effective in treating.
Rachel: Does binge watching Netflix at one in the morning count as an unhealthy?
Caroline: Again, short term, brilliant. Longer term, if you’re doing it every night, probably going to not be helpful. I think normalise is absolutely fine. We all do it right, but yeah, just keeping an eye if it’s creeping up, or if it’s causing you problems, you’re then running late, or you’re knackered, and then yeah, that’s the time to think about whether this might be something you need to face with a bit of support and help.
Rachel: Brilliant, great. Well do check the links in the show notes and, Caroline, if people wanted to get ahold of you, find out more about what you do. How can they do that?
Caroline: Now, they can check out joyfuldoctor.com or we’re across all social media as Joyful Doctor, and they can email me at firstname.lastname@example.org.
Rachel: Brilliant, thank you so much for being with us, and we’ll speak to you again soon.
Caroline: Thanks so much for having me Rachel. Bye for now.
Rachel: Thanks for listening. If you’ve enjoyed this episode, then please share it with your friends and colleagues. Please subscribe to my You Are Not A Frog email list and subscribe to the podcast, and if you have enjoyed it then please leave me a rating wherever you listen to your podcasts. Keep well everyone. You’re doing a great job. You got this.
Sign up for Rachel and Dr Caroline Walker’s How to Give Yourself Permission to Thrive FREE WEBINAR happening on July 14, 8 pm!
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PCNs and other organisations can get a special discounted rate at the Resilient Team Academy! Find out more.
More episodes with Dr Caroline Walker:
Episode 27: How to manage our stress and anxiety through the crisis
Episode 28: How to deal with our sadness, anger and grief through the crisis
Episode 30: Moral injury hurts
Episode 33: Great expectations? Why we expect too much of ourselves and how to give ourselves a break
Episode 36: COVID fatigue – what’s going on, and what we can do about it
Episode 43: COVID boredom – what should we do?
Episode 51: How to stay calm and focused in the face of uncertainty
Episode 63: How to survive even when times are tough
Episode 82: Complaints and How to Survive Them Series Episode 3: Surviving the Process
Episode 106: How to Stop Worrying When There’s a Lot to Worry About
Connect with Caroline: The Joyful Doctor | Facebook | Instagram | Twitter | LinkedIn
This is Going to Hurt by Adam Kay
4000 Weeks by Oliver Burkeman
TED Talk: Oliver Burkeman: How to stop fighting against time.
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