Thoughts and ideas

Month: March 2022

Introduction

Welcome to my blog.

If you have logged on here in a state of stress or distress you may like to look immediately at the article Five minute stress reduction note

Or maybe the note of the workshop I ran very recently for other child care lawyers. Workshop at the 2022 Annual Conference of the Association of Lawyers for Children

And – excuse the dramatic note if it doesn’t apply to you if it is more urgent that that – the Samaritans are on 116 123 or jo@samaritans.org

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I set up this blog as a convenient place to explore and store ideas and papers that I had developed and written about over the last few years. I hope you find something of interest and value here.

It was originally only about my area of law – relating to children cases – but for some years has been mainly about therapy – and a combination of those two subjects: articles and workshops about psychological and therapy issues for lawyers and judges. I have sometimes labelled these as about Stress Management as that is language that is recognised and accepted. In fact it is about emotional health and resilience.

More recently I have been working with NHS front line staff – via Frontline 19 – https://www.frontline19.com/ and I have made a note about that work here: My experience of working with NHS intensive care staff. which explains that I found the work within my capacity and immensely rewarding. There is also a list of terms and abbreviations that I have developed in order to be able to listen without interrupting: List of medical terms and abbreviations for Frontline 19    March 2022   I hope these articles may be of use to therapists and counsellors who are hesitating about signing up with Frontline 19. Please do. There is quite a waiting list of nurses, doctors and others who really need our support.

A bit about me: For over 30 years I have been a solicitor, initially with a more general practice, but for a long time specialising in childcare work – which, with tragic irony, actually means legal work around child abuse and neglect.

I have written a certain amount about that, run some workshops and contributed to various government enquiries. That legal material is tucked away at the very end of this website.

About 20 years ago I also trained as a psychotherapist with Spectrum Therapy and I started to bring some therapeutic aspects into the issue of skills with legal clients as explained in Article in Family Law September 2010 (Please excuse the rather boastful sounding introduction – it was insisted on by the editor.)

I have also offered those ideas and increasingly ideas about stress management and emotional health to people through working one-to-one with clients, many of whom are lawyers. My most recent development is running workshops for lawyers including judges – see the one mentioned above.

Steve Biddulph. Also quite recently I have been writing articles for legal journals and one of those interested my friend Steve Biddulph who has recently published a new book called “Fully Human“ which contains many of his really interesting and valuable ideas. https://www.theguardian.com/science/2021/jun/03/supersense-secret-steve-biddulph-become-healthier-happier-more-fully-human

He has kindly given a bit of a plug to some of my ideas and it is possible that someone looking at this website might have come here because of that reference.

He introduces me as a friend and colleague and says “One of his most intriguing ideas is that trauma does more than just cause massive anxiety it also may act as a break in our development. Trauma can freeze us at the age when it took place, at least on some dimensions of maturation which requires trust, learning and physiological calm to proceed well. As a consequence we see many adults today who are emotionally frozen in an infantile stage of development, for example, or an adolescent one. If this is very widespread, then the whole society can be skewed towards certain kinds of immaturity.… we have a somewhat adolescent culture today.“

This is a partial summary of some ideas which are contained in one of the articles on this website – Our culture of permanent adolescence – anger, stress and other addictions By the way, I am very aware that this article is long and dense. Too much so for a website. So I have now inserted a much shorter summary at the beginning of the article.

Parenting note. This idea fed into my note about parenting on this website. Having benefited hugely from attending a parenting course many years ago, (as well as reading books and attending a workshop with Steve) I went on to train and then deliver such courses at various schools and organisations. The notes that I used and offered to participants are at Some ideas about parenting

Workshops. As I mention, over the last few years I have been running workshops. These were initially within my own firm and subsequently for other firms and barristers’ chambers and national organisations like the Association of Lawyers for Children and the Family Law Bar Association (FLBA) and Immigration Law Practitioners Association. These offerings were initially along the lines of a somewhat simplistic “stress management model“. Please see the various articles here on stress busting or “How to be a Happier, Healthier, more Efficient and Ever Youthful Workaholic!” Stress and looking after ourselves – a 15 minute read

And that includes a suggested routine of Breathing Stretching and Bending – which I have pulled out as a separate article. This is what I see as the essence of yoga but it’s only standing postures so it’s easy to do at home: no mat, no fee, no self consciousness from being in a class: Breathing, Stretching and Bending – the essence of Yoga

More recently the workshop for the FLBA was recorded and is the first article on the website My first webinar 6 May.

As it says at the beginning, this is my first webinar and is really amateur, with rather unhelpful interruptions by various people and some really retro visual aids – paper and felt tip! (The next one had PowerPoint which can be a mixed blessing and happily wasn’t recorded.)

Most recent events have been workshops I have ran for judges. Text of the presentation with additional material is at: Workshops on Stress and Judges: 2021

That is really quite long and I have done a one page summary: Three short take home messages from Workshops on Stress /Psychological Health for Judges.

Controversial Articles. Finally I have written some articles for the Journal of the Family Law Bar Association including one for the Christmas Issue examining the emotional side of the law and asking Why are we so stressed? Why are we family lawyers anyway?Article in the Christmas Edition of Family Affairs, the journal of the Family Law Bar Association (Answer in brief – we are fascinated by family dysfunctionality in other people …. and … having put it in those terms it may suggest the obvious idea which is that we hope to bring order to it because of difficult aspects our own formative experiences in childhood; experiences that we are in denial about partly because they are so normal. And that is why the article will make such uncomfortable, even unacceptable reading for some people.)

Do you find yourself motivated to care for everyone and care about everything… to the extent that you are exhausted? and might even dare to be resentful? If so, maybe in fact you are driven to rescue – have a compulsion to rescue. In which case you may find the Drama Triangle is a useful model to understand yourself. (and others – it’s often easier to see this in others first!) The Drama Triangle was developed by Stephen Karpman in the 1960s and is used in many fields. I find it really helpful in understanding others and myself. I offer this version – as the point is not just to notice unhealthy behaviour but to move from that compulsive, often unskilful behaviour to a more mature and effective motivation. The Drama Triangle. A very useful model

I would welcome feedback on anything on this website to me at david.jockelson@milesandpartners.com

Five minute stress reduction note

STRESS REDUCTION Learning to be confident and relaxed in the face of everyday stress.

Before we even start:   Right now: Pretend to steam up a mirror. Hold up your hand in front of your mouth and pretend it is a mirror that you want to steam up. Breathe out with an open mouth and an open throat. Hot breath. This can usefully turn into a Yawn.   Three breaths.  Good?

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The basic point of this whole note is this: as soon as we become anxious the body reflects and expresses this…. in three main ways – 1. holding the breath. 2. tensing the muscles3. the racing mind.  The classic response to threats and stress is Fight and Flight.  But very often neither of those actions are possible. If Fight and Flight are impossible we get stuck in Freeze and Search -i. e the three reactions numbered above.

The next major point is that this is not just a one way traffic – the brain sending messages to body. It is a loop: the body sends messages back to the brain.

The body’s breath holding and muscular tension sends messages to the brain. Imagine for an animal ..it says : “Careful. Danger of some kind. Maybe we are under attack – therefore freeze, be super alert, search for the dangers, the negatives, the threats, assume the worst, exaggerate the problems, see them before they get to us…..search to find solutions..”

This searching for threats is experienced as loss of confidence. Fear. Pessimism. Catastrophising.

Obviously, this is a perfect recipe for more anxiety: So this is the Vicious Circle. Anxious > tense breath holding > hyper-alert > seeing threats > more anxiety etc.

This keeps a person trapped in a state of anxiety for longer than they need to be. And the logic of the circle is very powerful..

Hormonally we keep cortisol, the fear hormone circulating. And adrenaline -trying to offset fear with excitement. Anaethetising the fear. And, like any anaesthetic, it can become addictive.

But by the very same logic we have a magic answer: The logic of the circle is very powerful. This therefore gives us a marvellous opportunity to interrupt that circle and start a very powerful ‘benign circle’.

If we can achieve less physical stress – ie less bodily tension and breath holding – we can achieve less messages being sent to the brain , leading to less hyper-alertness and less anxiety > leading to less tense breath holding etc. I.e. we can escape the trap.

So the immediate solution to immediate stress is physical – to do with breath and with physical muscular tensing.  This note only deal with the breathing aspect.  I will address the issue of muscular tensing at the end.

ANSWER: The solution is not just deep breathing. Breathing in the right way is not simply about driving large amounts of air in and out of the lungs.  It is open throat breathing. And then the best body language – posture when breathing.

So start with this thought: It is about the state of the muscles of the throat.

This is because the actual holding of the breath is not done by chest or lung muscles; it is done by closing the throat.

This may sound surprising but it is very easy to check. Right now – as you read this. Breathe in. Hold the breath for a moment and then release the breath sharply and watch which bit of the body is mainly involved. It is the epiglottis and the vocal chords. You may need to do this several times before it is clear. Make a noise and it is more obvious. The chest moves but the control comes from the throat.

The fact that the vocal chords are involved is fairly clear from the fact that in certain stressful situation we speak with a higher pitched voice, or even lose our voice entirely.

Fear tends to make us squeak with alarm or panic. People also squeak with indignation – a frightened, controlled anger. Awe – where we gasp and whisper in a hoarse tone? People suffering from stifled grief sometimes suffer from the ‘fish bone in the throat’ feeling – which is muscles in the throat in spasm.

Now consider the opposite – the moment when the throat is opened. Laughing, crying openly, howling, shouting in a confident way (strong anger), singing for joy. Saying ‘phew’. These are all situation of uninhibited emotion expression.

Possible exercises to try – anytime –  in fact right now as you read this!  Hopefully you have already started with this one – so maybe repeat it?

1. Pretending to steam up a mirror. Hold up your hand in front of your mouth and pretend it is a mirror that you want to steam up. That opens the throat very well. This can usefully turn into a Yawn.

Stop reading this and do that for at least three good out-breaths.

2. Then try breathing very slowly and as silently as possible with the mouth wide open.

3. Breathe out fully. Then breathe out some more. There is always more to come. Then some More! And More! It is quite surprising – and it can perhaps make us realise how the bottom of the lungs are never fully used. I like to think that I am expelling old stale air that’s been there for weeks!

Then hold it there – throat open, lungs empty. Peaceful. Strange.

Later you can experiment with other techniques and you may find one or two that really suit you:

4. Pretending to smoke a cigarette. Breathe in deep, then breathe out – slowly, luxuriantly, savouring the moment. I suspect half of the pleasure of smoking comes from this enforced or encouraged good breathing. The use of nicotine is a sad, ironic poison and an unnecessary addition. Using this technique, we can get the benefit without the poison.

5. It can help to cover the mouth. Pressing something to the lips. Covering the face as in prayer or extreme emotion. Being under a cover.

6. Counting the breaths. Or focussing really hard on the throat and the movement of air.

7. One you cannot do in public : Experiment with different sounds as you breathe out – A, E, I, O, U, – the classic ‘Om’. Watch how the throat changes with the different noises.

I find the best are: AAAAH (in) then HAAAAA (out). You can do them silently.

Belly breathing –v- Chest breathing.

There is another aspect of holding back the breath: The seven exercises or techniques mentioned above focus on opening the throat on the out-breath – but one aspect of tension is that stressed breathing becomes shallow and confined to the top of the lungs.

A closed throat goes with upper chest breathing. What is needed is to open the throat and then also breathe with the belly and then the chest. Breathe in – extend the stomach. What is happening is that the diaphragm is drawing down.

So, like many people writing about this subject, I have emphasised the benefits of the out-breath. If you want to check it out, technically speaking this is called “the parasympathetic nervous system” trigger and it brings somebody out of the freeze, flight, flight,search mode into what is sometimes described as the “rest and digest “state.   And that can refer to digesting events and emotional reactions.

Most people agree that this is indeed effective in heading off anxiety and panic, but I have been hearing therapy clients who tell me that their main problem is the in-breath. They say that to try and breathe in fully is hard or even actually painful.

In the literature the in-breath – (again check it out as being the “sympathetic nervous system trigger”) – you may see it wrongly identified simply with fight and flight. This is because it can be simply associated with the sharp intake of breath caused by an acute stress and then the state of having the held breath as described above.

But this is not the only form of in-breath. A calmer, fuller in-breath which is followed by a calm out-breath is in fact a source of strength and confidence. The readiness and ability to act but not the anxiety state created by the shallow breathing.

Accordingly, with myself and with clients, I have been exploring and encouraging the fuller in-breath; first to the belly and then to the upper chest. Personally I can also certainly feel a form of resistance this causes in me, as if it requires courage simply to take my full space, take my full oxygen, and the associated body language of standing up taller and prouder.

You may indeed find that it does automatically that makes you stand – or even sit – tall and proud. And then the out-breath causes the shoulders to drop and a sense of relaxation to come over you.

Try that now, as you read this? Dare to breathe in – then to breathe out fully?

You then have the apparently paradoxical but in fact perfectly sensible indeed brilliant combination of confidence and relaxation.

It may be good to think: “As I breathe in I am daring to breathe in. I am breathing in courage and confidence and strength. I have the right to be here.”

” When I breathe out I am daring to relax, to come out of emergency mode. I am safe.”

And it’s free and legal and healthy.

That deals with breathing.  What about the frozen body ?   Yoga has addressed that for centuries and it is increasingly popular.  Doing yoga often means going to a class once or twice a  week , travelling, paying money and being told what to do by one person – the same exercise and postures for everyone.

Doing it on our own has many advantages –  ten or twenty minutes a day is far healthier than a weekly one hour intensive.  And, listening to our bodies,  we can in fact tailor our practice to what we need most.

As I have mentioned – I offer some simple exercise routine at:  Breathing, Stretching and Bending – the essence of Yoga. Standing poses that you may actually do regularly.

Breathing, Stretching and Bending – the essence of Yoga. Standing poses that you may actually do regularly.

Action: BreathingComment:Because in stress…
Open throatYawn, steam up a mirror.We close our throats to hold our breath. Squeaky voice
Breath from bellyStick it out. Pull it in.We only use top of lungs
Really empty lungsBreathe out. Hah. Then more. HahhhhhWe hold back
Hold it thereStill small point of calmWe are usually in a hurry
10 timesFocusWe are often distracted
Then use top of lungsShoulder back. Proud.We are too frightened to
Put them all togetherNew habitWe have damaging habits
Then explore powerful body language  
Hang headSurrenderWe are too proud to do so
Tilt, rotate headLoosen up, stretchWe are tight and stiff
Open mouth wideYoga Lion faceWe are tight lipped, controlled
Loosen, flex jawLoosen up, wiggleWe clench our teeth
Pull facesPuzzled, angry etcWe overcontrol our faces
Raise then lower shouldersExaggerate. Fast then slowWe both display and suppress our fear in our shoulders
Rotate shouldersWindmill, swim, punchDitto. And anger
Twist trunkLook behind youWe are rigid
Touch the groundWith bent knees and then straightWe get very bad lower back problems
PelvisDirty dancing – Pelvic  thrusts, shake that assWe are too embarrassed about sexual display
   
Do it slow and long: First for 5 minutes, later for 10 minutes.   Keep breathing all the time. I.e. put the two things together: breathing and movement.Think of Nelson Mandela who did (much harder) exercise every day to stay sane. Note how hard to keep motivation. Left brain snobbery. Use a clock.In stress we produce hormones and our bodies express emotions/impulses: Freeze, Fight, Flight, Search, Flirt, Surrender. But we are ashamed and suppress them. We lock the emotions/impulses in. Our bodies then feed back stress to our minds.   This is a vicious circle. It can be reversed and made into a virtuous circle: Release stress. Clean up the blood. New messages to the mind. Quick, free, safe anti-anxiety treatment.

Some notes about counselling and therapy with NHS intensive care staff.

I hope this note is useful for therapy practitioners and the clients themselves – as well as any supporters of front line staff including friends, colleagues and family members.

Before starting work at Frontline19 I was anxious about working with people on the front line who had been exposed to the unprecedented situation of Covid and associated stress and trauma.  I have a fairly standard private therapy practice, having trained at Spectrum Therapy, and I now practice as a humanistic and integrative therapist. I have also worked for many years as a volunteer at our local Bereavement Service. I was not sure how this background would prepare me for working with people like intensive care nurses and doctors who carried on during the height of the Covid epidemic.

I was very pleased to find that time-honoured, simple, conventional counselling skills were in fact extremely effective in allowing them to have their experiences and emotions heard, acknowledged and, to some useful degree, processed. 

I have now worked with eight intensive care health professionals and every single one talked about having to shut down their emotions during the crisis. “Going into robot mode“ was a phrase that all of them independently used.

Obviously that degree of immediate self-repression can lead to significant later emotional consequences in terms of exhaustion, demoralisation, depression and / or generalised anxiety.

Detailed history:  My approach was simply to ask them to describe in great detail exactly what their experiences had been. I explained that I was not medically qualified, so I asked them to explain some of the terminology and some of the techniques. I said that this was educational for me and would be of benefit therefore to the other work I was doing at Frontline 19 and maybe even something I could pass on to other colleagues.

List of medical terms and abbreviations for Frontline 19  March 2022  

Importantly, this seemed to give them a degree of agency and power which is precisely what had been missing during those traumatic months.

It also evened up our relationship in a way that I appreciated as a humanistic practitioner.

Initially some of them talked very much about the objective clinical circumstances but avoided mentioning the deaths that occurred; but after a few sessions like that, they begin to be able to talk about that subject – although initially still in quite a detached way.

On several occasions I heard the remark that they had not actually realised what they had been through until they told me about it.

Acknowledging and naming.  During the telling of their experiences, I made very strong acknowledging remarks including helping them name it in the words that they had never dared to use before – eg “a complete nightmare … way beyond anything that we had ever had before”. “All the techniques which we had relied upon to save lives previously were now failing.” “We were facing this unknown illness which seemed to go on and on.”

The fact was that they were nursing other young people – indeed some of their own colleagues – but they had initially been in complete denial about the possibility of them becoming ill and dying. Then a sort of sick humour took hold of the ward but the explicit word “fear“ was never used by them until they spoke with me about it.

Shame.  One aspect which took me some time to identify was the fact that going into robot mode meant that they let go of their normal level of empathy and connectedness with their patients that they had always had before and prided themselves on. They were often on the edge of endurance on a 13 hour shift, wearing full PPE and coping with hopeless cases and deaths and they were simply looking at the clock and longing for the shift to end. 

They were able eventually to say that they had been secretly suffering a great deal of shame about the fact that they lost that empathy and connectedness. They had never talked about this subject before. Again, talking it through represented a massive lifting of that unnecessary and unwarranted sense of shame or guilt.

There was also another sense of shame which was really unhelpful – and unnecessary: the shame about being anxious, stressed, angry – in fact shame about being emotional at all! To some extent it seems this comes from their own histories but it is greatly exacerbated by the deeply unhealthy culture of the NHS – or at least those parts that I am hearing about.

Just to explore that and to explore the damaging cost of self repression and the simple fact that we all totally need to be emotional seems to have been a revelation to some clients – and a very healthy one.

Moral Injury. Another emotional issue which is related to shame is Moral Injury. This is not a phrase I had heard before but it is well known in medical circles. It refers to the emotional impact – often shame and guilt – of not being able to do one’s duty – often because of lack of resources. “There were not enough beds, enough ventilators, enough time – to do things properly – to do thing in the way I knew they should be done.” The sense of powerlessness, helplessness is massive and destructive. And not much discussed.

In terms of understanding the trauma of our clients, a worthwhile distinction may be that the intensive care world is a world of high drama.

But drama does not always mean trauma.

Even when it involves gruesome images and experiences, there is a protective factor if the person concerned has agency – some degree of power – in their involvement in medical treatment. 

Obviously that is at its strongest if treatment is successful and the patient recovers but It may be present even perhaps if it is ultimately futile and the patient dies so long as the client knows that all proper steps were taken. ie the moral injury element is not present.

Working with NHS staff both generally and especially during their experiences during the Covid crisis, what is striking is the extent to which the traumatic legacy is far greater in situations where they are powerless.

General powerlessness for NHS staff.
However powerlessness is also present generally and less obviously in the fact that they work in a large, very hierarchical organisation where others inevitably have power over them.

Even if that power is exercised in a benign and skilful way, there might be a degree of added stress for the client but sadly the cliche that power corrupts is very evident in the NHS. And that doesn’t only refer to bullying and harassment but even to a very generalised insensitivity and lack of skill by management and by senior staff.

Unspoken anger. The result is that our clients will often have experienced huge levels of frustration throughout their working life and it may continue even when we are speaking with them. And “frustration“ can sometimes be examined and understood as being a polite and a half repressed emotion of anger But, precisely because they are in a position of powerlessness, it is an anger which dares not say its name.

I have found that helping clients identify and  name that frustration and resulting anger has actually been very helpful for them.

One phrase that has come up is one that sounds childish and therefore we tend to suppress it – and therefore to repress the background emotion – of anger: “It’s not fair”. That is what people feel about the fact that they are blamed or blame themselves for things that are not their fault. And it really helps to have that acknowledged and the client allowed to say those words – loudly.

This is hugely true of the situation , in the early days of Covid when there was simply not enough PPE and staff were being forced to put themselves in huge danger. Many died as a result. And all the while the government were denying this reality, effectively gaslighting the medical profession – and the country. Some people have said they didn’t have time or energy to be angry. Maybe not explicitly but I am aware that the anger remains now – and needs to be expressed.

Those early days are now two years ago but the results continue for our clients. See below the note: “What now that the hospital crisis seems to have eased? ”

Pride in working for the NHS is reducing . A new matter that is coming up is the loss of public trust and respect for the NHS. Previously that was a major protective factor for the staff. Whatever local or temporary failings there were because of the exceptional demands of Covid, basically the NHS was seen as world leading and highly respected and valued. So staff felt supported by that respect and value.

However that is being significantly eroded with the recent enquiry of Shrewsbury Maternity Department scandal with others to come.

https://www.kingsfund.org.uk/publications/public-satisfaction-nhs-social-care-2021#reasons

Satisfaction with the NHS overall in 2021: Overall satisfaction with the NHS fell to 36 per cent – an unprecedented 17 percentage point decrease on 2020. This is the lowest level of satisfaction recorded since 1997, when satisfaction fell to 34 per cent. More people (41 per cent) were dissatisfied with the NHS than satisfied.

It is crucial to see that this is also a part of moral injury. People are being blamed or are receiving less respect because of the failings of others – often the failings of the NHS system and the lack of resources from years of government underfunding.

Does counselling work? Answer: Yes! In spite of all these problems.

Talking about all of this really does help clients. They have all said that offloading this material did indeed make them feel much lighter and more able to cope in the future. With her permission I quote one client who said “My guilt from the situation has quite drastically faded.” and “The change in my thought patterns over the last few weeks has been outstanding and is reflected quite clearly in my mood and behaviour”

I do find that eight to ten counselling sessions were enough for most of the people I have been working with although we have put in the diary some extra sessions, as a sort of check-in, three weeks and then four weeks further on.

It is my particular style to make a brief note of the contents of the sessions and send it back to the client later and this was particularly appreciated by them. Seeing it written down made it even more real and acknowledged. But that may not be possible for most professional with full time other work, nor appropriate for non-professional supporters.

Polarised thinking. Like many people under extreme stress, they had sometimes gone into quite rigid, black-and-white thinking. “Either you remain cold and hard and robot-like or you’d inevitably collapse into a complete heap.”

It took time for them to explore and accept that they could healthily and safely move in and out of a state of being warmer, softer and more emotionally in touch, without the feared opening of the floodgates of endless, debilitating grief.

Self care, self soothing. Breathing. Suggesting and exploring with them good breathing techniques, particularly of course the parasympathetic, open throat, full out breath, enabled them to see that there are safe ways of lowering their guard and coming out of robot mode. Equally other self soothing such as exercise, yoga, dance, swimming, massage and hugs – even self massage and self hugs.

Five minute stress reduction note

Yoga doesn’t have to be formal group yoga. I offer my very simple 15 minute standing poses exercises. This is so undemanding and simple that I actually do manage to do them almost every morning !

Breathing, Stretching and Bending – the essence of Yoga. Standing poses that you may actually do regularly.

Other support. Curiously with each single one I asked them about who they have been able to talk with honestly during the crisis and since; and they had all hugely limited that possibility, projecting onto their partner, family and friends the belief that they would be overwhelmed – even when those people were asking for more information and protesting their readiness to hear it.

Encouraging them to negotiate and establish quite a considered approach – almost a regular routine – for some limited offloading – proved to be highly effective. This is also something they could continue after we have finished our work together.

NHS and career stress.  As mentioned above, sometimes the way that they were managed or aggressive treatment by other members of staff were a source of great stress and distress and they had never been able to share this before. 

This included oppressive behaviour by senior staff or even, in the case of one non-English doctor, being undermined and suffering prejudice by nursing staff. They had no faith in the internal NHS complaints procedures.  The very extended, demanding and ruthless process of doctors’ training and their career structure can also contribute to high levels of stress and unhappiness. 

Talking all this through has clearly been very helpful to many clients. On some occasions it has even allowed them to make certain career decisions, for example changing hospitals or departments.

What if the hospital crisis seems to ease? At one point some clients seemed to be struggling with the fact that the hospital pressures were at that moment far less. The time of total nightmare was receding – while Covid rates are very high and hospital admissions are increasing, deaths are very much down. The real nightmare was two years ago for some people. So the doubt creeps in – surely things are ok now? What will people say? Do I really still need counselling? Answer: maybe very much so. The trauma often remains as a post-traumatic legacy of anxiety, jumpiness, depression and detachment.

And the doubts creeping in may connect with a pre-existing strong tendency to deny or minimise the reality of what happened. This issue needs to be explored and confronted or the really significant impact of the events will go on and on.

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I hope this has been useful. Please stop here if you want to -it’s long enough already! But if you want to go a bit deeper into the background of this work....

Trauma counselling and deeper therapy? Since writing the above note, I have been discussing this in my supervision – supervision is not a part of Frontline 19 so it is with my normal therapy supervisor.

And it was therefore quite useful to realise a major difference between my ordinary work as a therapist and my work with FL19.

As an ordinary therapist – and I suspect this is true for most of the other volunteers at Frontline 19 – I am used to working with people whose main problem is CPTSD – which I believe should stand for Childhood Post Traumatic Stress Disorder. Complex (or childhood) PTSD – Adverse childhood experiences

Or even CPTSC – Childhood Post Traumatic Stress Condition – picking up on the move from simply talking pathologisingly about Autism Spectrum Disorder to Autism Spectrum Condition. That emphasises not only that we are all on the Autism Spectrum but that there can be positive aspects to some of the characteristics – especially the ability to hyperfocus. There concept of post traumatic growth connects with compassion and pride in the positive consequences of our adverse childhood experiences – ACEs – that are the origin of CPTSC.

And the challenge there is that their adverse childhood experiences have been repressed. Literally put out of consciousness. This obviously is on a sliding scale from the very earliest, pre-verbal experiences which are unreachable by talking therapies (which is why I have for years been engaged in body work for myself – yes I’m up for the humanistic self-disclosure style!) through other, later childhood experiences when the memories become gradually more factually available – although the emotional experiences crucially may not be available without considerable skill on the part of the therapist and courage on behalf of the client.

This is all in contrast to working with people for whom the trauma is relatively recent and the factual information is readily available but the repression of the emotions is also largely recent but very real.  

In some senses it is more like a surface wound that has been covered up and is not healing but which will heal if it’s uncovered. That is in contrast to much earlier wounds where the infection has gone much deeper, maybe “into the bones.”

Of course there is not always such a clear distinction. People who are attracted towards the high drama and compulsive rescuing of A&E and other front line work may well be people for whom the motivation is rooted in adverse childhood experiences, although this may not be obvious to them. 

I can feel the temptation to go too quickly to that aspect rather than deal with the recent traumas fully enough.  And this is partly because the clients are often really eager to explore some early material and, because they have often not explored this, there are some nice low hanging fruits in terms of insights and breakthroughs with real benefits. If someone is a compulsive rescuer, especially if it is to the extent that they become a victim of that compulsion, then the Drama Triangle can be quite a valuable model. The Drama Triangle. A very useful model.

Naturally this approach is not relevant to everyone so I am becoming more careful to discuss this issue explicitly with each client and be transparent about how we work.

List of medical terms and abbreviations for Frontline 19    March 2022  

Based on a list in “Life Support” by Jim Down. Some references that were just about his hospital have been removed. Some refer only to ultra-acute Covid situations.  

I also used the web generally and  https://www.healthcareers.nhs.uk/glossary#CCT 

‘A&E’  Accident and Emergency. Previously called ‘Casualty’ and sometime called ‘ED’ Emergency Department.  Within the medical profession the branch of medicine relating to A&E is increasingly described as ‘EM’ Emergency Medicine.  

ACT: Acute care team.    

AED: Automated External Defibrillator 

ARDS Acute respiratory distress syndrome  

ART: Acute response team.  

Ambulatory patients. A patient able to walk around.  Eg often patients who make their own way to hospital and are not brought by ambulance. 

Ambulatory care:  medical services performed on an outpatient basis including after discharge from inpatient care.  

Blood gas: A bedside blood test that measures the levels of oxygen, carbon dioxide, acid, haemoglobin, sodium and potassium in the blood. 

‘Bloods’: Colloquial term for blood tests, used to measure blood cell counts, electrolytes and other molecules in the blood.  

‘Blue lighted’: – emergency transport to hospital. 

CHD: Coronary heart disease, a condition in which the major blood vessels that supply the heart get clogged with deposits of cholesterol, known as plaques. A chronic condition which may lead to heart attack.  See MI below  

COVID-19 (covid) COronaVIrus Disease 2019. Disease caused by SARS-CoV 2 and discovered in 2019 

CPAP: Continuous Positive Airway Pressure. Constant positive pressure applied by mask or hood to the airways. This can be air or have added oxygen. Contrast with ‘Oxygen therapy’ which delivers only pure oxygen.  

CPR:  cardiopulmonary resuscitation. Given when a patient stops breathing (respiratory arrest) or their heart stops beating (cardiac arrest). It generally refers to repeatedly pushing down very firmly on the chest but may also refer to “defib” – Defibrillator – see AED above – using electric shocks to try to restart the heart. Previously ‘mouth-to-mouth’ breathing but that is less recommended now. It can include reference to CPAP see above  

CRP: CReactive Protein. A blood marker of inflammation – typically very high in Covid. 

CT scanner. Medical scanner that gives cross sectional images of all or of parts of the body.  Sometimes referred to as a CAT scanner. Computerised tomography scan. 

DNR or DNAR: Do Not Resuscitate – or more modern language Do Not Attempt Resuscitation or DNARCPR.   

Defib – Defibrillator – see CPR above.  

“Donning and Doffing”:   Putting on and taking off PPE. Usually in separate sealed sections of the ward to avoid contamination. It can be time consuming and is needed even for toilet breaks – hence delays and under time pressure not drinking enough hence UTIs for staff.  

The Doppler: A probe that passes through the mouth into the oesophagus to measure blood flow out of the heart. 

EAU: Emergency Assessment Unit. 

ECG: Electrocardiogram. A recording of the electrical activity of the heart via sensors on the skin. ECGs detect the rhythm and rate of the heartbeat and identify abnormalities such as heart attacks. 

Echocardiogram: Ultrasound scan to look at the structure and function of the heart. 

ECMO: ExtraCorporeal Membrane Oxygenation. A machine to oxygenate blood and remove carbon dioxide in a circuit outside of the body. 

ED: Emergency Department (also known as A and E and Casualty). 

Encephalitis: Inflammation of the brain sometimes caused by viruses 

ENT: Ear Nose and Throat. 

Endotracheal tube: A breathing tube that passes through the mouth down into the windpipe (trachea). 

FFP3 mask:  Filtering Face Pieces 3 mask. A mask that protects against viruses, bacteria and fungal spores.  As opposed to the ordinary cloth surgical mask 

‘The filter’: ICU dialysis type of machine takes over the function of the kidneys when they ceased to function adequately. 

GA: general anaesthetic  

GIK: glucose, insulin number potassium. A combination of infusions to improve the heart function. 

Haematologist. Doctor specialising in blood. Some specialise in blood cancer, others in blood clotting, others in sickle-cell disease, et cetera 
 
HASU: hyper acute/unit. 
 
HDRU: high-Dependency Unit 

HCA health care assistant  

HCSW Health care support worker  

Hierarchy of nurses:  Band 5 basic grade nurses although maybe for several years . Band 6 after five or so years. Typically includes Senior Nurses, Deputy Ward Managers, Health Visitors and various specialist Nurses. Band 7 include Ward Managers, Emergency Nurse Practitioners and clinical specialists.   Band 8 and 9 roles normally only apply to Modern Matrons, Chief Nurses and Consultants. https://www.nurses.co.uk/blog/a-nurses-guide-to-nhs-pay-bands-in-2022/ 

Nurses have this very clear hierarchy and except when Covid forced everyone into scrubs, different uniforms which allowed accurate delegation of tasks. https://www.royalmarsden.nhs.uk/your-care/your-visit/nurses-roles-and-uniforms 

IV: Intra venous – injection or line into a vein  
 
ICU: intensive Care Unit (also known as at Intensive Therapy Unit (ITU) and Critical Care Unit (CCU). 
 
LA: Local Anaesthetic. 

Levels: these are ways of describing degrees of medical needs in patients. Level 1. Minor. Discharged or admitted to wards. Level 2. Intensive care may need CPAP, renal filter n=but not vented. Level 3. ICU and Resus Vented. 1 2 1 care.

Lymphocyte: the type of white blood cell, typically low in Covid patients. 
 
MDT:  Multidisciplinary team meeting.  Different professionals meet together to discuss the diagnosis and treatment of patients including doctors from different specialties, nurses and many other professionals such as physiotherapists and occupational therapists. 

Meningitis: infection of the lining of the brain. 

MI: myocardial infarction – a heart attack.  
 
Microbiologist: Doctor who specialises in the bacteria and other microorganisms that cause infections 

Moral Injury: The emotional impact – often shame and guilt – of not being able to do one’s duty – often because of lack of resources. See online definitions.  
 
On call:  Where a member of staff is available to be called for work, usually outside normal working hours. This can involve answering enquiries over the phone, or physically attending the workplace. It can also sometimes involve sleeping at the workplace to be available to deal with emergencies. 

Perioperative medicine: the clinical care of patients before during and after high-risk surgery. 
 
PPE: personal protective equipment. Basic surgical masks or much better: FFP3 filtering facepiece 

Proning: moving a patient from lying on the back to lying face down, a therapy used to increase the likelihood of survival in patients with Covid. Requires six staff and is hard and dangerous with trachies and lines. Has to be unproned quite often.  

Red flag: Symptoms that indicate a potentially serious disease and warrant prompt investigation and treatment. 

 
“Resus”: resuscitation. Hence resus nurse or officer.   See CPR above.  

Registrar: middle grade doctor between SHO and consultant. 
 
RTA: Road traffic accident.  

SARS-CoV 2: Severe Acute Respiratory Syndrome Coronavirus 2, so called because the virus is related to the coronavirus that caused SARS in 2003 

Sepsis: a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs.  

Scrubs: the sanitary clothing workers involved in patient care in hospitals. Originally designed for use by surgeons and other operating room personnel, who would put them on when sterilizing themselves, or “scrubbing in”, before surgery, they are now worn by many hospital personnel. Originally only blue now more colours are available.  

SHO: Senior house officer, a junior training doctor 

SOP: Standard Operating Procedure 

Stroke: Caused when there is interruption of the blood supply to the brain, which is often the result of a blood clot in a cerebral (brain) artery (ischaemic stroke). It may also be caused by the rupturing of a blood vessel in or near the brain (haemorrhagic stroke).  

Transient ischaemic attack (TIA) Also known as a “mini-stroke”, this occurs when there is a brief interruption of the blood supply to the brain, causing symptoms similar to those of a stroke. The symptoms typically last less than one hour and are completely resolved within 24 hours. 

Tracheostomy: Breathing tube placed through the front of the neck into the windpipe.”Trachy” 

TPR: Temperature, pulse, respiration hence TPR Chart for each patient.  

Triage: Once a patient is registered at A&E they will be pre-assessed by a nurse or doctor before further actions are taken. 

UTI: Urinary tract infection 

Ventilated: “Vented”  The principal function of a ventilator is to pump or blow oxygen-rich air into the lungs; this is referred to as “oxygenation”. Ventilators also assist in the removal of carbon dioxide from the lungs, and this is referred to as “ventilation”.   Ventilation can be by mask or tracheostomy.  

One basic type of ventilator is the Bag Valve Mask (BVM). The BVM is operated manually by a person squeezing a self-inflating bladder. This is an essential tool for ambulance crews, first responders and critical care units. It is light, compact and easy to use. Mechanical ventilator is what is used on an ICU.  

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