Thoughts and ideas

Author: noslo (Page 1 of 2)

No time for Yoga?  Not enough room for Yoga at home?

 I would like to offer the perspective of this very short, 10 minute series of exercises. Carried out several times a week, ideally every day, this is a very acceptable substitute for full yoga sessions. 

10 minutes every day amounts to over an hour a week and the benefit is spread throughout the week.  And you are not paying money, travelling or being self-conscious. And you can really listen to your body and what you need – rather than what the yoga teacher reckons everyone in the class needs.

My practice is entirely using standing poses – so the slight resistance that someone might have to acquiring and then using a yoga mat is removed. It’s also possible, weather permitting, to do it outside much more easily than floor exercises. 

My understanding of the essence of yoga is that it is the form of undoing the freeze reflex that we all get into in the presence of tension, anxiety.  

The classic response to threat or problems is usually described as the Fight and Flight reflex but in fact the Freeze response comes first and often continues chronically in two ways –  shallow breathing and very poor, tense physical posture.

And these two pieces of behaviour don’t just reflect anxiety and stress but in fact lock us into that anxiety, perpetuating the state and creating something of a trap. I see yoga as focused on both those aspects – improved breathing and muscular loosening by stretching and bending.  

Recent research has highlighted the fact that a frozen body state is not just held in the joints and muscles but in the fascia –  “Fascia is a thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fibre and muscle in place. The tissue does more than provide internal structure; fascia has nerves that make it almost as sensitive as skin. When stressed, it tightens up.

Although fascia looks like one sheet of tissue, it’s actually made up of multiple layers with liquid in between called hyaluronan. It’s designed to stretch as you move. But there are certain things that cause fascia to thicken and become sticky. When it dries up and tightens around muscles, it can limit mobility and cause painful knots to develop.”

https://www.hopkinsmedicine.org/health/wellness-and-prevention/muscle-pain-it-may-actually-be-your-fascia

 So there is this additional scientific evidence base for the value of simple stretching and bending. There is also evidence that most of the now familiar elaborate yoga poses with impressive Sanskrit names are in fact not the classic, quite simple yoga poses but were imported by western gymnasts in the 20th century. Search Mark Singleton – Yoga Body.

If I may share my own routine: 

I start with breathing. The essence is not so much pumping large amounts of air in and out of the lungs as exploring the opposite of the startled, held breath that is triggered by anxiety. 

I am not quoting ancient yoga wisdom when I tell you about Sister Act 2, when Whoopi Goldberg calms down her panicking school choir by telling them to “yawn!”  After some protests they do that and they find that their anxiety levels drop radically and immediately. 

All we are doing when we yawn in that way is to open our throats and exhale fully. 

If you want some science, that triggers the parasympathetic nervous system which helps to reduce the anxiety hormone cortisol and releases the feel-good hormones of serotonin and even the prosocial hormone oxytocin. 

Quite a good result from such a simple action? 

One of the aspects of holding the breath is that we breathe mainly with the top of our chests – so the other aspect is to breathe into the belly fully – and then the chest – and then maybe pause ….. before breathing out fully – like the yawn and empty the lungs completely. 

It may be a good idea to do that sitting down because you can get quite dizzy initially because you may not have used your lungs that fully for some weeks – unless you do aerobic exercises 

After maybe 10 of those breaths, I start the stretching and bending aspect. I start at the top of my body with my jaw which I loosen with wide opening and then side to side movement. 

Rolling the head is really important because so much of the startled body language of stress is reflected in the strange angle that we hold our heads. 

Bending it right forward and pulling it slightly with hands on the back of the head stretches the muscles and the facia in the neck and shoulders that control the head angle. Tipping it right back also has real benefits.  

The classic neck rolling is effective. I find that shaking the head does something really interesting. It seems to trigger off  a sensation of childish, angry defiance. Just like children do when they do not want to be fed at the table. A great way of embracing the inner sulky child that we may all need to give more voice to. 

Shoulder rolling is pretty obvious because when we are tense, our shoulders tend to come around our ears.  

Shoulder joints can get quite stiff and I enjoy swimming movements at this stage which have a great advantage of my not getting wet. Crawl and the butterfly and even the backward butterfly are really quite safe in the living room. 

The lower back seems to be a real focus point for anxiety and is a huge medical problem for western cultures. Forward bends are pretty good and there is no need to let the hamstrings limit the stretch. The slight bending the knee allows a better bend in the back.  Conventional yoga gets people to go into poses and hold them for a few seconds. That is not adequate to stretch out and change the entangled state of the fascia. Try “yin yoga” style holding the posse for a minute – or two – or three.. I do my yoga to my favourite music and that makes it much easier to hold poses for quite a long time.

The pelvis is really where the tension lies and some over-controlled western cultures are  notorious for having frozen pelvises. 

Hulahoop, and slightly embarrassing movements of thrusting and twerking are really great for loosening up the pelvis and lower back and preventing back problems. (Twerking yoga? You heard it here first.) 

I feel that my legs do not get much attention in this routine but then we do walk a great deal so hopefully that makes up for it.  

Happy to have feedback.       David J

Introduction

Welcome to my blog or website.

If you have logged on here in a state of stress or distress you may like to look immediately at the very short, two minute read – the one page note for the workshops I ran recently for other child care lawyers. Current short introduction to reducing stress.

Or there are a number of other articles here on this subject starting with the slightly fuller one: Five minute stress reduction note and continuing with some longer ones that are mentioned below with links.

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: for example 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 required 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. These were initially within my own firm and subsequently for about twenty other firms and barristers’ chambers, courts and national organisations like the Association of Lawyers for Children and the Family Law Bar Association (FLBA) the Association of District Judges and Immigration Law Practitioners Association.

These offerings were initially along the lines of a somewhat simplistic “stress management model“. But they have developed to be a bit deeper – 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

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.

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

Controversial Articles. I have also 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.)

Finally – 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

Workshop for a national firm of solicitors on 6 June 2023

David Jockelson MBACP – https://davidjockelson.com/

1. “Stress.”   Let’s look at the concept of “Stress.” It’s a very unhelpful word.  Firstly, it implies inevitably – “We have stressful jobs, therefore we suffer stress.”  Cause and inevitable effect.These are two separate things. But “stress” rolls them together. 

Let’s separate them: First start with the alleged cause. “Stress” is a rolled-up concept for what is much more usefully explored as a mixture of things.  And how we label them is really important in terms of attitude. There is some truth in the old and rather irritating slogan that the difference between stress and challenge is simply one of attitude.

So “stress” is a mixture of what can be seen as exciting challenges or as interesting demands or as bearable pressure or as threats – and distinguishing between those is much more useful. In fact, it is vital.

And secondly “Stress” also refers to the effect – the subjective impact on people.  But again in a rolled-up, vague and unhelpful way. And again, it is far more useful to unpack that and be honest about what is really happening here.  

And that means talking clearly and honestly about emotions. 

Insofar as we identify the elements of “stress” which are genuinely unhealthy or toxic – then we are talking about threat.  And it is necessary to be honest and say that in fact we respond to threat with fear. 

And chronic threat means that we are chronically anxious. Familiar to anyone?

And at a less acute level, we can respond often to some challenges with frustration – which can more honestly and therefore usefully be explored simply as anger.

And we can respond to overload with an impulse to surrender. Or using clearer language – sadness or depression. 

So next we need to ask what attitude we have – how do we respond to these demands of challenges? How can we come to feel positive or less negative about the challenges and the demands? How can we identify situations where there is a real threat. And identify what is that threat? Fear of being in trouble? Fear of making a mistake? Fear of failure?

And what individually and as an organisation we can do about that in terms of – key word here – Honesty. 

People admitting what is happening to them and sharing it – is for their immediate benefit and so that other people learn that they are not alone and the issue can be shared and discussed. No apology for:  “A problem shared is a problem halved”.

Reality checks, support and encouragement.

And the joker in the pack: let’s look at pride in our stress. Status. Boasting. Self-inflicting. Are we Stressaholics?  Love / hate relationship with stress?  Discuss.

2. Then impact of demands of the job.  So the second section of the workshop is dealing with the impact of these emotions on us and whether we can be more skilful.

We can make a distinction between “good stress” – bearable and sometimes functional pressure and “toxic stress” which is actually experienced as threat: in which case we can look at the automatic innate response to threat in the human animal.

And in this bit of the workshop we can actually do something! Which will certainly be more memorable than lots of words. 

We can enact the experience of being threatened and explore its physical impact on us in terms of breath holding or shallow breathing and physical body language response. 

We can note and fully absorbed the importance of the fact that these are being caused by threat and anxiety, but they will then hold us in that state and trigger more anxiety. That is a very vicious circle – unless we release ourselves. 

And that release moment is the essence of reducing anxiety and anger and sadness and depression.  

And there are very simple actions needed to come out of the uptight threat response body.

So we will practice how to stop shallow breathing and use the whole of our lungs and to open our throats. And then to use our whole bodies to loosen up and to come out of threat response tension and to stretch and bend. In particular to stretch the fascia – explanation of this in the workshop

3. And the third section is  about where to take it from here?

Firstly, to acknowledge that many, possibly most of us do something along these lines – gym, running, yoga, Pilates and so on and that is great   And significantly the benefit can be enhanced if they are seen in the context of everything that we’ve explored here. You can call it mindfulness, or you can call it placebo effect – and that is not something dismissive – placebo is genuinely important medically – it’s probably about half the benefit of any medical or health intervention.

But for me the real question is how we can – each of us and as an organisation – move along a spectrum from a one-off workshop like this to more regular workshops or events – through to a weekly or then a daily session of breathing and stretching and bending – whatever that is called – yoga, Pilates or just breathing, stretching and bending – my label. 

And then the final question is how can we be doing that hour by hour? All day

I don’t have a real answer, but I’m interested in the fact that the Alexander Technique was and is about becoming conscious of and achieving a more healthy body language which has a continuous ongoing benefit physically and emotionally.

Can we create the equivalent for breathing and bodily relaxation?

Current short introduction to reducing stress.

This is based on the note for the workshops I ran each morning at the 2022 Annual Conference of the Association of Lawyers for Children

Reducing stress: A super informal, super simple yoga style session.    

Are you by any chance feeling stressed?!

And does that show first with your restless anxious mind: Looking for answers? Looking for problems? Exaggerating problems? Overthinking? The racing mind?

And then also, in your body with shallow breathing and a tensely held body?

If so, the crucial and unobvious secret is this: that stressed body feeds back to the mind. And worse, it makes you more anxious and more sensitive to stress. So it all becomes a vicious circle or a loop that can make you feel trapped.

You can try and work on this through counselling – talking and thinking. 

And you can see that body work like yoga is also valuable: By undoing those physical stress symptoms we can reduce the level of emotional distress; escaping the trap.

First address shallow breathing: Upper chest breathing. With throat half closed.

Answer: Open the throat. Pretend to steam up a  mirror as you breathe out. Yawn. Sigh.

Then breath in – first to the belly. Then to the chest: stand or sit up taller, stronger, more confident. Then again, the long slow open throat out-breath. Shoulders go down. Relaxed.  Strong and relaxed. Great combination.

Secondly the tense body:  The stress in the body is held in the joints, muscles and also in the fascia – a subject that Pilates and other disciplines have long known about, but which is now becoming more mainstream.

Fascia is the network of fibres under the skin, over the muscles and around the organs which we are beginning to understand is highly significant. And when the body is held in stressful tension, then the fibres can become unhealthily rigid and entangled.

And that can generate complications including emotional ones and inflammation throughout the body which has serious implications especially with autoimmune problems.

Stretching the fascia therefore has huge benefits, far beyond simply improving flexibility. It may well be the secret of the fact that Yoga is more than just a physical routine but has significant emotional – they would say spiritual – benefits.

Yoga can be in a paid-for class with others, all following the same routine, often with a degree of self-consciousness.  Or it can be at home, private, free, a flexible series of exercises listening to what your body needs at that moment. 

I do my very simple Breathing, Stretching and Bending exercises each morning before breakfast and maybe it is a form of yoga you could take home and do every morning?

It is just standing poses. No mat required. No special clothing. No elaborate or difficult poses. Just Breathing, Stretching and Bending. And therefore reduced stress.

Elements of my simple routine are below. It’s not a set routine – it’s pick and mix for what my body needs that day.   

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

David Jockelson  https://davidjockelson.com/ 

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

Action: BreathingComment:Because in stress…
Release the breath. Open the throatYawn, steam up a mirror.We close our throats to hold our breath. Squeaky voice
Then breath in fully – to belly and then the chestStand or sit taller and stronger.We only use top of lungs
Really empty lungs again. Breathe 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 lungs again. Shoulder 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 care staff.

I hope this note is reassuring and 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 ten 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 start by asking 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.

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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.

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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  https://www.nhs.uk/nhs-app/nhs-app-help-and-support/health-records-in-the-nhs-app/abbreviations-commonly-found-in-medical-records/

‘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.  

NOK: Next of Kin
 
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 non-invasive by mask.

Mask ventilation can be Bapa or BVM – Bag Valve Mask. 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.

Or ventilation can be invasive intubation – a tube down the throat or via a traceostomy.

  

Three short take home messages from Workshops on Stress /Psychological Health for Judges.

From the CFC talk on Psychological Health for Judges 7 December 2021  

Three take home messages:

 1. The value – the necessity – of seeing the need for public judicial detachment – super controlled, uncomplaining, tough – emotionally cut off, unreal, almost inhuman – and also seeing the cost of that.

And privately to name and acknowledge the reality: firstly, the reality of the objective stress factors; and then to see that there is no emotion called stress. We need to name and acknowledge the reality of the subjective reactions – the emotions: anxiety, frustration, anger, resentment, sadness. Then we have some power and can address what is actually happening to us and do something about it.  

This is the paradox – fully acknowledging the negative has a positive outcome. To name is to de-shame. This is not whinging or collapsing.

Acknowledgement is with others – colleagues, family and friends, counsellor or therapist, and with ourselves privately – possibly by journaling.

2. It’s not self-indulgent or a waste of valuable worktime to look after yourself. It is your duty to look after yourself!   This is the turn-key insight – which unlocks everything else.

And this is becoming the new cultural norm. Duty, perfectionism and even workaholism are ok. Masochism and self-neglect are now being seen as stupid and unnecessary.

If you do care for yourself, you have taken some power – in a situation where the enemy is a general sense of powerlessness. If we really value that step of taking power to look after ourselves, then of itself it significantly, (perhaps disproportionally – value the powerful placebo addition effect) reduces demoralisation and the risk of burnout.  

3. The body mind connection is real and is a powerful potential way to cope with the demands of the job.

Breathe, sigh, yawn, cry.

Move, walk, stretch and bend.

Ensure a steady blood sugar level. Keep hydrated. Care for your eyes.

https://davidjockelson.com/

Survival Handbook for stressed Judges.

This document is a typed note of the workshop I ran on Tuesday 7 December for judges at Central Family Court, which in turn builds on a workshop I ran on Friday 5 November 2021 for the Association of District Judges. The passages in ordinary type are what I said in the 30 minutes we had. To read them takes about 15 minutes. The passages in italics are what I would have liked to have had time to add – with explanations of some very compressed material and a few links to resources I mention.  To read the whole document takes about 20 minutes.

But if that is too long, I have created a summary: A one page “Three Take Home Messages” page also on this website. Three short take home messages from Workshops on Stress /Psychological Health for Judges.

Continue reading

The Drama Triangle. A very useful model

This is my version of the Drama Triangle which is a model invented by Stephen Karpman. You can research it online and find lots of articles and diagrams.

I hope this version makes sense. To be honest it makes more and more sense to me, and is more and more useful, the more I work with it – on myself and clients.

This is often put forward in quite a CBT style approach. 

The model is: If we are addressing unwelcome behaviour that is automatic – unconscious in a shallow sense – then becoming aware of it can lead to change. 

My experience is that this can be very effective. It can significantly moderate our behaviour. And that is very worthwhile.

Most people using the model stop there. However if we find the behaviour is not simply habitual but is compulsive, then it is coming from somewhere deeper, somewhere genuinely unconscious. If that is the case I suggest we have to use psychodynamic techniques and uncover the formative experiences that are being acted out in the behaviours. 

I would be interested to hear if this makes sense and is useful to you.

David 

It is really helpful to explore these roles in detail.  It’s not a case that an individual is always one or the other. We can Rescue to the extent we become Victims i.e martyrs.  We can be a Victim and use it to Persecute people around us. And it’s worth noting for those of us who identify mainly with the Rescuer, that being a compulsive Rescuer means we come from a place of our needs and may make us insensitive and unskilful.

The moderate, healthy version with increased awareness can be:                       

It is certainly possible to move to some degree from the unhealthy version to the healthy version by awareness and challenging our habitual behaviour.

However we may find that it goes deeper and in fact the behaviour is not changed much by willpower. We may find the behaviour is really powerful, almost irresistible.  In which case we need to go deeper and try and resolve or at least address the root cause.

My experience and understanding is that the behaviour is the acting out of our own history of having been a victim in childhood – not necessarily of gross abuse or trauma but of a range of adverse childhood experiences which have been ignored, kept secret or normalised and therefore never processed.

Indeed the adverse childhood experience may in fact be so much within the normal range that it is not actually seen as adverse or is minimised: Parents who are in conflict or who may separate. Sibling conflict and bullying. Parents who do not give the necessary attention because of mental or emotional health issue like depression and anxiety or addictions like alcohol or workaholism. Indeed workaholism is applauded and the impact on parental availability is often unseen.

That discussion is is very challenging because if we have had those experiences, we will tend to think about ourselves either as simply having had a happy childhood with no questions necessary or, if we see the adverse experiences, we can see ourselves as courageous Survivors. It is not at all obvious that it requires extra courage and clarity to see and accept the reality that we were also Victims and we retain that feeling deep within us.

It may be a question of moving from feeling generally angry and aggressive or anxious, depressed and sorry for ourselves, to feeling anger and sorrow for the child that we were and in some senses still are.  And having those feelings does not necessarily mean either a dramatic or noisy cathartic or a blaming experience.

It can mean gradually letting the anger and the sorrow come up; articulate, ventilate; saying the previously unsaid, possibly the unsayable.  We can then in time achieve a calm, matter-of-fact attitude to our histories and then be able to act more in line with the healthy roles described above.

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(Being more radical again, I suggest that the Nuclear Family, which is so valued as being the ideal in our culture is in fact innately unhealthy. The well known and wise saying “It takes a village to raise a child” highlights the healthiness of a child being raised by a wider group, including older children who are siblings or cousins or friends as well as wider range of adults. These are people who can socialise the child; check them, give them boundaries as well as examples to imitate. This idea is explored elsewhere in this website. See “Our culture of permanent adolescence – anger, stress and other addictions.”)

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