Moving on after trauma

Attending your first-ever trauma therapy group can bring up lots of emotions. You're sitting in an unfamiliar room with a group of people you do not know. You are unaware whether the content will be triggering, whether you will have to share your experiences, as well as trying to gauge the other attendees. Are they going to judge what you say? How will they perceive you, and will they relate?

The facilitator reassures the group that no one will be asked to share their experiences and it is important to keep ourselves safe. We are told the focus will be on learning how trauma is processed and skills to help us manage the symptoms. The group starts by discussing the definition of trauma and what symptoms we may experience. The group shares ideas such as nausea, anxiety and increasing the use of alcohol; all of which I relate to. I had no idea that trauma could have such a physical impact on our health.

The facilitator explains what happens to the body when in our fight and flight response. They go on to say how trauma can keep us in that state, even after the event has happened. It helps me understand why I am so easily startled. We talk through some grounding techniques and finish the group with a progressive muscle relaxation exercise. I feel safe and regulated, I feel understood and I feel ready to engage.

I'm an Assistant Psychologist (AP) on an inpatient drug and alcohol detoxification and stabilisation ward. The scenario you have just read is pulled together from feedback I've had from our patients. These are people living with a dual diagnosis, defined as having both a mental health and substance use problem, who often slip through the gaps in services.

Over 70 per cent of those in drug and alcohol services identify as having a mental health need (Delgadillo et al., 2012). A further 54 per cent of suicides in people experiencing a mental health issue, involve those with a substance use background (NCISH, 2016). With a large amount of this population with co-occurring conditions being excluded from services (CQC, 2015), people commonly find themselves trapped in a cycle with very little support.

This called for change. The government commissioned Dame Carol Black for an independent review on drugs which enabled the creation of Project ADDER. Project ADDER focuses on drug treatment, recovery and prevention as well as the creation of many new job roles, including my own. My role is the first psychological role to be based on the ward, and one where there is no Clinical Psychologist physically present, alongside.

Helping to set up a new mental health provision within the prison service in my previous role, I had some experience, but this role certainly came with its own challenges. My job role has so many positives, and our team are continuously working together to develop our service. Nonetheless, with a new job role in a new environment and no previous AP to shadow, my resilience was put to the test.

'Not a mental health ward'?

When I started my role, I had my job description and guidance from my Clinical Psychologist Supervisor, but instructions on how to fit into the ward did not exist. I learned very quickly that clinical staff on the ward were very unfamiliar with psychological staff and had no conception about how I would fit in on the ward. Many staff believed that the two to three weeks that patients were with us were to physically detox, and this was not the time to be exploring their mental health. On a couple of occasions when seeking advice, I was met with we are 'not a mental health ward'.

With my confidence gradually decreasing and my instinct to seek help and support from the team, I ended up moulding to the absent role of the group facilitator. The team had been without a group facilitator for a couple of months and our HCAs were burnt out from covering the group programme trying to cover the content. So, I stepped in. I created new content for the group programme and trained in delivering MOAT (Moving on after Trauma) groups.

Many of our patients, especially in the first week, can find it very difficult to engage in an hour long group whilst feeling so physically unwell. Going through a detox, patients will be experiencing withdrawals and exhaustion. We typically have up to 10 patients on the ward and with limited support staff available, I was frequently facilitating these groups on my own. After around six months of this routine, my confidence grew as my ability to manage a large group setting on my own improved. I became more knowledgeable and comfortable with the material that I was delivering. It was rewarding to work with patients who are so passionate and motivated to learn and move forward in their recovery.

Even though I gained so much joy from facilitating the group programme, there was still a part of me feeling misunderstood and underappreciated by the team. The support I received from my manager and supervisor were requisite in me moving forward. However, even with this support, I was continually aware that solely doing groups was never intended to be my role.

Arrival to discharge

I wanted to become familiar with what my role should look like. There was no other NHS inpatient units in the surrounding area, and therefore no one with my role. I got in contact with my Supervisor to see if they had knowledge of any similar roles. I was given the contact for an AP in an inpatient detox unit in Manchester. This team had a wider Psychology team with a Psychologist present, which educated me on the potential our ward held. Moving forward, I started to attend more training to widen my skillset and build my relationships with wider teams. This is when I started to increase my understanding of what my role should look like.

I created an 'arrival' questionnaire to complete with patients on their admission, to gain an understanding of their mental health need. Where applicable, psychometric measures would also be completed. I engage in 1:1s with patients which mostly involve teaching healthy coping strategies and together forming a plan for when in crisis and/or distress. As well as this, I created a 'discharge' questionnaire to go through with patients to monitor how their mental health need had progressed throughout their stay with us.

Many of our service users will have a history of developmental trauma, which can be difficult without a Clinical Psychologist on the ward. There was no option of going back to the office for a reflective de-brief amongst your Psychology colleagues. That being said, being within a team all working all in the same environment naturally created a safe space to provide each other support. My clinical supervision is key in navigating these experiences and prioritising my self-care. I quickly learnt that I was able to reach out to my Supervisor or call any of the Community Psychology Team when required.

Whilst I was developing and building my role, we had a group facilitator join the team, which really helped with my capacity. My relationships with the team were stronger and I was able to be boundaried regarding the work I was now carrying out. With time, staff were beginning to understand the purpose of my role and started to seek out my knowledge when a patient was in distress. I felt empowered having got to this place in my role, considering my feelings when I started. The challenges I now faced was having the capacity to provide 1:1 work to all of our patients as well as any unprecedented situations we face on the ward. We started to grow the Psychology team on the ward and once a week I had a Psychology student and another AP supporting me. Although staffing levels vary, the presence was growing.

I was approached by a Clinical Psychologist, enquiring about co-facilitating a CBT group on our ward. Knowing the benefits and impact this could have, we were very quick to implement this. Due to capacity, we started to trial the group by having the Clinical Psychologist link in virtually. This was very new to us – we had not used any technology in our groups up until this point. We have now been doing this group for around a year, collecting feedback from patients to gather their thoughts. Generally, the feedback has been really positive, with patients scoring it an average of 15/20. It was anticipated that hosting the group virtually would raise some comments. However, only one person had mentioned they would have preferred the facilitator in person. We hope to continue this and plan to keep this routine enduring.

I am now at a place where I am building on my existing skills and pushing myself further. This includes co-facilitating training to drug and alcohol services in our area, co-facilitating research, leading an AP group within our trust and future plans to share at conferences. Each day will continue to bring new challenges and learning opportunities. I am very grateful to be in the role I am and look forward to what comes next.

References

Care Quality Commission (2015) Right here, right now.

Delgadillo, J., Godfrey, C., Gilbody, S., & Payne, S. (2013). Depression, anxiety and comorbid substance use: association patterns in outpatient addictions treatment. Mental Health and Substance Use, 6(1), 59-75.

The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Annual Report 2016: England, Northern Ireland, Scotland and Wales October 2016. University of Manchester.