z. education
Education and adaptation after psycho traumatic events; a matter of reflexion
1. Introduction
As scholars, professionals demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge. Professionals engage in a lifelong pursuit of mastering their domain of expertise. As learners, they recognize the need to be continually learning and model this for others. Through their scholarly activities, they contribute to the creation, dissemination, application and translation of medical knowledge. As teachers, they facilitate the education of their students, patients, colleagues, and others (Canmeds).
Although the starting position is different, the adaptive tasks of scholars is identical to those of patients after a major change in their life history. Life events like the confrontation with and treatment of cancer, infertility or even the loss of a child all require a major resetting of our brain by extensive reflection, usually referred to as mourning or in more neutral terms adaptation. In all cases people have to replace old by new cognitions and the more fundamental the change, the more intense the accompanying emotions. Because human beings are build to resist this kind of enforced changes, this process requires effort and mourning over ‘lost cognitions’. In order to understand the process of learning in terms of replacement of cognitions, we will look at the process of grief and bereavement of our patients. We will focus on the psychodynamics of the adaptation process and, based on this insights, provide some recommendations for stepwise patient education and counselling.
2. Grief and bereavement
If one thing becomes clear from the literature and our own clinical experiences with psycho traumatic events like stillbirth, cancer etc., it is the enormous emotional burden of ‘medical events’. People felt that the earth stood still, that they were hit by a truck etc. when their lives, or that of close relatives, was at stake. Even as health care professionals, we can easily misinterpret the emotional reactions to these situations as a sort of ‘side effects’, which should be treated immediately, e.g. by using psycho pharmacotherapy. Although this of course sometimes can be necessary, most of the times this probably would have a iatrogenic effect. In order to prevent misunderstanding about the dynamic process of grief and bereavement, we will focus here on the psychodynamic aspects of adjustment after traumatic experiences. As Horowitz (1976) and later Lazarus (1991) pointed out adjustment and emotions are in fact two sides of the same coin. Emotions can not only be seen as the fuel for the process of adaptation but they also point the way in our search for a new balance in life. In other words emotions motivate until behaviour, as a reaction to a radical change, is directed towards the promotion of recovery. No emotions if nothing fundamental changes; no change without emotions.
Where psycho trauma only occurs when a fundamental change is present that is accompanied , experienced as loss of emotional well-being, autonomy and especially future prospects. Instead of psychological growth there is the issue of a process of psychological ‘shrinkage’. It is important to understand that this shrinkage sets in immediately after confrontation with stillbirth, but often only surfaces once everything is going relatively well with the patient. This is confusing for therapists, especially if one is strictly somatically orientated, because the psychological blow comes just as everything somatically is going better.
3. The adaptation process
In the term “work through” the word “work” is included with good reason.
Working through costs energy and it refers to the carrying out of a number of tasks or assignments that the change in the situation inflicts upon the patient. Kleber, Brom & Defares (1986) suggest, based on the theory of Horowitz (1976) that, in general, the following undertakings can be distinguished:
- The experience of the pain of the loss on an emotional level;
- The acceptance of the reality of the loss on an intellectual or cognitive level;
- The adjustment to the new situation and the taking on of the associated new tasks on a behavioural level.
The above mentioned integration tasks can only be logically carried out one after the other. Yet sometimes it seems as if this is not the case. In this way someone can apparently have adjusted to the knowledge that the child is dead, while that same person a little while later will talk to the child about future plans. This sort of antithesis seems more confusing than it is. In fact, execution of the integration tasks occurs, substantially, chronologically except that there is sometimes the matter of a pause. The process itself achieves resolution through the reliving of the events. Through reliving the experience, old cognitions are slowly but surely replaced by new ones which fit better with the new reality. By constantly reliving the pain of the experience it gradually diminishes. The renewal of cognitions costs so much energy and is sometimes so painful that it is necessary to more or less regularly halt the process. This halt or pause is partly a conscious activity, for example when one actively looks for a distraction. More often it is a question of an unconscious process that people associate with the term repression. The alternation of repression and reliving of the experience exhibits a wave pattern, whereby, just after the shock, episodes of extreme grief, anger or anxiety can alternate with notably calm behaviour. After the passage of time the wave dampens; the amplitude lessens and the associated emotions slowly but surely lose their impact. It is not so much that time heals all wounds, as that the recovery process by means of reliving of the experience gradually decreases the strength of the emotions.
Figure 1 (*) The pendulum of emotional recovery
(*) Translation:
Sterkte van emotie = intensity of emotional response
Emotionele steun = emotional support
Uitleg = providing information
Gespreksverloop = chronology of the consultation
Rationeel gebied = rational area in cognitive terms
In order to work through drastic events it is of crucial importance that emotions be expressed. Without experienced emotions there can be no adjustment and experiencing emotions requires ‘an audience’. Just how much emotion can be expressed, the associated reliving of the experience and therefore how much recovery takes place, is dependent on the tolerance level of the person. In short, emotional support from others is of great importance for the recovery process and recovery issues often have a lot to do with a lack of “supporters” to help lessen the load.
4. In search of support
No matter how important and necessary the (re)experiencing of emotions is, naturally it remains painful and the desire to block out or suppress is only human. Apart from the sometimes painful nature of the emotions, repression goes hand in hand with the strong desire to overcome emotional confusion. Strong emotions, especially extreme anxiety, sadness or anger, accompany feelings of loss of control and powerlessness. The patient has lost control of the situation and her own life. In order to overcome the ensuing uncertainty and confusion, one seeks a support. In the counselling of patients it is especially important to recognise this need for support and exploit it. Because the recovery process progresses accompanied by psychological changes, and they in turn are guided by the course of the disease, a phased approach appropriate to the phase in the disease process is recommended.
Although there are often signs that warn of problems, many women and their spouses too of course, are still totally surprised by the death of their child, the diagnosis cancer or the final diagnosis ‘infertility’. The processing of it begins only after the phase of active examination and medical treatment, but that doesn’t mean that this acute phase is unimportant. Patient experience attests that the period wherein the person themselves perceives that there is something wrong, for example with some symptoms or waiting for the outcome of a test, is a sort of existence “between hope and fear”. One can become active and, for example, gather information from the Internet and search for the “best” doctor, or just wait passively, seek distraction or use other forms of emotional coping. Psychosocial care is generally restricted to the provision of (procedural) information and emotional support. If there is subsequently a question of e.g. stillbirth, psychologically speaking, there is a turbulent period ahead. Just as with other illnesses, a patient dealing with loss reacts with certain coping mechanisms such as limiting the world in which he lives in with regards to space and time. Only the here and now is still important; one lives from day to day and has little room for emotional reflection. The treatments are often so emotionally charged that even a certain amount of disassociation occurs. Where this is not the case, the patient will be especially troubled by very intense and painful emotions. Although these feelings are often intense and taxing, seldom does one resort to specific psychological intervention, unless it concerns extreme forms of anxiety or depression. In principle one sees these sorts of complaints as “healthy (psychic) reactions to an unhealthy (somatic) situation”. In general, the experiencing of emotions such as anxiety, grief and anger is seen as inconvenient, but also as a “healthy reaction to an unhealthy situation”. In this sense there is no external intervention indicated other than the standard information and counselling that every patient receives. Specialised psychological treatment is also usually not required in this clinical phase, because a certain amount of dissociation occurs and one appears emotionally calm. The strongest emotions occur only later, especially when everything is somatically going better. While for most women this indicates the end of gynaecological intervention, for others it heralds the need for intensive counselling.
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Box 1 : professional help; stepped care after stillbirth
Professional help; patient education and counselling
Within the available assistance with recovery one can define diverse types of interventions, which can differ both in method and in the degree of intervention. The most traditional forms are described here.
1 Information and advice. One of the most important forms of assistance is the providing of information. The problems which the patient will have to deal with during the different phases require much more than information alone. Patients also need, apart from the content of the information, advice, direction on how to act on the information, how they can translate knowledge into deeds or decisions.
2 Counselling. Counselling is a non-directive manner of assistance with the primary goal to help the patient gain insight into unclear and confusing feelings and make a decision when faced with an emotionally laden choice. Examples of dilemmas concerned with stillbirths are the name giving, burial and other types of bonding rituals such as holding, taking photos etc.
3 Psycho-education. This category is understood to provide intellectual enlightenment specific to the medico-psychological circumstance and personality of the patient. By increasing the knowledge of the patient, she can better accept her situation, can more easily handle the disease symptoms and confidence in therapy is increased.
4 Psychotherapy. Psychological treatment is directed to the improvement of psychological complaints or symptoms. The treatment is methodical. It is a combination of both directive and non-directive techniques, in individual, group, as well as family settings.
5 Psychiatric treatments and medications. Dependent upon the gravity of the psychic symptoms the problems can sometimes be termed psychiatric. Here it involves serious cognitive disturbances, psychoses, depression or personality disorders. The symptoms could have existed before the occurrence of the stillbirth. The diagnosis and the prescription of medications (psychopharmacological) especially are associated with psychiatry.
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6. Standard treatment and screening
If any conclusion can be drawn from psychosocial obstetric research, especially from quality of life studies, it is that “the” patient does not exist. Even under extremely taxing circumstances people display diverse requirements for professional support. This finding has two important implications. First that psychosocial intervention, just as medical treatment, requires a clear indication. Secondly, in order for one to determine this indication, one would have to be involved with all patients at a low level. Only then can one determine if “this” patient does or does not require further intervention and if so, which. That the associated caution is exercised so as to not endanger the autonomy of the patient further than the medical situation has already done, is self-evident. The implication is that (new) patients should be “screened” for the presence or absence of issues and the indication for further intervention.
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Box 2: Do’s & Don’ts in case of stillbirth
Do’s:
- stimulate adaptation by patient education in terms of useful and understandable information and by giving this information in a pro-active way;
- provide structure in order to reduce mental chaos and emotional disturbance, e.g. by enable parents to see the same caregivers again and to offer extra ultrasound investigations and checkups;
- provide counseling in order to help parents ‘sort things out’ and to help them in taking difficult decisions with regard to timing and location of delivery and postpartum care burial options, autopsy results etc;
- provide emotional support, especially when the parents are confronted with the meeting and separation of the baby, but also try to take away feelings of insufficiency, guild and shame;
- encourage couples to hold and touch their child and facilitate provision of photos and memorabilia;
- screen on post traumatic stress symptoms, especially in mothers, and provide if necessary psychosocial help.
Don’ts
- Don’t take away parental responsibilities; let parents take their own decisions, even if the decisions to be made are painful;
- Don’t try to cheer parents up; give them time for grief and mourning;
- Don’t confuse emotional utterances of despair (How is this possible? How could this happen to us?) with cognitive deficits of information!
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Transformation to education; lessons to be learned
Although this knowledge about adaptation after psycho traumatic events helps us to understand and help our patients, the question rises what it means for dealing with educational problems of our students, colleagues and ourselves. In order to answer this question we have to keep in mind that the bio psycho social approach of medicine is especially worthwhile when the person as a whole is involved. When learning is not only about new facts and figures but also about the way we think and reason (methods) and even about how we relate to each other and think about the world. In order to establish the required development or growth, as a person and as an organisation, ‘drieslagleren’ is a sine qua non.
Eventueel toelichting bij de niveaus:
Enkelslag leren (single loop leren)
Argyris (1996) omschrijft deze vorm van leren als volgt: 'Wanneer een fout wordt ontdekt en hersteld zonder de onderliggende waarden van het (individuele, groeps, intergroeps-, organisatorische of interorganisatorische) systeem ter discussie te stellen of te veranderen, spreken we van single loop leren'. Deze vorm van leren wordt gebruikt bij routinematige aangelegenheden. Doelen, middelen, regels, procedures en normen staan bij enkelslag leren vooraf vast en staan als zodanig niet ter discussie. Bepaald wordt in hoeverre de beoogde resultaten zijn bereikt volgens de normen en of de regels juist zijn toegepast. Indien norm en resultaat niet met elkaar overeenstemmen wordt alsnog geprobeerd deze op één lijn te brengen.
Bij organisatieveranderingen wordt doorgaans gebruik gemaakt van single loop leren (blz. 22). Complexe zaken worden opgedeeld in eenvoudige taken. Het veranderkundig model van K. Lewin (unfreezing, moving, refreezing) gaat volgens Argyris uit van single loop leren (blz. 23). Single loop leren veronderstelt beheersing van de situatie. Interventies zijn erop gericht beter te functioneren binnen het bestaande kader. Het management zorgt ervoor de situatie de baas te blijven, maximaliseert de mogelijkheden om te 'winnen' en tracht 'verliezen' te beperken. Men onderdrukt negatieve gevoelens en stelt zich rationeel op (Mensink o.c.).
Dubbelslag leren (double loop leren)
Bij 'double loop' leren wordt een grondige analyse gemaakt. Er wordt gebruik gemaakt van inzichten, dat wil zeggen van methodische of theoretische kennis, om problemen te verhelderen. Bij dubbelslag leren worden de bepalende variabelen onderzocht en gewijzigd. Bepalende variabelen zijn behoeften die individuen hebben en die zij trachten te bevredigen. (1996: 20,21). Deze variabelen zijn observeerbaar. Double loop acties zijn overkoepelende programma's.
Het gaat daarbij niet alleen om het expliciteren van de onderliggende overtuigingen of waarden. Double loop leren richt zich eveneens op het bespreekbaar maken van het onbespreekbare. Deze vorm van leren vereist dat cognitieve regels of redeneringen expliciet worden gemaakt. De extra lus bestaat eruit dat de gewenste resultaten, normen of toegepaste theorieën zélf geëvalueerd en gewijzigd worden. Aan moderne managers worden andere eisen gesteld. Zij moeten effectief met teams werken, productieve relaties aangaan met cliënten en kritisch nadenken over hun organisatorisch handelen. Voorwaarde is dat de professionals hun eigen fouten bespreken in het team. In een team dient een gemeenschappelijke taal te worden ontwikkeld om elkaar te begrijpen (1996: 110-112). Voorkomen dient te worden dat men op zich zelf staande monologen voert. Dubbelslag leren werkt productief mits premissen openlijk worden besproken. Conclusies zijn duidelijk. De strategie wordt helder geformuleerd. Concepten houden rechtstreeks met elkaar verband. Er worden duidelijke regels voor het zorgvuldig gebruik van concepten en theorieën gebruikt teneinde toelaatbare gevolgtrekkingen te formuleren en toetsbare conclusies te trekken. Bovendien worden criteria gebruikt om de validiteit van de toetsingscriteria zelf te bepalen.
Drieslag leren
Aan enkelslag leren en dubbelslag leren voegt Wierdsma drieslag leren toe. Wanneer niet alleen nagedacht wordt over vigerende regels en theoretische inzichten, maar bovendien reflectie plaats vindt op principes, waarden en normen, spreken we van drieslag leren (Swieringa & Wierdsema, 1990; Van der Krogt, 1995: 119-120). Bij drieslag leren wordt reflectie gepleegd op het bestaande paradigma en gezocht naar een alternatief.
Dit laatste lijkt sterk op het verwerkingsproces dat mensen gedwongen moeten maken als zij worden geconfronteerd met medische life events.
Literature
Gold KJ, Dalton VK and Schwenk TL: Hospital care for parents after perinatal death. Obstet Gynecol 2007;109:1156–66.
Horowitz MJ: Stress response syndromes. 1976. New York, Jason Aronson.
Kleber RJ, Brom D & Defares PB: Traumatic experiences, consequences and adaptation. 1986. Lisse, Swets & Zeitlinger.
Lazarus RS. Emotion and adaption. 1991. New York: Oxford University Press.
Saflund, K, Sjogren, B and Wredling, R: Physicians' attitudes and advice concerning pregnancy subsequent to the birth of a stillborn child. 2002, Journal of Psychosomatic Obstetrics and Gynaecology, Jun;23(2):109-15.
Saflund, K, Sjogren, B and Wredling, R: The Role of Caregivers after a Stillbirth: Views and Experiences of Parents. BIRTH 31:2 June 2004.
Saflund K & Wredling R: Differences within couples’ experiences of their hospital care and well-being three months after experiencing a stillbirth . Acta Obstetricia et Gynecologica. 2006; 85: 1193_1199