3B.5 Adaptation

The treatment of complex grief following a work-related psychotrauma; from traumatic to instructive*

Prof. Harry van de Wiel, clinical psychologist, UMCG

Version: 12 February 2015

h.wiel@umcg.nl; har.wiel@planet.nl

 * This chapter is based on an earlier publication in Dutch by the same author (1) 

Introduction

This document describes the treatment of healthcare professionals whose actions have caused severe damage to a patient. Examples include medical complications, medical error or, as is most commonly the case, an unforeseen combination of events with a severe result. Alongside the patient as the primary victim in these cases, there are often also secondary victims: the caregivers. They are also referred to in international publications as second victims. It is characteristic of these second victims that they not only suffer a disruption of their normal coping process, but this disruption is also closely related to their position as a ‘‘medical professional’’. The likelihood of their suffering from complex grief and Post Traumatic Stress Disorder (PTSD) is increased due to their special position and the role they played in the events. One of the characteristics of PTSD is that the disruption of normal psychological functioning one would normally expect is postponed for between a few weeks to a month. Instead, the individual either recovers remarkably quickly, appearing to be unaffected by the event and continuing immediately with their daily tasks, or else they drown themselves in feelings of inadequacy, call in sick and slip further into depression. The characteristic pattern of healthy coping behaviour, involving going back and forth between reliving and repressing the traumatic event, whereby the intensity of the relevant emotions slowly decreases (see Figure 1), is absent.

 

Figure 1: the characteristic oscillating and decreasing pattern of psychological coping, with alternating reliving (intrusion) and repression (denial) of the event   

 

 

The problems – and PTSD – are often recognized only after a considerable period of time has passed, meaning that the individual is often only referred to a specialist for cognitive therapeutic treatment much later and/or only after the case has been deliberated at length. The objectives of such interventions are:

·    reduction of the complaints associated with the trauma;

·    reduced consumption of medical services and sick leave;

·    prevention of errors and subsequent incidents.

The intervention proposed here has the additional secondary goals of being:

·    transparent and effective;

·    transferrable to other healthcare professionals and generalizable to other target groups and/or similar situations.

 

This document can be used as a guideline for carrying out this intervention. Before the description of the intervention itself, the terms that occur regularly in this document are defined below:

·    The target group of the intervention consists of second victims, in this case healthcare professionals. These may be physicians, nurses, paramedics, obstetricians and others who can be held individually liable in a legal and/or moral sense.

·    The nature of the complaint concerns complex grief following a psychotraumatic event. Complex grief is diagnosed if the duration and/or intensity of the normal reactions, such as intrusion and denial and the associated thoughts and feelings, are disproportionate.

·    The cause is normally a traumatic event at the workplace. In some cases this may be a series of minor incidents. These incidents may be characterized by major negative consequences to others caused by the professional’s actions, for example in the case of individual error. The complaints may also occur even if no error has been made, but severe injuries or death ensue during or despite the treatment provided by the professional. Another form of incident may involve the professional themselves being a victim, for example in the case of aggression directed at them or a colleague, a complaint submitted by a patient, or a disciplinary case against them.

·    The complaints or symptoms of complex grief – the complaints associated with coping with the incident – can be diverse in nature and intensity, varying from clearly recognizable emotional problems to less visible problems such as vague somatic complaints, fatigue, lack of concentration, insomnia and depression.­

 

The intervention described here is theoretically underpinned by cognitive behavioural principles and emotional processing theories (2, 3). The intervention itself, however, is primarily described in terms of communicative strategies as widely applied in directive psychotherapy and previously described by us (4). We have included some background information on this subject in the appendices.

 

This intervention is structured as follows:

 

1.  Assessment of needs: complaints, reactions, expertise

2.  Rationale of the intervention

3.  The step-by-step plan, with the following phases:

A.  Making acquaintance and providing structure

B.  Venting thoughts and feelings

C. Explicating ambivalence

D. Reformulating in positive terms

E. Homework: written assignment

F. Assignment with guaranteed success

G. Challenging irrational thoughts (RET)

H. Doubting success

I. End of therapy with multi-use ticket

4.  Contraindications and required expertise

5.  Final remarks

 

Note:

·    We use a case study throughout to illustrate the intervention. This case study is primarily intended to illustrate a number of key communicative strategies.

·    The subjects are healthcare professionals who have become ‘clients’ themselves following incidents with their ‘patients’.    

 

Case study

Verda Green is an archetypal modern medical specialist: young, highly intelligent and ambitious. She has just turned 33, she graduated from her medical programme with distinction and she has been working at the gynaecology department of a university medical centre for the past six months. As if that were not enough, she also became the mother of two children during her combined degree and PhD programme. In short, an illustrious career would appear to be guaranteed. Until that one birth goes wrong.

 

1. Needs assessment

An interim analysis of a survey of gynaecologists that is currently underway has not yet produced exact figures, but it has revealed that problems with coping with a work-related psychotraumatic incident are by no means rare (Van Pampus, 2014; exact figures to follow). The individuals involved are referred to as second victims. Insiders in the world of obstetrics, where the occurrence of second victims is relatively high, indicate that there is probably a case of an iceberg phenomenon here. The main reasons for this iceberg phenomenon, alongside a closed institutional culture and a mentality of looking forward rather than backwards, is that the symptoms are hard to interpret. Trauma-related coping problems are sometimes difficult to recognize as such due to:

·    The nature of the complaints or symptoms: psychotraumatic incidents often result in preverbal symptoms. The client feels generally out of sorts and has vague physical symptoms but cannot explain their complaint precisely in words. Only after an extended period of time and/or professional help will the client (2e) fully understand what is wrong with them and that this is related to the incident.

·    The course of the symptoms: the client needs to come to terms with the incident before they can process what happened. The problem with work-related incidents is that the work has to go on regardless of what happened. It is well-known that incidents at work are often not processed until holidays, because only then is there enough time and rest to really take stock and confront the incident. The complaints are initially strong, which is logical as the incident is still fresh. The complaints often then diminish, giving rise to the hope that the client has successfully coped with the incident and will return to business as usual. Unfortunately, the worst is yet to come, but this is typically contrary to the expectations of the client and their family, friends, colleagues and other people in their social support network. This makes it all the more difficult to link the complaints to the incident.

·    The response to the complaints: all the parties involved (the client, their partner, colleagues, etc.) find it difficult to accept that the client has not been able to resume their normal work activities after all the efforts that have been made. This implies that if the client is still visibly suffering from complaints after a certain period, these are seen as complaints against – that is, a poor reflection on – their own resilience and their social network. Social support (perspective) soon degenerates into social resistance (trivialization) and then the safest course is often to deny the problems.

 

 

Case study continued

It is an excessively busy night and to top it all off, Verda is completely on her own as the duty supervisor. Her colleague on standby duty cannot be reached for some reason. It will be revealed later on that she had accidentally turned her phone off. Verda makes a misjudgement during her shift. She fails to notice the signs of an impending uterine rupture. At the end of her shift, by now exhausted and irritated, she realizes that the uterus must have ruptured and performs an emergency caesarean. Although the baby is still alive when she retrieves it, it appears to be severely asphyxiated and the prognosis looks bad. The boy suffers a whole range of complications and is admitted to a neonatal intensive care unit and kept cool. However, the prognosis fails to improve. After he is warmed up, the physicians decide to refrain from further intervention and the boy dies in his parents’ arms three days after his birth. The contact with the parents is initially good, given the circumstances. Verda freely admits she made an error and patiently answers all their questions. She also accounts for her actions during the handover meeting. She maintains daily contact with the parents. A team meeting is convened, during which she shows her vulnerability and answers all the questions from her colleagues and the nursing staff. After one-and-a-half months, just when everybody is starting to think the worst is over, Verda starts regressing. She has been sleeping poorly for some time and notices that she finds it more and more difficult to concentrate. She has also become terribly afraid of making mistakes. She is irritable and even manages to antagonize her closest colleagues. After a few months she is completely exhausted and has to stop work altogether and report to the occupational health physician, who diagnoses ‘fatigue’.  

 

2. Rationale of the intervention

Although there are obviously many differences in the positions of first and second victims, the psychological coping process is identical. In order to understand the client’s coping process, we will now briefly explain a normal and an abnormal grief or coping process following a traumatic event. This ‘coping with shock theory’ also forms the basis of the treatment, and as such is necessary to be able to understand the rationale of the intervention.

 

·    According to the latest insights on abnormal grief, the key issue is that the client is faced with a dilemma that is so huge that cognitive integration of the incident is impossible (de Keijser, 2014). On the one hand, the client realizes they have experienced a traumatic event and that it is normal that this is accompanied by intensely painful emotions and extremely disturbing thoughts. Emotions and cognitions hereby form two sides of the same coin. On the other hand, the client cannot endure these painful emotions or accept the disturbing thoughts.­ An event has taken place that is so inconceivable that a number of existential foundations are in danger of being swept away.

·    Such existential crises can be seen as information processing problems, whereby the autobiographical memory is compromised (Boelen & Van de Bout, 2010), but they also involve a confrontation with existential questions and can damage the subject’s world view. If an event does not agree with our world view, if something truly inconceivable happens, then the subject is faced with two options: either they must change their perception of the event or they must change their world view. The more shocking the event, the more far-reaching the necessary change and hence the greater the stress experienced (Lobb et al., 201[OL1] ; Coleman & Neimeijer, 2010).

·    What becomes painfully clear here is that, after events like these, the basic assumption ‘that the world is good’ is replaced by the assumption that ‘the world is extremely dangerous.’ (Janof-Bulman, 1992). The people involved in such an event suffer from extreme anxiety, feel hounded and indicate that they have ‘lost touch with themselves’ (De Keijser, 2014).

·    A third way of examining such a case involves emphasizing the victim’s context. For the first victim, the patient, this is typically the partner or family. For the second victim, the client (the healthcare professional), this will be the workplace, the team and their direct colleagues. The Melbourne Studies (Kissane et al., 1996) demonstrate that there are roughly three types of social context:

1.  Supportive and conflict-solving. There is open communication and a joint effort to find a solution or acceptance.

2.  The in-between group. Communication is initially poorer and some victims will withdraw into isolation. However, after some time the victim will find a new balance, either on their own or with some support.

3.  Stiff and hostile families or work situations. Communication is poor, the victim holds others at a distance and hence there is a significant risk of complex grief developing.

 

·    What many people only realize after they have had a traumatic experience is that we tend to foster a positive illusion under normal conditions, namely that the world is meaningful, fair and predictable (Taylor, 1976). The confrontation with the incident makes it clear that those very important assumptions have only very limited validity.

·    In psychological terms, there is a significant degree of ambivalence, so that the emotions required for coping with the incident are suppressed and the coping process stagnates.

·    The rationale of the intervention is to rebuild the positive illusions. But old assumptions, such as “everybody makes mistakes except for me”, have to be buried first. In communicative terms, this concerns the reappraisal of the following contextual cognitive schemata in the following order:

1.  The subject believes that life (or in any case their own life) is meaningful, fair and predictable.

2.  An event takes place that destroys these assumptions.

3.  The subject now feels that life is utterly meaningless, unpredictable and unfair.

4.  Their initial response is “there must be something wrong with this feeling,” but in fact they are absolutely right: life is in and of itself amoral and has no inherent meaning. This is confusing, but the good news is that this demonstrates that there is nothing wrong with the subject’s thoughts and feelings. In fact, the healthcare professional is actually having the ‘right’ thoughts and feelings for the first time. This process is wonderfully expressed in the phrase “sadder but wiser”.

5.  This is a painful process, but actually highly beneficial for healthcare professionals, because with this new knowledge they will become more capable of helping others.

6.  With the wisdom that this helping brings, life becomes meaningful, predictable, etc. again (despite or thanks to the foregoing events).

 

The main objective of the intervention is to facilitate the acceptance of the most fundamental and thus most painful emotions and cognitions. This is achieved by creating a framework that allows the ambivalence to be converted from two simultaneous contradictory contexts into two sequential contradictory contexts. A kind of ‘interim putting into perspective’ of the initial starting points must take place so that an acceptable final conclusion can be reached. Schematically:

 

Simultaneous:

“I do my best but still it all goes wrong.” à “There is something wrong with me!”

 

Sequential:

1. “I do my best.”

Interim perspective: “That’s good, but it does not guarantee success.”

2. “It still goes wrong.” à “It could happen to anybody!”

 

The latter statement allows both contexts to be true: “I do my best but it still goes wrong, but this does not imply that there is something wrong with me.” A methodical approach is required to convert this ambivalence into ‘ambiguity’ and its success depends for a large part on the working relationship between the therapist and the client. Extremely intense emotional support is required if the client is to successfully confront such painful emotions. Please note: this support, and particularly the intimacy that ensues from transference and countertransference, cannot normally be provided by non-professionals!

 

Case study continued

When Verda visits her GP and, following a short examination, hears that she appears to be in good health, it suddenly all becomes too much for her. She had expected to be relieved that at the very least nothing was seriously wrong, but after a few seconds she starts to cry. She even berates the GP, where normally she is always very polite to her colleagues. “Well? What do you mean well? It’s not going well at all!” Thankfully, the GP understands that the anger is not directed at him and recognizes the impotence in Verda’s voice. His response is short and to the point: “What’s not going well?” After which he deliberately remains silent to give Verda the opportunity to consider her reply. Smiling shyly, she gradually pulls herself back together. “I... I don’t know. Of course I’m glad there are no somatic problems, but... I’m so tired... everything seems to be going wrong. I feel incapable of doing anything...”

 

 

3. The step-by-step plan