Clinical psychologist, Dr Angela Kent, has extensive experience in supporting individuals and families after catastrophic, life-changing injury and devising and implementing interventions that can help them to rebuild their lives after a traumatic personal injury.
Here, she discusses her approach to assessment and treatment, the importance of considering the wellbeing needs of whole families, and how PsychWorks Associates’ approach to trauma makes it stand out in its levels of support
Assessing what support is needed
Our office at PsychWorks Associates has a policy of responding to referrers within 72 hours with a potential Associate who matches the needs of the client. Assuming Sue in our office has all the referral details she needs to make a best-match decision, the case is taken to our twice-weekly held referral meetings in which our MD, Dr Shabnam Berry-Khan, and others meet to discuss clinical skills, experience in general, language/cultural needs, capacity and locality to recommend the best from our team of 25+ associates. Of course, Sue will discuss any potential shortcomings with the referrer directly so we are not wasting anyone’s time. The office focus is very much on getting the client what they need as quickly as possibly. If that support is not with us, then we do not want to be a barrier to a client’s rehabilitation – time is of the essence. We are happy to signpost or support sourcing a suitable clinician, even if not with us.
We are also aware that we often receive referrals at crisis points in client packages – for example distressing situations, continued disengagement, breakdown in relationships, identification of care team training, support for behaviours that challenge etc – so we aim to be as responsive as we can to those who refer to us. This is why our induction programme, CPD timetable and ‘virtual cabinet’ of resources for associates have been revamped to ensure our team is enabled and ready to engage.
As a first step in the clinical journey, I always try to gain an overview of the person and their circumstances, who they are and what they were like before their injury. Whilst, of course, the nature and impact of the incident that caused their current situation and what is needed for their physical injuries, is included in the assessment process, my focus is on the psychological impact for the individual and their family. For this, it’s a matter of talking with the person themselves and significant others.
The assessment process is tailored totally to the individual and can, therefore, vary significantly from one person to the next, but my general approach is to try and clarify the day-to-day difficulties they are facing and how they are already coping with these. This will include asking about mood, anxiety, any cognitive or behavioural changes and any ongoing post traumatic symptoms.
We are hugely interested in the whole person at PsychWorks Associates, so the assessment process may highlight other areas of functioning that would benefit from additional assessment and input, for example, there may be cognitive changes that the individual is having to contend with which would benefit from a more in-depth neuropsychological assessment and treatment plan. It might also include ideas about activities of daily living, pain management, mobility or communication. This could then lead to the interdisciplinary work we like to promote at PsychWorks Associates with therapy colleagues later down the line.
At this stage, I would also be looking to identify the most meaningful quantitative measures, to provide more information and set a benchmark to enable a review to see what change there has been further down the line. So, if the individual is presenting with low mood or there are post-traumatic symptoms being reported, such as flashbacks or nightmares, I might administer a mood questionnaire (for say, depression and/or anxiety) and an Impact of Events Scale (for trauma) to provide this type of quantitative information. We like to revisit these measures throughout the therapy we offer, too.
Whilst the focus is predominantly on the individual who has been injured, the assessment might also highlight difficulties being experienced by other family members and these are also part of the assessment and treatment recommendations.
Supporting the individual – and the support network
We know from research that family functioning and resilience correlate positively with helpful outcomes. So, as well as thinking holistically about the client’s needs, PsychWorks Associates is also keen on considering the impact of an injury on the whole system around the client. That might include the family – parents, partners, siblings, extended family members – but we also understand the need to think about the professional network – the care team, the therapy team, the legal professionals.
When considering the client through this multi-systemic lens, we learn 2 key things: the complexity of the client from all their ‘parts’ to use therapeutic term, but also we can work more collaboratively on shared goals and aims, something we know that will make the outcomes more likely and joined-up. We know that clients and families find it less confusing when shared goals are worked on which means they can focus on the rehabilitation better.
My background is in supporting people with brain injury and other life-changing injuries, as well as families affected by this, and this wider system approach is hugely important. For parents and siblings, the serious injury of a child is a very traumatic event and a huge amount of adjustment will be needed.
The emotional adjustment can be a very difficult process for parents and families, and it could well be that during the assessment or the treatment process, we identify that one individual family member needs particular support. For example, it may be that one of the siblings is showing symptoms of distress. Once identified, this need can also be discussed and addressed.
Communication within families during times like this can sometimes be difficult, and it can feel like you’re not making the progress you hoped to. That can be for a number of reasons, perhaps some family members aren’t at a point at which they can engage or there are other factors, even pre dating the trauma, at play. In such a situation, I would work with those family members who are able and wanting to engage, whilst ‘keeping an eye’ on the others in terms of their readiness. We can move at everyone’s own pace, but by being aware of the issues that exist, we can then address them at the best point for the individual and family.
Mapping out the way forward
Once I have ‘got to know’ the individual, their family, their circumstances and impact of the trauma and made an assessment of their needs, I will formulate the difficulties and then devise a treatment plan. Again, this is wholly bespoke and determined by the specific circumstances. The formulation of the individual’s difficulties is basically an understanding of their situation and all of the factors that have contributed to or are maintaining the presenting difficulties.
Our MD, Shabnam has developed a theoretical model currently referred to as the Personal Injury Formulation and Intervention Model (PIFIM) which will be published this year. It focuses on the whole client and the multi-systemic context in which the client exists, allowing a shared understanding of the goals to be documented while remaining client-centred. It also links the understanding to a process of intervention that builds in review and connection to those identified goals with the team around the client.
The treatment plan can therefore include many elements and can be carried out with the individual, the family or the professional network. One element that can often be beneficial is a psycho-educational component which looks at understanding the impact of the injury on the individual’s day-to-day functioning, and from there, developing a range of strategies to cope with that impact. For example, following a brain injury, individuals might experience significant changes in how they are able to manage their emotions and deal with frustration. We can look at a range of strategies to help them better understand and manage these. We might then involve the family or the wider care team to support the individual in implementing those strategies. Formulation – or case conceptualisation in non-jargon terms – becomes a really important tool here.
The treatment plan might also include some time and space devoted to adjustment in terms of the emotional impact and the personal meaning of the trauma to the individual and family; the way it has changed their view of themselves and their outlook on their future. This might involve more conventional ‘talking therapy’ such as grief therapy or trauma focussed CBT. If there are ongoing post-traumatic symptoms, such as intrusive thoughts or hyper arousal, I might consider Eye Movement Desensitisation and Reprocessing (EMDR) or Narrative Exposure Therapy (NET) to help to resolve these symptoms. It’s often a mix of different approaches, depending on the needs of the individual, as well as their families and the wider system.
The importance of a trauma-informed approach
A trauma-informed approach is absolutely crucial when working with people who have suffered a life-changing injury and their families. PsychWorks Associates often talks about the importance of this understanding across the professional network and I particularly value this approach because it considers the individual’s entire trauma history and the impact that this can have on their current coping. This can prove critical in successful engagement in treatment as it promotes the importance of creating a safe, contained, threat free space.
A trauma-informed approach also considers the impact of the trauma on the wider system, be it other family members or professionals involved. Trauma never happens in isolation and this approach highlights the need to consider everyone involved.
Support for the treating team
As our focus at PsychWorks Associates is on trauma-informed care and being aware of the impact of trauma on the system, that basic tenet is a very important part of the supervision and support offered to us as clinicians.
It’s important to be given the space to reflect on the impact of trauma work on the clinician – not only to review how the work is progressing for the client, whether the right support is being delivered at every stage – but, also, in terms of feeling supported with the intensity of the work.
We hear a lot about clinicians feeling burnt out and overwhelmed and this can often happen in healthcare, particularly for clinicians dealing with trauma on a regular basis. Because understanding and working effectively with trauma is integral to Psychworks, there is an understanding that working with traumatised clients and their families will, at times, be emotionally demanding at times and that the clinician’s support system needs to include a regular, safe place to review their clinical work. The precise nature of this space can vary (peer support or one to one clinical supervision) but what is important is that there is an opportunity to discuss the emotional impact of the work as well.
At PsychWorks Associates, there are regular group support meetings as well as an in-house register of clinical supervisors who have a wide range of therapeutic specialisms within the injury field. I recently, for example, carried out a needs assessment with a recently bereaved family and wished to discuss my impressions and recommendations with someone experienced in working with very young children. This was no problem at all and I was speaking with my more experienced colleague within days of reaching out.
Working as a psychologist in the case management and injury world is a different context in which to apply the evidence-based therapy skills that we have learnt over years of training within the NHS and other settings. Those who are drawn to work in this field like me can feel like we are providing something that speaks to our widest skills in the most complex of needs with bespoke systems in similar positions – that we are so motivated to work with our injured individual and make some kind of change. But, we know we cannot do it alone and so we strive to push from our side backed by a service like PsychWorks Associates that provides accessible tools and resources so we can simply be the clinician and we can co-create a way forward with our clients, their families and our colleagues.
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