MENTAL HEALTH

Mental health and the patient, family and care provider

While ‘mental health’ is now a phrase used regularly and widely in society, how many of us prioritise it for ourselves? But, as Breakthrough Case Management discuss here, the need to consider mental health is absolutely vital in rehabilitation for both the injured person and their family - as well as for those tasked with delivering the life-changing care

Now, more than ever before, the focus is firmly on mental health. As something that impacts everyone in society, and the struggle with isolation and lockdowns leaving few of us untouched over the past two years, mental health is something that is rightly now in wide discussion. But, in reality, how many people are actually looking after their mental health? Is the awareness translating into action and support? Certainly, in rehabilitation, the need to consider the mental health of someone living with lifechanging injury is paramount. Research clearly links the failure to do so with a limit on the progress they make in their physical recovery. For their family and loved ones too, the impact on their mental health of their lives being changed beyond recognition is vast. But for those case managers, clinicians and care workers whose role it is to support these people, to maximise the recovery potential of their loved one, their mental health is seriously under pressure too. With an ongoing recruitment crisis into social care and burnout and people leaving the profession being at an all-time high, are they considering themselves at any point? “Mental health affects absolutely every one of us,” says Kate Golding, a leading figure in infant, child, adolescent and adult mental health nationally, who recently joined fastgrowing Breakthrough Case Management. “We all need to take some responsibility for it. We've got to be personally accountable and do as much as we can to stay well ourselves - but amidst life in general, sometimes the mental health needs we all have can be overlooked.” “After life-changing injury, the lives of people and their families will never be the same, their children’s lives are turned upside down overnight, and the injured person’s life as they knew it has changed beyond recognition,” continues Annabelle Lofthouse, co-founder and director of Breakthrough, which was recently rated Outstanding at its first CQC inspection. “And for those working in healthcare, whose job it is to support them, their mental health needs attention too. While they will always look at things from a client perspective, they need to think of themselves too.” Here, Kate and Annabelle discuss the vital role of good mental health in the patient, their family and the care professional, and the steps that can be taken to maximise our emotional wellbeing. Patient Following a traumatic brain injury, given the challenging circumstances in which most people find themselves and the rehabilitation journey they often need to embark on, it is understandable that a significant proportion of survivors will experience a decline in mental health. “But this is against a backdrop of one in four people being diagnosed with a mental health issue at any time, even without brain injury,” says Kate, who is a national trainer for Mental Health First Aid England. “A traumatic brain injury is going to dramatically increase your likelihood of mental illness, and that is including things like mild head injuries or concussion too, which affect one in three of us at some point in our lives.” But while it is so commonplace, why is mental health not always given the same prominence as physical recovery, particularly in lifechanging injury? “You can't measure mental health in the same way as you can a broken bone, but we're finding more and more that there are links between the body and the mind,” continues Kate.

“There are lots of ways the brain can be affected by a traumatic brain injury, some directly through physical injury, and some psychological, but they both cause the brain to not be working as it should. “It's much more difficult to quantify because you can't see it, but we absolutely need to give it some priority and focus.” “So many of our clients suffer greatly as they come to terms with the changes to their life,” says Annabelle. “The impact of life-changing injury is huge; how do you even begin to understand how difficult it must be to be able to do something one day and then you can’t the next? “At Breakthrough, we absolutely understand the connection between physical and mental health, which is why we prioritise both - for rehabilitation to be successful, and for us to achieve the outcomes we do, it’s essential to progress the physical rehabilitation and recovery, while supporting mental health at every stage too.” Mental Health First Aid England (MHFA) framework of support, for those who are trained to offer it, follows the ALGEE model: Approach, assess and assist for crisis. Listen and communicate non-judgementally. Give support and information. Encourage appropriate professional support. Encourage other supports “These are really vital steps to take by anyone supporting a person in crisis who has completed MHFA training, and Mental Health First Aid England are really helping to drive this forward,” says Kate, who regularly attends Parliament in helping to inform mental health policy. “You will get all the information you need if you listen, and you hear what they're saying or what they're communicating. If they can't communicate verbally, you need to be keeping records of behaviours which are also a form of communication. “Just let them tell their story, let them start to talk and encourage it, and offer reassurance and compassion towards them for doing so. “It might take time. It’s about building a trusting relationship which you have to take time to nurture and develop. Sometimes people will open up straight away, others take many, many months, or even decades to get the point where they trust you completely. “But that reassurance they will get from your support and through standing by them, giving them the information to help them make informed decisions, is so important.” Family While after life-changing injury, naturally, the rehabilitation efforts are focused on the injured person, the impact of this seismic change to the life of the whole family should not be underestimated. For a husband or wife left to pick up the pieces and attempting to rebuild their family in the best way they can, while also supporting their loved one in their recovery, that can be overwhelmingly distressing - and the impact on children, who struggle to understand and comprehend what has happened, potentially even further-reaching. “The effects within the family dynamic are significant,” says Annabelle, who co-founded Breakthrough with fellow director Catrin May. “Often the focus is on the injury and the injured person, and not the wider effects on the family, but these wider repercussions can be immense, because life is often never the same again. “I know some people say that children are the most resilient of all, but I’m not so sure I believe that, I think that’s quite old fashioned dogma. “As humans, we are adaptable, just look at what has happened in the past two years with the Covid 19 pandemic. But I think for children to experience something so traumatic happening within their family, it can leave a legacy they carry into adulthood. “For a child, if mum or dad has a brain injury, and they don't seem like mum and dad anymore, it’s very unsettling. The environment in their home often changes, perhaps there are also physical adaptations to the home, and that can be very difficult. “Holidays change, activities change. Where dad used to always play football with them in the garden, maybe now dad can’t play football anymore, perhaps he doesn’t know what a football is. The legacy of that for a child is enormous.” “At the time of the injury, there will be lots of stress in the house, and anxiety spreads,” continues Kate. “Quite often you'll see changes in a child’s presentation following something catastrophic happening to a parent. It might be behavioural, it might be emotional, it might be fear, terror that they're going to lose the other parent, or they might become ill. It’s very distressing.” Statistics show that 75 per cent of adult mental illness starts before the age of 18 - which helps to illustrate the need for support for children during such traumatic times. For Kate, who has worked in healthcare since 1998, she has her own tried and tested strategies of support, which are equally as relevant to adults as children. “I focus primarily on five key areas, I always call it Kate's Hands with children because I get them to draw around their hand - we look at diet, exercise, hobbies and interests, relationships, and sleep,” she says.

“And when you look at it, all five key areas can be fundamentally affected by this life-changing event. We need to address all of them. “For young people, sleep is probably an easy one to start with. You can look at getting those routines sorted out, having wind down time, trying to get that back. See if friends and other parents can help with taking them to clubs, which can ease the time pressure on a parent. “There are all kinds of tweaks we can make without having to go to CAMHS or a counsellor. We can all make little improvements. If they don't work, that is where you then would step it up to counselling. “But the trick we're missing, I feel, is getting those basic things right.” For adults too, the five areas are really important, although most will probably admit to overlooking their own mental health needs to focus on their injured loved one and the welfare of their children, says Kate. “You need to look at how is the parent’s diet going, and how is it for the kids? Probably not very good if mum is in hospital and dad's trying to support things as best he can. It’s not surprising if maintaining a good diet starts to slip,” she says. “And with sleep, that can be hard after such a life changing event. Is dad able to get out socially? Is he getting some time for him? “We all know that when we’re busy, hobbies and clubs are the first thing to become a lower priority. Relationships can also really suffer under the pressure of everything else. “If we can look at the five areas, and sometimes the quite simple changes you can make to get some improvements back into your lives, that is a great place to start.”

Healthcare workers In helping to rebuild lives and families after catastrophic injury, clinicians and care workers play an invaluable role - but working in a sector which is under immense pressure, with an estimated and growing shortfall of 80,000 professionals, their own welfare is a major concern. “Social care is literally, as we know, on its knees. We work hard anyway, but I think the last few years, the stress of working within a system that actually is so under-resourced, does start to take its toll,” says Annabelle. “It's very worrying for those of us who are very experienced and know what good care and good support looks like, we are witnessing a drop in standards and that’s both upsetting and frightening. “People do incredible things looking after and on behalf of their clients, but working in a system without the resources, or the staff, or the training, it’s no wonder that people are just burnt out. “And amidst this, we aren’t getting the chance to look at the work we’re doing, to reflect on the amazing impact we’re making, the fact we’re showing what great support looks like. And that impacts on mental health massively. “I think if we had a room of 100 health care professionals and you asked, ‘Do you prioritise your own mental health?’ I’d be surprised whether any of those 100 said they did.” With efforts ongoing for more support and recognition from Government for the social care sector, and change certainly not going to happen overnight, what can employers do to help the situation? Kate is a passionate campaigner for Mental Health First Aid to become mandatory just as is physical first aid, which is one step she believes should be taken. “What we want is for it to be mandated, so it gets parity of esteem with physical first aid training. We want every workplace to have a mental health first aider, as well as a physical one,” she says. “We're lobbying Parliament for that at the moment, and interestingly, the House of Commons are very keen to have it provided within House as well, to support their own members. “For me, it’s about role modelling and leading from the top, having that culture embedded within your organisation - so you're taking care of yourself, but you're also taking care of your staff. “So, on an acute medical ward, it could be that the break times are written on the board, so a member of staff knows when they're going to be taking their break. “Or things like having bowls of fruits out for people to help themselves, which might sound silly, but it's so important for your mental health to be healthy and look after yourself physically.” Supervision and the need to offload and share experiences are vital, Kate and Annabelle agree. “I was a nurse in A&E for 10 years and not once did I have any clinical supervision. But in mental health, I used to have three hours a month, peer supervision with a psychiatrist,” says Kate. “We bring cases along and talk it through with peers, who would either give praise for how well we were managing it, or maybe say something hasn’t gone so well, how about trying it like this? “It’s good for people in a really safe environment to question why you’ve gone down this path, why you’ve made this decision, as it gives us all a chance to improve, develop and grow through sharing common experiences because you’re all from a similar background. “Through sharing experiences with MDT colleagues, you end up developing loads more skills, which you pass on to the patient. “But in terms of your own mental health, it keeps you contained and safe within your role, which means that your brain is then freed up from the level of worry and self-doubt you may have otherwise.” Annabelle continues: “A lot of healthcare practice is carried out in isolation, case managers spend a great deal of time working on their own. “And as busy as you are, you’ve got to prioritise clients, but it's so important to have that protected time to interact with colleagues and have those discussions. “It's good for Catrin and I, as directors, to make the time to meet every week, just us, to run through cases, things we've picked up on supervisions with staff and case managers, and question whether we’ve handled things the best way we could. And we’ll learn from that. And that then influences and improves the continuing support we ensure all the team benefit from. “By embedding a culture, you really are learning from absolutely everybody, and then you have more confidence and ability in your own job.” For Breakthrough, the wellbeing of staff is at the heart of its offering, with initiatives such as the Cycle to Work scheme running alongside supervisions to offer support with wellbeing. “It’s down to individual company culture of course, but for us, we really recognise the value of supervision - not just for carers as that’s a CQC requirement, but it makes good sense and good practice clinically that we offer it to Breakthrough case managers and teams working with us,” says Annabelle. “Rehabilitation is certainly not an exact science, and the recovery process is not always straightforward. Sometimes, as professionals, we just need the opportunity to offload and talk about things - and we need to recognise the value of that and make time for it.”

Music Therapy offers a unique outlet for addressing psychological issues and emotional expression

When talking therapies do not work, therapeutic song writing provides clients with the voice they desperately need.

Song writing enables clients to process difficult or traumatic memories, through writing, providing a less daunting way to approach complex subjects. Alex Lowman, a qualified Neurologic Music Therapist at Chroma, implements song writing into her music therapy sessions with clients to support their emotional expression. Because song writing activates the part of the brain associated with emotion processing and regulation, the process allows clients to explore difficult memories and emotions in a less overwhelming way. Once a song is complete, the client and therapist can return to it at any stage and explore further if necessary. Lyrics can uncover painful memories or emotions that the client has had trouble facing. Being able to explore the lyrics together offers the client a safe space for emotional expression. Therapeutic song writing can also help to improve a client’s mental wellbeing and as a result, increase self-esteem and self-expression. Improving mental wellbeing allows the client to feel more comfortable to express their thoughts and feelings during subsequent sessions, supporting opportunities for continual progress throughout the healing process. Working with a young woman - client A - born with near total hypoxic-ischaemic encephalopathy, Alex uses song writing to gain a deeper understanding of her clients’ mental wellbeing. Lyrics provide a window into A’s mind-set allowing her to explore the emotions and themes within those songs. This process helps the client confront and process emotions too difficult to face alone, effectively supporting mental healing. ‘A’ enjoys song writing, and studies drama and theatre singing at a performing arts college. Her goal was to record songs she had written in her songbook. Alex also encouraged the client to develop her executive functioning skills though basic learning to play an instrument. Organising sheet music then translating the information to being able to play a note and then a tune, she then learnt to sing and play at the same time, which is a complex skill. The client was also able to retain the information she learnt one session and use it in the following session, which was rewarding for the client, helping to build her self-esteem further. Alex witnessed the client demonstrate numerous transferable skills such as initiating the songs to work on, the instrument she wanted to play, if she wanted Alex to accompany her, all of which lent themselves effectively to improving self-esteem, confidence, mental wellbeing, her quality of life - and of course, her performing arts college course. In the final music therapy session, the client went on to record five of her own songs in a recording studio and was able to perform them confidently. Commenting on the experience, neuropsychologist, Dr David Quinn, said: “In a recent case I have been working with, music therapy provided by one of the Chroma therapists has opened unique possibilities in terms of occupation and career, social communication skills and artistic expression. As a team, we had the wonderful opportunity of seeing our service user perform her own music for the first time, it was a striking and wonderful moment in her therapeutic journey.” Alex said, “Working with this young woman has been an amazing experience. She is clearly versed in music and the arts, which lends itself nicely to music therapy. She responded well and I hope that now the college is aware of her musical abilities, that they can provide more support in order for her to continue to excel in music.”

For more information on Chroma’s work go to www.wearechroma.com, call 0330 440 1838 or email: sayhello@wearechroma.com.

Benefits of Dramatherapy for people living with a Traumatic Brain Injury (TBI)

Traumatic Brain Injury survivors suffer cognitive and functional impairments.

Katy Weston is a experienced Dramatherapist at Chroma working with TBI survivors. Recently, Katy began working with a client who sustained a catastrophic brain injury. The client is non-verbal, uses a wheelchair full time, requires support for movement and has a vast support network. Dramatherapy (DT) was introduced with the intention of helping the client develop a strong voice in terms of access to communication options and choice making, as well as to enable the client to expand emotional expression, and allow time and space for a range of feelings to be shared. The intervention also offers the space for the client to choose how to structure therapy time, for example being active, relaxing or listening. Furthermore, the sessions provide music-led intervention to support motor skills including the use of rhythm to promote movement. Initially, DT was implemented to identify whether the client would respond to drama as a treatment modality. To date, the client has become more comfortable and open to Dramatherapy techniques and actively tries to stay engaged and alert even when fatigued. Above all else, the client is finding their voice and knows they are respected. Dramatherapists aim to find a way to connect with their clients – to find a language that works for both of them and that provides them with a way to connect. The connection allows for a more successful therapeutic outcome. Katy implements props into sessions to help determine a client’s emotions, thoughts and feelings that day to decide which way the session will go. For instance, introducing Winnie the Pooh characters to clients in a dramatic manner - imitating their typical emotion (Tigger – happy, excitable, Eeyore depressed, lethargic etc) to help clients determine which character best describes their own feelings at that time. It is a simple, yet effective way to determine whom they connect with and she is better able to guide the session from there. Sessions can also involve techniques such as verbal or non-verbal creative play, body work, playing games, memory games, Theraplay (attachment work) and Sherborne Movement to name a few. DT offers TBI survivors a safe space to express, explore and come to terms with the event surrounding their injury – the loss of self, and enjoy memories prior to the acquisition of brain injury whilst still being able to process emotions in the present day. TBI survivors should be able to make decisions in their life where possible. Dramatherapy provides clients with the space to feel empowered so they know, even though they are non-verbal or physically impaired, they can still have an opinion on their life, such as being presented with choices on where to sit instead of just being ‘put’ somewhere. For those living with a TBI, Dramatherapy lets them know they are respected and empowered, providing them with a voice where there are, more often than not, no words.

Dramatherapy offers TBI survivors a safe space to express, explore and come to terms with the event surrounding their injury