Understanding how trauma affects the brain

Dear friends -

The theme of the Canadian Association for Suicide Prevention conference that Andrew and I attended in Winnipeg this past fall was traumatic experience and its relationship to suicide risk. Someone said to me recently that mental illness or injury is what happens when a person’s central nervous system is overwhelmed. I like the simplicity and concreteness of this definition. It brings it down to the level of a physics equation: If enough force is applied to a bone in a particular direction, the bone will break. The amount of force will depend on the shape of the individual bone, how strong or brittle it is, and the direction in which the force is applied. The same applies to people’s minds.

If Internal + External Resources > Trauma, the result is Coping or Thriving
If Internal + External Resources < Trauma, the result is Mental Injury or Illness

Some at the conferences talked of people they had known who had survived incredibly tumultuous and traumatic childhoods and many ups and downs in their adult years, but then died by suicide following what seemed like a much lesser event such as the end of romantic relationship or (as in Cliff's case) a perceived threat to job security. They hypothesized that this was because it was the straw that broke the camel's back, something that finally overwhelmed the person's remaining inner resources.

Since attending the conference, I’ve read an excellent book, Traumatic Experience and the Brain, in which David Ziegler describes the neurological damage that can be caused by traumatic experience and childhood neglect. He provides a helpful description of what traumatic experience does to a brain and the long-term consequences that can result. One presenter at the conference spoke about the increased suicide risk that occurs for some people with mild to moderate brain damage. Ziegler seems to be talking about a similar degree of neurological damage occurring as the result of trauma or childhood neglect.

Ziegler comments at several points in his book about the length of time it takes to do neurological reparative therapy with children who have experienced severe long-term trauma or neglect, and that government is increasingly reluctant to pay for that type of long-term treatment. If it takes one to three years for a young child to develop more functional relationships and more adaptive ways of responding to the world, how long might it take for an adult for whom beliefs, emotional responses, and patterns of reaction have become deeply ingrained? And where in our health care system are the provisions for that type of treatment and the people equipped to provide it?

He also says, "The most serious finding concerning the effects of trauma is that neglect appears to be the most pervasive and persistent form of trauma when considering implications with a lifelong trajectory.... The implications for safety, nourishment, and the pivotal issue of attachment can be profound." (pp.40-1) Yet those of us who haven't experienced childhood neglect, including many therapists, don't understand the reality of that experience and its affects, don’t take it as seriously as more dramatic events such as physical or sexual assault, and aren't equipped to treat it.

Not all people who are at risk of or have died by suicide were neglected or abused as children or have experienced traumatic events. For some, perhaps particularly teenagers and young adults, the onset of a severe mental illness can, in and of itself, overwhelm their internal and external resources leading to a suicidal crisis. For others, repeated or ongoing experiences of mental illness, particularly schizophrenia, bipolar disorder, and mixed anxiety-depression, lead to the same outcome.

It’s also apparent that mental injury in and of itself doesn’t necessarily heighten someone’s suicide risk. Victims of torture, for example, are generally found to still have a relatively low risk of suicide, while war veterans and victims of childhood neglect and abuse have a markedly higher risk. I wonder whether the difference is the degree to which each takes the blame for the trauma and their ability to cope with the resulting mental injuries — that is, the amount of shame the individual experiences.

What’s been important for me to learn through this:

Neurological injuries are as real and debilitating as physical injuries, but more difficult to recognize.

Two people can experience the same event and emerge with different injuries, or one may not be injured at all — this is just as true mentally as it is physically.

Effective treatment for neurological injuries is possible. As for most injuries, the potential for healing is greatest when treatment is received soon after the injury occurs, but treatment later in life can also be of great benefit.

The length and intensity of the treatment required is relative to the severity of the injury. Brief or solutions-focused therapies are not effective treatments for severe or long-standing injuries.

Knowing that one is injured — that there are real, physiological reasons for one’s experience and behaviour — and having others recognize this, too, can provide immense relief in and of itself. Knowing that it’s not your fault — that this isn’t just an individual failure to think positively enough or see things from the right perspective, it’s the symptom of a physiological injury — and that there are things you can do to mitigate or ameliorate your experience is a message that many more people who have survived neglect and trauma need to hear.

Psychological Safety in the Workplace

Dear friends -

After Cliff died, I was furious at the leaders and managers at his workplace for the role I perceive them to have played in his death. Because I had worked for the same organization and with many of the same people, I had my own experience and perspective of what he was dealing with.

Cliff's experience

The extreme anxiety and major depression that took Cliff's life were precipitated and aggravated by events in his workplace. The anxiety began after he learned that his employer's contract for IT services would not be renewed by BC Hydro, which put his job in jeopardy. Other aspects of the situation added to the stress and pressure:

• Management of Cliff's team had changed frequently, especially in the past two years. The current manager seemed inexperienced, awkward, and unaware of his impact on the team. He was focused on pleasing his superiors rather than taking care of his employees. Some of the decisions he made and the way those were implemented caused Cliff to feel ostracized, scrutinized, or embarrassed, and Cliff did not trust him.
  
• Contract workers from India, paid at a much lower rate, had been brought to B.C. to do work closely related to that of Cliff's team. The employer made no attempt to educate the Canadian team members about working cross-culturally, and there were many communication challenges. The use of contract workers was perceived by Cliff and some of his colleagues as a threat to their employment.
• Some team members were already leaving to work for other employers, meaning the team was losing knowledge, skill, resources, and established relationships. This increased pressure on the remaining team members.
• Cliff's team was responsible for maintaining the integrity of an enterprise IT system, SAP, through which all of BC Hydro's customer, human resources, and financial information is managed. Despite the team being under-resourced and dealing with news about the impending end of the contract, they were still required to take on a project to integrate customer payments into SAP -- further increasing the profile and risk of the system, and the pressure on the team. The suicide attempt that led to Cliff's hospitalization in December occurred immediately after he finished work on this project.

Strategy #3: Psychological safety in the workplace

There were other factors that made Cliff vulnerable to these events -- just as there are factors that heighten people's risk of cancer, broken bones, and other illnesses and injuries. That doesn't negate the effect that workplaces have on people's lives, or the responsibility that we each have as employers, managers, and workers to take reasonable steps to promote the physical and psychological safety of our employees, our colleagues, and ourselves.

Risk stimulates us, challenges us, makes life more interesting. Workplace safety isn't about eliminating risk or not engaging in risky activities; it's about recognizing risk and taking appropriate precautions so that at the end of the day workers return home with their health and safety uncompromised. In North America, we've been protecting worker's physical safety for years. Only now are we recognizing we also need to attend to workers' psychological safety.

Initial steps towards regulating psychological safety

Last June, British Columbia passed Bill 14, legislation that expands eligibility for compensable psychological workplace injuries. (Because mental stress and injury due to management behaviours and decisions are explicitly excluded from coverage, someone in Cliff's position would still not be eligible for compensation.) This legislation paves the way for Workers' Compensation Boards and other provincial health and safety regulators to begin playing a role in developing and enforcing psychological safety regulations.

An important factor in that will be defining the standards which employers are required to meet. This month, the Canadian Standards Association is certifying a new voluntary standard for psychological health and safety in the workplace.

Neither Bill 14 nor the voluntary standard for psychological health and safety are yet enough to prevent deaths like Cliff's, but they are significant changes in how we hold ourselves responsible for workplace mental health. Mental illness and injury are not just individual weaknesses or problems, they are societal, cultural, and economic issues that affect more of us than we may believe; that really do debilitate people and threaten their lives; and that are often caused, triggered, or worsened by outside events.

Where I'm at with this

While I still believe Cliff's workplace conditions played a pivotal role in his death, I haven't found a way to influence significant change in this area. I tried to meet and talk with managers and leaders in Cliffs organization soon after his death, and met with resistance, fearfulness, and stonewalling. The most positive thing I was able to achieve was a brief email exchange with his immediate manager, who refused to meet in person. With the end of the contract with BC Hydro, that area of the organization is folding up shop. Many of the things Cliff was afraid would happen in that process have happened.

On a much more positive side, people like Martin Shain, founder of Neighbour at Work; Great West Life, commissioners of Guarding Minds at Work; and Bill Wilkerson, co-founder and CEO of the Global Business and Economic Roundtable on Addiction and Mental Health have already been doing impressive work in this area for many years, work that is paying off in new standards and changes in legislation.

Psychological workplace safety remains a concern for me. For now I am putting my efforts into other areas where change seems possible and much needed.