Dr Dominic Murphy: But on the other side, actually, this is a time where the NHS is drawing together, it's working at its maximum efficiency. And it's important to remember that most people who get COVID-19 get better. They do recover. And they do leave the hospital and and it's important to recognise that as well.
Dr Rupy: Welcome to the Doctor's Kitchen podcast with me, Dr Rupy, where we discuss food, lifestyle, medicine, and how to help your health today. The title of our podcast is How to Heal a Moral Injury because I think it's really pragmatic to think about mental wounds in the aftermath of the pandemic, and that's why I'm speaking to Dr Dominic Murphy. He is head of research at Combat Stress, which is a national veterans mental health charity based here in the UK. He established and now leads a research department there, specialising in veterans mental health, and we're going to be talking about PTSD today. In today's podcast, we're going to define exactly what we mean by PTSD, what a moral injury is and what the relationship is between PTSD and moral injuries, why we're doing this in the UK, and also whether this is actually relevant to the current COVID-19 crisis. We also sort of segue into a number of different topics, including how to deal with children, what the impacts are of emotional and physical stress in childhood and how that could potentially predispose to a whole bunch of different psychological illnesses, any gender and ethnicity differences. And I also bring to attention the likelihood of PTSD across different medical specialities prior to COVID. And actually, this is something that we really haven't been good at in terms of recognising and trying to provide access to or even changing the culture of looking for mental health support as a result of our general work. We in the healthcare industry run on adrenaline in normal times. And if you've looked at any of the documentaries like Hospital or 24 hours in A&E or intensive care, which are across a number of different terrestrial channels, you'll realise this has already been a crisis that's been evolving. I don't mean to catastrophise, but I think there are a number of different things that we could be doing better. At the end of this podcast, it's my aim for you to at least have an idea of the suite of different interventions that are available to you right now, whether you're a healthcare worker, whether you're a lay person, whether you're a key worker, it does not matter. I think we can all benefit from better mental health and better actions to look after and prevent mental health issues. It's something that we talked about on a previous podcast with a good colleague of mine where he is a psychiatrist, said mental health affects five out of five of us. We all have mental health issues. It's the degree to different mental health issues that we have. And there are a number of different things that we can do to help ourselves. We talk about alcohol, we talk about exercise, we also talk a little bit about nutrition as well. So, without further ado, I'm going to get Dominic to speak and introduce himself at the start of this podcast. And I really, really hope you find some good gems of information and also a whole suite of different resources that I've left on the podcast show notes page. Please remember to sign up to our newsletter. We give two recipes every single week, plus links on how to live a healthier, happier life. There's also some PDF downloadable guides that I provide, plus a whole bunch of things that are going to be coming up soon. So I really do hope you enjoy that and enjoy the podcast. So I've been working in the field of trauma, military mental health and PTSD now for about 17 years, since 2003, where I was studying for my undergraduate psychology degree at Glasgow Uni and there was the 2003 invasion of Iraq. And this kind of coincided with the Easter holidays and instead of revising, I kind of watched this sort of very strange phenomenon of an invasion in Iraq, but got kind of really interested in thinking about the psychological consequences of this. Subsequently, I got a job at King's College London University to help set up and run a very large scale project looking at the health and wellbeing of military personnel that went to Iraq and then a group who didn't. This has been running now for that 17 years as well. And what I really was interested in there was learning more about PTSD, post-traumatic stress disorder. I first did a PhD there, but wanted to get a bit more hands on clinical experience, so we trained as a clinical psychologist and then joined Combat Stress in 2013, just at a time where Combat Stress, so for your listeners who don't know, Combat Stress is a national mental health charity in the UK that really has been focusing on supporting the needs of veterans with mental health difficulties. We've been around for over 100 years now, just set up after World War One. And for the last 10 years, we've been far more focused on meeting the kind of clinical needs of veterans with mental health difficulties. And I joined at a time where Combat Stress were thinking about expanding and thinking a bit more about research and proper formal evaluation of some of our services. So I was tasked with kind of setting up and now running a research department, which I do. In addition, I have taken over the presidency of an organisation called the UK Psychological Trauma Society. It's a multidisciplinary group of practitioners working in the field of psychotraumatology, and we're linked into various other networks. So I wear several kind of hats and on top of that, I still do some clinical work working with a variety of different people unfortunately who have experienced symptoms of PTSD.
Dr Rupy: It's amazing, isn't it, how our human experiences direct the narrative by which we go into work and stuff like that. So that that short Easter break where there so happened to be a war unfolding on our hands has kind of led to you getting involved in this aspect of psychological research.
Dr Dominic Murphy: Yeah, even though I can trace it probably further back to, I mean, I think we all have things in our backgrounds that draw us to certain areas and experiences. But yeah, contingency and luck play big parts sometimes.
Dr Rupy: Yeah, yeah. And I think before we get into the whole subject of PTSD and how we treat it and how pivotal combat stress is, particularly for veterans, maybe we should define exactly what we mean, because I think it's one of those terms that is banded around quite a bit without a true understanding of what the umbrella term is and what it can refer to as well.
Dr Dominic Murphy: Exactly. I think it is, it's useful that it's banded around a lot, but having a clear understanding is extremely helpful. So post-traumatic stress disorder is a collection of symptoms that are very common in people that have gone through very difficult experiences. We can think about those symptoms clustering in kind of three different groups. Well, before I get there, the first point is people need to be exposed to a traumatic experience. And traumatic experiences, whilst they vary a lot, the kind of the working definition is it's a trauma where someone's life or someone else's life has been put at risk and that we've witnessed this. Or there could be a damage to our own personal integrity in some ways, such as being tortured or things like this. So we have that kind of threshold, that's an important part. You can't have PTSD without exposure to a trauma. Then the sort of symptoms we see cluster within three groups. We have what we think of as reliving symptoms. People re-experiencing some of these difficult symptoms again. These can be through very difficult nightmares where they're kind of replaying aspects of the trauma, through intrusive thoughts or feelings, or sometimes at the more extreme end, through sort of flashbacks where people are reliving kind of some of the traumas as if they're happening right now again. Naturally, this causes a whole array of what we think of as hyperarousal symptoms. So things like feeling on edge all the time, having an exaggerated startle response. So there's a loud bang, really kind of being distracted by it. Sleep difficulties, anger, irritability, and lots of problems with concentration. Because if your mind is constantly in the past, focusing on potential dangers, it's very hard to be in the present and focus on what's going on, which then can have some serious implications for trying to be, for work, for relationships, or just for looking after ourselves. And then the third set of symptoms, which we think of are the set of symptoms that maintain some of the PTSD symptoms, are what we think of as avoidance symptoms. So these could be conscious avoidance symptoms, so things like avoiding looking at news articles about particular traumas, avoiding reading about them, or avoiding trying to go to certain places. So if something bad happened in a pub, avoiding going to all pubs. Or they can be more unconscious where a lot of the people I work with sort of are emotionally very numb. They kind of don't feel any, they don't report not feeling any sort of emotions, feeling very flat. Now, what I often say when patients, people I work with, when I describe that, they kind of say, yeah, but what's, why is this? And I kind of think, well, in a way, it's a sort of a maladaptive way that the brain has developed to help keep us safe. So we, we, people have gone through these difficult experiences and it's not a real trauma this, but I'm just taking it as an example. If we've been attacked by a dog, well, you know, it is a bad trauma, but it's not as bad as some of the other ones. If we've been attacked by a dog and that dog's bitten us and it really hurts and we bled, we had feelings that we might die, and that's a sort of a trauma memory. And then when next time we're walking down a street and we see another dog, that memory comes back to us very vividly as if it's happening again here and now. And then that our kind of hyper kind of arousal symptoms kick in, more adrenaline gets released, and we kind of go into a sort of fight or flight or maybe a freeze response, and we run away from the dog. And by doing that, we're avoiding it. So we're disconfirming the belief that the dog actually isn't going to harm us, because, you know, most dogs are kind of lovely and friendly. And so kind of that kind of pattern maintains it. But actually, by doing that, it's kind of keeping us, our brain's trying to keep us safe from being exposed to any of these dangers again. So it's very unpleasant. So the people I work with really describe feeling as if their traumas are happening again right now in the present day, and they're in that constant state of anxiety and agitation, which I hope you can imagine is very difficult and distressing for people.
Dr Rupy: Absolutely. And we seem to solely think about PTSD in the context of veterans and people who have experienced war. What other sorts of people have, perhaps not through your clinical work with combat stress particularly, but what other sorts of experiences might fall into that into that category of people who could suffer with PTSD?
Dr Dominic Murphy: Yeah, I mean, I think that's an excellent point. I think we, and I'm obviously working within the field of military mental health, and there's a lot of research that's gone into that. But actually, veterans, military are a relatively small part of society. And there's a whole array of other people that are exposed to traumas in their everyday life. So, for example, these could be getting into fights, getting into car, having car crashes, instances of domestic abuse, people have lived through very difficult childhood experiences, so childhood abuse. A lot of refugees, a lot of people that end up coming to our country often are coming because they're escaping persecution, some very difficult environments, or sometimes the journey in themselves, the journey away from one country to another can be extremely difficult. So I think trauma is, it's quite prevalent across the population and lots of different people are exposed to traumas. But just because you're exposed to trauma doesn't mean you get PTSD. So for example, men typically report higher levels of exposure to trauma because of things like seeing acts of violence, but women seem to be more likely to develop unfortunately symptoms of PTSD because the traumas they're exposed to are more interpersonal. So things like sexual violence, things like domestic abuse. So I think trauma can touch any of us.
Dr Rupy: Yeah. And as well as the different types of trauma here, the reason why we're discussing this today is because in the wake of what is happening with COVID-19 and the difficult decisions that a number of different healthcare workers are having to make over the course of the time, we have to be slightly aware of the potential for PTSD in the future, as well as some other papers that I've come across as well that we're getting to a little bit later about current training pre-pandemic and the prevalence of PTSD-like symptoms. So just before we get into that, there's one more definition I think we should probably establish, which is something you mentioned earlier, moral injury. What is a moral injury? How do we define that and how does that relate to PTSD?
Dr Dominic Murphy: So moral injury is a relatively new term in the literature, which is really about defining profound psychological distress which results from actions or lack of them that violate one's moral or ethical code. So to be more concrete, this can be in some of the veterans we've worked with, they've talked about, for example, being on certain deployments where they may have wanted to help the locals by giving them food or things like this, but feeling unable to do that. That's violating their moral code. And then they're seeing, you know, some pretty dire consequences of not being able to feed people that are starving. And so I think that's kind of our kind of working definition of moral injury. How it relates to PTSD is it's important to know that moral injury isn't a mental health disorder on its own right. But what we think of moral injury is highly associated with complex with PTSD, and it's also unfortunately associated with suicidality. So it seems to be an overlapping construct with post-traumatic stress disorder. And because of this, it seems to be not just overlapping with PTSD, but overlapping with the more complex presentations that we sometimes see clinically in people with complex PTSD. And thinking about, we don't want to jump ahead too much, but thinking about what's going on now with COVID-19, I think there's a lot of people that are being exposed to not only awful traumas in their everyday, in their working practice, but also being exposed to some very difficult decision making around kind of the allocation of resources, which patients to treat, which patients they can't treat, or just the communication with family members and lots of different things that might be morally more more difficult and challenging. And so I think there is a definite risk that people might be exposed to a whole, I'm talking about really NHS staff here, might be exposed to a whole risk of a very complex mental health difficulties.
Dr Rupy: Yeah. And before we go into like the kind of treatments that we have for PTSD and moral injury and how they might overlap going forward, as well as the experience of combat stress, particularly, one of the things you mentioned there was a maladaptive way that the brain has responded to a traumatic event, which we discussed earlier can be a whole bunch of different things. What kind of things predispose a brain to react inappropriately or perhaps appropriately for argument's sake, but what kind of things can predispose someone to have PTSD in the first place? Because there are a number of associations that I'm aware of and I'm trying to unpick exactly why those might be.
Dr Dominic Murphy: Yeah, I mean, in some of the research literature really suggests there are some obvious risk factors. So pre-trauma, one of the biggest risk factors is exposure to a whole array of childhood adversity, particularly more complex types of abuse in childhood that might predispose people. Now, why this is, you know, it's hard to really know, but from my clinical experiences and from some research data, it seems that unfortunately, people, part of growing up is often about learning how to really regulate our emotions, particularly, you know, you think when we're born, the kind of one of the areas that really grows a lot is the frontal lobes and very central to emotional regulation and executive function. And particularly things like the way oxytocin's released and stuff like this with good caregivers. Now, if unfortunately people grow up in more adverse environments, sometimes we don't learn helpful ways to regulate our own emotions, or we may have very difficult views about ourselves, the world and other places. So if you're growing up in an environment where every time you're upset, a primary caregiver, instead of comforts you, which if they kind of comfort you and they comfort you again and again, oxytocin, there's a hormone gets released that helps bring down our emotions and we learn over time to internalise that emotional regulation. If the opposite happens, we get upset and our caregivers shout at us, shame us, abuse us, what we don't learn that emotions are, we don't learn a way to regulate our emotions. So emotions become extremely scary and difficult to manage. Then we come along to a trauma and actually, traumas, you know, they're not, not everyone's exposed to trauma. So, you know, people get exposed to difficult traumas, we all have different ways of managing. If we are predisposed to not be able to regulate our emotions quite so well, we're more likely to dissociate during the trauma, which means sort of not be fully present, or we're more likely to be so distressed by the trauma, we can't do the natural kind of processing of a traumatic event. So, and a lot of the clients I work with, they often turn to alcohol as a way to manage, to try to manage traumas, which doesn't, which gets in the way of the natural kind of processing, or become workaholics and just try to fill their day with work so they're not thinking about the traumas. So, the predisposing stuff, the childhood stuff seems very important. The type of traumas we're exposed to, unfortunately, are related to kind of how our chance of developing PTSD. The more interpersonal, the more violations of trust between people in our social circle, that increases the chance. The more they're repeated, so being, some of the language we use is a single incident trauma like a car crash is less risky for PTSD than unfortunately, like living with spousal abuse, where it's a repeated awful type of interpersonal trauma that's happening a lot that people can't escape. If people dissociate during the trauma, which I kind of mentioned earlier, so it's so bad their mind takes them elsewhere, that's a big risk factor. Also, post-trauma, we know that the people that have less social support around them, so the people that are less, feel less able to talk to their friends, their family, maybe healthcare workers in the immediate kind of aftermath of traumas are also more likely to develop more complex PTSD type reactions in the longer term.
Dr Rupy: It's, yeah, it's it's a really interesting topic. And I just want to digress very briefly if I could, because I think there might be a lot of listeners thinking, well, I've got young children at the moment, I'm going through quite a troublesome time, whether it be financial difficulties, whether it be the lack of interpersonal skills. How do we kind of shelter children from this potential of lack of oxytocin, lack of appropriate responses to questions from children or even just the living in the household with kids everyone around, you don't want to give them a negative experience of what is basically a time where everyone's together in the same household at the moment. So before we go on to to talk about PTSD and the wider aspect, perhaps that's just something to touch on.
Dr Dominic Murphy: I mean, I think that's an excellent point. And it's not, I guess, you know, protecting children, but protecting each other as well. It's it's an extremely difficult time we're all living through right now. I mean, some of the advice I would give and I give clinically is think about what we can control and what we can't control. The things some of us can control are things like actually ensuring if we're able to get as much exercise as we can, you know, actually taking the advice, going out that one once a day for exercise, but also doing exercise at home, trying to do things like actually limit the amount of media exposure we expose ourselves to in the, you know, on social media as well. There's a lot of very difficult news stories out there at the moment and trying to be more managed with our kind of our relationship with both the media but with also social media. I think, so they're kind of key things. I think other things is kind of actually making time to talk about how people are feeling, our emotional wellbeing. Now, with children, a really good exercise I often recommend is something called a bag of emotions. So sometimes kids don't always have the emotional language that we have, or sometimes I don't, and it's easier for me to express like this as well. But you can, you know, you could draw a pretend sack on a bit of paper and within it you can draw lots of different ways to express emotions like balloons or colours. And it's about giving children or anyone really, but giving people an express, a way to express how they're feeling and the different types of thoughts and feelings they may be having and allow a parent to have that kind of conversation and be able to hear kind of what the what the experience is like for the children. I think, you know, we, I'm a parent as well, and and, you know, maybe my wife maybe thinks I'm not a very good parent, who knows. But I think as much as it's about good enough sometimes, and it's about trying and it's about and not putting too much pressure on ourselves as well at the moment. Like I think, you know, the challenges of work and homeschooling or just being locked in the house with everyone, it's about trying to make time each day to show your children that you really, you need to, you want to know what they're thinking and feeling. And I think that's what's important right now, to let kids have that kind of connection so they can feel heard if they're if they're feeling difficult emotions, which we probably all are feeling at this time.
Dr Rupy: You know, I know that advice was for children, but I think that really resonates with me at the moment. Um, certainly trying to maintain the connections that have obviously been lost through the lack of physical contact and trying to do that via the Skype or Zoom or whatever collaboration tool you're using. Um, but spending time to explore the irrationality of the way that some of my friends and some of my family members are feeling and and the exact same for myself as well, putting myself through the the lens of the traumatic experience right now. I think it's really important to have those open, honest conversations at length and without distraction. Um, which is been one of the, I think, positives out of this, the fact that we actually have time to dedicate to those and actually taking advantage of the increased amount of time that we have to have those conversations too. Um, and the neurobiological element of it really does fascinate me, particularly when we're looking at kids as well. Um, before we digress too much, perhaps we should talk about um, why what uh, sort of things that you're doing at the moment to explore moral injury um, with regard to healthcare workers, um, and uh, any sort of uh, things that we should be aware of going forward as a lot of healthcare workers do listen to the podcast.
Dr Dominic Murphy: Um, there's a, so there's a number of different initiatives that are going on. I mean, one of the bigger ones we're involved in is we're trying to do a study of key workers to look at kind of, by we, it's a collaboration between Combat Stress and King's College London University and Oxford University. We're trying to look at the impact of moral injury and its relationship with mental health difficulties on key workers, NHS staff that are on the front line, because the thing is moral injury is as an area of research is in its infancy. And actually what we need is sensible research right now to better understand the phenomenon, better understand who, which groups might be more at risk of developing moral injury, psychological distress because of being exposed to potentially morally injurious events, and then thinking about how we can then target, kind of how we can support those groups. What we don't want to do is rush in and say we've got all the answers basically, because we don't, and it's about kind of learning together. I think we, there's a lot of research that the team I kind of mentioned that we've been working on in the military mental health world that might be very applicable to what's going on now. So we've been doing for the last few years, we've been very generously funded by an organisation called the Forces in Mind Trust to do work looking at moral injury in UK veterans. And part of it is understanding kind of what are, kind of how does moral injury differ from PTSD? And what are, how does it differ and what are the particular risk factors? So for example, we've identified kind of four PTSD only as a difficulty, but also a more of a mixed presentation with people with PTSD and moral injury and they seem to increase the risk of problems. And then it's about trying to how we translate some of these findings to the current crisis, what's going on to support kind of NHS staff as best we can. Um, we're also trying to work um, internationally with colleagues from Australia, from Canada and America in this field to generate better ways to measure moral injury which are more universally acceptable, well more universally validated so we can compare and contrast some way, but also we can learn from each other's experiences. And then the kind of the final thing is we're right now in the process of trying to um, develop a new treatment which is tailored to the unique needs of the UK population that may be experiencing that kind of that kind of mixed PTSD and moral injury because we think some of the kind of gold standards for PTSD might not be quite right for people that are exposed to moral injury.
Dr Rupy: Yeah. But before we go into the current treatments that are available for PTSD right now and things that combat stress have been involved in, is there a, sort of already touched on this, if there's a difference between outcomes based on pre-morbid state or pre-morbid personality or life experiences. But and I know I'm kind of asking you to look into a crystal ball right now, but would you hypothesise that the personality of a healthcare worker that we would sort of stereotype as altruistic and compassionate could lead to a more severe traumatic experience after the events of the last couple of months? Or is it just, and I hate to sort of stereotype an entire huge workforce of over a million, um, but you know, what what would you say about the kind of personality traits that lead people to go into healthcare in the first place and what their experiences might be in the future?
Dr Dominic Murphy: Um, let me answer that in two ways. I think the first is from a very purely academic perspective, we don't have much work done on kind of personality traits. We do know the biggest risk factors are things like exposure to childhood adversity, um, and then the types of traumas people are exposed to and the kind of social support networks afterwards. But I kind of tapping into what you're saying the other part, I do think that, you know, I I'm a therapist, a psychological clinical psychologist myself. I think one massive generalisation which, you know, I think holds that true is that most people enter the healthcare profession because they want to help others. And, you know, the kind of ethos is to kind of do no harm to start off with and then try to, you know, make positive changes in people's lives as much as we can. I think people are having to make uh, difficult decisions about the allocation of resources on who to ventilate, who not to ventilate, who to kind of triage and who not to triage based on um, based on resource, not based on kind of the pure kind of what everyone would like to do on clinical need. I think also there's some extremely complicated situations with family members. I've heard some extreme distressing stories about, you know, patients being admitted to ICU, they're not being able to have any contact with their family members, not being able to say goodbye, and actually doctors, nurses having to have those really complex and difficult, morally difficult conversations with family members and having to do things like some really heartbreaking stories about like, you know, getting photographs and things like this. And these are really complex things that I think NHS staff are being exposed to. And because of the altruistic kind of nature, they might, you know, these are kind of violating some of our moral codes, I think, in some ways. I think, you know, the thing that drives a lot of people into the healthcare profession is to help others. And actually being exposed to lots of situations where we can't help other people because of various reasons, or we're having to make some really complex phone calls to relatives or um, or not being able to give the kind of level of support we might normally want to be able to give, it's it's really complicated. And I think that might put a lot of people at potentially at risk of of um, of experiencing difficulties. But on the other side, actually, this is, you know, this is a time where the NHS is drawing together, it's working at its maximum efficiency. And it's important to remember that most people who get uh, COVID-19 get better. They do recover and they do leave the hospital and it's important to recognise that as well.
Dr Rupy: Yeah, there's a couple of points there that I wanted to pick up actually. Um, so I agree. I think this is perhaps one of the most uh, incredible times to work in the NHS um, for the fact that things appear to be seamless in terms of how they work together and how everyone is pulling together in the same direction is quite incredible to be part of that of a multitude of different teams. My personal experience in emergency has been brilliant. Everything seems to be uh, you know, working and going in the right direction. And the number of changes that we've seen in our department from changing it into two different areas, both red and green, um, representing uh, COVID dirty areas and COVID negative areas has been astounding. The critical response that we've had mirrors that of a major incident on a single on a daily basis, which again has worked very well. I think we're definitely more prepared than we ever have been. We had a shaky start obviously with PPE, but I think that's definitely coming together. In my non-clinical role, which still spans clinical knowledge, uh, it's um, I'm part of a senior doctor led team where we liaise with patient families uh, who have loved ones in the intensive care unit that they can't visit, which is completely unprecedented. And so we have to respond in that way by pulling together a a number of different professionals. There are consultant dermatologists I work with, consultant cardiologists, all of which who have had some ICU experience so we can translate what is going on in the intensive care environment, how we're supporting patients as well as um, dealing with the unknown and actually having the humility to say, we don't know what the long-term prognosis is and breaking bad news in that way. I mean, these are some powerful conversations that we've had to have, but the camaraderie is something else. And I think if there's any positive to take from this, it's the experience of working within a healthcare service that apparently has completely turned around in the last couple of months and actually is actually working more efficiently than I ever remember in my 10 plus year experience of working within the National Health Service. Um, so so there are like some amazing things, but also I think we need to be uh, sort of uh, pragmatic in that there are going to be people for whatever reason, whether there is a pre-existing condition or whether they have um, things that predispose them that are going to have a a poor psychological outcome after this for the the the for the reasons that we've discussed in terms of the decisions that we're having to make. And prior to this, and this is something I wanted to bring you back on, we've known that pre-pandemic, fellows and um, uh, members of of all different healthcare teams uh, have experienced PTSD-like symptoms. There was a study that came out in the um, uh, British Journal of Obstetrics and Gynaecology that surveyed 6,000 fellows, they had about 1,000 responders, and about one in five of the responders reported clinically significant PTSD symptoms. And one of the most striking things from my point of view is that there appeared to be an increased risk of PTSD of those um, from black or Asian or ethnic minority um, backgrounds as well. And it was associated with lower job satisfaction, emotional exhaustion, depersonalisation, all the things that I'm sure we'll get on to in a bit. And and linked to staff leaving the specialty as well, which is a significant problem across a number of different specialties with people leaving the healthcare service because of exhaustion. So in a in a a situation where we've already had this issue pre-pandemic, and I don't want to, you know, catastrophise or sound alarmist, but we really do need to think about this. And this is why I really wanted to have this conversation about the management and what what things we can uh, provide in a in a sort of like a self-care package.
Dr Dominic Murphy: I mean, I think that's, you know, it is, it's important to recognise that the, people come from a variety of backgrounds. So we're all going to have, you know, but PTSD is prevalent for that as well. But it's about the exposure to to traumas. And it's well known that people who work in certain professions, healthcare, for example, journalists, maybe at increased risk of PTSD compared to other professions that aren't. I think it's not just that there might be predisposing risk factors for individuals. These only increase your risk factor, your risk. But actually, anyone that's exposed to very complicated traumatic experiences can be at risk, irrelevant of their risk, irrelevant of their backgrounds or whatever. Um, you know, I didn't know about that research or particularly about the kind of the minority groups being at risk, and I wonder what what that is, whether it's about stigma about seeking support, whether it's about perceived um, kind of um, other barriers to other areas and professions. I don't know, but it is, it is worrying when there are obvious groups that are at increased risk. If everyone's being exposed to the same level of traumas, but there are there are particular groups that are at increased risk of developing PTSD-like symptoms, I think that is something that we need a lot more work doing to understand why that is, because it won't be, my personal opinion, it won't be about the individuals, it'll be about something more systemic that's going on for that group of individuals. And then because of that, it might give us an opportunity to think how better to support those sort of more vulnerable groups.
Dr Rupy: Yeah, I agree. Absolutely. I mean, um, I was quite surprised to see that come out in the um, in the data that they provided for that. And there might be some other examples of um, prevalence of PTSD um, symptoms in in in other specialties. That was just from specifically from obstetrics and gynaecology earlier this year, which is why it came to mind. Um, but it just seems that, you know, we run on adrenaline in normal times. And these are abnormal times. And this is something that we do need to prepare for. So so going back to sort of the kind of work that you do with combat stress, which I've looked at, it looks amazing. What kind of uh, what is the suite of different interventions that we have, um, both uh, pharmaceutical and and non-pharmaceutical and and how do you see perhaps translating some of this knowledge uh, that we have um, from your work uh, into something that could prepare us going forward?
Dr Dominic Murphy: You mean in terms of supporting staff with PTSD? I mean, I think, to take a step back a second, at Combat Stress, we work with veterans that have that have had um, PTSD, that have PTSD, many of them. And often they've had PTSD for many, many years. And actually we've got really, we have some quite um, standardized kind of programs where we're kind of ensuring best practice to kind of the NICE guidelines for trauma-focused cognitive behaviour therapy. And we get good outcomes. And I think it's, it's about recognising actually we do have very good established treatments for PTSD, but it's about helping people access those treatments. For some with more complex needs, we might need better treatments, but for the majority, we have good treatments and it's how we best, it's about getting people access to those treatments. Now, one of the things that I'm sure we'll agree on this is that often I see in kind of healthcare staff is that sort of putting other people first before their own needs. Yeah, absolutely. And actually that kind of cracking on at all cost. And actually, I think you said, you know, right now it's a bit like a major disaster but every single day. And I think actually we need to, some of the things that we've learned from combat stress from the and some of the work we've done at Kings and how we can translate that to the NHS right now is really helping frontline staff be made aware of the possibility of the of actually they're going to be exposed to potentially morally injurious events. And that's some what some of the common thoughts and feelings might be around that. And kind of trying to discuss this as much as we can to particularly facilitated by those in leadership roles that might help develop some sort of more preparedness and to recognise in staff kind of their what some of their symptoms of distress might be and that these are normal as well. It's normal to have these thoughts and feelings because actually, if you look at people that are exposed to traumas, most people have PTSD type symptoms in the immediate aftermath of a trauma, but these normally wane and for the vast majority disappear very, very quickly. But for some, they need, you know, some they might stay for a month or two, and then they're the people that might need extra support. So it's about kind of saying these are the symptoms that might happen and and sort of preparing people for that. I think also, some of the stuff we've learned is the importance of encouraging frontline staff to seek informal support, particularly from from some of the what we've done at combat stress, for example, the importance of having really good trained peer supporters, whether these are colleagues or managers that can offer some really good peer-led support with this idea of the kind of the nip it in the bud and talking, you know, helping people access support straight away rather than leaving them to uh, dwell on some of the difficulties they might be having. But at the same time, I think, you know, informal support can only go so far. And for people that are experiencing significant distress and that that distress is is staying for, you know, a month or two months, actually this is when we should be trying to help encourage people to access professional support as quickly as we can. I'm really encouraged to know that and I'm working in other kind of trauma groups, there's one really great one that's been led out of UCL that combat stress are involved in, that are doing just this. So it's about how to encourage frontline staff to access psychological support as quickly as possible if they need it. Um, and I think, you know, it's an important thing that leaders, we have an all have an important role to actively encourage, you know, proactively to check in on staff and to offer that kind of both informal support, but then helping people engage in more formal help seeking where where necessary.
Dr Rupy: Yeah, and you know, that that mirrors a lot with my personal experience actually. I'm quite impressed with the response of our our hospital at the moment. So I work in West London and um, as part of our team, we have an ICU psychologist that's usually there anyway for the families of patients who are in ICU. Um, obviously her workload is trebled over the last couple of weeks. Um, and they're also offering and actively seeking out um, uh, work or uh, counselling sessions for the staff themselves. They haven't made it mandatory and I actually think that it should be mandatory because even within myself and within my peer group, we do have that sort of alpha mentality of we don't need it, we we can power through that. And that is very much a medic mindset. And again, I don't mean to generalize, but I think that's certainly prevalent in the type of person that goes into medicine as well. Um, but that kind of psychological support, I think has been um, uh, really pivotal and it will be pivotal. And if I could sort of uh, distill a lot of the things that you've just said in terms of how we manage this going forward, it's awareness, it's improving access, which is kind of what's going on in my hospital at the moment. Um, but it's also preventative. Um, and I think there are things that we can do to make sure that we uh, mitigate the potential effects of uh, moral injury or PTSD uh, going forward. And and you know, you picked up on on exercise, on alcohol, um, and the one piece of uh, thing that obviously I'm going to be talking about is nutrition and how we can actually utilize nutrition and maintain people's mental wellbeing as well as their overall wellbeing by making sure that we're we're being fed or we're being given the actual information about being fed well as well.
Dr Dominic Murphy: I completely agree. I mean, if, you know, people are working long shifts, we actually need to make sure that they're going to make it through those shifts in the best way possible. Um, I think in my work as a psychologist, actually nutrition is something that's very, we we sometimes, we're so busy, something that's overlooked. In the sense that often we're kind of very focused on some of the psychological symptoms, but actually getting a kind of really good basis for people if they are, it can be really helpful. We need to look after ourselves, yeah. I think another thing about kind of the preventative side of it is there's something about kind of leaders taking responsibility to legitimize it's okay to seek help. It's not a sign of weakness. In some respects, it's sometimes a sign of strength. And that by seeking help, you can be, you might be more effective. And those sort of cultural changes as well, uh, and you know, I don't know the exact nature of your service and especially some of the nutrition stuff, but I do know in there are some generalizability stuff from the military world where actually nutrition is taken very seriously because they're thinking about operational effectiveness all the time. And for that, they need people to be, you know, eating the right foods, eating the right foods that are going to release energy over the course of whatever operation they're doing or whatever kind of work function they're doing, that are eating foods that are going to, you know, even things around kind of like sleep and what time of day we eat the food to not impinge on sleep and that kind of natural healing and restorative times like that.
Dr Rupy: Yeah, and I think like, I mean, I hold some nutrition uh, workshops with within the emergency department. I have done prior to uh, the pandemic and I think I will be doing when I can fit in my clinical time as well, at least um, trying to find some innovative ways in which I can educate um, without actually being there in person. So some of the stuff that combat stress have done as well with regard to tele uh, conferencing and and tele workshops as well, which everyone's getting super used to. The the the three main things I talk about, um, alcohol. So a lot of people, um, myself included, are sort of drinking a little bit more than we're used to drinking. And in my case, it might be a glass of wine every other day or at the end of a shift. Um, but and for certain people, let's call it a 10% of the population, as alcohol is an addictive substance, it's something that we need to be careful of, um, and to to utilize responsibly. And I think, you know, the the the depressant effects of alcohol are well documented. So it's something that I I want people to be mindful of not spiraling into. The other nutritional impact is um, of uh, fats and omega-3 is the one that comes to mind, but you know, a good quality fats are integral for um, brain function and you know, the activation of elements of brain derived neurotrophic factor and signaling pathways and how that helps with the frontal cortex as well, um, and our emotional responses. And the other thing, the last thing is um, simply energy density. So making sure you're looking at the quality of your food. So, um, we're really lucky at the moment in our hospital, and I'm not too sure if this is mirrored up and down the country, but the trust is actually giving all workers uh, in the hospital free food. So we don't have to worry about uh, you know, meal prepping the day before or making sure that, you know, we have to go outside and buy something, you know, it's there for us. And that, I'm that is a core pillar of wellbeing. The meditation stuff is great, the stuff is very important, but a core pillar of wellbeing is not having to worry about, you know, making your food and making sure it's healthy before you go in for a 13-hour shift. And I really hope, and it's something that I talked to the NHS food panel about as well. I really hope that that is just something that continues because, you know, it's such a um, it's such a comfort to know that you're being looked after by your hospital and that the food that they're giving you is actually going to be having a direct impact on your nutritional wellbeing, your emotional wellbeing. Um, so yeah, those are the those are the things that I talk about. And and I'd love to see this uh, be involved a little bit more in in sort of psychological consults too.
Dr Dominic Murphy: I mean, that sounds fantastic from from your hospital. I mean, I think if I was going to just pick on, I also agree with all of those pillars, particularly in the psychological sense, alcohol. We know there's compelling research to show that alcohol has that depressive effect, but there's also compelling research to show that alcohol can kind of get in the way of the natural processing of trauma memories. And that that so and therefore can make be increase our risk of developing PTSD type symptoms in the longer term. It's very common for me as well when I work with patients or with people, they tell me that, you know, they they kind of using alcohol, they've been using for a long time to try to push away difficult thoughts and feelings, but actually the very nature of that means that they're not processing those thoughts and feelings, so it kind of keeps people, it can uh, keep them kind of stuck in that kind of very difficult um, we think of it as a as a kind of maladaptive coping strategy. So it actually maintains some of the symptoms of PTSD. Yeah, I think alcohol, you know, it's part of our culture as well, isn't it? We often use alcohol to debrief or to to close the end of a shift or something like this, but
Dr Rupy: Absolutely. Right now, it's about, I'd recommend finding other ways to do that, to have those other other types of ways to kind of close off a shift, whatever they may be. Yeah. Yeah, absolutely. I was joking. I mean, it's it's a sort of a cultural thing like you said across different industries, isn't it? I was speaking to an aesthetic colleague of mine about what's the first thing that we're going to do when this is all over? And he said, go to the pub. And and I resonate with that, you know, it's something that uh, I would love to enjoy um, at the end whenever this is over, but um, right now it's something just to be to be wary of. I just want to close by asking you, um, uh, Dominic, what if you were, if you were a czar uh, for the day in terms of the psychological wellbeing of healthcare workers up and down the country, what are the interventions that you think should be intervened with regards to uh, mitigating moral injury going forward? What are the things that you would love to see happen, um, beyond the things that we've just mentioned here in terms of uh, nutritional wellbeing and and alcohol? Um, but what are the things that you think we should be thinking about right now in a pragmatic sense?
Dr Dominic Murphy: Well, I mean, I think, um, I think firstly thinking about prevention, I think establishing uh, trained peer support workers that are non-mental health professionals, so it's an informal structure of peer support to help give a space for staff to talk about their thoughts and feelings on a daily basis, because that might make it feel like one, they would they would increase accessibility, but it might feel more acceptable to have to be able to speak to a trained peer as well as a mental health professional. I think that might be one, that could be a very helpful thing. How it's facilitated, that could be through online chat or by, you know, there might be lots of technological ways to do that. I think the second thing is having really strong leadership to show the importance, just like the importance of nutrition, but the importance of giving us space to uh, to legitimize having um, experiencing psychological distress because of the what's going on right now. So I think that's kind of those things up front. I think at the other end, I think research is helpful to to uh, try to understand which groups are at the are going to be at most, which groups of staff are going to be at the most um, unfortunately highest risk factors for developing problems in the longer term. And then in the longer term, I'd be thinking again about those peer support networks to help, to help kind of pick up who is really struggling, uh, and then have the resources necessary to to channel people towards professional support, which is easy and accessible for them to access as well. It might be having to provide this from different trusts, so it kind of so people can feel it's more confidential. Um, but kind of having that easy, easy access so people aren't, staff aren't having to go and seek it out, it's almost coming to them if they if they if they want it.
Dr Rupy: Yeah, I agree. I think those are great points and spoken like a true academic trying to get the research in there as well. That's um, no, that's great. And and thank you so much Dominic for making time today. I uh, I hope um, that this conversation legitimizes it and I think you're right, leadership in this space to uh, give people um, the the space to to voice concerns and actually access treatments if need be, um, and prevent uh, treatment, I think would be fantastic. So I really do appreciate uh, every all the stuff that you're doing with combat stress and and how that extends to healthcare as well.
Dr Dominic Murphy: And thank you very much for inviting me along today.
Dr Rupy: Dominic is uh, I just love the way he talks as well, actually. I just think he's got this mellifluous voice and it's uh, it's very radio friendly or podcast friendly, I should say. If I was to summarize our podcast, it is awareness, access, and prevention. So awareness of the fact that we all may be having or suffering with traumatic events, being aware of that and being attuned to that and being present with that. Recognizing that there are access to treatments and trying to figure out what treatments there are available to us as well, and preventing them as well. And I think the peer support worker idea is an incredible initiative and I think there should be more of that as well because I would feel a lot more comfortable speaking to a peer regularly rather than having to book myself in with a a counselor or or schedule an appointment because I think it over medicalizes it, which again is a fault of my own. I think it's just my own sort of insecurity coming out there. But uh, I think it's just makes it a little bit more accessible too. The different online tools I think are fantastic. And if anyone is interested, uh, there's the anesthetic room.com and also be COVID, uh, which are um, nonprofit organizations that have a suite of different um, uh, collaborative uh, workshops where people can talk about um, how they're dealing with the current situation. Um, and one thing we didn't get to talk about too much was um, uh, omega-3. So I personally take an omega-3 supplement because I don't feel like I get enough in my diet. We tend to get it from things like oily fish, uh, algae, if you're um, vegan or vegetarian. Um, and there are algae supplements as well for vegans too. So this is something that I take in a small dose, making sure that there's EPA and DHA. And I think there's enough research about the plethora of benefits beyond brain health that uh, make it uh, a sort of pragmatic thing for me to do personally. If you enjoy this podcast, please do give us a five-star review. We really, really do value the comments as well. And uh, subscribe to the newsletter. I will see you here next week. Take care.
