In my work as a psychiatric liaison nurse at San Francisco General Hospital, I was asked to evaluate Keith, a long-time substance abuser. At that time, in the mid-90s, the residential drug treatment program his social worker had lined up for him had a policy of refusing patients with concurrent psychiatric diagnoses, including depression. Although he denied feeling depressed, when I asked about his family’s history of depression Keith said, “I guess you’d have to say my mother was depressed.” He proceeded to tell me that when he was six and playing in front of the housing project where he lived with his mother, she jumped from their 12th floor apartment, landing in front of him and breaking her neck. After his mother’s suicide, Keith was passed around the family like a hot potato. Although he had nightmares and intrusive images during the day, no one sought treatment for him. At 10, he discovered that sniffing glue offered him temporary relief from symptoms of PTSD. From there he graduated to alcohol, marijuana, LSD, and finally heroin.
After listening to Keith’s story and witnessing the effect that reliving it had on him, I felt choked with emotion. People who study the psychological effects of trauma would say that I had become “dysregulated,” meaning that my amygdala, the alarm center of the brain, had hijacked my neocortex resulting in autonomic arousal. This affects nurses health a lot. In my culture, the Yiddish word “verklempt” is useful in describing this state of dyregulation, of being so full of feeling that you can’t speak.
That night, after putting the kids to bed, I needed to talk about what I had witnessed. My husband, an attorney who avoids listening to stories of childhood trauma whenever possible, was preparing for a deposition. Since it was too late to call one of my psych nurse friends, I started writing a journal. After pouring out my heart, I felt better. In trauma-speak, I had discovered a way of re-regulating myself which I have used ever since. It is called therapeutic writing.
In the course of writing The Comfort Garden, I came across the work of James Pennybaker PhD, a research psychologist at the University of Texas at Austin. In his book, Opening Up: The Healing Power of Expressing Emotions (1990), Dr. Pennybaker describes the results of his early research in which students were asked to write about the most traumatic thing that had ever happened to them. They wrote for 20 minutes on four consecutive days. Students assigned to a control group were asked to write about mundane, unemotional topics. According to Pennybaker, “People who wrote about their deepest thoughts and feelings surrounding traumatic experiences evidenced heightened immune function compared with those who wrote about superficial topics. Although this effect was most pronounced after the last day of writing, it tended to persist 6 weeks after the study. In addition, health center visits for illness dropped for the people who wrote about traumas compared to those who wrote on the trivial topics.” This study and variations of it have been replicated many times.
Sharing our innermost thoughts and feelings with someone who cares about us is beneficial to our physical and mental health, yet too few of us “open up” to others to reap these benefits. In 2004, Duke University researcher Miller McPherson reported that between 1985 and 2004, our intimate relationships—people identified as someone with whom one could discuss important personal issues- had decreased from 3 to 2. Even more regrettable was the finding that one quarter of those surveyed indicated they had no one in their lives with whom they could discuss important matters.
Nurses often have terrible knowledge of the dark side of the human experience. Sometimes this results in symptoms of vicarious trauma: nightmares, fear, intrusive memories, exaggerated startle reactions, sleep disturbances, anxiety, a sense of unease, and somatic symptoms such as headaches, backaches, nausea, palpitations, and shortness of breath. Although it is beneficial for us to share our feelings with others, many of us avoid burdening our friends and family with the stories that keep us awake at night. A workplace that allows time for colleagues to process their emotions together in a confidential and nonjudgmental environment is ideal. When that is not possible, time spent writing and reflecting may help us to re-regulate when we are feeling “verklempt.”
Writing requires that we focus attention on our thoughts and feelings. It allows us time to examine how our own experiences may overlap with our patients’ and how they may be different. It provides us with a safe place to express strong feelings, to analyze them, and to wrestle with our fundamental beliefs about the world. Writing offers perspective and a chance to feel gratitude for the grace in our own lives. In these ways, writing can be a meditative and spiritual practice that results in deeper self-knowledge and self-compassion.
Nurses have a lot to write about. I hope that my book will inspire others to capture the essence of their nursing practice in words and simultaneously improve nurses health anywhere in the world. Nurses in the UK have been doing this for years. It is called Reflective Practice.