A couple of Sundays ago my 7 year old was acting out of sorts. Nothing dramatic – just a bit more clingy than usual, picking fights with his brother, getting upset over things he’d normally brush off.
I’d taken the week that should have been half-term off as annual leave, to try to keep some sense of normality going, and so I was a bit irritated that the last day of our time off together had been a bit bad tempered, but didn’t think too much more about it.
Then 10 minutes after going to bed, he called me back into the room. He told me between sobs that he was worrying, that he felt like he had something in his throat and that he was choking. And suddenly we were back in April. Back to the three bleak weeks when as a household we staged our own battle against Covid.
His tears were an abrupt reminder of the long tail of fear.
My husband and I were both unwell with the virus at the same time. We avoided hospital admission, though arguably, maybe shouldn’t have done. Family and friends brought us daily care drops and checked in on us, but of course couldn’t come in to distract the kids. Our youngest knew that things weren’t right, but wasn’t going to question the chance to watch Paw Patrol for 8 hours a day whilst chomping down beans on toast. Our 7 year old however, understood that the seriousness of the situation. The daily bombardment of news was unavoidable. Reports of the growing death toll, of the emerging evidence that men (my husband) and people from BAME backgrounds (me) were at higher risk of dying seeped into the house despite our best efforts to cocoon ourselves. And although he didn’t ‘get’ all of it, he got enough and became increasingly anxious. It didn’t immediately stop when we recovered, and for a few weeks after, me going into work was a worry for him, and Sunday evenings were a particular trigger.
And so on that Sunday evening came the dawning realisation that his fear hadn’t gone. He’d got used to managing it well enough that he’d stopped talking about it, but my week off from work was enough of a disruption to his new routine, that suddenly the fear was prominent in his mind again.
I don’t think he is alone in that. Coronavirus is a fear inducing disease. Just the phrase ‘global pandemic’ is enough to make your heart skip a beat, and not in a good way. Enough time has passed since the start of the outbreak that the fear might not be as acute and visible as at the beginning, but it hasn’t gone away, we’ve just got used to it.
We are not all scared. But some of us have been, and some of us still are. And that’s ok. Lots of people who I talk to are scared for others rather than themselves, and at times that creates a new set of dilemmas between your responsibility to your employers or patients, and your responsibility to loved ones.
There is a risk that in our rush to make things normal, and ok again, that we inadvertently end up pathologising fear. That we talk about it as sign that something is wrong. When arguably, being scared of the thing that at the time of recording has killed nearly half a million people around the world, seems like a pretty normal reaction to me.
There have been many comparisons made to the war and military. We talk about going to battle, about the frontline, about command structures and being deployed into units or teams. Having Covid, to me, felt like being invaded. But for all of the accuracies of the parallel, and I realise I’m stating the obvious here, health and social care staff aren’t soldiers. The experience of working in an environment that carries a high level of personal risk, the realities of losing colleagues who you may have worked alongside for years, is new. Very new, and it requires an adjustment.
Whether we like it or not, and whether we are individually experiencing it or not, fear (our own, our families’, our colleagues’, patients’) is now a much more frequent feature of our working lives. The challenge is how we are able to acknowledge this whilst still getting on with the job.
When the first wave of lockdown restrictions were lifted, sections of the media ran with a narrative that the government messaging had been too effective and that people would need to be forced back out into public spaces. The sunny weather and bank holiday weekends proved them to be very wrong. But behind the narrative was an undercurrent that people’s fear was somehow silly or unfounded, and worse, that it was being used as an excuse to shirk responsibility. I’ve heard similar conversations played out across workplaces up and down the country in recent weeks.
Now more than ever, when we’re tired and stretched, we need to be kind to each other. To work harder to understand different perspectives. To notice when a colleague might be struggling and need a hand. To create a culture in our teams where fear isn’t treated by default as a sign of illness or weakness, but that can be openly acknowledged without judgement.
Rachel Surtees is the Director of Strategy and Transformation at the Tavistock and Portman NHS Foundation Trust. Rachel powerfully describes the impact of fear in the experience of a family being forced to really face the reality of the serious illness that Covid-19 is.
Wellbeing Quiz Profile: #RelivingTrauma
We find ourselves in a time of great uncertainty where, amidst significant change to most areas of our lives, we continue to experience considerable change to our job roles and responsibilities.
Throughout my conversations with staff members, and mirroring my own personal experience, I have been struck by the range and intensity of emotions evoked by this change of role. Staff members have shown great strength in speaking about their experience of difficult feelings such as stress and anxiety, particularly in relation to a high clinical demand in the context of limited resources, or to a change of role prompting feelings of uncertainty or inadequacy. Staff members have also shown great strength in speaking about difficult feelings such as guilt that may arise due to their clinical load being reduced, or to feeling as if they “should be doing more”.
Across each of these challenging situations there lies a common theme; staff members are experiencing a jarring between their values (i.e. the care that they feel they should, or they want, to provide) and the care that they are practically able to deliver.
I therefore wanted to write a blog with this in mind. To raise awareness of the concept of “moral injury”, and to support staff to effectively prepare for, identify and manage potentially morally injurious events (PMIEs).
The following content is a summary of a recent paper titled “COVID-19 and experiences of moral injury in front-line key workers” authored by Williamson, Murphy and Greenberg (2020). I’ve attached the paper to this podcast and would definitely recommend giving it a read. Whilst I’ve focused predominately on understanding what moral injury is, and how to best manage this in NHS settings, they also provide really helpful recommendations for clinicians working with moral injury presentation.
What is a Moral Injury?
Moral injury is defined as the profound psychological distress which results from actions, or the lack of them, which violate one’s moral or ethical code.
Morally injurious events can include acts of perpetration (i.e. situations where we feel we have actively done something that goes against our moral code), omission (i.e. situations where we feel we have not helped in the way our moral code dictates) or experiences of betrayal typically from leaders or trusted others (i.e. situations where we feel that others have not treated us in the way that we would treat them).
When we experience a moral injury we might feel overwhelmed by difficult thoughts such as “I’m an awful person” or “my colleagues don’t care about me” and difficult feelings such as guilt, shame or disgust. Whilst moral injury is, in itself, not classed as a mental illness, we see how these experiences may contribute to the development of other mental health problems such as depression, anxiety or post-traumatic stress disorder.
NHS staff members will encounter PMIEs on a daily basis; redeployment may mean that clients we used to treat are without their usual care, a higher clinical load may mean that we have less time to spend with a seriously ill patient, or a lack of resources or training may mean that we do not feel that our own health and wellbeing is being properly considered by those who are supposed to protect us.
Research shows that a number of factors may also exacerbate these existing challenges, possibly increasing the likelihood of developing a moral injury. Potential risk factors for moral injury may include situations where; a vulnerable person has died, staff members do not feel adequately supported, staff members do not feel prepared for the emotional/psychological consequences of decisions, staff members experience a PMIE in addition to other traumatic events (e.g. loss of a loved one), or there is a lack of social support.
It is important to note that not everyone who encounters a PMIE will experience a moral injury. However, raising awareness of PMIEs allows us to better understand and effectively attend to an often misunderstood or neglected distress response (both in ourselves and others).
Supporting NHS Workers Exposed to PMIEs
Williamson, Murphy and Greenberg (2020) outline five practical recommendations to support staff experiencing potentially morally injurious events. These include:
So that is just a brief overview of moral injury and some of the ways we can manage that within an NHS setting. I would definitely recommend giving the paper a read just to get a bit more in depth explanation on that as well if you are interested. Thank you.
Dr Sarah Appleton is a Clinical Psychologist working in Employee Health for Central London Community Healthcare NHS Foundation Trust. Sarah raises our awareness of the concept of “moral injury”, and how to support staff to effectively prepare for, identify, and manage potentially morally injurious events.
Sarah references the recent paper titled “COVID-19 and experiences of moral injury in front-line key workers” authored by Williamson, Murphy and Greenberg (2020).
Wellbeing Quiz Profile: #RelivingTrauma
In the early hours, half asleep, I received a call to say one of our residents had died of Covid in hospital. I could feel the sadness over coming me, that feeling in your throat. I got dressed and left.
At this time, my colleague and I were supporting a residential nursing home as an interim, due to the manager being unwell at the start of Covid lockdown.
As services we are now supporting people in different ways and we have different systems in place.
Infection control, PPE, social distancing is all the current trend at work and at home.
Driving to work on that day, brought a different feeling, I didn’t have concerns about being late or I need to finish a piece of work but an anxious feeling in my stomach, my mouth was dry, different thoughts went through my head, sadness for the person who had died other families who will be fearing the same for their loved ones, how do we support families, what if staff don’t turn up for work because of their fear of Covid or have family member affected by this, the questions, thoughts continued for the rest of the drive.
Now when I look back on this drive, I realise this was just anxiety getting the better of me.
All the policies and procedures can be followed but what no one really knew, was the impact of the emotional trauma that this would have, on all of us.
This was going to pull upon every bit of my experience and knowledge and the skills I had learnt over the years, I also knew I was going to work along side a great colleague who also had years of experience, and was very knowledgeable.
Working together, we will get through this. This became my inner voice.
I walked through the residential doors, with confidence, “Morning” I said. I was greeted with, “Morning” – but there was a “but, we have no staff, no nurse on site, staff worried about Covid being in our care home, is it true someone has died of Covid?”
I have always been honest with staff and at this time, it was important that staff knew that we had sadly lost someone in hospital with Covid but the reception area of a residential home was not the place to discuss it, so with a deep breath, calm voice, I acknowledged the staff worries, explained we would have a meeting to update staff.
The next step was to look at ensuring our residents were safe.
By the early afternoon, my colleague and Ihad started to implement an action plan.
Our 4 priorities were:
Leading a team in the Covid 19 pandemic brought out an inner strength that I wasn’t aware of before.
My expectation of staff was high, things needed to change quickly and at times I found myself frustrated and annoyed, not with the staff but with the situation.
The expectations from staff, family members, commissioners, GP’s and others was sometimes over whelming, at times you just didn’t have the time to think but I had to keep calm, think through the priorities, even making a list, got me through these times.
Communication was vital – being seen and working alongside care staff enabled you to check in with staff on how they felt and share their experiences.
It was important that we supported and responded to our staff’s mental health needs. Staff needed to know that we cared and valued them.
Regular meetings, where staff could bring anything to the table, were listened to, respected, and difficult situations discussed in a sensitive way. We all reflected on the days together, the sadness, and keeping people well.
Sarah Carney is an Independence & Well Being Service Manager in Enfield. She shares her experience of supporting a Care Home at the onset of a pandemic and the need for emotional strength during a time of uncertainty.
Wellbeing Quiz Profile: #FeelingHopeless
Hello, my name is Caroline Mayger. I am a Service Manager for Independence and Wellbeing, front line social care services to vulnerable adults living in Enfield and this is my story:
I returned to the UK from India on March 16th, 2020 after 6 months of travelling.
What a return! No smooth entry but a large bump!
The world I found was upside-down chaotic, full of insecurities and fear – an unknown narrative and I realised India was about 3 weeks behind the curve. I went in to self-imposed 7- day isolation, a drift and struggling to make sense – It definitely wasn’t normal and I can remember thinking that if this was the new normal I didn’t like it!
Reflecting now on my return to the UK I can see that it took me time to find some rhythm to my day get up, shower, get dressed, breakfast, emails, Zoom, lunch, day time TV, watch a film, yoga…anything to get me through the day.
Once I managed that I felt a little better and I was reframing my day to day life as information came through. I still felt very unsettled but was becoming adjusted to my new normal.
I returned to work on the 4th April 2020. From the outset I was remotely working – that took some getting used to – no existing workload, no face to face contact and Covid-19 causing chaos, upset and fear. I felt impotent – it was like being in a vacuum.
Lockdown was in place and our frontline staff remained in work looking after vulnerable people – the first cases of Covid were present in services. I remember one early managers’ meeting – I was present but not. As a remote worker I felt guilty at not being with colleagues in work.
I felt a clear resonance with the time I spent at home – insecurity, the need for routine, searching and shifting for information that ‘felt’ real. We needed a clear pragmatic approach for our staff and managers – to provide reassurance and to navigate the risks. I found myself a new role – coordinating clear information, structure and an evidence-based approach to supporting services, leaving colleagues to focus on the front line, manage the risks, support staff.
My role was an outside-in view of what was happening and in response to an ever-changing landscape. This was a whole team effort with everyone playing a part to create an environment where we could deliver services.
Gaining staff trust was paramount – it was and is a new environment for us all – If the staff felt like I did – what did we as an organisation need to do to get through this? At the time it was about survival and trying to find a way through, to take staff with us and to reduce the risk and get the job done.
In terms of leadership, during this time we took a directive approach to provide a structure for people to work within whilst also being very supportive to individual and team needs when required – providing people space to question and communicate with us – our approach has been by being consistent, sharing information – we listened flexed and responded – sometimes hour by hour.
Feedback from staff is that this was appreciated, and our care staff continued to provide services during the biggest challenge we have ever had despite their own anxieties.
My emotional intelligence has been at full stretch – especially as a remote worker – picking up on issues through tone and nuance – checking in with people, offering time to just listen. On a day to day basis and from a distance communication was key – ensuring information was valid and fact based. This was especially difficult in the first two or three weeks when the information was changing, being updated and we had to respond daily to review the guidance and practice – on a personal level I was anxious that we were doing enough – was it correct? Were we creating risk? I had to trust in our approach – open communication, respond when required, be transparent, listen.
We were often reactive to the changing landscape and ensuring these messages were communicated effectively to staff. I think that the one thing that worked for us was that we were very open about not having all the answers, we couldn’t eliminate risk completely but based on best available advice this was the approach we were taking. We did not waiver from that stance and it stood us in good stead.
During this crisis our staff and our managers have stepped up and provided the stability needed to provide safe and responsive services.
I hope that from a distance I have been in some way able to provide the framework for those on the front line to focus on their work and to stay safe.
We are not at the end of this journey yet – We need to continue to provide consistent leadership – to be clear, to listen, to communicate and to be available – this will support our staff in the best way possible and enable them carry on caring. I am very proud to be part of these Teams. Thank you for listening.
Caroline Mayger is an Independence & Well Being Service Manager in Enfield. She shares how it feels to manage an adult social care service remotely by creating stability within care settings from a distance.
Wellbeing Quiz Profile: #LessInterested
Hello, my name is Fiona Hartnett and I am the General Manager for Clinical Services at the Tavistock and Portman NHS Foundation Trust. My role involves overseeing operational and administrative support to our childrens and adults services. During the Covid-19 pandemic this has required a real increase in the frequency of communication with staff across the Directorates and today I am going to reflect on how we have done that and hopefully offer some useful advice to both those receiving and those delivering communications in this context.
In these challenging times it can feel difficult to keep on top all the information that is flying around and it may feel that somehow you have missed something that everyone else knows, or that you can’t keep your team up to date quickly enough. Guidance and information is constantly changing and what was right one week may no longer be the next.
It is important to remember that lots of people at all levels in organisations can feel this way and that usually this is not about you not paying attention, it really is difficult. It is important that you find a balance between keeping in the loop and supporting your own wellbeing by not becoming overloaded with information. Managers also need to strike this balance and not give their teams too much information that can be overwhelming.
For those on the receiving end, remember its normally not necessary to know the latest information straight away. It may help you to set a time of the day to catch up on emails, read minutes of meetings or listen in to staff briefings that may have been recorded. Having a specific time may make it feel less overwhelming and can hopefully mean you see the latest information and can digest it at your own pace. Linked to this I would advise considering setting periods in the day when you close your email so you are not bombarded and can focus on specific tasks, if anyone really needs to contact you they will find a way to do so.
Secondly don’t be afraid to ask – if something is unclear you can be sure you are not the only person to think so. Ask for clarification or for more details. Similarly if you have an idea for how the team can improve communication let your manager know, it may be something they hadn’t thought about.
For those of you responsible for communicating with staff be sure to keep communication regular – I have found that even team catch ups where I thought I didn’t have anything to say have been helpful to check in, confirm nothing has changed and to let people bring their own questions. If you send email updates consider doing this at the same time each week or day so people know when to expect it.
In email communication where possible keep it brief. Consider sending headlines in the body of the email and more complex breakdowns of information in attachments so people can choose how much they can or need to read now but can get the salient points quickly. Make sure you check your emails and documents before you send them to be sure that they are clear and if necessary ask a trusted colleague to look over it for you as its easy to miss something when you understand the information well yourself.
Think about communicating in more than one format – one email is unlikely to be enough so do try various methods to get messages across. Linked to this you should be prepared to repeat yourself and be patient in doing so. People will miss messages and in these challenging times it’s important to give them that time and accept you may need to say things more times and in more ways than usual.
Finally, while it is of course OK to say you don’t know, don’t ignore people, explain that you need to look into it further and that you will get back to them. While it may be difficult or feel unimportant to you it isn’t to whoever asked.
I hope this was useful to you and encourage you to remember that communicating in this environment is difficult for everyone and if you are finding it hard to know what is going on you are not alone.
Fiona Hartnett is the General Manager of Children, Young Adults and Families and Adult and Forensic Services at The Tavistock and Portman NHS Foundation Trust. Fiona reflects on the impact COVID-19 has had on communications with staff and offers some useful advice to both those receiving and those delivering communications in this context.
Hello, my name is Jane O’Rourke. I’m a Child, Adolescent and Family Psychotherapist, and I’m a yoga and meditation teacher. Today we are going to do a tree visualisation.
Many of us are finding that being in nature can be really helpful when we are feeling stressed and overwhelmed, it helps to calm the nervous system and there is lots of evidence that people who suffer from depression or anxiety are helped by being in nature.
So, before we begin, start to find a comfortable posture, perhaps sitting on a cushion or maybe just sitting on the floor, or you can be standing if you like. And being able to relax the spine enough to feel comfortable but you are aiming for a straightish back. Relax the neck, just notice if you are holding any tension in your shoulders, soften the jaw, and you can start to soften the eyes by either lowering the eyes or just keeping them open a little.
And start to feel your connection with the floor and the earth below. By feeling the connection with the earth we can feel also the qualities of the earth, the feeling of steadiness and calm, that’s always there for us whenever we need it. And then I invite you to remember a tree that you might have seen, maybe on holiday or maybe it’s just closer to home. A tree that has made an impression on you, for its strength and solidity, and if you like imagine yourself next to this tree, and you can look up into the branches into the canopy, seeing the leaves and the sun glinting through the leaves, and the sky beyond. And noticing the strength of this tree, its trunk and the branches that reach out, up to the sky. And of course, like us, trees have had to weather storms and periods of draught, and in these times they grow deeper roots. And for us when things are difficult it is important that we can dig deep too, that we can reach into our resources, and connect with others and find strength and solidity by doing so. So in this way the tree is a friend and we can imagine ourselves growing roots into the earth when we are sitting here.
On an each in breath bringing up the qualities of the earth, of strength, solidity and steadiness and on the out breath a releasing and letting go. So imagine this in your breath cycle, bringing up strength and solidity on the in breath, all the way up through the body. And on the out breath a releasing and letting go back down to the earth. And all the while feeling your connection to the earth.
It’s known that oak trees, for example, do much better in groups, as often we do too. We need other people to help us in times of adversity and when oak trees are feeling compromised and maybe they have had an attack of fungus or they have got some insect invasion the other oak trees send nutrients in their roots to them.
And so bringing to mind someone you know who is feeling that this is a time of difficulty for them, they might be struggling or in pain, or stressed, or anxious. And bringing them to mind and sending your good wishes to them and you can say to them “may you be happy, may you be healthy, and may you live with ease and grace”. And then letting them say to you in return “may you be healthy, may you be happy, and may you live with ease and grace”. And then sending out your good wishes to everyone who needs it, everybody you know and everybody in your wider community and the world beyond. You can say to them “may you be happy, may you be healthy, and may you live with ease and grace”.
So as this image of this mighty tree that you have been visualising fades, know that this is a resource that you can come back to anytime when you need to feel more grounded and stronger. And know that receiving compassion and good wishes from everyone is also available, and it’s what you can do for others too. So very gently, coming back into the room in your own time.
Jane O’Rourke guides us through a tree visualisation exercise to help us connect with nature when feeling stressed and overwhelmed. Jane is a Yoga and Meditation Teacher, and a Psychodynamic Psychotherapist with Children, Young People and Families. She teaches Yoga4Trauma within the Trauma Service at the Tavistock and Portman NHS Foundation Trust.
Wellbeing Quiz Profile: #MoreFrantic #RelivingTrauma
This week there is a global initiative asking health care staff to ask the question: ‘What Matters to You’? of their patients and service users. It prompts us to think about the need for staff to feel that what matters to them is able to be expressed and being listened to. Can we ask our colleagues, our leaders, our team members the same question and can we really listen to their answers? How can we create and sustain workplaces that understand the importance of communication, praise and acknowledgment? We know that organisations that create cultures that encourage open communication, where the giving and receiving of feedback is valued, are organisations that thrive. They benefit from the diversity of experience and perspective from their staff members. They are organisations that are more able to navigate and respond to challenges successfully.
As we continue to respond to the pandemic with many people working in potentially traumatising and certainly challenging situations this is all the more important. So how do we really listen to our colleagues and develop our listening and questioning skills and through this broaden our awareness of what problems are, might be and how individual beliefs and assumptions frame and contribute to them.
In this time when we are all under considerable pressure it is even more important to check in with colleagues, ask them how they are and then give time and present attention to the answer – listen with you whole self, notice the emotions you feel, when your attention wanders or when it is piqued, whether you move to thinking about solutions instead of listening. Is it possible simply to listen and to be alongside people as a witness to their experience, to allow them the space to talk and to work through their dilemmas?
We are often asked to be experts, indeed many of us are experts in our roles in the disciplines in which we practice but this can also impede our ability to listen as we are hard wired to think about and come up with solutions. Can we also be facilitators and enablers and to sit in open curiosity with another and to really hear what they are saying and in so doing begin to know how they are doing. We can then begin to think about listening as an active process that is a skill that can be developed and honed.
Sometimes this active listening is just just about being emotionally present and able to sit through the uncomfortableness of just being and listening without rushing to those solutions. But questions that show openness and curiosity and a desire to understand as well as just hear can also be helpful – the so called what and how questions. So ask someone: How important is this to you? What’s at stake here? What is your greatest fear? How is this affecting you? What is the broadest range of options open to you? What could you start to do differently?
A helpful concept to support this stance of curiosity and presence is that of negative capability coined by the poet John Keats in 1817 who describes it as the state in which a person is `capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason’. If we can tolerate ambiguity and paradox, and anxiety and stay in uncertainty, new thoughts and perceptions may emerge.
Breakthroughs in understanding often occur at the edge of ‘knowing’ and ‘not knowing’. Around every situation or ‘presenting problem’ lies an ‘empty space’ (full of issues about which we are not aware, tacit/unconscious assumptions, and unspoken imaginings and beliefs). The key is to resist the pressure to fill that space with our own assumptions and solutions.
All work provokes emotional responses in us all – is there space to reflect on and think about those issues and what they mean as a way of accessing some of the creativity within the organisation that sheds new light on the organisation’s challenges and dilemmas? I think there is.
Helen Shaw is the Portfolio Manager for Social Care, Leadership in the Directorate of Education & Training at the Tavistock and Portman NHS Foundation Trust. She is also an organisational and leadership consultant. To celebrate What Matters to You? Day 2020, Helen talks about the concept of listening and the importance of this skill as we respond to the current pandemic.
Wellbeing Quiz Profile: #LessInterested #DoingOkay
Hello, my name is Jane O’Rourke. I’m a Child, Adolescent and Family Psychotherapist, and I’m a yoga and mindfulness teacher. Today we are going to be practicing soothing rhythm breathing.
How we feel effects how we breathe and how we breathe effects how we feel. So by slowing the breath down to a soothing regular rhythm, we can start to slow the mind down, and slow the body down, and feel less anxious and stressed. It’s also a really good way to give ourselves self-compassion, looking after ourselves, supporting ourselves. Soothing rhythm breathing also helps us to self-regulate by stimulating the vagus nerve and it increases our heartrate variability which is a really good marker of our body’s ability to respond effectively to stress. It will also activate your brain’s soothing system.
So starting to find a comfortable seated posture, somewhere where you can feel comfortable and your spine can rise tall, and your chest is open, your heart is open, your jaw soft, your shoulders are sliding down the back and you feel yourself rooted to the ground, and supported by the earth below. You can rest your hands in your lap.
We are going to be really slowing the breath down to about five breaths a minute. We are going to be aiming for a really smooth in breath and a really smooth out breath, so that the length of time you breathe in matches the length of time that you breathe out, and as we breathe we will be focussing on slowing the body down, so the mind can slow down too.
And before we start just checking our facial expression, and softening and relaxing the face so that you have a friendly expression on your face, reinforcing a friendly intent to ourselves. So I am going to be counting you in and out and then you can rest for a while afterwards, just breathing at your own rhythm.
So breathing in for a count of 1, 2, breathing out 1, 2, breathing in 1, 2, 3, breathing out 1, 2, 3, breathing in 1, 2, 3, 4, breathing out 1, 2, 3, 4, breathing in 1, 2, 3, 4, breathing out 1, 2, 3, 4, breathing in 1, 2, 3, 4, breathing out 1, 2, 3, 4, breathing in 1, 2, 3, 4, breathing out 1, 2, 3, 4, breathing in 1, 2, 3, 4, breathing out 1, 2, 3, 4, breathing in 1, 2, 3, 4, breathing out 1, 2, 3, 4, breathing in 1, 2, 3, 4, breathing out 1, 2, 3, 4, breathing in 1, 2, 3, 4, breathing out 1, 2, 3, 4, breathing in 1, 2, 3, 4, breathing out 1, 2, 3, 4. Last time, breathing in 1, 2, 3, 4, breathing out 1, 2, 3, 4.
For now just let your breath just go at its own rhythm, breathing in and out in your own time and noticing as the breath has slowed down, with your mind has managed to slow down a little too. And all the while feeling connected to the ground and the earth below. Feeling a steadiness and rootedness, just focusing on the flow of the in breath and the steady flow of the out breath. And you can stay here for as long as you like, just watching the breath, feeling a steadiness and a rootedness or in your own time coming back into the room.
This breathing exercise is a good way to experience self-compassion for times when you need more self-care. Soothing Rhythm Breathing relieves stress and anxiety by slowing the body and mind down. Jane is a Yoga and Meditation Teacher, and a Psychodynamic Psychotherapist with Children, Young People and Families. She teaches Yoga4Trauma within the Trauma Service at the Tavistock and Portman NHS Foundation Trust.
Wellbeing Quiz Profile: #MoreFrantic #FeelingHopeless
Hello. My name is Dominic O’Ryan and I am the Lead Psychologist in Substance Misuse and the CBT Training Lead for Camden and Islington NHS Foundation Trust and I’m going to talk to you for a few minutes about sleeping well; in particular about sleeping well during these strange times.
I think it’s best to avoid all the literature that tells you about how bad it is to sleep badly. You don’t need any more information then how you feel. Sleeping well is also by definition good for you. Getting a good night’s sleep helps us feel refreshed and is very important for our physical and mental health.
However, heightened levels of arousal due to constant work and social stress, broken and shifting routines, home working, difficulties switching off and broken boundaries between work space and home space and sleep space, are amongst the kind of pressures that people are under at the moment and they can have an enormous impact on our wellbeing, and our sleep in particular.
We can find ourselves struggling to get off to sleep, we can experience broken sleep and nightmares, and we can experience general fatigue on waking, wondering if we’ve got any sleep at all.
So I’m just going to say a few things about what’s going on during sleep because I think it is helpful to remember that sleep has a natural structure and its own way of managing itself.
Firstly, sleep is driven by the earth’s own day-night cycle. This circadian rhythm is as in-built and important as any other biological or physical process. If we are working shifts, or not getting natural light in the day or we’re exposed to high levels of light at night, sleep will be broken. So the first step is to check on our own day-night cycle and to take steps as far as possible to retain or reset that soon and often.
Secondly, and paradoxically, sleep is designed to be broken. Sleep has distinct phases of light sleep, deep sleep and rapid eye movement or REM sleep. Dreaming happens in all phases but is mostly associated with REM sleep. These phases together last for an hour and a half or maybe 2 hours at a time. Even though we might think we should be sleeping for longer, we naturally come back to the surface of wakefulness after this time, then generally speaking we drift back to sleep without paying much attention.
But something that happens to all of us sometimes, and to more and more of us at these times, is we noticed that we’re awake and then we can become quite agitated about this, which in itself gets in the way of the natural process of falling back to sleep. And so accepting that waking up in the night is actually a part of sleeping well is a key step in returning to sleep.
Thirdly, humans are natural problem solvers. And we can easily fall into the trap of trying to use day-time active, conscious problem solving at night. We try to solve the problems of the day and we try to solve the problem of why we’re not asleep by actively thinking about them. This kind of problem solving is for day time only.
Instead, that’s something that’s sleep is designed to do on its own. The phases of sleep all have problem-solving components built in. They are there to help us consolidate memories, make sense of things, practice our emotional responses, and anything that we do that interferes with the natural process of sleep just makes the natural process unworkable.
If sleep is proving to be elusive just let sleep look after itself. If you’re not getting to sleep then look for a tendency to problem-solve and just allow yourself to gently stretch and let your mind wander off and do something else. The more we try and bring it back to problem solving of getting back to sleep, the more we’re getting trapped in active problem-solving mode when the problem really is something that can solve itself.
Paul Gilbert’s model of threat mind, drive mind and compassionate mind is very helpful here. We can experience poor sleep as a threat, so we get more aroused. We respond by using our drive systems to try to fix it. In reality the best thing to do is just to be gentle, kind, open and let the compassionate mind look after itself.
This part of ourselves can sometimes be tricky to activate and a simple soothing rhythm breathing practice for a few minutes, a few times during the day, can make it easier to bring on line at night.
And so, if you’re lying still in bed with your eyes closed in the dark, breathing gently, who is to say that you aren’t actually already asleep and you just think you’re awake.
Overall, allow your mind and body to look after you, by being kind to yourself during day and particularly at night.
Dominic O’Ryan qualified as a Clinical Psychologist from UCL in 2000. He is the Lead Psychologist in Substance Misuse Services and the CBT Training Lead for Camden and Islington NHS Foundation Trust. He talks about three simple approaches to sleeping well.
Wellbeing Quiz Profile: #MoreFrantic
The past few months have been a whirlwind; a time that has flown by whilst feeling protracted, life changing and leaving us struggling to remember what “pre-COVID-19” life looked like. You may have worked longer, harder hours than you ever thought possible. You may have been redeployed to a new role, moving even further away from “normal” life. You may have been told to “watch and wait”, bouncing between feelings of guilt that you “should be doing more” and anxiety as you anticipated the threat of redeployment.
Whilst our individual experiences may look different, we are united by two common themes: 1.We have all, for an uncertain period of time, had to say goodbye to our “normal” professional roles and 2. We have all been living in a high threat environment.
So, as talk turns to establishing a “new normal” and re-opening services, I wanted to spend time thinking about what it’s like to “come home” from the experiences we have had.
Whilst our understanding of the psychological impact of COVID-19 on NHS staff is still emerging, we can begin to anticipate some of the likely psychological responses (and possible avenues for psychological support) from other areas of literature.
For example, research into the experience of humanitarian aid workers highlights how difficult it can be for them to return home from the experiences that they have had.
Humanitarian aid workers will often return home feeling emotionally and physically exhausted (following a prolonged period of time in a “high threat” state). Research highlights the experience of “vicarious traumatisation”, or the belief that one’s self (i.e. an individual’s hope or meaning) has inherently changed following exposure to a trauma environment. They have seen things that they can’t unsee, and are now acutely aware of how cruel Mother Nature and mankind can be.
Adjusting back to an old but now unfamiliar environment can contribute to a complex mixture of emotions including guilt, anxiety, anger and loneliness. It may also leave an individual longing for what they left behind, wanting to return to those that understood the challenges they faced.
Importantly, research further documents how difficult it can be for aid workers to seek support on their return either viewing this as “weak” or neglecting their own distress because “other people have it worse”.
Whilst the experience of NHS staff working in the COVID-19 pandemic and humanitarian aid workers cannot be directly compared, there are a number of similarities that may be able to inform psychological support moving forward. Importantly, research highlights the value of preparing staff for returning home (including debriefing and reintegration sessions), psychological assessment and psychoeducation.
Preparing to Come Home: Key Questions
With that in mind, I invite you to consider the following questions as you navigate this next period of uncertainty (it might help to get a pen and paper and write your answers down):
Take a moment of gentle reflection, gently breathing as you do this. What impact did COVID-19 have upon your job role? What other challenges did COVID-19 bring? What difficult emotions have you had to navigate over the past few months? Try to offer yourself a sense of kindness and compassion as you reflect back upon some of the challenges you have faced.
Now turn reflection to your strengths, again gently breathing as you do this. How did you manage to navigate this time of difficulty? What helped you to cope? What did you say to yourself? Who else helped to support you?
This may include reflection on what your new working role or environment looks like. Acknowledge that this may have changed, and that this may create new anxieties.
If you notice yourself getting overwhelmed by difficult thoughts or feelings, it may help to practice a grounding technique such as ACE.
Continuing with your gentle breathing, try to think about what you are bringing home with you. This could be difficult emotions such as stress or anxiety about the future. This could be feelings of guilt if you think you “have not done enough” , or a sense of sadness for a team that you are no longer working with.
You could also be returning home with positive emotions. What adventures did you have? How did you help and feel worthwhile?
Take a moment to notice what emotions are showing up for you. Gently acknowledge these, without judgement. As you gently explore these emotions, try to offer yourself the same kindness and compassion that you would to someone that you care deeply about.
Whilst this can sometimes be a difficult question to answer, try to focus on labelling the main emotion that you are struggling with. What might help you to best navigate this? What has helped you to manage this emotional response in the past? This might include seeking support from those around you, prioritising self-care, or problem solving areas of difficulty.
For additional ideas on how to best manage difficult emotions please visit the resources page on this website.
Dr Sarah Appleton is a Clinical Psychologist working in Employee Health for Central London Community Healthcare NHS Foundation Trust. Sarah explores the experience of returning to ‘business as usual’ following participation in a crisis response such as COVID-19, and helps us prepare to navigate this next period of uncertainty.
Wellbeing Quiz Profile: #LessInterested
Podcasts are regular, short messages from wellbeing and mental health practitioners within this network. They will be directly responding to what we are hearing from you through both the Wellbeing Quiz and the ‘How Are You Today’ survey, as well as offering more specific presentations for targeted staff groups, for example social workers.
Once you have completed the Wellbeing Quiz, keep an eye on the hashtags underneath each of podcasts to help identify those which might be most helpful for you.
Keeping Well NCL is a wellbeing and mental health project that connects and supports the North Central London health and social care workforce during the Coronavirus outbreak.
