I hope this note is useful for therapy practitioners and the clients themselves – as well as any supporters of front line staff including friends, colleagues and family members.
Before starting work at Frontline19 I was anxious about working with people on the front line who had been exposed to the unprecedented situation of Covid and associated stress and trauma. I have a fairly standard private therapy practice, having trained at Spectrum Therapy, and I now practice as a humanistic and integrative therapist. I have also worked for many years as a volunteer at our local Bereavement Service. I was not sure how this background would prepare me for working with people like intensive care nurses and doctors who carried on during the height of the Covid epidemic.
I was very pleased to find that time-honoured, simple, conventional counselling skills were in fact extremely effective in allowing them to have their experiences and emotions heard, acknowledged and, to some useful degree, processed.
I have now worked with eight intensive care health professionals and every single one talked about having to shut down their emotions during the crisis. “Going into robot mode“ was a phrase that all of them independently used.
Obviously that degree of immediate self-repression can lead to significant later emotional consequences in terms of exhaustion, demoralisation, depression and / or generalised anxiety.
Detailed history: My approach was simply to ask them to describe in great detail exactly what their experiences had been. I explained that I was not medically qualified, so I asked them to explain some of the terminology and some of the techniques. I said that this was educational for me and would be of benefit therefore to the other work I was doing at Frontline 19 and maybe even something I could pass on to other colleagues.
Importantly, this seemed to give them a degree of agency and power which is precisely what had been missing during those traumatic months.
It also evened up our relationship in a way that I appreciated as a humanistic practitioner.
Initially some of them talked very much about the objective clinical circumstances but avoided mentioning the deaths that occurred; but after a few sessions like that, they begin to be able to talk about that subject – although initially still in quite a detached way.
On several occasions I heard the remark that they had not actually realised what they had been through until they told me about it.
Acknowledging and naming. During the telling of their experiences, I made very strong acknowledging remarks including helping them name it in the words that they had never dared to use before – eg “a complete nightmare … way beyond anything that we had ever had before”. “All the techniques which we had relied upon to save lives previously were now failing.” “We were facing this unknown illness which seemed to go on and on.”
The fact was that they were nursing other young people – indeed some of their own colleagues – but they had initially been in complete denial about the possibility of them becoming ill and dying. Then a sort of sick humour took hold of the ward but the explicit word “fear“ was never used by them until they spoke with me about it.
Shame. One aspect which took me some time to identify was the fact that going into robot mode meant that they let go of their normal level of empathy and connectedness with their patients that they had always had before and prided themselves on. They were often on the edge of endurance on a 13 hour shift, wearing full PPE and coping with hopeless cases and deaths and they were simply looking at the clock and longing for the shift to end.
They were able eventually to say that they had been secretly suffering a great deal of shame about the fact that they lost that empathy and connectedness. They had never talked about this subject before. Again, talking it through represented a massive lifting of that unnecessary and unwarranted sense of shame or guilt.
There was also another sense of shame which was really unhelpful – and unnecessary: the shame about being anxious, stressed, angry – in fact shame about being emotional at all! To some extent it seems this comes from their own histories but it is greatly exacerbated by the deeply unhealthy culture of the NHS – or at least those parts that I am hearing about.
Just to explore that and to explore the damaging cost of self repression and the simple fact that we all totally need to be emotional seems to have been a revelation to some clients – and a very healthy one.
Moral Injury. Another emotional issue which is related to shame is Moral Injury. This is not a phrase I had heard before but it is well known in medical circles. It refers to the emotional impact – often shame and guilt – of not being able to do one’s duty – often because of lack of resources. “There were not enough beds, enough ventilators, enough time – to do things properly – to do thing in the way I knew they should be done.” The sense of powerlessness, helplessness is massive and destructive. And not much discussed.
In terms of understanding the trauma of our clients, a worthwhile distinction may be that the intensive care world is a world of high drama.
But drama does not always mean trauma.
Even when it involves gruesome images and experiences, there is a protective factor if the person concerned has agency – some degree of power – in their involvement in medical treatment.
Obviously that is at its strongest if treatment is successful and the patient recovers but It may be present even perhaps if it is ultimately futile and the patient dies so long as the client knows that all proper steps were taken. ie the moral injury element is not present.
Working with NHS staff both generally and especially during their experiences during the Covid crisis, what is striking is the extent to which the traumatic legacy is far greater in situations where they are powerless.
General powerlessness for NHS staff. However powerlessness is also present generally and less obviously in the fact that they work in a large, very hierarchical organisation where others inevitably have power over them.
Even if that power is exercised in a benign and skilful way, there might be a degree of added stress for the client but sadly the cliche that power corrupts is very evident in the NHS. And that doesn’t only refer to bullying and harassment but even to a very generalised insensitivity and lack of skill by management and by senior staff.
Unspoken anger. The result is that our clients will often have experienced huge levels of frustration throughout their working life and it may continue even when we are speaking with them. And “frustration“ can sometimes be examined and understood as being a polite and a half repressed emotion of anger But, precisely because they are in a position of powerlessness, it is an anger which dares not say its name.
I have found that helping clients identify and name that frustration and resulting anger has actually been very helpful for them.
One phrase that has come up is one that sounds childish and therefore we tend to suppress it – and therefore to repress the background emotion – of anger: “It’s not fair”. That is what people feel about the fact that they are blamed or blame themselves for things that are not their fault. And it really helps to have that acknowledged and the client allowed to say those words – loudly.
This is hugely true of the situation , in the early days of Covid when there was simply not enough PPE and staff were being forced to put themselves in huge danger. Many died as a result. And all the while the government were denying this reality, effectively gaslighting the medical profession – and the country. Some people have said they didn’t have time or energy to be angry. Maybe not explicitly but I am aware that the anger remains now – and needs to be expressed.
Those early days are now two years ago but the results continue for our clients. See below the note: “What now that the hospital crisis seems to have eased? ”
Pride in working for the NHS is reducing . A new matter that is coming up is the loss of public trust and respect for the NHS. Previously that was a major protective factor for the staff. Whatever local or temporary failings there were because of the exceptional demands of Covid, basically the NHS was seen as world leading and highly respected and valued. So staff felt supported by that respect and value.
However that is being significantly eroded with the recent enquiry of Shrewsbury Maternity Department scandal with others to come.
Satisfaction with the NHS overall in 2021: Overall satisfaction with the NHS fell to 36 per cent – an unprecedented 17 percentage point decrease on 2020. This is the lowest level of satisfaction recorded since 1997, when satisfaction fell to 34 per cent. More people (41 per cent) were dissatisfied with the NHS than satisfied.
It is crucial to see that this is also a part of moral injury. People are being blamed or are receiving less respect because of the failings of others – often the failings of the NHS system and the lack of resources from years of government underfunding.
Does counselling work? Answer: Yes! In spite of all these problems.
Talking about all of this really does help clients. They have all said that offloading this material did indeed make them feel much lighter and more able to cope in the future. With her permission I quote one client who said “My guilt from the situation has quite drastically faded.” and “The change in my thought patterns over the last few weeks has been outstanding and is reflected quite clearly in my mood and behaviour”
I do find that eight to ten counselling sessions were enough for most of the people I have been working with although we have put in the diary some extra sessions, as a sort of check-in, three weeks and then four weeks further on.
It is my particular style to make a brief note of the contents of the sessions and send it back to the client later and this was particularly appreciated by them. Seeing it written down made it even more real and acknowledged. But that may not be possible for most professional with full time other work, nor appropriate for non-professional supporters.
Polarised thinking. Like many people under extreme stress, they had sometimes gone into quite rigid, black-and-white thinking. “Either you remain cold and hard and robot-like or you’d inevitably collapse into a complete heap.”
It took time for them to explore and accept that they could healthily and safely move in and out of a state of being warmer, softer and more emotionally in touch, without the feared opening of the floodgates of endless, debilitating grief.
Self care, self soothing. Breathing. Suggesting and exploring with them good breathing techniques, particularly of course the parasympathetic, open throat, full out breath, enabled them to see that there are safe ways of lowering their guard and coming out of robot mode. Equally other self soothing such as exercise, yoga, dance, swimming, massage and hugs – even self massage and self hugs.
Yoga doesn’t have to be formal group yoga. I offer my very simple 15 minute standing poses exercises. This is so undemanding and simple that I actually do manage to do them almost every morning !
Other support. Curiously with each single one I asked them about who they have been able to talk with honestly during the crisis and since; and they had all hugely limited that possibility, projecting onto their partner, family and friends the belief that they would be overwhelmed – even when those people were asking for more information and protesting their readiness to hear it.
Encouraging them to negotiate and establish quite a considered approach – almost a regular routine – for some limited offloading – proved to be highly effective. This is also something they could continue after we have finished our work together.
NHS and career stress. As mentioned above, sometimes the way that they were managed or aggressive treatment by other members of staff were a source of great stress and distress and they had never been able to share this before.
This included oppressive behaviour by senior staff or even, in the case of one non-English doctor, being undermined and suffering prejudice by nursing staff. They had no faith in the internal NHS complaints procedures. The very extended, demanding and ruthless process of doctors’ training and their career structure can also contribute to high levels of stress and unhappiness.
Talking all this through has clearly been very helpful to many clients. On some occasions it has even allowed them to make certain career decisions, for example changing hospitals or departments.
What if the hospital crisis seems to ease? At one point some clients seemed to be struggling with the fact that the hospital pressures were at that moment far less. The time of total nightmare was receding – while Covid rates are very high and hospital admissions are increasing, deaths are very much down. The real nightmare was two years ago for some people. So the doubt creeps in – surely things are ok now? What will people say? Do I really still need counselling? Answer: maybe very much so. The trauma often remains as a post-traumatic legacy of anxiety, jumpiness, depression and detachment.
And the doubts creeping in may connect with a pre-existing strong tendency to deny or minimise the reality of what happened. This issue needs to be explored and confronted or the really significant impact of the events will go on and on.
I hope this has been useful. Please stop here if you want to -it’s long enough already! But if you want to go a bit deeper into the background of this work....
Trauma counselling and deeper therapy? Since writing the above note, I have been discussing this in my supervision – supervision is not a part of Frontline 19 so it is with my normal therapy supervisor.
And it was therefore quite useful to realise a major difference between my ordinary work as a therapist and my work with FL19.
As an ordinary therapist – and I suspect this is true for most of the other volunteers at Frontline 19 – I am used to working with people whose main problem is CPTSD – which I believe should stand for Childhood Post Traumatic Stress Disorder. Complex (or childhood) PTSD – Adverse childhood experiences
Or even CPTSC – Childhood Post Traumatic Stress Condition – picking up on the move from simply talking pathologisingly about Autism Spectrum Disorder to Autism Spectrum Condition. That emphasises not only that we are all on the Autism Spectrum but that there can be positive aspects to some of the characteristics – especially the ability to hyperfocus. There concept of post traumatic growth connects with compassion and pride in the positive consequences of our adverse childhood experiences – ACEs – that are the origin of CPTSC.
And the challenge there is that their adverse childhood experiences have been repressed. Literally put out of consciousness. This obviously is on a sliding scale from the very earliest, pre-verbal experiences which are unreachable by talking therapies (which is why I have for years been engaged in body work for myself – yes I’m up for the humanistic self-disclosure style!) through other, later childhood experiences when the memories become gradually more factually available – although the emotional experiences crucially may not be available without considerable skill on the part of the therapist and courage on behalf of the client.
This is all in contrast to working with people for whom the trauma is relatively recent and the factual information is readily available but the repression of the emotions is also largely recent but very real.
In some senses it is more like a surface wound that has been covered up and is not healing but which will heal if it’s uncovered. That is in contrast to much earlier wounds where the infection has gone much deeper, maybe “into the bones.”
Of course there is not always such a clear distinction. People who are attracted towards the high drama and compulsive rescuing of A&E and other front line work may well be people for whom the motivation is rooted in adverse childhood experiences, although this may not be obvious to them.
I can feel the temptation to go too quickly to that aspect rather than deal with the recent traumas fully enough. And this is partly because the clients are often really eager to explore some early material and, because they have often not explored this, there are some nice low hanging fruits in terms of insights and breakthroughs with real benefits. If someone is a compulsive rescuer, especially if it is to the extent that they become a victim of that compulsion, then the Drama Triangle can be quite a valuable model. The Drama Triangle. A very useful model.
Naturally this approach is not relevant to everyone so I am becoming more careful to discuss this issue explicitly with each client and be transparent about how we work.