It was an honour to be a runner-up in the Mental Health Nurse of the Year category of the BJN Awards 2021, and I would like to share some of the work that I have been undertaking with colleagues that contributed to my nomination.
The pandemic
The wearing of face coverings in shops and supermarkets became mandatory in the UK on 24 July 2020, shortly followed by their mandated use across many sectors and settings, with the failure to comply with the law subject to financial penalties.
In the context of the COVID-19 pandemic, many of those who have experienced trauma, including but not limited to sexual violence in all its forms, may have needed to deal with the prospect of wearing a face covering as a mitigation against the transmission of COVID-19. For those who have experience of such trauma, which may have involved the covering of their nose and mouth, as well as the experience of being smothered or choked, wearing a face covering may cause not only a vivid re-experiencing of the event in the form of flashbacks, but also induce feelings of anxiety and claustrophobia.
There were exemptions in place for those for whom putting on, wearing or removing a face covering may give rise to distress. However, disclosing and communicating past experiences, most likely to strangers querying the absence of a covering, could potentially give rise to feelings of shame or judgment (MIND, 2020).
Furthermore, in the case of individuals who were exempt but wished to wear a face covering—because they considered it to be an effective means of protecting themselves and others—there could be an inability to overcome the fear of having a flashback or panic attack, which could lead to additional distress.
At the beginning of the pandemic, I began to consider how individuals with a previous experience of trauma could find the need to wear a face covering challenging. These thoughts came with the benefit of personal knowledge as I understood that, with the worsening of COVID-19 and the suggestion that face coverings would be required across multiple settings, the necessity of having my nose and mouth uncovered would be compromised in a way that I knew would give rise to anxiety and possibly re-traumatisation.
Potential challenges
Having an understanding of some of the difficulties that those with the experience of trauma could potentially face, therefore, meant that the issue of face coverings and their use became an area of growing interest for me. Around the time that I was contemplating the potential challenges around their use, I also coincidently read a Tweet related to the subject, which was a personal declaration around the difficulties caused by having to wear a face covering for travel and work.
With the knowledge that wearing face coverings was indeed something that was proving a challenge for others, I began to look online to seek information or strategies on how to make wearing face coverings less anxiety provoking. Aside from articles discussing anxiety as a consequence of wearing radiotherapy masks for the treatment of head and neck cancers, I was unable to find any literature that specifically discussed or highlighted a link between sexual violence and wearing face coverings or masks.
Collaboration
Thinking that this could become an area of concern both for individuals who had experienced trauma and for those working across all healthcare settings and professions, I contacted the author of the Tweet, Rachel Luby.
In my message, I put forward the idea of collaborating to write an article that would outline strategies to make the wearing of face coverings more manageable. Although the article that emerged was written specifically for those who had experienced trauma, there was an appreciation that it could also be of interest and relevance to those who find the wearing of face coverings uncomfortable—wearing face coverings was novel for most of the population.
To her considerable credit, in view of the fact that I was a total stranger, her response was positive. She also suggested involving a third person, Lenna Adley, who was also struggling with the use of face coverings, and who would be able to offer insights from a service-user perspective.
To round off the collaboration I made contact with the director of the East Kent Rape Crisis Centre, Zoe Bell, who was keen to become involved. What had started with an idea and a Twitter message led four strangers, from four different backgrounds, to collaborate on novel work via email during a global pandemic. The outcome of our collaboration was four pieces of work.
I had initially suggested that we should submit the article to a peer-reviewed journal. However, while it was under review, the wearing of face coverings became mandatory: as a result, a raft of positional pieces began to emerge in the UK media, with discussions around how their use was indeed re-traumatising for those who had experienced sexual violence.
Survivors were reporting that the need to wear a face covering was causing them to avoid a variety of settings for fear that they might face abuse if they declared themselves exempt from having to wear one. They feared that members of the public would assume they were not wearing a covering because they did not care, were selfish or unconcerned with their own health and safety or that of others, rather than due to the unseen consequences of past trauma (Ferguson, 2020).
Unfortunately, for those who have experienced trauma, particularly interpersonal trauma, such unsympathetic encounters with members of the public can be re-traumatising, especially when they happen against a backdrop of sudden changes in how health services are being delivered during the pandemic. As already cited, many would have difficulties accessing services and face the anxiety of cancelled appointments, as well as have their regular means of support and contact limited, or delivered in an alternative format, all of which could be yet more triggers for anxiety.
Personal narratives
With the above in mind I felt that, although there could be a place for our work in a journal, its subject and content was relevant to the situation unfolding in the pandemic. To make our work timely and more immediately accessible to those who needed it but were unlikely to access it through healthcare journals, I withdrew it from the peer review process; we self-published the work on ResearchGate and promoted it via Twitter.
The success we had was unprecedented. Within 3 hours we had in excess of 500 reads with the number increasing daily from that point on, with 4291 to date.
The strength of this first piece of work lay in the fact that it was co-produced by contributors with both personal and professional perspectives using a series of personal narratives to highlight the individual impact of wearing face coverings, and in addition sharing strategies to prevent anxiety and the recurrence of trauma that used grounding techniques.
These techniques involve the wearer looking at themselves with the covering on and reminding themselves that it is simply a covering that they are putting on and nothing else, and noticing its colour texture and design. Other suggestions for grounding incorporated the senses of sound and smell, such as listening to music or spraying a favourite scent on the fabric of the covering. We had personally developed and practised these techniques between ourselves, alongside applying Siegel's (1999) ‘window of tolerance’ to provide a means of conceptualising the cognitive, physiological, emotional and behavioural reactions that the wearing of face coverings can produce (Welfare-Wilson et al, 2020.).
Feedback
Shortly after sharing our work, we began to receive feedback from individuals who had practised our strategies. They told us that doing so had enabled them to travel on public transport, to shop, to attend appointments and, more importantly, to feel less alone in their struggles.
In addition, the strategies were adopted by helplines as a means to support survivors of all forms of sexual violence and abuse who were seeking guidance on the use of coverings and by a survivor group that was using our work as a discussion topic. In response to one piece of feedback, we produced an easy-read sheet summarising the salient points of the article, alongside the grounding techniques and the window of tolerance. Like the original piece of work this was well received.
Around this time I was also contacted by an online mental health blog, which led us to produce a shorter piece of work that was then disseminated via their website, Twitter and Facebook (Welfare-Wilson et al, 2020).
In February 2021, we published an article based on our original piece of work in a peer-reviewed journal (Welfare-Wilson et al, 2021), to provide health professionals with an understanding of how those with an experience of trauma may find the wearing of masks distressing, anxiety provoking and re-traumatising, and that this needs to be considered in the case of such individuals accessing healthcare services.
As far as I am aware, this is the first peer-reviewed article that discusses the link between the wearing of face coverings and how people who have experienced trauma may be affected.
The nature of this work has made it difficult to fully evaluate its impact. It has only been due to the kindness of individuals who have benefited from what we have produced—and who have then taken the time to make contact and let us know—that we have been able to get a sense of how valuable it has been to individuals.
I am proud to have led this work and to be collaborating with such passionate, engaged individuals. Without their contribution, this work would not have been possible.