In Mindcast

Andrew Cooper – the impact of living and working with death

Andrew Cooper is a Family Therapist and a Professor of Social Work at the Tavistock and Portman NHS Foundation Trust. Andrew talks about one of the most difficult things that any of us face in the current situation, the impact of living and working with death, a particular challenge with COVID-19 even for very experienced NHS and social care staff. He brings some thoughts together about what can make our contact with death in this context so hard, and has some suggestions and practical examples of what can work well in trying to look after ourselves and each other when facing the emotional labour of caring for those at the end of their life.

Wellbeing Quiz Profile: #FeelingHopeless #RelivingTrauma

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Hello, my name is Andrew Cooper and I work at the Tavistock and Portman as a Family Therapist and I’m Professor of social work. I’m going to speak about some of the challenges of working with death and with dying people, and some possible ways of helping ourselves with this very demanding task.

In this crisis many more NHS and social care staff find themselves caring for dying patients or are in the situation with unprecedented regularity and intensity. Increasingly, because of isolation procedures, nurses and doctors are alone with people at the moment of their deaths. Families and loved ones are excluded – on the outside looking in. You may be acutely aware of their grief and anguish. Staff are fearful for themselves and for their own families. Professionalism and a sense of duty spurs people on, while the instinct of self-preservation pulls strongly in the opposite direction.

You may want to move towards the dangerous situation and simultaneously flee from it. This conflict can cause huge anxiety, to act on all the other anxieties. Most of you will have suffered the loss of someone close to you at least once in your life. A family member or friend may be very ill right now whether from Covid-19 or another illness. Working in close contact with dying people stirs up these memories even if the pressures of the job mean you hardly have time to think about them – if a patient dies, but you have to move on to the next emergency. Your feelings for the dying person in front of you can become mixed up with your own grief and anxiety about loved ones. This is normal, but immensely stressful. It can feel somehow selfish to be preoccupied with your own losses and fears when you’re supposed to be caring for others. It isn’t selfish, it’s ordinary.

I myself had an uncle I never met because as a young man he was killed in the Second World War, but my mother told me stories about him, while his brother; my father, never spoke of him. Somewhere the grief about his loss passed into me and is still alive. Many of us carry these ghosts inside us and they can come to life in the face of our work with dying people. Will all tend to carry around an idea of what a good death might be like. Whatever that is, your experiences at present will be far removed from this image or ideal. That’s hard to bear in itself and in these pressurised circumstances, when a patient dies you may be left with painful questions: did I do enough? Make the right decisions? Give them enough at the very end of life? Sometimes these thoughts collect in a very difficult way: did I in effect kill this patient? We may know such thoughts are not rational but they can still be very real in our minds.

My colleague Jo Stubley made another podcast in the series about trauma. Most of what she says is completely relevant to you if you’re working with dying people, or people you’re afraid might die. The same situation affects different people differently. You may hardly have had time to get to know many patients, or they are sedated, but something about a particular person can still trigger powerful memories and feelings, and unexpected grief wells up in you when you are working under these exceptional conditions day after day. If you don’t find some release for these feelings they accumulate into what Jo Stubley calls cumulative trauma.

So, what can you do to look after yourself and your colleagues? Letting yourself feel and think when you’re having to work so relentlessly can feel risky. You may worry you’ll fall apart and not be able to function, so you might want to pick your time and place to let yourself slow down and allow some feelings to surface. Most people will find it a relief and feel a bit stronger afterwards.

in some acute assessment wards where patients often die, but the throughput of work is relentless, a team working with the patient who dies do something called ‘the pause’: they stop and take two minutes together to remember this was someone’s daughter, mother, son, partner, friend. But also to remember how hard they themselves worked to try to save the patient. You might try this but if not, you can find a trusted colleague and take some time with them to share your feelings from the shift: fear and anxiety, distress, grief, guilt, anger.

Closeness to death and dying frightens us and makes us want to weep. It’s the most normal reaction in the world but as the saying goes, we need a shoulder to cry on. If you can trust someone else to receive your distress and also offer them some time and understanding, this can be hugely helpful. An honest recognition of what you’re facing together is a bond and to get through this terribly difficult time, strong bonds with colleagues are vital. We are assailed by images of the crisis in the media. I remember one: an exhausted hospital worker sitting on the pavement, head in his hands, being comforted by standing colleague who has her hand on his shoulder. But lastly if these approaches don’t work here or there is just no time, and you feel the pain and distress rising up in you, then a few moments of steady deep breathing will probably settle you, calm your mind and body.

There is no magic solution for the stress of what people are doing when working so close to death and dying. whatever ways you find help yourself, it’s so important to remember that everyone is finding it just as difficult, although each in their own way to some extent. In all this there are moments of hope and success. Some patients recover and can be discharged. You feel you did as good a job as possible in breaking the bad news to a patient’s family. Colleagues thanks you for your support and understanding. It is important to hold onto these moments because they can be wiped out by the overwhelming demands of the art of our task. Everyone in the caring system may be touched by some or all of what I’ve spoken about: porters, cleaners, administrators, managers. Remember one another, everyone has their part to play and is vital to the overall effort. Reaching out to others when you sense distress and being open to others when they offer you something are the best route to getting through and being able to carry on doing your best for the patients and their families.

In Mindcast

Lorna Fortune – the value of Psychological First Aid

Lorna Fortune is the Lead Psychologist for Psychiatric Liaison Services in Barnet, Enfield and Haringey Mental Health NHS Trust. Here Lorna speaks about the value of Psychological First Aid (PFA) in this time of crisis, particularly for those of you working in acute settings providing physical care. A brief introduction to PFA is provided, the goal of which is to help stabilise and mitigate distress by supporting people in the midst of a crisis situation.

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Hello, my name is Lorna Fortune and I’m the Lead Psychologist for Psychiatric Liaison Services in Barnet, Enfield and Haringey Mental Health NHS Trust and I’ve been working with the acute trust to think about how we support our physical health professionals through this crisis period.

So, I’m going to talk about Psychological First Aid. At the moment our physical health colleagues are working in extreme conditions with very high numbers of very unwell patients, with services and resources stretched in ways we’ve never seen before. So, we’ve looked at what’s helped in other countries who’ve been through similar situations and the evidence suggests that Psychological First Aid is a helpful and useful approach for our frontline staff.

Psychological First Aid or PFA provides a compassionate and supportive presence, designed to help support people in the midst of a crisis situation, by helping to stabilise them and mitigate acute stress and assess if there’s a need for continued mental health care. Psychological First Aid uses quite simple yet powerful principles to help people build support and containment within teams.

It’s worth noting that this model largely uses skills that our health professionals will already have. It’s quite an ordinary way of talking to people that optimises their existing communication and interpersonal skills. However, at times like this, teams can benefit from additional training and support in providing PFA as this will give them an opportunity to think about, practice and build upon their existing communication and interpersonal skills so that they feel more ready and confident in supporting their colleagues.

It’s worth saying that PFA is different to counselling and psychotherapy. The goal of PFA is to help stabilise and mitigate distress, rather than provide long term personal growth. PFA can be provided by almost anyone and it’s usually best provided by people within the existing team as this will help to build on and further develop existing team relationships and support.

So, what does PFA look like? It’s quite a simple model, it can be used quickly to increase connection and reduce stress. There are some basic steps. First of all, it’s noticing when colleagues are struggling or in emotional distress, prioritising them, offering them support. An important part of the support is taking time to listen and to respond, understanding and validating that person’s experiences and reactions. And then its about thinking about how to think through with them what might help and what can be done to help stabilise their emotions in the moment and think together about how they can build their existing coping skills. Also, PFA is not a once only intervention, but it’s an ongoing process that can be bedded into the team culture and structures, helping teams to be mindful of each other, the impact of this situation and feel more confident in supporting each other.

Often in these situations people feel like they’re not doing enough or not making a difference, so I want to remind you that being there for your colleagues, noticing when they are struggling and offering them support by listening and helping them through, can make a very big difference too. It might seem like a small thing, but it can have a significant impact, by helping us work together, connect with each other and look after each other.

In Mindcast

Nicky Lambert – navigating your way as a student nurse

Nicky Lambert is an Associate Professor (Practice) at Middlesex University, where she is Director of Teaching and Learning for Mental Health and Social Work. She is registered as a Specialist Practitioner and is a Senior Teaching Fellow She is also a co-director of the Centre for Coproduction in Mental Health and Social Care. Here Nicky talks directly to student nurses as they navigate their way through their training during the Coronavirus outbreak.

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Hello there, my name is Nicky Lambert. I’ve been asked to put together a few thoughts for student nurses at this very strange time that we are going through. I think when you start a course as a student nurse you assume that things will smoothly go ahead, you’ll go from module to module, placement to placement, and you’ll come out the end and you’ll have received your goal. One of the really interesting, exciting, scary, fabulous, weird things about nursing is that you can’t predict what will happen. No two days are the same and certainly no nursing journey, no learning journeys, is the same.

I think what I wanted to say to you was a story that I heard when I was a student nurse, and it was something that really stuck with me and it was about the anthropologist Margaret Mead being asked what she thought were the first signs of civilisation in the culture. I think people assume you’re going to talk about wars or axes or clay pots, and what she said was the first sign of civilisation in ancient culture was a broken leg that you could see had healed and she was saying in any situation if an animal breaks its leg, it can’t get food, it can’t hunt and an animal just doesn’t survive a broken leg usually long enough for the bone to heal.

What Margaret Mead was saying was that a broken femur that healed is evidence that somebody was there with that person, somebody stayed with them, somebody picked them up when they fell, carried them to safety, tended them, helped them to get recovered. Helping someone else through difficulties is where civilisation starts, that’s where we are at the moment. We are certainly in a difficult situation, not easy to see how it will turn out at the moment, there will be lots of changes.

The learning journey that we thought we were all on is probably going to be quite different and it’s an opportunity to grow and learn and more importantly it’s an opportunity for us to be together.

So the reason you want to be a nurse, to help other people, to serve the public, to be part of a team, all those things are still same. I think when I first started as a nurse I wanted to learn and grow and be challenged and certainly that’s what these times are bringing us.

So just a few thoughts for you. One is: prioritise your own self-care, make sure you’re rested, make sure you’re eating properly and prioritise your family and your loved ones. You can’t keep drawing on your resources if you don’t have any, so treat yourself with the compassion and respect that you treat the public and that that will help you going through this time.

Also be aware that your colleagues are there for you, your lecturers in college and your peers and even service users and the public will be there to support you. You are doing a really important job, at a very difficult time, people recognise that and I think nurses, your colleagues, really respect you stepping up. If it’s something that you can’t do, if you can’t step up through health issues and through family issues, the other thing I would say is please don’t feel bad. That’s the reason we work as a team, we each have a time and a place to act. This is a long, long game. Do what you can. Support others where you can and step back when you need, to that’s why there’s so many of us and that’s why we stand together. So I hope that’s helped and I would say as well is – thank you.

In Mindcast

Rachel Surtees – understanding your role during this time of crisis

Rachel Surtees is the director of strategy at the Tavistock and Portman NHS Foundation Trust. Rachel speaks to the many health and social care staff who are in corporate or support service roles, who may be finding it difficult to understand their roles during this time of crisis.  

Wellbeing Quiz Profile: #MoreFrantic

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Hi, I’m Rachel Surtees, I’m Director of Strategy and Transformation at the Tavistock and Portman. In my normal job I spend much of my time thinking about and planning for the future, but things don’t feel very normal for any of us right now and I don’t know if it’s the same for you but my concept of time has become pretty distorted so long-term planning right now, feels a bit more like thinking about what might be happening in three hours’ time rather than three months’ time.

But the long-term still matters. We will get through this pandemic and when we do our hospitals and organisations will all need to return to normality so that we can continue to care for our patients and vulnerable adults and children who depend on our services.

One of the really important principles of NCL In Mind is that everybody matters. Our doctors, nurses, receptionists, administrators, cleaners, porters, and everybody else whose roles means that they are really at the face of this thing are doing an incredible job and we are all very grateful. But there are also a huge number of other health and social care staff in more corporate facing roles and your jobs are also still important and your well-being matters and is being thought of too.

Computers still need to be fixed, staff still need to be paid, invoices still need to be raised and all these other hundreds of daily tasks that keep organisations running, still need to happen.

I know from talking to my own teams, who I manage, who are in corporate roles, that this feels like a really complicated and difficult time. They want to help, but just like everybody else fill a bit daunted about stepping into the unknown. They also want to try and keep their day jobs going because they know that is one of the ways to limit the long-term damage of this pandemic, but they are worried about bothering people who are busy dealing with today’s priorities.

There’s no easy answer, but if you’re in a corporate or support service role and have been asked and are able to do other things, that’s great. No-one expects you to be an expert overnight, so do your best, be clear about what is being asked of you and ask for help if you need it. And crucially, stay in regular contact with your core team. Staying connected is one of the very best things that you can be doing right now to look after your wellbeing.

And for those of you who are still plugging away at your day jobs, keep going and thank you. The way that we can help those who are really feeling the heat of this virus is to keep everything else running as smoothly as possible. You may need to adapt how you’re working, I’m sure you already have, but be available, be kind and stay in touch with colleagues.

You can use the NCL In Mind webpage to tell us what you struggling, or what you’d like to hear podcasts on, and we’ll do our best to get helpful content up and online as quickly as we can.

In Mindcast

Paul Dugmore – working in children’s social care and looking after ourselves

Paul Dugmore, Consultant Social Worker at the Tavistock and Portman NHS Foundation Trust. Paul speaks to those of us working in children’s social care, and how we can manage and look after ourselves as well as others, during these very difficult times.

Wellbeing Quiz Profile: #MoreFrantic

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My name is Paul Dugmore and I am a Consultant Social Worker at the Tavistock and Portman NHS Foundation Trust. This podcast is about how those of us working in children’s social care can manage and look after ourselves as well as others during these very difficult times. There is rightly lots of focus on the NHS and our colleagues who are really on the front line in tackling the coronavirus pandemic, but it’s also important to recognise the essential and invaluable role that social care plays in helping the hundreds of thousands of children and families affected in different ways or worsened by the current situation.

I want to acknowledge the many challenges you may be facing as a social care worker within the system and the likelihood of you absorbing lots of professional anxiety about issues such as safeguarding, and worries about vulnerable children not being in school, compounded by the global anxiety about COVID-19 in the recent lockdown.

There is to, the added complexity for social care workers in navigating whose needs to prioritise: your own; your children’s; your family and friends; as well as the children and families you work with; the needs of your organisation and colleagues who might be unable to work. Within all of this there will be a mixture of emotions, perhaps conflicting, such as compassion and worry, anger and guilt, which can feel overwhelming at time. There is no right way to deal with the challenges we’re up against, but having time and space to think about how you may be feeling, and what some of these things mean can be helpful.

So, within this context I just want to offer some tips for coping with all of this, and the continuing importance of relationships, which can feel difficult to prioritise especially when our usual opportunities for making connections may not be there. Work meetings may still be an option, face-to-face or via video or telephone conferencing. In the absence of this it’s really important to maintain contact so picking up the phone and checking in on your colleagues is really important. Being able to share experiences and offload and talk about some of your difficult feelings are helpful ways of bearing the load. In the absence of normal working practices, the types of concerns we might have about a child or family don’t diminish, so is more important than ever to connect with colleagues in the wider professional network, to talk things through so you’re not holding onto things and making decisions by yourself.

If you’re needing to stay-at-home because you all your family are self-isolating, this can make you feel more disconnected from others so making the most of social media messaging, phone and video calling are all good ways of keeping connected and you might want to be creative in how you connect online.

If you’re remote working in these strange new times, the importance of keeping a routine and boundaries around work and home life is even more important now in order to look after yourself and those around you.

Checking in and out – consciously identifying a list of who your consistent supports are and planning in a 10 minute check with someone at the beginning of the day to say what you hope to achieve today in terms of work and self-care, and someone at the end of the day to sign up with.

Who’s looking after you – remember the importance of supervision with your manager or supervisor and if their absence someone else with appropriate responsibility in your organisation.

Pace – breaking tasks into smaller chunks so not doing anything for longer than an hour. Taking a five-minute pause at the end of each task and concentrating on your breathing, a ten second meditation when you’re sitting up straight with your feet on the ground, breathing in for four seconds and out for six. Do this every hour and keep hydrated, drinking a glass of water regularly.

Kindness can’t be underestimated – think about how to be kind to yourself and manage your own expectations of what you can achieve in a working day. Recognise that this might be less than usual due to the emotional landscape of the current climate.

Appreciating your colleagues – everyone will be dealing with this in their own way which might be different to yours; showing compassion and empathy to yourself and others and finally ending the day by doing something positive that makes you feel good.

In Mindcast

Dr Jo Stubley – Introduction to Trauma and the Current Pandemic

Dr Jo Stubley, Consultant Medical Psychotherapist, Psychoanalyst and Lead Clinician for the Tavistock Trauma Service. Here Jo presents a brief introduction to trauma in relation to the current pandemic.

Wellbeing Quiz Profile: #RelivingTrauma

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Hello my name is Jo Stubley, I am a Psychiatrist and Psychoanalyst and I run the Tavistock Trauma Service. I am aware in these difficult times that many NHS frontline staff may well be experiencing a number of traumatic events, and I thought it might be helpful to say a little bit about that today.

So what do I mean when I’m talking about this idea of trauma? Well I think at the heart of this is an experience of helplessness, and that can be really difficult for NHS staff who are used to doing the things, not to feeling helpless. I think the other aspect of trauma is that it is often something that is overwhelming, so that our usual ways of coping no longer work. Now that might be a single episode of something terrible happening, either that you witness or that you are involved in, or sometimes it can even just be something that you hear about. Trauma though can also be cumulative, so it may be something that small but significant episodes build up over time. What is traumatic for one person may not be so traumatic for the other, it is often a combination of that particular moment for that person, with their history and if we have a lot of trauma or difficult losses in our background, that may make us somewhat more likely to develop some symptoms after a traumatic event. It might also be that trauma occurring now can link up with these earlier experiences and one might find that earlier losses or traumas get brought to the forefront of one’s mind again.

So, in relation to thinking about the kinds of symptoms that you might have having had something traumatic happen. First of all I want to say that it is very normal after something traumatic occurs to have a number of symptoms that are not part of a mental health issue, they are a normal response to an abnormal event and for the majority of people will settle over time, particularly if one is able to use self-care and the supports that are around. The sorts of things that we find might get activated after a traumatic event come under three main headings:

  1. The first we might call anxiety or hyper-arousal. This is like the fight-flight response; a threat is perceived and one has something activated inside in terms of our body’s response to threat that keeps happening, so you can feel agitated, distressed, find it difficult to sleep, might have moments of real panic. These are the kind of symptoms of anxiety and hyper-arousal.
  2. The second type is those of re-experiencing symptoms, the reliving of the traumatic experience which might be intrusive images that come to mind, it might be intrusive thoughts, it could be nightmares or even flashbacks, where one relives over again what is happening and these things are often triggered by something in the environment that reminds us of the event, quite often it is smells that are particularly powerful for that.
  3. The third type is avoidance and numbing, and it is a way that we kind of shut down a bit, we don’t feel as much, we may not wish to talk to people, we may wish to avoid having interactions or even going back to work, and that is often a way of trying to shut down these symptoms, not get triggered, not feel so over aroused but can be problematic if one feels too much like we want to avoid.

Now all of these symptoms are normal, they are the kinds of things that over time will settle, but it is important to think about what can be done in the meantime. The first thing to say is that all of the evidence suggests that people recover from this much more easily if they feel they have a good social network around them. Now I am aware that that means at the moment we have to work particularly hard to hold on to that because it mainly has to be virtual, but it does stress the importance of keeping our connections in this difficult time. The other thing that is really important is to think about basic areas of self-care; diet, exercise, as much sleep as possible, not using alcohol, prescription or illicit drugs to try and manage these things, the kinds of basics that are really important to come back to.

We will be talking more about how to think about trauma but I hope that this brief start is something that can be helpful for you, thank you.

In Mindcast

Lydia Hartland-Rowe – difficult decisions and emotions during the outbreak

Lydia Hartland-Rowe is a Consultant Child and Adolescent Psychotherapist and Portfolio Manager for Psychological Therapies for the Tavistock and Portman NHS Foundation Trust. Here Lydia talks about the difficult decisions we are making as a health and social care worker during Coronavirus outbreak and the emotions this may trigger

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“Well this is a time that isn’t like anything else I think any of us can remember working in the NHS and social care, and this is the first of what we hope will be frequent and relevant short podcasts that come from staff across the North Central London STP, really just aimed at providing each other with the contact and support and ideas that will help us to be able to come back tomorrow at the end of today.

My name is Lydia Hartland-Rowe and I’m the Clinical Lead for a Workplace Mental Health and Well-being project that we have at the Tavistock, and I’m really just speaking now with a few thoughts just to get us started. These are things that I’m aware from contacts, professional colleagues, friends, family, that are on people’s minds in relation to the work that we are all needing to do as part of the NHS and social care workforce.

There are three parts to this and they are connected, and in a way they’re all to do with the first thing which is the difficult decisions that the COVID-19 situation is forcing us all to make and to find a way to feel okay about. The decisions range from; the decision to, if you have a choice, to be working remotely, the decision to visit elderly relatives, the decision to send your children to school or not given your position as an NHS worker. So every decision that we are faced with making, even on that level, feels like it has an impact on other people and of course for some people those difficult decisions will be acute, painful, professional decisions that have to do with providing care for others. Of course some members of the workforce are very used to making decisions of that kind every day, anyone working in acute services where life and death are around are used to making those sorts of decisions, but possibly not with the frequency, possibly not with the sort of heavy constant public scrutiny and public awareness of what’s going on, and not in the context of something that is happening simultaneously all over the world so it adds a weight to decisions that may normally feel like they’re part of ordinary professional life.

Of course for people returning to the frontline or perhaps being exposed to the frontline in a way that has not been encountered before, the need to make those decisions and to find a way to manage them and balance them internally is an additional challenge. One of the things that perhaps is around for all of us, in all sorts of ways, from you know the question of whether you visit your mother on Mother’s Day, to a really difficult decision about who gets a ventilator, is something to do with the guilt that is around for many of us, potentially, and the disabling nature of guilt and the isolating nature of guilt, so that very often, you know one can feel as if the guilt that we feel about the decisions we are having to make at the moment kind of needs to be kept private or that we need to be keeping ourselves to ourselves, and I guess one of the things that we’re certainly finding where I work and that I’m hearing and seeing partly in the sort of proliferation of all the stuff that is coming out on the internet is that actually it is our connections with each other, the groups that we create, whether they are virtual or real, those human contacts and the places where we can talk openly about what we’re experiencing, you know what we need from each other, that those connections are probably more important now than ever have been.”