In the wake of the coronavirus pandemic we spoke to Professor Stephen Regel, Clinical Lead at the Centre for Trauma, Resilience and Growth, part of the Nottinghamshire NHS Trust. Through his work he helps others learn to cope with the pain of loss, separation and trauma.
In the wake of the pandemic, as a society we are having to come to terms with the collective trauma of the past few months. As we move toward a ‘new normal’ we spoke to Professor Stephen Regel, Clinical Lead and the Centre for Trauma, Resilience and Growth, seeking his thoughts on how to cope as we move forward.
Professor Regel was interviewed by James Abbott for the Art of Dying Well podcast, episode 19: Lockdown, loss and pandemic trauma.
Q. Stephen you are also a Senior Psychosocial Mental Health Practitioner as well as a volunteer for the British Red Cross, you must’ve seen some sights?
A “Yes, that’s a bit of a mouthful isn’t it? My current role is very UK-based, I’ve volunteered for the Red Cross for many, many years, but this is a specific UK-based project for the British Red Cross, so whilst the title sounds very grand – I’m part of a small team of psychosocial mental health practitioners within the British Red Cross.
“We’re dotted all around the country, and deal with anything from responding to some of the major incidents we’ve had… I have colleagues, for example, who were very closely involved in supporting families and survivors after Grenfell, and over the past year or two there have been a number of house fires, the floods…. the Red Cross does a lot of crisis response work in this country.”
Q. You’ve been involved in helping people recover after terror attacks, such as the London Bridge attack… and that got me thinking about the subject of sudden, unexpected, sometimes violent loss. I hope this isn’t too difficult a question, but what are the fundamental differences in the grieving process if you lose someone unexpectedly, vs a long-term or terminal illness, where perhaps you can at least see it coming to a certain extent?
A. “As far as I’m concerned, and I’m only speaking from personal experience in the people that I’ve seen, when I say traumatic loss I’m really talking about something sudden, violent, or unexpected… though any loss is traumatic, whether it’s losing a loved one because they’re suffering from a terminal illness, or even something like COVID-19, for example. COVID-19 fits into the traumatic loss in the sense of the grieving process and the rituals that come afterwards, which often you’d be able to carry out, regardless of the loss…
“I would see the difference being, that if you have a family member or a friend, and they’re suffering from a long term illness, it’s rather like being on those trains that go across Canada; you can sit in the cars at the front and you can see the landscape around you; you can see what the topography is like; and you can see what the weather’s going to be like; and you can see things change. Ultimately you know what’s going to happen at the destination, you know what the weather is going to be like certainly, but you have that sense of expectation, you kind of know what’s coming I guess.
“With a sudden traumatic loss it’s like somebody blindfolding you and throwing you out on a dark, deserted road at night, out of the back of a truck and just leaving you. That sense of bewilderment, loneliness. And whether you’re an individual or a family it’s completely overwhelming for many people; they don’t have that ability to see into the distance.
“I often say when I talk to colleagues about how do we support people, is that I’m a passionate believer in early interventions following traumatic experiences, because I know in our service, we often see people far too late. And consequently you’re often able to do very, very little in terms of making any substantial change to people’s lives.
“The therapist’s role with somebody with a bereavement of that kind is almost to turn up with the sandwiches, the cagoule, the map, and we use this phrase that Tedeschi and Calhoun – psychologists who’ve done a lot of work in post-traumatic growth – use about ‘the expert guide’; I would call it ‘the experienced guide’.
“So I would say to people, because we’ve been travelling this road before… let’s see where we can go; we’re going to get lost sometimes and we’re going to have to backtrack; and we’re going to have to just deal with some of the new obstacles we come up against; but ultimately we’ll get you to that point at the edge of the clearing, and then I’ll give you the map, and we’ll wave each other goodbye, because it’s about navigating that course, and I think if you see people earlier on you can prepare them for the obstacles that are to come.
“For many people who are suddenly and traumatically bereaved, there’s some very practical advice such as how do you access somebody’s bank account or money; if you have a joint account, or if you don’t have a joint account?
“Sometimes the person who has died is the buffer between warring parties, sometimes in the family. Or has kept the peace, or holds the family together, and that brings up additional stresses. I read somewhere, and I think it’s so true, that families can either be healing or pathological, we’ve all been to enough weddings and funerals to know how people respond sometimes.
“Amidst all this there are so many challenges for someone who’s been traumatically bereaved, and if that person is alone, they don’t have family, it makes that journey even more challenging if they don’t have that social support.
“We know from research that social support is a really important, protective factor for when people have been through adverse life events and trauma. If it’s not there, then it’s almost a predictor of long term difficulties. It doesn’t mean to say that it always will be, and it also doesn’t mean that if somebody has social support, they’re not going to experience difficulties.”
Q. But then I guess, even if you are fortunate enough to have that support, or not, what COVID-19 is presenting to us is that disconnection, that isolation. Everyone is experiencing it differently, but now sometimes you can’t be at the hospital when someone dies, and you may not be allowed to go to the graveside because of the measures in place to stop the spread of the virus, so is that something that you can counsel people in recovery?
A. “That’s a really interesting question, because I think for me, I’ve been asked about this by some really lovely colleagues I have who work in the hospice sector, because they were concerned about this element of the loss and bereavement process. It occurred to me that they are expert at what they do and therefore actually don’t need to do anything differently; it’s about accepting that context and helping somebody to understand that context.
“I said to these colleagues you have the skills – we were on a Zoom call – and I could see them saying ‘I guess we do’. It’s about not forgetting the fundamental processes that take place in those kind of relationships, it’s just that the circumstances of the loss need to be considered. It’s about dealing with, and helping somebody to work through and process that experience.
“If you take the COVID-19 example, it’s perhaps about being preoccupied with not being there at the time, and with managing the ceremonies, rituals and the funeral, and also having to deal with all the practicalities of the loss. And because people may not be able to make sense of things at the time, they kind of open up the imaginary bag – that we all have – pile it all in, zip it up and off we go, and over time we unpack and we re-pack, and we unpack and we re-pack.
“If somebody goes along for counselling or for some therapeutic help, that’s the process that’s happening, the person is being helped to unpack and re-pack and eventually you have to get rid of things, like guilt and anger and fear, but there are certain things you have to keep. You can get rid of the experience of the event, that’s a process, and often that process is painful, I would actually liken it to emotional physiotherapy; if you break a limb it’s immobilised and then you have to through a process of recovery.
Q. Does that mean that in the early days – again I’m thinking of COVID-19, but also of your experience with extraordinary circumstances, like terror attacks. A lot of people use the word ‘closure’ when it comes to grieving, or ‘moving on’ – and you mentioned guilt as well. I guess there is something of a survivor guilt when you’re wrenched away from someone and don’t feel that you’ve had the closure of a funeral as you would’ve expected it, and the ability, perhaps, to say goodbye as you would’ve wanted to, not through an iPad or in some other artificial means. Do you get that sort of closure, given that it’s a lot harder because people probably don’t want to even start the process until they’ve got their head around what’s happened?
A. “No, like you, I’ve never really understood what ‘closure’ is… Does closure mean that you don’t think about the person? For me I always see it as coming to terms with that loss. And if somebody said to me ‘what do you mean by coming to terms with it?’ I would say being able to talk about it, able to think about it, able to revisit reminders; whatever those reminders are. There’s still going to be that element of pain and sadness. And hopefully the guilt might be significantly less.
“When a child has died, not necessarily a young child, but teenagers, and the parents say ‘I should’ve…’ all the ‘what ifs’…. I’ve often tried to help them understand there’s often no ‘what ifs’, there’s only a what is – a patient once said to me ‘the what ifs are the route to hell’ and it really struck me, so in that process of repacking and unpacking, if you like, you can minimise the guilt, so people will still get twinges of it, will still feel it. I don’t know if I’ve ever felt comfortable with the idea of closure.”
Q. I’m going to ask you a question based on the word ‘trauma’ actually, because we all trot it out, I certainly do, oh I’ve had a traumatic experience, everyone says it, whether that’s true or not. Do you class what’s happened with the COVID pandemic as a sort of collective traumatic experience, is it a trauma so-to-speak?
A. “I would guess it is. I think you only have to look at the faces of the frontline staff, people who are bereaved, people who have had a loss as a result of this, people who are struggling because of the economic impact of this, and to lose your job is traumatic, I mean it’s not traumatic in the sense of the diagnostic label of post-traumatic stress disorder, but it has a significant impact which will really disorient people in terms of their own mental health and their journey though this experience.
“For example, we know that employment is good for mental health, and if you don’t have it and people have either lost their job or their income or their earnings, they have to struggle in all sorts of ways. People have the challenges of schooling kids at home, I also know people with children with special needs for example, who’ve struggled throughout this, so I think if you use trauma in the general sense – because I think for me it’s all about the meaning of the experience – what does this mean for you at this particular time? So trauma, often in terms of how we perceive it, is about the meaning of the event, because it will mean different things to different people.”
Q. I’m thinking to go back to your really visual analogy before, if we see a person who has a blindfold and has literally been chucked out the back of a van in the pouring rain, and we’re the one who comes across them, how do we help them? Is there a toolkit or perhaps three things you can do to help someone who is suddenly bereft in that way?
A. “I would say you first of all take off the blindfold and I think be realistic with people about the challenges that are to come. I’m a really firm believer in being very, very honest with the people we see, about what we can and what we can’t do. So, take off the blindfold, talk about some of the realities and the challenges, but then actually be there with them through the realities and challenges that they have to face, and it’s the idea of being that ‘experienced guide’; staying with somebody and seeing them through those early challenges, and kind of highlighting things that are going to be ahead, you so take off the blindfold, be realistic about it, and offer some direction, show them what the map is like, what the landscape is like, and help them to walk through that, but in a very structured way.
“I’m very active so if it means writing to the school, or the employer, to say look I think that this person actually needs a little more time off or they need special measures to return to their workplace, for example, then I will do that. So I think to be much more active in terms of our guiding, if you like, in that respect, and that may not sit comfortably with a lot of people who work therapeutically, but it depends on your model, and what you believe. I think particularly with loss and grief, and with this sudden loss, it’s really important.”
Q. And then finally, who cares for the carers? Because you have mentioned some of the staff who look worn out and exhausted, shaking at the end of a shift knowing they’ve got to go back in the next day or for the next shift… Who cares for them?
A. “I don’t think we do enough caring for carers, I think there’s a lot of talk about it, within the last few months I’ve seen a plethora of guidance coming out from the mental health community, about what everybody should be doing, and ought to be doing, and I appreciate that we’re playing catch up in some degree, but I think that it’s woken people up to the fact that actually people need to have something in place to care for people, or to support people, doing extremely difficult jobs.
“I think they’ve had the volume they’ve never had to deal with as a rule. I think if you look at the police force for example, and the fire service, it’s not been consistent but often they’ve had post incident support for people who’ve done those emergency service roles, and certainly they’ve introduced peer support roles – the ambulance service over in Northern Ireland have been doing it, and some mental health trusts and some general hospitals may have it, but it’s not universal. I think these things need to be put in place, and we need to pay more than lip service to them.”
Read more about dealing with bereavement and grief.
Professor Stephen Regel was interviewed for the Art of Dying Well podcast, episode 19: Lockdown, loss and pandemic trauma.