It is not until you look back over the last six months that you realise just how much has been transformed by COVID-19, with the way we socialise, travel and communicate all having changed beyond recognition. Its impact has undoubtedly been far-reaching. However, for those with a history of trauma, COVID-19 has brought about additional challenges, namely the wearing of face coverings.
The mandatory wearing of face coverings across settings such as shops and supermarkets, as well as within food outlets, when using public transport and accessing healthcare appointments, may, for those with an experience of trauma give rise to difficulties related to anxiety, claustrophobia, or re-traumatisation due to a forced sensory link triggering past experiences. Although there are exemptions for whom the use of a face covering will cause distress; an individual may wish to wear one, but struggle with its use.
How then does somebody with such an experience wear a face covering without triggering flashbacks or dissociation? Firstly, we need to understand trauma and the role that it plays in the wearing of face coverings.
Trauma is pervasive in our lives, from smaller situations that trigger feelings of inability and fear, to larger catastrophes that render our entire being useless as we careen out of control. The wearing of face coverings, or seeing others wear them, can for some trigger feelings of anxiety, safety, claustrophobia or a fear of feeling out of control for reasons of interpersonal trauma, domestic violence, injury or illness, or by any event (they consciously or unconsciously) perceive to be threatening.
The window of tolerance, along with the practising and use of grounding techniques can help those struggling with the wearing of face coverings in minimising or stopping periods of dissociation, flashbacks and distressing physiological symptoms of anxiety. The window of tolerance provides a visual representation of an optimum ‘zone’ whereby a person is able to most effectively function and cope with stressors and triggers. Movement outside of this ‘zone’ into either hypo or hyper-arousal increases the risk of re-traumatisation as well as disturbances to feelings, cognitions, behaviours, and physical symptoms. Having an understanding of this can help those struggling due to trauma make sense of what can often be debilitating symptoms.
Alongside an appreciation of the window of tolerance, the use of grounding techniques can help reduce and avoid the movement into hypo and hyper-arousal, feeling overwhelmed by memories, strong emotions or dissociation by helping develop an awareness of the here and now, and reduce the risk of being pulled back into memories of past trauma. Grounding techniques such as those suggested by Rape Crisis will enable professionals, and non-professional health and social care workers to work collaboratively and proactively with users of their services where the use of face coverings is mandatory but may be distressing due to an experience of trauma – and for those whom the use of face coverings is causing distress and anxiety, to practise and use the skills, and hold hope that you are not alone in the difficulties that the wearing of face coverings can cause.
For many, including those without any experience of trauma, the wearing of face coverings or masks can be unpleasant, and in such a situation the use of grounding techniques can still be of use. Being aware that colleagues, service users, peers and others around you may not – for reasons we are unaware of – be wearing a face covering, helps us move away from a belief that it is because they don’t care or aren’t taking it seriously and many other comments that the authors have heard, for even professionals can have trauma histories.
Even with an understanding and the application of skills, the wearing of face coverings for some may prove to be re-traumatising, or their use may vary. In such situations, the Hidden Disabilities Sunflower discreetly indicates to people around the wearer that they may need additional support, help, or patience. Since its launch in 2016, it has been recognised by major airports, supermarkets, railway and coach stations, the NHS and emergency services, as well as an increasing number of small and large business organisations. A ‘face-covering exempt’ card is now available (at a cost of £0.55) that indicates the wearer has a hidden disability and is therefore exempt from wearing a face covering.
As awareness increases about this scheme, it is hoped that those wearing the card are less likely to experience prejudice or discrimination based on their inability to wear a face covering.
With a predicted second wave imminent, a recent return to education and work, lifted restrictions on shielding and now the announced fining of those not wearing face coverings, the use of face coverings and their potential associated difficulties for those with an experience of trauma will remain. It is inevitable that within health and social care settings there will be individuals who may be struggling to access services, attend appointments, or leave the house due to the distress caused by the use of face coverings. Having an understanding of this, and how to support could begin to make a difference to an individual’s social, occupational functioning and experience of distress and trauma.
Trauma and its consequences are multi-faceted and unique to the individual and their experience. For the vast majority of us, the wearing of face coverings is a new experience, thrust upon us in the midst of a pandemic, which on its own has the potential to be a significant stressor.
Alison Welfare-Wilson works within the Research and Innovation Department of Kent and Medway NHS and Social Care Partnership Trust; Lenna Adley works with Service User and People Participation Department of East London NHS Foundation Trust; Zoe Bell works for East Kent Rape Crisis Centre; Rachel Luby works within the Health-Based Place of Safety at East London NHS Foundation Trust.