Good Grief

The world has changed. We cannot go back to where we were, nor continue to head in the same direction we were set upon before this crisis. But that is easier said than done and will be impossible if we do not embrace the grief of what we are journeying through together. There has been and continues to be painful loss. We have lost dear friends, family members, neighbours and colleagues. We have lost jobs, income, holidays and social gatherings. We have missed births and birthdays, key social events, final goodbyes and funerals. We are bereaved of whole ways of behaving – our ways of life, everything we’ve known has been entirely interrupted.

 

For me, as a type 7 on the Enneagram, it’s all too easy to engage in the future, to think about the ‘what next?’, to avoid the pain of the here and now, by letting my imagination run wild of what the world might be like instead. But we cannot and must not miss the vital part of our current journey, which is to recognise, embrace and partake in the grieving process. Grief is not comfortable, it is not easy, it is not enjoyable – in fact it is both tumultuous and painful…..but it is good. Refusing to enter into it, or trying to suppress it, will only lead to a deepening of the trauma and a delay of this inevitable experience.

 

The thing about grief is that it is unpredictable and what makes it even more so in this current experience is that it is both personal and corporate. However, the cycle of grief is well known and although each of us will go through the cycle differently, it’s worth recognising where in the cycle we might be, both as individuals and as a wider community/society.


This is the classic ‘grief cycle’ (I’ve borrowed the graphic from psychcentral.com) and it demonstrates well how the experience of grief is neither straightforward nor easy. However, psychologists agree that each of us will pass through each of these phases, no matter how briefly – though we can remain stuck in some areas for quite some time.

 

The isolation of this time has been the starting place for most of us. For some that was coupled with an acceptance that we are where we are, but for others there was a denial that this could be real and a refusal to engage with the idea of social distancing (although with police enforcement, this quickly began to change!).

 

The anger phase is clearly present for many at the moment, and understandably so. Anger is not wrong, it’s how we respond to it that becomes the issue. Sadly, in many households we’re seeing a rise in Domestic Violence , particularly towards women and children and this is something we need to take really seriously. Learning to control our anger and find a positive outlet for it is absolutely key. There are all kinds of online resources to help with this, but the deep cuts to social services and policing over recent years have made it difficult to work with families in a more proactive way. The Violence Reduction Unit in Lancashire, led by Detective Chief Superintendent Sue Clarke, who is a brilliant leader,  have done some incredible work in this area over the past couple of years, which is well worth learning from. The approach is much more productive than traditional methods of dealing with this issue and involves being with families more proactively to bring restoration and redemption into broken situations.

 

We’re also seeing the rise of a corporate anger. Tony Blair stated the other day that this is the most difficult time to contemplate being in government, and it’s true that we are in unprecedented times, but he feels our response nationally was slow. However, many feel that more serious questions, now being asked across the media spectrum, still need an answer:

 

These are all important questions that require an answer. Anger can be used to facilitate the right kind of conversations to bring challenge to the status quo and demand that it never leads us here again. The outcomes we are seeing were not inevitable – so what will we learn? What will be different? How will we change? If people in positions of power are willing to own up to mistakes, are we willing to forgive? I hope so…..how do we rebuild society otherwise? We must be able to learn and change our ways. It’s at the heart of what it means to love. But we must also recognise that some of this anger is simply part of the grief cycle and there may be no answers. We’re angry in part, because we are grieving. Sometimes our anger brings challenge and change, but sometimes we yell into the night and are met with silence.

 

Depression in grief can become clinical depression, but the word, in the context of grief, more describes a sense of deep sadness, loss, numbness, apathy and is often accompanied by tears. We must not try and keep a stiff upper lip, or push this away. Some of us will feel this more acutely than others, depending on our personality type, but this is a vitally important part of the process. This deep sadness can catch us unawares. It can come almost out of nowhere and we can find ourselves having a good cry in the bath or struggling to find the motivation to get out of bed of a morning. Talking about these feelings is absolutely vital, and it’s important that those of us who listen, ensure that the person experiencing these emotions feels heard. They don’t need fixing. They need validating. They need to know it’s OK to feel like this. We can’t just wish it away or get back on with things. There is a certain wallowing in this place that is extremely healthy and right. It’s true, we don’t want to get stuck here, and by putting some positive measures in place, like exercising, eating well, mindfulness and keeping a positive sense of routine, we can avoid becoming more mentally unwell. However, we must not try and rush through this phase or refuse to embrace the pain of it.  But this can become a very dark experience and some people will wonder if life is even worth living. We can find ourselves asking searching questions: Can we really go on without our loved one? Will we ever get through the brokenness of this current situation, when we have lost so much? If this becomes overwhelming or there are serious thoughts of not wanting to carry on with life, this is where therapeutic interventions or medical treatment in the form of medication can be really important and literally life-saving.

 

At a corporate level, we share a sadness that 20000 people in the UK and 200000 people globally have lost their lives so far, due to COVID-19 – and that is just the recorded deaths. We will potentially feel lost that a whole way of being together is no longer possible, nor perhaps, desired. The artists will help us the most here. Songwriters, painters, choreographers and playwrights. Are we mature enough to embrace the songs and dances of lament? DO we know how to do this?

 

Bargaining is about us trying to begin to formulate some meaning or sense of what has happened/is happening. We might find that we want to talk about our experiences more, tell our stories, reach out to others and explore some of the ‘why’ questions we’re wrestling with. We might find we start ‘big conversations’ with God or ‘the universe’ – some thing like – ‘if you help me get my job back, then I’ll live a good life from now on’ or we might find we’re dealing with several regrets in our interactions or relationship with the person we have lost.

 

Acceptance is about realising that we are where we are and we cannot change a thing. It allows us to breathe deeply into the reality of the horrors we have walked through and begin to face into the future. Some people think of the grief cycle as more like a river with the grief cycle being a whirlpool that we get stuck in for a while. We go round and round, but eventually we come out the other side. On a personal level, perhaps, before we entered the whirlpool, we had a dearly loved one in our boat with us and we entered this whirlpool once that person became sick or was no longer in the boat with us, because they had died. The whirlpool can feel overwhelmingly difficult, with the stages above. We come out of the whirlpool with an acceptance that this dearly loved person is no longer in the boat with us….but there are other boats that we travel alongside, and perhaps there are others who still remain in our boat. We must now learn to live in this boat, without the person who was with us before but knowing we can face the future with our other companions. At a corporate level, this is about us sense making that the future cannot be like the past. Things have fundamentally changed. We cannot go back to how things were and so together we can build an altogether fairer and kinder future for our global population and the planet we inhabit together. This becomes what some refer to as the 6th stage of grief – ‘Meaning’. We begin to make sense of what we have journeyed through and use it to transform our experience of the world and how we want to live in it. My next blog will explore some of the meaning we may find the other side of COVID-19.

 

Whatever your experience of grief at this time, embrace it and talk about it, but don’t try and hurry it away. Good grief is a part of life and enables to process our loss, feel our pain, heal our wounds, accept our scars and find a new future. The ‘Good Grief’ movement is something I would really recommend exploring, especially if you are struggling to process your own grief. There is also lots of mental health support available through your local GP or online via nhs.uk. Grieving allows us not only to engage with the pain we are going through, but allows us to let go, so that we can reset and rediscover a way forward together. It’s impossible to walk through it alone, which is why as the city of Liverpool reminds us in the amazing song, sung at Anfield, friendship is everything.

 

 

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Changing the Future of Adverse Childhood Experiences

Applying a Population Health Approach to Adverse Childhood Experiences

 

Adverse Childhood Experiences are one of our most important Population Health issues due to their long lasting impact on the physical, mental and emotional health and wellbeing of a person and indeed the wider community. It is therefore really important that we apply a ‘population health’ approach in our thinking about them so that we can begin to transform the future together. This is an area of great complexity with several contributing factors and will take significant partnership across all levels of government, public bodies, organisations and communities to bring about a lasting change. There are things we can do immediately and things that will take longer, but with a growing awareness of just what a significant impact ACEs are having on our society, we must act together to do something now. Here in Morecambe Bay, we have developed a way of thinking about Population Health in what we call our ‘Pentagon Approach’. It can be applied to ACEs as a helpful framework for thinking about how we begin to turn this tide and cut out this cancer from our society and feeds into the already great work being done across Lancashire and South Cumbria, lead by Dr Arif Rajpura and Dr Helen Lowey, who have spearheaded so much!

 

Prevent

 

When we examine the list of things that pertain to ACEs (see previous https://reimagininghealth.com/facing-our-past-finding-a-better-future/ blog), it is easy to feel overwhelmed and put it into the ‘too hard to do’ box. This is no longer an option for us. We must begin to think radically at a societal level about how we prevent ACEs from happening in the first place (recognising that some ACEs are more possible to prevent than others). Prevention will entail a mixture of community grass-roots initiatives, changes in policy and a re-prioritisation of commissioning decisions for us to make a difference together. Here are some practical suggestions:

 

  • The first step is most certainly to break down the taboo of the subject and continue to raise awareness of just how common ACEs are and how utterly devastating they are for human flourishing. ACE aware training is therefore vital as part of all statutory safeguarding training.
  • We have to tackle health inequality and inequality in our society. ACEs, although common across the social spectrum are more common in areas of poverty. Although we now have more people in work, many people are not being paid a living wage, work settings are not necessarily healthy and child poverty has actually increased over the last 5 years in our most deprived areas https://www.jrf.org.uk/blog/poverty-taking-hold-families-what-can-we-do.
  • Parenting Classes should be introduced at High School in Personal and Social Education Classes to help the next generation think about what it would mean to be a good parent. These should also form an important part of antenatal and post-natal care, with further classes available in the community for each stage of a child’s development. Extra support is needed for the parents of children with special developmental or educational needs due to the increased stress levels involved.
  • There needs to be a particular focus on fatherhood and encouraging young men to think about what it means to father children. Recent papers have demonstrated just how important the role of a father can be (positive or negative) in a child’s life and it is not acceptable for the parenting role to fall solely to the mother. www.eani.org.uk/_resources/assets/attachment/full/0/55028.pdf
  • We have much to learn from the ‘recovery community’ about how to work effectively with families caught in cycles of addiction from alcohol or drugs. Finding a more positive approach to keeping families together whilst helping those caught in addictive behaviour to take responsibility for their parenting or learn more positive styles of parenting, whilst helping to build support and resilience for the children involved is really important.
  • We must ensure that our social services are adequately funded and that there is continuity and consistency in the people working with any given family, especially around the area of mental health. Relationships are absolutely key in bringing supportive change and we must breathe this back into our welfare state.
  • Hilary Cottam writes powerfully in her book, Radical Help that we must foster the capabilities of local communities, making local connections and “above all, relationships”. As Cottam states, “The welfare state is incapable of ‘fixing’ this, but it has an important role to play. It can catch us when we fall, but it cannot give us flight.
  • Sex education in schools needs to be more open and honest about the realities of paedophilia and developing sexual desire. Elizabeth Letourneau argues powerfully that paedophilia is preventable not inevitable. We must break open this taboo and start talking to our teenagers about it. (https://www.tedmed.com/talks/show?id=620399&utm_source=rss&utm_medium=rss)

 

Detect

 

If we want to make a real difference to ACEs and their impact on society, we need to be willing to talk about them. We can’t detect something we’re not looking for. Therefore as our awareness levels rise of the pandemic reality of ACEs, we need to develop ways of asking questions that will enable children or people to ‘tell their story’ and uncover things which may be happening to them or may have happened to them which may be deeply painful, or of which they may have memories which are difficult to access. Again, our approach needs to be multi-level across many areas of expertise. We need to be willing to think the unthinkable and create environments in which children can talk about their reality. For children in particular, this may need to involve the use of play or art therapy.

 

  • Whole school culture change is vital, with a high level of prioritisation from the school leadership team is needed to ensure this becomes everybody’s business.
  • School teachers and teaching assistants need to be given specific training, as part of their ‘safeguarding’ development about how to recognise when a child may be experiencing an ACE and how to enable them to talk about it in a non-coercive, non-judgmental way.
  • Police and social services need training in recognising the signs of ACEs in any home they go into. For example, in the case of a drug-related death, how much consideration is currently given to the children of the family involved, and how much information is shared with the child’s school so that a proactive, pastoral approach can be taken. There are good examples around England where this is now beginning to happen. (http://www.eelga.gov.uk/documents/conferences/2017/20%20march%202017%20safer%20communities/barbara_paterson_ppt.pdf)

 

For adults, we need to recognise where ACEs might have played a part in a person’s physical or mental health condition (remember the stark statistics in the previous blog on this subject). Therefore we need to develop tools and techniques to help people open up about their story and perhaps for clinicians to learn how to take a ‘trauma history’.

 

  • Clinical staff working in healthcare need to be given REACh training (routine enquiry about adverse childhood experiences – Prof Warren Larkin) as part of their ongoing Continuous Professional Development (CPD). In busy clinics it is easier to focus on the symptoms a person has, rather than do a deeper dive into what might be the cause of the symptoms being experienced. A wise man once said to me, “You have to deal with the root and not the fruit”. Learning to ask open questions like “tell me a bit about what has happened to you” rather than “what is wrong with you”, can open up the opportunity for people to share difficult things about their childhood, which may be profoundly affecting their physical or mental health well into adulthood. There is a concern that opening up such a conversation might lead to much more work on the part of the clinician, but studies have shown that simply by giving someone space to talk about ACEs they have experienced, they will subsequently reduce their use of GPs by over 30% and their use of the ED by 11%.
  • We can ask each other. This issue is too far reaching to be left to professionals. If simply by talking about our past experiences, we can realise that we are not alone, we are not freaks and we do not have to become ‘abusers’ ourselves, then we can learn to help to heal one another in society. Caring enough to have a cup of tea with a friend and really learn about each other’s life story can be an utterly healing and transformational experience. When we are listened to by someone with kind and fascinated, compassionate eye, we can find incredible healing and restoration. One very helpful process, ned by the ‘more to life’ team is about processing life-shocks. Sophie Sabbage has written a really helpful book on this, called ‘Lifeshocks’).

 

Protect

 

When a child is caught in a situation in which they are experiencing one or more ACE, we must be vigilant and act on their behalf to intervene and bring them and their family help. When an adult has disclosed that they have been through one or more ACE as a child, we must enable them to be able to process this and not let them feel any sense of shame or judgement.

 

  • We need to ensure school teachers are more naturally prone to thinking that ‘naughty’ or ‘difficult’ children are actually highly likely to be in a state of hyper vigilance due to stressful things they are experiencing at home. Expecting them to ‘focus, behave and get on with it’, is not only unrealistic, it’s actually unkind. Equally, children who are incredibly shy and easily go unnoticed must not be ignored. Simply recognising that kids might be having a really hard time, giving them space to talk about it with someone skilled, teaching them some resilience and finding a way to work with their parents/carers via the school nurse/social worker could make a lifetime of difference. It is far more important that our kids leave school knowing they are loved, with a real sense of self-esteem and belonging than with good SATS scores or GCSEs. The academic stuff can come later if necessary and we need to get far better at accepting this. A child’s health and wellbeing carries far more importance than any academic outcomes and Ofsted needs to find a way to recognise this officially. In other words, we need to create compassionate schools and try to ensure that school itself does not become an adverse childhood experience for those already living in the midst of trauma.
  • In North Lancashire, we have created a hub and spoke model to enable schools to be supportive to one another and offer advice when complex safeguarding issues are arising. So, when a teacher knows that they need to get a child some help, they can access timely advice with a real sense of support as they act to ensure a child is safe. These hubs and spokes need to be properly connected to a multidisciplinary team, who can help them act in accordance with best safeguarding practice. This MDT needs to incorporate the police, social services, the local health centre (for whichever member of staff is most appropriate) and the child and adolescent mental health team.
  • For adults who disclose that they have experienced an ACE, appropriate initial follow up should be offered and a suicide risk assessment should be carried out.

 

Manage

 

For children/Young People, the management will depend on the age of the child and must be tailored according to a) the level of risk involved and b) the needs of the child/young person involved. Some of the options include:

 

  • In severe cases the child/YP must be removed from the dangerous situation and brought under the care of the state, until it is clear who would be the best person to look after the child/YP
  • Adopting the whole family into a fostering scenario, to help the parents learn appropriate skills whilst keeping the family together, where possible.
  • EmBRACE (Sue Irwin) training for safeguarding leads and head teachers in each school, enabling children/YP to learn emotional resilience in the context of difficult circumstances.
  • Art/play therapy to enable the child to process the difficulties they have been facing.

 

For adults who disclose that they have experienced ACEs, many will find that simply by talking about them, they are able to process the trauma and find significant healing in this process alone. However, some will need more help, depending on the physical or mental health sequelae of the trauma experienced. Thus may include:

 

  • Psychological support in dealing with the physical symptoms of trauma
  • Targeted psychological therapies, e.g. CBT or EMDR to help with the consequences of things like PTSD (post traumatic stress disorder).
  • Medication to help alleviate what can be debilitating symptoms, e.g. anti-depressants
  • Targeted lifestyle changes around relaxation, sleep, eating well and being active
  • Help with any addictive behaviours, e.g. alcohol, drugs, pornography, food

 

Recover

 

Again, this will follow on from whatever management is needed in the ‘healing phase’ to enable more long term recovery. There are many things which may be needed, especially as the process of recovery is not always straightforward. These may include:

 

  • The 12 step programme, or something similar in walking free from any addiction.
  • Revisiting psychological or other therapeutic support
  • Walking through a process of forgiveness (https://www.youtube.com/watch?v=JQ-j7NuhDEY&list=PLEWM0B0r7I-BXq6_wO4sL0qIwzTWwn_vx&index=9&t=0s, https://www.youtube.com/watch?v=EtexaUCBl5k&list=PLEWM0B0r7I-BXq6_wO4sL0qIwzTWwn_vx&index=9)
  • We may need to help children go through development phases, which they have missed, at a later stage than usual, e.g. some children will need much more holding, cuddling and eye contact if they have been victims of significant neglect.
  • Compassionate school environments to help children and young people catch-up on any work missed, in a way they can cope with and reintegrate into the classroom setting where possible, but with head teacher discretion around sitting exams.

 

To complete the cycle, those who have walked through a journey of recovery are then able, if they would like to, to help others and form part of the growing network of people involved in this holistic approach to how we tackle ACEs in our society.

 

Hopefully this is a helpful framework to think as widely and holistically as possible. There is much great work going on around ACEs now and we must develop a community of learning and practice as we look to transform society together. We can’t do this alone, but together we can!

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Embracing Weakness

Tweet Last weekend, I spent the weekend with my wife and a bunch of close friends, immersing ourselves in the enneagram. It’s something I’ve done a bit of before and highly recommend it! The enneagram is an ancient way of understanding the human personality, our instincts, gifts, struggles and strengths. There are several different perspectives [Continue Reading …]

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