In the above diagram we have conceptualised the window of tolerance whereby the green box represents the zone described by Siegel (1999) as the optimum zone for feeling connected and balanced, and the area to re-centre and re- connect to if you, or others identify with movement into the red or blue areas. However hunger, tiredness and feelings of safety can also cause movement away from the green zone. Recognising when we fall outside of the zone, or simply having the ability to stay within it requires resources and skills which pre- trauma may not have been required, or existing skills may not be meeting the requirements of this new area of difficulty. If skills are not taught, practiced, and their rationale explained then it may feel that there is a frequent ricocheting between hypo and hyper arousal, or movement between the two at colossal speed for seemingly for no reason, instead only feeling the resulting behavioural, physiological or emotional consequences.

Grounding techniques slow this movement, calm the senses and allow for movement back into the green zone. These techniques help a person who is overwhelmed by memories, strong emotions or is dissociating by helping develop an awareness of the here and now (Melnik and Bassuk 2000). As authors Melnik and Bassuk use the metaphor of walking out of a cinema. In times of dissociation there may be a disconnect between the person and the world as a means of dealing with stress or trauma (MIND 2019). Experience of flashbacks, which is the re-experiencing of an event from the past, can be triggered by a reminder of the experience leading to feelings of anxiety, fear and isolation (Rape Crisis Scotland 2013). When caught up in watching an internal movie of previous experiences, grounding techniques help step out of the cinema and into the present environment, thus ending dissociation or flashbacks.

Grounding techniques are exercises and practical techniques which can help individuals keep a connection to the present and avoid or reduce memories, flashbacks and dissociation (MIND 2019). Examples of such techniques and their

use in relation to the window of tolerance are shared below through first person insights following personal experiences, all of which share themes of distress, dissociation, flashbacks and impact upon social and occupational functioning due to the wearing of face coverings.

The wearing of face coverings and dissociation due to PTSD

Post-Traumatic Stress Disorder (PTSD) has been a struggle for several years and face coverings have been a trigger that can lead to dissociation. When I heard that they were going to become mandatory on public transport, I knew I was going to have to work hard to try and find a way of making wearing one manageable.

A starting point was finding a face covering that felt comfortable next to my skin. I made a flash card with details such as my age, and a reminder that the covering was being worn to help keep others safe and others were wearing them to help keep me safe. This would help ground me if I were to dissociate, which can leave me feeling vulnerable. I began to wear the covering at home where I felt safe, to build a tolerance, initially wearing it for twenty seconds and managing the anxiety by reading my flash card, leaving it off for an hour and increasing the time I was wearing it to thirty seconds.

I was worried about using public transport but I had my flash card with me and listened to music that I find empowering. I intend to do this when I have appointments and at the shops. I’m not sure I will ever feel completely comfortable wearing a face covering; it does however feel a lot more manageable.

In this example a number of grounding and coping techniques were developed and practiced over a period of time to minimise potential distress. This required an understanding of personal triggers and when movement occurred outside of the green zone of the window of tolerance. Similar to the window of tolerance grounding techniques can utilise the five primary senses, in this case the learnt knowledge that music was beneficial.

I need to wear masks for the benefit of patients, but I didn’t know it would be this difficult

I have always found that despite what is going on personally, work is my ‘safe space’ where I can use my experiences for the good. What I did not anticipate was how a history of trauma would suddenly enter my workspace, or that that would happen as soon as I put on a mask. I was not expecting it to be difficult and had not prepared for the strong reaction that happened, and that was probably what has affected me the most.

My body reacts instinctively, survival mode takes over and I want to take it off and run. I am unsure if that is because past reactions were passive, and so my arousal levels are high. I don’t really know. Initially I was in denial, but with face coverings now being mandatory in so many places, denial is not an option.

Alongside the trying of lots of different types, the choosing of a design has been empowering and allows the taking back of control. I have also started writing acrostic poems on my journey. These are simple poems where the first letter of each line forms a word or phrase vertically. Trying to think of what words fit in has been a distraction. In the evenings after work, I paint pebbles that I ‘plant’ around the hospital; it is a way of coming back to the present.

Aside from grounding, self-kindness is important. When I anticipate exhaustion from journeys I take a minicab which becomes a form of self-care, a small investment to continue to function well.

Grounding techniques such as the cognitive techniques described above in the form of acrostic poems, can also include the describing of objects, scenery, reciting of poems, songs, passages and the counting of objects, all of which help re-centre and calm. However, as a word of caution, do not undertake or suggest the use or practicing of grounding techniques if they cause undue distress or concerns around safety.

Wearing a face covering feels like a hand is over my mouth

But it’s not just any hand, it’s his hand, and although part of me knows that I can take the covering off and I will be able to breathe, in that moment I’m back there and I can’t breathe again.

When their use was first needed, only having them on for a short time, literally seconds caused nausea and a feeling of suffocation, and each time their use is required somewhere else my heart sinks because it means applying the techniques to yet another setting, each one bringing a different challenge because what worked in one environment doesn't always work in another. For example wearing a face covering where it is busy and noisy is very different to wearing one where it is quiet, as quiet environments leads to fears around safety which brings its own triggers.

In terms of grounding techniques, their use has been a real challenge. The feeling of suffocation overwhelms with frightening speed, holding on to the knowledge that it is a fabric mask which I have put on, can at times be impossible.

Noting the difference in colour, although simple took months to master well, and even then at times I get caught out, as in that moment it is not red, floral or spotty but black like a glove, I then become aware of the heat of the mask, the fabric and I start to panic.

Techniques therefore started small, reminding myself I put it on, reminding myself of the colour, talking myself through what I see around me, the difference between the environment I am in and the environment where my flashbacks take me. The feeling of suffocation has been much harder to overcome. As soon as this and the feeling of nausea creeps in I fall outside of the green zone. If I go into the red I start to panic which further affects my breathing and it confirms that I can’t breathe. If I move into the blue I go still and quiet, my thoughts are about preservation; don’t move, stay still.

It has taken five months to wear them as often as I can, but I can’t tolerate any longer than 20-30 minutes, even then it varies day to day and with how I’m feeling or for the reason I’m wearing them.

We have discussed how triggers can be sensory reminders. In this example the feel and heat of the fabric was a trigger. We recognise that symptoms, when triggered can be unpleasant, but if in public, at the store, appointments, work or study they can be paralysing. Survivors can get stuck and pulled down in the aftermath of trauma and this will be exacerbated by post-traumatic stress triggers.

Practical examples of grounding techniques when using face coverings

Based on experience of managing and working with trauma, as well as techniques mentioned in the above excerpts, we have developed and practiced the following grounding techniques.

These skills, together with a theoretical understanding of the window of tolerance 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. For those who are reading this because their use is causing distress and anxiety, we invite you to practice and use the skills that you find work for you, and hold hope that you are not alone in the difficulties that the wearing of face coverings can cause.

Sight

• When you can, look at yourself wearing your face covering. This may help you remember that it is a covering that you are wearing and nothing else.
• When you have it on look down and notice its colour, describe it to yourself “it’s mine, my (colour) covering that I have put on and I can take off”
• Name five things you can see that are a certain colour, or begin with a letter of the alphabet.

Smell

• Is the smell of the fabric a trigger? A spray of your favourite scent might be of use. However, as one of the authors found, too much of a generous spray just before putting it on can be a little overwhelming, but a spray before it is worn may help.

Touch

• Keep small objects in your pocket or within easy reach, such as textured shells, stones, squishies or fiddle toys.
• Try different types of face coverings or shields and experiment with the tightness and fit. Being able to choose your fabric may help exert control over design, texture, weight and size.
• Notice the feel of the covering on your face, without it is just an object, a piece of fabric that you are choosing to put over your face. Can you describe an object that you can see? Its texture, design, shape.

Sound

• Listen to music, podcasts or audiobooks
• How far can you stretch your hearing? Start with listening to a sound that is close to you and then challenge yourself to hear sounds that are further and further away.

Taste

• Mints or gum can be useful in keeping you present, however as one author found out, trying a variety of strengths of mint may be useful before entering a difficult situation as going straight for the extra strong mints can lead to its own difficulties (they are very strong mints to use for the first time when in a tricky situation!)

Cognitive techniques

• What’s next on your shopping list?
• How many red cars of a certain colour are going past? Think of an animal or object that begins with each letter of the alphabet.
• Count backwards from 1000 in 7’s.

Environmental considerations

• Is there anything in, or about the environment that you need to wear your face covering in that was also present during your own experience of trauma? If so, ensure that you are prepared e.g. crowds, certain noises, time of day.
• Notice what you are wearing. In the case of sexual trauma, it is often experienced in isolation from others. The wearing of a face covering may help in informing you that it is a safety measure so you can be with others, not alone.
• Be aware of how the weather may impact physiological symptom and become a trigger. Would taking some water out with you be useful?
  The change of seasons leads us to dressing differently; too many layers inside a hot or busy shop may contribute to the face covering feeling uncomfortable and hot. A covering in a different material or weight may be needed for changes in seasons, or the use of a face shield may be preferable.

What we realise, and what users of services and professionals will appreciate, is that these suggestions may not be helpful for everybody, and may not work first time, we also acknowledge that the process of developing grounding techniques can be exhausting, distressing, require a lot of creativity and practice.

Above all, we have come to understand that this is a more common experience than realised, and it has tested our ability to cope, despite how well practiced and previously well-resourced we have been. For this reason practicing with, or going out whilst wearing a face covering with a trusted person may provide a source of support and encouragement, particularly if they are able to prompt the remembering of, and continued practicing of skills to ensure that there is no movement along the window of tolerance.

For many, including those without an 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.

And if it’s all simply too much....

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. (Hidden Disabilities 2020). 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.

Implications for practice

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 remain, and as we have seen their use does not remain static. 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.

Conclusion

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.

Whether an experience is sexual or interpersonal, due to injury, accident, illness or bereavement, happened recently or a long time ago, we recognise the distress that the use of face coverings may bring and we hope, though our insights and suggestions that the potential difficulties that the wearing of face coverings may bring can begin to diminish, and individuals can feel empowered and that they are not alone in navigating this ‘new normal’.

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