COVID-19 pandemic - Where are we now?

1 April 2021

Dr Joanne Stubley, Consultant Medical Psychotherapist & Psychoanalyst, and lead for the Tavistock Trauma service writes.

I wrote a paper near the beginning of the pandemic, as the first peak was hitting the UK, trying to bring to bear what contemporary trauma theory might tell us about this extraordinary situation. Much of the focus at that time was on understanding the impact of the threat of the virus and its societal consequence of lockdowns and social distancing. Implicit in what I wrote was an attempt to slow down the understandable wish to offer help, to intervene in some way, on the part of many people in the helping professions. This rush to help is something that is often seen after a significant community or collective trauma. The response after the Grenfell Tower Fire was one example of this and whilst it may have many different motivations including altruism, there is also an important unconscious motivation. Traumatic events by their very nature lead to experiences of helplessness and stir up powerful infantile anxieties. Through projective identification, we can defend against these feelings by locating the helplessness in the other, whilst we can then become the helper, the rescuer who is empowered. Thus, our approach in the Tavistock Trauma Service is to attempt to be a steady presence that is available when needed and this has been our approach in this pandemic. In the intervening months, the impact of the pandemic on individuals who have already experienced considerable trauma in their lives – the many people the Tavistock Trauma Service sees who have had to cope with potential re-traumatisation as well as the fallout of the growing health and social inequalities that have increased over this period has becoming increasingly evident.

As I write this, we are emerging from a national lockdown, the number of new cases, hospitalisations and deaths is slowly creeping down from what felt like the precipice of terrible disaster of hospitals being overwhelmed, and mass vaccination is progressing. The creativity and compassion of wellbeing services working to support frontline staff, the innovative and helpful research that is being published to further inform this work, and the individual and collective learning that has occurred is impressive. However, what began in March 2020 in the UK as an adrenaline-fuelled response to the unknowable situation that faced us all has now become a marathon, as yet without end, that is taking its toll on many.

I hope in this paper to bring a trauma-informed understanding, alongside psychoanalytic, attachment and neurobiological theory, to tease out some aspects of what the pandemic has faced us with – individually, as families and as part of a community. Some of this might specifically apply to certain groups within society who have had particular burdens to carry, such as frontline health and social care workers, blue light services or those with significant trauma in their own backgrounds, or individuals who are socially isolated, marginalised or deprived. There has been a paradox during the pandemic of a need to recognise the universality of the experience coupled with a growing recognition of the differences. These differences are perhaps most succinctly understood in relation to privilege versus deprivation and play out across many different aspects of society. Privilege may be as simple as having a garden, access to good broadband and a decent computer for home schooling or being able to set up a home office that is separate to one’s bedroom. With privilege comes guilt as the ever-expanding gap between those who have and those who do not becomes more pronounced.

In the early days of the pandemic in the UK, Holmes et al (2020) set out to describe the potentially vulnerable groups who may be more at risk during this time. They included those with previous mental health problems, older adults with multiple co-morbidities, individuals with learning disabilities, individuals marginalised and deprived by society and children and families exposed to substance abuse, interpersonal violence and child maltreatment. It is interesting to notice how most of these groups are also likely to be at an increased risk to have already experienced significant traumatic events and to struggle with the consequences. Suggesting these groups as potentially vulnerable is to acknowledge, perhaps, that the impact of the pandemic will inevitably be felt by those who are already deprived, marginalised, traumatised and / or socially isolated. Of course, this fits with the known risk factors for Post Traumatic Stress Disorder (PTSD) where a previous history of trauma, on-going psychosocial stressors and perceived social isolation are of particular significance (Brewin 2000). One might also understand this from an attachment perspective whereby the presence of unresolved trauma in a caregiver is relationally transmitted to the next generation, with the significant risk of disorganised attachment and trauma-related disorders through to adulthood.

The threat of the virus has likely for most of us, at least at times, stirred up powerful anxieties described by Melanie Klein (1946) as paranoid-schizoid anxieties from early infantile life – anxieties of annihilation, disintegration, fragmentation and persecution. The threat of an invisible, silent and potentially lethal virus is fertile ground for these kinds of anxieties. Garland (1998) suggested that the experience of trauma also activates these anxieties and over time the mind attempts to manage the overwhelming terror and threat through a process of binding. The experience becomes bound up to earlier moments of paranoid-schizoid functioning to give the event its unconscious meaning. One might think of this as pockets of vulnerability that reside in us all – unresolved, unprocessed traumas and losses – that become bound up with the current event. Interestingly, I think this also links to one way to understand the effectiveness of EMDR (Eye Movement Desensitization and Reprocessing), which appears to rapidly facilitate the conscious awareness of the associative links to the trauma being processed. What the EMDR therapists call the channels that active trauma processing can take you down might also be understood as the pockets of vulnerability – unprocessed trauma – that have been bound to the current event. An example of this might be an intensive care nurse during the pandemic who feels increasingly traumatised by the high mortality and sense of helplessness in her work and that this becomes bound to her early life experiences of witnessing interpersonal violence between her mother and father, watching helplessly and fearing for her mother’s (and her own) life.

The collective and individual traumas that have been experienced by many in this pandemic may thus have become bound up with earlier experiences of unresolved trauma and loss. Alongside this entwining of past with present traumas, earlier traumas may also return to the mind in the present through context- dependent retrieval of memories. In studying memory recall and retrieval, neuroscientists note that both the context and state in which the original experience occurs are important (Radulovic 2017). Maximum retrieval is possible when the context and state is similar to the original experience. In terms of context, one might best understand this from those moments of forgetfulness that can occur when we go into a room and then forget what we have come for. Returning to the room where the idea originated usually allows for a higher likelihood of retrieving the memory.

State dependent retrieval of memories will be more likely if, for instance, a similar affective state to the original experience is again present. As an example, a young woman who had suffered severe sexual abuse as a teenager reported during the lockdown that many memories of the abuse were returning to her, mostly as re-experiencing symptoms – flashbacks, intrusive images and somatic symptoms. When we explored this further, they were being triggered whenever she went for a walk. This was not an activity she had done since she was an adolescent, having mainly used exercise classes as an adult. Walking as an adolescent was associated in her mind with a combination of feelings including boredom, feeling trapped, hyperarousal and fury. She was clear that lockdown had created a similar affective state.

Social connection is a significant resilience and protective factor in relation to trauma.  There is clear evidence that the level of social support before and after traumatic experience will play a role in whether symptoms develop over time. (Brewin et al 2000). This links with Porges’ idea of the ventral vagus nerve (the safety of attachment) as an antidote to fight / flight / freeze responses (Porges 2011). Isolation and loneliness during the lockdown may have increased risk for re-traumatisation. This also links with oxytocin, the attachment hormone, which is most commonly secreted in response to human touch. For many, living alone deprived them of this essential experience, often voiced by people longing for a hug from their loved ones. Oxytocin has been found to be reduced in the cerebrospinal fluid in childhood trauma, suggesting a greater vulnerability to the impact of the deprivation of physical contact. (Ellis et al 2021)

An Object Relations perspective of trauma emphasizes that all traumatic experiences, no matter what their origin, are perceived unconsciously in terms of a relationship – a someone or something has done this to me. Alongside this persecutory attack from a bad object, there is inevitably the failure of the good object to protect us from harm, leading to a loss of trust. Therapy emphasizes making reconnections and strengthening trust through the experience of new relationships, particularly the therapeutic relationship but also with others, which makes group work important in this context. Psychoanalytically one may consider this reconnection as a (re-)establishment of a good internal object, allowing for the capacity to trust and engage with others. A number of complex trauma patients within the Tavistock Trauma Service suggested when the pandemic first began that there was a sense of relief for them. Now the rest of the world might begin to understand the world they had always lived in – where everyone was a potential threat and the safest place to be was at home alone. This may also be understood in relation to Fonagy’s description of epistemic mistrust which occurs secondary to relational trauma. (Luyten et al 2019) Epistemic trust allows for an openness and receptivity to social learning from others; it is an important way in which the mind is recalibrated through engaging with the experiences and perspectives with others. Trauma closes this down and epistemic mistrust may then contribute to the internal stasis, the never-ending state of being in “trauma time”.

This notion of trauma time encapsulates the shutting down, closing off and disconnection that may occur with unresolved trauma. It is closely linked to the defence of dissociation, the escape when there is no escape, which then allows an individual to disengage from their bodies, their emotional state and the present. In this way, a timelessness is inevitable and is often linked to the endless repetition of re-experiencing symptoms such as nightmares, flashbacks and intrusive images or somatic states as the trauma endlessly replays. Freud’s concept of the repetition compulsion (Freud 1920) is linked to this as he highlighted the endless unconscious re-enactment that occurs in relationships when it is not possible to remember. In this context I believe he was suggesting that remembering involves the complex interaction of narrative and affective responses that include mourning.

As we find a way to move forwards in this pandemic, remembering in this sense will be necessary for us all. Mourning together what we have lost will be an important aspect of the social reconnection that will be required. As a society, the need to attend to social injustice, deprivation and marginalisation is now greater than ever. Collective traumas evident in the Black Lives Matter movement and before that, #Me Too require a collective remembrance that may provide an opportunity for post traumatic growth, and perhaps this will also be true for the pandemic and its legacy.

References

Holmes, E.A., O’Connor, R., Perry, V.H., Tracey, I., Wessely, S., Arseneault, L., et al (2020) Multidisciplinary research priorities for the Covid 19 pandemic: a call for action for mental health science. Lancet. Vol 7: 6; 547-560

Brewin, CR, Andrews, B, Valentine, JD (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology 68, 748–766.

Klein, M. (1946) Notes on some Schizoid Mechanisms. International Journal of Psychoanalysis 27:99-110

Garland, C. (ed) (1998). Understanding trauma: A psychoanalytic approach. Tavistock Book Series. London

Radulovic, J., Jovasevic, V. & Meyer, M. (2017) Neurobiological Mechanisms of state-dependent learning. Current opinion Neurobiology Journal. 45:92-98

Porges, S.W. (2011) The polyvagal Theory: neurophysiological Foundations of emotions, attachment, communication and self-regulation. New York: Norton

Ellis, B., Horn, A., Carter, C., Van Ijzendoorn, M., Bakermans-Kranenburg, M. (2021) Developmental programming of oxytocin through variation in early life stress. Clinical psychology review. Online 15.2.2021

Luyten, P., Campbell, C., Fonagy, P. (2019) Borderline personality disorder, complex trauma, and problems with self and identity: a social-communicative approach. Journal of Personality 88: 88-105

Freud, S. (1920) Beyond the Pleasure Principle, S.E.18. London: Hogarth

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