COVID-19: vulnerability and the fear of vulnerability – a Tavistock Policy Seminar
1 June 2020
At our May Tavistock Policy Seminar Tim Dartington, Angela Foster and John Simmonds explored the psychological and social reality of the coronavirus pandemic for older people, mental health professionals and children.
Vulnerability and older people – heroism versus stoicism
Tim Dartington, author of Managing Vulnerability (Karnac Books), highlighted the vulnerability of older people in care homes and social settings who have been forgotten during this crisis. He foregrounded his talk by explaining the historical policy split between health and social care. Both previous Labour and Conservative governments have grappled with debates about free social care, and the divide between health and social care has intensified over the last 10 years. Last year, Boris Johnson in his maiden speech as Prime Minister, promised to ‘fix the crisis in social care once and for all.’
Tim suggested that the lack of focus on older people in care homes followed a predictable pattern in relation to politicians’ and policymakers’ attitudes to health and social care. Public health responses feature a psychological split between ‘heroic’ and ‘stoical’ responses, in which ‘heroic’ responses – those to cure and bring back to good health efficiently – are prioritised. In contrast, the stoical response is for those who neither die nor get better, those with long-term and progressive conditions that are resistant to heroic interventions. Stoical responses are reserved for those in social care and are not prioritised.
During the beginning of the crisis, attention was focused on the capacity of the NHS to cope, meaning the capacity of hospitals to cope. This was seen through the rapid construction of the NHS Nightingale hospital. In this same period the plight of those in need of social care, those living in isolation at home or in care homes was slower to emerge. “Social care was not thought to be relevant to containing the pandemic,” he said. He also argued the “simple fact” that social distancing was incompatible with certain kinds of care.
Vulnerability and mental health professionals – finding spaces to detoxify and explore
Author, psychotherapist and consultant Angela Foster talked about the vulnerability of staff in mental health services who “we don’t hear about on the news”. Referring to her writing on risk’ (1998) she proposed that “the real task of professionals in mental health work is to do what highly anxious and disturbed people, communities or systems cannot do: that is, to think whilst keeping in mind the disturbing and conflicting aspects of the situation,” and asked, “how are we to do this in the midst of a pandemic when we are all anxious, disturbed and vulnerable?".
Teams need safe, reliable spaces in order to detoxify and explore their experiences of the working with disturbed people. Such exploration, when possible, increases insight, stimulates creativity and minimises risk. “Without the team base and this teamwork we’re all more exposed and vulnerable,” she said, speaking of the importance of meetings, supervision and reflective practice. These activities are vehicles for the emotional processes of container/contained as identified by Wilfred Bion.
Online working presents a variety of professional and personal challenges. Angela highlighted the tiredness she herself felt and this has now been acknowledged as a common experience. It can also be distressing, as the video call serves to remind us of those we have temporarily lost. For clients too the continuity of the setting and frequency of face-to-face contact are containing elements and conducting key worker sessions remotely poses a number of challenges, especially for people who may have difficulty in locating safe, private spaces. Do we use audio or visual methods? Such ‘meetings’ with highly distressed clients can feel like traumatic invasions into the worker’s personal space yet home visits present further challenges in respect of the personal risk and the possibility of feeling shame when the visit exposes something that, under normal circumstances, might have been seen and acted on previously.
Aspects of our lives that used to be separate – work, friends, family – are all now happening in the same space. This lack of variety renders us more vulnerable to negative feelings. Some people report feeling a “flatness that’s difficult to put into words” while at other times feelings are heightened. Angela noted the importance of exploring the impact of this work on colleagues, including an awareness of their home circumstances. Workers who live alone or lack a room to which work can be confined are particularly vulnerable to feeling invaded, and this may impact on what they are able to take on.
Finally, Angela speculated about the ways in which we might recreate our ‘therapeutic community’. If emotional containment is the basis of therapeutic work we need to define this new virtual container with our teams and our clients, in other words be explicit about the shape it is taking and explore how this impacts on our experience. Additional supervision time may be helpful. Also, because working in this way is tiring, meetings should perhaps be limited to a max of 1.5 hours with breaks in between.
Vulnerability and children – dramatic unplanned changes
John Simmonds, Director of Research, Policy and Development at Coram, acknowledged that the public health agenda had been geared towards adults rather than children, since COVID-19 affects older adults disproportionately. He said there had been little space to think about the impact on children and the dramatic and unplanned changes on them.
Children have been impacted in several ways. It will have disrupted their relationships at school, and with friends and wider family. It will have resulted in them seeing and trying to adapt to their parents working at home, parents losing their jobs, parents having to re-adjust themselves to complex and worrying issues often well outside the child’s understanding and certainly control. It may have stirred up parental conflict. It will have confronted some children with the reality of serious illness or death. The likelihood of the child’s experience of sadness, loss and grief will run through several of these examples, he said. He highlighted the difficulties for children in expressing these emotions and feeling understood, which may be expressed through fear, anxiety and anger.
John took us through the earliest phases of human development, highlighting its fragility and vulnerability, and how we don’t yet know what the impact of the pandemic may be on babies, infants and their caregivers. The answer to these issues is “to think, feel, reflect and then act”. The challenge from the serious levels of threat resulting from this pandemic is that it will drive people through powerful instinctual responses based on splitting into factions, oppositional narratives and triumphal claims. He said human beings are at their best when in a relational and cooperative mode. John closed his presentation by expressing his concerns that children will be too easily forgotten in the challenge they face in their experiences of the threats, burdens and uncertainties of COVID-19.
After discussion in break-out groups, the importance of acknowledging individual experiences of people during this crisis was identified and not making assumptions about how people are thinking or feeling. One participant described neighbours on both sides with children: on one side the neighbours were struggling, on the other the children were ‘living the dream’.
One participant echoed the important of acknowledging individual experience ‘for all of us’. He highlighted a University of Essex project which is collecting individual stories. He said that trauma work at the Tavistock had shown how in the Zeebrugge disaster some people managed better than others in their responses. It would be invaluable to map how people are currently managing the crisis. This chimed with another participant who said this was about resilience and ‘what that means in detail’.
The recognition of media narratives of ‘splitting’ between the heroic health professionals and otherwise also held resonance. One colleague spoke of the shame she felt in working for the NHS and not quite being on the ‘heroic’ front-line, while another said his initial enthusiasm for the weekly ‘clap for carers’ phenomenon had waned. Another colleague said clapping felt uncomfortable for her.
One participant said: “There was a massive collusion in denying that COVID-19 was going to come our way”. She pointed out a “systemic denial” of vulnerability. It was easy to point a finger of blame at the government, but there is also a correlation between the denial at Downing Street and among other professionals. There was a reluctance to act to protect patients. Another participant noted the absurd British attitude “we won’t be affected and we’ll tough it out”, despite evidence of the scale of the outbreak elsewhere.
Tavistock Policy Seminars are a space in which the human, relational and emotional aspects of public policy initiatives and ideas are presented and debated. The seminars offer an audience the opportunity to contribute to, develop and ‘own’ their part in thinking about the complexities of policy as a lived experience, and not just something handed down to us by experts and specialists.