Wednesday 15 April

Late last night came the announcement that President Trump was withdrawing US funding from the World Health Organisation. How helpful is that at a time like this, as global deaths pass 125,000? The US is the largest contributor to WHO, so this begs the question of how that funding gap be closed when, arguably, WHO advice is more important than ever? We have to wonder if this is a muscle-flexing response to individual states asserting their rights to end lockdown when Trump asserts that he alone has that power. A CNN reporter tweeted:  ‘Ha. Trump says he will be “authorizing” each governor to reopen their state at the time of their choosing. This isn’t his call; he doesn’t get to authorize. The power is already theirs’.

Issues about care homes and vulnerable residents continue to dominate the airwaves, some shocked to be told by homes that their relative wouldn’t be taken to hospital if they got COVID and it’s not only care home staff and residents who feel so vulnerable. An anonymous psychiatric ward clinician writing in the Guardian says they are ‘sitting ducks’ because ‘physical distancing is impossible, we have no PPE, patients aren’t allowed to go out, and violence and anxiety are on the rise. Lockdown has ended patients’ leave and visits. This affects their stability, and to many feels punitive. If self-harm increases, our patients will not be a priority on general wards. We worry for them’.

It’s not surprising the writer chose anonymity, as the Guardian also reports on the widespread gagging of NHS staff by their employers, forbidding staff from speaking to the media. As if they didn’t already have a hard enough job. One mental health professional said: “When it comes to the day-to-day clinical issues and challenges we face, there is a definite power dynamic at play, and [we] are generally petrified to speak out”.

Today Labour is pressing firmly for a transparent strategy on ending lockdown. Staying at home and self-isolating are the very opposites of what’s important for optimum mental wellbeing, yet this could continue for many more weeks and some will become disillusioned and may breach the lockdown. The Guardian reports on scientists’ warnings that physical distancing measures may need to be in place intermittently until 2022, in an analysis that suggests there could be resurgences of Covid-19 for years to come. The paper, published in the journal Science, concludes that a one-time lockdown will be insufficient to bring the pandemic under control and that without continuing restrictions secondary peaks could be larger than the current one.

Will we ever again feel safe to hug and kiss friends and loved ones? What will this lack of physical contact do to our psyches? It’s well known (and currently there’s a large research project underway about it) that touch is essential to wellbeing and yet we are all having to mostly avoid it. You can check out the Radio4/Wellcome Collection/Goldsmiths University research here.

BBC Economics editor Faisal Islam broke the news that a draft document from Public Health England discussed “last resort arrangements” for “acute supply shortages” of PPE because of “stock & reduced ability to resupply”. The ‘arrangements’ include using “sportswear” and reusing normally single use masks and will have to be reviewed by HSE.

This afternoon we heard that another 761 COVID19 patients with have died in UK hospitals, bringing the total to 12,868, but it’s suggested figures are far higher because of the exclusion of care home and community death stats. At the daily press briefing (painful to listen to) a key part of the social care announcement turned out to be the plan to introduce a badge of honour for workers, enabling them to be more easily identified and recognised, no mention of decent pay. You couldn’t make it up. As someone tweeted:

‘Badges for social care staff sounds like a lovely idea, but feels more like yet another costly PR stunt by this Tory administration that is essentially an empty gesture following years of underfunding’.

Don’t forget to tune into Fallout tonight if you can: 8 pm on BBC Radio4 with Mary Ann Sieghart on what kind of society and changes we’ll see post COVID2019. The third in the series focuses on health and although there’s no mental health expert on the panel Ms Sieghart assured me on Twitter that the topic will be covered.

Tuesday 14 April

Pensions and later life expert Baroness Ros Altmann is the latest public figure to highlight the plight of elderly people, ‘abandoned’ in care homes without the necessary level of care and care for the carers. It’s not surprising these residents could feel disturbed: those with dementia could struggle to understand why their loved ones are no longer visiting them; many are seen by carers who reportedly aren’t adhering to the required hygiene standards; doctors are reluctant to visit these homes; and a high number of care home residents are already on anti-depressants when many would prefer talking therapy. All these factors will exacerbate pre-existing mental health difficulties and create yet more.  

Care home death statistics are only updated weekly and now numerous voices are pressing for the longstanding artificial divide between NHS and social care to be erased. It sounds promising that amid the rising clamour for daily and accurate recording of COVID deaths in care homes and the community, the Care Quality Commission has stepped up to take the lead on this important work. A related, delicate and under-recognised issue has been how the cause of death is represented on a death certificate. It’s long been known but goes under the radar that doctors (and now they don’t even have to see the patient) often put the surface presenting ‘cause’ eg pneumonia, when the underlying cause is actually neglect or a combination of problems. So it follows that the COVID death toll could be much higher if older people’s deaths weren’t attributed to these other ‘causes’.

The Guardian reveals how Britain missed three opportunities to be part of an EU scheme to bulk-buy masks, gowns and gloves and has been absent from key talks about future purchases,  as pressure grows on ministers to protect NHS medics and care workers on the coronavirus frontline. A survey by the Doctors’ Association UK found that only 52% of clinicians carrying out the highest-risk procedures said they had access to the correct full-sleeve gowns. Refusing to cooperate with the EU on this is an example of doctrinaire adherence to Brexit policy, leading to damaging delay in obtaining vital supplies.

Two million more unemployed and a 35% drop in economic performance are predicted by June as a result of this crisis. A regular listener to BBC World at One tweeted: ‘It’s quite possible that lockdown is causing additional deaths. If your business is in free fall, you’re in financial meltdown, and/or whole range of mental illnesses. e.g. our Trust has seen a collapse in eating order referrals. That is storing up trouble’. It certainly is. So many facets of this COVID crisis are bringing about a mental health domino action.

Choice of language is important in every field, conveying powerful messages about the beliefs of the speaker or speakers. COVID has thrown up some good examples, eg criticism levelled at politicians and the media for using bellicose terms (‘it’s war’, ‘it’s a battle’ or about the PM ‘he’s a fighter’) and drawing comparisons with WW2 and the alleged Churchill/PM likeness.

No-one wants to hear it, but we’re going to have to make uncomfortable choices about how we pay for this.”

Psychotherapist Mark Vernon tweeted: ‘I’m wondering about the gendered nature of language around COVID. For example, military metaphors seem spontaneous, “fighting the virus” etc, plus the objection that they imply “defeat”. It sounds masculine, echoing science’s “control” of (mother) nature etc. Make any sense?’

And have you noticed how many politicians and public figures, when being grilled (or being given an easy ride) by the media use obfuscatory and diversionary phraseology like ‘What’s important now is….’ (implying the big mistake they’re being asked about is trivial) or ‘What we want to see is/what we’d very much like is….’ when wanting is just that – not actually getting something done or rectified?

Tonight’s Downing Street press briefing had several main points including the Chancellor saying   he will “have to right the ship” when we’re through this, implying cuts and some are already predicting austerity Mark 2. At tomorrow’s conference we’re promised a statement on social care – way overdue. Let’s hope it has some substance.

Monday 13 April

It’s much cooler today so police forces shouldn’t have so much trouble monitoring the lockdown. As the death toll reached 10,600, the Government is again lambasted over the lack of PPE and tests, not to mention the absence of reliable stats on deaths in care homes and the community. To Matt Hancock’s assertion that it’s ‘impossible’ to get personal protective equipment to everyone that needs it ‘because the quest is to get the right PPE to the right people on the frontline at the right time to many millions of people across the NHS’, a doctor tweeted simply ‘It isn’t impossible.’

While deaths in UK hospitals rose to 11,329 today, Hancock also couldn’t give an update on the number of care home and community residents and NHS staff who have died. We’re told the Office for National Statistics is giving some information on the former (over 1,000 in England), stats only updated weekly, and statements from hospitals and workers’ families show the NHS staff figure is more than 30.). The Radio 4 PM programme featured a heartrending interview with care home manager, struggling with the admissions they are forced to accept from the public sector, maintaining staffing and lack of PPE. This situation draws further attention to the social care crisis in this country.

The Guardian reports that snapshot data from varying official sources shows that in Italy, Spain, France, Ireland and Belgium between 42% and 57% of virus deaths have been in homes, according to the report by academics based at the London School of Economics (LSE).

The government is under fire on another front, having admitted that only 1.4% of businesses enquiring about its corona virus business interruption loan scheme (CBILS) have so far been successful. Heaven knows what those business owners must be going through. This is the trouble with trumpeting great-sounding schemes without necessarily thinking through and implementing the infrastructure to effectively roll them out.

A decision about extending the lockdown has to be made by Thursday because that’s when the regulations covering England need to be reviewed. It’s thought inevitable that the lockdown will be extended – necessary but with severe effects on the economy and people’s mental health. Polling organisation IPSOS Mori is reporting increased anxiety, depression and sleep difficulties in half the UK population.

The Guardian reported that over this holiday weekend, when highways would usually be busy with holidaymakers, traffic on some major roads fell by as much as 86%. But this drop has encouraged some to drive at ‘extreme speeds’, like the one doing 151 mph on the M1. Elsewhere, a scuba diver and a family drove more than 200 miles for a fishing trip and people visiting second homes in Wales are reportedly sending luggage via couriers to prevent detection, prompting police to wonder about ‘that level of cunning’.

On the European front, we learn that France is continuing the lockdown for several more weeks and Spain is allowing some people back to work.

Meanwhile, in other news, broadcaster Chris Packham said he will continue his fight against the construction of HS2, which environmentalists say is leading to irreversible destruction of ancient habitats and woodlands. The High Court dismissed his application last week for an urgent injunction to halt construction work, arguing for a judicial review of the government’s decision-making process in relation to the £106bn high-speed railway. Such pieces raise the interesting issue of what’s not being reported due to wall-to-call corona coverage.

Sunday 12 April

Last night the Guardian tweeted: ‘The Queen has given an Easter message to reassure the people of the UK that this pandemic can be beaten. The monarch’s speech is said to be her contribution to those marking the occasion at home’. Interestingly, the Queen didn’t appear in the 2 minute video, which mostly featured a lit candle. She spoke about the importance of hope and light overcoming darkness, referencing the lighting of candles during the vigil preceding the Resurrection. I wonder how much impact these messages are having: as with the Queen’s Christmas broadcast, there are those who never watch and would prefer not to have a monarchy here, and those who watch religiously, regarding any avoidance almost as heresy. These messages are clearly very sincerely meant, but I wonder how comforting people are finding them.

The government faced a chorus of cross-party calls on Sunday for the urgent recall of parliament (closed down on 25 March) in “virtual” form as MPs and peers demanded the right to hold ministers to account over the escalating coronavirus crisis.

At 3 pm, having been discharged from hospital, the PM issued a 5 minute video message, praising the NHS to the skies and thanking the population for observing the lockdown. Within minutes it had received thousands of views and retweets on Twitter. It will be interesting to see, over the forthcoming week, what emerges from him now he’s recovering at Chequers.

Saturday 11 April

The long Easter weekend is upon us and during the last few days much time and energy has been expended by the media on the subject of lockdown, now into its fourth week – its viability during warm weather, different views as to its implementation, its possible extension and its gradual reduction as COVID19 cases and deaths decline. What’s missing is any reflection on the psychological factors underpinning lockdown flouting. Police and politicians seem to think flouters are not hearing the message or not understanding it. While this is in the mix, I think it’s important to understand that no amount of news coverage, notices in parks or tv adverts will cut any ice with some, who actually enjoy breaking rules and see it as a kind of ego-driven achievement. This behaviour can stem from longstanding patterns of challenging authority so the perpetrators are unlikely to respond to hearing the same thing over and over. Another aspect is the perceived inconsistency in lockdown policy: we are under unprecedented pressure to stay at home apart from four exceptions, keep two metres apart, to not congregate in groups and to not visit friends and family, yet flights are still regularly coming into the UK from Corona hotspots like New York and differences between police forces are resulting in scarce police presence in some areas and over-zealous exercising of power in others. It will be interesting to watch news coverage later to see how closely the guidance is being observed, when temperatures are set to rise to 25C in some parts of the UK and when certain public figures have already been caught flouting the very rules they are trying to enforce.

Another disconnect for many is the contrast between the mantra of social distancing, when this is clearly not being observed in the aisles of most supermarkets and on shared pavements and paths. It could be argued that it’s not much use making people stand at distance in a queue, but then allow a free-for-all in the aisles. If you politely ask someone to stand further back, this can often produce an angry response, likely to be a displacement of deeper anxiety. This morning a neighbour had a customer shout and wave his stick aggressively at her for making such a request. Despite some encouraging examples of etiquette being observed, it’s still common for people to pass by too closely in the street or while jogging/cycling, seemingly oblivious of others they are forcing to step back or jump into the nearest ditch. A sign has appeared on some well-known running routes around here: a jogger is pictured swerving to avoid an elderly woman with a stick and carrying shopping, the text reading ‘The grass won’t hurt you’. The million dollar question has to be: why aren’t some seeing and observing this or why don’t think they think it applies to them?

Meanwhile, the judgementalism manifested before the ‘rules’ or ‘instructions’ (not law!) were tightened up still persists in some quarters, for example people being frowned on (often by non-exercisers) for going out for their run or walk. It was interesting to learn that the ‘no sunbathing’ and ‘no travel to exercise’ rules do not apply to psychiatric patients, who use these activities as a way of managing their condition.

Today many have been incensed by the astonishing suggestion that NHS staff could be using PPE irresponsibly, when the concept of ‘overusing’ it is clearly nonsense: as clinicians have clarified, it’s crucial for them to change their masks and gowns for every patient they attend to. This is a politician’s attempt to divert attention from manifest incompetence by trying to apportion blame elsewhere. This evening further opprobrium has greeted the long absent Home Secretary’s ‘apology’ at the press briefing for people ‘feeling’ that there’s a shortage of PPE when there manifestly is a shortage. Such tactics will convince few except a few diehard Conservative supporters, but the next morning, the fake apology was used again by Alok Sharma on the Marr programme, suggesting to some that this is the latest Cummings mantra.

This evening we hear that nearly 10,000 altogether have died in hospital so far, but this excludes those dying in the community. Clinicians are lamenting the continuing shortage of PPE, with 55% saying they feel pressured to work in this unprotected environment. ‘We don’t deserve this’, said one. Writer Matt Haig captured the zeitgeist by tweeting ‘Just washed the shopping. After going for a run in the garden. 2020 is an odd one’. And we learn that the Queen will address the nation tomorrow, the second time in a week, on the subject of hope, ‘light overcoming darkness’. After all this it will be a relief to escape into ITV’s Belgravia tomorrow night!

Wednesday 8 April

During the week there was endless speculation in the media about the extent of the PM’s illness, whether or not his powers had been delegated to deputy Dominic Raab, and whether the public was being kept adequately informed of his state and capacity to lead the country. There was relief, then, after some days at the news that the PM was out of danger and recovering well, tempered by the ghastly statistics – corona virus deaths reaching over 9,000 in the UK by Friday 10 April.

Numerous media presenters are posing this question to their interviewees: ‘what will we become and what kind of society will exist after this?’ Some argue that society will change beyond recognition, whereas others reckon the waters will effectively close over our heads and life will go on as before. There have been articles in the Times and Guardian on this topic and it’s worth tuning into Radio 4 (8 pm on Wednesdays) to hear Mary Ann Sieghart present Fallout, in which she poses this very question to a number of interviewees. The first focused on the role and image of the state and politics post pandemic, guests including writer and broadcaster Paul Mason, former Danish PM Helle Thorning-Schmidt and journalist Danny Finkelstein. If you missed it you can catch up on BBC Sounds. 

I’ve long found one of the most important things in life is structure and the capacity to create this for ourselves. Structuring our day and implementing a healthy routine are needed even more at times like this but it can take time to organise and some will find it more challenging than others. Important elements include work, exercise, shopping and keeping in touch with family and friends via email, WhatsApp , Skype or Zoom, even handwritten  letters – remember them?!

When all this is over, I wonder if some of us will be as busy as we were before, flying around from one commitment to another. Will we get used to dressing smartly again rather than donning the same tracksuit bottoms, gym gear or even pyjamas? And will our homes ever be as clean and sorted as some are now, due to the unaccustomed attention they could be getting? As part of clearing and sorting a room, I’ve unearthed my badminton skirt dating from the 1980s and yes, it still fits! What other treasures or complete rubbish could be lurking in our wardrobes, lofts and sheds, forgotten about over the years?

Despite the terrible death toll, it nevertheless seems important to recognise some good coming out of this situation: traffic reduction has led to a significant drop in pollution and we can actually hear birds singing; people may actually be taking more exercise as this is one of the permitted exceptions to lockdown; there are many examples of kindness and consideration, as evidenced by the huge number of volunteers helping in their communities and the NHS; and people are communicating in different ways and checking in with friends and acquaintances they may long have been out of contact with. Perhaps it could lead to a society more focused on the collective good rather than the individual and maybe one more given to reflection, more Being rather than solely Doing.

Corona virus and mental health

Sunday 5 April 2020

“There are decades where nothing happens; and there are weeks where decades happen.”

“There are decades where nothing happens; and there are weeks where decades happen.”

‘So said Vladimir Ilyich Lenin of the ferment of revolution, but he could just as easily have been talking about the 100 days that have passed since the moment corona virus officially became a global phenomenon, the day China reported the new contagion to the World Health Organization. The world has been transformed in that time, perhaps nowhere more so than Britain’. And so wrote journalist and broadcaster Jonathan Freedland in the Guardian recently.

It’s now two weeks since the start of lockdown and most of us have had to accommodate the massive overnight lifestyle changes which come along with that. At one fell swoop, travel was severely restricted and numerous venues we may otherwise visit regularly, such as bars, cafes, restaurants, gyms, churches, cinemas, theatres, libraries and galleries closed, forcing us perhaps more than ever before to access or develop our inner resources and resilience.

During just one weekend came the announcement of Keir Starmer’s victory in the Labour leadership contest (finally allowing some proper opposition), numerous floutings of the lockdown due to the unseasonably warm weather, the Queen speaking to the nation and the Prime Minister being taken to hospital and subsequently moved into intensive care. We’re now getting used to things changing quickly, yet more for us to absorb and needing ministers and policymakers to demonstrate agility and think on their feet.

Sudden changes make significant demands on our mental wellbeing and sense of equilibrium, which could already be fragile. The overnight deletion of much habitual external stimulus will expose vulnerabilities and fears which everyday ‘busyness’ tends to mask. It can also mask longstanding fragility, stemming from insecure attachment and lack of ‘containment’ in early life. (‘Containment’ is the important term coined by psychoanalyst Wilfred Bion to describe the kind of psychological holding, which, if all goes well, the mother or caregiver performs for their infant, which detoxifies their fears and makes them manageable. This function ideally is then ingested by the child and sustains them in the years to come). During adulthood, authority figures such as employers and governments become proxies for these parental ones. We consciously or unconsciously look to them for this same kind of ‘holding’, whereby our anxieties during an unprecedented crisis are ideally met with understanding and made manageable via a considered and effective response we cannot implement as individuals. Therefore, anxiety can be magnified when, instead of sensing and benefiting from genuine authority and capability in our government and policymakers, we witness incompetence and lack of preparedness.

It’s understandable that we chafe against unprecedented restrictions on our freedom, feel frustrated at not being able to get to our normal activities and sad, perhaps even distraught, at not seeing loved ones except via a screen. There are also the ‘first world problem’ irritations of not being able to get to the hairdresser or beautician, and the cancellation of holiday plans, with the attendant hassle of trying to obtain refunds. But these are minor compared with the very real difficulties some are facing, their livelihoods having disappeared overnight and it becoming increasingly clear that the Chancellor’s apparently generous offer will still not be enough.

Added to this there’s the expectation for people to work from home, (unfamiliar for many), the isolation of those living alone, the challenges posed by sharing small spaces, often with no access to garden or balcony, the rise of domestic violence, cancellation of routine but necessary treatment and surgery due to reallocation of NHS resources, and concern about obtaining food, supplies and medication. The government’s initial strategy of ‘herd immunity’, besides stockpiling and panic buying in shops, raised the Darwinesque spectre of ‘survival of the fittest’, exacerbating anxiety across the population. If we’re not worried about becoming ill ourselves, we could be worried about family and friends, about infecting others, about losing work and income with dire consequences like losing our homes, and generally what all this is doing to the social fabric. Added to this anxiety is the stigma and burden many still feel of having to hide their feelings, to appear capable, able to ‘just get on with it’. Stress also exacerbates numerous physical conditions, such as dermatological and gastrointestinal disorders. Then there’s the bereavement experienced by those who have lost those close to them, in circumstances bordering on disenfranchised grief (Doka,1989), where the loss and/or the bereaved cannot be properly recognised or processed and therefore mourned, in this case because of the enforced distance, people dying alone with loved ones unable to say their farewells.

It’s likely everyone’s mental wellbeing will be impacted to some degree, yet the government has been silent about this important aspect of the pandemic, the questions actually coming from one or two journalists at the PM’s daily press briefing. Mental health has long been the Cinderella service of the NHS and evidence of longstanding underinvestment is very clear at times like this. The primary care service (IAPT – Increasing Access to Psychological Therapies) has long attracted criticism for its privileging of Cognitive Behavioural Therapy over relational therapies, limited success rates and its long waiting lists. So anyone expecting help from this quarter is likely to be disappointed, at least in the short term.

A huge mental health burden is likely to emerge post Corona virus, not to mention the position of those in secondary mental health services, including those detained in hospital under the Mental Health Act, many of whom are feeling additionally neglected.

Meanwhile, many counsellors in private practice, who had to switch very quickly to online and telephone working (and they should be undertaking training for this very different way of working), have seen their incomes under severe pressure because of clients not wishing to work in this way or because they can no longer afford it due to their own financial difficulties. Therapists have an additional ethical dilemma to navigate- that of again (much counselling goes unpaid because of an arguably outdated training model of unpaid placements and its widespread exploitation by employers and others) being asked to support NHS workers for low fees or no payment. Because we’re a nurturing profession and because of the longstanding tradition of so much counselling work being unpaid, not to mention empathy for NHS staff, we could feel drawn towards donating our time and many have done just that. On the other hand, self-care is another important principle in our ethical framework and which other caring professions are compelled to work for free? Therapists under financial pressure themselves will have to carefully consider these issues.