key: cord-0870185-1yju49n6
authors: Rivett, Mark
title: Relational lockdown and relational trauma* in the time of Coronavirus: a reflection from a UK family therapist
date: 2020-06-26
journal: Fam Process
DOI: 10.1111/famp.12571
sha: d4a126c7e27e3d20ec47bd4d79e0385415f2dfa3
doc_id: 870185
cord_uid: 1yju49n6

Like a meteor hitting the earth’s surface, 41,698* unexpected deaths have shaken, disturbed and saddened the core of our Nation. This reflection considers the consequences of the Coronavirus crisis on the UK with particular reference to the impact on families and on the practice of family therapists. The perspective presented can only be partial because of the fast changing situation and the limited access to alternative perspectives that is available during this period of relational lockdown. The author provides a systemic understanding of what has happened and what is happening.

The first case of Coronavirus death was recorded in the UK in early March 2020. By the writing of this piece, there have been 41,698 deaths in which Covid-19 has been noted as a cause of death (Wikipedia 2020) . The majority of those who have died have had "preexisting health conditions", are over 60 years of age, and male. Like most health conditions, the prevalence of fatality with Covid-19 mirrors social and financial disadvantage. Further, there is evidence that being from a minority ethnic population increases risk of death even when socio-economic disadvantage is considered. At the start of this pandemic, the UK Prime Minister, Boris Johnson warned the Nation (four Nations: England, Wales, Scotland and Northern Ireland) that families "will lose their loved ones before their time" (BBC 2020a). I doubt anyone understood that those loved ones would be isolated during their final hours. This includes elderly relatives in care homes as well as young babies and children, alone, during their last moments of life. Nor did the nation understand that the consequence of "Stay home, Protect the NHS, Save lives" (the UK Government strapline) would be vast economic turmoil leading, possibly, to an extra 1.4. million unemployed citizens (Independent 2020a) ; further deaths from the shutdown of all other health services (BBC 2020b); vulnerable individuals (children and adults) being exposed to abusive interactions during lockdown (Guardian 2020a ); a potential rise in mental health conditions (through isolation, trauma and the reduction in routine services) (Independent 2020b ); a significant loss of learning within all levels of education; and eye watering levels of national debt unprecedented outside of a world war situation. It would be fair to repeat the hyperboles of the politicians: never has a stable, Western, democratic nation had to withstand such a cataclysm outside of a World War; the last of which is now three generations in the past.

The ramifications of this cataclysm echo in system after system within our country. As I am writing this, the country is taking its first gradual steps out of lockdown and most of us expect the future to resemble a science fiction story in which the survivors emerge from a bunker to view a devastated landscape (Forster 1909) . The enormity of the rebuilding task is beyond both imagination and comprehension. Work, recreation, family life, social

This article is protected by copyright. All rights reserved interactions will all be different. The economic ramifications quite probably mean a generation of young people being under-employed. Small businesses have never seemed so vulnerable while the hospitality and tourism industries appear to have suffered the same catastrophe as large-scale manufacturing did in the UK in the 1980s. This piece will seek to provide some thoughts about the effects of this crisis both on families and on the practice of family therapy in the UK. Many of my comments will be similar to those of colleagues around Europe although we have yet to hear from those who worked through the Coronavirus 'tsunami' in Northern Italy which seriously incapacitated their health system. Almost syntonic with the times, the evidence that will be drawn upon is, of necessity, less robust and reliable than that provided in most academic papers. Undoubtedly, a plethora of research will shortly emerge from more traditional sources, but here I will have to rely on news published on the human creation that has sustained us through these times of Coronavirus: the internet. The fullness of time will let us know if this evidence is substantiated or proves to be "false news".

The day before the emergency was declared, my wife broke her wrist. We were due to attend the International Family Therapy Association conference in Basel, Switzerland but, as it was cancelled, chose to do some walking on the Cornish coast. She slipped and heard the crack. Therefore, throughout the crisis, we have been coping with our own personal crisis, clearly nowhere near as traumatic as the suffering of others around us. But still, it has catapulted us into a family pattern well documented by family therapists (Altschuler 1997; Rolland 2018) in which we 'hunkered down' and a relatively equal partnership became one where one partner was dependent on the other. We both fear that, in the years to come, this "first fall" might stand out in significance because of what was happening around us at the time.

I have chosen to call these times 'relational lockdown' not to imply that there is no human connection happening. After all, systems practitioners know that it is impossible not to be in some sort of relationship. To a systemic sensibility, isolation is simply another form of

This article is protected by copyright. All rights reserved relational context. Rather, I have used this phrase because what has happened has radically affected both the forms and breadth of relating. It has both 'pressed the pause button' and added intensity. It is also worth noting that such a process is profoundly contrary to everything that constitutes "being human" (Harari 2011) . We are a social species (curiously, Coronavirus is a social virus). This has defined our whole evolution.

Having said that, a kind of relational paradox has been unfolding. On the one hand, families have made great efforts to remain in contact with extended family members. In There is some evidence that this family focused inwardness has led to more cohesive families (KCL 2020a; Mirror 2020). One survey reports that four out of five parents think their family has got closer as a result of lockdown. Social media has been full of advice to parents and children about how to spend their time including playing games, learning and exercising together. There has also been a surge in "community" orientation with 750,000 people volunteering under a government scheme to help out older citizens and those who are "shielded" from the virus (The Guardian 2020b). The rhetoric around lockdown therefore seems to be dominated by the concept of the nuclear family. As such, societal challenge has reverted to a narrow view of 'family' in which single people, isolated older people and extended family relationships appear to be marginalised.

But, of course, there has also been a less positive outcome of relational lockdown. The KCL (2020b) survey suggested that almost half the respondents were experiencing high levels of anxiety and depression, almost a fifth were drinking more alcohol and a fifth reported more arguments within their families during this time. Many young people (42% KCL 2020a) described "really struggling" with the restrictions on their ability to meet friends and partners. Domestic violence support services have seen a rise in referrals (The Guardian 2020b) and the Police have been called to more mental health 'incidents'

This article is protected by copyright. All rights reserved (Independent 2020b) . Contrary to the rosy view about family life becoming more cohesive, while presentations to Accident and Emergency Departments have halved over the lockdown, at least one hospital reports that sibling on sibling injuries have increased by 150% (BBC 2020d).

The relational paradox also seems present in our relationships with other citizens.

Despite the recorded rise in community feeling, the virus (and government messages) have often promoted fear. One insidious aspect of 'social distancing' (in parks and supermarkets) reinforces the idea that the 'other person' might be infectious. To make matters worse, they may be asymptomatic and not suffer the consequences of infecting us! There are, within the family therapy world, a number of self-evident truths. One is that social calamity always hits the disadvantaged more than the socially privileged. Another, is that disadvantages have a compounding effect. So just as those who have "preexisting health conditions" are more likely to be harder hit by the virus, those families that are already suffering from psychological problems are more likely to be worse affected by

lockdown. An unhappy couple relationship is unlikely, after all, to blossom into joy when the couple are together 24/7. Finally, in large part, how a family manages during the lockdown will be related to which stage in the family life cycle they are in ( Le Grange 2013). In the current situation, the young people are acutely conscious that they cannot get back on the appropriate developmental trajectory. Moreover, treatment relies on helping the parental system to be more containing of their young person's distress. Significant work is done on helping the parents act as a team (even if they are not a couple). In relational lockdown, all the stresses of helping their young person are amplified with no distractions or escapes from the task.

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In this clinical situation, myself and my team are constantly having to enquire what our families wish to do: 'tread water' during the crisis and delay the challenges of change until we can support them face to face, or manage the consequences of change without the consistent backing of our service. Each option entails aspects of risk that would not have been present but for the lockdown (Independent 2020). One risks the eating disorder continuing and blighting the young person's development for longer. The other risks an escalating emotional dysregulation that might lead to admission. As a family therapist, this is a very difficult place to inhabit. The experience feels as if I have a hand tied behind my back. The only clinical way it can be managed is to collaborate almost on every statement and every intervention in order to match the family's current capacity. It is too soon to know if there has been a rise in in-patient admissions (paediatric or psychiatric) during this crisis but anecdotal reports suggest that young people might be presenting in more acute situations.

The National Health Service (NHS) has a particular place within UK national culture (Welch 2018) . Founded in 1948, almost every citizen has some form of relationship to Most UK family therapists work within the NHS, often with a "mixed portfolio of employment" including some private work. One survey of UK family therapists found that 80% worked for the NHS (Street and Rivett 1996) . The Coronavirus crisis has had a number of impacts on this health system. Firstly, all resources have been temporarily diverted to manage the demand caused by patients with Covid-19 symptoms. This has included the effective closing down of a range of "routine" services including regular screening programmes, cancer treatment and all dentistry. Luckily for us, orthopaedic services have remained active. Secondly, NHS staff have been redeployed into areas

This article is protected by copyright. All rights reserved where the Covid-19 need is high. So, nurses who have worked in mental health services have been asked to work on wards. Some mental health wards have been designated dual words for psychiatric patients who have Covid-19. Some psychological staff have joined "well being" teams to offer support to frontline workers. Within mental health services, except in acute psychiatry, face to face work has largely been suspended due to the infectiousness of the virus. Most family therapists have therefore had a steep learning curve in the delivery of online therapy (Salivar et al 2020) .

Unfortunately, the NHS, which is excellent at physical crisis management, has very poor IT infrastructure. Equally, it has stringent confidentiality procedures which preclude the 

This article is protected by copyright. All rights reserved Family Therapy Association (EFTA 2020) has also started developing evidence around the use of digital family therapy. This debate is limited by the lack of research into 'online family therapy' in contrast to the evidence that our CBT colleagues can draw on (Andersson et al 2014) .

As noted above (Independent 2020a; there are suggestions that after the lockdown, mental health services may be as severely stretched as their physical health colleagues have been during the crisis. It is worth noting that until this crisis, UK health policy had been aiming to reach a funding situation in which 'mental health' and 'physical health' were funded equally (Gov.UK 2015) . This pandemic seems to have dented that policy, if not made it obsolete.

Prior to Coronavirus, the UK was still grappling with the divisive consequences of the Brexit referendum in 2016. This pandemic has constituted a very different social trauma.

Almost certainly, there will be an enquiry into how our Government behaved and how the scientific advice did or did not help prevent further deaths. It may be that this enquiry will function in a similar way to the 'Truth and Reconciliation Committees' in South Africa.

What we can say, is that no nation can lose 41,698 of its citizens, with the ripples of each death giving pain to so many loved ones, without experiencing trauma. This trauma is possibly a unique kind of trauma, not one that is reflected in the family therapy literature on trauma itself (Charlés and Nelson 2019; Coulter, 2013; Figley and Figley 2009; Landau et al 2008; Mendenhall and Berge 2010; Saltzman 2016; Walsh 2007 

This article is protected by copyright. All rights reserved Once more the pandemic introduces a complexity to the concept of "mass trauma". All of them highlight the role of family and community resources to promote resilience and recovery. This undoubtedly will be the place where family therapists can offer their skills later on. But in the foreseeable future, the isolation of social distancing will surely act to compound the struggle to heal and rebuild. The major UK government message (apart from regular hand washing) is that "we are all in it together". And yet, it is only by TV and social media that the connections of society are being maintained. In many ways we have become even more of a "society of the spectacle" as predicted by the Situation Internationalists in the 1960s (Plant 1992) . In this case, relational lockdown acts as a kind of barrier to immediate experience, to vivid engagement with each other's suffering.

The risks of not finding a way of harnessing these family and community resources is noted by all the trauma writers: increased individual and family difficulties; social expression of anger and resentment; and blame being attached to specific populations (often racial groups). Landau et al (2008) also point out that within a society which is coping with a trauma, there is frequently a process of "transitional conflict " (2008: 196) because different family members; different families; different sections of society experience the trauma differently. This is likely to lead to factionalism and polarised positions rather than a communal ethic of working together. The Coronavirus has affected different parts of the UK very differently. The cities have largely been hubs of infection and mortality. Like in other nations, coffins have had to be stored in containers awaiting time for burial. But other parts of the country have been relatively free of infection: leading to signs asking for "city folk to stay away". There is also evidence that the different nations within the UK are responding to the virus in different ways especially in managing the easing of restrictions. The risk therefore, is that divisions will not heal but will expand and blame will become the predominant pursuit of influencers, politicians and journalists. There can be no greater clarion call for systemic thinkers than this.

All the trauma writers comment about the possibility of "traumatic growth" arising out of a collective challenge. Walsh states:

This article is protected by copyright. All rights reserved "traumatic experience often yields remarkable transformation and positive growth" (Walsh 2007: 208) .

The EFTA website also asserts:

"most families build family/social resilience out of crises/adversity" (EFTA 2020) Media commentators (and ecologists) are emphasising that society "will not go back to the old ways" (BBC 2020c). They cite more working from home, less commuting, more exercising outdoors and an increase in local holiday making. But systems theory might predict "homeostasis" will be an equal (if not stronger) pull. I think we are all yearning for "things to get back to normal". It also feels very insensitive to consider positives in this crisis when so many families are losing loved ones and others are losing their livelihoods.

However, there is a general agreement that online working: teaching or providing therapy, is here to stay. Universities are talking about a 'blended' curriculum (meaning a mixture of online learning and face to face). The University of Cambridge (BBC 2020b) has already announced that for the 2020-2021 academic year lectures will stay online.

Mental health services are talking about the cost savings of online therapy. Families are getting used to receiving services within their own homes and some find it more accessible because of this. It is easy to understand the appeal of online therapy when the alternative (at present) is to offer therapy while all participants are dressed in full PPE (Personal Protective Equipment).

In the UK, debates about training excepted, family therapy has moved online. There are now some excellent guides available about how to 'do' online therapy (AFT 2020b; Levy et al 2020). My own favourite 'tip' is to have more than one device running for each family so individual reactions can be integrated into the session. Clinicians now need to develop competencies in this mode of intervention, and a range of courses are being set up. But we still do not know whether it is as effective as face to face therapy, although Salivar et al (2020) provide some evidence that an online version of Integrative Behavioral Couple Therapy is as effective as the 'live' version. The examples that we have might imply that this medium could benefit some of the more manualised family therapy models (Levy et al 2020) rather than the more conversational and social constructionist ones. Nor do we

This article is protected by copyright. All rights reserved know if all the family therapy competencies can be demonstrated in online therapy (Gehart 2010; Nelson et al 2007; Stanton and Welsh 2011) . As a teacher of family therapy, I believe that the 'process' skills of our craft (e.g. attending to interactions within sessions) are much harder to evidence in a piece of online therapy.

UK family therapists are also noticing that online therapy does not always work in the same way, or as well as face to face therapy. For instance, I have heard of a client who had to sit against the door while talking to her therapist to avoid her children interrupting the session*. Not all families have the ability or financial capacity to use online therapy.

The Office for National Statistics (2019) about what they miss in providing online therapy. One of the significant 'losses' of online therapy is that human bodies are not interacting with each other. It is difficult to quantify exactly what this takes away from therapy, but we know that family therapists are conscious about this embodied dimension in their work (Bownas and Fredman 2017; van der Kolk 2015) . The lack of embodied presence relates to an idea first proposed by Turkle (2017) that the online world is one in which we are "alone, together". Petriglieri, (2020) has crystallised this experience in his pithy phrase that "it is easier being in each other's presence, or in each other's absence, than in the constant presence of each other's absence". There may therefore be a further paradox in the way Coronavirus is affecting family therapy: the new medium of therapy rather than overcoming isolation (Entis 2020 ) may in fact be replicating it. For UK family therapists, who have largely retained some team working within their week, the new online world reduces their contact with colleagues in ways that almost certainly will diminish job satisfaction.

Throughout the ages a range of spiritual teachers have exhorted human beings to accept the uncertainties of their lives (Watts 1988) . We now seem to be living in an uncertain world. We do not know how many more colleagues, friends and family members will lose

This article is protected by copyright. All rights reserved their lives to this virus. In the UK, we sit on a knife's edge wondering if we will experience a 'second peak' (or even a 'third peak'). We cannot know when we will be able, once more, to actually meet our clients and work with them face to face. We cannot predict the unique psychological problems that arise from this virus that will challenge our clinical creativity. But we do know how to help families bear what seems unbearable, and to mourn fruitfully.

My wife's cast came off last week and the tough pain of recovery is just starting. 

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