Dr Jo O’Reilly is a Consultant Psychiatrist in Medical Psychotherapy at the Camden and Islington Psychodynamic Psychotherapy Service. She is also a member of the British Psychoanalytic Society. Jo talks here about the kinds of familiar and potentially unhelpful processes that get going in organisations at highly challenging times like these, with some suggestions about how we can try and respond from wherever we sit in the organisation. Her starting point is a mental health trust, but the difficulties are shared across working settings and being better prepared to manage them can make a big difference. To accompany this podcast we have added three resources; Using Controlled Breathing During Covid-19, Using Grounding Techniques During Covid-19 and Coping With Anger And Irritability During Covid-19, which we hope you will find useful.
Hello my name is Jo O’Reilly. These are extraordinary times and our health services are under great strain. The wellbeing of an organisation is fundamental to the staff that work within it and to their ability to carry out their work. I’m going to be talking in this podcast about how all staff can contribute to supporting the mental health trust in a simpler way as possible during the coronavirus pandemic. In ordinary times, anxiety is managed and dilemmas are thought about in discussions with colleagues, supervision, meetings from clinical teams to trust board level. In a well-functioning organisation there is a hierarchical framework of activities, proving containment for anxiety in a multi layered way, which enables staff to perform their specific roles within their team. Support for the process of thinking is embedded within the fabric of the organisation, through these activities. These are extraordinary times however; COVID-19 brings a unique fear and level of threat related to survival. There is no blueprint to draw from; we are learning as we go along; there are few certainties.
The place of work and contact with our patients has become a potential source of danger. The ability of the mental health trust to manage anxiety has never been more important. So what can help the mental health trust to function in a healthier way as possible during the current crisis? I have 10 points to suggest.
- Anxiety and emotional distress at this time permeates every level of the organisation and challenges the ability to think. This affects all staff. It’s important to establish a culture and activities such as buddy schemes within which all teams and all staff check in with themselves and others about how they are doing. These can normalise anxiety and distress as entirely understandable responses, affecting us all. Identify particular vulnerabilitors and stressors within yourself and colleagues and have a low threshold for seeking further support. Increased uses of defences against anxiety may become problematics. Omnipotence is a common defence in healthcare professionals, in which we carry on as if we are invincible. This can place us at unnecessary risk of infection or emotional strain. All staff need to be realistic about their vulnerability. Look after your own health, follow precautions, use the protective equipment as advised and point out to colleagues when they are not doing so. Projection and splitting also increase when anxiety increases, which may mean uncomfortable feelings of helplessness or inadequacies may become located in others. This creates divisions between teams when we need unity. Avoid terms such as “non-essential services” or other urges to behave in such ways which may exacerbate such splits. Excessive projection in to managers to “do something” can also leave other staff losing their own agency and ability to contribute to the crisis. We are all in this together and we have something to contribute.
- Avoid the urge to “do” as a response to anxiety. Immediate and precipitative actions can create further anxiety in the long term. A degree of anxiety is inevitable and understand and we need to find ways to stay with this. Check that your decisions and behaviours are coming from a place of thought, rather than as an overreaction to anxiety or are based on panic. Running decisions by a colleague to think through usually helps. A word about emails; because of their rapidity and their wide reach, emails can be powerful vehicles to discharge anxiety into others. Take care when you write to people and watch out especially at times of peak anxiety, when writing a quick email may be an attempt to release anxiety within yourself and can create anxiety in others.
- Maintain, attend and support usually activities as much as possible. The organisation functions in some ways like a living organism, in which a change in one part of the system affects the whole. Closure or suspension of services causes further destabilisation and strain elsewhere and can make staff and patients more anxious. Education activities should continue in adapted forms where possible. There are opportunities for new learning and this also demonstrates that the senior staff and supervisors are not overwhelmed, which contains trainees and other staff.
- Maintain and increase opportunities for thinking and emotional containment. Excessive anxiety paralyses thought and leads to fight-flight modes of behaviour and decisions becoming led by anxiety, anxiety becomes the tail that wags the dog as it were. Increased anxiety in staff needs increased opportunities in the organisation to address it, reflective practice and opportunities to think about the emotional impact of the work and the dilemmas which arise should be continued and increased throughout all levels of the organisation, using remote platforms. These support staff to tolerate the discomfort of anxiety without becoming overwhelmed and enable them to perform their roles, whilst limiting contamination with anxiety from other parts of the organisation.
- Maintain differentiation of staff roles as much as possible, staff are not equally exposed to risk within the organisation and this needs explicit acknowledgement. It may be unfair, it is role dependent, and is a reality which cannot be avoided if staff more exposed to the virus are to have their specific needs attended to. Guilt in staff not working in the hot-spots of the organisation is increasingly and understandably being expressed. All staff can be helpfully reminded that they have skills to offer which will be needed at different stages of the crisis and they can best contribute from their areas of expertise. Unless acknowledged, guilt may lead to staff taking unnecessary and unrealistic risks, or putting themselves forward for roles they are not equipped to do.
- Leadership. The leadership of the organisation is crucial in setting the emotional tone and supporting staff to do their work. It is also having to make some very difficult decisions at the current time and needs the support of the staff. Establish regular, open and consistent channels of communication from the senior managers and use this to show that the leadership really wants to know where the areas of difficult lie. It’s really important that staff feed back to the leadership team and that they see how their feedback is contributing to decision making. It is also really important that the senior managers recognise helplessness and loss of control in the workforce as contributing to anxiety and to try to mitigate this as much as possible. Avoid overly positive messages which turn a blind eye to difficulties and which can undermine trust and increase anxiety within staff. The leadership team also model an attitude of curiosity and learning from experience when things go wrong. A hallmark of healthy functioning is not that the organisation and its staff make mistakes, we all do, it’s how the organisation responds when it gets things wrong.
- Team and colleague relationships are key to how we perform our tasks. Redeployment leads to loss of usual peer relationships and new teams are being rapidly created in which staff are carrying out new tasks. Don’t give up activities such as supervision and team meetings because the teams have changed. They are of even more importance in new teams where staff may be carrying out unfamiliar tasks and need peer support more than ever.
- Triggers and blind spots. Encourage all staff to be mindful of their internal states. Fear and threat trigger reactions based on previous experiences of trauma and loss, and teams will have their triggers and blind spots reactivated by anxiety. A team recently traumatised by patient suicide for example may have particular anxieties about further deaths in their patient group and may need additional support. Making these links helps to unpick anxiety and to process it, relieving some of its effects.
- The need for unity. Be kind to one another. Functioning during a crisis calls for unity. Increased stress will hit upon pre-existing tensions in the organisation. Expect this, it can be addressed later, and is best not done so in the heat of a crisis.
- Start preparing for recovery. This will not last forever; recovery will require opportunities for staff to process their experiences at work and should be negotiated with teams. If not addressed, challenging and traumatic experiences are likely to continue to exert their influences within the organisation. Loss and mourning for the workplace as being able to protect and adequately care for its staff will need to be openly worked through, to prevent ongoing grievance which can prevent psychological recovery. New ways of working, creative solutions, increased working across teams and cutting back of unnecessary tasks will also have emerged from this. The organisation will also have had an opportunity to learn about itself, its strengths and limitations, which can be taken forward as the basis for its continued development.