Editors Picks Home Categories Social commentary

Too much to lose? Why OnlyFans fails to censor its explicit content

Dr Elena Martellozzo and Paula Bradbury of the Centre for Abuse and Trauma Studies (CATS) warn about the impact of OnlyFans’ decision to keep allowing users to post nude content

OnlyFans, a subscription-based social media platform where users can sell and/or purchase original softcore or X-rated content, has come under scrutiny in recent weeks for restricting its sexually explicit content and, a few days later, for changing its mind.

Created by a London based company, this controversial content-sharing platform allows creators to share paywalled or subscriber-only content. This model has earned the company billions from its more than 120 million users, by applying a 20% fee for the created content. This has been financially advantageous to both the company and the creators, with the top 1% of creators earning six figure sums per year.

Whilst OnlyFans initially took an ‘anything can be uploaded’ approach to user content, on 19 August, in response to concerns of banking partners and payment processors about potentially illegal content, the platform decided to restrict the availability of its sexually explicit content. People would still be able to post nude content on the site, but this would have to be in line with OnlyFans’ policies. However, just a few days later, the decision to restrict the availability of sexually explicit content was overruled following widespread backlash from its users. In a response, OnlyFans defended the decision noting that it “is short-term good news for sex workers reliant on the platform.”

However, what does this mean for the platform’s responsibility to protect users?

Exploitation of children

Over the last few years, concerns have been raised about the sexual exploitation of individuals using OnlyFans after revelations that some under 18s, particularly girls, have been circumnavigating the age verification measures and setting up their own accounts to upload explicit images of themselves in exchange for money or gifts. Experts working in child protection are concerned that sites such as OnlyFans may be used by adults who are interested in targeting those who appear significantly younger than the rest of content creators. As we have previously argued, whilst the site might have changed sex work forever by creating a safe environment for sex workers to engage with their clients, it has also opened up a new arena for inexperienced and naive young people who are tempted by the financial rewards, yet not subject to the usual legal protections for under 18s.

It is indeed a dangerous temptation. The law in the UK is very clear: it states that to be able to sell or distribute explicit content the creator must be 18 or over. Yet there is currently no legal requirement for online platforms to monitor explicit content that might have been generated by underage users. This suggests that both the underage person creating the content and the person that buys it could face criminal liability.

This image has an empty alt attribute; its file name is shutterstock_2027924147.jpg

Adults are not risk-free

There are also a number of harms and risks posed to adults who join the site as content creators. In a recent interview on BBC Radio 5 Live, one female content creator, Camilla L, reported making over a million dollars a year but has, as a consequence, been greatly affected by stalkers who send her messages reporting their observations of her movements, causing her to move home and live constantly in fear. The platform creates the risk of cyberstalking, yet is not doing anything to address this.

OnlyFans has being used by ex-intimate perpetrators of stalking to sell images of their victims – a practice known as image-based abuse (IBA). IBA occurs when an intimate image or video is shared without the consent of the person pictured and stalking advocacy agencies have reported a significant increase in the rise of this form of crime. This further highlights how important it is that OnlyFans becomes a true partner to its creators and protects all users from abuse and non-consensual posts.      

The debate over ‘explicit’ content

These risks contributed to the pressure on OnlyFans that led to the short-lived ban on explicit content. But it is also critical to reflect on the potential risks of pushing content creators away from this site, into possibly darker and less regulated corners of cyberspace, and therefore important to consider the potential benefits of a platform which provides a safer, more visible and regulated environment for sex workers.

The key is doing more to protect users

OnlyFans’ decision not to ‘explicitly’ change, however, appears to be purely financial. This focus also overlooks the importance of doing more to protect its users, such as more effectively regulating or preventing minors from accessing the site; tracking down and stopping sex perpetrators, and protecting all users from abuse and non-consensual posts. This view was supported by Honza Cervenka, an English lawyer representing victims of discrimination, harassment and non-consensual pornography, who told us that OnlyFans has yet to “properly and diligently check that all content on the page is legitimate and consensual. The reason for this is because it is simply too laborious, expensive and eats up into their profit margins”.    

While the company claims to be evaluating more than 300,000 media files a day and has more than 500 agents involved in compliance and moderation to flag content, artificial intelligence is not always reliable for detecting all types of harmful material. As argued by Professor Aiken, ‘cybersecurity does not protect what is to be human‘. If OnlyFans would train experts to ensure that moderation is carried out successfully, it could allow for creators to continue to produce content in a safer environment.

The steps that OnlyFans has taken so far to protect its users have been unsatisfactory, to say the least. In May 2019, the platform introduced a new account verification process whereby the creator must provide a ‘selfie’ along with their ID on the image to prove their identity. However, this proved to be a futile system, as underage users have been able to use adult ID’s to create fake accounts.

More robust action is needed, and the UK government indicated that one of the aims of the 2017 Digital Economy Act was precisely “to have robust age verification controls in place to prevent children and young people under 18 from accessing pornographic material”. However, the long-awaited Online Safety Bill has left us somewhat disillusioned, as an effective and trusted method of age assurance has yet to be mandated to prevent under 18s from accessing sites like OnlyFans, which permit them to sell and access explicit images and puts them at risk of exploitation. So why wait any longer to build the digital environment they deserve?

This blog was originally published by Media@LSE.

About the authors

Dr Elena Martellozzo

Dr Elena Martellozzo

Dr Elena Martellozzo is an Associate Professor in Criminology at the centre for Child Abuse and Trauma Studies (CATS) at Middlesex University. Elena has extensive experience of applied research within the Criminal Justice arena. Elena’s research includes online stalking, exploring children and young people’s online behaviour, the analysis of sexual grooming and police practice in the area of child sexual abuse. Elena has emerged as a leading researcher and global voice in the field of child protection, victimology, policing and cybercrime. She is a prolific writer and has participated in highly sensitive research with the Police, the IWF, the NSPCC, the OCC, the Home Office and other government departments. Elena has also acted as an advisor on child online protection to governments and practitioners in Italy (since 2004) and Bahrain (2016) to develop a national child internet safety policy framework

Twitter: @E_Martellozzo

Paula Bradbury

Paula Bradbury

Paula Bradbury is a Criminology Lecturer and Doctoral Researcher within the School of Law at Middlesex University, exploring the appropriateness of current policy and practice relating to adolescent sexual offending and sexual behaviour between peers. She is passionate about researching online sexual offending behaviour and child abuse.

Paula is an active member of the CATS team engaging in multiple research pathways to combat child sexual abuse both online and offline as a mixed methods researcher proficient in both quantitative and qualitative analysis, and project management. She is also the National Child Sexual Abuse Lead for Victim Support, serving as a project manager developing online support content for adult survivors or child sexual abuse. 

Twitter: @PB_Cybercrime

Coronavirus and COVID-19 Health & wellbeing Social commentary

Cash for kink: the online risky sexual behaviour by young women during COVID pandemic

Dr Elena Martellozzo and Paula Bradbury of the Centre for Abuse and Trauma Studies examine the impact OnlyFans has had on young women during the coronavirus pandemic.

The existence of OnlyFans predates the COVID-19 pandemic lockdown of 2020, but its popularity and notoriety increased significantly over the last year. OnlyFans came to our attention through celebrity endorsements, other social media platforms, and apps. Notably, there was also the BBC Three documentary entitled Nudes4Sale.

This British investigative documentary revealed how thousands of people across the world – including celebrities, ordinary members of the public and, more concerningly, teenagers – are making a healthy profit from selling self-generated sexual content for cash through the platform OnlyFans. On OnlyFans you earn money by gaining member subscriptions and by generating content that people want to pay for. The girls featured in the documentary reported to be earning as much as £35,000 in a single month. We now know that potential earning figures go way beyond this.

A woman wearing a t-shirt looking at a laptop. Photo cropped so the woman's head is no visible

But these kinds of successes are unique, and only experienced by the few – leaving a significant number vulnerable to a darker side of OnlyFans, and the manipulative and predatory behaviours of individuals that operate within it.

With a fast-growing subscription of more than 200,000 new members every 24 hours, it’s easy to see how enthusiastic endorsements by the likes of Beyoncé and Cardi B make OnlyFans an attractive site for young women.

What the endorsements don’t show, though, is that OnlyFans is a fiercely competitive market where young women fall into a cycle: they are compelled to raise their game by sharing more and more of their bodies, and perform sexual acts requested by subscribers to maintain their interest, increase their popularity and earn more money.

The women in the Nudes4Sale documentary had all received messages from subscribers asking them to participate in offline sex acts. One of the girls interviewed in the documentary, Lauren, admitted that she received messages offering £5,000 for sex. While Lauren can afford to say no, many less successful young women – potentially young teenage girls – cannot. And so, they’re lured into danger with the promise of money.

And during a pandemic, having an income is more crucial than ever.

“It’s impossible to say precisely how lockdown is impacting our behaviour and what the side effects will be”, said Anne Marie Tomchak, in her recent piece in Glamour,  “but there are already indications that more nudes are being requested and sent during this time as people increase their digital interactions while staying at home, and OnlyFans reports a spike in activity.”

OnlyFans sparked a global media response to rising concerns of adolescent online risk-taking, and the legal ramifications of creating, distributing and possessing sexual images of a minor – laws which children themselves are no less impervious to.

A 2020 report published by the IWF revealed that they have identified a 44% increase (of all intercepted content) in the number of self-generated indecent images produced by children, of which the most prolific age group is girls between 11 and 13.

COVID-19 and child protection

The COVID-19 global pandemic has not only revealed our vulnerabilities to biological viral threats, but also to our ability to protect our children online.

In the midst of lockdown, COVID-19 has facilitated a greater opportunity for digital immersion. While the internet opens up a plethora of positive opportunities for individual growth and self-acceptance, there is also the potential for great harm to be caused against the most vulnerable in our communities; children and young people.

Immature cognitive development and reduced capacity to self-regulate has left children at risk from criminal accountability, sexual predators, and the dark side of the online sex industry (Naezer, 2018). With the easy opportunity to view pornography and violent content at the click of a button, there’s also the easy opportunity to produce it, and sell it to those with a sexual predilection in children (IWF, 2020).

In 2021, the online marketplace for sharing sexual images for cash is no longer dominated by the sex industry and adult sex workers. It is a phenomenon that goes beyond regulation, and is being dominated by teenagers as purveyors for their self-production of nude, semi-nude, on-demand kink images and videos for online clients.

Andy Burrows, head of child safety online policy at the NSPCC, said:  “We are concerned that there are risks to be associated with user-generated explicit abuse content sites, such as Only Fans, which are worthy of substantive academic focus. This relates to children being readily able to access inappropriate and sexually explicit content, both on the site itself but also as a result of user generated content being posted as ‘trailers’ to social networks.”

What can parents do?

We would encourage all parents to familiarise themselves with social media, particularly those platforms which are popular with young people. Don’t assume that your teen will not visit sites such as OnlyFans.

Parents need to be aware that social media apps such as Instagram, Facebook and Snapchat are the most commonly used platforms for sex offenders to target and groom children, at a rate of 37% of recorded cases for Instagram alone (NSPCC, 2020).

Tiktok has aggressively responded to the high volume of Onlyfans members who prolifically use their platform to advertise links to their accounts and content by introducing stricter community guidelines, but as the authors have seen, a large volume falls beneath the radar which includes sexually explicit information about sex acts, fetishes and violence. Many Onlyfans members simply create a new account once removed.

If you discover that your child is actively engaging with such sites, don’t make them feel guilty. It’s not your child’s fault. Children often visit such sites through peer pressure, general curiosity or simply by accident. However, do prevent them from accessing it in future. It may not make you a popular parent, but it’s what needs to be done to keep your child safe, online and offline. We recommend the following:

  • If you don’t have a filter on your child’s laptop or home computer already, make sure you get one as soon as you can
  • Browse your teen’s tracking history. If you see OnlyFans on there, that’s a red flag
  • Scan your credit card for any charges that look like they may be from OnlyFans
  • If you suspect your teen has been on the site, have an honest discussion with them about online safety
  • Talk to your teen, in general, about the damaging effects of pornography
  • Make sure your child understands that they never know who they’re talking to online, and that by sharing personal information they’re putting themselves at risk.

Martellozzo et al (2020) found that stumbling across inappropriate content can have significant adverse impacts for children and young people. This includes distorting their view of sex and relationships, and potentially having a desensitising effect for some young people.

Online pornography is increasingly widely identified as an influence on children’s and young people’s sexual lives (Crabbe & Flood, 2021) . Whether we like or not, pornography is recognised as an important part of young people’s sexual socialisation and deserves to be addressed with young people. The existence of sites such as OnlyFans should be included in the discussions.

About the authors

Dr Elena Martellozzo

Dr Elena Martellozzo

Dr Martellozzo is an Associate Professor in Criminology at the centre for Child Abuse and Trauma Studies (CATS) at Middlesex University. She has extensive experience of applied research within the Criminal Justice arena, and her research includes exploring children and young people’s online behaviour, the analysis of sexual grooming and police practice in the area of child sexual abuse.

Dr Martellozzo is a prolific writer and has participated in highly sensitive research with the Police, the IWF, the NSPCC, the OCC, the Home Office and other government departments. She has also acted as an advisor on child online protection to governments and practitioners in Italy (since 2004), Bahrain (2016) and the Rwandan Government (2019) to develop a national child internet safety policy framework.

Twitter: @E_Martellozzo

Paula Bradbury

Paula Bradbury

Paula Bradbury is a Criminology Lecturer and Doctoral Researcher within the School of Law at Middlesex University, exploring the appropriateness of current policy and practice relating to adolescent sexual offending and sexual behaviour between peers. She is passionate about researching online sexual offending behaviour and child abuse.

Paula is an active member of the CATS team engaging in multiple research pathways to combat child sexual abuse both online and offline as a mixed methods researcher proficient in both quantitative and qualitative analysis, and project management. She is also the National Child Sexual Abuse Lead for Victim Support, serving as a project manager developing online support content for adult survivors or child sexual abuse. 

Twitter: @PB_Cybercrime

Coronavirus and COVID-19

Social capital and COVID-19

Tom Dickins, Professor of Behavioural Science, explores the notion of social capital in the context of the COVID-19 pandemic.

People are a resource for one another.  Groups therefore have social capital as a consequence of network structures and the properties of individuals. Bonding social capital refers to networks of highly similar individuals and bridging social capital is found in networks of dissimilar individuals.  Finally, linking social capital is a property of networks formed between individuals and institutions.

Social capital can facilitate disaster survival and recovery [1], positive environmental interventions [2] and resilience during pandemics [3]. 

A pan-European study of the COVID-19 pandemic of 2020/21 revealed the following:

First, we find that high-social-capital areas accumulated between 14% and 40% fewer COVID-19 cases between mid-March and end of June. Likewise, high-social-capital areas also exhibit between 7% and 14% less excess deaths in Great Britain, the Netherlands, Italy, and Sweden. A one standard deviation increase in social capital could have prevented between 459 deaths in Sweden and 8,800 deaths in Great Britain.

Second, we find qualitatively similar patterns across all independently analysed countries, which we regard as strong evidence for the robustness of our empirical results.

Third, we show a consistent dynamic pattern – the number of COVID-19 cases is initially higher in high-social-capital areas. However, as information on the virus spreads, high-social-capital areas start to show a slower increase in COVID-19 cases in all seven countries. The role of social capital diminishes as soon as national lockdowns are enforced. [4]

One interpretation is that in highly bonded social networks SARS-CoV-2, the virus responsible for COVID-19, will have been able to spread with ease.  But once the risk was exposed, those same groups who by definition have well-established norms of cooperation, are more likely to organise to protect themselves by considering the community situation, prior to the imposition of lockdowns.

Challenges to social capital

Inequality impacts negatively upon health [5,6] and the most serious outcomes of COVID-19 will be unevenly distributed across socio-economic strata [7,8]. 

In a systematic review, Uphoff and colleagues found that lower socio-economic status was associated with lower social capital and poorer health outcomes [9].  But bonding social capital could act to buffer low socio-economic status people against some of the worst effects of somatic and mental poor health. However, being poor reduced bridging and linking capital and this was also linked to poor outcomes.

Poverty under inequality amounts to irregular and low value resourcing where futures are unpredictable. This makes it hard to stabilise extended reciprocal interactions over time as any failure to repay a debt outweighs the minimal benefits of help further down the line.

Trust is more likely to form within a close group of similar people with whom values can more easily be communicated and norms for processing what is owed can be readily established: if you see each other all the time there is less opportunity for defection from social contracts. 

Forming such alliances with dissimilar people and institutions is a riskier proposition.  It is known that distrust of authorities by socio-economically isolated groups prevents uptake of public health interventions [10].  We might therefore predict that individuals with reduced bridging and linking capital will be more resistant to current public health messages about COVID-19 and perhaps more likely to violate restrictions and less likely to engage with subsequent recovery plans including vaccination. 

That resistance might be socio-economically distributed, as suggested, but we should also note that prolonged social isolation will increase everyone’s reliance upon bonding capital whilst measures are in place.  Any distrust of institutions will be magnified by this isolation and further compounded by changing messaging as a complex pandemic unfolds.

Social capital in a digital age

It is not only health interventions that rely upon bridging and linking capital.  As we remain at home we increasingly rely upon digital technologies but access to devices that can deliver on all tasks is unequally and socio-economically distributed.  

For example, home schooling has put delivery of our national curriculum into the hands of parents.  The plethora of online material to support this is impressive but not all families have the relevant or sufficient technology to teach their children.  There are schemes to help but they are not well advertised and they require brokering by parents with schools, thereby relying upon linking capital to make them work. Given that poorer groups within the UK are likely to have less experience of linking, of negotiating, of simply asking for help, it is likely that not everyone who should be will be supported.

A full strategy would take account not only of missing technology, due to inequality, but also of the way people will seek help; poverty will heavily weight bond social capital and stop broader search strategies.

Pitas and Ehmer [3] state that the US Government should invest in growing social capital in order to facilitate management of and recovery from the current pandemic. But they suggest mobilising digital technologies to do this for bridging capital, without recognising that this is potentially excluding. 

One thing this crisis reinforces is the idea that digital connectivity is a human right due to our reliance upon it to manage the quotidian and the extraordinary.  That right must be extended to all, and public health spending on the distribution of tablet technologies and internet access to all could facilitate social capital gains and improve resilience. 

A similar lesson should be drawn at the global scale where there are marked inequalities and outcomes.


The social resources we have are affected by socio-economic realities, and both impact upon our health and resilience.  Existing inequality will affect outcomes during the current COVID-19 pandemic but interventions will also impact upon social capital in ways that might exacerbate existing risks of disengagement. 

More generally, bridging and linking social capital will prove important for managing other aspects of the crisis.  Policy makers should attend to these effects and think about how interventions will be accessed by those with relatively reduced social capital.

To attend to social capital is to attend to our ghettos and to break down their walls.  Doing so will reduce inequality, improve health, and increase creative engagement with the problems of the world. 

We need to do this now because we will face future disasters together.


  1. Hawkins RL, Maurer K. 2010 Bonding, bridging and linking: How social capital operated in New Orleans following Hurricane Katrina. Br. J. Soc. Work 40, 1777–1793. (doi:10.1093/bjsw/bcp087)
  2. Dahal GR, Adhikari KP. 2008 Bridging, Linking, and Bonding Social Capital in Collective Action. CAPRi Work. Pap.
  3. Pitas N, Ehmer C. 2020 Social Capital in the Response to COVID-19. Am. J. Heal. Promot. 34, 942–944. (doi:10.1177/0890117120924531)
  4. Bartscher AK, Seitz S, Siegloch S, Slotwinski M, Wehrhöfer N. 2020 Social Capital and the Spread of Covid-19: Insights from European Countries. SSRN Electron. J. (doi:10.2139/ssrn.3616714)
  5. Marmot M. 2010 Fair society, healthy lives. Public Health 126 Suppl, S4-10. (doi:10.1016/j.puhe.2012.05.014)
  6. Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. 2020 Health Equity in England: The Marmot Review 10 Years On. London: Institute of Health Equity.
  7. Patel JA, Nielsen FBH, Badiani AA, Assi S, Unadkat VA, Patel B, Ravinedrane R, Wardle H. 2020 Poverty, inequality and COVID-19: the forgotten vulnerable. Public Health 183, 110–111.
  8. Ahmed F, Ahmed N, Pissarides C, Stiglitz J. 2020 Why inequality could spread COVID-19. Lancet Public Heal. 5, e240. (doi:10.1016/S2468-2667(20)30085-2)
  9. Uphoff EP, Pickett KE, Cabieses B, Small N, Wright J. 2013 A systematic review of the relationships between social capital and socioeconomic inequalities in health: A contribution to understanding the psychosocial pathway of health inequalities. Int. J. Equity Health 12, 1–12. (doi:10.1186/1475-9276-12-54)
  10. McConnell BB. 2016 Music and health communication in The Gambia: A social capital approach. Soc. Sci. Med. 169, 132–140. (doi:10.1016/j.socscimed.2016.09.028)
Arts Coronavirus and COVID-19 Health & wellbeing

Exploring the impact of dance

Michela Vecchi, an Associate Professor of Economics at MDX, is leading a team of researchers to explore the potential effects of dance on wellbeing and on our professional life across cultures.

Benefits of exercise

The benefits of physical exercise on mental and physical health have been known since the ancient Greek and Roman times; often summarised by the motto ‘mens sana in corpore sano’, meaning “a healthy mind in a healthy body”.

Recent research across different disciplines is providing increasing evidence to suggest the presence of important connections between body and mind. In particular, keeping active and exercising is not only good for our physical health but has also important consequences on our mental health.

Michela dancing in her kitchen

Dance can boost wellbeing

Although any form of physical exercise has beneficial effects, dance gives an additional boost to our brain functions and our wellbeing.

Current studies, carried out by scholars across a diverse range of fields including psychology and neuroscience, are showing the effectiveness of dance in improving cognitive functions and wellbeing among a wide range of individuals and particularly those affected by dementia. Dance blends the positive effect of music, which stimulates the reward centre of the brain, with the motor, sensor and coordination regions of the brain. Dance involves memory, emotions and creativity, hence the secret of its success, is its complexity.

In recent years, various organisations, such as Dance Well and Aesop, have been organising dance sessions for elderly people and those suffering from Parkinson’s. These initiatives are growing and increasingly involving individuals of all ages and disadvantaged groups among society, such as refugees. Dance promotes connections among people and contributes to build a sense of community and inclusivity.  

Can dance improve our performance at work?

Economists have always recognised the positive relationship between cognitive skills and productivity and, more recently, wellbeing is often listed among the factors that can promote performance. Therefore, dance at work could improve our working life, the quality of our work and promote creativity and productivity. These are important assumptions that require new evidence.

The outbreak of COVID-19 has profoundly changed our working life. Those of us who are not key workers have spent significantly more time at home than before. Adjusting to the “new normal” often involves a new working routine, with keeping fit at home and maintaining our wellbeing becoming more important than ever.  The dance world has also had to quickly adjust to the changing environment and move to online delivery of classes on a much larger scale than in the past.

Be part of the research

In our study, my team and I explore the effects of dance on wellbeing and productivity during these challenging times. To this end, we are calling on amateur dancers who practice in their free time at home, novices, semi-professionals and professional dancers alike to complete our survey.

You can also complete the survey in another language other than English.

Michela stretches on her kitchen island with ballet point shoes

Blog written by Dr Michela Vecchi and Dr Patrick Elf

Coronavirus and COVID-19 Health & wellbeing

#MentalHealth Awareness Week

Nicky Lambert, Associate Professor in the Department of Mental Health and Social Work at Middlesex, encourages focusing on our mental wellbeing and looks at the mental health of current NHS staff.

We are in the middle of #MentalHealthAwarenessWeek  and this is an excellent time to think about this year’s theme:  #KindnessMatters. The focus for the campaign was originally going to be sleep, but in this socially distanced world, which has shown how precarious things can be, kindness could not be more important.

Graffiti of nurse wearing a mask and making her hands form a heart in front of her

This crisis has brought out the best in many of us. Communities have come together to help each other and friends and families are taking time to connect and noticing how much they miss each other. A sudden shock can make us reevaluate our choices, but the shock of this pandemic is passing.

Being anxious gets tiring, we get used to it and it gets boring. We notice that the summer we had expected is passing us by; the anticipation of sports, holidays, graduations are all gone now. We are at the stage when old habits reassert themselves, people get grumpy and complain and tempers can fray.

This is when the importance of practising kindness kicks in – it’s not something that comes naturally to everyone, all the time. It takes intention, and it takes well, practice! 

Practice good mental health wellbeing

As a mental health nurse of twenty years standing, I’d like to make a plea that you take some time out this week to consider your mental health in the same way that you monitor your physical wellbeing. Many of us have noticed that we are less physically active because of lockdown, not eating or sleeping well because of our worries and we are starting to take steps to readjust.

During this # MentalHealthAwarenessWeek please take some time to think how you support your mental wellbeing as well and purposefully do something every day to be kind to yourself and the people round you.

Mental health of NHS front line staff

This is a concerning time for everyone. For the 1.4 million NHS staff, it’s not only worrying, but it’s also a confusing and sometimes frightening experience. On one hand the public are literally applauding their efforts and there is praise for staff working in challenging situations and putting the wellbeing of others before their own. However longstanding issues of poor pay and staff shortages have been compounded by dangerous working conditions due to a lack of Personal Protective Equipment (PPE) particularly in the early days of this crisis.

Not only are staff dying as a result of caring for people with COVID-19, those deaths are falling disproportionately on the BAME community who make up a significant part of London’s heath staff.  Those who are unable to be with their colleagues on the front lines of practice because of their own health status or carers responsibilities can feel guilty. Those who find themselves described as ‘heroes’ and ‘angels’ sometimes struggle to process their negative feelings. It can be hard to be open about feeling despair or fear when you are expected to be superhuman. It may also lead to ‘moral injury’ (the psychological impact of bearing seeing things or having to make decisions that violate one’s everyday moral expectations).

What support is being offered?

 A mental health hotline has been launched for NHS staff to receive support and advice (tellingly it’s staffed by volunteers). However staff in Mental Health and Social work and Nursing departments at Middlesex University are also rising to this challenge. 

We are working with The Pan London Practice Learning Group and others to develop resources for the capital’s nursing students as they take up an extended placement to help staff our health services.

A request from a local trust led to a joint project between MDX nursing staff and My Care Academy who developed free online resources to support staff who needed to learn new skills to offer care after death for patients suspected or confirmed COVID-19.

For the International Year of the Nurse and Midwife, we were to host the prestigious International Mental Health Nursing Research Conference. Obviously a conference is not possible this year but our Centre for Coproduction in Mental Health and Social Care have helped develop a solution in the shape of an innovative collaboration between @Unite_MHNA @WeMHNurses and @MHNRconf. By using a range of social media channels, the Centre will bring a range of mental health speakers to new listeners, connect up colleagues and celebrate the work of mental health staff at this challenging time.

What next

The last few years have discouraged us all from making predictions, but our staff and academics will continue to be flexible in the support of our students and to ensure they have access to the best quality online learning.

We will use our expertise to be responsive to the needs of front line services and help to build and sustain the health and social care communities that we all rely on in these challenging times.

Coronavirus and COVID-19 Social commentary

Using social and behavioural science to support COVID-19 pandemic response

MDX academics have collaborated with 36 scholars from all over the world to create a review of what social and behavioural sciences can do to protect and promote physical and mental health during a pandemic.

Social and behavioural sciences can support efforts to identify effective public health messages, encourage compliance with government directives, design institutional responses that are well-calibrated to human behaviour, sustain prosocial motivations in large, disconnected societies, manage anxiety and loneliness, identify cultural factors that can minimise the spread of the virus and motivate compassion for, and costly actions that benefit, vulnerable groups.

The current paper reviews insights derived from several particularly relevant areas of research in the social and behavioural sciences. For each of these areas, we highlight relevant findings, derive insights of potential use to policy makers, leaders, and the general public, and highlight areas where future research is needed.

Navigating threat

This first section discusses how people perceive and respond to threats during a pandemic and the downstream consequences for decision-making and intergroup relations.

Pandemics are often associated with rampant cases of discrimination and cases of individual assault, especially against outgroups. But pandemics may also offer opportunities to reduce distances. For example, 21 countries donated medical supplies to China in February, and China has reciprocated. Government officials can highlight events like these to improve out-group attitudes.

The media typically focus on the percentage of people who die, and less so on those who survive. Providing the opposite frame may help to educate the public and relieve some people’s feelings of panic.

To allow people to work with each other rather than against each other, the key factor is the emergence of a sense of shared identity which leads people to be concerned and care for others. It can be encouraged by addressing the public in collective terms and by urging us to act for the common good.

Social and cultural factors

This section reviews how social and cultural factors can affect response to the pandemic, and how this can be used to protect and promote healthy behavior.

People are influenced by perceptions of norms, especially when they come from people with whom they share identity. Messages that provide in-group models for norms (e.g. members of your community) may be most effective.

The spread of COVID-19 will tighten communities. A critical question is whether loose societies (UK, USA, Italy) will adapt quickly to the virus. Countries accustomed to prioritising freedom over security may have more difficulty coordinating in the face of a pandemic. We describe some of these issues in the section on social support and coping below.

Science communication

This section discusses the challenges associated with different types of misinformation during a pandemic as well as strategies for engaging in effective science communication and persuasion around public health.

People are more drawn to conspiracy theories when important psychological needs are frustrated. Conspiracy theories can have harmful consequences; belief in conspiracy theories has been linked to vaccine hesitancy, climate denial, extremist political views, and prejudice. Some evidence suggests that inoculating people with factual information prior to exposure can reduce the impact of conspiracy theories.

Fake news about COVID-19 has proliferated widely. One approach is to debunk using fact-checking and correction. However, these may not keep up with the vast amount of false information. One prebunking approach involves psychological inoculation. For example, preemptively exposing people to small doses of misinformation techniques or providing subtle prompts that emphasise accuracy.

Other approaches that increase the likelihood of the information being understood: credibility of the source, messages focusing on the benefits to the recipient, aligning message with recipient’s moral values. For health issues, there is some evidence that a focus on protecting others can be more effective (e.g. “wash your hands to protect your parents and grandparents”).

Moral decision-making

In this section, we consider how research on morality and co-operation can encourage prosocial behaviours.

Moral decision-making during a pandemic involves uncertainty. Research suggests people are more risk-averse when their decisions affect others compared to themselves, suggesting that focusing on risks to others (rather than oneself) may be more effective in convincing individuals to practice public health behaviors. Research shows also that focusing on worst-case scenarios, even if they are uncertain, can encourage people to make sacrifices for others.

Fighting a global pandemic requires large-scale co-operation. Sanctioning defectors or rewarding co-operators typically promote co-operation but are costly. Cheaper techniques can include providing cues that make the morality of an action salient or providing cues suggesting that other people are already co-operating.

Moral elevation is the feeling of being uplifted and inspired by others’ prosocial, selfless acts, and this experience prompts observers to also act with kindness and generosity themselves. Thus, exceptional role models can motivate people to put their own values into action.


Crises create a strong demand for leadership and this demand is present in all the groups to which we belong; our family, our local community, our workplace, and our nation. What should leaders do?

The first responsibility of leaders in times of crisis is to set aside personal or partisan interests and cultivate an inclusive sense of “us”.

Solidarity within and between nations is critical during a global pandemic. The belief in national greatness can be maladaptive in a number of ways. For instance, it is likely to promote greater focus on protecting the image of the country, rather than on caring for its citizens.

Stress and coping

Distancing threatens to produce an epidemic of loneliness. There are strategies to mitigate these outcomes.

We suggest the term “social distancing” be replaced when possible with “physical distancing”, to highlight that deep social connection with a broader community is possible even when people are physically apart through the use of technology.

Major stressors alter the trajectories of our intimate relationships. Divorce rates typically surge, but also marriage and birth rates. People should calibrate expectations for the relationship to the circumstances. Continuing to expect the same level of excitement and adventure from the relationship is a recipe for disappointment.

It is important to instill adaptive mindsets, guiding individuals towards the mindsets that this illness is manageable, their bodies are capable, and that this can be an opportunity to make positive changes in the world.


Van Bavel, J. J., Baicker, K., Boggio, P., Capraro, V., Cichocka, A., Crockett, M., … Willer, R. (2020). Using social and behavioural science to support COVID-19 pandemic response. Nature Human Behaviour.

Coronavirus and COVID-19 Health & wellbeing

COVID-19 deaths and NHS staff. What can we conclude?

Roger Kline, Research Fellow at Middlesex University, highlights the three principles NHS organisations should take forward immediately to avoid unecessary staff deaths.

Well over a hundred NHS staff have died from COVID-19 and we’re not clear why.

COVID-19 disproportionately impacts on some groups of people but we have known for a long time that it was likely to. The NHS nationally failed to ensure (or even ask whether) all employers conducted the statutory risk assessments which should have been carried out weeks ago and which might have prevented some of the tragic staff deaths and illness we have seen.

There are growing signs that the NHS nationally and individual employers are starting to do what should have been done weeks ago.  I want to suggest three principles which should inform employers’ approach going forward

1. What employers do can make a substantial difference

When the deaths of 119 NHS staff were analysed by three leading clinicians they  found that the proportion of nursing and support staff who died from COVID-19 was three times as high as their proportion in the NHS workforce and for doctors it was twice as high.

But their most remarkable finding seemed to largely slip under the radar.

Anaesthetists, intensive care doctors and by association nurses and physiotherapists who work in similar settings are believed to be among the highest risk groups of all healthcare workers because they care for the sickest patients with COVID-19, undertake airway management and have high risk of viral exposure and transmission.

However the analysis found there were no anaesthetists or other intensive care doctors amongst those who died. They found that of those whose speciality was identified, none were described as intensive care nurses. There were also no deaths of physiotherapists reported. The researchers conclude that

…the reason for this is not known and data on infections and serious illnesses are important to consider as well as fatalities, but this data is also currently lacking. What is likely is that these groups of healthcare staff are rigorous about use of personal protective equipment and the associated practices known to reduce risk (emphasis added).

It may be that this rigour is protecting staff better than some fear and the results can be considered cautiously reassuring. However, this finding is not a reason to slacken off on the appropriately rigorous use of PPE, but rather to wonder why others, who are likely involved in what are generally considered to be lower risk activities, are becoming infected and consider whether wider use of rigorous PPE is indicated.

What implications does this have for NHS employers? The researchers suggest a crucial one

It is not possible to know whether infection occurred at home or at work, but we have determined that the vast majority of individuals who died had both patient-facing jobs and were actively working during the pandemic. It seems likely that, unfortunately, many of the episodes of infection will have occurred during the course of work.

Had the statutory risk assessments been undertaken several weeks ago as they should have been, they would have highlighted  the greater risks to some groups of staff and inevitably recommended special attention be paid to eliminating or mitigating those risks.

The risks were:

  • Staff from any backgrounds with long term health conditions would be especially vulnerable to a Coronavirus pandemic
  • BME staff being amongst those groups especially prone to such long term health conditions
  • BME staff being disproportionately represented amongst lower graded front line health and social care staff who might generally be at greater risk  
  • BME staff have been found to be less likely to raise safety concerns either because they do not believe they are listened to or because they fear the consequences of doing so
  • BME being more likely (I’ve not seen robust data on this) to work night shifts where communication and safety measures may be more poorly managed

In addition, there has been significant anecdotal evidence that BME staff believe they are being disproportionately placed on wards with greater COVID-19 risks where staff are reorganised on a temporary basis to cope with the pandemic.

Finally, those dying do not look like those making the decisions. There is a steep ethnicity gradient across the NHS with career progression much harder for BME staff and senior positions generally well out of reach despite some recent limited progress. Diverse teams make better decisions and we don’t have nearly enough diverse senior leadership teams prepared to put themselves in other peoples’ shoes.

At a time when PPE was in serious shortage, these factors contributed to a perfect storm. The results are in the news bulletins every day. The risks were reasonably foreseeable. However, not only were many of these deaths probably avoidable but if the right measures are taken now by NHS employers, the death rate and illness rates amongst all staff but especially BME staff can be radically cut. 

For that to happen two other conditions must be met.

2. Employers must take prime responsibility for staff health, safety and well-being

The statutory requirements on health and safety at work of employees, and the statutory requirements in respect of equality are primarily for employers to actively implement rather than for employees to complain when they are breached.

For example:

  • Section 1 (2) Health and Safety at Work etc Act 1974 states: “It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees.”
  • Regulation 3 (1) of the Management of Health and Safety at Work Regulations 1999 provides that: “Every employer shall make a suitable and sufficient assessment of the risks to the health and safety of his employees to which they are exposed whilst they are at work; and the risks to the health and safety of persons not in his employment arising out of or in connection with the conduct by him of his undertaking”
  • The Personal Protective Equipment at Work Regulations 1992. Regulation 4 (1) provides that “every employer shall ensure that suitable personal protective equipment is provided to his employees who may be exposed to a risk to their health and safety except where and to the extent such a risk has been adequately controlled by other means which are equally or more effective.”

At the same time however, human resources practice has steadily drifted towards a culture where policies, procedures and training are put in place which focus on enabling individuals to safely raise concerns rather than the employer being proactive and preventative. The problem is that such an approach does not work. Research on bullying, for example, concluded that

In sum, while policies and training are doubtless essential components of effective strategies for addressing bullying in the workplace, there are significant obstacles to resolution at every stage of the process that such policies typically provide. It is perhaps not surprising, then, that research has generated no evidence that, in isolation, this approach can work to reduce the overall incidence of bullying in Britain’s workplaces.

Similarly for equality:

…attempts to reduce managerial bias through diversity training and diversity evaluations were the least effective methods of increasing the proportion of women in management […] programmes which targeted managerial stereotyping through education and feedback (i.e. diversity training and diversity evaluations) were not followed by increases in diversity.

There has been a similar approach in respect of staff raising concerns (whistle blowing) where it is still left far too much to individual members of staff to be brave or foolish enough to raise concerns rather than employers proactively intervening to change the organisational climate at work.

The wider industrial relations context over the last three decades has been one that has seen a move away from ‘collective bargaining’, towards one that has relied much more on a floor of employment rights that is overwhelmingly individualist in nature. Even when individuals successfully challenge inappropriate decision making using employer policies and procedures, they often have little impact on the conditions of other workers other than possibly tightening up employer policies, procedures and training, which are designed as much to defend employers as to improve outcomes – impacting on what trade unions can achieve

In respect of COVID-19, therefore, it is crucial that the emphasis is on clear expectations, monitored by both the CQC and NHSi/E, that employers will act decisively to protect all staff and especially those that evidence suggests are most at risk.

This should be done through:

  • Urgent risk assessments made public and involving staff and unions
  • The provision of suitable and safe PPE
  • Enhanced staff testing
  • Enhanced data collection and analysis to assist proactive intervention
  • Enforcing social distancing and ensuring that staff who can do so work from home subject to service needs
  • Actively listening to staff and acting on their concerns and suggestions, and ensuring it is safe to do so

3. The narrative is crucial

All employers have a statutory duty to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all their employees. It is one aspect of the duty of care owed by all employers to their employees, contractors and visitors.

No member of staff should be exposed to risks that are reasonably foreseeable and which can be eliminated or mitigated. We know that some groups of NHS staff are at particular risk, notably those with underlying health conditions. We know that Black and Minority Ethnic staff are amongst those particularly at risk and are disproportionately working on the front line in lower graded roles, subject to more bullying, more reluctant to raise concerns, and may be more likely to work night shifts.

It is therefore especially important that when undertaking and acting on risk assessments Black and Minority Ethnic staff are accorded particular attention because they may be at greater risk, as the death and infection rates from COVID-19 for NHS staff as a whole show.

Failure to do so would be a breach of the employer’s duty of care and would risk unnecessary harm. Let us be clear. This is not an alternative to addressing the risks faced by all staff and ensuring all staff are as safe as possible, but is an integral part of such an approach which recognises that some groups, notably BME staff, are especially at risk.

The initial analysis of NHS staff deaths suggest that where the statutory requirements are fully met, risk is indeed greatly reduced. There is no time to be lost in taking the steps suggested especially as individual trusts and the NHS nationally have now accepted there is much to be done, and at speed.

Coronavirus and COVID-19 Health & wellbeing

The disproportionate deaths of NHS staff during COVID-19

Roger Kline, Research Fellow at Middlesex University Business School, discusses the disproportionate deaths for BME NHS staff.

Health and social staff are dying from Coronavirus and a disproportionate number are of Black and Minority Ethnic (BME) heritage. Ministers have finally agreed a Review of why so many BME staff are dying, though the terms of reference and timescale for reporting are currently unknown.

A Review is welcome as we do not know why so many dedicated health and social care staff (of all backgrounds) are becoming infected and dying. Not least the relative importance of workplace and other factors.

The NHS Providers briefing summarises the immense effort and flexibility shown by NHS employers and staff responding to the pandemic. However, it seems likely that decision making failures, particularly at Ministerial level have made that job much harder. Governments were warned on January 30 2020 by the World Health organisation (WHO) that COVID-19 was a ‘public health emergency of international concern’, the highest level of alert that WHO can issue, however it’s clear that the UK Government was ponderous in its response.

Risk assessments

One casualty was that two crucial risk assessments for NHS and social care staff which could (and should) have started in February 2020 did not – a Management of Health and Safety at Work Regulations (1999) risk assessment and an Equality Impact Assessment (EIA).

Between them they would have helped local NHS and social care employers determine which groups of staff:

  • might be especially at risk (e.g. pregnant women, older workers, with pre-existing health conditions)
  • might be at greater risk such as the poor (greater likelihood of chronic health conditions) or those from particular communities
  • in particular locations might be most at risk (most notably social care and residential and nursing homes)

The Care Quality Commission signed off their EIA for patients on 24 March 2020 but it is unclear which national body published an EIA for the NHS and social care workforce or required local employers to do so.

Existing advice

Government advice to the public is that “some people are at a higher risk and need to take extra steps to avoid becoming unwell” and states that “you may be at increased risk from coronavirus if you are 70 or older, are pregnant or have a condition that may increase your risk from coronavirus

The advice for people who may be at increased risk from Coronavirus is the same as for most other people. You should only leave the house for very limited purposes. It also lists a second category of people who are “extremely vulnerable” and are at very high risk of severe illness from COVID-19 because of specific underlying health conditions. These people are strongly advised to stay at home at all times and avoid any face-to-face contact for at least 12 weeks from the day they are contacted by their GP or healthcare team.

NHS Employers, the umbrella HR body for the NHS, issued guidance on 27 March 2020 which also distinguishes between staff who are in either “extremely vulnerable” or “at risk” categories. Whilst members of the public in the “at risk” group are advised to “only leave the house for very limited purposes”, NHS Providers states:

Staff who are deemed to be in what is described as less vulnerable “at risk” groups are advised to take particular care to minimise their social contact through social distancing. For these staff “employers should support individuals and consider adjustments or redeployment for any staff in the at risk group. Adjustments may include working remotely, for example in 111 services, ambulance dispatch or virtual patient consultations, or moving to a lower-risk area”.

The Royal College of Physicians, in guidance endorsed by 16 professional bodies, added a caveat:

In addition, those doctors with care responsibilities for vulnerable family members should also be given the option of stepping back from front-line care of patients with COVID-19, as part of their duty of care to that family.

Why might some NHS and social care staff groups be at particular risk?

Firstly, we know that people who are poorer (many lower graded NHS and social care staff from all backgrounds including BME staff) are more likely to have “underlying health conditions” and live in more crowded housing where social distancing may be impossible.

We have known for a long time that:

Evidence for a differential impact from pandemic influenza includes both higher rates of underlying health conditions in minority populations, increasing their risk of influenza-related complications, and larger socioeconomic (e.g. access to health care), cultural, educational, and linguistic barriers to adoption of pandemic interventions.

Protection of Racial/Ethnic Minority Populations During an Influenza Pandemic

For example:

  • African Caribbean people have a higher prevalence of high blood pressure
  • South Asians have higher rates of coronary heart disease and are up to six times more likely to have diabetes
  • Hypertension and diabetes are more than three times more likely in BME  groups in the UK.

Secondly, we know that BME staff disproportionately work on the front line in the NHS and social care, whether as doctors, as nurses, as healthcare assistants and in adult social care. More than half the BME nurses in London work on the lowest grade (Band 5) and less than 2% in the middle and senior managers (Bands 8a – 9).

Thirdly, as Robert Francis’ 2015 Speaking Up Review found, BME staff are significantly less likely to raise concerns at work because they fear they will be taken less notice of, and/or be disproportionately victimised if they do so. We also know from successive NHS staff surveys that BME staff and staff with disabilities are more likely to be bullied by colleagues and managers than other staff bullying.

Fourthly, staff (from all backgrounds) have expressed concerns that amongst the staff expected to work in circumstances where the available PPE does not meet the minimum PHE standards, or where social distancing is extremely challenging are staff in “at risk” groups.

We do not know the balance of responsibility for the disproportionate deaths and illness of BME health and social care staff between “external” underlying causes and workplace risks. But clearly, workplace risks will play an important part.

Addressing workforce risks

NHS Trusts have made immense efforts to keep a viable service going in the face of rapidly increasing demand and substantial numbers of staff off sick. The NHS Providers guidance was an effort to ensure more vulnerable staff were placed less at risk. But, under pressure, there is no question that some staff with “underlying conditions”, at greater risk, who might be less likely to speak up, were asked or required to work where there was inadequate PPE or poor social distancing.

Similarly some staff were told they could not be found other work even if a household member was particularly vulnerable and those staff would have included BME staff who were disproportionately on the front line.

Why were those risks not highlighted sufficiently? Is that in part because the overall diversity of the health and social care workforce is not reflected in the diversity of the UK’s health and social care leadership? We know inclusive diverse leadership is better leadership, yet, the Cabinet ministers directly influencing the NHS during the pandemic, and their senior experts, are overwhelmingly white men. It is perhaps not surprising that issues of inclusion and diversity were not upper most in their thinking. Those dying do not look like those deciding.

Key questions

Based on numerous discussions with staff where Trusts are doing what they should be doing, here are some questions the Review team might consider:

  1. Where NHS Trusts have cross-checked staff who become ill (not just deaths) with COVID-19, and their ethnicity, role, gender, age, nationality with whether they had “underlying conditions”, what did they find?
  2. Where NHS Trusts cross-checked how many staff who have become ill from COVID-19 were asked to work in situations where PPE was inadequate or social distancing difficult to observe, what did they find?  What proportion of these were staff returning to work, or students and newly qualified staff?
  3. Where Trusts have “listened with attention” in a safe environment to staff at special risk, what did they find? In particular, what did their BME staff tell them?
  4. Where NHS Trusts found staff are worried about raising concerns linked to COVID-19 and their work, how have Trusts prioritised ensuring those voices can be heard? Especially as it may well be that some of the most vulnerable staff are those least willing to raise concerns.
  5. How can NHS Trusts best demonstrate that whilst “command and control” will be part of the current pandemic response, respect and inclusion should be too? The recent NHS efforts to improve poor workforce culture in bullying, discrimination, inappropriate discipline and the silencing of staff who raise concerns must not in vain.

We do not know the answers or even all the questions about these NHS and social staff deaths. But surely we don’t need to wait for all Trusts to do what the best ones are already doing?

The final point

Too much of the available guidance places responsibility on individual staff to raise concerns. It would be much better if the organisation took the bulk of the responsibility, given that these are system issues, not individual ones.

The Royal College of Physicians guidance on Ethical dimensions of COVID-19 for front-line staff states:

Doctors have a duty to protect the public from harm, an extension of which is the right to protect themselves from harm so they can continue to care effectively. In this respect, it is ethical for those doctors who would be harmed by contracting the virus to refrain from treating patients with (or suspected) COVID-19.

No healthcare worker wants to find themselves in that situation. The Review must ensure that, going forward, none do, especially those (such as BME staff) who may be at greater risk.

Coronavirus and COVID-19

The “Playtime for Everyone” report amidst COVID-19

Dr Jacqueline Harding, a senior lecturer at Middlesex University and an international expert in child development and neurophysiology, discuss the Fisher-Price report and what it can tell us about the importance of playtime during the COVID-19 pandemic.

The COVID-19 crisis is in full effect affecting many countries. We are probably unwittingly in the throes of one of the biggest social experiments of our times. Young families have been forced to live in close proximity for an unidentified period (often in total isolation) with the extra role of acting as ‘teacher’ as well as parent, with nursery schools closed for an unspecified amount of time. And, in many cases with the absence of grandparents or friends to lend a hand.

What can we learn from the “Playtime for Everyone” report?

I am delighted to have been part of this wider Fisher-Price campaign, “Let’s Be Kids,” which now takes on a new purpose in these unprecedented times that we find ourselves in. Will there be a mass breakdown in relationships between parents and young children or could we witness the wonder of true human survival based on a new appreciation of close playful social connection?

The answer lies in how we understand the science of the developing child while also taking care of parents’ own needs. Regardless of parenting style, it’s important to take into account the adult’s emotional and mental health. That might need to happen simultaneously while looking after young children in close quarters. Not to mention the needs of those who must work from home at the same time.

The science behind child development will now be visible – we know that the young child’s greatest need (excluding food, shelter and safety) is close human connection.

Quite simply, the science is twofold:

  1. Playful contact with an adult who cares for a young child and enjoys being with them, deeply impacts their neurophysiology and is the very real ‘education’ they need. Playful Triangulation unleashes the power of interpersonal neurobiology
  2. One of the most unexplored and remarkable scientific discoveries is that playful interaction between the parent/carer and the young child can act as an inoculation against the very stress that COVID-19 presents for parents themselves. Strengthening the immune system in every way is vital at this time.
Dr Harding’s Playful Triangulation

The scene is set for an unimaginable lockdown in society and the question is how will young families adapt? The hope is that thousands of young families will rise to this challenge and begin to carve out a new way of being that puts human connection at its centre and finds an antidote to stress. It is all about survival.

Ironically, there may well be a surge in human competence and a more fulfilled and emotionally competent family unit will emerge which in turn will benefit wider society. But we will all have to change our mind-set and see this as an opportunity in the face of adversity. And, for some parents the challenge will be even greater having to work from home, with restricted accommodation, and for many, no garden.

With one of the biggest social experiments to take place in recent history, my hope is that parents will be enlightened with the benefits of play to both themselves as well as their children and demonstrate how humanity has seized the opportunity to reprogram itself with playful relationships as vital and core to its existence.

We need to bring playfulness back and who better to show us how than our kids! Sitting down and playing could not only be the best thing you do for your child, it could also be the best thing you do for yourself as a parent.

Coronavirus and COVID-19

Personal reflections from a psychologist on COVID-19

‘Six months in a leaky boat, lucky just to keep afloat’. Professor Antonia Bifulco, Professor of Lifespan Psychology at Middlesex University, gives her perspective of the UKs social distancing.

We are all in the same boat. Or at least in our own boats, but in perilous seas with the current COVID-19 crisis.

Split Enz (1982)

For some it may seem like being in a dingy, for others a houseboat or an Ark but none of us get to sail anywhere. COVID-19 has us housebound – either socially distancing, or for the elderly and infirm – in relative social isolation or lockdown.

So how are we faring at this relatively early stage of lockdown? How do we pace ourselves for a long voyage? Can a psychological approach provide any aid?

Why is the boat leaky?

Well firstly because not all the population respect the restrictions, and antisocial behaviour has involved flaunting advice on moderate food buying in favour of hoarding, of having social gatherings despite risks to self and others, and opting to travel to country locations and national parks endangering the local villagers.

Although the majority respect the restrictions in the hope of containing the virus, others are in denial of the dangers, or think they are the exception or simply don’t care about health risks to others. This can have very damaging effects in terms of effecting a quarantine.

Secondly because essential workers in a range of occupations continue as usual of necessity. This is of course approved and applauded but means we cannot have a total quarantine. Those in healthcare, food production and distribution workers, and those in transport or police service need to be operational. But such planned and considered ‘leaks’ are to provide some brake on the virus spread and aim to reduce and spread the ‘peak’ of contagion much talked about.

Getting the balance between isolating to stop the spread and keeping essential services and vestiges of the economy operating is a fine balancing act.

As a psychologist, what elements of my knowledge of attachment theory (of close bonding with others) and depression can be used to interpret current morale, distancing behaviour and threats, and trust in experts and government advice?

Here are some thoughts and pointers.

Morale and trust

Should we panic or not? Clearly panic is a bad thing, but too much downplaying of the threat can lead to a nonchalance which undermines the restrictions required.  

The messages now given out by government, contrary to usual advice, for example over terrorism where there is an exhortation not to panic, is to – well – panic. At least to take dramatic steps to acknowledge the real and widespread danger of the virus and to change behaviour radically. The numbers reported of deaths to Covid-19 are now escalating and potentially causing real fear[1]. And the same is true worldwide.

For psychologists the issue is about emotional-regulation and how we can control negative emotions such as fear, distress and anger to enable us to take appropriate action and keep calm. Not just for ourselves but also in order to reassure others and set a positive tone in our households and (remotely) with family, friends and colleagues.

Techniques for good emotional regulation are varied but can be simple such as reframing the problem – social comparison of how our situation is better than that of others, positive thinking – knowing the threat will pass eventually  and counteracting a tendency to catastrophise or look on the bleak side. Activities around structuring our day, getting some exercise, arranging social contact through technology, keeping work or hobbies going, even keeping a journal to express feelings can help[2].

Related to this is an issue of trust and whether those in charge can help to keep us calm. Do we trust health experts? Do we trust government action and advice? Do we see others as a threat to our safety?

Trust is a key tenet of attachment theory – those of us who felt safe as children develop a sense of trust in others which in turn leads to feelings of safety and security. Those with a problematic childhood are more likely to develop mistrust of others which can then persist as feelings of insecurity and danger into adult life. The current situation needs an amount of trust for social cohesion. This can be aided by being reassured and reassuring others.

There has been an evidence of greater trust shown to health experts and scientists. I suspect most of the population now know what an epidemiologist is, and how it varies form a public health expert!  

Our government has highlighted scientific expertise in the advice given and taken. We need this to continue, but it will get harder as the rates of those affected and those dying of COVID-19 increase. It is heartening that scientists and universities have been at the forefront advising government, modelling the virus spread, giving health and distancing advice, and tackling research on vaccinations and antibody testing. Colleagues internationally have been swift in designing studies to help us understand this pandemic and its psychological effects on emotions, coping and clinical symptoms.  

We are asked to trust in the government in order to keep national unity and they in return cease political infighting. The hope is that by taking initiative to protect the nation the more it will command respect. Much will depend on both government ability to communicate effectively at each stage of this crisis, and its effectiveness at managing it and the emotional tone[3].

The political discourse is of facing war to invoke fighting spirit.  However, it is an invisible foe and we are asked neither to fight or flee but rather to hide, to ensure safety. Today on Radio 4 there was a call for a Dunkirk spirit of opening up a range of testing facilities outside those used in Public Health England to gear up for the massive numbers required[4]. Both a wartime reference, and the smaller actions of private firms, university labs and even the general populace given prominence – small boats to the rescue.

Yet most people will also be aware that whilst applauding health workers, and relying fully on them to deal with the crisis, for a decade or more our health and social care services have been under-resourced and effectively hollowed out – having lost thousands of beds, suffering high staff shortages and carrying large debt. The public at least are rediscovering the value of public sector workers and their essential contribution in keeping us safe and well. As a society we need to rebalance our values from wealth generation to societal wellbeing not just in this crisis but hereafter. Let’s hope this message will be endorsed after this crisis has passed.

The COVID-19 pandemic is of course global. All countries are affected and taking action to combat the disease albeit to different time scales and agendas.  The outbreak has been worse earlier in some countries, for example Italy and Spain who have had less choice in their restrictive distancing agendas. Other countries have been tardier in both East (Russia) and West (USA) with the UK also not in the vanguard of taking action.

Maybe our tendency to keep calm and downplay which has worked well with coping with terrorism has let us down when very prompt action was required.

Social distancing and isolation

Whilst most psychologists would advocate utilising social support and increasing social contact with close others at time of stress, this has been curtailed in the current situation. There are of course ways round it using technology and social media, but the strong attachment instinct to rush to be close to others when under threat needs to be controlled.

This is particularly important for those in older age. In the UK, all those over 70 are required to socially isolate within their households. This means they cannot leave their homes – so provisions have to be delivered – and external contacts have to be through technological means. Such isolation is usually associated with increased mental health risk. Family members in this situation need additional support-at-a-distance from family, friends and neighbours.

This becomes particularly stressful when older age relatives get ill – whether from COVID-19 or other complaints – and families are unable to visit. Those suffering bereavement of a close relative to COVID-19, who then cannot observe bereavement practices and cultural funeral rites due to restriction of gatherings suffer even more. Pictures of churches full of coffins and mortuary vans taking those deceased away under cover of darkness shown on Italian television will become real here as well.

Social distancing is more benign. As we know, we can only interact face-to-face with household members, for anyone else a distance of 2m (6ft) is required on the rare trips outside the home. Everyone (apart from essential workers) must stay at home and only leave under certain conditions. This is to exercise; shop for basic necessities; and medical help or to care for a vulnerable person. Essential workers can also travel to work. Other valid reasons include attending the funeral of a close family member and taking children to childcare[5].

A psychologist would ask whether different individuals experience distancing or isolating restriction in different ways? Attachment theory suggests that these will vary in relation to our particular attachment (or interpersonal) style. Those secure will adapt to closeness and distance, but those with avoidant or distancing styles will find being in close confines with household members stressful with anxious, angry or shut down responses. In contrast, those with anxious-dependent styles will find separation from others outside the home most distressing and will show emotional volatility.

Individuals will benefit from understanding their own style and that of those around them and creating strategies to deal with the restrictions imposed[6]. Maintaining routines in the household will help and respecting each others’ needs for ‘time out’ even if this is just escape to another room, garden or to walk outside. Scheduling regular contact with others through technological means will aid those with separation issues, but control needs to be exercised in keeping messages transmitted as essentially positive and calming.

The attachment principles of distancing-mistrust vs closeness-cooperation also apply on a national level. The pandemic has had somewhat contradictory effects in Europe and beyond[7]. On the one hand distancing has been required by the closing of national borders and curtailing of travel. This has led to mistrust of others entering the country – and sometimes attributions of blame to other countries for not controlling the virus better. On the other hand, cooperation is required across nations for the search for a vaccine and antibody testing, for understanding timings around peaks of the spread, and getting nationals back home.

Each government is having to focus on its own people.  It is likely some will prioritise their own citizens over others in providing healthcare.  Governments are asking their populations to erect walls between states as well as individuals to halt the virus[8]. Yet the immediate dangers of contagion are likely from those closest rather than those more distant.

Response to future crises may change in relation to keeping open borders, yet it is a global crisis and we will need to work together to fight the crisis, share knowledge and resources[9].

Coping and threats

How do the bulk of us restricted in our homes cope? Particularly if this is extended over a period of months? Positive coping is defined in terms of practical strategising, retaining optimism, downplaying of negative emotions and using social comparison to feel lucky – these sustain us in relation to emotional disorder[10]. Conversely features of poor coping, whether of blame or self-blame, pessimism, denial of the problem or failure to access social support are more common to those with insecure styles (either avoidant or anxious) and much more highly related to emotional disorder.

As academics, working from home is familiar – we are used to spending our summers this way. Usually a good time to get written work done without interruption. However, we are not used to the current restrictions – only able to leave the house for relatively brief amounts of time and constrained from visiting family or friends or indeed travelling to conferences or research meetings. So the feeling is very different. And the thought of doing it for three or even six months is troubling.

For those, like myself, who live alone, being solitary can aid contemplation, and I find I am getting through a lot of work – writing, marking, REF preparation, retaining international collaborations. The downside is achieving balance – regulating the work hours, learning to differentiate weekdays from weekends (what is the difference?). For an extended period this calls for some rigorous personal timetabling. Slots for Skyping family or friends, exercise time, inventing a hobby…etc.

For others with partners and children at home, the opposite is likely to be true – finding space for thinking, balancing work/life and demands of home schooling. Much may depend on the living space and number of household members – in particular having garden space as we come into spring. My colleagues are finding teaching their own young children (as opposed to students) challenging at times. Their children not overly impressed with their expert knowledge (‘you can’t do kid talk!’; ‘Oh stats, I’ve done that’). Not so much time for academic contemplation of theory or analysis of data on human behaviour when young minds need instructing.

For some people the situation will indeed be dire. For people who do not experience their home as a safe haven, due to domestic violence or abuse, socially isolating will become entrapment. Calls to help services have increased. Other people for whom home is not safe are people living in refugee camps unable to follow the handwashing advice because they did not have access to water and unable to socially distance in their primitive living conditions. Some people are stranded abroad – holiday makers who could not get back before borders were close – but also immigrants who if they lose their jobs because of economic downturn cannot return to their home country. Many in the population will lose their jobs and experience hardship. Many businesses will fail. The financial consequences are a very real concern. People rely on the government as a collective defence against the pandemic to change people’s behaviour and find the resources to save the sinking economy. There is a conundrum between containing the spread of the pandemic at the cost of the economy or tolerating a higher human cost to save the economy.

Reasons to be cheerful

There are, at least, some positive aspects to the situation to help us retain some optimism.

  • Our children do not seem to be affected by the virus
  • Most of us can distance ourselves in comfortable surroundings in a setting in which we feel safe (i.e. our homes)
  • We have great benefits from technology and most of us now have the means to communicate for work, education, social and leisure activity
  • The government is active in giving out funds as needed. There is also plentiful information on the ever-changing situation in the media
  • Health workers are being applauded for their unselfish contribution and the ‘outbreak of altruism’ in terms of neighbourhood schemes and volunteering is heartening
  • The environment seems to be taking a break from pollution – in London bird song can be heard and seems more plentiful. We also benefit in London from mild spring weather. As stated on the European website:

    As we look up at the quiet of empty skies above us; rejoice at the return of marine life to Venice’s canals; and marvel at the dramatic improvements in air quality in the world’s cities – so we can hope that the unfolding tragedy of the coronavirus will at least have long-term environmental benefits. We may, for example, conclude that periodic shutdowns of normal human activity, if pre-planned, would be a blessing – how about an annual World Respiration Month? (30 March 2020)[11] N Whitney
  • The virus pandemic will pass… and lessons will be learned.


As others, I have had much opportunity to read in the last weeks. I have just completed a very engaging book, which ironically, involves a character put under house arrest in a hotel for 35 years! This seems topical.  ‘

A Gentleman of Moscow by Amor Towles, depicts a Russian aristocrat punished by Bolsheviks for his assumed anti-revolutionary views in 1917 by enforced and indefinite house arrest in his then residence in the rather luxurious Metropol Hotel central Moscow. He eventually leaves forty years later, the hotel meanwhile, encompassing his whole world.

The book is a keen observation not only of social survival but adaptation to restricted circumstances to which with attuned social skills, keen coping, optimism and wonderful gourmet observations of Count Alexander Rostov leads to his reflection of how lucky he has been in life. The hotel proved something of a safe haven as the most dire, political conflicts of the 20th century unfold. His friend Mishka, writer and poet, whose life took a different path involving being deported to a labour camp, on refusing to edit from his commentary of exceptional Russian literature a quotation of Chekhov’s stating Russian bread wasn’t the best in the world, comments:

‘’Who would have imagined’, he said ‘when you were sentenced to life in the Metropol all those years ago, that you had just become the luckiest man in all of Russia’.”

Maybe we will yet find benefits from our current predicament – looking back after all this is over and maybe recalibrating our lives.




[3] De Gruyter






[9] (Varma)