On the question of vulnerability

Citation

Perkins, R. and Repper, J. (2020), "On the question of vulnerability", Mental Health and Social Inclusion, Vol. 24 No. 3, pp. 113-116. https://doi.org/10.1108/MHSI-08-2020-065

On the question of vulnerability

The COVID-19 pandemic has led to a resurgence of the word “vulnerable” and the concept of “vulnerable people”. Within the Government’s COVID-19 strategy three groups of “vulnerable people” are defined (HM Government, 2020, p. 51):

1. The “Clinically Extremely Vulnerable” (at greatest risk of severe disease because of other health conditions around whom a “protective shield” should be wrapped);

2. The “Clinically Vulnerable” (at higher risk of severe disease because of their age or health condition); and

3. “Vulnerable People (Non-clinical)” who may require support for other reasons.

People with more serious mental health challenges have frequently been defined as “vulnerable”, and the higher incidence of serious health conditions among such people may well also place them in the “Clinically Extremely Vulnerable” or “Clinically Vulnerable” groups.

While the desire to identify “vulnerable people” often comes from a place of caring and a wish to look after those who cannot look after themselves, the concept is not without problems and the desire to “protect the vulnerable” may actively harm those embraced within its ambit.

In Collins dictionary, “Someone who is vulnerable is weak and without protection, with the result that they are easily hurt physically or emotionally” [1].

This, like most other definitions, locates vulnerability firmly within the person to whom it refers. This serves to increase damaging prejudice and stereotypes. The identification of classes of people as “vulnerable” increases destructive “them” and “us” divisions between the “vulnerable” and the “non-vulnerable”. Vulnerability is typically associated with weakness, passivity, incompetence, an inability to look after yourself or take on responsibilities and it fosters paternalistic attitudes – “looking after the poor unfortunates”. The skills and abilities of those deemed vulnerable are rarely considered and their capacity for reciprocity is generally overlooked: it is typically assumed that “vulnerable people” are invariably on the receiving end of support and make little contribution to others or our communities in general. As Sayce (2020) points out, with all the talk of the “needs” of “vulnerable people” in the COVID-19 crisis, there has been little mention of the contribution made by those so classified. From the contribution to government, policy and disability rights made by the “clinically extremely vulnerable” Baroness Jane Campbell of Surbiton (Campbell, 2020) to the group of people with learning disabilities in Wandsworth cooking and delivering hot meals to others with learning disabilities who are less good at cooking [2].

To be defined a “vulnerable person” is definitely not a desirable place to be, yet it is where many people with mental health challenges find themselves:

[…] vulnerability comes with so many negative connotations in our society. Vulnerability, we are told, is something to be avoided. We are encouraged to be independent, self-sufficient, autonomous, and free from reliance on others. The ideal that politicians urge us to aspire to is a person not dependent on state benefits, a burden to others, but to be self-reliant. (Herring, 2016, p. 1)

The designation of vulnerable (inferior) populations reinforces and valorizes the ideal liberal subject, who is positioned as the polar opposite of the vulnerable population. The liberal subject is thus constructed as invulnerable […] and represents the desirable and achievable ideals of autonomy, independence and self-sufficiency. (Fineman, 2012, p. 86)

Fiske et al. (2002) observed that not all stereotypes are alike: some people are disrespected because they are incapable and pitied while others seen as dangerous and threatening. They developed a “stereotype content model” which described different types of prejudice in terms of the dimensions of perceived “warmth” and “competence” which lead to different types of prejudice (Table 1).

The “ideal liberal subject” of which Herring (2016) and Fineman (2012) speak falls in the “high competence/high warmth” quadrant evoking admiration and pride. By contrast “vulnerable people” are firmly in the “low competence/high warmth” quadrant, evoking sympathy and pity – paternalistic prejudice. The traditional image of people with serious mental health challenges as unpredictable and inadequate and frequently dangerous has often placed them in the “low competence/low warmth” quadrant, evoking fear, anger and disgust – “contemptuous prejudice” (Table 1). Sometimes, efforts to decrease the prejudice and discrimination experienced by people with mental health challenges have sought to replace the image of the dangerous and unpredictable “mad axe murderer” with the image of a ‘vulnerable person’ - someone who is ill and to be pitied (Sayce, 2020). That is, shift the stereotype from the “low competence/low warmth” quadrant to the “low competence/high warmth”. However, to replace “contemptuous prejudice” with “paternalistic prejudice” does little to promote inclusion, citizenship and value, but such a move may ensure that people get at least some help and support.

As well as reinforcing paternalistic prejudice, and creating destructive divisions between “them” and “us”, another problem is using the classification of people into vulnerable and non-vulnerable groups to determine entitlement to help and support: dividing the “deserving” and the “non-deserving”. Indeed the entitlement to support was embedded in the Department of Health (2000) definition of a “vulnerable adult” as someone:

[…] who is or may be in need of community care services by reason of mental or other disability, age, or illness; and who is or may be unable to take care of him or herself or unable to protect him or herself against significant harm or exploitation. (Department of Health, 2000, p. 8).

The classification of people into “vulnerable” and “non-vulnerable” categories is a way not only of allocating resource to some people, it is also a way of taking away resource from others, with different groups competing for who is more “vulnerable”:

Additionally pernicious are the ways in which vulnerable populations are placed in opposition to and in competition with each other when it comes to the relatively scant resources. (Fineman, 2012, p. 86)

The COVID-19 “Clinically Extremely Vulnerable” group was entitled to food boxes and priority deliveries from supermarkets (HM Government, 2020). However, this also meant that many disabled people, including those with mental health challenges, who had not been placed in this group were denied the food delivery from supermarkets on which they relied. People cannot be divided into sharply delineated groups in terms of their “vulnerability”: gradients of different types of support are required to ensure that the needs and aspirations of everyone are met.

To be categorised as vulnerable limits and defines your identity and your life chances. The concept of vulnerability fails to acknowledge the ingenuity, creativity and contribution of people with mental health challenges and other “vulnerable” groups. We need to move away from the concept of “vulnerable people” and attempts to define “vulnerable groups” and recognise that vulnerability is universal (Fineman, 2012):

We are all vulnerable […] We all need others to provide the services we cannot provide ourselves: from electricity to food; from emotional support to transport […] Yet with interdependence comes vulnerability. Others may let us down in the provision of what we need, we might let others down and fail to provide them with what they need. (Herring, 2016, p. 11).

Herring (2016) goes further in proclaiming “Let us rejoice in our vulnerability.” (p. 1). He argues we need to recognise “mutual vulnerability”, and the interdependence and relational responsibilities that it engenders. We should welcome it because it has many positive effects: it causes us to come together, pool resources, co-operate, support each other (Herring, 2020).

We are profoundly dependant on others to meet our bodily, emotional, and cultural needs. Our relationships are essential to our wellbeing; our sense of self; and our understanding of the world around us. (Herring, 2020, p. 1).

However, in the words of Farquarson (2020):

We are weathering the same storm but not in the same boat. Many people are in vessels not strong enough to weather the storm.

No individual or group of people is intrinsically more vulnerable than others, but inequalities and injustices exist. Poverty, poor housing, prejudice, discrimination and exclusion limit the extent to which you can access the support you need and leave you in a vulnerable situation. Vulnerability is a universal condition but there are some people and groups of people who are rendered vulnerable by lack of resources, social support and services and by discriminatory social organisation and structures (Herring, 2016):

We cannot accept charitable solutions to structural problems. (Farquarson, 2020)

If vulnerability is located within individuals then we seek individual solutions rather than looking at the economic, social and structural factors that leave people in vulnerable situations. Someone with serious mental health challenges is not intrinsically “vulnerable”, but if they are living in unsafe and insecure housing with no job, little money, few friends, neighbours who jeer at them and little support, they are in a vulnerable situation. The solution is not to change the person, but to change the situation.

Perhaps it really is time to get rid of our liberal ideal of independence, self-sufficiency, autonomy and freedom from reliance on others. The idea that dependence is a bad thing and independence is a good thing has bedevilled mental health services for too long. We are all vulnerable and we are all dependant on each other, but some of us have access to a wide range of social and financial resources that mask our vulnerability. The challenge is to create systems, structures, supports and services that enable everyone to have the resources they need not just to stay alive, but to thrive and live a life of their choosing. Perhaps this is better achieved by concepts like human rights and equality.

You don’t get citizenship rights by being vulnerable! (Campbell, 2020)

Table 1

Warmth and competence stereotypes: types of “out-groups”

Warmth
High	Paternalistic prejudice (e.g. older people, disabled people) Emotions evoked: pity, sympathy	Admiration (e.g. middle class, in-group) Emotions evoked: pride, admiration
Low	Contemptuous prejudice (e.g. welfare recipients, homeless people) Emotions evoked: contempt, disgust, anger	Envious prejudice (e.g. rich people, business people) Emotions evoked: envy, jealousy
	Low	High
	Competence

Sources: From Fiske et al. (2002, p. 68) and Fiske (2018, p. 881); Crowther (2020)

Notes

1. www.collinsdictionary.com/dictionary/english/vulnerable (accessed 24 June 20).

2. Generate, Wandsworth https://generate-uk.org/blog/