It was October 2020 when I realised I was going to have to ask for help. I’ve always been anxious, but thanks to the pandemic, I developed debilitating health anxiety. A dire winter was coming and any respite we’d had over the summer felt like it was slipping away. I couldn’t get to sleep and when I finally did, I had nightmares. My stomach churned and my hands shook so badly I had to give up caffeine. I developed a chronic reflux cough and, on more than one occasion, got into such an irrational spiral about it being Covid that I had to book a PCR test just to be able to function.
“One of the most diabolical things about this pandemic is the on and on-ness of it all,” says Amanda Ripley, author of The Unthinkable: Who Survives When Disaster Strikes – and Why. “Humans can withstand a lot of turmoil and instability if they can recover.” Prior to Covid, Ripley studied people who survived tornadoes and terror attacks, emergencies for which the mental health consequences are much better understood than the long, slow-burn, seemingly endless one we find ourselves living through.
As Ripley knows, this is not the first disaster humans have had to live through, so are there things we can learn from other disasters about what they do to our brains, relationships and communities? And, more importantly, how to make things better?
“There’s a tremendous amount we can learn from how we’ve responded to previous emergencies,” say Dr Brandon Kohrt, professor of psychiatry at George Washington University, who works in Liberia, Uganda and Nepal, dealing with the mental health aftermath of everything from Ebola to earthquakes. “Many low- and middle-income countries, like South Africa, India and Uganda, immediately rolled out mental health and psychosocial plans in February, March and April 2020. They had experienced prior disasters, but these approaches could be just as beneficial in high-resource places like the US and UK,” he tells me, and I can’t help wondering, do we in the Global North think of ourselves with such superiority that we find it hard to learn from the experiences of the Global South?
“With population-wide trauma, a war or a terrorist attack, we heal socially,” says Kohrt. “Being together when the awful thing happens and then healing together is really crucial. People who come together in that healing process tend to do better than those who either self-isolate as a response to distress or are ostracised. So I think what’s happened with Covid is that although the stress isn’t necessarily as acute or sudden as an earthquake or an explosion, the isolation we all experienced in the context of stress and trauma is eating away at us psychologically.”
Not everyone who experiences a disaster will develop a mental health problem: people survive trauma well all the time, but “between 5 and 10% of people who’ve been through traumatic events such as a terrorist attack will go on to develop clinical levels of PTSD,” says Dr Sarita Robinson, who studies the psychobiology of survival at the University of Central Lancashire.
Around one in five people who experience a humanitarian emergency will go on to develop a mental health problem (prevalence of common mental health problems in the global population is about 1 in 10), and rates of serious mental health disorders, such as schizophrenia, increase from 2-3% to 3-4%. “Research from 2018 suggested mental health problems double in emergency settings. I wouldn’t be surprised if that turned out to be the result of the pandemic, too,” says Ashley Nemiro, senior adviser for the global Mental Health and Psychosocial Support Network, which helps people working in crises.
The psychological challenges of Covid are huge, but many practitioners feel they aren’t being addressed at all. Willem van de Put is co-founder of the Mental Health in Complex Emergencies course. “Covid has made things worse and, to the chagrin of leaders in global mental health, everybody is saying we should do something but, basically, absolutely nothing is happening. Governments are not willing to address it.” Investment in mental health is so low that, as Nemiro puts it: “Every country is a developing country when it comes to mental health services.”
Research this year by the Centre for Mental Health, a thinktank, suggests that 8 million British adults and 1.5 million children will need mental health support in the next 10 years as a direct result of the pandemic. Office for National Statistics data already shows rates of depression doubling since the pandemic began, but it isn’t being evenly felt, says Leila Reyburn of mental health charity Mind. “The people who’ve been impacted the most and are continuing to feel that impact are people who had pre-existing mental health problems, people of colour, those living in deprivation and young people.”
“In the UK, we have a system based on late intervention and crisis response,” says Andy Bell from the Centre for Mental Health. “Only a third of people with common mental health problems get support. We don’t offer it quickly and we tend to wait until people’s needs are so severe that they need specialised treatment.”
But work by Kohrt and colleagues shows that early intervention is effective, especially for common mental health problems, such as depression and anxiety – and that it doesn’t always have to be carried out by highly trained professionals. He implements a community-level post-emergency support programme called Problem Management Plus, first developed by the World Health Organization in Pakistan and Kenya in 2015, which he then successfully trialled in Nepal (with similar programmes now running all over the middle- and lower-income world).
Through the programme, anyone with a high-school education can be trained in just a few weeks to deliver psychological support to those who need it, often embedded in places where people seek help for problems with housing or employment, rather than specifically for mental health. Clients get five weekly 90-minute sessions, usually one-to-one, or longer sessions in a small group, and are taught stress-management skills, breath control, problem solving, how to overcome inertia and how to develop a social support network. The final session is about how not to relapse.
“We’re taking interventions that were developed for earthquakes, floods or war, which we’ve used for years, and using them in New York City right now,” Kohrt says. “It doesn’t have to be by psychiatrists or psychologists in a specialised clinical location.”
Similar early intervention projects do exist in the UK, but they’re few and far between. A coalition of charities, including the Children and Young People’s Mental Health Coalition, Mind, YoungMinds and the Children’s Society, is currently trying to push government to “Fund the Hubs’’ and create a network of informal community support centres for children and young people, to which they can self refer. One such hub, the Nest, is already up and running in the London borough of Southwark – and 78% of its users say their wellbeing has improved.
This won’t shock you, but the ongoing nature of the pandemic really isn’t good for us. “Our brains operate in a very different way when they experience prolonged threats: you’re constantly on edge and alert, and that shrinks our ability to empathise with others,” says Kohrt. “We become much more focused on a very tight-knit group, and everybody else seems a threat. What’s most challenging about the pandemic is that even family members became threats – especially pre-vaccines. If kids are going to be a threat to their grandparents’ health or vice versa, suddenly we’re on alert even with people who should be helping us.” This disrupts our ability to be empathic in general. “We become more prejudiced, we become more stigmatising, we become more discriminating.” And if we’re discriminating against our loved ones, imagine how much worse our broader societal discrimination and stigmatisation is.” Which explains quite a lot about now, doesn’t it?
Some of us may find it harder to regulate our emotions, too, says Kohrt, something I can identify with. “We call it ‘self-regulation’, but it’s always a mix of self-regulation and regulation with others. Total reliance on self-regulation of emotions doesn’t work. We’ve evolved to constantly regulate our emotions with our peers.” But even if you were locked down with your family, that might not have helped. “Family units are connected to many other people as well, and if they don’t have contact with extended family, friends, peers, then that family’s own emotional regulation gets disrupted.”
“In humanitarian emergencies, one of the biggest things we do is make sure people have a sense of control and agency,” says Nemiro. “Often that is taken away when their social fabric is destroyed – and the pandemic did the same thing.” While schools, churches and community centres weren’t reduced to rubble, as they might have been in other disasters, they became so hard to access that they might as well have vanished. “Lack of social connection, lack of community and feeling out of control all break down mental health,” says Nemiro.
“The first thing we need is to realise that we have to repair the social fabric,” says Amanda Ripley. “People come to me all the time saying: ‘We don’t know what to do – our church, our school, our town is exploding with conflict.’ There’s so much pent-up frustration, alienation and sadness that has not been dealt with – we will find a target of convenience. After every disaster, there’s a short golden hour of solidarity [rainbows in windows! Clap for carers!] followed by a deep valley of division. Repairing the social fabric needs to be an explicit mission.”
Luckily, the repairs can be simple. “Say I’m a head teacher and I’m going to have parents come to an event in person. Afterwards, I don’t just let everybody go – these are opportunities for connection and we are in a deficit situation – so I serve drinks and snacks outside for half an hour afterward.” So is the casual socialising that we previously thought so little of – the school plays, the church fêtes – more important than we noticed at the time? “Those things are not just pleasant and fun: they’re investments in your future sanity and wellbeing. The way you build community resilience is through knowing each other so that we don’t assume the worst, so that it gets a little harder to demonise each other, and that prepares us for the next disaster,” says Ripley.
Bruce Daisley, former VP of Twitter, has written a book about resilience, Fortitude. “Police and firefighters who were in the thick of the events of 9/11 have been well researched and generally the closer they report being to their colleagues, the better protection to their mental health they felt,” he says. “Resilience is social strength, and social connectedness helps us recover better from operations, prevents us from falling into depression and generally improves wellbeing.”
“A huge part of emotional regulation requires positive interactions with others, including touch – if you look at other species, the way that that’s done is through grooming and other non-sexual touch among group members. We’ve had so little opportunity for that,” says Kohrt. Connecting when we’re in distress is even more powerful. “If I’m not the one in distress, I can help you regulate your distress,” he says. “There’s a feedback loop between the helper and the helpee with neurobiological changes that are health-promoting for both, to the point where helping others probably reduces our inflammatory responses and improves our antiviral responses.”
If we remain in Ripley’s valley of division, though, then “we’re vulnerable to conflict entrepreneurs,” she says. “It is incredibly easy to turn us against each other, whether you’re a politician, pundit or social-media platform. We need to know that and remind ourselves that we don’t want to be played this way. We’re not going to be chumps.”
One way to offset that particular danger as well as helping us to cope with the aftermath of an emergency is to deliberately tell ourselves a story of the experience which allows us to have agency within it. “Reappraisal is one of the main ways we manage our emotions as humans, and it’s probably one of the most sophisticated tricks of the mind,” says Ripley. “Are there stories we can tell ourselves that are true, but also leave us some hope? Yes there has been real suffering and hardship, but maybe you or your child showed remarkable resilience in finding a way to adapt or to be with that loss and still create new things.”
Ripley suggests spending 15 minutes writing your own story of the pandemic, but as though you were a benign third party, observing (you can also do this with kids). “With writing there’s a kind of organisation of the experience that happens in the brain, that you don’t have the space to do when you’re in a disaster that keeps going on and on. Writing a story can create that space and since there’s not enough space for recovery in this type of slow disaster, we have to create it.”
Coincidentally, I recently tried something similar, inspired by an article by Daisy Dowling in the Harvard Business Review. Rather than a story, she encourages us to list our achievements throughout the pandemic – which could include not snapping all your child’s pencils in an impotent rage while home schooling, or cooking 654 dinners in a row since March 2020, as well as more traditional wins. It was an uplifting way to look back and reframe the shitshow of the last two years.
Does writing a story give the emergency a longed-for ending, too? “The brain wants an ending because the brain needs psychological certainty,” says Ripley. “There is no end, but by repeatedly creating a narrative that has a conclusion maybe we could give it an end.”