Like everyone else, I am trying to understand my response to a virus that threatens my life and the lives of the people I love. But it also happens that for nearly 30 years I have worked as a clinical psychologist with people facing cancer, and I am noticing some parallels between what my patients have told me and what people seem to be talking about now.
Like cancer, covid-19 is fairly indiscriminate in terms of who it infects and how badly it affects people, and both diseases share age as a risk factor. But unlike cancer, covid is new, and healthcare is struggling to cope with its rapid spread. It exposes our limited medical ability to respond to new viruses, and clinical medicine may continue to be relatively helpless until a vaccine has been developed. Cancer, incidentally, causes the death of 9.6 million people across the world every year. Covid is a one-time pandemic and we don’t yet know how many deaths it will cause, probably far fewer. Our adversary is a virus that simply wants to replicate and pass on its selfish genes so that they survive, which of course is why social distancing and isolation policies work.
But of course, the threat we face is not only the virus itself, but the astonishing and rapid changes to the way that society normally works. The virus has led to abrupt social change at many levels.
“It feels like the whole world is muscling in on my personal tragedy,” said one of my clients with cancer this week. Another patient said “Other people are finally getting a taste of living with uncertainty. For me, it’s been like this for years.” More so, now that his chemotherapy has had to be stopped.
What do we understand about the psychology of change? This question seems especially pertinent to these times, and these are my thoughts as a psychologist.
The ability to anticipate the future has made us humans the dominant species for the past few centuries. Being able to symbolically model and thus imagine and anticipate the future has given our species a huge survival advantage. Yet this mental ability to model the future is also a source of real human anguish affecting our mental wellbeing. We are famously the only species that is able to worry about the future and be aware of its mortality.
Human minds feel distress when faced with an ill-defined threat or sudden change, and covid is both. The threat of change also lies in an unknown future that we are not yet able to adjust to, but one that we know we will have to. So the lives of everyone are changing, everyone is scared, and everyone is feeling emotionally tired and frustrated, wanting life just to get back to normal.
Distress is almost always relative to expectations. Covid reminds us that just being alive is precarious and we live with risk all the time, but we have got used to the mental illusion that we are safe and that life is largely predictable. And it often is. Psychologically, we like to be able to assume that the world that we know and take for granted will remain the same from one day to the next: our health, our financial security, the future, the safety of our loved ones, and so on. This is how minds work. But at the moment these assumptions about our lives are taking a beating, and change is most certainly in the air.
In the face of threat and change, such as this virus, people very naturally feel fear. They feel worried, apprehensive and anxious. There are many words to describe the many manifestations of fear. Fear is a normal and entirely appropriate emotion in the face of threat, uncertainty and change. Most animals instinctively adopt a state of vigilance and heightened physical arousal when faced with the unfamiliar. So a fear of the unknown is a natural biological and emotional response, and in our survival interests.
Emotions, such as fear and anger, are instinctive failsafe programs of physical and behavioural activity that provide all mammals with biological protection, much like our immune system. In the face of threat or change, the body responds with heightened preparedness (the so-called fight-or-flight response). The muscles become more tense, breathing rate increases, our senses are more alert, and so on. This is a state of biological vigilance, and it is tiring to sustain. It is stressful.
But for us humans, threat and change also engage our minds. Other species just get ill and die… or not. Only humans have to suffer emotionally and psychologically. It is the price of having a mind. People have been telling me about their sense of foreboding, their constant worrying and ruminating, as if their minds are working just as hard as their bodies to prepare themselves for the ordeal ahead. Covid, like any illness or loss, may cause sudden changes to people’s basic assumptions. It will therefore take time for people to make sense of what has happened to the previous world that they had so long taken for granted. Among people with cancer this is known as the loss of blissful naivety, being left in a permanent state of vigilance because you know that the threat is always out there somewhere, hiding in the bushes, even if it never attacks again. At least with covid this threat will effectively pass in a few months. The social consequences will be felt much longer.
Illness and other ‘life-changing’ events violate our unexamined assumptions about our lives and our future, so these core assumptions about our life plans and relationships become sharper and real. This ‘wake-up call’ tends to provoke a lot of emotion as we and everyone around us reconsider and adjust our assumptions… Will I survive? Will my loved ones survive? Will I have a job? Will I be able to afford to live here? What does the future hold? And so on.
Some people have told me that they have been feeling as if they are living in a bad dream, in a surreal world where everything is the same but different. Other people seem to feel the burden of their thinking: “It has robbed me of my peace of mind… I want to return to my previous life of not worrying about this all the time”, as one friend put it. Social distancing measures and stay-at-home policies subtly threaten some of the taken-for-granted assumptions by which we daily negotiate our lives. We glance at a cooking programme on the TV and find ourselves shocked at how close everyone was standing to one another just a few weeks ago. So although we are able to adjust our expectations very quickly, we also find subtle ways to ‘make all this not be happening’.
Change, such as getting cancer or living through this covid pandemic, violates our taken-for-granted assumptions and expectations. This naturally feels dangerous and threatening so our emotions, such as fear and anger, become activated. We become more alert and vigilant. At the same time, our minds are recalibrating and building on our previous models and expectations, so that we are better prepared to manage the future.
However, if the change is too big or too quick, we are inclined to use defence mechanisms, such as denial or avoidance, to slow down the rate at which we absorb the new information. When a change is too quick and too threatening, people dissociate their minds from the trauma they are experiencing.
A healthy level of denial and avoidance is therefore a natural part of mental adjustment. Our minds are able to maintain threatening information at a safe distance until we can gradually absorb it. But in our own time. Too much, too quickly and we can feel slightly dissociated from our experience, as if we are living in a dream. In profound trauma this attenuation of our experience of reality is stronger still.
Clearly there is much to worry about. Uncertain times like these can lead to a desperate need to gather up one’s kin and hold them close, and where this is not possible, we inevitably worry for their safety. The virus has already had a ruinous impact on the financial security of almost everyone. Uncertainty and change leave people feeling a lack of control and powerlessness, and that feels frightening, but also frustrating. The body is subtly tense and worked up a lot of the time, and the mind can make this worse by imagining frightening scenarios that are often unrealistic or implausible but not impossible.
This physiological and mental vigilance is physically and emotionally exhausting, so you may find yourself more tired than normal yet unable to unwind, and if so, you may find yourself a bit low or irritable. The problem is that we don’t always notice these changed emotional states, or how much emotion we have absorbed or swallowed. Pent-up frustration and other emotions eventually find expression and the danger is that they take the form of explosive anger directed at other people rather than the real source of our fear and uncertainty: the covid virus.
Most people are not used to having free time forced upon them, along with the resulting lack of structure (work, schools etc.). Like other illnesses, covid makes it difficult to plan with any certainty, and some people may feel that it would be tempting fate to try to do so. After a few days of furious busyness, friends have told me that I am not alone in finding it hard to settle down and get on with what work I still have. The problem here is that without ‘motivational structure’ people tend to feel a sense of pointlessness, becoming a bit low and hopeless. The long-term unemployed often report these feelings.
Lockdown is in danger of undermining personal confidence, not only economic confidence, because personal confidence is acquired through the experience of doing something. Hope and positive mood come from having a wished-for future and working towards it, so if we fail to invest in the future by making plans for it, we risk feeling low in mood. It therefore helps to have plans to structure one’s time.
Confronted by threat and uncertainty, people of all ages tend to seek out figures of benign authority, such as parents, political leaders and trusted experts, to keep us all safe. This was why the Prime Minister’s hospitalisation was symbolically so alarming. However, more than anyone, we turn to the people we most trust, our confidantes. We expect our family, friends and partners to be able to talk and listen and maybe make sense of things, but our feelings can be hard to articulate and frightening to discuss, so they become avoided or pushed underground, resulting in more tension. Consequently, it is a good idea to work towards keeping lines of communication open with people who matter to you.
Social isolation is the biggest threat to people’s mental wellbeing. Connection with other people, known within the social sciences as ‘social support’, has been extensively shown to have huge implications for our health, wellbeing and mortality. A lack of control and disengagement from the normal world leaves us with more time with our thoughts than we might wish. Solitary confinement, after all, is a punishment. So talk to whoever you feel comfortable with and trust, but think about being a source of confiding support for this other person too.
At the other extreme, interaction with other people can be enhanced by time on one’s own for personal reflection, where this is possible. Temporary withdrawal, even just having one’s headphones on, can be restorative. This does not mean shutting other people out, though some women friends have said they are enjoying having less intense contact with other women but worry they will become insular as a result. Therefore, work towards maintaining sufficient connections with other people, and put your feelings into words, even if only to yourself.
In times of stress, ‘confiding support’, or having someone to talk to, helps people get through the adversity better than all the therapists in the world. Turning experiences into words enables people to congeal otherwise nebulous feelings into more coherent trains of thought and identifiable ideas. When we talk out loud, whether to ourselves or someone else, we get to hear what we actually think. Words help to anchor experience by disentangling ‘logic’ from fantasy.
Talking (and writing) helps by giving shape to our feelings and fears, and this leads us to feel more in control of them. Other people’s responses can corroborate and validate our experiences, and provide us with a useful social reference point – how reasonable do our feelings and thoughts seem to other people? Finally, talking is a crucially important method of mental adjustment.
So, try to have daily contact with other people, even if it is a helpline, realising that at this time the other person is probably feeling much as you are, only in their own way. And we can all be kind to one another. We are fortunate to live in a digital age where audio-visual contact is possible without any risk of infection. People are compensating for their lack of face-to-face contact by increasing their use of virtual or remote connection (Skype, Facetime, Zoom, etc.). Admittedly I am unable to support this with evidence, but I would venture that many people are currently feeling more loving, more in touch with one another, and showing more affection than they normally would. In times of uncertainty there is a very obvious need to connect with other people.
However, being cooped up with others and confined to home may be fine for a few days but soon frustration sets in and this, combined with underlying anxiety and worry, can lead to outbursts of anger, another core emotion and the flip side of fear (i.e. the fight-or-flight response). Last week from my window in Bristol I was hearing many more car horns than I would normally hear. This may have been a coincidence, but perhaps it was a reflection of general anxiety that was being displaced as irritability and intolerance. We must try to remember that we are angry at the virus, not one another. Other people are facing their own fears and uncertainties.
Listen to trustworthy sources of information but remain critical about their accuracy. Obtain as much information as you are comfortable with, but ration it. If it upsets you, give it a break. Constant anxious rumination tends to bring down people’s mood and make other people’s lives a misery. Restricting your diet to one thing is never healthy, so take regular mental holidays from covid (while of course observing the rules!) and absorb yourself in other things. Distraction is another defence mechanism that has its place. Be creative, play games with others, learn something, read, listen, watch TV and films, and so on, but do your best to ensure that passive entertainment does not become the default position because that would be an anaemic diet. Human minds are, above all, creative.
Worry is productive if it enables you to lessen the threat (e.g. staying at home to prevent catching or spreading the infection), but it is unproductive and unhelpful if you are worrying about something over which you have no control (imagining yourself in Intensive Care). Again, consider the evidence available at the current moment (the vast majority of people survive) and make a clear distinction between what is possible (i.e. almost anything) and what is probable (toilet paper has never been in short supply).
Defensive pessimism (preparing for the worst while hoping for the best) is a perfectly valid strategy, and if you struggle with intrusive thoughts it is a good idea to confront them. What is the worst-case scenario? Even death is something everyone eventually negotiates, and we will too whenever it comes to us, but for most people there is every chance that it will not be now. By examining our worst-case scenarios, and following them through to the end, we can often detoxify our more intrusive worrying thoughts. This is best done with the support of someone else.
Having structure in our lives enables people to maintain a positive mood, so it really helps to have things to work towards and achieve, and things to look forward to. Create a diary if you don’t have one and sprinkle it with things to look forward to and things to achieve. Or perhaps make a list at the start of each day, structuring what you hope to achieve, along with pleasant breaks and even treats to look forward to. Domestic chores may have to be one part of this, but be creative in trying something new, such as learning a new craft, or researching something you’ve often wondered about. Find activities that will benefit others, or make something you will be able to give to someone else. Engage other people in a shared plan (‘Let’s…’) while still social distancing. Join the many other people who have volunteered to help the wider community in some way.
Be careful not to take your tension and frustration out on other people. Instead, talk about what you are feeling and then listen. Emotions are a source of information for those who can read them. If you cannot talk, try to decompress your pent-up feelings in other ways: exercise, stretching, physical relaxation, breathing exercises, mindfulness practice, etc. Instructions for all these are readily available online. Do not forget that crying is an emotional response that is built into our species to allow us to release emotion that would otherwise be suppressed, so don’t imagine there is anything wrong with it. Distress is not a mental health problem, it is part of the human condition.
Maintain hope. This ordeal is like an undeserved prison sentence, but we are in it together, and we must all serve out our time as gracefully and responsibly as we can. For some people it will be a tragedy, but this strange and sad time will pass, and in a few months we will once again be adjusting our minds to a changed world, but one in which the virus is under control, much like cancer except far less of a threat. In time, this new post-covid world will itself become the taken-for-granted normal, and not long from now we will look back on the 2020 pandemic as an historical event, just as we currently do 9/11. If my work with people with cancer has taught me anything, it is that human beings have an extraordinary capacity for mental adjustment.
For individual people change is inherently stressful, but among people with cancer it often also leads to a feeling of renewal and personal growth. So perhaps we can all learn something useful from this social, relational, and psychological body blow. What will you be thinking about yourself when you look back on these days in a year’s time? We may come to think of this time as a punctuation mark in our lives, a time when we reflected on the things that matter to us most. We may find ourselves thinking about our mortality for the first time, and reconsidering some basic assumptions that we had previously taken for granted: the preciousness of life and the people we love, and a fresh appreciation of the beauty of Nature. Other things may come to seem downright trivial, or at least far less important than they once did. And maybe that is no bad thing.
There is much to feel heartened by during these changing and uncertain times. It turns out that we humans don’t just selfishly hoard, we are also kind and generous-spirited. We have an enormous capacity for compassion towards people we do not personally know. It is a mark of our humanity, what anthropologists call altruism, and there has been plenty of heart-warming evidence of that recently.
Like other illnesses, covid reminds us that sometimes in life we simply have to get through an ordeal, day by day, doing what we can and reminding ourselves that life will eventually get better. Humans are pulling together in a way that no other species can, and nowhere more so than among scientists and doctors who are sharing data and knowledge across the world as soon as it is available. Science carries this strong ethic of sharing so that its findings can be used and replicated, and national governments are starting to show a similar spirit of collaboration.
Despite our many faults, we are an amazing species with a noble history of caring for one another. Most impressively, people in the healthcare sciences have shown great courage, compassion and intelligence in this crisis, and the rest of society owes them an enormous debt of gratitude. So let us not talk falsely now, for those of us living in relatively wealthy UK, there is much to be grateful for.
It would be nice to imagine that when this is all over, we humans will be slow to return to our lazy selfish indulgences, our small-minded ignorance, and our idiot conspiracy theories. It would be nice to think that this crisis will reset the registers about where our human values lie, and enable us to collaborate and support one another better in the future and address our shameful inequalities.
Perhaps we will better appreciate how much we depend on the many people who work in our supermarkets or care homes, or who make deliveries or take away our rubbish. But I also hope that we will remember that experts are people who have learned and studied and perhaps know more than we do. Every apprentice learns that. Human knowledge is valuable and when the chips are down we turn to science and experts.
James Brennan’s new book Making Sense of Being Alive – A Natural Philosophy of the Mind will be published in the autumn.