Caring for our mental health during and beyond the COVID-19 pandemic

COVID-19. (Wikipedia.org)

Editor’s note: Dr. Joe Burley is a psychiatrist who works with the Prince Edward County Family Health Team.  A Picton native who now commutes regularly from Kingston to his office at the Habourview Clinic, Burley has been a psychiatrist for 35 yrs and practiced medicine for 42 yrs. Burley has written an article about the effects of the COVID-19 Pandemic and related life changes on mental health which has been been distributed to FHT staff and is presented below.

We are entering our 10 week since the restrictions of the COVID-19 pandemic came into effect.  We are seeing the curve flatten and the feared effects of overwhelmed hospitals and massive mortality have, happily, not been realized. But the changes incurred by this crisis have been unparalleled and resulted in much anxiety, fear, uncertainty and change in our lives.  We are already seeing increases in cases of depression, anxiety, OCD, substance abuse and early PTSD in the community.  There are predictions of a coming “COVID Echo” related increase in the incidence of mental health problems as the COVID related changes continue and even after things begin to open up.   Although many of us may not reach the diagnostic criteria for these disorders, few of us will be spared at least some of the symptoms of a stress response.  

These changes are bound to affect our mental health, not to mention our perception of our future, our way of life, our relationships and work as well as the workings of our society.  We are inundated with media which is often catastrophic in its reporting and predictions for our future and which appear to focus more on mortality rates and statistics than on the manner in which we are affected and how we are coping.  

I am finding as time progresses and there’s ongoing change and uncertainty about so many aspects of my life, I’m feeling progressively more worn down and stressed.  There are so many changes I can’t locate a single stressor.  So when I’m asked how I am coping I am likely to respond with ‘OK I guess’ but when I begin to talk about it I become aware of the many changes and quickly start to feel overwhelmed to the point I want to change the subject. I also feel a sense of being stuck in a kind of paralysis of time and routine which makes it difficult to see any clear sense of out future.  With these reactions there is a sense of heavy and impatient fatigue.    I see the same effect in many of my friends and family and my patients.  

Unless we look at these changes and how they affect us, we have little chance of learning to cope.  As uncomfortable as it may be, it’s something that we should be sharing with each other.  

So, what are the changes and challenges that are causing us to be stressed and threaten our individual mental health and the health of our society and humanity?  Here are only a few we can identify. 

This is a global phenomenon to which no one has a clear and accessible approach or solution.  We are in the midst of a global experiment.  It’s understandable we might be afraid when the people we trust to manage crises don’t have a ready answer.  This is worsened by the disunified state of world politics at present.  Humanity is threatened by something which we can’t immediately control.  It’s the classical existential threat which potentially changes the way we live and interact and some scientists are already talking of a second wave or future viral pandemics.  

We are confronted with a situation we have never had to confront before.  Karl Jaspers called these “Limit Situations”- life events for which we have no preplanned coping strategy and which take us to the edge or limit of our ability to exist effectively.   This, by itself is maybe the biggest stressor.  It causes us to feel afraid because it’s an unknown phenomenon, we are uncertain about the best way to cope or if we will survive it. In spite of the repeated phrase ‘We’re all in this together’ we often feel we are facing it alone.  

There is the fear of suffering, illness and death in those we love and ourselves.  Our society has done a good job pushing the reality of our finite existence to the periphery, which leaves us without the resources to cope and deal with it.  It’s  interesting the media tends to put the reality of mortality in statistical terms, rather than experiential and human terms.  This is exacerbated by the fear that we may have to die alone and there will be no way to gather to mourn and celebrate the death of a loved one.  Many of us may feel afraid or unprepared to face the suffering of others or in themselves.

 Our perception of our future has been blurred or lost.  We have normally taken for granted our ability to plan for a future.  This includes being able to imagine or predict when, how and where certain events will happen.  This has changed and what we once could do effortlessly and transparently now requires a whole new set of rules or is impossible (for now) to do.  Along with this, our sense of time and space are altered.  As we are more limited in our ability to leave our homes, lived space becomes more limited, and with this, time seems to stretch out and move more slowly.  These lived experiences of time and space are complex and important regulators to our physical and mental health.  These rhythms are regulated by our daily routines, cues from our environment, our interactions with others, and our sleep-wake patterns, all of which are being altered by the limits imposed by our attempts to control the spread of the virus.

We have lost a great deal or had a great deal taken from us.  Our freedom to come and go safely, our ability to meet and interact and touch, our ability to gather in groups for entertainment, education, health care, shopping etc. has been lost for the time being.  Access to many of the material goods we took for granted is more difficult or impossible. There is no certainty that these losses will be regained in the way that we know them.

Our sense of agency and opportunities are changed.  We can no longer act easily toward goals as we used to.   We cannot reach for others and move in relationships as we used to.  We cannot leave our homes and move about as we once could.  There are so few choices of activities and things to do and places to go so that, as we start our day, we feel stunted and blocked before we have stepped out the door.  Even travel in the way that we once knew it has changed and is less available.  It is an opportunity for boredom to set in.

Our economy, troubled as it may have been before, is threatened and shattered and there are no obvious pathways to recover to its previous place.  Employment, ability to support and feed ourselves, ability to progress and adapt, are all threatened. 

We are afraid for our children who are trying to understand why their world and routines have changed and why they can’t be in school and see their friends.  They are also exposed through social media to all sorts of scary messages about this virus.  They are less able to understand and cope with this situation than most adults and need our help to interpret this information and reassure them that they are safe. It is a situation we have not encountered with our children and we may feel afraid that we won’t handle it in the right way and that our children will be psychologically damaged.  We will be anxious about keeping them safe from the virus.  Many of us may find that we are coping reasonably well ourselves but when we see our children become affected it may be more difficult to cope and react appropriately

So yes, we are understandably stressed by these changes and threats.  If mental health is defined, in part, by a balance between what life confronts us with and our ability to cope and adapt, then our mental health is threatened.  Some of us may become ill with various physical and psychosocial illness such as heart disease, strokes, cancer depression, anxiety, PTSD etc.  These are illnesses which are known to be correlated with increased and chronic stress and which persist beyond the present.  They need to be detected, addressed and treated. Some of us may already have a history of mental illness and we need to be watchful for worsening of our symptoms and have access to help.  We should be alert for signs of illness and seek help if we see them in ourselves or others.  

Many of us, even if we don’t become ill will experience stress reactions, symptoms which interfere with concentration, sleep, energy, motivation etc.  What kinds of reactions or symptoms might we see in response to this admittedly huge threat.

Sleep may be more difficult. Our confidence may decline.  We may find it harder to relax.  We may find ourselves feeling persistently tired or that we tire more easily.  We may become more irritable.  Making choices and problem solving may be more difficult. Our sense of the future may become more pessimistic or threatening.  Our mood may become persistently sad and low or anxious and hypervigilant.  We may notice that our interest wanes and that it is more difficult to motivate ourselves toward goal directed activity.  We may feel inclined to withdraw from others or feel less confident or patient in our relationships.  We may feel inclined to drink more or use other substances that bring us temporary relief from feelings of stress, anxiety or negativity. 

 We may experience symptoms such as palpitations, headaches, tremors, dizziness, chest tightness, GI complaints.  Any or all of these, among countless others may be noticeable responses to stress or early indicators of mental illness.  If any of these persist and interfere with our function, we should tell our families and supports and see our health care giver for help.

We may see our kids sleeping poorly or being more argumentative or sad or afraid. They may become more oppositional or test their limits.  They may develop worrisome behaviors.  Adolescents may withdraw or become angry or confrontational as they deal with their frustrations and fears.

Dr. Joe Burley demonstrates good hand washing practices in this PEFHT Twitter photo. (Twitter)

We may see more or worsened conflict in our families   At a time when we need to be collaborative and problem solving, we may find it harder to interact and find instead we are irritable, blaming, arguing.  There is a tendency for domestic violence to increase during crises.  

All of this sounds pretty dire and you may wonder why I would try to make visible the threats, fears, challenges, and unpleasant responses more visible.  Believe me, it’s not to make us more uncomfortable.  It’s only when we know what the origins of our fear and stress are and that we can identify signs and symptoms of stress and anxiety and depression that we can get help and develop coping strategies or solutions.  

But there are things we can do to help ourselves and others get through these difficult times and keep ourselves healthier.  I think if we examine and not avoid the challenges I have noted above as problems we will be better off.  Because problems generally have solutions.  As a species and a society we are good problem solvers, survivors and we have an impressive capacity for resilience.   

Washing our hands, avoiding close community contact, social distancing and reporting symptoms are all ways that we can decreased the risk to ourselves and others.  These are simple, achievable behaviors that we can do to minimize the risk which should help decrease our feelings of stress or anxiety.

It’s important, as much as possible, to be grounded in reality.  Catastrophzing, imagining the worst, focusing on the negative are dangerous and make us less able to adapt and problem solve.  This’s why we frequently hear we should limit our exposure to media which is inaccurate and leads us down the path of worsened fear, anxiety and helplessness.  Talking with each other about how we can cope, what the solutions to our problems might be, will be much safer and more productive.  We can share our rationality and reality testing and empathy as a way to help each other.  

It will be useful for us to remind ourselves and others it is normal to feel stressed, afraid, challenged and even less competent during these times. There is no need for feelings of shame or embarrassment because we feel less able to cope.  These responses only mean we are human.  If we can make ourselves and others aware of this there will be less tendency to hide, to blame or stigmatize.   In recognizing we are stressed and suffering it becomes clear there is a need to take care of ourselves and others.  Generally, when we relate to ourselves in a caring fashion there is more opportunity for healing and wholeness. The same goes for caring for others.    Even when we are feeling stressed and afraid it is adaptive and healing to offer care to others.  It helps us and it helps keep our society working in a collaborative and cooperative manner and it is central to our sense of purpose and meaning.  Taking time to relax, meditate, reflect, enjoy ourselves and to think about and discuss our lives in a creative manner are health promoting and preventative strategies during times of stress.  On a daily basis we should be giving ourselves time to do something that feels good, is relaxing and enjoyable and that is just for us. 

There’s a tendency, when we are stressed or not well, to do less and withdraw from people. It is an evolutionary adaptive strategy which can be protective at times. However, if we prolong this, it will make us worse. Physically we will get weaker and less able.  So even if we don’t feel motivated it is important for us to keep our bodies moving.  Exercise has been proven over and over to improve function and decrease symptoms of stress, depression and anxiety and to decrease the risk if illness.  We need to have goals toward which we can work.  This gives us an improved sense of competence and creativity and if we are wise, we will ask for help from others to create and achieve these goals.  There is a tendency when bored to eat improperly.  This can cause imbalances and deficiencies in our physical status and feelings of wellbeing.  So being thoughtful and mindful of what and how we eat will protect us.

If we withdraw, we will become less socially adept and we will deprive ourselves of the people who love and care and support us.  It will limit our coping and problem-solving abilities which, during times of stress can become more limited and circular and less adaptive.  It will also take us away from our capacity to help, support and care for others.   We need to become more comfortable with our vulnerability and learn how to ask for help from others.  Even if we don’t understand another’s fear or suffering we can at least be present and listen with care and empathy.  If we can share our experience of stress and suffering with others and feel recognized and understood, we will be more inclined to look for ways to care for ourselves and to problem solve.

We may have to develop new routines. Having routines during the day which give us a sense of predictability and achievement are essential to maintaining health.  These routines are part of how we know who we are.  They are part of our identity and they keep our bodies and minds attuned to our environment and to others. They also regulate our sense of time and help maintain memory and cognitive function. 

We are, by nature, social beings.  We require relationships to help us see ourselves clearly and to navigate through life and find meaning and purpose.  Much as we might value independence, the reality is that we need each other to live effectively and find meaning and purpose.  We cannot see ourselves accurately or find meaning without others.  This is more the case when we are confronted with change and fear.  We are intentional in our existence and we can’t help but be drawn toward the world, each other and our future.  When, as I mentioned above, these things are altered or become less predictable or available, we will need to be creative and collaborative in finding ways to navigate in our environment and to move toward the future.  Making plans for the future and exploring and identifying possibilities together will help us see our way forward and engender hope.  Hope (that we will cope and survive, that we will find ways to overcome this event and regain a sense of balance and future) is essential to our survival.

Emmanuel Levinas, a 20th century existential philosopher and theologian who survived the Holocaust, based his philosophy on the concept that when we face another person, we are immediately obliged to recognize a person who is suffering and reach out to care for and comfort them.  It goes both ways.  When others see us in our fear and suffering, they have the same obligation.  The bottom line being that we cannot live successfully in this world without each other.  Levinas knew the morality he directed toward “the other” was also a morality that humanity needed to survive.  Relationships for him are the largest part of meaning to individuals but also to humanity and society.  And relationships require a desire to care and be cared for, to give of ourselves even when it means sacrificing out own needs.  In doing so, we don’t have to confront life and existence on our own.  We can see stressful times in our society give selfishness, division, blaming and separation the ground to breed (i.e when we forget or lose this sense of loving responsibility toward each other ).  It becomes easy for us to ignore or forget those of us who are in need, isolated and alone.  These behaviors only weaken our ability to cope and create.  

You might note, as I identify ways of coping and responding to the challenges brought on to us by this pandemic, that there is a recurring theme of connecting and caring for ourselves and others.  Every strategy I have mentioned involves relationships with ourselves, with those that we love and with our community, culture and society.   Without reaching out or asking for help there is little chance of coping and maintaining health and wellbeing. Without others there is no place to find or create hope or meaning.  The phrase that we hear often these days is “we are all in this together” brings with it the need to be active in our being together.  With our global divisiveness (another source of stress), it sometimes feels more like “we are all in this alone”.

The other theme that runs through this discussion is our need to be creative, collaborative and to see the challenges we face as opportunities for learning, reflecting on ourselves and our society and creating a path forward.  Suffering and existential challenges are opportunities for learning about ourselves, our world and for continuing our search for meaning and wholeness in this miracle of life that we are given.  It is possible to come through this difficult chapter as more whole, more capable, closer and more functional.  

There is indeed reason for hope, but it will take work and community.

-Dr. Joe Burley