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| PERSPECTIVE/VIEWPOINT - GLOBAL |
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| Year : 2020 | Volume
: 2
| Issue : 2 | Page : 88-93 |
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Mental Health and the Coronavirus: A Global Perspective
Vandana Gopikumar1, Deborah K Padgett2, Alok Sarin3, Roberto Mezzina4, Andrew Willford5, Sanjeev Jain6
1 Founder, The Banyan, and The Banyan Academy of Leadership in Mental Health, Chennai, India
2 Professor, Silver School of Social Work, New York University, U.S.A
3 Senior Consultant in Psychiatry, Sitaram Bhartia Institute of Science and Research, (SBISR), New Delhi, India
4 Chair, International Mental Health Collaborating Network; Regional Vice President, World Federation for Mental Health, Italy
5 Professor of Anthropology, Cornell University, U.S.A
6 Senior Professor of Psychiatry, National Institute of Mental Health and Neurosciences, (NIMHANS), Bengaluru, India
| Date of Submission | 26-May-2020 |
| Date of Decision | 29-May-2020 |
| Date of Acceptance | 01-Jun-2020 |
| Date of Web Publication | 14-Aug-2020 |
Correspondence Address:
Dr. Alok Sarin
Sitaram Bhartia Institute of Science and Research, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | 4 |
DOI: 10.4103/WSP.WSP_51_20
Any epidemic of infectious disease such as the present one that we are witnessing puts a strain on both the individual and the community. The very basis of physical and emotional health, dependent as it is on the body and social networks, is threatened. Existing inequalities in society get accentuated, and systemic responses that provide succor to all sections of society, especially the marginalized, are critical. Scientific and technological insights will, ultimately, provide solutions (or at least a better understanding), but the broader engagement of the “social body” in this endeavor is very important. Humans are social beings, and the isolation, stigma and the labeling of those infected; indeed, the very “othering” of the virus, makes us concerned about the long-term consequences of this pandemic. From health-care workers and those seeking help who are concerned about imminent infection and morbidity, to those displaced and dispossessed, who now face months of poverty and hardship, the spectrum of mental health needs is very large. Pandemics like this underline the urgent need to work beyond real and imagined boundaries. As a group of mental health professionals and social scientists, we hope that the social and psychological responses will help us emerge from this with a greater sense of harmony and cohesiveness.
Keywords: COVID 19, humanitarian crisis, mental health crisis, migrants, pandemic, social psychiatry
How to cite this article:
Gopikumar V, Padgett DK, Sarin A, Mezzina R, Willford A, Jain S. Mental Health and the Coronavirus: A Global Perspective. World Soc Psychiatry 2020;2:88-93 |
As a group of mental health professionals, academics, and social scientists from India, the United States and Italy, we are acutely aware of our privilege as part of a minority who enjoy the luxury of being able to intellectualize the health, humanitarian, and existential crisis around COVID 19. In this knowledge, we attempt in all humility to present a broad interdisciplinary narrative of how population mental health may be addressed, both now and in the longer term. In doing so, we try to revivify mental health, broadening its scope, incessantly cognizant of its multifactorial causal pathways, especially in anomalous times such as this.
Health services in many countries are under enormous pressure and face unprecedented challenges. Medical professionals, scientists, health and social care providers, and other frontline workers, among others, have been at the forefront of relentlessly driving the effort to save lives and build systemic responses both by dissemination of adequate public health approaches, and in parallel, genetic mapping, drug, and vaccine development. Despite persistent efforts, millions are being infected by this virus and hundreds of thousands have died. This emergency has put all aspects of normal everyday life on hold, with expectations that individuals as well as institutions will focus on a single goal: containment and mitigation. Meanwhile, mental health care takes a back seat to life or death decisions made by exhausted health care workers.
| The Hidden Epidemic of Emotional Distress | |  |
For a newly mutated virus that has no vaccine or cure, the only tool that we have to slow the velocity of spread is reducing social contact. Hence, apart from maintaining hygiene, the mechanism of “bending the curve” of spread is social distancing. The problem is that “social distancing” (also known as “physical distancing”) is the very antithesis of all that is considered therapeutic in mental health. Enforced isolation deprives human beings of social contact, the need for which is hard-wired into our brains.[1] Indeed, in human primates, the need for social behavior is as keenly experienced as that of hunger.[2] The difficulty is obvious. Social distancing takes away what people need most in times of great distress - warmth, support, and collective meaning-making.
In this scenario, psychological distress, inextricably linked to social losses and grief, has to be addressed adequately. Narratives of the catastrophic effects of the pandemic (in addition to infection and death, further consequences such as mass unemployment, depletion of support networks, gender-based violence, and housing instability), find fertile breeding grounds in disenfranchisement and marginalization. Although not yet being documented by epidemiologists, there will likely be an increase in deaths by suicide,[3] in severe depressive episodes and in spikes in anxiety, characterized by feelings of apathy, excessive rumination, loss of control and hopelessness. Similar trends were observed around the Spanish Flu Epidemic of 1918[4] and the Great Depression in the 1930s, indicating that the mental health sequelae associated with catastrophic events have not changed significantly over time.
Regrettably, access to mental health care has not kept pace with access to health care, in part due to a lack of parity in insurance coverage for the latter. In many nations, “specialist” outpatient services (including mental health services) are largely the province of private practitioners, and thus accessible only to those who can pay for them. Meanwhile, public mental health services are severely overburdened with lengthy wait lists and a shortage of providers. The people with severe mental disorders in low-income households experiencing an acute episode have been particularly affected, with notional or negligible access to ambulatory services or emergency care. Therefore, stabilization is largely being managed and monitored at home, in the background of food scarcity, overcrowding at homes and wage insecurity.
Key principles of effective mental health care, such as close engagement and involvement with clients, cannot be maintained from a distance or solely through a computer screen (assuming the person in need has access to a computer). Barriers of cost - now compounded by distance requirements - render mental health care even more unattainable. The individual-provider relationship, the main instrument of success in therapy and assistance in mental health, can no longer be used freely and directly.
Franco Basaglia, the Italian mental health reformer, defined the “social body” as “the sum of the subjects who participate in their own (social) organization, and in the organization of responses to their own needs and to those of the group.”[5] For him, the “restitution of the social body” of those who were discriminated, socially excluded and institutionalized was the utopia for modern mental health reform.
This is now under threat as social networks shrink to the essential. Increasingly, people are exhorted to distance themselves from the social body and social contacts are reduced to video conferencing, telephone calls, and social media sharing. This, in turn, increases exposure to unreliable sources, exploitation and perceived loss of security, amplifying the experience of stress and suspicion. Alienation generated by the absence of social ties and exacerbation of conflict experienced within families can also sharpen leading to moments of domestic crisis.
While we do not wish to pathologize and classify reasonable, unprocessed, and innate distress into a diagnostic box, sudden, and overwhelming stress may indeed exacerbate depressive symptoms and preexisting mental disorders. Developed in the early part of the 20th century, “psychological first aid”[6] was the first response of mental health professionals as part of the treatment for shell-shocked soldiers facing the horrors of a brutal war that rained death from within and beyond one's gaze.[7] Attending to basic needs, providing succor, demonstrating empathy and concern, and hope were seen as essential to the process of healing. While a mental health professional would typically offer therapeutic support of this nature, it is an opportune time to focus on the social alongside the intra-psychic, cognitive and behavioral aspects of mental health care.
Mental health treatment in combination with biomedical care can provide essential recourse, no doubt. However, to the surprise of the mental health provider community in the aftermath of the 9/11 attacks, volunteer professionals offering free access to the latest disaster trauma therapy sat idly by while New Yorkers opted for communal dinners, parent-led support groups and spontaneous acts of altruistic caring.[8] Emergent needs mandate that human service professionals formulate collaborative care plans, and account for and address structural and systemic barriers as well, that often precipitate and perpetuate distress with a vigorous capability to influence ill health and recovery trajectories. The integration of democratic and supportive methods such as open dialogue[9] and sociotherapy[10] is essential in fostering a sense of belonging to one's own community, thereby enhancing active collective engagement, now more than ever before. The effectiveness of problem-solving efforts and mental health solutions would be improved considerably by addressing the lived experience of service users.
| The Unequal Burden of Both Epidemics | | |
To assert that the social gradient in mental health is reinforced in the current crisis would be an understatement.[11] For a majority caught in a web of economic marginalization, social disadvantage, inequity, gender disparity and powerlessness, the human experience of the pandemic and related social losses and opportunity costs could bolster a further downward spiral into a state of hopelessness. Globally, health, social, and economic inequities, stand unconcealed, and evident, today more than ever before.
The onset of the COVID 19 pandemic came amidst an already-deepening crisis of rising economic inequalities and homelessness in much of the world. Mandated “stay-at-home” policies have been a cruel reminder that homeless persons have no place to seek refuge. Moreover, the dominant model of homeless services - crowding dozens or hundreds of people into a shelter with poor sanitation and poor nutrition - was a recipe for impending disaster. Globally, encampment “clearings” - sweeps by sanitation workers and police - continue unabated and remove what little refuge their inhabitants have managed to cobble together, exposing them to the elements and greater risk of infection. With foot traffic on the streets and access to casual labor virtually nonexistent, opportunities to generate a meager income have disappeared. The loss of jobs-especially low-wage service industry and jobs in the informal sector-is likely to push more and more into homelessness.
Similarly, lockdowns in many parts of the world have exposed other vulnerable groups and communities to further risk. Women may find themselves in the way of harm, exposed in isolation, to intimate partner violence or/and domestic violence, with no reprieve in sight. Casteism, classism, and cruel antisocial behaviors are often both amplified and justified, in times such as this, resulting in further alienation and othering, as herd mentality and group identity gets the better of reason, humanity, and social connectedness. Meanwhile, the wealthy are able to “shelter” in capacious homes or escape the density of cities altogether, fleeing to their country homes. Left behind are the underpaid and at-risk “essential workers” who maintain transportation networks, food supply chains, and the all-important health care that sustains society's vital infrastructures. The burdens of inequality have increased exponentially.
To further compound this is the fact that, in India at least, much of the labor force are actually migrants from other states. Left without the possibility of earning, hundreds of thousands of migrant workers attempted to make their way “home,” only to be stopped by fairly strict lockdown procedures, continue to lead to another series of humanitarian crises unfolding as a horrified society watches.[12],[13] There has, also, been an outpouring of help, both by state and civil society.[14],[15],[16] Both the magnitude of these multiple catastrophes and the adequacy of the response will need the lenses of time and criticality to be adequately comprehended.
It has therefore never been more urgent to step aside from conservative and rigid kinship practices, social processes and individualistic notions and embrace the values and practices of sharing and solidarity, both civil and social. This is critical if we want to enhance the sense of being part of a community. In this context, mental health services can act as bridges. In a re-discovery of the self, we should pay attention not merely to physical care, for example fitness and the healthy lifestyle, but focus on a form of Foucauldian “care of the self.[17] What do we really need? What is essential? Who are we, as individuals and groups? How do we behave? Important questions in today's day and age. As we are thrown back on ourselves, something quite new to many of us, we must seize the opportunity to listen to ourselves and at the same time, reinvigorate a sense of community and common struggle.
| Othering and Identity of the Virus | | |
We see both dimensions of our human nature on display in our response to this pandemic. We are told that the invisible danger lurks in every touch, on every surface, and in every breath shared with others. At the same time, we are also made aware that the virus is a mutation of the influenza virus, that it originated in bats, can spread only by droplet infection, and can cause death only in a small segment by an acute inflammation of the lungs, identified by ground glass opacities in the lungs.[18],[19] In a population that has limited social capital and unequal access to education and health care, the voice of reason and science[20] may be drowned by the fear of disease, amplified by polemical discourse. The need to democratize science and medical care and make it transparent and accessible to all is an essential approach to quell fear and unconfounded terror and panic, often a cause for knee jerk reactions and self-harm.
On the ugly side, we have seen callous indifference to the economic divides within our society that allocates resources, economic, medical and educational, in response to our varied lockdowns and social distancing measures. A few communities, in particular, are experiencing racist rhetoric and attacks on an alarming scale, exacerbated, sadly, and unnecessarily, by labeling COVID 19 the “Chinese virus.” Expert knowledge being shared by medical professionals and immunologists is being publicly doubted and derided through a political lens that amplifies conspiracy theories and gives voice to irrational forms of political denialism by leaders of many nations. The need to label, deflect and externalize that which levels all of humanity is on full display with its attendant ugliness, racialization, and (oftentimes religious) obscurantist anti-expert populism.
Catastrophic events of this nature are bound to deepen and widen fault lines, be they personal, societal, economic or communal. Anxieties emanating from the uncanny and sublime oftentimes lead to frenetic and feverish archiving of the other's evil, as an attempt to exteriorize and name that power and malevolent force. This is the logic that drives witchcraft accusations as seen in the anthropological literature[21] and contemporary India. We do not want to push this analogy beyond utility, but want to suggest that the uncanny forces of something that can be everywhere and nowhere at the same time, and which exceeds our ability to figure or fully understand, see, or grasp; and which can exist within oneself, as much as in one's neighbor, can be a source of social violence and distrust as the malevolence is mystified, mythologized, and externalized. The potential slippage of pandemic anxieties into something like demonologies that attempt to figure and personify anxieties through the image of the other would not only hasten more social distrust and anxiety, worsening an already serious mental health crisis, but would also further dissolve faith in scientific expertise leading to a potentially lethal populist cauldron of accusation and counter-accusation. Valuable time and focus in combatting the pandemic would be lost, as would our global goodwill and unity as fingers were pointed, fuelled by today's version of a witch-frenzied mob of conspiracy theorists operating through the shadows of rumor and its contagion through social media and dubious “news” outlets.
In the second phase, as the lockdown was generalized to half the population of the world, this has changed both policy and governance practice. Individual citizenship rights and fundamental freedoms get called into question, and legal prescription and emergency ordinance often spread beyond control of the outbreak. The opposite risk is of neoliberalism, which incites revolt against the same power that it evoked to preserve production and consumption without considering health and life itself.
We may want to remember that essentially health is a participatory and re-appropriation process of the bond between the “organic” and the “social” body we mentioned before. Therefore, we believe that all forms of sharing and sociability that can work within the space of a sustainable risk can hinder this enormous biopower.
We remember the UN Special Rapporteur on Right to Health (art 25 CRPD)[22] who wrote that mental health and wellbeing require “the creation of enabling environments that value both social connection and respect through nonviolent and healthy relationships at the individual and societal levels throughout life.” If among required policies there is a cross-sectoral strategy that prevents inequality, discrimination, and violence in all settings and increases mutual trust between authorities and civil society, how can this be possible in the current dramatic and tragic circumstances? This will require addressing the issue of social determinants while supporting community resilience and reducing the impact on vulnerable populations.
| Humans as Social Beings | | |
Literally, millions of people are willing to stay indoors out of a sense of caring for others' well-being as well as their own. To sacrifice one's own freedom for the good of others. Yes, there are egregious exceptions among youthful party-goers and some religious groups but the outpouring of good will and-yes-loving care being shown has caught many of us by pleasant surprise. The zeitgeist of competitive individualism has suddenly been called into question. The longer-term effects of this great social experiment remain to be seen but it is hard to imagine a return to the previous status quo.
This is a case in point to realize that there is within humanity an intrinsic sociality and altruism, that strives to overcome the overwhelming sway of anxiety not through othering, but through empathy and care. It is no exaggeration to say that “culture is in our bones,”[23] given our evolutionary species-being. We, unlike many of the animals we share the planet with, evolved through a selection pressure toward plasticity, or a capacity to learn through symbols, which, in turn, was also a selection pressure towards social cooperation and the learning it enabled.[24] Rather than the “naked ape” depicted in Stanley Kubrick's classic, 2001: A Space Odyssey - a weapon wielding aggressive hominid, the evidence from the paleontological record suggests otherwise. From endocasts, we see that the sulci within the brain associated with language and learning corresponded to greater social complexity within our material culture, as well as the morphological changes to our bodies that allowed for the selection of larger and more complicated brains. That is to say, we are, despite our oftentimes pathological descents into racial and ethnic othering, also hard-wired, paradoxically, for culture and meaning as that “software” that makes us truly human. A selection pressure for incompleteness and plasticity then means that the human adaptation was, and remains, one of learning, empathy, and cooperation, as much as it is of labeling the inherent dangers and exteriority of the other as a threat. Or to put it in another way, as John Dunne did half a millennium ago, “no man is an island.”
| Systemic Social Health Responses | | |
In the background of uncertainty and despite some governance, social and political blips, flourishes of cooperative and determined action have left many people around the world feeling hopeful. Many positive moves have surfaced, if only to stem the tide of infection and reduce the strain on medical care. Moratoriums on evictions have been enacted (but whether they are enforced or practiced is not clear), compensation measures for daily wage earners have been initiated (but require considerable form-filling), community kitchens have opened; the suggestion of a basic income has been revived in a few countries. On a larger scale, greater attention to the interface of climate change and pandemics highlights how zoonotic diseases are made more likely by the loss of natural habitats to deforestation and pollution, the so called Anthropocene effect, leading to a growing exposure of humans to animals who are vectors of lethal viruses.[25]
It remains an open question whether political leaders will further harness and nurture our better nature and tear down the archives of difference that threaten to make this disaster truly catastrophic for the future of our common humanity. Or hopefully, the inarticulate trauma and the silences that it harbors within (in particular in the younger generations), will be met by an opening of spirit and psychological inquiry that does not rush to judgment, and with it, the pathologizing of those who are suffering, by erecting more borders and exacerbating racial, ethnic, and religious differences (exploiting the “tyranny” of small differences). If our better angels emerge at the international, national, and local levels, perhaps this moment will not only better prepare us to meet other existential challenges, such as future pandemics, climate change, and inequitable progress and development, but will also push us past the brink of intolerance, classism, sexism, ableism, populism, and nationalist xenophobia that are plaguing our planet at this time.
In what could be best described as a natural social experiment, the current scenario presents us with threats, challenges and opportunities of an unprecedented scale. As a consequence, how we behave as nation states, communities and individuals, may have the propensity to influence not just our immediate, but future life, culture, and society. Is there then embedded in the recesses of this tale of despondency and gloom, an opportunity to re-calibrate our collective consciousness?
Moreover, yet the mental health consequences of this brand new form of quarantine called “social or physical distancing” should not be under-estimated. Boredom, isolation, loneliness, fear and anxiety, along with enormous grief for the deaths of loved ones, the very existential dread needs a recipe for care that goes well beyond the rudiments of hand-washing and mask-wearing. But - as with the 9/11 attacks in New York City or the 2004 tsunami that hit large parts of Asia - the effects are mitigated by the “we're all in this together” sense that consumed these cities and regions in the months afterward. Every walk through empty city streets is a reminder not only that the worst pandemic in a century is upon us but the best social caring response possible is also with us. And, if the virus is contagious, so is hope.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest. NOTE: An earlier version of this article was published in Frontline magazine on 24 April 2020, titled “Mental Health Concerns: enforced isolation and mental health.”
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