Photo: Cat O’Neil
Amy Nitza has spent decades helping people in crisis. The director of the Institute for Disaster Mental Health at the State University of New York at New Paltz has traveled to Puerto Rico in the wake of Hurricane Maria, to Botswana during an HIV crisis, and to Haiti to help traumatized children forced into domestic servitude.
But the COVID-19 pandemic, Nitza says, is different. It keeps coming at people month after month as loved ones get sick or die, as jobs are lost, and as the actions taken to avoid infection—such as isolation from family—cause intense emotional pain and stress. As of December 2020, more than 1.6 million people around the globe have died from the coronavirus. Grief, fear, and economic hardship have hit every nation. In the U.S. the numbers have been overwhelming: more than 300,000 people have died, and about 17 million have been infected with the virus, according to the Johns Hopkins Coronavirus Resource Center. Usually disasters have survivors and responders, Nitza says, but COVID is so widespread that people are both of those things at once. “We’re training everybody [on] how to take care of themselves and how to support the people around them,” she says.
The upcoming winter looks especially dark and hard as deaths climb to exceed the losses of 9/11 every day. As soon as we hear that outbreaks are receding, they rise back up again like storm-tossed seas. Perhaps the toughest part is that no one knows when the pandemic will end or whether the future will look anything like the past. Vaccines are here for some health-care workers and nursing-home residents, but for most of us, they are still months away. At the moment, many hospitals are overwhelmed with waves of new COVID patients. “We as a nation have never been in anything like this,” says Charles Figley, who has worked in disaster psychology for 40 years and is director of the Traumatology Institute at Tulane University in New Orleans.
The stresses are taking a terrible toll on our country’s mental health. In June researchers at the Centers for Disease Control and Prevention surveyed 5,412 U.S. adults and found that 25.5 percent had symptoms of anxiety and 24.3 percent had symptoms of depression—a threefold and fourfold increase, respectively, from 2019. It is “a staggering number,” says Susan Borja, chief of the National Institute of Mental Health’s Dimensional Traumatic Stress Research Program. In a study that has not yet been peer-reviewed, researchers at the City University of New York and the University of North Carolina at Chapel Hill surveyed 5,250 U.S. adults in April 2020 and found that 35 percent were experiencing moderate or severe anxiety symptoms. Those who had recently lost income were doing extremely poorly.
The pains of the pandemic and its consequences are sharpest among people of color, who are “more exposed and less protected,” in the words of physician Camara Phyllis Jones, who studies health inequities. In November 2020 unemployment rates among Black and Hispanic workers were 75 and 42 percent higher, respectively, than that among white workers. Compared with white households, many more Black and Hispanic households are struggling with food insecurity, and nonwhite children are more likely to be learning remotely from home rather than in person at school. These hardships fall on top of the direct agonies inflicted by the disease: In a study published in July 2020, New York University researchers found that in urban U.S. counties where the population was substantially nonwhite, the COVID death rate was nearly 10 times higher than it was in predominantly white counties with the same median income. Among Native Americans, another less protected group, the death rate during the first half of 2020 was nearly twice that among white people.
We can now glimpse, with the advent of vaccines, that there will be an end to this pandemic. But to get there, we have to somehow keep going through months of trauma and strain. How do we do that? How do we endure more and more of the isolation, the deaths, the flare-ups, the economic wreckage, the fear, and the uncertainty?
There are ways—not perfect solutions but methods that can help. Psychologists who specialize in trauma and disaster recovery, as well as those who work with patients who have chronic injuries or disabilities, say that although it feels impossible and although there will be losses, most of us will get through this disaster. And they point to strategies for coping born of experience and science. When people in devastating situations can spot warning signs of mental trouble, acknowledge and express their distress, focus on the present moment and the small things they can control, and find ways to connect with others, they can get through the darkest of moments and show resilience.
“The majority of people who have a major catastrophic life event are going to eventually either return to baseline or, in some cases, come out better on the other side than they were before,” says Megan Hosey, a rehabilitation psychologist at Johns Hopkins Medicine, who works with chronically ill patients in intensive care units. Most of us, she says, “will be able to adapt and recover.” But to do so, we will need to be flexible, open, and honest with ourselves and learn how to take things one day at a time.
Look for Warning Signs
It can be hard to tell the difference, in the midst of a crisis, between normal levels of angst and those that indicate we might be tiptoeing toward a dangerous ledge. Key signs of declining mental health include changes in appetite or sleep patterns that last more than a week. If you find yourself becoming more irritable—maybe you are lashing out more frequently at your family members—that can be another sign of depression or anxiety. Having more trouble concentrating than usual or being unable to enjoy things you used to enjoy may also indicate that your mental health is declining and that you need to try new coping strategies.
Keep track, too, of how much you rely on medications, as well as on recreational drugs or alcohol. “We are seeing an uptick in substance and alcohol use in the context of the pandemic,” Hosey says. This does not mean that it is dangerous to have a beer or a glass of wine when you are feeling stressed. But “if a medication or a substance is one of your primary ways of coping and you’re finding you need more and more of it to get through the day, that’s a red flag,” she says.
Other things to look out for are physical symptoms such as pain, dizziness, or indigestion. When people struggle emotionally, their distress often manifests itself physically (of course, serious physical symptoms warrant a visit to a physician to rule out other causes). Psychologist Tracy A. Prout and her colleagues at Yeshiva University, along with researchers at the University of Haifa in Israel and the University of Pisa in Italy, surveyed 2,787 adults around the world about their mental health during the pandemic. They found that the people who were experiencing the most distress also had the most physical symptoms, as the group reported in their study, published in November 2020 in Frontiers in Psychology.
Fear Is Okay
Behind these signals are the loneliness, unpredictability, fear, and deprivation of the pandemic, and those are experiences that hospital patients with long-term illnesses and injuries know all too well. Mana Ali, a rehabilitation psychologist at MedStar National Rehabilitation Hospital in Washington, D.C., treats people with spinal cord injuries and paralysis. She says that one of the first things she tells these individuals is to acknowledge such emotions and to not feel bad about having them. “I always tell my patients, ‘It’s totally normal that the anxiety is there—it’s about managing it,’ ” she says. We tend to think that fear and worrying are bad and that strength is the absence of those things, but that is not the case, she adds: “You can feel scared and fearful and angry and resentful and simultaneously be a victor and be resilient. Reminding people that they are both, versus either/or, is extremely important.”
Disaster and rehabilitation psychologists have done research showing that writing about negative feelings is very effective. “There’s something about writing it down that’s super important,” Nitza says. In the early 1980s psychologist James W. Pennebaker, then at the University of Virginia, and his colleague conducted a study in which they told some college students to write about their stressful experiences and feelings for 15 minutes a day four days a week. They told others not to do anything unusual. The students who engaged in this “expressive writing,” as Pennebaker called it, were only half as likely to visit the student health center over the next six months as those who did not. More recent analyses have supported these findings, confirming that writing about feelings is a powerful way to work through them.
These admissions about negative emotions are important because they “open the door for, ‘What can I do next?’ ” Hosey explains. To be fair, this question can be hard to answer in the midst of a world-shaking pandemic. Nitza suggests trying to pinpoint what exactly worries you most at the moment and then identifying aspects of the situation that you can control or make progress on. If you have just lost your job and you are worried about paying your bills, brainstorm small things you can do to give yourself a sense of control. Maybe a goal for this week is to create a new household budget or to find out about financial relief programs you might be eligible for.
This kind of brainstorming requires open-mindedness about “things you’re willing to learn and try,” explains Deepa Ramanathan-Elion, a rehabilitation psychologist at the National Intrepid Center of Excellence at Fort Belvoir in Virginia, who works with military service members who have traumatic brain injuries. “If you continue in a sort of rigid way of thinking, it’s going to be very difficult for you to adapt to a changing environment, no matter what the situation is—whether it’s COVID or something else,” she says. “You really need to be able to adapt and be flexible.” That might mean considering jobs you would not have considered in the past or asking people you would not normally reach out to for help or support.
The idea is to think of problems as obstacles you can overcome (at least partially) rather than as insurmountable hurdles you can do nothing about. There are aspects of this pandemic we cannot control—but by focusing on the things we can tweak at least a bit and by thinking of ourselves as resilient and adaptable, we will do better, Ali says. Cognitive-behavioral therapy, which focuses on helping individuals identify, understand, and change their thinking and behavior patterns in these ways, has consistently been shown to boost mental health. A 2020 study found that Internet-based cognitive-behavioral therapy improved symptoms in people suffering from either anxiety or depression.
Ali often thinks of her father and his family, who are from Somalia and have faced many hardships. “They have absolutely nothing, but they have this strong sense of resilience,” she says. “If they feel like they can get through it, they can get through it. So trying to cultivate that in people, regardless of resources—having them see that ‘you can do this—I think is very, very, very important.”
Find New Ways to Connect
Seeking out others can help, too. Researchers at the RAND Corporation found, based on interviews done after the 9/11 terrorist attacks, that the most common way adults dealt with their distress was by connecting with friends and family.
The trouble now is that staying safe during this pandemic strains those connections. It often requires physical distance from loved ones, which means people are forced to give up what they emotionally need the most. In a 2015 analysis of 70 studies, researchers at Brigham Young University found that people who reported feeling lonely were 26 percent more likely to die over the next seven years, on average, than those who were not lonely. “There is a consistent and growing—and highly replicated across context and across countries—literature on the detrimental effects of social isolation and loneliness and the mitigating or positive well-being effects of social support,” says Courtney Welton-Mitchell, a psychologist at the Colorado School of Public Health and the Natural Hazards Center at the University of Colorado. (If you are feeling extremely isolated or are having thoughts of suicide, please call the National Suicide Prevention Lifeline at 1-800-273-8255.)
If you are older and alone, connecting with others can be hard, especially if you are not tech-savvy enough to link up over a computer or a smartphone. Welton-Mitchell suggests reaching out to family members and friends regularly by phone, e-mail or snail mail and perhaps setting up regular phone calls or physically distanced visits. You can also sign up for Caring Calls, a service organized by the nonprofit organization DOROT, which facilitates once- or twice-weekly telephone conversations between older adults and volunteers. To sign up by phone, call 1-212-769-2850. If you are comfortable using the Internet, you can sign up for a service such as Big & Mini or Eldera, either of which connects older adults with younger people through video calls.
Working toward a meaningful cause—even from the safety of your home—can also improve emotional health. It helps to “feel like you’re committing to something that’s greater than yourself,” says William Garmoe, a neuropsychologist who works with Ali at MedStar National Rehabilitation Hospital. In a 2007 paper, a group of 20 international disaster psychologists analyzed research on the most important psychological needs people have in the midst of a disaster. They reported the top five are to feel safe, calm, self-efficacious, socially connected, and hopeful. When people engage in activities that benefit others, they may be able to check off three of those needs—feeling more useful, connected, and hopeful about the future. If you are not sure where to start, search VolunteerMatch.org or Idealist.org for local or virtual opportunities.
Virtual therapy provides another means of connection. Since the pandemic began, federal and state legislation has loosened a number of restrictions on the use of telemedicine, so it is now easier for people to access mental health services online. Finding a therapist can be difficult if you do not have health insurance or the means to pay, but free or low-cost options do exist: Opencounseling.com, for instance, allows you to search for free or low-cost therapists in addition to those who accept insurance or who can be paid for out-of-pocket.
One key benefit of therapy is the close relationship between the patient and the provider, which fosters a strong sense of belonging. “You’re meeting with somebody with whom you have a real relationship—this is a person who cares about you, seeks to understand you, is warm and accepting,” says Bruce Wampold, a professor emeritus of counseling psychology at the University of Wisconsin–Madison. “And for many people, this is particularly healing.”
Therapy can also help by nudging people toward constructive ways of coping with stress and anxiety. In their November 2020 study, Prout and her colleagues surveyed adults about what strategies they used to make themselves feel better during the pandemic. They found that people who connected with and helped others felt less distressed than those who coped in less healthy ways, such as by repressing their feelings or behaving passive-aggressively.
Pay Attention to Yourself
One of the hardest things about the coronavirus is that it creates so much uncertainty about the future. “We like to be able to plan and set goals,” Ramanathan-Elion says. “We like to go through life in this very organized fashion.” Yet many of us do not know when we will get access to a COVID vaccine or whether we can pay next month’s rent or when social isolation will end. We do not know whether we will get sick with COVID or what will happen if we do.
Psychologists who work with people who have serious injuries or chronic illnesses note that such people always have to manage an unknown future, and they often do so best by focusing on the present—paying attention to their sensations and feelings in the moment rather than focusing on what cannot be known with any assurance. The goal is to “just look at this one day at a time. Because we really don’t know what tomorrow is going to look like,” Hosey says.
One evidence-based approach that helps people stay grounded in the present is “mindfulness,” and there are various ways to do it, including through short meditations. A 2018 review and analysis of 18 studies concluded that regular mindfulness exercises—such as focused breathing and “body scans,” in which you pay attention to how the parts of your body feel and try to relax them—reduce symptoms of anxiety and depression even in the absence of any other treatments. (If you want to try guided meditations, Ramanathan-Elion recommends the smartphone apps Breathe 2 Relax and Mindfulness Coach.)
If the idea of meditation makes you uncomfortable, it is possible to be mindful without it. One way is to focus on the sensations you experience while you do everyday things such as eating and brushing your teeth. Nitza says she recently bought several adult coloring books because she has found that coloring is what helps her “focus my attention on the immediate thing.”
However we get to it, mindfulness makes us feel calmer because “it slows down our breathing, and it sends that message to the brain that we’re okay and there’s no trigger in the environment; there’s no stressful issue that we need to be attending to,” Ramanathan-Elion says.
There is no one-size-fits-all approach to keeping your mental health intact, and the approach that is best for you will depend on your situation, your access to resources, and your preferences. Psychologists say to trust your instincts and to try the available strategies that you think might help the most. Be willing to try out new things if the approaches you first choose do not seem to be working.
And keep in mind that the more time we spend in this pandemic, the better we will get at muddling our way through—because humans adapt surprisingly well to challenging situations. It has been tough, and it could get tougher, no question. But people are “stronger than they think,” Figley says. “I frequently find people are unbelievably resilient."