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By Suzanne M. Anderson, DPST
 
Westerners have often oversimplified the Chinese symbol for "crisis" to mean danger and opportunity, when in fact, it means "danger at an incipient moment" (Zimmer, 2007). Linguists argue whether "the moment" is neutral or has a positive inflection in its original language. A crisis is an incipient moment--a moment when change begins and has the potential for harm and growth. Part I of this article will address the threat, the emotional and social impact, and Part II, to follow, will discuss the potential to respond with or build resilience in the response of Covid-19.
 
Part 1: The Danger: The Emotional and Social Impact of Covid-19
 
Over the last couple of weeks, I have talked with international school educators in central and eastern China, where Covid-19 has forced the closure of schools since the Lunar New Year, and where they are expected to be closed for a number of weeks. These educators are both Chinese and internationals. Some have remained in China, some have gone to neighboring countries like Thailand, and some have returned to home countries, such as Australia and the United States. Not all had choices about whether to leave. Those who remain seem to mostly be Chinese educators whose homes and families are in China, and international educators with pets, who would have had to navigate finding care for, or moved with, their pet—often an expensive and drawn-out process in the best of times. Every educator with whom I spoke is working harder day-after-day, around the clock, to support continued learning for their students; to remain connected with their colleagues in various time zones; for some, to support their own children's education; and, to eke out, in the very little time left, some time to care for themselves. 
 
Talking to people who have survived traumatic situations always has a profound effect on me. Usually, I am onsite. Usually, I have come to where the crisis has occurred and talked to survivors face-to-face. This time I have been providing support remotely—while living in a Covid-19 affected country—however, sitting in the relative comfort and freedom of my home and office in Singapore. Even at a distance, these conversations palpably conveyed the impact of the virus in a way that I have not often felt. And, as always, these conversations impressed me with a profound picture of human endurance, resilience, and creativity. There is no playbook, no set of guidelines on how to survive an epidemic, effectively on house arrest, or unable to go "home." These educators are making it up as they go along, trying to make the next best decision, professionally and personally.
 
For those who are not infected, but none-the-less have had their lives significantly altered, the emotional impact of Covid-19 can be overlooked. Unless you are infected, the danger of this virus is invisible, we only see its impact on the society writ large. And while the threat is active (the virus is spreading), the focus is on efforts to stay healthy—to survive. When infections subside, routines are reinstated without evidence of the previous disruption. Also, for those of us strongly affected, but who have not had the virus, the strength of the emotional and social impact can seem larger than it “should” be—after all we “should” be grateful we didn’t contract the dreaded illness. The very real emotional and social burden and accompanying recovery are not given proper due.
 
Even without the stressor of the Coronavirus or Covid-19 disease, everyone has a pre-crisis equilibrium that is either already distressed or already resilient. Educators have the day-to-day challenges that life brings—kids trying to get through exams, health issues, challenges with student’s parents, learning difficulties, elderly parents to care for, and living in a foreign country where ex-pats often don’t speak the language. The virus can feel like a weighted blanket coming down on top of all of life’s challenges. Those living with the impact of it must find a way to move around, to do the ordinary things of life, while lifting or holding up the weighted blanket at the same time. 
 
While we may be tempted to want to jump to coping and resilience, for many people, the impact must first be acknowledged. There is a series of reactions and emotions that are not uncommon in crisis—the crisis reaction (NOVA, 2009). Just like Elizabeth Kubler-Ross’s stages of grief helped create order out of the chaos of grief and loss, so too can understanding the stages of a crisis reaction help to create some feeling of order and understanding out of our responses to a crisis or disaster. Without understanding this pattern of response to a crisis, victims and survivors often feel like "they are going crazy," and they use those exact words. They hold it together on the outside (think Facebook feeds of how good life is) and see each other doing that while experiencing a rollercoaster of emotions inside and assuming they must be the only one feeling some of the strongest emotions one can experience in a lifetime.     
 
When a crisis first begins, we often experience shock, denial, and disbelief. Almost, universally our response is, "I can't believe it!" The event feels impossible, surreal, or incomprehensible. Some of us experience the unfolding of the incident in slow motion, others in fast forward. Some of us feel frozen, unable to move. Often, we are reacting with our old brain (the same one a lizard has), with only our instincts to survive. At this stage, we may also experience regression—we may look for someone else to tell us what we should do. Often, we may go back and judge ourselves harshly for having not used our human brains to organize, plan, analyze, and manage the crisis. 
 
As the denial and disbelief begin to wear off, we can experience what feels like a cataclysm or roller coaster of emotions. Often the first reaction we experience is fear and terror. It may feel as if the “veil of immortality” has been ripped away as we “think” or “know” we are going to die. This may have been experienced by some who were sick for other reasons at the same time as the Coronavirus started, and ended up at the same medical facilities as those who are later found to have the virus. Several educators have described experiencing panic and anxiety attacks that they have not experienced before. We are also feeling ongoing fear when someone around us coughs or sneezes. 

It is not uncommon in situations like this for us to feel anger, fury, and even outrage. This can be directed towards the cause of the crisis (the virus) or towards those trying to provide help in the aftermath. There can also be a strong experience of secondary injuries--when we go to people or organizations seeking help and support but perceive those responses to be unhelpful or insensitive. Employers can be guilty of creating these secondary injuries: employers often expect us to get on with our work, to keep functioning at past performance levels or maybe higher levels without recognizing the personal and professional impact of the crisis. 
 
As we try to get help, fix what has been broken, and make sense out of what happened and why it happened, we often feel confusion and frustration. Confusion and frustration seem particularly salient with the Coronavirus because in the early stages, information about the disease and how to respond seemed hard to access and continually changing.  Timing was another barrier to clear communication--the impact of Covid-19 began to unfold at a time when international schools in China were breaking for a week, and school administrators and educators were traveling. We are likely to see growing confusion and frustration as schools make plans to re-open (or not), student quarantines (or not), and so on.  
 
As we try to figure out what happened and why it happened, we may experience guilt and self-blame, feeling that they “if only” we had done something different, our circumstances in the crisis could have been prevented. We will see our colleagues and friends wrestle with the many “should(s)” that survivors tell themselves. “I should have left,” or “I should have stayed,” or “why did I go overseas to teach in the first place?” The conflict between family left at home and those who have gone overseas can be highlighted: when something disastrous happens, those at home who didn't want what their loved ones to travel can begin to feel justified. 
 
We may feel shame and humiliation if we blame themselves for how we chose to respond and cope, and especially if our lives are changed for the worse, physically, financially, relationally, or otherwise. Shame and humiliation can be exacerbated if details about our lives in these areas that have remained private become public. For educators, especially those who have left China, there has been for many an extra financial toll—renting temporary accommodations—sometimes needing to relocate during the duration, additional travel expenses, and more. For others, there is a subtler experience, of having to live indefinitely in the homes of family and friends without autonomous control of many of the fundamental routines of one's own time and space.
 
As we begin to realize how our lives have been irrevocably changed by the crisis, we may experience grief and sorrow. Each and every physical, material, and intangible loss we experience can trigger its own grief, its own sorrow. The apparent losses are for those who become ill and for those who succumb to the illness. There can be material losses of financial resources that are having to be re-channeled into staying safe. There are many other less tangible losses that are harder to identify. There is a fear of losing time and experience for many students and teachers. Many students have lost school trip opportunities they have anticipated for years. There could be a loss of afternoons and summertime if school days are run longer to make up for the lost academic time. 
 
For many, there appears to be a sensory deprivation—the loss of being with people face-to-face during this time when most communication is done through a computer. The loss of independence as families in China are in homes—all day, every day, for days on end with little opportunity to go outside. When schools re-open, there are educators and students who may never return, and they left sadly without proper goodbyes. This compounds the grief of third culture kids and families who experience many transitions.
 
The loss of feeling the air on one’s face as masks are required to go outdoors. The loss of energy—every time we change our routines, it takes extra energy to develop a new pattern of activity. Educators have been forced to learn a new approach to teaching solely through technology, relating to their students while observing child protection protocols, as well as learning to use new technologies to deliver educational content, all being done in the context of unstable and inconsistent Internet connections. Some having left for the holidays without their laptops have found themselves running or taking classes with only a cell phone. Many educators have helpers who have not been able to return after the Lunar New Year, thus have taken on domestic workloads in addition to increased professional workloads.
 
The loss of certainty that comes with the normal anticipated pace and sequencing of life and the school year. Educators are having to meet and run classes across international times zones. Typically, families are setting dates and making reservations at this time for the school summer break. The most essential looming question is, "When will this end?" Without knowing that answer, we are not able to plan.

Having experienced this cataclysm of emotion, our hope and goal is a reconstruction of equilibrium--otherwise described as creating a "new normal." It is not possible to go back to normal as it was before the crisis. Still, it is possible to create a fulfilling new normal--that while recognising the losses of the crisis--recognizes the unique strengths and growth that have occurred as a result of the crisis. More discussion on the reconstruction of equilibrium throughout and after this crisis will be addressed in Part II.

It is essential to recognize that we will all have very different reactions and ways of coping or creating a new normal. Strong opinions about the “right” and the “wrong” way to cope can create tears in the social fabric of an organization. In this situation, these tears in the social fabric may emerge between the "stayers" and the "leavers," and between those who had a choice to leave and those who did not. By recognizing that each individual will have their own unique experience of reacting and coping and by allowing and supporting each other, we can help to maintain or strengthen the fabric—the relationships—within our organizations.
 
In a crisis that is time-limited—the disaster comes and goes, and recovery begins quickly—these strong emotions will most often taper off after the one to three months. But in a long-term crisis where the disaster keeps unfolding, these reactions can last much longer and can come on strongly over and over as the crisis comes closer—there is an infection nearby, a friend is infected, as teachers return to China to start school again, or as there are notices that teachers may have to work differently to deliver a complete school year for students. Essentially, the longer the duration of the incident, the more significant the impact. As of this writing, the WHO has issued its 44th daily report and with no definitive end in sight.
 
We don’t have to wait until the crisis is over to take care of ourselves and build our resilience, we can start now. Part II will address ways of coping and developing resilience during the extended duration of this epidemic. 
 
If you are reading this and wondering if it would be helpful to reach out for support, I encourage you to answer the questions of the Trauma Screening Questionnaire. This can provide another perspective on how the circumstances of Covid-19 are affecting you individually. We would encourage you to consider the resources and support offered by your school, or the counselors who may be available in your community. You can also consult the International Therapists Directory for therapists familiar with the issues of expatriates and third culture kids and families.
 
I know that there are many other significant ways that we have been socially and emotionally affected and losses endured as a result of Covid-19. Please feel free to share your experiences in the comments section below. 
 
While they will remain anonymous, I would like to recognize the educators in central and eastern China who contributed to this article and add a thank you to long-time friend Pam Schuur who expertly provided editorial support.
 
Reference 
 
NOVA. (2009). The community crisis response team training manual: Edition 4.0. Washington, DC: National Organization for Victim Assistance.

Zimmer, B. (27 March 2007). Crisis = Danger + Opportunity: The Plot Thickens. Retrieved from The Language Log. 

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Also published on TherapyRoute.

By Suzanne M. Anderson, DPST
 
Singapore has been my home for 20 years. It has been 17 years since I lived through SARS with three kids under 6 years of age. My strongest memory was grabbing the newspaper each morning and taking in the numbers found in the center column of the front page. Were they going up or down? Had we hit the low point (the worst it will get) or was that still to come? I was trying to answer an essential question, “Are we safe? Are we not safe?” And then to decide what my children and I could safely do that day.
 
This time my “go to” for monitoring the numbers are Singapore’s MOH reports and the WHO Situation Reports. Asking the same essential question, “Safe? Unsafe?”  
 
Carrying the news of an increase in alert levels and news stories of emptying grocery store shelves into the darkness of night can make us worry what the world will be like when we wake in eight short hours.
 
And yet when we wake, checking the numbers is not our only way of centering ourselves.  We can also look outside and see that the sun has once again risen to a day of sunshine, birds chirping, and connections with loved ones and neighbors.
 
It is a rollercoaster of emotion to manage from sun-up to sun-down, regulating ourselves, even when we see the dysregulation of others.
 
A friend of mine, a measured, thoughtful, and non-reactive friend shared with me the story of heading to Cold Storage to pick up some fruit for breakfast the next day and seeing the number of people, the lines at the cashiers, the emptying shelves and later reflected, “I am normally calm, but seeing people going crazy, made me react.” Strong, a sociologist says, “…the subjective experience of the first social impact of such epidemics has a compelling, highly dramatic quality (Rosenburg 1989 in Strong 1990, 249).”
 
What is your first memory of the Coronavirus? When did it first become a real concern or threat? That is where your story begins. It will be different for each of us, and yet there will be some commonalities. How we think and what we do matters. It matters to your own well-being and it matters to the well-being of each person who looks at you – who reads your face and interacts with you throughout your day.
 
I knew I needed to “make patterns out of the chaos of events” so that my actions wouldn’t be bouncing on inevitable waves of disaster chaos, contributing to it. Ideally, I would engage with measured, thoughtful understanding of the larger narrative. More simply put, I didn’t want to feed on fear or put out fear for others to feed on.
 
As a mental health provider watching the Coronavirus unfold, I began looking for words to codify and communicate internal and social experiences into thought and language. And as I always do, I started to read. 
 
A Google search elicits only six to a dozen articles. Some of the articles were quite dated. My “go-to” trauma resource pages focus much more attention on coping with bush fires, mass shootings, but not coping with an epidemic. The trauma literature is skewed to the Western world, even as the numbers of those affected by disease in the Eastern world surpasses many of the apparently higher priority crises. I was surprised that I was surprised. It is a dilemma known to survivors of and responders to crises—the confusing inequalities of the world’s attention. 
 
The search surfaced an insightful discussion of “epidemic psychology” (Strong, 1990, 251). Philip Strong coined the term as he sought to identify a model for understanding people and societies reactions in the wake of the AIDS/HIV crisis. He described epidemic psychology as consisting of parallel epidemics. Not only is the epidemic biological. There is also the potential for a psychological epidemic of fear. In the process of Strong’s proposed model after fear comes explanation and moralization and then the implementation of solutions or proposed solutions to the disease itself or the social and individual impact. These are concepts that affect both individuals and communities.
 
The following discussion looks at the epidemic psychology of Coronavirus and the role of the media. The article finishes with some recommendations for coping or finding a middle path through the almost predictable over-sized fears that can result in the midst of a disease outbreak.
 
Fear, suspicion, panic & irrationality 
When we are rattled by the question, “Am I safe?” describing the feeling as fear does not quite encapsulate it. For many, when the danger is invisible or incalculable – when one cannot see the enemy or the threat, but only the results – the fear may become more intense: an uncomfortable feeling of terror or dread. The feeling of having the “veil of immortality” (NOVA, 2009) torn away when thoughts, “Could I die?, Will I die? Will others I know and care about die?” come. Humans have a natural tendency to catastrophize, an evolutionary survival orientation—a primal skill of survival designed to help us survive the worst. It is natural for us to start to view, every cough, sneeze, breath, communally-touched item (railings, doorknobs, elevator buttons), with fear, terror, and dread.  
 
Suspicion and its underlying belief that that danger could be nearby, but can’t readily be verified, informs our behavior. We may suspect other people may have the disease. We may suspect medical practitioners are not doing enough to effectively respond to the medical threat. We may suspect governments are not releasing true and accurate information. We may suspect the media is releasing inaccurate or sensational fearing-inducing stories. We may suspect neighbors are stocking up on or getting the needed medical or daily living supplies and that there will not be enough left for ourselves when we need it. In a kiasu/kiasi (translated scared to lose, scared to die) culture that is scared to lose out it seems this fear of others getting what we might need could be amplified in this crisis. 
 
For some, fear and suspicion can rise to the level of irrationality. In some cases individuals can believe they have the disease or illness when there are no facts to support it. This irrationality may be fueled in some parts of the world by the worldview that accepts magic and the unexplainable to be as legitimate as the empirical. 
 
Explanation: stigma & moral judgment
On our way to action, we try to find an explanation or manufacture a rationalization. Unfortunately, our natural efforts at trying to understand what is happening and keep ourselves safe can at times lead society to respond with “avoidance, segregation and abuse” (Strong, 1990, 253). This can be in found in the form of shunning the doctors and nurses who treat the virus patients. It can be found sadly in explanations made by some that the virus is God’s judgment. It can be found in judgments of others ways of living. 
 
The more quickly we can move through this phase, the more quickly we can get to a phase of interacting with the problem in a meaningful way and the less likely we are to harm relationships within our communities.
 
Action & solutions
Strong (1990, 254) describes the intellectual confusion at the start of a disease in which “People may be unable to decide whether a new disease or a new outbreak is trivial or whether it is really something enormously important.” There comes a time when someone becomes convinced in the proportions of a religious conversion of the danger of the disease and sets about to warn and educate people (Strong, 1990). In the present response to the Coronavirus I think many would be the Dr. Le Wenliang, who was among the first to warn about the virus outbreak and was subsequently silenced.
 
As the first responder “converts” learn and begin to educate, others begin their own journeys. They experience shock, denial, disbelief. And for a health disaster that spreads like Coronavirus, it seems natural to take longer for reality to settle in and propel one from the state of confusion to the full action of warning and educating others. 
 
Like SARS and MERS before it, Coronavirus is yet another reminder that the actions and solutions of prior epidemics have affected, perhaps unrealistically, our expectations of current epidemics. When my grandmother was growing up in the 1920’s she lost two of her siblings before they were five years old. Her parents had two children die before they did. It was not uncommon at that time. The invention of antibiotics and childhood immunizations have lulled us into forgetting that life is often messy. Engineering, science, and medicine truly accomplished amazing things, but they cannot control all of nature.  What was a common occurrence during the years that my grandmother was growing up has now been deemed unnatural. I am not suggesting that we want to go back to that time. I am suggesting that we need to acknowledge the frailty of life while we aim live life more fully and meaningfully, with hope for our future in all its messiness, supporting our scientists as they work to fight these diseases, as we take positive steps for our own mental health.
 
Effect of disease on social systems
Our daily lives are ordered by innumerable behaviours and actions that happen on auto-pilot (Strong, 1990, 258). Many of these auto-pilot behaviours are related to social interactions and hygiene. In Singapore these are made visible with the initiatives such as the National Courtesy Campaign and are closely related to generating a belief in the good will or positive intentions of friends and neighbors to live in harmony. When disease arrives, the essential positive assumptions are replaced with the parallel epidemic of fear and suspicion.  From a sociological perspective, we humans then have the capacity to share those fears and suspicions through language to others. This phenomenon is heightened in the era of globalization; social media makes it easier and faster, and harder to contain. It is interesting to note that Facebook and other media platforms were not a part of the response to SARS. 
 
Medical and mental health professionals have long known the foundational positive impact of social support in difficult times. It presents a unique challenge in the case of disease, where the very person who needs your connection and support may also be the person that is the carrier of the looming catastrophe. 
 
Impact of media on mental health
Yotam Ophir from the University of Buffalo has studied the content of news information during the outbreaks of infectious disease. He concluded that the media does not generally provide the kinds of information that is most helpful. He identified three types of information found in the reporting of disease: scientific information, social stories, and pandemic themes—issues related to preventing the spread. Often the news is focused on the human-interest stories—and often the extreme behaviours (Lu, 2015), but is lacking in the information needed for the public to make fact informed decisions. Ophir finds that during the course of an outbreak such as Coronavirus, the public needs simple and clear information about the risks and healthy ways to cope. On average, however, in his study, only one in five articles included coping information. Unfortunately, information about diseases without coping information can result in an increase emotional distress and a feeling of not being able to take steps to protect oneself (Ophir, 2015).
 
Suggestions for coping & finding a middle path
A clearer understanding of how we as individuals and societies are affected by a disease crisis can lead us to a better understanding of how to take care of ourselves, and prevent a biological epidemic from becoming a mental health epidemic. The following, though not exhaustive, provide some ideas for effectively coping. 
 
Recognize that the tasks of daily living take more energy when it takes place against the backdrop of an epidemic. Figure out what you can let go or postpone some things and spend more time in self-care.
 
Identify what can be controlled and implement measures to control them. Identify things that can’t be controlled and let those things go. 
 
Recognize when our thinking is leaning towards a natural tendency to catastrophize and find a measured response the acknowledges the facts. For example, “It is possible I could get the virus, but it is not probable.”
 
Assert control where it will be useful such as routinizing new social patterns of washing hands, keeping hands from touching our faces and keeping a measured distance from others.
 
Engage in activities that develop our equanimity (calmness and composure, especially in a difficult situation (Oxford)), such as yoga, mindfulness, and meditation.
 
Turn off screens for several hours a day to engage in exercise, reading or other pleasurable hobbies.
 
Increase your connection with loved ones by spending time together and expressing affection.
 
Find support with a mentor, wise friend, medical or mental health practitioner if you find that concerns about the virus are interfering with your ability to engage in the responsibilities of daily life.
 
Look for opportunities to engage in “random acts of kindness” that will increase our own positive feelings as well as strengthen the social fabric that binds us together as community in Singapore. 
 
Be clear about the type of media reports you are consuming. Media reports without clear messages about how to protect yourself will increase anxiety. 
 
Listen to information provided by friends and family and share information with others discerningly. Is it fact? What is the source? Is it helpful or anxiety provoking?
 
When spending time getting informed about the Coronavirus be sure to spend more time on official sites that provide reliable information about risk and guidance on coping. Singapore’s MOH site or the Gov.sg WhatsApp Subscription are a reliable ones.

A special thank you to long-time friend Pam Schuur who graciously edited this piece and helped the content and flow come together. 

References
 
Dingwall, R. (2020, January 29). We should deescalate the war on the Coronavirus. Retrieved from https://www.wired.com/story/opinion-we-should-deescalate-the-war-on-the-coronavirus/
 
Lu, S. (2015). An epidemic of fear: Psychologists’ research is guiding governments and health leaders in their efforts to communicate with the public during disease outbreaks. Monitor on Psychology, 46(3), 46. Retrieved from https://www.apa.org/monitor/2015/03/fear
 
Ophir, Y. (2018, August 15). How media coverage of epidemics helps raise anxiety and reduce trust. Retreived from https://www.niemanlab.org/2018/08/how-media-coverage-of-epidemics-helps-raise-anxiety-and-reduce-trust/
 
Strong, P. (1990). Epidemic psychology: A model. Sociology of Health & Illness, 12(3), 249-259.
 
Young, M. (2009). The community crisis response team training manual:  4th edition. Washington, DC: National Organization for Victim Assistance.

Photos: Bernard Spragg (Tree lined avenue). Flickr Public Domain Dedication (CC0).