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.
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).
Dr. Suzanne M. Anderson is a mental health counsellor and crisis responder and trainer in Singapore.