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10 March 2021

Mourning and melancholia: the psychological shadow-pandemic

Why the Covid crisis is the biggest hit to mental health since the Second World War.

By Sophie McBain

When organs fail, the staff on intensive care units try to take over their work. Ventilators act as lungs, medicines delivered intravenously maintain a person’s heartbeat and blood pressure, filter machines prevent a fatal build-up of waste, and everything – every drop of fluid that enters the body and every drop that leaves it – is constantly monitored by a nurse. For days or weeks or even months the ICU staff maintain bodies that have all but shut down, and still on average around one in five of their patients will not make it.

At least, that was the case before the pandemic. Now, most of the intensive care beds are taken up by desperately sick Covid-19 patients. Some of the medics are not critical care specialists and, having been drafted in from other parts of the hospital, they are less intimately acquainted with the machinery and the constant proximity to death. Now, each nurse is often monitoring not one patient but two or sometimes more. And around 40 per cent of the patients are expected to die.

Sometimes within ten minutes of arriving at work a doctor or nurse will have a panic attack and be unable to continue, Andrew Breen, the clinical director of adult critical care at Leeds Teaching Hospital, told me. Every day he will come across one of his staff sobbing in the corridor. The unit has started describing the anticipatory anxiety many feel before their shift as pre-TSD – pre-traumatic stress disorder. Breen worried about what this pressure and grief was doing to his colleagues. “It’s not just crying at the end of a tough day, it’s altering who you are, how you feel about yourself, your personality,” he said.

His clinical care team usually think of themselves as tough and irreverent. A gallows humour helps them cope. But what is now eating away at them more than the catastrophic death toll is the fear that people might die for want of better care, that patients deserve more than this overstretched healthcare system can offer. Breen is haunted by the people who should be on his ward but are not, such as the cancer patients whose surgery has been postponed. A survey of 709 critical care staff published in the Occupational Medicine journal in January found that almost half of them were reporting symptoms consistent with PTSD, severe depression or anxiety, or problem drinking. One in five of the nurses surveyed reported recent thoughts of self-harm or believing they were better off dead. The survey was conducted in June and July, well before the second wave hit Britain. Breen described the pressure his staff are under as a “ticking time bomb”.

Nurses may be the most acutely affected by the Covid-19 surge. In normal times they might sit and talk to their patients, but there is so little time for anything now but the constant adjustment of machines and medication. When relatives cannot come to the hospital to say goodbye (often because they are themselves shielding) the nurses hold the patient’s hand as they die, far from their loved ones. Julie Highfield, a clinical psychologist and the director of the well-being project at the Intensive Care Society, told me she’d recently spoken to a nurse who was consumed by guilt for leaving her job but felt she could not go on. “Maybe you’re heartbroken,” Highfield had suggested, “maybe you’re grieving.”

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***

Humans have long understood the psychologically destructive nature of pandemics. In the second century AD, when a plague – likely of smallpox – was killing thousands of people a day in Rome, the emperor Marcus Aurelius observed that “the corruption of the mind is a pest far worse than any such miasma and vitiation of the air which we breathe around us”. “Deadly epidemics always spawn parallel epidemics of a psychological or existential nature – less tangible but equally virulent,” the Yale sociologist Nicholas Christakis writes in his 2020 book, Apollo’s Arrow. The immediate impact is clear: how could a community not be disturbed when so many people are ill, when you do not know who will fall sick next, when ordinary life has been upturned? Usually in times of hardship our instinct is to seek comfort in physical closeness, but now we must stay apart. Isolation hurts humans in ways we do not yet fully understand: it is said that loneliness is as harmful to one’s health as smoking 15 cigarettes a day.

The psychological shadow-pandemic, much like the virus itself, spares no one but is unequal in its impact. There is an emotional front line, of healthcare and essential workers, the recently bereaved, the sick. And there are those living with long-term mental illness, poverty or isolation: pre-existing conditions that may amplify the emotional harm of the pandemic. Already, NHS statistics show that demand for mental health services has reached record highs, and some hospital trusts are reporting that their mental-health wards are at capacity. Adrian James, the president of the Royal College of Psychiatrists, has described the pandemic as the “biggest hit to mental health since the Second World War”.

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[See also: It’s not just you: Why the current lockdown is having an extreme effect on mental health]

The thread that links our varied emotional responses to the pandemic is our shared experience of loss. Not all of our losses are of the same magnitude, but almost everyone is grappling with loss: of loved ones, livelihoods, landmark life experiences (weddings, graduations, years of school or university). There is the loss of futures we had imagined for ourselves, the knowledge that the world as we once knew it will never be the same. The most immediate and natural response to loss is grief.

In the Atlantic, the physician Amitha Kalaichandran wrote that her mother, a survivor of the civil war in Sri Lanka, identified “two unique forms of grief that everyone touched by war understands”: the grief associated with the loss of human life, and then the grief of “the loss of a life as we once knew it… [the] loss of identity as a ‘pre-war person’ and the subsequent need to start over”. “The two run along together like two dark snakes intertwined,” Kalaichandran wrote.

There are other forms of grief, too, that are conceptually distinct but impossible to disentangle. We are feeling grief as individuals grappling with personal losses, and we are feeling collective grief over the lonely deaths of millions of strangers. We are also feeling what might be termed ambiguous grief, a grief that has uncertain dimensions, when our losses are ill-defined, as when we grieve for a relative who has advanced Alzheimer’s, who is both there and not there. We cannot fully know what this pandemic will cost us.

When Highfield talks to critical care staff, she sometimes describes how their role might require them to split into two selves: their day-to-day self, which can maintain a professional distance from the daily heartache of hospital life, and their grieving self, which carries years of losses and trauma witnessed on the job. Usually the two selves run in parallel but sometimes an event touches a person so deeply that they collide. When this happens, the trick is not to let this long-suppressed grief overwhelm you but to titrate it slowly. This medical metaphor might also capture the feeling other people experience when, considering themselves one of the “lucky ones” and apparently coping OK, something unexpected – reading an especially poignant obituary, watching a moving film, a kind gesture from a friend – unleashes a torrent of pent-up pandemic grief.

***

Facing for the first time a truly cataclysmic event, many people struggle to identify their feelings as a form of grief. One reason may be that death is everywhere and it is nowhere. When, in August 2020, more than 200 people were killed in an explosion in Beirut, the miles of wreckage – flattened buildings, shattered glass, twisted metal – were visible from space, but when 1,820 deaths were registered in the UK on 20 January, the deadliest day of the pandemic so far, what most people saw was an uptick on a graph. Unless one of the hundreds of daily deaths is a person you know, you might scan a newspaper headline between checking your emails and brushing your teeth, and then get on with your day, determined to ignore the sense of dread looming at the edge of your consciousness.

Our fear is similarly hard to identify. The anxiety produced by the buzz of a drone or the wail of an air-raid siren, though no easier to bear, might at least be easier to acknowledge. Instead, I notice how friends beat themselves up for feeling so low and unproductive, or wonder why they are having terrifying dreams or not sleeping, forgetting that they are going about their everyday lives trying to ignore the insistent hum of Covid-fears: What if my vulnerable parents get sick? What if I get sick and die? Will it ever feel safe to hug my friends again? Will this ever end?

The pandemic has wrought untold damage on lives, economies and societies. And yet it’s hard to accept that living through something utterly catastrophic could involve this much boredom – that we’d be doing Yoga with Adriene or sharing goat videos on Twitter while around us so many people lose their lives. The enormity of this crisis is too much to compute while you sit doom-scrolling on your sofa, but that doesn’t mean it can’t crush you. “Many people say they are feeling a heavy sadness – and what they’re describing is grief,” the psychologist David Kessler told the Guardian recently. “Everything has changed. And change is actually grief – grief is a change we didn’t want.”

[See also: How we misunderstand depression]

Recognising our feelings of grief is important, not only because we cannot mourn our losses if we do not acknowledge them, but also because the literature and science of grief offer guidance for how to respond to this pandemic in ways that make psychological healing possible. In his 2008 book, The New Black: Mourning, Melancholia and Depression, the psychoanalyst Darian Leader argues that British society has lost a vital connection to grief, preferring to interpret the pain of unacknowledged or unresolved loss and separation medically, as depression, and opting for what he calls “mental hygiene” – the management of troublesome, superficial symptoms – over the deeper, harder work of mourning. We do not find it easy, in this culture of self-optimisation and life-hacks, to accept that grief is not something you can “get over”, that there is no cure for pain. The act of mourning is not to recover from loss, Leader argues, but rather to find a way to accommodate and live with it. And, if we put off or bypass the work of mourning, the pain of our losses will return to torment us, often in disruptive or unexpected ways.

Many are sceptical of a clinical psychiatric tradition that views mental illness as a type of disease. The clinical psychologist Lucy Johnstone is concerned that the language of epidemics, depression, anxiety and PTSD risks “medicalising” and “individualising” natural and proportionate responses to the pandemic. But thinking about the pandemic in terms of grief underlines how a person’s suffering is inseparable from their wider environment. You cannot, after all, understand the nature of a person’s grief without understanding the nature of their loss. That doesn’t mean that grief is predictable. We know that sometimes people find ways to live with the most traumatic of losses and that sometimes these losses destroy them. It might be helpful to understand why.

***

On 14 April 2020 the therapist Kathryn de Prudhoe lost her father Tony Clay, a 60-year-old retired civil engineer and devoted grandfather, to Covid-19. Seven months later, his younger brother also died of the virus. Theirs was a close-knit family; these deaths would always have been devastating. But the pandemic compounded their grief. De Prudhoe could not say goodbye to her father in hospital, and for 11 days after his death she could not be with her mother, who was self-isolating. Only five people could attend her father’s funeral, which was a pared-down 20-minute service, not a celebration of his life.

As a therapist, de Prudhoe is acutely aware that people who are bereaved during the pandemic are at heightened risk of complicated grief. Complicated grief is persistent and all-consuming grief, the kind that begins as an acutely painful response to loss and may progress to something pathological. (The so-called psychiatrist’s bible, the DSM-5, added in 2013 a new condition known as “persistent complex bereavement disorder”, an alternative name for complicated grief.)

If grief is often experienced as a cut that heals with time, albeit slowly and painfully, complicated grief is like a wound that becomes inflamed, that only becomes more debilitating and may require expert care. Research suggests that one in ten bereavements result in complicated grief, and also that this kind of grief is more common after sudden, unexpected, traumatic deaths – as so many solitary Covid deaths are. It is also more common when people lack social support, and when the circumstances of a person’s death are fraught for other reasons. It is normal after suffering bereavement to feel guilt, but in the pandemic many people are left wondering if they transmitted the virus that killed the person they loved, and many are tormented by the knowledge that so many Covid deaths could have been prevented. De Prudhoe was struck by how frequently people’s grief was manifesting as a trauma response, as panic attacks and debilitating anxiety. She had spoken to a woman who had lost her partner of decades and had not left the house in months.

Since her father died, de Prudhoe has thrown herself into the work of Covid-19 Bereaved Families for Justice, a campaign and peer-support group with around 2,500 members that is advocating for a public inquiry into the government’s pandemic response and for increased funding for specialist bereavement support. It worked with the National Bereavement Partnership to ensure support for its members, but de Prudhoe described this as a “drop in the ocean”, given how many are in need.

In July American researchers developed a “bereavement multiplier” estimating that, in the US, each Covid death leaves behind nine close relatives. This multiplier did not include friends. At a conservative estimate, there are more than a million people bereaved by Covid in the UK. A substantial proportion of those are believed to be at risk of experiencing complicated grief.

Many people bereaved by Covid-19 have found their grief is compounded by the fear that their loved one has been subsumed into a statistic. There have been calls for national or local memorials for victims. The Forest of Memories project intends to plant a tree for every person who died of Covid-19, and there are other smaller initiatives taking place, but the UK has a poor record in commemorating deaths from infectious disease outbreaks. We have no national memorial to the 1918 flu pandemic; as the New Statesman’s Anoosh Chakelian has observed, we are afflicted by “pandemic amnesia”. This matters, because such a memorial might help us come to terms with both our individual and our collective grief.

***

The anthropologist Geoffrey Gorer argued that the mass deaths of the First World War so overwhelmed British communities that people began to abandon traditional mourning rituals, something that served to transform grief from a communal experience to a private emotion. The pandemic might be accelerating this process, as people are left to mourn alone in lockdown and to pay their final respects over Zoom. And yet, Darian Leader contends that we cannot properly mourn in isolation; mourning is a social task. “A loss, after all, always requires some kind of recognition, some sense that it has been witnessed and made real,” Leader writes. This is why we have such an elemental need to feel heard, why we make the effort to commemorate past conflicts, why post-conflict truth and reconciliation commissions are less about punishment than recognising the crimes. The demands for a public inquiry into the British government’s pandemic response speaks to this need, and to another dimension of pandemic grief. In a sense, families such as de Prudhoe’s are grieving for the justice they feel they have been denied.

Leader argues that public displays of grief help facilitate individual mourning. In his view, it is through public ceremonies that people are able to access their own, personal grief. This is the function performed by traditions of hiring professional mourners to keen at funerals, and it helps explain why celebrity deaths sometimes unleash an outpouring of grief. The near-hysterical response to the death of Princess Diana in 1997 was not, as some newspapers contended, a mark of “mourning sickness” or “crocodile tears”. Rather, the public mood provided people with a way to access their grief over other, unrelated losses.

[See also: Prince Harry and Meghan Markle show the triumph of bohemian values over bourgeois ones]

Those who study grief often point to the inevitability of pain. When people put off the business of mourning, the pain of loss and separation finds a way to reassert itself. Leader describes the phenomenon of “anniversary symptoms”, the findings that adult hospitalisation dates coincide remarkably with anniversaries of childhood losses, or that GP surgery records reveal that people often return to doctors in the same week or month as their previous visit. “Rather than access their memories, the body commemorates them,” Leader writes. Research on intergenerational trauma points to the idea that unresolved losses can be transmitted down family lines, so that, for instance, the grandchildren of Holocaust survivors are at higher risk than the general population of developing conditions such as depression or anxiety. “What isn’t dealt with in one generation passes to the next generation until someone is prepared to feel the pain,” the psychotherapist Julia Samuel told the Good Grief Festival in November.

“We can’t ignore the pain. Pain is the agent of change,” Samuel said. She spoke of the opportunity we now face to “grow through grief”. Perhaps by taking the time to fully mourn all that we have lost we will gain a clearer vision of the changes we want to see in the future. Maybe it is only through rebuilding after this period of national emergency that we will find a way to live with our multiple, compounding private and collective losses.

***

Grief has political power. Alex Evans, the founder of Larger Us, a research and campaign group that focuses on “where our states of mind and the state of the world meet”, told me that his work on climate change had helped him to understand the potency of grief. He experienced an epiphany in 2013 when he witnessed the emotive speech by Naderev Saño, a delegate from the Philippines who wept at a climate change conference as he described the devastation caused by Typhoon Haiyan. Climate change activists were good at offering hard reality checks and sobering statistics, Evans said, and they weren’t bad at giving cause for hope, by outlining green recovery plans. But it was only recently that activists such as Greta Thunberg began harnessing the galvanising power of grief, of telling a story with “emotional truth”.

“How we work through grief matters, and it does to some extent affect what happens next. In saying that I don’t mean that grief is a test, it’s not something we pass or fail. But grief is a necessary part of regeneration and restoration,” Alex Evans told me. “We have to climb into the grief, and drink deep from it, before we can move on.”

***

Many of the mental health experts I spoke to expressed concern that once the British population is fully vaccinated, the government will have its happy ending. It will recast its pandemic response as a victory and will invite everyone to move on psychologically from this devastating pandemic year. That the speed of the vaccine roll-out is indeed cause for celebration does not detract from our need, as individuals and as a nation, to begin to confront our losses, to find ways to “grow through grief”. If the UK does record a surge in serious mental illness in the coming months, it will not only be a result of the pandemic, but also the product of years of austerity, the swingeing cuts to mental health and community services. Just as the physical effects of the virus have exposed how inequality has weakened British bodies, the emotional aftermath of the pandemic may be felt more forcefully in the UK because so many people were vulnerable to begin with. Perhaps our grief will force us to confront these social injustices.

If months from now the sun is shining and the pubs are open and you still feel sad, that is because we’ve all lost people we love or things that are irreplaceable; it is because as individuals and as a nation we may still be searching for a way to find meaning and purpose amid all this pain. Just as survivors of war describe feeling they have lost their identity as a “pre-war person”, we will each have to learn how to become post-pandemic people. Perhaps that could mean having a deeper sense of empathy and compassion, a restored sense of social solidarity, a political purpose. There is pain in grief, but there can also be hope.

This article appears in the 10 Mar 2021 issue of the New Statesman, Grief nation