Update: 20 April 2020: Graphic designer Franzi Scheithauer has kindly produced a wonderful, updated infographic on the Covid-19 Five-a-day. You can download a version by following the link at the end of the article. Franzi is Creative Director at Studio Brand Up (studiobrandup.com) and specialises in brand strategy and identity design.
We have all been advised to change our behaviour in order to stem the spread of the coronavirus outbreak. Public health messages ask us to self-isolate at home if we show symptoms, and to change the way we interact with people around us – referred to as social distancing. Social distancing involves, among other things, avoiding both small and large gatherings of people and accessing services remotely where possible. At the time of writing this, all pubs, clubs, and restaurants in the UK have been shut and so have educational institutions for all but the children of key workers.
These measures are a first in living memory. Time will tell the impact on almost every aspect of our society. Many expect that there will also be profound implications for our mental health and well-being. In this piece I would like to share some ideas and perspectives from psychological theory and research that may be relevant to the way our lives have suddenly changed.
We have never been in this situation before, not on such a vast international scale at least, so there is little direct evidence to draw on, but both recently published research and our existing knowledge can provide helpful ideas and some steps everyone can take to stay as mentally well as possible during these challenging times.
I refer to some of these steps as the Covid-19 Five-a-day: Five important goals you can work on daily to enhance your resilience in the face of self-isolation and social distancing. The rest of this post explain the theory and research behind them. It is a slightly longer read than most posts on this site, so if you would like to find out more about the Covid-19 Five-a-day straight away, click here.
More Covid-19 Five-a-day resources will follow soon.
If you have a few minutes to spare and you would like to explore the research and evidence behind the Covid-19 Five-a-day, please read on. You can read the original research I refer to in the papers mentioned in the bibliography and resource list at the end; apart from book chapters cited these are all freely available online in fulltext. I have also included some, selected academic references in the text for material that readers might wish to explore further.
Feel free to contact us or leave your comments and if you like what you’ve read, give us a like and tell your friends, family, and colleagues. The coronavirus crisis is a global problem and all of us should do what we can to get through this and help others where we can, and, as the evidence cited here shows, we all need to take steps to protect both our physical and mental health!
The psychological impact of isolation and quarantine during epidemics.
Measures of isolation and quarantine aim to prevent the transmission of disease through limiting contact between potentially infected individuals and those deemed at risk – which can be vulnerable groups or even whole populations. But, we humans are social creatures. There is a lot of evidence from psychological research that limiting direct interaction between people is psychologically stressful, even traumatic. Research on psychological resilience, for example, shows that interpersonal relationships and social connection are key determinants of well-being. And so is relationships with others that include social touch! In fact, the skin is the largest organ in the body and has nerve receptors that detect the emotional qualities of tactile input and transmit some of these signals to parts of the cortex that are involved in our ongoing sense of self and our reward systems (leading to activating the “liking” centres of the brain giving us “good” feelings) (Burleson & Davis, 2014, pp 131, 135). When we ask people to isolate themselves and “keep their distance”, we are also asking them to forego some of the social interaction that can serve to promote their well-being under conditions of strain.
A recent review of studies on the experiences of people who faced isolation in the face of outbreaks such as MRSA and SARS indicate that likely reactions include irritability, fear, loneliness, boredom, disruption of their usual routines, feelings of being dirty or stigmatised, and loss of control (Hussain, Sultana, & Purohit, 2020). The reviewers also found that approximately a third of people undergoing isolation in some studies had poor mental health status, with a particularly high incidence of anxiety, and about 60% of people showed increased irritability. The reviewers indicated that healthcare staff working under conditions of quarantine experienced higher levels of mental health concerns too. These were related to increased stress and exhaustion, anxiety, depression and insomnia.
These findings should be taken as warning signs of what we can potentially expect to happen over time as more people self-isolate and measures of social distancing start to bed in. They show us that, as a society, we should take active steps to preserve our mental well-being, and that we should develop strategies to support the well-being of those staff in health and social care who are at the front line of the battle against this virus.
Recent experience in China during the coronavirus outbreak, support these ideas. Psychological crisis intervention services were developed to deal with the anxiety and distress of both the general public and healthcare workers – one example is the service model of the West China Hospital (Zhang, Wu, Zhao, & Zhang, 2020). Their approach took account of factors such as the public’s knowledge of infectious disease, health behaviour, coping skills, and psychological self-awareness. Online resources that included mental health self evaluation, public health information, a telephone helpline, and an App were developed to provide information, screening and an online platform of social support. A “psychological rescue team” was formed to provide psychological crisis intervention to those who needed it.
Medical and other key staff were also supported using a psychological model of crisis intervention called APD: Anticipate, Plan, and Deter. The three phases involved, respectively, training staff in what they could expect to happen during the disaster and in stress management techniques (Anticipate), finding their own coping resources and developing a personal resilience plan (Plan), and follow-on work focusing on learning to use their resilience plans, and monitoring their own stress levels. The authors recognised that psychosocial support for both staff and patients would need to continue after the epidemic has ended.
Coping with isolation and extreme conditions
There is little published research on how people cope with isolation and social distancing when these measures are applied across whole countries as is the case at present. However, we do have psychological studies of how relatively small groups of individuals cope with living in cramped, isolated conditions where they have limited contact with the outside world for long periods of time. Psychologists have studied groups such as astronauts, polar scientists, submariners, and oil rig workers. In their post on the British Psychological Society Website, Proffs Nathan Smith and Emma Barrett relate findings from this interesting field of research and provide a number of very helpful tips for people entering a period of self-isolation. Some key ideas from their article include the following:
Know what to expect; you may need a period of adaptation to your new circumstances so give yourself time to adjust. It is common to experience periods of boredom and monotony which may be accompanied by low mood and lack of motivation, so find ways to keep busy and establish a daily routine. And then there are all the problems that can arise from spending so much of your time in close proximity to the same people! Many of us will have to work hard at not only being more tolerant of others, but also at becoming more tolerable to those around us! Further helpful ideas on managing include building exercise into your routine, and managing your own anxiety and fear (and those of others) by carefully filtering the social media content you access and post!
Joanne McVeigh and her coworkers did some work applying positive psychology interventions to improve the well-being of seafarers while at sea. Positive psychology focuses on discovering how people stay well and thrive, and psychologists in this field develop interventions that enhance well-being.
Ships (while at sea) form isolated and confined environments, and sea farers experience many of the pressures that apply to people in quarantine or isolation mentioned above, such as living in confined quarters, being around the same people for long periods of time, and limited contact with family and friends. Some of the positive psychology interventions that McVeigh and her co-workers felt were helpful to this group include:
- Thinking of three good things in one’s life.
- Developing a sense of self-efficacy, hope and optimism (building psychological capital).
- Practicing mindfulness meditation.
- Writing about life goals.
- Identifying one’s strengths and then using these in new ways.
- Cultivating laughter and humour.
These ideas were thought to contribute to an increase in sea farers’ well-being and s decrease in mental health symptoms. In short: they were more resilient! In fact, the American Psychological Association lists 10 ways we can all build our resilience. These are:
- Make connections with others.
- Avoid seeing crises as insurmountable problems.
- Accept change as part of living.
- Move towards your goals.
- Take decisive actions
- Look for opportunities for self-discovery
- Nurture a positive view of yourself
- Keep things in perspective
- Maintain hope
- Take care of yourself
You can follow the link given in the resource list to find out more.
Earlier I have mentioned the well-established connection between social connectedness (the first point in the APA list above) and resilience. I also mentioned the power of social touch to generate good feelings and support resilience – a coping resource that will certainly be less available to us when we self-isolate. However, there may other helpful ways to generate positive emotion as intriguing research on the positive impact of volunteering show. Brin and Okun (2014) argued that doing something for someone else out of choice (altruistic motivation) has been shown to increase individuals’ sense of competence and choice, create positive emotions, improve social support, and increase well-being and cognitive functioning – and ultimately, improve physical health, well-being, and longevity!
So far we have reviewed the potential psychological stress that may arise from self-isolation and social distancing and highlighted a number of research-based ideas on how we can protect our mental health and support those around us. At this point it might be helpful to ask if psychology can offer us an approach that can bring all of this research together and help us to both conceptualise the impact on mental health that self-isolation and social distancing might have, and what we, as individuals, families, and a society can do about it?
A framework for understanding the mental health impact of isolation and social distancing.
Self Determination Theory (SDT, Deci & Ryan, 2002) is a framework, based on decades of social and clinical psychological research, that attempts to integrate two seemingly opposing approaches to the field. On the one hand, humanistic and psychoanalytic psychology is based on the belief that humans have intrinsic tendencies towards growth and development irrespective of their contexts, and on the other hand, the behavioural psychologies construe us as shaped by conditioned responses and social contexts. SDT attempts to bridge the divide by accepting the influence of conditioning and contexts, but adds the idea that all human beings have three basic needs which drive our behaviour. The three basic needs are the needs for competence, relatedness, and autonomy.
Competence: Feeling effective in one’s interactions with one’s context (“I can”).
Relatedness: Feeling connected to others (“I belong”).
Autonomy: Feeling one’s own behaviour arises from oneself. Autonomy refers to a sense of self as an integrated being. High autonomy individuals feel that their actions are consistent with their values and sense of self (“I am”).
The key idea in SDT is that these universal human needs occur in everyone, regardless of culture or context and if we feel thwarted in meeting any of these, we will experience a drive to address the need that is frustrated. SDT therefore views humans as striving to be active agents in their own lives, needing to experience a sense of belonging and a sense of self that includes feeling their actions are consistent with who they feel they are.
When we consider the psychological impact of social distancing and isolation from an SDT framework, we find that every one of the three basic human needs are negatively affected:
Restricting people’s free movement and right of assembly, placing constraints on (or even ending) their productive employment or right to conduct business, and ending their access to traditional classroom learning, we are restricting the sense of agency (need for competence) for millions of citizens.
Social distancing, self-isolation and quarantine can serve as serious detriments to social connections between people. Loneliness, stigmatisation and the sense of isolation that accompany these measures for many people, especially those who have been vulnerable and socially isolated even before the pandemic, highlights the need for individuals and social systems to attend to the need for relatedness in vulnerable individuals who feel isolated, perhaps despite living in close physical proximity to others.
Finally, when the state takes control over individual freedoms and attempts to regulate the day to day actions of the population – even if for the greater good – there is a danger that individuals’ sense of autonomy will be detrimentally affected through a sense of loss of choice and control and the inability to plan and take control of one’s own future.
Using self-determination theory to address the human dimensions of the coronavirus outbreak.
Considering the impact of coronavirus and our present attempts to stem its spread from the SDT perspective, provides us with more than a framework for understanding why the psychological impact has the potential to be so profoundly distressing for many people. The framework also provides us with ways to design policy and systems interventions that place human needs at the heart of our approach.
In this regard, it is constructive to consider the findings of a survey done in Guinea after the ebola outbreak which necessitated large scale community quarantine measures. Participants were asked about the acceptability of quarantine under a range of conditions. Only a minority of participants indicated that they did not feel quarantine measures were ever acceptable. But almost 40% of the participants felt that quarantine would only be an acceptable measure if there were also support services provided for those affected (Kpanake and co-workers, 2019).
Government and local policy
The implications of an SDT approach at both national and local government levels are profound and deserve a more thorough analysis than I can offer here. However, what is very clear is that we need to support individuals – especially vulnerable people who live alone, families, and key workers in ways that enable them to maintain (or strengthen) their sense of belonging, give people choices, and find ways to provide information and tangible support that will allow individuals to set goals and plan. Some examples of helpful actions that require the resources of national or local government include setting up safe online platforms designed to deliver social support and offer ways to connect to others, making sure that mental health services and psychological crisis interventions are available and accessible to all who need them, and setting up readily accessible psychological support for healthcare staff who provide front line services. Given the huge impact on thousands of small businesses across the nation and the many thousands of people who will have to survive on reduced incomes for the foreseeable future, I also wonder if strong Government support for the sharing economy and time banks may provide new ways for many people on furlough or unemployed (but symptom free) to offer much needed support to others in a context where they may get some reciprocation for their efforts.
Individual and family actions
At individual and family levels, the three basic needs that underpin SDT form the basis of the healthful actions you can take to help protect your own mental health and that of your family. As you adapt to living with potential self-isolation and adjust to the behavioural changes that social distancing requires, you will benefit from giving careful consideration to the three basic human needs as they manifest in your own life and that of your family.
Strategies that enhance a sense of autonomy include making sure that everyone has opportunities to make choices and set goals for themselves. A sense of competence is enhanced through taking a proactive approach and combating low motivation and boredom through creating structure and routine, and actively engaging in projects that promote self-development and a sense of achievement. Relatedness is fostered through maintaining existing links with others and developing new ones. Within families, shared meals, playing together and laughter can serve as powerful binding forces to craft a sense of belonging in family members.
A particular challenge for all of us in the current crisis is that of developing and maintaining links at the community level: Many of us are fortunate enough to be able to help others in smaller or larger ways, and, as the evidence shows, consequently, we can benefit from an enhanced sense of purpose, feeling valued by others, and an enhanced sense of well-being.
We can also take steps to counteract some of the consequences of isolation and social distancing that undermine our sense of competence, autonomy and relatedness. Examples of this include choosing to control our own fear and anxiety by actively managing the information and social media we consume and share, which would include limiting ourselves to accessing only high quality information. We can take steps to access mental health and crisis support services if we become aware that we need them (while the relevant government agencies should accept their responsibility to ensure services are available and accessible within reasonable time frames), and by refusing to exclude others through stigmatisation.
Bringing it all together: The Covid-19 Five-a-day.
The Covid-19 Five-a-day is a set of daily goals or practices that have been drawn from the research reviewed here and provides a set of pointers towards practical ways each of us can take responsibility for meeting our basic human needs of competence, relatedness and autonomy, even through periods of isolation and social distancing. Each of these goals easily translate into many activities you can actively engage with; proactively plan them into your day.
The five key goals are:
- Have some fun!
Laughter, play and having fun are powerful resilience resources. Shared laughter can strengthen feelings of social connectedness. Making time to share a funny moment or a joke can create positive feelings and combat fear and anxiety.
- Take time for me!
We all need a bit of personal space. Give yourself permission to take some time for you. This could take different forms depending on you and your circumstances: You may be able to enjoy some quiet time away from everyone else in your house, have a relaxing bath, go for a run, or you may have to put on your headphones and listen to your music while others are going about their business around you. It is also important to make sure everyone else who share your home has the ability to take some me-time, especially during periods where the household is self-isolating.
- Cultivate compassion
Cultivating self-kindness, tolerance, and helping others have already been mentioned as key resilience resources that are all relevant to the current crisis. Compassion towards yourself can help you feel less anxious about the many unknowns in the situation you face and help you develop a sense of inner calm, while compassion towards others can be a powerful driving force for altruistic helping. There are many helpful activities that can support you with this goal, including a number of online resources that teach mindfulness and meditation or relaxation skills.
- Interact with others!
We are social creatures and the need to belong and to interact with others is fundamental to our sense of self. This is why it is so important to have daily positive interactions with others. Maintaining social connectedness and possibly forming new connections during this crisis, will enhance your sense of relatedness. This is also the area that may be most easily affected by social distancing practices and may therefore require some extra effort from you.
Scheduling time to connect with friends or family using either the phone or online resources can help. It might also help to volunteer to help others during periods of time you are not self-isolating. Positive interactions do not always have to be face to face either, so joining an online community or support group, or setting up a social media group with friends perhaps just to share something of your daily lives with each other can certainly help.
- Be positive!
This consists of adopting a positive attitude towards the situation, actively seeking to engage in positive action to solve problems, address challenges, and grow as a person. We also need to take steps to avoid unnecessary fear and worry. One example of the latter is the degree of fear and anxiety we generate for ourselves and others by excessive information gathering and then sharing frightening stories based on unverified or poor-quality sources. Other examples of positive action include undertaking a personal project, learning a new language, or improving your qualifications by undertaking some distance learning.
The idea behind the Five-a-day concept is that you proactively seek activities and actions you can take that fall into these categories. All five are important and the challenge is to engage in behaviours that fall into every one of these five categories every day. That will require some discipline and might be quite challenging. However, each of these areas has been shown by research to be important in staying well when facing stress. My hope in offering the Covid-19 Five-a-day is that it will provide a useful guide to individuals and families who want to build their resilience during the current crisis.
Dr Natius Oelofsen Copyright: The Psychology Consultancy
Resources, references and credits
You can download a flyer of the Covid-19 Five-a-day here: TPC-Covid19_-5-a-Day-Infographic
Guidelines on the UK government website:
https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults Accessed 21/3/2020.
APA resilience link:
Burleson, M. , & Davis, M. (2014). Social touch and resilience. In: Kent, M., Davis, M., & Reich, J. (Eds). The resilience handbook. New York: Routledge, Chapter 10 pp131-143
Brown, S., & Okun, M. (2014). Using the caregiver system model to explain the resilience related benefits older adults derive from volunteering. In: Kent, M., Davis, M., & Reich, J. (Eds). The resilience handbook. New York: Routledge, Chapter 13, pp 169-182.
Deci, E. & Ryan, R. (2002). Handbook of self-determination research. Rochester, New York: The University of Rochester Press.
Hossain, M. M., Sultana, A., & Purohit, N. (2020). Mental health outcomes of quarantine and isolation for infection prevention: A systematic umbrella review of the global evidence. Published online. Accessed via: Google scholar.
Kpanake, L., Leno, J. P., Sorum, P. C., & Mullet, E. (2019). Acceptability of community quarantine in contexts of communicable disease epidemics: perspectives of literate lay people living in Conakry, Guinea. Epidemiology & Infection, 147, pp 1-7.
McVeigh, J., MacLachlan, M, Stilz, R., Cox, H., Doyle, N., Fraser, A., and Dyer, M. (2017). Positive psychology and well-being at sea. Maritime Psychology, Vol 15, pp 19-47.
Smith, N., & Barrett, E. (2020). Coping with life in isolation and confinement during the Covid-19 pandemic. Blog Post. The Psychologist, British Psychological Society. Available at: www.bps.org.uk accessed: 19/03/2020
Zhang, J., Wu, W., Zhao, X., & Zhang, W. (2020). Recommended psychological crisis intervention response to the 2019 novel coronavirus pneumonia outbreak in China: a model of West China Hospital. Precision Clinical Medicine, pp 1-6. Accessed via Google Scholar
Image credits: Covid-19 Five-a-day
Coronavirus illustration: Copyright Tiranajwahaura | Dreamstime.com
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