I grew up in a divided community where people had conflicting views on many issues, because of their differing religious, political, social, and cultural backgrounds. As I trained in psychiatry, I learned how biological, psychological, and sociological perspectives competed for allegiance in the profession. Later the diversity of views within our scientific communities was brought home to me when I was invited by the World Federation of Scientists to help them with a major division that had opened up as they tried to apply their expertise in the aftermath of the 9/11 terrorist attacks. Western scientists wanted to assist in the fight against Al Qaeda, whereas those from Eastern countries insisted that we must understand why the attacks were taking place. These conflicting perspectives among scientists showed how, even within the rational scientific community, we develop different narratives to explain and explore traumatic events and major incidents.
We see similar divergence with the COVID-19 pandemic caused by the SARS-CoV-2 coronavirus. Epidemiologists give a response based on their developing understanding of the community transmission of the virus. Clinicians focus on treating the disease resulting from the over-reaction of the immune system that occurs in a minority of individual patients, and which may lead to serious illness and death. The impact on the healthcare system as a whole is the concern for people on lengthening waiting lists, and government officials are constantly balancing these pressures and the economic and societal consequences. More profound divergences are seen between those who accept the need for social distancing, mask wearing, and the vaccination rollout, and those ‘anti-vaxxers’ who, for personal, political, religious, historical, or cultural reasons, do not accept this narrative. Even within our communities, at this time in history, facing a global pandemic, there is no one view.
Four years ago my wife and I moved from the city of Belfast, where we had lived and worked during the Troubles, to a quiet village in rural Oxfordshire. We wanted to be closer to my activities in Westminster and Oxford, and to our children and grandchildren living in England and Scotland. We thought that we had planned for most eventualities, but we did not expect the pandemic. We were fortunate. Spending the lockdown in an Oxfordshire village is not a hardship. We were not locked in, suffering the ravages of the pandemic in crowded city housing. Nor were we suffering directly from the increasing geopolitical instability, the risk of terrorist attacks, or other such traumatic incidents. However, this was not always the case in our rural idyll.
The early pre-Norman settlement grew up away from the nearby Roman road for safety reasons, since that was the route taken by the Viking marauders. Even so, during the English Civil War there was a military skirmish because of the proximity of the settlement to the Royalist centre of Oxford, and the Anglican rector in the village was replaced by a religious non-conformist until the restoration of Charles II. Walking the local bridle paths, we noticed that some historic villages no longer exist because almost all of their inhabitants died during the plague years. I tell this story because – from the parables of Jesus to the case histories of Sigmund Freud and the broadcasts of current affairs – it is not through theory that we learn most easily, remember best, and construe our lives, but through the medium of ‘human interest’ stories. We view traumatic events, including violence, pandemics, and their mental health implications, through the stories we tell ourselves and the reactions of our communities moulded by history, place, and culture.
The Astronomer Royal, Lord (Martin) Rees, has pointed out that when the Black Death swept across Europe in the fourteenth century, communities continued to function even if they lost half of their population, because the survivors had a fatalistic attitude to the massive death toll [Reference Rees1]. ‘In contrast,’ he says, ‘the feeling of entitlement is so strong in today’s wealthier countries that there would be a breakdown in the social order as soon as hospitals overflowed, key workers stayed at home, and health services were overwhelmed. This would occur when those infected were still a fraction of 1 percent’. One might imagine that with a scientific education, the ready availability of expert medical professionals, the prospect of protection through vaccination, and measures such as social distancing, disinfection, approved personal protective equipment, and an effective healthcare system, people would be less anxious and more resilient. Paradoxically, however, we have seen the fear that has gripped responsible governments with the appearance of each new variant of COVID. Despite the relief of financial hardship for many people through furloughing schemes for those who could not work remotely, and the ease of online social communication, there are still daily reports of ‘serious mental health consequences’ across wealthy countries, instead of a sense of confidence that the pandemic will be contained, and that life can continue. There are many reasons for this twenty-first-century response, and Rees identifies one of them. When we live with a narrative that focuses on ‘me’ as an individual, living only in the here and now, and expecting that all ought to be well for me, any deviation from that ‘entitlement to wellbeing’ is experienced as more frightening and unfair than if I expect to live with uncertainty, and am sustained by a mixture of religious belief and fatalism.
Such ‘paradoxical’ responses can be found in other contexts, too. When people are told that everyone can achieve anything they want, this does not bring reassurance and confidence about life. Instead, it results in anxiety and unhappiness as people discover that life is not like that for them, and they either blame themselves or ‘the system’. The philosopher Onora O’Neill pointed to another apparently paradoxical outcome in her 2002 Reith Lectures, showing that current approaches to openness and accountability have reduced rather than increased public trust – the opposite of what had been expected [Reference O’Neill2]. Dominic Johnson has recently shown how cognitive biases that were assumed to lead inevitably to catastrophic defeats in war may instead result in remarkable successes [Reference Johnson3]. These and other findings are raising questions about whether what are regarded as ‘rational’ views of how to address societal problems are not as successful as we might expect.
A further problem of expectation, specifically with regard to mental wellbeing, has been created by widening the meaning of ‘mental health problem’. In the past, disturbed mental functioning was regarded as being caused by moral weakness or the influence of evil spirits. More recently, mental illnesses, which might have physical, psychological, or social contributors, have been viewed through a medical lens that sees definable categories of mental illness whose diagnoses have pathological and therapeutic implications. Such an approach regarded low spirits and anxiety as symptoms of mental illness only when they were experienced in an inappropriate context or to an excessive degree. In bereavement, disappointments in love, miserable life circumstances, and unhappy relationships, low spirits are a normal reaction. Anxiety is also an appropriate response to a threatening situation, such as receiving worrying news about one’s health, uncertainty about employment, or environments where security is an issue. Symptoms such as low spirits or anxiety may be an indication of mental illness if they arise without external disturbances, but otherwise they are appropriate responses to challenging life circumstances. Today such symptoms are regarded by many people as ‘mental health problems’, and there are many referrals to mental health services of people whose complaints are a reaction to the vicissitudes of normal life, rather than a sign of abnormal mental functioning. In a time of pandemic, when the vast majority of people are experiencing challenging life circumstances, the majority of the population might be regarded as suffering from mental health problems. Is this an appropriate use of scarce professional resources? Does it mislead people into thinking that they are suffering from a disorder when they may simply be showing a normal reaction to an abnormal circumstance?
Focusing on adverse reactions to trauma, major incidents, and disease outbreaks also diverts us from studying the resilience of individual people and communities. After major terrorist incidents, most people do not suffer from post-traumatic stress disorder (PTSD) or other adverse mental health consequences, and a greater focus on how and why some people are more resilient than others might be as productive as trying to understand why a minority break down or do not recover [Reference Bonanno, Galea, Bucciarelli and Vlahov4]. Studying why some countries are stable and suffer less conflict, rather than why some break down into violence, has been the focus of the Institute for Economics and Peace. Its founder, Steve Killelea, recently described how he arrived at this approach, and the benefits that arise from it [Reference Killelea5]. His approach has resulted in the identification of eight pillars of ‘Positive Peace’, rather than a list of reasons why things break down into conflict. These pillars – well-functioning government, equitable distribution of resources, a sound business environment, low levels of corruption, free flow of information, acceptance of the rights of others, high levels of human capital, and good relations with neighbours – were identified through the analysis of many data sets, are followed up globally each year, and are applied using a systems approach to understanding communal relations.
Another reason for the wide range of worldviews is the dramatic pace of change in technology. One example is a consequence of the insatiable appetite of the 24/7 news cycle and pervasive social media. Both of these excite emotional responses rather than merely providing information that can be rationally processed, and the uncertainty and anxiety that they stimulate are now being exacerbated by hostile politically motivated actors using synthetic bots driven by artificial intelligence to deepen splits and foment social and political instability. This new element of ‘hybrid warfare’ is producing a global conflict in cyberspace. Although most people are unaware of it, there are significant impacts on mental and physical healthcare as well as on industry, politics, and security. One example of this was the WannaCry ransomware attack on 12 May 2017.
Although this was a relatively unsophisticated attack, it had a major impact on National Health Service hospitals in England and Scotland, and up to 70,000 devices – including computers, MRI scanners, blood-storage refrigerators, and theatre equipment – may have been affected. On 12 May 2017, some NHS services had to turn away non-critical emergencies, and ambulances were diverted. In 2016, thousands of computers in 42 separate NHS trusts in England had already been reported to be still running the Windows XP operating system, although support for the latter had ended 3 years previously and Microsoft was no longer providing security updates or technical support. The system should have been replaced before the attack, but in 2018, a year after the WannaCry attack, a report by British Members of Parliament concluded that all 200 NHS hospitals or other organisations checked in the wake of the attack still failed cybersecurity checks. This failure to address necessary protections before and after a major attack in a major developed country with a uniquely networked and government-funded healthcare system shows that the threat we face may not just be external, or solely a consequence of financial pressures. It may also be a form of denial seen in the absence of a serious public debate about these new threats, which are increasing at an exponential rate and are a form of psychological warfare that is having significant impacts on our mental wellbeing.
In his interview study after the 2001 Al Qaeda attacks in New York, Charles Strozier described ‘zones of sadness’ in which the distance from the scene of death affected people’s experience. Survivors who saw people die in real time were not just those who escaped from the buildings, but those who saw people die by jumping from the buildings [Reference Strozier6]. Witnesses experienced the destruction, but remained just far enough away not to actually see people die. Participants felt the danger, but all they saw was a lot of smoke. Onlookers watched the attacks on television, distanced from the actuality of the scenes of death. These four cohorts – survivors, witnesses, participants, and onlookers – were defined by both physical and psychological distance. Recently, Strozier has also applied this perspective to the pandemic, showing how the four similar groups can be identified in that context, too. Apart from the differences between the people in the four groups, the one-off attack that they experienced is very different from situations where people live in a community traumatised by ongoing wars or constant terrorist campaigns. Victims such as these suffer repeated and sometime regular traumatic experiences. Mental disturbance in response to trauma is affected not only by psychological distance but also by whether people have one-off or repeated experiences.
This chapter has outlined why there can be no single worldview of the mental health implications of traumatic events, major incidents, and serious contagious diseases. It also implies that although our perspectives have evolved from previous views, we shall continue to change those perspectives. With the further passage of time and changes in culture and technology, current views will become substantially modified. We can only wonder how future generations will assess our views, how they will understand what we now refer to as ‘mental health’, and whether the separation that we observe between physical and mental health will survive.
