A Pandemic of False Choices

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Schools need to be at the heart of our response to the COVID-19 mental health crisis.

The SARS-CoV-2 (COVID-19) pandemic has exposed a series of critical fractures in our social fabric. These social ruptures should concern medical health professionals, because social determinants of health not only drive chronic health conditions, but also create acute mental health vulnerabilities. At the same time, not every mental health issue requires a mental health professional for a public health response. There are simply not enough of us out there, and—most importantly—there is so much primary and secondary prevention that should be done to prevent debilitating anxiety and depression, traumatic stress, and other symptoms that drive functional impairment, disrupt supportive relationships, and increase risk of suicide.

A central site for such prevention is our educational system. Historically inequitable in its distribution of resources, it serves not only as a source of scholarly succor, but also as facilitator of nutritional security, safety, monitoring of well-being, and connection to services for family systems. Thus, as we properly give priority to frontline health responders and the fragile elderly as recipients of coronavirus vaccines, we must not undervalue education and neglect vulnerable teachers as deserving a measure of priority in the vaccination queue.

There seems to be some acknowledgment that the mental health crisis coming fast on the heels of the pandemic’s peak may drive deaths of despair in equal proportion.1 Little attention is being given, however, to the pandemic of false choices, or what Langer2 and Lifton3 have called “Choiceless Choices” that people have had to make—and will be increasingly pressured to make in the months to come as health care institutions and businesses reopen and on-site work resumes. Such choiceless choices, long a subject of analysis in bioethically informed medical and legal practice, often involve tragic choices, in which any choice one makes can lead to a tragic outcome.4 Thus, many families who are dependent on schools for de facto childcare (including single-parent families and those in which both parents work) may face the choice between doing without food or rent money and failing to give children an environment for learning at home. In these circumstances, parents often feel helplessness, guilt, and shame for not being able to provide both financial stability and education, and children often feel they have become a burden on their worried parents. With such feelings amid social isolation and aloneness in the pandemic, there is now a likelihood that healthy resilience may be impeded across generations.5,6 Choiceless choices tend to foster a climate of malignant competition and toxic perfectionism, as represented in Hyman Bloom’s 1953 drawing of Marsyas, the music satyr whose drive for perfection led him to provoke a malignant competition with Apollo, the Greek god of art.

One component of our mental health response must therefore be a substantial investment in our educational systems, from pre-K through high school. Curricular deficits must be made up, following the ongoing limitations of remote learning. Innovation and adaptation with respect to socializing are also a priority, given the need for physical distancing. There will be a need for nurses in every school, as well as for counselors who can screen for signs not only of anxiety and depression that may have arisen during the pandemic, but also of demoralization, alienation, and increased exposure to domestic violence that may have persisted and escalated under the pressures of family isolation and economic insecurity.

This current crisis provides a timely opportunity to introduce a broad repertoire of positive coping strategies that are developmentally appropriate across the school system, interventions that will serve our society for decades to come. Strong attention needs to be given to professional development for teachers, both to support their retention and to ensure that our children are sufficiently engaged, challenged, and inspired to envision themselves as something more than avatars in a virtual world of TikTok memes and YouTube novelties. By reintroducing a way of life beyond Zoom, we can avoid toxic coping strategies and empower resilience, thereby strengthening both the health care system and the economy.

In the conditions created by the pandemic, it is essential that we not lose sight of the good in pursuit of the perfect.7 There are, and will be, choiceless choices to be made and losses to be grieved.8 There is still time to shift the trajectory of this pandemic’s aftermath; the choices we make now may reflect both current and aspirational values. If we keep schools closed while reopening bars and gyms, we risk restructuring (or perpetuating) our value system in a way that not only creates a context for increased individual, interpersonal, and community trauma, but also perpetuates it across generations.6 Our capacity to make those choices and to grieve those losses, even as we strive to minimize them, will be vital to our—and our children’s and grandchildren’s—potential for post-traumatic growth as the pandemic eventually remits. 

History (past and present) suggests the societal stakes involved in the wake of pandemics—namely, that a robust investment in the educational system serves as a buttress against widespread alienation and further polarization in access to resources. An educated populace is fundamental to democracy and to a bioethically informed life. The importance of preserving and advancing a heritage of knowledge has long been recognized by many religious and spiritual traditions, including Judaism, as in Hyman Bloom’s painting of a rabbi saving the Torah in the midst of a calamity.

At a time when political systems have demonstrated such vulnerability, the global stakes could not be more evident. Given the direct impact of the school system on the mental and physical health of individuals and communities, we must recognize vaccination of teachers and school staff as a priority. There is much healing to be done outside the health care system, and the psychiatric community has a responsibility to recognize and highlight these opportunities.

Dr Bursztajn is associate professor of psychiatry (part-time) and co-founder of the Program in Psychiatry and the Law at Harvard Medical School and president of the American Unit of the UNESCO Bioethics Chair (Haifa). He practices clinical and forensic psychiatry in Cambridge, Massachusetts. Dr Levy-Carrick is assistant professor of psychiatry at Harvard Medical School, co-chair of the MGB Trauma Informed Care Initiative, and Associate Vice Chair, Ambulatory Services, in Brigham and Women’s Hospital Department of Psychiatry. 

References

1. Bursztajn HJ. Neither deaths from denial nor deaths from despair. Psychiatric Times. April 28, 2020. https://www.psychiatrictimes.com/view/neither-deaths-denial-nor-deaths-despair 

2. Langer LL. Versions of Survival: The Holocaust and the Human Spirit. State University of New York Press; 1982.

3. Lifton RJ. The Nazi Doctors: Medical Killing and the Psychology of Genocide. Basic Books; 1986/2000.

4. Calabrese G, Bobbitt PC. Tragic Choices. New York: Norton, 1978.

5. Haque OS, De Freitas J, Viani I, Niederschulte B, Bursztajn HJ. Why did so many German doctors join the Nazi Party early? Int J Law Psychiatry. 2012;35(5-6):473-479.

6. Tanaka G, Tang H, Haque OS, Bursztajn HJ. Preserve Enduring Personality Change After Catastrophic Experience (EPCACE) as a diagnostic resource. Lancet Psychiatry. 2018;5(5):e9.

7. Rabbis’ Teachings: Rabbi Ari Lev: The holiness of imperfection. Kol Tzedek, Yom Kippur 5777. October 12, 2016. Accessed December 1, 2020. https://www.kol-tzedek.org/imperfection.html

8. Bard TR, Bursztajn HJ. Triage trauma and moral distress. Psychiatric Times. October 1, 2020. https://www.psychiatrictimes.com/view/triage-trauma-moral-distress