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The field of psychiatry is uniquely suited to address the psychological factors associated with the past year (and what lies ahead).
“A time to tear down and a time to build up.”
Most of us entered January 2020 with the fresh hope that accompanies a new year. Little did we know that a new virus was percolating across the other side of the globe that would have a tremendous impact on so many aspects of our lives. Since those early days, attitudes have changed, with many individuals reporting that 2020 has been the worst year of their lives. Fortunately, history has taught us that bad things come and go. For instance, the Biblical wisdom from the book of Ecclesiastes teaches that off years happen. In one translation, the third chapter of Ecclesiastes begins: “Everything has its moment. There is a time for everything beneath the heavens.”1
Since Ecclesiastes is in the public domain, Pete Seeger famously rearranged the words for the song he wrote in the late 1950s—“Turn! Turn! Turn! (To Everything There Is a Season).” In 1965, it was adapted by The Byrds and became an international hit. The only new words in Seeger’s song are the phrase “Turn! Turn! Turn!” and the closing line of “a time for peace, I swear it’s not too late.” Those additional words seemed crucial for the controversial Vietnam war and ring true again for our present contentious time.
Most views of world history consist of a linear or circular model, but it may be a spiral model, with some progression forward peppered with occasional slips backward. One example of this spiral theory is the history of violence. Although a case can be made that violence has decreased over time, there have been periods of intense escalation (eg, World War II and the Holocaust).2 As we review some of the major social psychiatric challenges from 2020, we may still find reasons for optimism in 2021 as we move upward again through the spiral.
A time to tear down
So many of the events in the adverse half of Ecclesiastes’ verses seem timeless and like a perfect fit for 2020.
It was a time to die. Large numbers of loved ones died from the coronavirus.
It was a time to kill. The news and social media shed light on the unjust brutality toward Black Americans.
It was a time to avoid embracing. The contagious nature of coronavirus disease 2019 (COVID-19) necessitated social distancing.
It was a time to lose. With the pandemic-related lockdowns came the loss of jobs and livelihoods.
Throughout 2020, Psychiatric TimesTM has highlighted many social psychiatric problems. From the pandemic,3 to racism,4 to a significant rise in undue anxiety,5 and to losses due to wildfires,6 these issues often intersected and caused additional problems. As this issue goes to press, we are dealing with the uncertainties of the presidential election and additional stress and anxiety. Yet, the upcoming presidential term is symbolic of a time for hope and renewed opportunities, no matter who wins. Indeed, our current social problems seem to resonate with the difficult times predicted in Ecclesiastes (Table 1), but they also may be indicative of an expected move up the spiral.
A time to build up
If we look to the Chinese symbol for crisis, we see it represents both a danger and an opportunity. In that light, not everything has been completely negative from a social psychiatric perspective. For instance, quarantining gave some an opportunity for increased closeness with loved ones; yet, it also increased the risk for domestic violence and political conflict. Academic and other health care institutions used the opportunity to rise to the occasion to address the pandemic. Although this caused extra stresses, it may have also enhanced resilience. In reviewing some of the greatest psychiatric challenges from 2020, it becomes clear there is still much for which to be grateful and reasons for optimism and hope.7
A new look at COVID-19
There is no doubt the pandemic was a punch to the gut, and we likely will be dealing with medical, neuropsychiatric, emotional, and financial fallout for years to come. Yet, there are at least 2 reasons to be optimistic. First, we now scientifically know that wearing masks and practicing adequate social distancing significantly reduces the infection rate. The key is to psychologically convince enough of the public to do so.
The Group for the Advancement of Psychiatry (GAP) shed light on why this task is not an easy one.8 A seeming politicization of the pandemic and masks is an obstacle to adherence. There are also other issues. Individuals may need to gradually desensitize their discomfort or trauma triggers to wear masks. GAP members noted the importance of reminding individuals that social strategies help everyone, just like stoplights and street signs.
Indeed, our field is uniquely suited to help the country by addressing the psychological factors associated with mask resistance. Many lives are still at stake, as new modeling suggests.9 As of October 2020, approximately 50% of Americans were regularly wearing masks; projections note about 300,000 lives could be saved by the spring if we increase that percentage to 95%.
The passage of time is the second thing for which there is optimism. The last major pandemic, the Spanish flu, ended after about 2 years, even without therapeutics or a vaccine. A little patience may go a long way and, by the end of 2021, the pandemic will likely be less worrisome.
Racism, as we know, got intertwined with the pandemic. As is often human nature, society looked for blame and an outlet for the fears and frustrations at the onset of the pandemic. Because the virus originated in China, Chinese and Chinese-Americans became victims of harassment. Other minorities, such as Hispanic Americans and Jewish Americans, encountered rising hatred as well.
Because of socioeconomic inequities, we also discovered minorities were at higher risk for infection and death due to preexisting illnesses and social circumstances that made them more vulnerable. Black Americans, Native Americans, and other low-income minorities paid the price with their lives.
The nightly news also served as a racism wake-up call after videos showing police brutality against Black Americans surfaced. Although a comprehensive concept of racism was presented by the Kerner Commission in 1968, the issue was largely ignored after the civil rights gains of the time. This has resulted in the continued structural/societal, institutional, and individual racism of today.
In response, the American Psychiatric Association (APA) began to implement some organizational procedures to address racism internally and externally. There are critics who think the APA has not done enough, calling for the APA to apologize for their part in racism, as other guild medical organizations have done.10
It is not a surprise to climate scientists that 2020 was not a good year for the environment. In the United States alone, we experienced a near-record number of hurricanes and unprecedentedly destructive wildfires in the west. Earlier in the year, unparalleled wildfires devastated part of Australia during their scorching summer season. Calls were made for the United States and Australia to help each other, and included requests for assistance from psychiatrists.6
Thankfully, on the other side of the coin, there were some promising developments in the midst of the devastation. For instance, researchers found the dialectical approach can help the psychotherapeutic process with patients who have climate-related conditions.11 There was also a turn toward using the traditional environmental knowledge and, especially in Australia, the focus on mirroring indigenous individuals’ desire for balance and protecting their environment.6
Finally, the pandemic lockdowns reduced fossil fuel use and carbon emissions—a faint but important silver lining. The question remains: can these reductions be maintained when the pandemic is over?
Burnout is a common issue for all professions, especially during the pandemic, but physician burnout is the greatest.12 Physicians, including psychiatrists, have experienced a rising rate of burnout, which affects both patients and physicians. The burning out process starts in medical school and continues into residency and thereafter. Depending on the specialty and the measurement tool, 40% or more clinicians experience burnout; the APA’s survey indicated that the percentage is close to 80% for psychiatrists.13 Although we lack data on the pandemic’s impact on burnout, there is definitely a reason for concern—not just for clinicians and employees, but parents as well. On the other hand, we have also heard rewarding stories from clinicians, who took pride in the recognition of their dedication during the pandemic.7 The gratitude and outreach may help turn the burnout tide.
As we move forward, we can work on removing the barriers to self-care and encourage businesses and communities to make positive changes. For instance, there is the promise of reducing burnout and saving money by installing a chief wellness officer. We can continue to fight stigma, especially within the medical field. Our clinician colleagues in medicine and psychiatry should feel empowered, not dissuaded, to reach out for mental health care support.
Unfortunately, while we can identify some of these “social psychopathologies” (even without a formal classification system), we do not have the tools to treat them. Our treatment armamentarium for individual patients and small groups cannot readily be transferred to social problems. And yet, during 2020, some social processes that seem therapeutic have become a potential kind of social glue, like apologizing for racism.10 It is psychologically beneficial to apologize for doing something harmful to individuals, inadvertently or not. If that leads to forgiveness, all the better.
In South Africa, formal truth and reconciliation events helped prevent violence, allowing the country to come out of apartheid with a degree of social healing. We may need to leverage those strategies in the United States to address our current divisiveness. It might also help healing from the historical injustices of Native American displacement and Black slavery.
Similarly, we can take a page from research that shows the importance of collaborative care and integrating psychiatry into the rest of clinical medicine. It would be helpful to have a psychiatric expert who partnered with the surgeon general. In essence, it could be a psychiatric assistant to the surgeon general or, better yet, a psychiatric general. At the very least, we should increase our presence and further share and promote our knowledge of human nature with regards to societal issues.
As reported in the October 2020 article on election anxiety, many varieties of undue anxiety seemed to increase over recent years, and more dramatically in 2020. The same holds true for variations of depression, especially as we grieve the lost experiences, people, and opportunities. Substance use, abuse, and dependence remain a concern. The full repercussions of this year’s traumas will take time to emerge. While these increases may not reach the level of a mental health pandemic, millions of individuals are suffering emotionally as a result of COVID-19.14
At the same time as this increased need for mental health services, there have been limited advances in therapeutics. There is some promise from the new research on psychedelics, as discussed in a report from the 2020 Annual Psychiatric Times® World CME ConferenceTM.15 Underground micro-doses of lysergic acid diethylamide (LSD) have been used for self-help, with anecdotal evidence concerning its benefit for anxiety and depression.16 Given that LSD and other psychedelics have been touted for eliciting a sense of cosmic connections, could they be of help in reducing our divisiveness and scapegoating?
On the positive side, we saw major advances in the integration and use of telepsychiatry, which was quickly and widely used to replace in-person visits for safety reasons. Historically, this modality was used in remote areas to help underserved populations. During the pandemic, telepsychiatry allowed clinicians to see where and how patients lived, meet members of their family (and pets), and connect with their patients on new levels.17
Concluding with (cautious) optimism
The third chapter of Ecclesiastes suggests that difficulties do not last forever. Will 2021 turn around the spiral toward healing, building up, speaking out, bringing peace, laughing, and loving? Time will tell, but given what we have learned in 2020, it would seem that those in mental health care can promote these positive goals (Table 2). There are clear examples of how we need to fulfill our ethical imperative to improve the health of our communities. Importantly, social psychiatric goals (such as those listed here) correlate with social justice, and new research suggests that countries with greater concern for social justice initiatives have happier and more satisfied citizens.18
And so we look to 2021 with optimism, which is often described as viewing the glass half full instead of half empty. In general, optimism has its own therapeutic repercussions for health and mental health, and it is part of the driving force behind the emergence of positive psychology.19 A Jungian sense of optimism can occur amidst our country’s periodic chaos and conflict; an example of such is the innovation and renewal that followed conflicts in 1968.20 Nevertheless, optimism does need to be tempered with realism, as in the Stockdale Paradox.21 Otherwise, it can lead to undue risk-taking, as the country witnessed during the early days of reopening during the pandemic.
Given the limitations of prediction, and that this article was written before the election results, the prognosis must be tentative and guarded, as it is for our individual patients.
Nevertheless, I am cautiously optimistic.
Dr Moffic is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of being a Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in ٢٠٠٢. He has recently been leading Tikkun Olam advocacy movements on climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of Psychiatric TimesTM.
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