by Dr Joan Camilleri, Health & Wellness Centre
‘Those who fail to learn from their mistakes, are condemned to repeat them’
Compliance to legal notices and directions issued by public health authorities, manifests self-discipline, responsibility, altruism and a sense of civic duty – a social contract approach evidencing mutuality and reciprocity (Kohlberg et al.’s, 1983). This requires us to be functioning at a satisfactory level of cognitive, emotional & behavioural adjustment. This means that we enjoy mental health and wellbeing, able to cope positively when faced with change. This level of functioning is challenged by quarantine since staying indoors to escape infection is known to precipitate unbearable stress and tension. The setting up of helplines indicates that public health authorities are aware and concerned that compliance to quarantine may negatively impact the mental health of the population. Indeed, there is no health without mental health.
In their research review, of articles written during previous epidemics, including SARS, the Ebola outbreak and Equine flu, Brooks et al., (2020) cite 24 studies which discuss the impact of quarantine on mental health. These studies highlight that quarantine lasting longer that 10 days may precipitate post-traumatic stress, avoidance behaviour and anger. The longer the quarantine, the more severe symptoms. Prolonged quarantine precipitates mental health issues, because our basic needs– food and safety – are challenged. Challenges encountered during quarantine include: fear of infection, uncertainty, feeling ineffectual, a disruption of one’s work-life balance and fear that the acquired basic needs are insufficient. Challenges which remain after quarantine is over, include: financial issues, stigma, and retention of avoidance behaviours adopted during quarantine.
Challenges during quarantine:
Fear of infection leads us to ask ‘Will following the legal notices ensure I don’t get infected?’ ‘Which sources of information can I trust?’ ‘How big can the spread of infection become?’ Clear, honest, timely and consistent information is required if people’s stress and anxiety levels are to be kept to a minimum. It is advisable that we do not seek information from unreliable sources. We need to limit the time we spend searching about such issues because though this may decrease our anxiety it will eventually render us more stressed.
Studies carried out in Wuhan (Public Health England, 2019) indicate that an indefinite quarantine causes stress and anxiety. Uncertainty precipitates questions such as ‘How serious can this get’ and ‘When will this end?’ If people in authority, in an effort to alleviate tension, set unrealistic time limits based on limited epidemiological studies, this will very likely result in having to prolong the quarantine period. In such a case scenario people are more likely to lose trust in these sources, whereby they would become even more uncertain, stressed and anxious which would greatly challenge their mental health. Our real certainty lies in our compliance. The greater this is, the shorter will the quarantine be, and the less people will die. Another source of uncertainty is conflicting information hailing from usually reliable sources. For instance some countries advocate the use of masks while others do not.
Feeling ineffectual, precipitates the query ‘How am I going to fill my time?’ as well as ‘What can I do in this overwhelming circumstance?’ With regards to the first question we may structure our day, set achievable tasks and give ourselves time to carry them out. Planned activity may do much to substitute feelings of frustration and boredom by a sense of achievement. With regards to the second question, depending on our age and experience, we may consider volunteering to help NGO’s work and/or those of the Department of Health.
Disruption of our work-life balance ensues from teleworking to maintain social distancing. Persons now working from home reported feeling disoriented, missing their workspace, and those colleagues with whom they shared a daily cuppa and chat. Others feel distracted by their children asking for attention. Young children are happy that the generally absent parent is at home and may wonder why s/he is not playing with them more. Concurrently, parents wish to oblige.
Feelings of anxiety and anger commencing during quarantine due to fear of lack of basic needs, frequently lead to panic shopping which may bring temporary relief. However, stress and tension related to this fear may continue to be felt up to four – six months after the quarantine is over. Research highlighted similar reactions and emotions during past epidemics when persons under quarantine perceived that they did not receive masks in time. Ironically, while some people reported that excessive food supplies lead to excessive eating. Additionally, others counted the number of glasses of water they drank daily in order to calculate how many water bottles they needed to buy. Others yet, realised that well planned shopping, freed more of their time, which could be dedicated to more productive activities.
Challenges remaining after quarantine:
Financial issues. During quarantine one begins to wonder ‘How can I cope financially?’ The socio- economic climate precipitated by the quarantine resulted in the temporary closing down of a number of smaller businesses. If this state of affairs is prolonged, this may result in such severe financial losses as to result in these businesses closing down. Ultimately, the socioeconomic distress could become so severe that one may be looking at unemployment rates soaring. Such challenges cause stress, anxiety and anger in both employers and employed long after quarantine is over. Financial challenges may result in the loss of leisure activities and ones’ social network. If people have to struggle for a long time with financial burdens, depressive symptoms may appear. Research carried out during previous epidemics indicate that organising one’s employees to work from home when possible and the receipt of timely financial support, mitigated such outcomes.
Persons who have been quarantined, may later feel unaccepted by one’s friends, peers and neighbours because of fear of infection. This amounts to stigma which has negative effects on mental health. Research indicates that those who suffer most are healthcare workers, who become infected due to their selfless act of caring for the infected. When a pandemic breaks out the family may question their relative’s profession, considering it dangerous. This is known to cause inter-family tensions, which is a great burden for those working in the field. They may feel that those who are meant to support them are abandoning them. Research indicates that if the media avoid fear mongering, dramatic headlines and sensationalism, the potential for stigmatisation may decrease. It is essential that the gratitude we feel for these heroes today continues to be expressed after the quarantine is over.
Feeling traumatized during quarantine may lead to becoming over-attached to behaviours encouraged by legal notices. Brooks et al., (2020), highlight that in previous pandemics over-attachment was more frequently encountered in healthcare workers because they were more likely to suffer from severe symptoms of post-traumatic stress than the general public. Healthcare workers were known to have:
- Continued engagement in avoidance behaviours including: minimising direct contact with patients, who coughed and/or sneezed and not reporting to work; avoiding crowded enclosed places and public spaces in the weeks following the quarantine period.
This trauma related behaviour reportedly precipitated alcohol abuse dependency problems.
There are apparently no predictors that can indicate the psycho-emotional reactions of persons undergoing quarantine, however, posttraumatic stress occuring as a result of experiencing traumatic events personally or virtually involves avoidance symptoms and distortion of cognition and emotional arousal. Social isolation seems to influence the predisposition onset and outcome of post-traumatic stress in humans (Vlachos et al., 2020). Studies indicate that there are no specific demographic factors associated with psycho-emotional outcomes. Having a history of psychiatric illness, however, was associated with experiencing anxiety and anger up to 4 - 6 months after quarantine.
Summary: It is necessary that we reflect on our ability to cope with adjustment. We need to discern which mind-sets and/or lack of knowledge hinder us from transiting into ways of being and acting that safeguard our mental wellbeing during quarantine. Healthy and flexible adaptation are necessary skills if we want to avoid over-attachment to dysfunctional cognitions, emotions and behaviours. We may realise that we need to learn time and stress management techniques. To avoid social distancing translating into social isolation we can activate our social networks, maintaining contact with friends and family online or by phone. Mutual support may take the form of sharing fears, exchanging ways of coping, thus enhancing each other’s resilience.
It is important not to lose hope that this too shall pass. To render this more tangible we may write a bucket list of rewards for after. Embarking on a psycho-emotional transition, supports us to become more serene and resilient, thus, better able to face future life challenges. Retaining mental well-being, in this context, involves counter-balancing the stress precipitated by COVID 19 and quarantine by the sense of self-actualisation which emerges when we self-transcend through self-discipline and civic responsibility by doing our duty.
‘Do not pray for easy lives, pray for stronger (wo)men’
- Brook, S. K., Webster, K. R., Smith, L. E., Woodland, L., Wessel, S., Greenberg, N., and Rubin G. J. (2020). The Psychological Impact of quarantine and how to reduce it: a rapid review of the evidence. Lancet 395:912 – 20.
- Kohlberg, L. Levine, C. & Hewer, A. (1983). Moral stages: a current formulation and a response to critics. Basel, NY: Karger.
- Public Health England. (2020) Novel corona virus (2019-nCoV) what you need to know. 2020. https://publichealthmatters.blog.gov.uk/2020/01/23/wuhan-novel-coronavirus-what-you-need-to-know/ (accessed March 15, 2020)
- Ricoeur, P. (1984). Time and narrative (Vol. 1). (Translated by Kathleen Mclaughlin and David Pellauer). Chicago: University of Chicago Press.
- Vlachos I. I., Papageorgiou, C., and Margariti, M. (2020). Neurobiological Trajectories involving Social Isolation in PTSD: A Systemic Review. Brain Sci 10,173; doi10.3390/brainsci10030173
