What Happens When Americans Can Finally Exhale
The pandemic’s mental wounds are still wide open.
This time last year, the United States seemed stuck on a COVID-19 plateau. Although 1,300 Americans were dying from the disease every day, states had begun to reopen in a patchwork fashion, and an anxious nation was looking ahead to an uncertain summer. Twelve months later, the situation is very different. Cases are falling quickly. About half as many people are dying every day. Several vaccines were developed faster than experts had dared to predict, and proved to be more effective than they had dared to hope. Despite a shaky start, the vaccination campaign has been successful, and almost half of the country has received at least one shot, including 85 percent of people older than 65. As the pandemic rages on elsewhere in the world, the U.S. is eyeing a summer of reconnection and rejuvenation.
But there is another crucial difference between May 2020 and May 2021: People have now lived through 14 months of pandemic life. Millions have endured a year of grief, anxiety, isolation, and rolling trauma. Some will recover uneventfully, but for others, the quiet moments after adrenaline fades and normalcy resumes may be unexpectedly punishing. When they finally get a chance to exhale, their breaths may emerge as sighs. “People put their heads down and do what they have to do, but suddenly, when there’s an opening, all these feelings come up,” Laura van Dernoot Lipsky, the founder and director of the Trauma Stewardship Institute, told me. Lipsky has spent decades helping people navigate the consequences of natural disasters, mass shootings, and other crises. “As hard as the initial trauma is,” she said, “it’s the aftermath that destroys people.”
The COVID-19 pandemic has been a singular disaster—a recurring series of traumatic events that have eroded the very social trust and connections that allow communities to recover from catastrophes. Even now, with COVID-19 cases in the U.S. falling and vaccinations rising, many of the people whom Lipsky works with are struggling. Things are getting better, so why don’t they feel better? “A lot of them are really confused by it, because they feel like they made it through and can see a little light at the end of the tunnel,” she said.
If you’ve been swimming furiously for a year, you don’t expect to finally reach dry land and feel like you’re drowning.
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A brief note on the word trauma: Psychologists and psychiatrists still debate its definition. Some feel that the word is used too loosely. Others argue that the official definition—which requires actual or threatened death, serious injury, or sexual violence—inappropriately excludes serious life events such as divorce, unemployment, or some chronic illnesses. Some argue that you cannot be traumatized by watching news coverage of disasters, and others say you can. Jessi Gold, a psychiatrist at the Washington University School of Medicine, in St. Louis, thinks in terms of “big-T trauma” (the officially defined term) and “little-t trauma” (its colloquial cousin). Both meaningfully affect one’s mental health. “We can be too nitpicky about where something ends and something else begins,” she told me. “If someone feels bad and it affects their day-to-day life, it’s a mental-health problem, and I don’t really care what you call it.”
Even in the more restrictive big-T sense, the pandemic has produced trauma at enormous scale. Millions of COVID-19 long-haulers spent months with debilitating symptoms, and many are still sick. In one study, 30 percent of people with lab-confirmed COVID-19, most of whom had not been hospitalized, were still experiencing symptoms after an average of six months. Many are still struggling with the byzantine world of disability benefits and long-term diagnoses such as myalgic encephalomyelitis. Many Americans who were hospitalized with COVID-19 will still be affected too. At the height of the winter surge, 132,000 people filled U.S. emergency rooms. Based on evidence from Italy and from past coronavirus epidemics, about a third of those people—and the hundreds of thousands more who were hospitalized before and after that moment—will develop PTSD.
At least 580,000 Americans have died from COVID-19, and this official tally probably omits hundreds of thousands of uncounted deaths. Because each death leaves an average of nine close relatives bereaved, roughly 5 million Americans have been grieving parents, children, siblings, spouses, or grandparents at a time when funerals, bedside goodbyes, and other rituals of mourning and loss have been disrupted. Some may feel guilt about surviving, as did New Yorkers who narrowly missed the 9/11 attacks, or gay men who were “spared at random” by HIV during the 1980s. Some grievers may not heal for a long time. In normal circumstances, about 10 percent of bereaved people develop prolonged grief, becoming incapacitated by intense, all-consuming grief that persists for more than a year and flattens their life. About half a million Americans will likely feel this way—roughly the population of Atlanta. Grief will germinate along the same societal cracks that the pandemic exploited and widened: Indigenous, Pacific Islander, Latino, and Black Americans were more than twice as likely to die from COVID-19 than white Americans, and are therefore more likely to have lost loved ones to the disease.
Medical traumas were compounded by social stressors including unemployment, isolation, the rigors of full-time parenting without child care, and a year of lost opportunities. Against this grim backdrop, other tragedies unfolded: the killings of Breonna Taylor, George Floyd, and many other Black people by police officers; a record wildfire season; the insurrection at the U.S. Capitol; the Texas power crisis; and mass shootings in Atlanta and elsewhere. “This has been an ongoing set of cascading collective traumas that have really not abated,” says UC Irvine’s Roxane Cohen Silver, a psychologist who has studied trauma for decades.
The pandemic itself has not fully abated, either. Even as Americans ponder “post-pandemic” life, 600 people are still dying of COVID-19 every day. Despite the historic success of the vaccination campaign, the rate of vaccinations is slowing, and is lowest among the most socially vulnerable communities. COVID-19 is burning with renewed ferocity through India, much of South America, and other countries. Globally, the pandemic is set to kill more people in 2021 than in 2020.
A sweeping and continuous crisis produces two almost paradoxical phenomena. First, people become inured and apathetic to suffering at a mass scale, experiencing what the psychologist Paul Slovic of the University of Oregon has called psychic numbing. But people also become sensitized to further traumas in their own life. Silver has repeatedly found this pattern among people who experience successive disasters, such as 9/11, Hurricane Sandy, and the Boston Marathon bombings. Many didn’t habituate: Each new blow brought more stress, not less. “Around the one-year anniversary of COVID, a number of journalists asked me, ‘It’s been a year; why aren’t we adjusted to this?’” Silver told me. “I found that question very unusual.”
The pandemic hasn’t been a one-off disaster but “a slow, recurrent onslaught of worsening things,” adds Tamar Rodney, from the Johns Hopkins University School of Nursing, who studies trauma. “We can’t expect people to go through that and for everyone to come out the other side being fine. People suffered in between, and those effects must be addressed, even if we’re walking around maskless.”
In 1969, the psychiatrist Elisabeth Kübler-Ross wrote that people with terminal illnesses go through five emotional stages: denial, anger, bargaining, depression, and acceptance. This influential model etched itself into the public consciousness and has been applied to every flavor of grief and loss, including that of COVID-19. But it is deeply misleading, and always has been. Grief isn’t predictable. It doesn’t involve clearly defined stages. It doesn’t unfold linearly. It doesn’t necessarily end in acceptance. It carves long, meandering, and varied paths that popular myths do little to prepare us for.
People who endure long bouts of stress often collapse when they get a chance to be calm. Soldiers who return to the everyday world “describe it as boring, which gives them more time to think about what happened in the theater of war,” Steven Taylor, a psychiatrist at the University of British Columbia, told me. Similarly, he predicts that, in the quieter moments after COVID-19 infections wane, health-care workers may remember the patients they lost, or the morally challenging decisions they had to make about apportioning care. And that’s if they get quiet moments between dealing with surgeries that were rescheduled during surges and patients who are coming in sicker than usual because they deferred care. “You’re just frayed, but you have to do everything that didn’t get done,” Saskia Popescu, an infection preventionist at George Mason University, told me last summer. “You don’t get a mental break.”
Even Americans who were spared the big-T traumas of the emergency room still experienced a year of fear, uncertainty, and disruption. They too might experience jarring moments of unexpected reflection, even as the national outlook begins to brighten. “When you get a chance to realize that your safety or your family’s safety is no longer at risk, you think, What was this experience like for me?” said Gold, the Washington University psychiatrist. “Your answer could be I haven’t slept in months, or I feel miserable, or My kid is really angry and upset all the time. I think the curve [of mental-health problems] is likely to go up exponentially once people have time to even realize that mental health is part of the equation.”
Such problems can be especially disquieting at times when people are expecting to feel renewed. Lipsky, the trauma specialist, told me that she has worked with many people who are “struggling with the struggle.” They might be nurses, doctors, judges, activists, or parents—hypercompetent individuals who are used to handling a constant baseline of stress, and who act as bedrocks and caregivers for their teams, communities, and families. The added burdens of the pandemic overwhelmed them, and rocked their identities. “People don’t recognize themselves,” Lipsky said. “They say, ‘I used to be the person who dealt with really hard things.’ I had parents questioning whether they were even meant to be a parent.”
Not everyone will feel this way. Perhaps most Americans won’t. In past work, Silver, the UC Irvine psychologist, found that even communities that go through extreme traumas, such as years of daily rocket fire, can show low levels of PTSD. Three factors seem to protect them: confidence in authorities, a sense of belonging, and community solidarity. In the U.S., the pandemic eroded all three. It reduced trust in institutions, separated people from their loved ones, and widened political divisions. It was something of a self-reinforcing disaster, exacerbating the conditions that make recovery harder.
“I don’t feel that we’re doomed,” Silver told me. “I do still believe that we will get through this.” She and other experts I talked with noted that people are resilient, and often more so than they realize. But they also agreed that the rhetoric of individual resilience can often be used to plaster over institutional failures: the shortage of mental-health-care providers, the labyrinthine insurance system, the lack of support from employers, the stigma around seeking care at all, and the societal tendency to bottle grief. “I don’t know anyone who looks to the U.S. as a model for grieving and mourning,” Lipsky told me. “We don’t talk about loss. By and large, it’s all about consumption to help numb you out.”
Lori Peek, a sociologist at the University of Colorado at Boulder, told me that recovery from disasters is usually gauged in terms of dollars regained, jobs restored, and infrastructure rebuilt. Mental health is harder to measure, and so easier to ignore. She is worried that the understandable societal desire to move past the pandemic will further alienate people who are still dealing with grief or symptoms. “What if someone is truly suffering and reaches out for help six months from now, and is told, ‘What are you talking about? The pandemic was ages ago’?” Peek said.
Loss can linger longer than expected. The time frame for recovering from disasters “is measured not in months, but in years or decades,” Peek said. In many cases, it lasts beyond the life span of human compassion. In late 2005, the people who were displaced by Hurricane Katrina initially found an outpouring of support, including meals, clothes, furniture, money, and music. But by early 2006, goodwill gave way to what disaster-relief workers called Katrina fatigue, and what the evacuees just called discrimination. “People were like, ‘Aren’t these people going home?’” Peek said. “And they had no homes.”
Similar tendencies are apparent now, as commentators wonder why many Americans are still anxious and risk averse, even as the U.S. begins to wake from its pandemic nightmare. “I think some people believe we pressed ‘pause,’ and we’ll go back to the way things were before, as if we didn’t have all the intervening experiences, as if 2020 didn’t happen, as if getting a vaccine erases your memory,” Gold said.
Consider the latest phase of the ceaseless discourse around masks. The SARS-CoV-2 virus spreads primarily through shared indoor air, the vaccines are extremely effective, and breakthrough infections among vaccinated people are rare. It is reasonable, then, for the CDC to advise that fully vaccinated people don’t need to wear masks outdoors. (The agency’s surprising move to extend those guidelines indoors is more debatable.)
But it is also reasonable for people to want to continue wearing masks, to feel anxious that others might now decide not to, or to be dubious that strangers will be honest about their vaccination status. People don’t make decisions about the present in a temporal vacuum. They integrate across their past experiences. They learn. Some have learned that the CDC can be slow in its assessment of evidence, or confusing in its proclamations. They watched their fellow citizens rail against steps that would protect one another from infections at a time when the U.S. had already weathered decades of eroding social trust. They internalized the lessons of a year in which they had to fend for themselves, absent support from a government that repeatedly downplayed a crisis that was evidently unfolding. “We had no other protections all year,” Gold said. “We had masks. No one else protected us. It’s understandable that people would be hesitant about taking them off.”
For some people, taking off a mask will mean just exposing the bottom half of their face. But for others, it signifies that they must reevaluate their understanding of risk and danger yet again, with fewer emotional reserves at hand. “I feel more clingy towards the routines I’ve established,” Whitney Robinson, a social epidemiologist at the University of North Carolina at Chapel Hill, told me. “Summer feels like an unknown, and kind of exhausting. [It means] navigating new situations, reestablishing relationships, and deciding on COVID norms. It feels tiring.”
Nicolette Louissaint was tired when I first spoke with her last June, and she is tired still. Louissaint is the executive director of Healthcare Ready, a nonprofit that works to prepare for disasters by strengthening medical supply chains. She and her team started working full tilt in January 2020, well before most of the U.S. took COVID-19 seriously. The work has taken a toll, and isn’t over. “Our personal lives are stabilizing, but there is still this fatigue from our professional lives,” she told me. “And we’re less than a month from hurricane and wildfire season.”
Those who work in emergency preparedness talk about panic-neglect cycles, where people and politicians lose interest in a crisis once it abates, withdrawing attention and resources that are needed to prevent the next one. Louissaint worries that the U.S. is set to go through that cycle again. “There’s a sense that political will and energy is now there, and might not be in a year,” she said. “At some point, no one’s going to want to hear about this anymore, so we’ll be fighting for infrastructure and investment, and we’ll be right back to where we are. Even now, when we do our normal trainings to get communities prepared for natural disasters, the feedback we often get is ‘Oh my God, I can’t even think about that right now,’” Louissaint told me. “So what happens when we have to face it?”
I asked her what she says to people who have just had enough, who feel that they’ve maxed out on their quota of catastrophe, who just want to move on from the pandemic, or who equate talk of preparedness with fearmongering. “I think there’s a difference between sitting around fearing that the worst will come, and actually understanding the things we must be prepared for,” she said. “If we were more prepared, we wouldn’t have to worry as much.”
“If you don’t want to have this conversation anymore, I understand. I don’t either,” she added. “My challenge is: How do we get to a position where we can afford not to?”