Capitalism, coronavirus and mental distress

Issue: 168

Iain Ferguson

When faced with great social and political crises, our usual response as socialists is to look for historical parallels and consider what lessons can be drawn from them.1 The Covid-19 pandemic that has ravaged the globe since early 2020 poses some challenges in this regard. The epidemic does share features with the severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) outbreaks that affected areas of South East Asia and the Middle East earlier this century. However, in terms of its global spread, Covid-19 arguably has more in common with the so-called Spanish flu epidemic of 1918, which killed between 50 and 100 million people worldwide.2 Moreover, its impact on the economy has been genuinely unprecendented, with more than 81 percent of the world’s workers affected by a lockdown.

That same difficulty in finding historical parallels applies when considering the potential impact of the pandemic on people’s mental health. The Covid-19 crisis has combined mental health stressors that have been studied before, in other disasters, but which have never been seen consolidated in one global crisis. So, for example, there is research on how humans cope with quarantine, mass disasters and ongoing stressors but not on all three.3

The Royal College of Psychiatrists has described the impact of the pandemic on mental health as being like a “tsunami”.4 The analogy is accurate in the sense that, like a real tsunami, the virus and the consequences it brings in its wake—biological, political, economic—can overwhelm our psychological defences, our normal ways of coping. Nevertheless, this analogy can also be misleading. As writers such as Mike Davis and Rob Wallace have shown, there is little that is natural about the origins of this pandemic, the ways in which it has spread or the degree of death and devastation that it has wrought across the globe.5 Rather, as has been argued previously in this journal, all of these processes have been shaped by factors such as global capitalism’s relentless drive for profit, the response (or lack of response) from national governments to the disease and the impact of existing divisions and inequalities on rates of infection and death.6

This applies no less to the short-term and long-term impact of the pandemic on mental health. Its effects will not be experienced evenly across society. Rather, as with every other aspect of this crisis, they will be shaped by the divisions and inequalities of neoliberal capitalist society. A major recent study of the mental health impacts of the pandemic concluded that although “we are all in the same storm…we are not all in the same boat”.7 These impacts will be discussed in the first part of this article.

It is not a given that governments respond to the mental pain and suffering resulting from the pandemic and its effects, since mental distress is rarely seen as a political priority. Insofar as governments do choose to recognise the issue, their response is likely to be shaped to a large extent by a model—biomedical psychiatry—that views mental distress as illness, with its origins in faulty brains and genes. Of course, mental distress does affect our physical and neurological functioning as well as our emotional functioning (not least, for example, in its impact on sleep).8 Indeed, there is now a substantial literature documenting the long-term impact of trauma on body and brain.9 In addition, many people will need support both during and after this crisis, including support from what remains of mental health services that have been devastated by more than a decade of cuts and austerity. However, in the context of the current pandemic, mainstream psychiatric approaches that focus on diagnosis and treatment can lead to medicalising or pathologising what are essentially normal human reactions to traumatic events. As we shall see below, this can also lead to individualising responses to what is essentially a collective and structural crisis that contains the possibility for social and collective responses.

One partial challenge to the biomedical model in recent decades has come from “trauma-informed” approaches, which see mental distress as originating primarily in our life experiences rather than in our brains.10 Some mental health professionals have suggested that the cumulative impact of the stressors listed above could lead to an “epidemic” of a different sort once this crisis is over, namely one of post-traumatic stress disorder (PTSD). Here, I will critically assess the strengths and weaknesses of trauma-informed approaches. The origins of these approaches lie in two sets of experiences. The first is the experience of imperialist wars and the trauma that results from them. The second is the everyday traumas of racism, sexism and exploitation that make up what passes for “normal” life under capitalism.

The 800,000 deaths across the globe that have already been caused by Covid-19 add up to a huge number of individual stories of personal loss and grief, and there is the likelihood of many more deaths in the coming months and years. Millions more will experience mental distress due to the multiple stresses associated with the pandemic. Thus, fighting for more and better mental health services for affected individuals is an important task. However, this is above all a collective crisis, the roots of which lie in a system which prioritises profits over lives. Millions of working-class people across the globe have lost their jobs. Many more are being forced to work in unsafe conditions without proper protective equipment. Moreover, we have all been forcefully reminded yet again just how little black lives matter in a society built on racism. As I shall argue in the final part of the article, that shared collective experience allows for the possibility of a collective political response. Such a response would challenge those responsible for so many avoidable deaths, but it could also challenge the feelings of powerlessness, shame and isolation that are associated with mental distress through promoting a sense of political agency and solidarity.

Coronavirus and mental distress

The coronavirus crisis is a global crisis, both in its geographical reach and its impact on so many areas of human life. Its potentially devastating impact on mental health is a result of the huge stress it places on many parts of people’s lives. To state some of the more obvious stressors:

• Within the space of a few months, millions of people across the globe have been left without jobs and income. In the United States alone, by June 2020 more than 40 million people had lost their jobs. As we know from Britain in the 1980s and the more recent experience of Greece following the imposition of brutal austerity from 2010, both unemployment and poverty have a huge impact on mental health, including increased levels of suicide.11
• Billions of people have been forced into quarantine and self-isolation, often alone and cut off from family and friends. The negative effects of this range from increased anxiety, confusion and loneliness to an increase in domestic violence that has been seen in Britain and elsewhere.
12 The pressures, however, are far from being evenly distributed. The experience of those who can afford to self-isolate in second homes or private islands is very different from that of the lone parent with young kids trying to self-isolate in a council flat or the refugee in an overcrowded camp on a Greek island.
• Millions of workers, from the meat-processing plants of North Carolina to the garment sweatshops of Leicester, have been forced to choose between work and hunger (and the possibility of infection and even death) by bosses who have required them to work without proper social distancing or personal protective equipment (PPE). In some reported cases bosses have even required employees to turn up for work when they are showing symptoms of Covid-19 or had tested positive.13

• Tens of thousands of people are losing loved ones long before their time and will often be unable to grieve properly for them. Again, the emotional pain is not equally distributed. The death rate for black and minority ethnic people in Britain, for example, is twice as high as for the white population. This is not due to biological differences but rather, as a recent report from the Runnymede Trust has shown, poor living and working conditions that leave them more exposed to the virus.14
• Many health and social care workers are experiencing “moral distress”, defined by the British Medical Journal as what occurs when “one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right action”.
15 Moral distress leads to stress and burnout and has increased considerably during the current crisis due to the lack of acute beds, PPE and adequate testing and tracing procedures.
• Not everyone will experience these pressures in the same way. For some workers, working from home is preferable to spending hours commuting in crowded public transport, having to face a bullying boss on a daily basis or having too little time to spend at home with family. A survey of local authority staff working for Kirklees Council, for example, found that about 83 percent of staff surveyed seemed happy with the arrangements that the council had put in place. That said, as I shall argue, early studies showed that more than half the population of Britain were experiencing increased levels of anxiety.

Assessing the impact of the crisis on mental health is not straightforward, for several reasons. Levels of anxiety, for example, are shaped by a wide range of both top-down and bottom-up factors that are not easily measured. An example of the top-down factors is the level of “institutional trust” in a society: how much people think they can believe their government, medical authorities and the state’s handling of the crisis. An example of bottom-up factors is how, according to some early research in Britain, a desire to protect the National Health Service (NHS) meant a large proportion of people (89 percent in the survey) supported the lockdown, even though they found it stressful. Indeed, arguably the lockdown in the UK was led from below.16

In addition, the pandemic’s impact on mental health is not static but ­constantly changing. Different sections of the population are more or less affected at different times, depending on the nature of the material and emotional threat. As the authors of a study published in Lancet Psychiatry in July 2020 conclude:

As the economic consequences of lockdown develop, furloughs turn to redundancies, mortgage holidays expire and recession takes effect. We believe that it is reasonable to expect not only sustained distress and clinically significant deterioration in mental health for some people, but the emergence of well described long-term effects of economic recession on mental health such as increasing suicide rates and hospital admissions for mental illness.17

Finally, when considering research findings that often rely on psychiatric definitions of conditions such as “anxiety” and “depression”, we should avoid medicalising or pathologising what might be normal reactions to an overwhelming crisis. As the writer and psychologist Lucy Johnstone has argued:

For several weeks now, I have been waking in the night with feelings of intense anxiety. I constantly monitor myself for symptoms of a possibly fatal illness. I can’t concentrate very well and my usual ways of coping don’t seem to be working. I feel a bit safer inside my house but I also feel trapped. One minute I feel fine, and the next I feel terrified. Have I suddenly developed a “mental health problem”, unfortunately timed to coincide with the Covid-19 pandemic? No, of course not. I’m having an entirely rational reaction to a major threat to our whole way of life.18

So, for example, figures showing high levels of anxiety affecting more than half the British population in the early stages of the pandemic do not mean that large numbers of people have suddenly developed a “mental illness”. That is not to deny or minimise the fact that some of us will experience extreme mental distress and may need additional social and emotional support to get through this crisis. This is a point to which I will return below.

With these caveats, what does the research tell us about how the pandemic is impacting on mental health? Studies from the first phase of the pandemic suggested it was having a considerable impact. For example, a study from China published in April 2020 reported that 70 percent of people there described symptoms of psychological distress during the outbreak.19 In Italy, in a survey in May 2020, eight in ten Italians said they needed psychological support to overcome the pandemic.20 In Britain, as noted above, a survey by the Office for National Statistics found that more than 25 million people were experiencing very high levels of anxiety in the early weeks of lockdown.21 The figure fell from 62 percent of the population in mid-March to 49 percent in mid-June.22

Since March, a number of large-scale studies have been conducted seeking to assess the impact of the pandemic on mental health in Britain. Here, for reasons of space, I will focus on the findings of one such study involving regularly repeated interviews with over 4,000 adults by the Mental Health Foundation, which worked with several universities.23 The report’s authors begin by making two important observations. Firstly, even before the pandemic levels of mental distress were already high. Secondly, factors such as poverty, economic disadvantage and racism mean that mental health problems disproportionately affect certain groups in society. What this research and other major research studies conducted during the crisis show is that the pandemic has exacerbated, rather than created, mental health inequalities.

Foremost among those at risk were young people, who consistently reported stress more than any other group and were also more likely to report hopelessness, not coping well and suicidal thoughts and feelings. The proportion of young people aged 18-24 reporting suicidal thoughts or feelings was more than double that of the population as a whole. The report’s authors comment:

Young adults have been especially badly hit during the pandemic with a triple whammy of curtailed education, diminished job prospects and reduced social contact with peers. The period between ages 18 and 24 is already a time of especially high risk for experiencing a mental health problem.24

Women have also been disproportionately affected by the pandemic. Women make up the majority of frontline health and social care workers, are over-represented in low-paid and insecure work and are more likely to have pre-existing difficulties with debt and bills. As the report notes:

All the women in these positions were seen as being at greater risk of developing mental health problems before the pandemic and will be at increased risk as the pandemic develops.25

As noted earlier, women have also been more exposed to the risk of domestic violence during lockdown. Lone parents (again, mainly women) were another group found to have been particularly affected, mainly due to financial concerns. Twice as many single parents had experienced suicidal feelings in the two weeks before they were surveyed compared to the population as a whole.

Those with a pre-existing mental health problem were most likely to experience stress and inability to cope. They also reported suicidal thoughts and feelings at a rate almost triple that of the general population. Often, this group will have lost access to services and sources of supports during lockdown. The report also found that the pandemic had hit the mental health and wellbeing of people with long-term, disabling conditions particularly hard.

The number of black and minority ethnic (BAME) people in this sample was too small to draw wider conclusions. However, a separate survey of over 14,000 adults by the charity Mind found:

Almost one in three…BAME people said problems with housing made their mental health worse during the pandemic, compared to almost one in four…white people. Employment worries have negatively affected the mental health of 61 percent of BAME people, compared to 51 percent of white people. Concerns about finances worsened the mental health of 52 percent of people who identified as BAME, compared to 45 percent of those who identified as white.26

In addition, a report by the Fawcett Society found that black and minority ethnic women were disproportionately affected. Some 42.9 percent of BAME women said they believed they would be in more debt than before the pandemic, compared to 37.1 percent of white women and 34.2 percent of white men; nearly a quarter of BAME mothers reported that they were struggling to feed their children (23.7 percent, compared to 19 percent of white mothers); and 65.1 percent of BAME women and 73.8 percent of BAME men working outside the home reported anxiety as a result of having to go out to work during the coronavirus pandemic.27

Capitalism, psychiatry and mental health

The responses of ruling classes to the mental health impacts of the pandemic are shaped by the dominant understandings of mental distress. These understandings are not politically neutral: they are shaped by class interests, class ideologies and class struggle. Not surprisingly, the dominant definitions of health within capitalism focus primarily on the ability to sell one’s labour power and are therefore usually negative or functional definitions—health as the absence of illness or disease, health as the ability to work. In other words, if you are not ill, you are well and, by implication, well enough to work.

This narrow view of health has framed the Tory assault on working class people, and disabled people in particular, in Britain over the past decade. Witness, for example, the attack on so-called “sick note culture” by then prime minister David Cameron in 2015 and the use of the hated work capability assessment, backed up by the threat of sanctions, to force workers with a range of (often severe) mental and physical health conditions back to work. Ideological support for these assaults on workers’ health has been provided by supine academics and medical leaders through, for example, the spurious argument that “work is good for you”. There has been a neoliberal redefinition of health as personal responsibility, with the insistence that it is up to the individual to maintain good health by exercising, keeping their weight down, not overindulging in alcohol and so on. This ignores the impact of structural factors such as poverty, the availability of healthy food and the pressures of work on people’s lives and “choices”.

In relation to mental health, these arguments find ideological support in the dominant biomedical model. This sees different forms of mental distress as discrete illnesses, similar in all major respects to physical illnesses. These illnesses are seen as originating in faulty brains or genes, with some allowance made for the influence of “environment”. As with the approaches discussed above, biomedical psychiatry individualises mental distress and downplays the well-documented role of structural factors, such as class, poverty and racism. Space does not allow for a full discussion and critique of this model.28 That critique does not, however, have to involve a denial that mental distress “involves” brains. Indeed, it would be hard to think of any aspect of human behaviour that does not involve brains. However, as Nikolas Rose has recently argued in a powerful review of biomedical psychiatry:

No one would doubt that mental distress and mild, moderate and severe mental disorders involve brains. But these are not “brains in vats”…brains are part of complex bodily systems, so disorders are of organisms—human beings—and human beings in particular and sometimes stressful social contexts.29

Hence, Rose argues, “we must be rather cautious with the powerful rhetoric about ‘the burden of brain disorders’, because…many of these conditions could equally well be called ‘social adversity disorders’”.30

It is the tendency of mainstream psychiatry to individualise mental distress, rather than its emphasis on brains, that is exemplified in leading Irish psychiatrist Brendan Kelly’s recent book, Coping with Coronavirus: How to Stay Calm and Protect your Mental Health.31 Some of Kelly’s suggestions for personal strategies for coping with the pressures of the crisis are uncontroversial. They include limiting use of social media, taking exercise and practising meditation (although how his expertise as a psychiatrist qualifies him to counsel so strongly against wearing face masks is unclear). Nevertheless, there are a number of problems with the book that highlight the individualistic focus of mainstream psychiatry.

Importantly, Kelly’s book offers no acknowledgement of the social, political and economic factors contributing to the pandemic. Rather, in Kelly’s naturalistic account, viruses simply “spread”. The solution to that spread “lies in the hands of health authorities and the governments that fund them at global national and local levels”.32 Of course, it may be unreasonable to expect an awareness of the role played by profit-driven neoliberal agricultural methods and global trade networks from a book of this type. However, some acknowledgement of the role played by governments across the globe (including the Irish one) in failing to prevent the spread of the virus—for example, through not imposing lockdowns early enough, not providing sufficient PPE and not protecting care homes—would be welcome.33 Such a recognition might lead to people becoming very angry indeed and taking collective action rather than “staying calm”, but such a response is not contemplated in this book.

The same lack of understanding of social context shapes Kelly’s understanding of how the virus impacts mental health. On the one hand, he argues that the anxiety associated with the virus is different to the anxiety seen in “traditional anxiety disorders”, such as agoraphobia: “The key to treating these conditions is that, in all of these disorders, treatment helps the patient to see that their anxiety has no basis. There is nothing to fear.” By contrast:

The problem with coronavirus is that there is indeed something to fear: the virus. There is nothing good about coronavirus. Although the illness is generally mild and over 97 percent of people who are diagnosed survive the infection, that is no consolation if you are one of the few who develop a severe illness or if you fear for a relative who is vulnerable, elderly or ill. Clearly there is plenty to fear with coronavirus.34

The recognition that fear is a normal human response to an existential threat is welcome. However, what is lacking from Kelly’s account is any awareness that neither these existential threats nor the material threats arising from the crisis—unemployment, poverty, being forced to work in unsafe conditions—are evenly shared or randomly distributed across society. Rather, they are shaped by the divisions and inequalities of capitalism. As noted above, the risk of dying from the virus is four times greater for black and minority ethnic people in Britain than for white people. Official figures show that men in low-skilled jobs are four times more likely to die from the virus than men in professional occupations . Kelly’s suggestion that “healthcare workers need to pay particular attention to their physical and mental health and their own stress levels” will be of little comfort for health and social care workers forced to work without adequate PPE.35

The same individualism shapes Kelly’s suggested responses to these mental health pressures—stay informed about the virus, be aware of your feelings, follow government advice and keep in touch with friends. As the concluding paragraph makes clear, he is not completely opposed to taking action:

Small actions hold the key. In that spirit, if you have been reading this book on a computer, tablet or smartphone, please wipe down your device and wash your hands with care. Simple actions save lives.36

At the same time, as he argues in an earlier chapter, it is important not to get too carried away:

The universal human tendency to act lies at the root of many human problems. Sometimes it would be better if we just sat back, reflected and chose our actions with greater care. In the words of the Buddhist proverb, “Don’t just do something, sit there”.37

Against this, as I shall argue in the final section of this article, it is precisely action—specifically, collective action—which offers the best hope, not only of challenging the “livelihood over lives” priorities of our rulers, but also of protecting our physical and mental health.

Capitalism, war and trauma

In contrast to the biomedical model, trauma-informed approaches have become more influential in recent decades. These approaches locate the origins of mental health problems in people’s lived experience rather in faulty brains or genes. The most general definition of trauma describes it as “a deeply disturbing or distressing experience”, but this perhaps fails to capture its full impact. One of the leading researchers and clinicians in the field describes trauma as “by definition, unbearable and intolerable”:

Most rape victims, combat soldiers and children who have been molested become so upset when they think about what they experienced that they try to push it out of their minds, try to act as if nothing happened, and move on. It takes tremendous energy to keep functioning while carrying the memory of terror, and the shame of utter weakness and vulnerability.38

An early use of the notion of trauma to explain mental illness or distress was Sigmund Freud’s so-called “seduction theory”. This theory, later abandoned by Freud, claimed that “hysteria” in women was due to the psychological impact of sexual assault or rape in childhood.39 However, with the advent of the First World War many of the symptoms previously associated with women diagnosed as “hysterical” were displayed by men on the battlefield. These included conversion symptoms, in which a person develops blindness, paralysis or other nervous system problems that cannot be explained by medical evaluation. In this context, a new understanding began to develop of the way in which overwhelming stressful events can contribute to serious mental health problems. As the feminist writer Judith Herman explains:

One of the many casualties of the war’s devastation was the illusion of manly honour and glory in battle. Under conditions of unremitting exposure to the horrors of trench warfare, men began to break down in shocking numbers. Confined and rendered helpless, subjected to constant threat of annihilation, and forced to witness the mutilation and death of their comrades without any hope of reprieve, many ­soldiers began to act like “hysterical” women. They screamed and wept uncontrollably. They froze and could not move. They became mute and unresponsive. They lost their memory and their capacity to feel. The number of psychiatric casualties was so great that hospitals had to be hastily requisitioned to house them. According to one estimate, mental breakdowns represented 40 percent of British casualties. Military authorities attempted to suppress reports of psychiatric casualties because of their demoralising effects on the public.40

That level of breakdown not only posed a threat to the fighting capacity of the British army. It also challenged the then dominant ideas about mental illness. These drew heavily on eugenics, seeing mental breakdown as a symptom of degeneration and essentially a problem affecting the lower classes. In the words of Charles Mercier, one of the leading British psychiatrists of the time:

Breakdowns do not occur in people who are of sound mental constitution. Mental illness does not, like smallpox and malaria, attack indifferently the weak and the strong. It occurs chiefly in those whose mental constitution is originally defective and whose defect is manifested in the lack of the power of self-control and of forgoing immediate indulgence.41

Predictably, the most common response of military leaderships to those suffering what was called “shell shock” was to portray it as malingering and cowardice. Some 306 British and Commonwealth soldiers were executed for crimes such as “desertion” and “cowardice”. The problem for the generals was, however, that it was not only rank and file soldiers who were suffering from shell shock. Many of their officers, the product of the best British public schools, were also exhibiting these symptoms, something that proved difficult to square with eugenicist theories. As Andrew Scull explains:

More and more doctors were drawn to the idea that, under sufficient stress, even the strongest minds gave way. Madness and mental trauma seemed tightly bound up with each other. Even if the trauma was not of the sexual kind that Freud had emphasised, his notions of unconscious conflict and the transformation of mental troubles into bodily symptoms seemed at least partially borne out by these wartime experiences.42

Any hope that this new understanding would lead to a more sympathetic response was misplaced. As Pat Barker describes in her factually based novel Regeneration, a small number of psychiatrists did adopt a humane approach, based on talking therapy, to victims of shell shock. These included W H R Rivers, who treated the poet Siegfried Sassoon at the Craiglockhart Hospital for officers in Edinburgh. More common, however, was the approach employed by Rivers’ contemporary Lewis Yealland, which involved the repeated application of powerful electric shocks to the body. This “treatment” was employed not only by British psychiatrists but also by their French, German and Austrian counterparts. Of course, whatever their professional differences, the shared aim of Rivers and Yealland, like most psychiatrists of the time, was to get their patients back to the killing fields of France as quickly as possible.

Psychiatric interest in trauma declined with the end of the war and did not resume again until the Second World War. By then there was a greater awareness that any soldier could break down under fire and experience what was now variously referred to as war neurosis, combat fatigue or battle stress. The length and severity of combat exposure, not individual resilience, was now seen as the key factor. Several psychiatrists also discovered, according to Herman, “the power of emotional relationships among fighting men”.43 The strongest protection against overwhelming terror, these psychiatrists argued, was the relationship between the soldier, his fighting unit and its leader; the strongest protection against psychological breakdown was the morale and leadership of the fighting unit. In the context of the Second World War, that finding often simply meant returning the soldier to his unit as quickly as possible. There was little support after the war for soldiers traumatised by their experiences and little recognition of the emotional problems they were experiencing. Rather, as later studies, novels and personal memoirs have shown, many were left to manage anger, depression, anxiety, sleep problems, and so on, often self-medicating with alcohol with their families on the receiving end of their disturbed behaviours.44

With the end of the war, psychiatric interest again soon waned. The last professional writing of the period on combat stress appeared in 1947. A diagnosis of “gross stress reaction” did appear in the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association, or DSM-I, which appeared in 1952. However, this diagnosis was dropped without explanation from the first revision of the manual, DSM-II, which appeared in 1968.45 It was not until almost three decades later that the issue of war-related trauma once again aroused attention, this time during the closing stages of the Vietnam War. In 1970, Vietnam Veterans Against the War was formed in the US. This initially involved a small group of soldiers, many of whom had distinguished themselves for bravery, who spoke out against the war, often returning their medals and offering testimony about their war crimes—activities requiring enormous bravery, given that the war was still going on. As Herman recounts, they organised “rap groups”, meetings where they could share their experiences of war and the traumatic events they had lived through. The purpose of these groups was both therapeutic and political. They gave solace to victims who had suffered psychological trauma but also raised public awareness about the effects of war. In the words of one veteran, Michael Norman:

Family and friends wondered why we were so angry. What are you crying about? they would ask. Why are you so ill-tempered and disaffected? Our fathers and grandfathers had gone off to war, done their duty, come home and got on with it. What made our generation so different? As it turns out, nothing. No difference at all. When old soldiers from “good” wars are dragged from behind the curtain of myth and sentiment, and brought into the light, they too seem to smoulder with choler and alienation… So we were angry. Our anger was old, atavistic. We were angry as all civilised men who have ever been sent to make murder were angry.46

By the mid-1970s hundreds of these rap groups had been organised across the US. Political pressure from the veterans’ organisation led to the creation of Operation Outreach. Over a hundred outreach centres were created, staffed by veterans and based on a self-help, peer-support model of care. That pressure also led to systematic psychiatric research into the relationship between wartime experiences and the psychological problems that veterans were experiencing. One result was the inclusion in 1980 of a new diagnosis in the revised DSM, DSM-III—post-traumatic stress disorder.

Extending trauma

Since the inclusion of PTSD in the DSM, the range of experiences seen to contribute to the symptoms associated with this diagnosis—such as nightmares, flashbacks, panic attacks and sleep disorders—has widened enormously. The growth of the women’s movement in the 1970s, for example, led to a heightened awareness of the incidence and traumatic long-lasting impact of rape, sexual violence and domestic violence. Later, in the 1980s, child abuse—whether physical, sexual or as a result of neglect—was also recognised as being much more widespread than had been previously thought. It also led to an awareness that the symptoms associated with PTSD need not be the product of one single event that disrupts “normal” life, but can result from ongoing abuse or sexist and racist harassment. This led researchers such as Bessel van der Kolk to argue for the inclusion of a new diagnosis of “complex PTSD” in the DSM. Although PTSD is generally related to a single event, complex PTSD is related to a series of events or a prolonged experience.

There are both positive aspects and limitations to the increasing use of trauma and PTSD to explain severe mental distress. Positively, it directs attention away from the dominant way of making sense of such distress, which locates its roots in the brains or genes of individuals. The key question in treatment becomes not “what’s wrong with you?” but “what’s happened to you?”. PTSD is, in fact, the only diagnosis in the DSM whose name references the causes of the condition. Potentially, therefore, it opens the door to an understanding of mental distress that sees it as a response to living in a racist, sexist, class-divided society. More pragmatically, the ideological influence of the biomedical model means that psychiatric diagnoses not only define understandings of mental distress, but also act as passports to services and benefits. This is especially true in the US, where access to insurance cover is dependent on having such a diagnosis. As the Vietnam Veterans found with PTSD, obtaining a diagnosis may be the only way of having mental health problems recognised and services provided. A criticism of the (generally very progressive) Power Threat Meaning Framework, published by critical psychologists in 2018, for example, was that it sought to replace diagnoses with “formulations”. Despite this arguably being a much more holistic way of making sense of mental distress, it could also make it much harder for those with mental health problems to access welfare benefits.47

Nonetheless, there are limits to the uses of trauma to explain mental distress. Firstly, there is a risk of reductionism in seeing every form of mental distress as rooted in some (known or unknown) earlier trauma. Many forms of mental distress do not fit easily into a trauma framework. These include: work-related stress; the complex grief that is experienced by people who have been unable to comfort dying loved ones; the depressive feelings and loss of hope experienced by young people who see their futures disappearing; and the low self-esteem of young women who are unable to attain the impossible body images that are demanded by social media.

Secondly, there is a danger of determinism in assuming that everyone will respond to events in the same way. Paul Michael Garrett has rightly critiqued the individualist focus of the notion of resilience, which is currently popular in social work and social policy discourses. Theories of resilience see success in overcoming setbacks as primarily a matter of individual strengths and qualities, which is an approach that fits well with the neoliberal focus on individual responsibility.48 Nevertheless, accepting Garrett’s critique does not preclude recognising that the life experience and resources—emotional, social, financial—of specific individuals may enable them to deal with trauma more effectively than others with fewer resources.

Thirdly, like the biomedical approach, trauma-informed approaches can also lead to highly individualised and medicalising responses. For example, describing post-traumatic stress as a “disorder” carries medical overtones, and it also implies there is something wrong about how an individual is responding to previous traumatic events. Indeed, almost every “diagnosis” (itself a medical term) in the DSM—including those relating to anxiety, depression and personality—ends with the word “disorder”. Despite this, the DSM says nothing whatsoever about their causes. As John Read and Pete Sanders comment:

It hasn’t always been so. In the very first edition of the DSM in 1952, the same problems now called disorders were all called “reactions”. This was a different era in which psychoanalytic psychiatrists were in the ascendancy in the US. Like the public…they understood that mental health problems stem largely from life events and our interpretation of these events, rather than from faulty genes or brain chemicals… The diagnostic approach to human distress medicalises all sorts of things, turning our reactions to life events into disorders.49

This is one reason why radical Latin American psychologists and psychoanalysts chose not to use these frameworks to make sense of people’s responses to the regimes of terror imposed by military juntas during the 1970s and 1980s:

We do not think the concept of PTSD is an adequate one to describe the ­psychological impact of state terror. It makes a psychiatric problem out of a social phenomenon…we don’t even speak of trauma because it is usually understood to mean an intrapsychic experience. We use the concept “traumatic situation” in order to represent the social sources of the psychological suffering produced by state terror… The essence of social trauma is that it is not a private experience but a public and shared experience.50

Similarly, the authors of The Power Threat Meaning Framework occasionally refer to “trauma” in order to convey the severe impact of some life events, but prefer the term “adversity”:

This is partly to avoid the medical overtones of “trauma”. However, it is also to avoid the potentially misleading impression of discrete, possibly very unusual, extreme or life-threatening events impinging from outside—rather than, as is often the case, of continuous or repeated very negative experiences. These experiences are often embedded in people’s lives and relationships and in the discourses, structures and practices of our social world. We would argue that these qualities of adversity can be crucial in understanding the experiences themselves, as well as children’s and adults’ responses.51

Collective trauma, collective responses

The coronavirus pandemic will have a profound impact on the mental health of many people around the globe, now and for years to come. Past experience suggests that the response of governments to that distress will be to minimise its extent and significance and to pathologise those experiencing it as “mentally ill” or as lacking “resilience”. As argued above, not everyone will respond to current events in the same way, although, as Judith Herman argues, “individual characteristics count for little in the face of overwhelming events… With severe enough traumatic exposure no person is immune”.52 Despite that, she notes, shame and isolation continue to be the hallmarks of trauma, be it the shame of “not coping” or of having thoughts or feelings experienced as “going mad”.

Victim-blaming and the conscious reinforcement of shame and isolation have been part of how powerful institutions—the police, the army, the church, major charities—have silenced victims of institutional crimes and failures. This silencing is more easily achieved where the traumatic event takes place between individuals and in secret. Then, great courage is required on the part of those affected to speak out and “break the silence”. However, when trauma takes the form of a collective event or experience, it is possible to develop collective responses. These can challenge the isolation and sense of powerlessness that are both cause and effect of mental distress. At the most basic level, these responses can take the form of mutual aid, which might not always address the political roots of the problem, but nevertheless offers emotional and practical support for those affected. After the devastating wildfires in California in 2018 and 2019—a symptom of climate change that destroyed thousands of homes and killed dozens of people—one survivor wrote:

Communal trauma creates immediate community support. Suffering is rapidly acknowledged and local resources activated. Within two days of the fire, for example, a handful of locals established a make-shift crisis and support centre in the backyard lot of a convenience store. People donated clothing, offered housing, brought cooked food and co-ordinated support systems that no local, county or state organisation had provided. The Facebook community went into overdrive with emotional support groups.53

Similarly, only weeks into the current coronavirus crisis, tens of thousands of people across Britain had volunteered to help the NHS and vulnerable neighbours. Others had set up local mutual aid support groups, challenging the Thatcherite myth that “there is no such thing as society”. Such examples are important in reducing the sense of isolation and helplessness that contribute to traumatic experiences. Similar phenomena were visible in the community response to the Grenfell Tower fire in London in June 2017. Susan Rudnik, an art therapist who helped support children and families after the disaster, quotes the writer David Garland:

Taking an active part in understanding and perhaps alleviating another’s distress acts to restore an individual’s sense of control after a period of acute and sometimes prolonged helplessness, which is the essence of a traumatising situation.54

Important as these responses are, they are not, of course, an alternative to properly funded, state-provided mental health services. Here the picture is grim. The period since the economic crash of 2008 has been marked by a huge increase in the number of people experiencing mental distress along with massive cuts to mental health services. For example, the number of people in Scotland being prescribed anti-depressants increased by 48 percent from 2009-10 to 2018-19, rising from 633,762 to 936,269. According to Scottish government statistics, people in the “most deprived” classification of the Scottish Index of Multiple Deprivation were more likely to be prescribed anti-depressants. In the poorest communities, 85,222,641 doses were handed out to 258,813 people.55 During the same period, mental health services across Britain have been cut and staffing levels have fallen. Since 2009, the budgets of mental health NHS Trusts in England have been cut by 30 percent, and the ratio of mental health doctors to service users has fallen from one doctor to 186 service users to one for every 253.56 Whatever the limitations of mainstream psychiatric care, the result of cuts is frequently a lack of beds for people experiencing acute mental health crises. Waiting times for those seeking support for their mental health problems, including children and young people, have got longer. Community-based mental health services—run by voluntary, community and charity organisations and more likely to offer non-medicalised forms of support—have also suffered hugely during this period.

Against that background, the demand of the service user movement for more and better services is an urgent one. “Better”, in this context, usually means less medicalised, less coercive services, with greater access to a range of different talking therapies and social supports. This is not the place for a discussion of what an alternative mental health system would look like.57 What is clear, however, is that the voices of mental health service users, including those whose mental health has been affected directly or indirectly by traumatic events and experiences, should be central to that discussion. Individual accounts of trauma often confirm the profound and devastating impact that such events have on mind and body. Writing 20 years after the Hillsborough Stadium disaster, for example, one survivor wrote:

What I have long suspected is that, emotionally, the clock stopped at age 19. Since holding death at arm’s length, I’ve held the advancing years there too. I was a mature teenager but I haven’t grown up at the same pace as my friends. I haven’t had kids. I won’t let my own youth go just yet. I will turn 40 next year but to most people I seem to be around 30.58

Given such troubling experiences, as well as the flashbacks, panic attacks and difficulties in sleeping associated with the diagnosis of PTSD, it is not surprising that many survivors seek out individual counselling and therapy. Often, however, it takes collective action to make such therapy available to those affected. This was certainly the case after the Grenfell Tower disaster. According to Moyra Samuels, a leading activist in the community campaigns that followed the fire, there was little help from statutory agencies to deal with immediate psychological fallout of the tragedy. It took hard campaigning before the NHS set up Grenfell Wellbeing Support, which is now one of the biggest mental health projects in Europe. Since then, important sources of emotional and social support have been collective activities such as the monthly “silent walks” that remember the 72 people who lost their lives.59 Also central to the Grenfell campaign has been the struggle for justice and accountability. The slogan “No Justice, No Peace” contains both a political and a psychological truth. Without a political understanding of the causes of tragedies such as Grenfell and Hillsborough, and a holding to account of those responsible, individual healing becomes much more difficult. Judith Herman’s comments on the study of psychological trauma apply no less to the process of recovery:

The systematic study of psychological trauma therefore depends on the support of a political movement. Indeed, whether such study can be pursued or discussed in public is itself a political question. The study of war trauma becomes legitimate only in a context that challenges the sacrifice of young men in war. The study of trauma in sexual and domestic life becomes legitimate only in a context that challenges the subordination of women and children… In the absence of strong political movements for human rights, the active process of bearing witness inevitably gives way to the active process of forgetting. Repression, dissociation and denial are phenomena of social as well as individual consciousness.60

Both the #MeToo movement against sexual harassment and abuse that grew massively in 2017 and the Black Lives Matter movement of 2020 provide concrete confirmation of Herman’s argument. #MeToo succeeded in collectivising the personal experiences and trauma of women who had been abused by powerful men. The 2020 Black Lives Matter movement erupted after the brutal murder of George Floyd by four cops in Minneapolis in May and triggered global demonstrations against police brutality and institutionalised racism. In a few months it achieved more than the top-down, reformist strategy of “black faces in high places” had accomplished in decades. Both movements have shown that, where trauma can be collectivised, made transparent and shared, it can become a source of strength and resistance. Therein lies their relevance to the current coronavirus crisis.

For those who belong to the revolutionary tradition, this is an old truth—albeit one that is renewed and refreshed by these inspiring movements from below. The theorist and activist who wrote most explicitly about the relationship between collective struggle and the overcoming of trauma was the psychiatrist and revolutionary Frantz Fanon. Fanon played a key role in the struggle for Algerian independence in the late 1950s. Leo Zelig’s recent biography provides an excellent introduction to the ideas and practice of this important thinker.61 Yet many of the great thinkers in the Marxist tradition have been acutely aware of the transformative potential of collective action and, above all, of revolution. In fact the need to shake off what Marx described as the “muck of ages”—not only backward racist and sexist ideas but also the feelings of shame, powerlessness and inferiority that many experience as a result of life in class society—was one of the reasons he saw revolution as necessary.62 Similarly, describing the dynamics of the mass strike, Rosa Luxemburg writes:

The most precious, lasting thing in this rapid ebb and flow…is its mental sediment: the intellectual, cultural growth of the proletariat which proceeds by fits and starts and which offers an inviolable guarantee of their further progress in the economic as in the political struggle.63

In a discussion of the October 1917 revolution in Russia, Tony Cliff writes:

The greatest achievement of the Russian Revolution was not the mass strikes, not even the Soviets. The greatest and most marvellous thing was the spiritual growth of Russian workers. Powerlessness does not give the opportunity for such growth.64

What these Marxist writers emphasised, in a way that Fanon did not, was the need to connect struggles against oppression with the power of the working class. This was not for sentimental or doctrinaire reasons, but rather because, as Rosa Luxemburg argued, “where the chains of capitalism are forged, there must the chains be broken”. In other words, a system that depends on the accumulation of profit, places potential power in the hands of those whose labour produces that profit, directly or indirectly. If the Covid-19 crisis has highlighted one thing above all others, it is that the “essential” workers in this society are not the likes of Jeff Bezos, Richard Branson or Mark Zuckerberg. Rather, they are the bus drivers, retail workers, cleaners, nurses and the social care workers, without whose labour the wheels of capitalism would grind to a halt. It is with these and with millions of other essential workers across the globe that our power as a class lies.

The passivity of most trade union leaders in Britain in the face of the crisis has meant that workplace-based resistance here has remained at a relatively low level. Nevertheless, as Mark Thomas showed in the previous issue of this journal, there have been some important examples of workers fighting back and winning. Most notable are the teachers in England and Wales. Members of the National Education Union refused to bow to pressure from Boris Johnson and allow a premature return to schools in June, when the virus was still raging, and thus protected the health of children, teachers and parents.65 Moreover, even when the level of struggle in workplaces is low, struggles in the wider world can raise the level of debate and discussion inside workplaces. For instance, the Black Lives Matter movement has reignited debate inside schools and universities about the need to decolonise the curriculum. Similarly, teachers across Britain will have been inspired by the astonishing victory of school students in August, when demonstrations forced the government to discard a skewed exams process that had been introduced to deal with the impact of lockdown. That process had seen tens of thousands of young people living in the poorest areas having their predicted grades lowered—and their hopes dashed—while the grades of students in more affluent areas were barely affected. It is a victory that will make a huge material difference to the lives of these students, but not just a material difference. The lesson that many of these young activists, some of whom were involved in the earlier school climate strikes, will take away from this experience is that collective action can win and that they are not powerless. A new generation across the globe is learning that change from below is possible and that they do not need to wait for the likes of Keir Starmer or Joe Biden to deliver change from above—change which they have no intention of delivering in any case. These are some of the resources of hope that can combat depression and despair and give grounds for optimism that another world is indeed possible.

Iain Ferguson is a long-standing member of the SWP in Scotland and author of Politics of the Mind: Marxism and Mental Distress (Bookmarks, 2017).


1 I am grateful to Joseph Choonara, Jane Hardy, Sheila McGregor, Camilla Royle and Roddy Slorach for their helpful comments on an earlier draft of this article. I am also grateful to Moyra Samuels and a Hillsborough survivor who did not wish to be identified for their thoughts on the personal and collective impact of trauma.

2 Spinney, 2018.

3 Higgins, 2020.

4 RCP, 2020.

5 Davis, 2005; Wallace, 2016.

6 Choonara, 2020; Parrington, 2020.

7 Mental Health Foundation, July, 2020.

8 Campbell, 2020.

9 Van der Kolk, 2014.

10 Van der Kolk, 2014; Herman, 2015.

11 Kawohl and Nordt, 2020.

12 Brooks and others, 2020.

13 Bland and Campbell, 2020.

14 Runnymede Trust, 2020.

15 Viens, McGowan and Vass, 2020.

16 Petter, 2020.

17 Peirce and ten others, 2020.

18 Johnstone, 2020.

19 Tian and others, 2020.

20 Giuffrida, 2020.

21 Elliott, 2020.

22 Mental Health Foundation, 2020.

23 Mental Health Foundation, 2020.

24 Mental Health Foundation, 2020.

25 Mental Health Foundation, 2020.

26 Mind, 2020.

27 Fawcett Society, 2020.

28 For an excellent critique, see Rose, 2019.

29 Rose, 2019, pp114.

30 Rose, 2019, pp115.

31 Kelly, 2020.

32 Kelly, 2020, p2.

33 For a critical assessment of the response of the Irish government to the crisis, see Allen, 2020.

34 Kelly, 2020, pp4-5.

35 Kelly, 2020, p57.

36 Kelly, 2020, p71.

37 Kelly, 2020, p45.

38 Van der Kolk, 2014, pp1-2.

39 Freud, 1995.

40 Herman, 2015, p20.

41 Cited in Scull, 2015, p295.

42 Scull, 2015, p296.

43 Herman, 2015, p25.

44 Mulvey, 2019.

45 Andreasen, 2010.

46 Cited in Herman, 2015, p26.

47 Johnstone and others, 2019.

48 Garrett, 2016.

49 Read and Sanders, 2010.

50 Cited in Hollander, 1997, pp110-111.

51 Johnstone and Boyle, 2018, p98.

52 Herman, 2015, p57.

53 Van Gelder, 2019.

54 Rudnik, 2018, p3.

55 Scotsman, 2019.

56 TUC, 2020.

57 For what such an alternative might look like, see Beresford and others, 2016.

58 Mental Health Foundation, 2016.

59 Personal communication.

60 Herman, 2015, p9.

61 Zelig, 2016.

62 Marx and Engels, 1976, p53.

63 Luxemburg, 1986, pp38-39.

64 Cliff, 1987.

65 Thomas, 2020.


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